ARGYLL & BUTE CHP COMMITTEE MEETING

Wednesday 17 December 2014 Training Room, Cowal Community Hospital, Dunoon

10.30am – 12.30pm – Committee Members Development Session

• AVA Reshaping Care – Sue Davies, Visiting Friends Co-Ordinator • Patient Opinion – Gina Alexander , Director, Patient Opinion Scotland

12.30pm - Lunch

1pm - Meeting

Time Agenda Item Title Presenter 1pm 1 Chairman’s Welcome Chair

2 Apologies Chair

3 Conflicts of Interest Chair

1.05pm 4 Minutes of Meeting of 22 -10 -14 (attached) Chair

1.10pm 5 Matters Arising Chair

6 NHS Highland 1.20pm 6.1 Highland NHS Board – 2 December 2014 (verbal) Chair 1.25pm 6.2 Director of Operations Report (attached) Christina West

7 Clinical Governance 1.35pm 7.1 Clinical Quality & Patient Safety Report (attached) Pat Tyrrell 1.50pm 7.2 Infection Control Report (attached) Pat Tyrrell 2.10pm 7.3 Public Health Annual Report (attached) Elaine Garman

8 Financial Governance 2.25pm 8.1 Finance Report (attached) George Morrison

3.10pm 9 A&B HSCP Integration Scheme (attached) Stephen Whiston

3.20pm 10 Mental Health Modernisation Update (attached) Christina West

3.30pm 11 St aff Governance 11.1 PDP/R & eKSF Implementation Update (attached) Gaye Boyd

3.40pm 12 Performance Management 12.1 Delayed Discharge Update (verbal) Christina West

3.45pm 13 Papers for Noting Chair a) Vale of Leven Hospital Enquiry Report – Executive Summary (attached) b) Aberdeen Royal Infirmary – Short Life Review of Quality & Safety (attached) c) Notes of Clinical Quality & Patient Safety Group – 09-09-14 (attached) d) Integration Newsletter – Dec 14 (attached) e) Reshaping Care for Older People – Survey https://www.surveymonkey.com/s/Reshaping_Care

f) NHSH Quality Awards Nomination Process (attached)

3.50pm 16 AOCB Chair

17 Details of Next Meeting :

Wednesday 18 February 2014 at 10am J03-J07, Mid Argyll Community Hospital, Lochgilphead

Public Session Chair

Argyll & Bute CHP Committee 17 December 2014 Item : 4

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

J03-J07, MACHICC, Lochgilphead 22 October 2014 – 1pm

Present Mr Robin Creelman, Chairman, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Elaine Wilkinson, Non-Executive Member Councillor John McAlpine, Argyll & Bute Council Representative Councillor Anne Horn, Argyll & Bute Council Representative Mr Alastair McLaren, Argyll Voluntary Action Mr Duncan Martin, Chairman, Public Partnership Forum Mr Michael Roberts, Vice-Chair, Public Partnership Forum

By VC Dr Peter Von-Kaehne, LMC Representative

In Attendance Mr George Morrison, Head of Finance Ms Lorraine Paterson, Locality Manager, Mid Argyll, Kintyre & Islay Mr John Dreghorn, Programme Director, Mental Health (agenda item 14) Mrs Sheena Clark, PA to Interim Director of Operations - Minute Secretary

Apologies Ms Christina West, Interim Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Mr Stephen Whiston, Head of Planning, Contracting & Performance, Argyll & Bute CHP Mr David Ritchie, CHP Communications Manager Ms Gaye Boyd, Personnel Manager Ms Dawn Gillies, Staffside Representative Ms Elizabeth McMillan, Staffside Representative Ms Glenn Heritage, CVO Representative Councillor Elaine Robertson, Argyll & Bute Council Representative

1. CHAIRMAN’S WELCOME

The Chairman welcomed everyone to the meeting.

2. APOLOGIES

Apologies for absence and the non-quoracy of the meeting were noted.

3. CONFLICTS OF INTEREST

There were no conflicts of interest noted.

4. MINUTE FROM PREVIOUS MEETING on 22 AUGUST 2014

The Minute of the meeting on 22 August 2014 was accepted as an accurate record.

The Committee:

• Approved the content of the Minute of 22 August 2014.

5. MATTERS ARISING

Obstetric Scanning – Mr Martin requested an update on the review of the service. Ms Tyrrell reported that the Review Group is working on a proposal to develop a model to enable CHP Midwives to carry out obstetric scanning under appropriate governance arrangements and a report will be taken to the Core Management Team in December. If agreed the Review Group will look at training and workforce requirements, with an anticipated implementation date of middle of 2016. In the interim scans will continue to be carried out by NHS Greater Glasgow & Clyde.

The Committee:

• Noted the update .

6. PARTNERSHIP WORKING PRESENTATION

Reshaping Care for Older People (RCOP) Consultation – Long, Healthy, Active & Happy Lives

The presentation given by Ms Tyrrell has been developed as part of the work of Reshaping Care for Older People and the Integration of health and social care and the draft Joint Strategic Plan for older people.

The services should meet the needs of the person rather than fitting the person into services, with the person at the centre of their care and support. It is also about health, social care and local communities all working together more, along with other partners.

The aim is to put people at the heart of the services provided and communities, as well as with partner agencies.

To support this work a booklet which has been developed with input from older people to explain how and why things are changing and to seek their views on the draft plans. The booklet includes a questionnaire to facilitate feedback, either online via http://livingwellinargyllandbute.co.uk/ or as a tear out from the booklet and using a freepost address. This can be completed individually or as a group with the facilitator providing the feedback, by the end of December.

In early 2015 the results will be reviewed to inform the draft Joint Strategy for Older People

Dr Von-Kaehne referred to the RCOP information available on the website not being up to date. Ms Tyrrell acknowledged the requirement for updated information to be available and advised that work is ongoing and feedback awaited, with progress being made on updating the information in 4-6 weeks.

Dr Von-Kaehne highlighted difficulties experienced in calling the central number used by health and social care professionals and self referring members of the public to access

2 Social Work Services and Home Care in Cowal. This results in unacceptable delays in early intervention and community care assessments.

Ms Tyrrell acknowledged that the use of this ‘Golden Number’ has resulted in some difficulties and work is being undertaken to the resolve issues raised. She requested that Dr Von-Kaehne provide her with further details of his concerns to inform the work underway.

Ms Tyrrell responded to comments by Dr Von-Kaehne relating to differing contract terms for external care providers and the impact on staff, advising that this is currently under review by the Council Procurement Department.

The presentation is being presented to staff and joint CHP and Council meetings before being issued to the wider public.

Ms Garman suggested that the joint work and plans to encourage community capacity building should be reflected in the presentation. Ms Tyrrell agreed with this proposal.

The Committee:

• Noted the content of the presentation.

7 NHS HIGHLAND

7.1 Highland NHS Board 7 October 2014

Mr Creelman advised that the Highland NHS Board meeting is now available to view on Webex and requested that this is publicised within Argyll & Bute. Ms Clark will advise Mr Ritchie, Communications Manager.

The Committee:

• Noted the information.

7.2 Director of Operations Report

Mr Morrison advised that Ms Christina West, Interim Director of Operations has been appointed as Chief Officer of Argyll & Bute Health & Social Care Partnership. The Committee offered their congratulations to Ms West.

Mr Morrison spoke to the circulated report.

Visit - the Cabinet Secretary for Health, Alex Neil, will be visiting Argyll & Bute CHP on Thursday 23 October. His visit will be focussed on Lorn & Islands Hospital, Oban, with several meetings with staff, community members and senior officers arranged. Mr Neil will be accompanied by local MSP, Michael Russell.

ADP - interviews for the post of ADP Co-ordinator are due to take place on 23 October. The annual report for 2013/14 was finalised and agreed at the ADP Executive Meeting on 13 October and will be submitted to the CPP Management Committee at the end of October for final sign off.

3 Mid Argyll, Kintyre & Islay (MAKI)

Mid Argyll -

• HEI post inspection report published with an action plan insitu and progressing.

• The Scottish Government funded sustainable medical services project continues. Ongoing recruitment in Mid Argyll & Kintyre for GPs, practice nursing and project manager. GP training program has been developed and planned for January 2015 to which GPs across the CHP have been invited to attend.

• Temporary movement of patients from Cara Ward into Knapdale Ward due to temporary staffing pressures continues. Patients continue to be cared for in a dementia continuing care ward by staff with dementia nursing skills.

Kintyre -

Sustainable medical services project continues. There were no applicants for the Kintyre Medical Group (KMG) salaried GP post and advertising continues. The KMG team are being supported by locum GPs to ensure continuity of service for patients.

Community engagement meetings to highlight the sustainable services project are underway, with the opportunity for community members to provide feedback.

Councillor Horn asked if there was Community Council involvement in the KMG. Ms Paterson replied that she was unaware of their participation, which will be reviewed.

Islay & Jura -

• Islay Implementation Group - key ongoing actions : GP recruitment, Integrated Workforce model being developed, IT infrastructure, hospital redesign and Community Engagement.

• Dental Services - Unfortunately the latest round of recruitment to the full-time dentist post on Islay has been unsuccessful. Although the CHP were hopeful of having a dentist in place by the end of the year, the appointment is not going to take place. There have been three rounds of recruitment for a dentist on Islay but none of the preferred candidates progressed to appointment. Two of the preferred candidates withdrew after having been offered the post and one did not meet the criteria for appointment to NHS Highland’s dental list. The recruitment process will start again immediately.

Councillor Horn expressed concern regarding the environment of the surgery on Islay. Ms Reilly advised that the dental facilities are included in the Islay Health Services Review and the possibility of relocating the dental service from the Portakabin to newly designed surgeries within the hospital is being considered.

The potential for an independent dentist is being explored with one dentist expressing an interest.

Cowal & Bute

• Ros Moore, Chief Nursing Officer and Heidi May, Director of Nursing visited Cowal on 14 August 2014. They toured the hospital and met with staff and community representatives and commented on the outstanding work done in shifting the balance

4 of care, modernising services, providing a wide range of services across a challenging geography and congratulated both staff and community representatives on working together to ensure services are designed based on the community’s needs.

• Reshaping Care for Older People - locality mapping exercise has been undertaken looking at preparing for the integrated inspection of adult services, local joint manager liaison arrangements, co-location, integration and joint reporting. A step up/down bed model proposal is currently under development for Cowal.

Helensburgh & Lomond

• Reshaping Care for Older People - in reach by Extended Community Care Team to Vale of Leven to undertake assessment prior to discharge is working well with a plan to extend to further NHS Greater Glasgow & Clyde hospitals.

• Physiotherapy services will now be provided by NHS Highland staff and locally managed.

Oban, Lorn & Islands

• Mull & Iona Out of Hours GP Services – following the opt out of the Tobermory GPs from January 2015, and the resignation of the Bunessan GP, the CHP held three community drop in sessions; Tobermory 21 August, Bunessan 27 August and Iona 18 September to discuss the continuing provision of services. Attendance at all three was good with 120 people attending in Tobermory, 54 in Bunessan and 40 on Iona. The Bunessan vacancy has a GP locum in post.

• Reshaping Care of Older People Services - Extended Community Care Team (ECCT) continues to develop. Hours of work by the team are being reviewed by the Team Leader. At present the team provide service across Oban & Lorn from 8am – 6.00 pm. The aim is to increase the hours of working to either 8.00 pm or 10.00 pm. A sample roster is being developed with three options within existing funding.

• Dental - discussions are on-going with the selected partner to conclude the terms of the lease for Oban Dental Access Centre.

• Surgical Services - Ms Ella Tolloczko recently commenced employment as Consultant Surgeon in Lorn & islands Hospital replacing Dr Barbera.

• Physician Post - Dr Jorge Cabo took up his appointment as Consultant Physician on 18 August 2014.

• Decontamination Unit - there have been delays in the decontamination unit becoming fully operational due to a failure in water testing. Executive and senior management support was put in place to support an action plan implementation. Some issues for the contractors remain outstanding, however a timescale for addressing these has been agreed and is progressing. During this period scopes have been decontaminated at the Belford Hospital, ensuring service continuity for patients attending Lorn & Islands Hospital.

The Committee:

• Noted the content of Director of Operations Report.

5 8. CLINICAL GOVERNANCE

8.1 Clinical Quality & Patient Safety Report

Ms Tyrrell spoke to the circulated paper.

Risk Management

Incidents - The overall number of incidents reported each month for Quarter Two is between 150 – 180.

The top four categories of reported incidents for Quarter Two are as follows:

• Slips, trips and falls – remains the highest reported category. Falls with harm have been reported in the ward for people with dementia in Mid Argyll Hospital. Work is underway to implement care and comfort rounds to increase patient contact time throughout the 24 hour period within the wards of Mid Argyll Hospital.

• Disruptive, violent and aggressive behaviour – the detail of the reported incidents is being analysed to understand the underlying reasons and to inform an action plan to address identified issues and assist in prevention and management. The majority of reported incidents occur in the mental health wards and dementia ward. Mr Roberts enquired about the use of CCTV in specific areas to use as learning apparatus. Ms Tyrrell stated that there would be consent and confidentiality issues in the use of CCTV but the use of technology in identifying when patients are moving around, i.e. pressure mats, is being considered.

• Pressure ulcers – the reduction in grades 3 and 4 pressure ulcers across all hospitals is being sustained. Lorn & Isles Hospital has shown sustained improvement in reducing pressure ulcer development within the hospital and staff are routinely applying the evidence based risk assessment and management plans.

Self harming behaviour – a review of the reported incidents showed that the statistics relate to a total of five patients and the majority of incidents being reported from the Intensive Psychiatric Care Unit at Argyll & Bute hospital. This is indicative of the complexity of providing care in this unit for patients who have intensive care needs. Further analysis of the levels of risk assessment and care management plans that are instituted for such patients is underway.

Councillor McAlpine asked about the requirement for Police involvement to administer drugs to disruptive patients. Ms Paterson advised that this can occur in A&E. Ms Tyrrell will discuss further with Councillor McAlpine any specific concerns he may have.

Significant Event Reviews (SER) - since the last report two incidents have been declared as SERs

• failure of fridge and temperature monitoring systems for childhood vaccinations in Helensburgh • sudden death in Mid Argyll, Kintyre and Islay

These cases are currently under review and SER report and action plan to address areas for improvement will be developed.

Feedback

Complaints - the detail of complaints type and response times will be included in the next report.

6

Inpatient Patient Experience Survey 2014 – the reports from the annual survey for NHS Highland have been received. Lorn & Islands Hospital and Cowal Community Hospital were the only two hospitals in the CHP with response levels of statistical significance. Overall feedback is very positive. Each hospital has developed actions relating to the areas identified for improvement, including the need to ensure patients know who is in charge of their care, the need to minimise noise levels in hospitals overnight and the need to improve the preparation and information that patients receive prior to discharge from hospital.

Quality & Safety

Clinical Quality Indicators (CQIs) - the standards CQIs for Pressure Ulcers, Falls and Food, Fluids and Nutritional Care showed that the overall compliance set out for each of these indicators is very good. A 95% compliance is required across all hospitals and action will be taken to address any area not achieving the compliance rate and the area re-audited.

Lorn & Islands Hospital – Scottish Patient Safety Programme (SPSP) - 6 members of the hospital staff attended the regional event in Inverness on the 7 th and 8 th October which focussed on the work to date and the implementation of CEL 19 looking at the deteriorating patient, falls, CAUTI and heart failure.

It is proving challenging to manage the mortality reviews on a monthly basis due to capacity issues of those trained to carry out the reviews. Training for more staff to undertake the reviews is to take place as soon as possible.

External Review / Inspection

Mental Welfare Commission (MWC) – visited in-patient psychiatric services in Argyll and Bute on 7 August 2014, including Succoth and Intensive Psychiatric Care and Glassary and Knapdale Ward in Mid Argyll Hospital.

The recommendations from their visit are as follows:

- audit the level of provision of activities for patients in Succoth and IPCU - audit the forms to authorise medical treatment for individuals detained in both Succoth and IPCU - keep the Mental Welfare Commission informed of progress in resettling patients ready to leave Argyll and Bute Hospital who are awaiting appropriate supported accommodation - information about Welfare Proxies should be recorded in patients’ case notes and copies of relevant orders should be requested from the Welfare Proxy

The actions to address these recommendations will be progressed through the Mental Health Operational group, and a progress report will be completed for the Mental Welfare Commission by 25 November 25 2014.

Health & Safety

Personal Protective Equipment – Power Visors - the Health and Safety Managers in conjunction with Infection Control staff have reviewed and sourced appropriate powered visors to be used by staff where there is a possibility of transmission of infection via an airborne route. These powered visors have been purchased, two per hospital, and have been distributed to the hospitals.

New Legislation - two new pieces of health and safety legislation, ‘The Acetylene Safety Regulations 2014’ and ‘The Petroleum (consolidation) Regulations 2014’ commence this

7 month. The legislation was reviewed to determine its applicability and necessary compliance for the CHP.

The Committee:

• Noted the content of the Clinical Quality & Patient Safety Report.

8.2 Infection Control Report

Ms Tyrrell spoke to the circulated paper.

Staphylococcus Aureua Bacteraemia (SAB) - there have been no further cases of SAB since February 2014.

Current initiatives are concentrating on infections associated with vascular devices (lines) and catheters as well as working to reduce blood culture contamination rate.

Clostridium Difficile (CDI) – there have been 6 cases of CDI in Argyll & Bute since April 2014, affecting 5 patients with one recurrence in the same patient (counted as 2 cases).

Protocol for Prescribing Restricted Antimicrobials – following the publication of the Scottish Management of Antimicrobial Resistance Action Plan 2014-2018, a date is being finalised to undertake a snapshot audit on appropriate prescribing and recording processes.

Ms Wilkinson asking if dental services were included in the audit. Ms Reilly responded that the same principles of prescribing apply to Dentists as apply to GPs. Ms Wilson advised that prescribing AHPs should also be included in the audit process.

Hand Hygiene - all clinical areas continue to be audited, with the compliance target of 95% being achieved.

Cleaning & Healthcare Environment – the monthly cleaning and estates audits are showing good compliance with the National Cleaning Services Specification.

Healthcare Environment Inspection (HEI) – Inspectors from HEI visited Mid Argyll Community Hospital and Integrated Care Centre on 29 and 30 July 2014 to carry out an announced inspection of the hospital.

The inspectors found that the hospital was clean in most areas and that staff were complying with the majority of standard infection control precautions. Staff were knowledgeable about their role and responsibility in preventing infections. The inspectors also noted a very low incidence of infections in the hospital.

The report contained four requirements and four recommendations :

Requirements -

••• ensure a robust system is in place to action failed standard infection control precautions (SICPs) audits. This should include a system of quality assurance to oversee the audit process and ensure that failed results are leading to improvement, within an appropriate timescale. ••• ensure that Craignish ward at Mid Argyll Community Hospital and Integrated Care Centre is included in the hospital’s standard infection control precautions (SICPs) audit process

8 ••• demonstrate compliance with the national infection prevention and control manual in terms of the safe management of linen in Glassary ward at Mid Argyll Community Hospital and Integrated Care Centre ••• implement an effective system throughout Mid Argyll Community Hospital and Integrated Care Centre for ensuring that patient beds are effectively decontaminated between each use. This will minimise the risk of infection to patients, staff and visitors.

Requirements -

••• review the access to alcohol hand gel in Cara ward at Mid Argyll Community Hospital and Integrated Care Centre. This will ensure that a practical solution is reached that addresses the needs of both patients and staff. ••• provide a risk assessment that demonstrates the appropriate selection of hand hygiene products in the accident and emergency department at Mid Argyll Community Hospital and Integrated Care Centre. ••• implement an assurance system for nursing cleaning duties across all wards and departments in Mid Argyll Community Hospital and Integrated Care Centre. ••• review the current method of input from the infection control team at Mid Argyll Community Hospital and Integrated Care Centre to provide assurance that infection control standards are being consistently implemented.

All of these actions are being progressed in Mid Argyll Hospital within the timescales identified, some of them are already completed. In addition, a programme of inspection visits to all other hospitals has been carried out to ensure that effective actions have been taken to address the areas highlighted through the report.

Recent findings have indicated the need for ongoing vigilance throughout the hospitals, coupled with high visibility within the clinical areas, and strong commitment to the HAI standards, by all clinical, professional and managerial leaders.

Review of the Infection Control Nursing service has indicated the need for more regular presence within each of the hospitals and a further strengthening of the Infection Control Link Practitioner role.

Mr Creelman advised that he did not welcome the HEI report as a learning tool for the CHP and it should be recognised that everyone is the CHP is accountable for ensuring compliance of HEI standards. Public involvement is important in the auditing processes. It is also essential that the information on the appropriate use of hand gel to avoid infection is made widely available.

Ms Paterson advised that managers are working with staff to ensure a cultural shift in HEI compliance and to imbed HEI standards in patient care.

Ms Wilkinson commented that she was encouraged by the determination of the CHP to learn from the findings of the report.

Ms Tyrrell stated that there is continual focus by everyone to identify and highlight any concerns about compliance.

Outbreaks and Incidents

• Norovirus – there was one gastrointestinal viral outbreak in a care home in Dunoon in September, suspected but not confirmed as Norovirus. Health Protection Scotland has confirmed that the norovirus season has begun and reminder guidance has been issued.

9 • Ebola Outbreak in West Africa – staff guidance has been given on the need for ongoing vigilance for cases that may be reported in Scotland and what action to take where patients may have been at risk. All areas have the required personal protection equipment available for dealing with any cases.

• Decontamination – issues arose in Lorn & Islands Hospital during September 2014 which affected the water safety for the washer disinfector in the endoscopy decontamination unit in the hospital and arrangements were put in place for endoscopes to be decontaminated in Belford Hospital. A root cause analysis is underway to identify the factors that caused the disruption in water quality and a significant event review will be organised.

The Committee: • Noted the content of the Infection Control Report.

8.3 Public Health Annual Report

Ms Garman informed the Committee that the 2014 annual report covers the health impacts of climate change and actions to adapt to and mitigate these impacts. The report also considers a range of environmental impacts on health and how these may modify under climate change. As the recommendations call for joint action across agencies, the voluntary sector and communities, they are primarily directed at Community Planning Partnerships for discussion and implementation.

The summary recommendations for Community Planning Partnerships include :

• Monitoring and reporting carbon emissions across agencies. • Supporting communities to develop resilience to extreme weather events. • Develop joint infrastructure and services across agencies, particularly in relation to transport, catering, procurement and use of renewable energy sources. • Reducing fuel poverty through reducing fuel costs as well as improving energy efficiency • Raising awareness of the changing natural environment through schools, public engagement and integrated impact assessment. • Promoting physical activity and mental health and well-being through a renewed strategic approach. • Promoting access to and use of the natural environment by all ages and population groups. • Helping to reduce overweight and obesity levels through reviewing and reducing the obesogenic nature of the local environment and improving access to affordable healthy food. • Reduce unintentional injuries and hazards through promoting outdoor activity and road safety awareness, awareness of Lyme Disease, testing private water supplies, preventing falls and home safety.

Ms Wilkinson advised that in NHS Highland there has been significant progress in carbon efficiency and suggested that a report should be brought the CHP Committee. Ms Garman will discuss this with the Head of Estates and confirm who in the CHP has the carbon emissions portfolio.

Mr McLaren highlighted the number of services and improvements available from energy companies, i.e. biomass boilers to advise on renewable energy sources.

Councillor McAlpine stated that, from a health perspective, the effect of increasing heating costs on low income families need to be highlighted at community planning meetings.

10 Ms Garman noted the above comments to be part of community planning discussions on the recommendations of the Public Health Report.

The Committee:

• Noted the details and the summary of the Public Health Report. • Considered the Planning Partnership incorporates the report’s recommendations into its action plans.

9 FINANCIAL GOVERNANCE

9.1 Finance Report

Mr Morrison reported that at end September 2014, Argyll & Bute CHP recorded an overspend of £424,000. This is a slight improvement on the overspend of £431,000 recorded at the end of August.

The budgetary performance across Argyll & Bute CHP for the first six months of this financial year indicates that management action is required to reduce forecast spending by £700,000 if the CHP is to break-even. However, it should be noted that this is reduced from the required management action figure of £1m shown in the last report to Committee which reflected the position at the end of July 2014.

In addition to pressure on budgets from savings targets, there are a number of in-year cost pressures causing budget overspends, most significantly :

• Medical Consultants at Lorn & Islands Hospital due to locum costs arising from vacancies and sickness absence.

• Increased prescribing costs due to an unexpected increase in the volume of prescriptions in response to the ageing population in Argyll & Bute >65 years. This matter is undergoing further investigation.

The £3.4m cost improvement programme continues to be challenging. Without major service change initiatives the extent of savings that can be achieved in one year is limited and the level of recurring savings being achieved is likely to fall short of the target by at least £1m.

A forecast year-end position continues to be forecast and managers are very aware that this is dependent on management action to reduce spending over the remainder of the year.

Mr Morrison reported that at month 6 NHS Highland is forecasting financial break-even and there is considerable effort to achieve this position. Discussions are ongoing regarding Argyll & Bute CHP’s input to contributing to NHS Highland’s break-even forecast.

Mr Creelman asked for assurance that the required management action is plausible and deliverable and can be achieved with the involvement of all managers. He requested that the CHP Committee is accurately informed on the effectiveness of management actions.

Mr Morrison acknowledged the concerns and provided assurance that in the finance report to the CHP Committee no non-recurring savings are declared as part of the savings plan.

Dr Von-Kaehne asked the timescale for the prescribing costs review. Mr Morrison advised that this will be undertaken shortly, in discussion with pharmacy staff.

11 Dr Von-Kaehne enquired about the locum spend in Bunessan Practice and work on the retention of GPs in remote and rural areas.

Mr Morrison acknowledged the difficulties in recruiting and retaining GPs to cover out of hours. A Scottish Government funded and sponsored project is underway in Argyll & Bute to look at sustaining rural medical services, with the focus on Mid Argyll and Kintyre initially.

He advised that in relation to Mull Out of Hours Service Provision, a CHP review group, with stakeholder and public representation, has been set up to establish a sustainable service structure.

The Committee:

• Noted the year-to-date financial position. • Noted the requirement for management action to address a forecast overspend.

10 RENAL DIALYSIS UPDATE

Ms Paterson summarised the content of the circulated paper, which advised on the proposed implementation of a Hub and Spoke model haemodialysis unit within Campbeltown Hospital.

The proposal was discussed at the CHP Core Management Team meeting on 26 September 2014 when it was agreed to implement the facility within Campbeltown Hospital under the remit that a detailed evaluation is carried out to consider :

• Location and number of patients • Ward establishments • Room conversion plans • Medical staffing arrangements • Staff training requirements • Finance • Service Level Agreement implications

A short-life working group is established to carry out the evaluation to a timescale of 6 months.

The service will be reviewed after one year from date of commencement to determine whether it is delivering what is required for patients.

Councillor McAlpine acknowledged the significant fund raising which has taken place, but stated his concerns regarding public capacity to respond to further fund raising requests and the continuance of the service at the conclusion of the pilot.

With regard to the Service Level Agreement with NHS Greater Glasgow and Clyde, it was confirmed that there will be no repatriation of costs to the CHP as renal patients will continue to receive clinical care from the Glasgow Consultant.

12 The Committee :

• Noted all of the information regarding the implementation of an outreach haemodialysis unit within Campbeltown Hospital. • Acknowledged the risks with regards implementation. • Acknowledged the willingness of the local community to financially support a local unit.

• Noted the content of the paper agreed by the CHP Core Management Team on

26-09-14 to implement this facility within Campbeltown Hospital under the remit that a

detailed evaluation will be carried out to ensure it is viable to continue in the future.

• Noted the parameters of the pilot.

11 REVIEW & REDESIGN OF HOSPITAL, COMMUNITY & CARE SERVICES IN KINTYRE

Ms Paterson referred to the circulated paper which updated the Committee on the lengthy and systematic and considered process undertaken by the CHP in reviewing, reorganising and rationalising health and care services within Campbeltown hospital with the involvement of all stakeholders and partners in the area.

The pause following the CHP committee review of the redesign in 2013 has allowed further analysis of bed usage to be assessed against the ongoing development of community services. This has clearly shown the GP Acute activity can be managed within the modelled bed complement.

It is recommended that the Kintyre locality progress the formal closure of the beds and development of community services aligned with patient need across the whole of Kintyre, subject to outcome of Scottish Health Council’s assessment of the service change.

Locality management will then undertake a proactive and responsive PFPI and communication process with the public and politicians on the community developments planned and the outcomes achieved across Kintyre over the coming 12 months.

The Committee :

• Noted the background and process conducted within the review and redesign of services in Campbeltown Hospital. • Noted the outcome of the final meeting to finalise the bed complement in the hospital. • Considered the feedback received from the community at the presentation meeting. • Noted the conclusion reached to close the continuing care beds transfer resources into the community. • Noted feedback from Scottish Health Council on major service change assessment which is in the process of being updated is still outstanding.

12 STAFF GOVERNANCE

12.1. PDP/R & eKSF Implementation Update

Mr Morrison referred to the circulated report.

The CHP reported 47.45% reviews completed, including bank staff, with 64.79% completion, excluding bank staff in the 12 month rolling year.

13 Planning reviews throughout the year remains paramount to the target being achieved. Historically the period December – March records higher activity however managers and team leaders have been encouraged to schedule the reviews throughout the year.

HR continue to support managers where necessary, however there will need to be considerable effort to ensure that all staff have an annual review and the 80% target is achieved.

The Committee :

• Noted the current position which shows an overall decline in PDP & R meetings taking place.

• Noted the need to re-invigorate this in practice and use it to support and direct staff

development in line with CHP and NHS Highland objectives.

• Noted the need to ensure that regular annual reviews and PDPs continue for all staff,

including bank staff. • Noted that the eKSF software licence has been extended to March 2015.

13 PERFORMANCE MANAGEMENT

13.1 Delayed Discharge Update

Ms Tyrrell reported 13 delayed discharges : 6 = > 4 weeks and 7 = < 4 weeks.

A number of areas are being reviewed in the process and decision making :

• Standardised procedures across all areas for non-complex cases. • Standardised discharge packs for people leaving hospital. • Clear communication to inform staff and teams. • Improved information sharing and shared IT system.

The involvement and input of the Extended Community Care Teams (ECCTs) in the discharge of patients is being progressed through the Reshaping Care for Older People Programme Board and review of ECCTs.

The CHP will be submitting a bid to the Scottish Government on 1 November 2014 for an additional payment of £92k funding to assist with delayed discharges

14 MENTAL HEALTH MODERNISATION UPDATE

Inpatient Services – Mr Dreghorn informed the Committee on concerns relating to the Intensive Care Unit (ICU) in Argyll & Bute Hospital due to the isolation of the ward and the below standard environment. The feasibility of relocating ICU patients to Succoth Ward is being considered. A meeting with the Architect and Quantity Surveyor is being arranged to provide an overview of required alterations to Succoth Ward to accommodate ICU patients. A paper will be submitted to the next meeting of the NHS Highland Asset Management Group requesting approval for capital funding for the conversion and refurbishment of Succoth Ward.

Vacancies/Recruitment – Psychological Therapies - Cowal and Bute locality continues to face a number of challenges in the provision of psychological therapies with vacancies in Clinical Psychology, Primary Mental Health Care and Cognitive Behavioural Therapy. This is resulting in an increase in waiting times for access to these services which will be highlighted further at the end of the year when national reporting in psychological therapies waiting times

14 begins. At present the CHP is showing a 56% compliance rate against a national target of 90%. The overall picture should improve as the data input and recording issues are resolved. A review of the number of practitioners involved in providing psychological therapies will identify areas where involvement can be enhanced.

New Hospital Project – Planning Application - the planning application and site master plan were considered and approved by Argyll & Bute Council’s Planning Committee on 24 September 2014.

Supported Transfer of Detained Patients – the initial audit report on patient transfers from January to August 2014 shows a significant increase in the number of patients detained and requiring supported transfer when compared to 2013. A review of the incident reports associated with this service shows a high number of incidents from 2 areas and the majority being due to transport problems (mainly Scottish Ambulance Service). Further work will be undertaken on this before a final report is produced in December. A meeting has been arranged with nursing staff to look at short term changes that could be made to improve this service, while we await the final report which will outline options to amend or replace the current service.

The Committee

• Noted the current key issues and progress against the action plan.

15 PAPERS FOR NOTING

o MacMillan Cancer Information & Support Service Annual Report 2013/14 o Minute of Argyll & Bute CHP eHealth Group of 07-05-14 o Minute of Partnership Forum Meeting of 26-06-14

The Committee :

Noted the content of the circulated papers.

16 AOCB

Flu Vaccinations – Mr McLaren enquired about the possible inclusion of 3 rd Sector staff in the vaccination programme. Ms Tyrrell with discuss this further with Mr McLaren to establish numbers and accessibility

Patient Management System (PMS) Programme Board – it was agreed that an update on PMS will be included in the next Director of Operations report to the Committee.

17. DATE, TIME & VENUE FOR NEXT MEETING :

Wednesday 17 December at 1pm Training Room, Cowal Community Hospital, Dunoon

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Argyll & Bute CHP Committee 17 December 2014 Item : 6.2

Argyll & Bute CHP Director of Operations Report – December 2014

Report by : Christina West, Interim Director of Operations

The CHP Committee is asked to:

• Note the content of this report

Introduction

The Director’s report highlights a range of issues in brief that feature in the ongoing business of the CHP and that are not the current focus of formal papers presented and discussed as substantive items at the CHP Committee meeting.

Integration

The first integration newsletter has been issued and information drop in events have been held in localities during December, with further events being arranged for early 2015. The public consultation for the draft integration scheme has been launched and closes at 12 noon on 23 December 2014. There will be continuing engagement with staff and the public during 2015.

Details of the consultation, newsletter, and public engagement events are available in the NHS Highland website on the link below. http://www.nhshighland.scot.nhs.uk/OurAreas/ArgyllandBute/Pages/HealthandSocialCareConsultation

Mid Argyll, Kintyre & Islay (MAKI)

Mid Argyll

CHP Senior Manager and members of the Reshaping Care of Older people implementation Group attended Community Council meetings in Inveraray, Tarbert & Skipness and Ardrishaig in November to consult on the Strategic Vision around Living Well in Argyll & Bute. The questionnaire booklet was highlighted and communities encouraged to consider their needs and to highlight them using this tool. The consultation has been extended until the end of January 2015. The Community Councils have welcomed the presentation and question/answer opportunities at these meetings.

Cara Ward in MACHICC remains closed on an interim basis due to staffing pressures. The staff and patients have moved and are now settled in adjacent wards. This situation remains under constant review.

The ongoing work following the announced Healthcare Inspection of MACHICC in July continues.

The recruitment process for remote and rural GPs continues with National Adverts on TV and a Poster campaign on buses. The Lochgilphead Medical Practice has had some interest and has undertaken some initial informal discussions with potential candidates.

Kintyre

A series of public consultation meetings have taken place across Kintyre to engage public in proposed changes to GP services, Reshaping Care for Older People and changes in the Extended Community Care Team (ECCT) and will continue into December.

There has been no interest expressed in the vacant GP post in Kintyre Medical Group. Service continuity is being provided through locum GPs and the substantive part time GPs taking on additional hours.

The vacant ECCT team lead post has been advertised internally. Interviews will take place at the same time as interviews for inpatient services Senior Charge Nurse (SCN) post.

The Extended community nursing team is now working to 22.00 hours x 7 days per week.

Islay & Jura

From 1 November 2014, the two Islay principal GPs will be running all three Islay practices. Recruitment of two additional GPs to replace the recently retired GPs is being undertaken. A Business Development Manager has been appointed and is working to integrate the three practices in a gradual manner.

Islay Hospital buildings are being reviewed by a multidisciplinary group with public representation. The optimal site is to be agreed for the location of a Macmillan end of life care room and relatives’ overnight room. Proposals are being considered for further development to improve the space, provision and configuration of the hospital and the feasibility of including dental facilities in the hospital.

Workforce development continues with an increase in patients being able to remain on the island for treatment as a result of improved clinical skills.

Work to develop use of telemedicine is continuing to prevent unnecessary travel for patients to the mainland, by replacing some face to face consultations as appropriate with videoconference consultations.

Recent engagement with the community continues with a Public Partnership Forum meeting being held during November and December in all four satellite areas of Islay and Jura.

Cowal & Bute

Cowal

Reshaping Care for Older People (RCOP)

Conversation Cafes planned as part of the engagement and involvement approach for RCOP and Integration sessions for November and December throughout Cowal.

Mental Health

Successful recruitment to the Community Psychiatric Nurse and Cognitive Behavioural Therapy posts has been completed.

The job description for the Clinical Psychology post is being amended to increase potential interest in the vacancy.

Wards & Day Therapy Centre

Refurbishment works have been completed in the Hospice Day Therapy Centre, to include for example, therapeutic treatments. . Launch date is to be confirmed.

A dementia friendly environment has been created in the admissions ward, including a quiet area, an orientation board and appropriate furnishings, music and television programmes.

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Bute

Reshaping Care for Older People (RCOP)

Locality RCOP meetings have been re-established. Three conversation cafes planned for December for involvement and engagement process.

Bute Option Appraisal Group convened and agreed scope to include NHS and Social Work and local Care Home and Housing. This will form a subgroup of the local RCOP Group

Helensburgh & Lomond

The Health Visitor Team Lead post has been recruited to and development post agreed.

Reshaping Care for Older People (RCOP)

Two conversation cafés have been arranged for Garelochead and Arrochar.

Argyll Voluntary Action have organised “Be Aware Prepare its Winter” event which was held on 26/11/14 at which RCOP and Integration involvement and engagement was encouraged.

Oban, Lorn & Islands

Mull & Iona

Following the resignation of the Tobermory GPs, with effect from 31 May 2015, the Mull & Iona Out of Hours Review Group will incorporate recruiting to the Tobermory GP vacancy as part of its work to provide a sustainable GP in and out of hours service on the islands of Mull and Iona. An action plan detailing the work to be progressed is to be agreed at the next meeting of the Review Group on 16 December 2014.

The Bunessan practice in the Ross of Mull continues to provide GP services through the use of long term locums at this time.

The interim model of GP out of hours and hospital out of hours arrangements model has been approved by the review group and an out of hours rota is being populated and will be ready for implementation in January 2015. This arrangement ensures island wide cover until the review is complete and the final model is implemented.

The Scottish Ambulance Service will be commencing an initial development for a first responder scheme on Mull (life threatening emergencies whilst awaiting for ambulance to arrive for a 999 call). In addition a community resilience event/workshop will be planned for January 2015.

A working group, led by Dr Richard Wilson, Locality Clinical Director will lead the development of a service model for day time GP services on the island to enable successful recruitment to the vacant GP posts. An initial outline of alternatives will be presented to the review group at its January 2015 meeting.

Port Appin Out of Hours Services

The GP in Port Appin has served notice that he wishes to opt out of providing out of hours services for the Port Appin practices which also covers the Island of Lismore by no later than the 1 st August 2015. Drop in events were held in Lismore and Port Appin recently to give patients the opportunity to provide feedback to representatives from NHS and Scottish Ambulance Service (SAS). The CHP will be looking to extend the current out of hours service based at Lorn & Islands Hospital to cover this service need as well as work with the

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communities and the SAS to develop community first responder schemes to enhance community resilience.

Reshaping Care of Older People Services Update

Conversation cafes have been organised within the locality to take forward the public engagement regarding the older peoples’ strategy. A successful event was held in Oban on 4 December and an event is due to take place on the island of Lismore on Wednesday 10 December 2014. Wider consultation is taking place at existing forums.

The extended community care team continues to develop within Oban, work currently being undertaken to increase the working hours of the team. The Falls Pathway has been implemented with the SAS within mainland area. A group has also been established to take forward the development of an Extended Community Care Team on Mull.

Dental

Discussions concluded with the dental practice who had expressed an interest in the lease within the new Dental; Access Centre. However negotiations have now started with a new prospective leaseholder which are at an early stage in the process.

Decontamination Unit

We are still experiencing challenges with compliant water testing and have utilised the Belford Hospital decontamination unit to ensure service continuity

Management Arrangements

Following the retirement of Veronica Kennedy, Locality Manager on 15 December, Marie Law, General Manager, Belford Hospital in Fort William has been appointed as Interim Locality Manager for acute services and will provide support to Donald Watt, Clinical Services Manager (Acute). Lorraine Paterson, Locality Manager in MAKI, has been appointed as Interim Locality Manager for Community Services and will provide support to Caroline Henderson, Acting Clinical Services Manager (Primary Care). This arrangement will continue until integration in April 2015.

Pain Service

The CHP continues to be challenged with the provision of the pain service, with associated waiting time breaches. We continue to work with the Planning Department to resolve the issues. Discussions are ongoing regarding how physiotherapy and psychology can develop in order to support the service.

Audiology Services

A review of service provision is required due to short term staffing pressures. Work with the planning team is underway to undertake a demand, capacity analysis and to identify a sustainable model of delivery.

Christina West Interim Director of Operations

4 Argyll & Bute CHP Committee 17 December 2014 Item : 7.1

Argyll and Bute CHP Clinical Quality and Patient Safety Report

Report by Pat Tyrrell, Lead Nurse and Fiona Campbell, Clinical Governance Manager

The CHP Committee is asked to: • Note the contents of the Clinical Quality and Patient Safety Report.

1. CONTRIBUTION TO THE BOARD’S CORPORATE OBJECTIVES

The vision of the Highland Quality Approach is:

• Better Health – improving the health of the population • Better Care – enhancing the experience of care for individuals • Better Value – controlling the per capita cost of care

In order to achieve this, the key elements of the Quality Strategy have been adopted:

Safe There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.

Effective The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

Person-Centred There will be mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making

2. RISK MANAGEMENT

2.1 Incidents

The following incidents were reported in Argyll and Bute during the period of 1 July to 30 September 2014 (Quarter 2). The data is correct as on 03/11/2014.

FIGURE 1: TOTAL NUMBER OF INCIDENTS PER MONTH OCTOBER 2013 – OCTOBER 2014

A total of 506 incidents were reported in Quarter 2 of 2014/15.

Locality breakdown: Cowal & Bute – 73 (14.4%) Helensburgh – 20 (3.9%) Mid Argyll & Kintyre – 285 (56.3%) Oban, Lorn & Isles – 120 (23.7%) Outwith Highland – 8 (1.6%)

FIGURE 2: CATEGORY OF INCIDENTS BY LOCALITY QUARTER 2

The top 3 categories of incidents for A&B were falls 105 (20.7%), V&A 94 (18.6%), pressure ulcers 39 (7.7%)

Cowal & Bute – falls 16 (21.9%), V&A 9 (12.3%), fire 4 (5.5%), transfer/discharge 4 (5.5%)

Helensburgh – pressure ulcers 4 (20.0%), equipment 4 (20.0%), V&A 3 (15.0%), medication 3 (15.0%)

Mid Argyll – V&A 68 (23.8%), falls 54 (18.9%), self harm 36 (12.6%)

Oban, Lorn and Isles – falls 33 (27.5%), V&A 14 (11.7%), Transfer/discharge 12 (10.0%)

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FIGURE 3: CONSEQUENCES OF INCIDENT BY LOCALITY QUARTER 2

Overall consequence of incidents:

Negligible – 313 (61.8%) Minor – 127 (25.1%) Moderate – 28 (5.5%) Major – 1 (0.2%) Extreme – 1 (0.2%)

The remaining 36 (7.1%) of incidents have not yet been reviewed.

FIGURE 4: INCIDENTS WITH MAJOR AND EXTREME CONSEQUENCE DEC2013 –SEPT 2014

In relation to the 2 incidents reviewed by a manager and graded with a consequence of major or extreme in Q2:

Helensburgh (1) – Medication (1) Mid Argyll (1) – Clinical event (1)

In addition to the above 2 incidents, which were both flagged as SERs, a further two, lower graded incidents were also flagged for SERs: Cowal & Bute – Absconder (1) Mid Argyll – Transfer/discharge (1)

Details of the 4 SERs are appended to this report.

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FIGURE 5: INCIDENTS by LOCALITY AND OUTCOME QUARTER 2

Overall outcome for the Operational Unit:

No injury / harm – 277 (54.7%) Near miss – 61 (12.0%) Harm / injury - 157 (31.0%) Death – 1 (0.2%) Property damage – 10 (2.0%)

FIGURE 6: RIDDOR REPORTABLE INCIDENTS FEB 2014-OCT 2014

There were 2 RIDDOR reportable incidents in Quarter 2.

Cowal & Bute – staff accident resulting in an over 7 day absence. Hand injury as a result of fingers trapped in door when closing fire door

Mid Argyll – staff member lost footing on stairs resulting in an over 7 day absence.

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FIGURES 7 - 10: NUMBER OF INCIDENTS BY LOCALITY FROM OCTOBER 2013- OCTOBER 2014

FIGURE 7 COWAL AND BUTE FIGURE 8 HELENSBURGH

FIGURE 9 MID ARGYLL, KINTYRE AND ISLAY FIGURE 10 OBAN, LORN & ISLES

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FIGURES 11 - 18: NUMBER OF INCIDENTS BY HOSPITAL FROM OCTOBER 2013 - OCTOBER 2014

FIGURE 11 ARGYLL & BUTE HOSPITAL FIGURE 12 ROTHESAY VICTORIA HOSPITAL

FIGURE 13 CAMPBELTOWN HOSPITAL FIGURE 14 COWAL HOSPITAL

FIGURE 15 ISLAY HOSPITAL FIGURE 16 MACHICC

FIGURE 17 MULL AND IONA HOSPITAL FIGURE 18 LORN AND ISLAND HOSPITAL

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2.2 Significant Event Reviews (SERs)

TABLE 1: SIGNIFICANT EVENT REVIEWS FROM QUARTER 2

Incident Summary SER meeting date Stage SERs declared in Q2 Breach in immunisation cold chain, 16.09.14 Reports being finalised before circulation. GP Practice, Helensburgh. Actions identified as a result of the Incident / SER: -Arrangements put in place to ensure that all fridges are locked -New fridge purchased -System put in place to ensure that all fridge temperatures are recorded on a daily basis (Monday – Friday) as per NHS Highland Medicines Cold Chain Policy. -As an additional safety feature a scheme of what and where items are stored in the fridge will be drawn up and stuck on fridge doors -Possibility of external scrutiny of fridge temperature monitoring for all Practices being explored -Out of date NHS Highland Medicines Cold Chain Policy has been removed from the intranet -A meeting has taken place between Practice staff and Health Visitors to ensure that all understand the new systems in place and assigned responsibilities - Before becoming involved in immunisation all nurses should undertake NES module: Promoting Effective Immunisation Practice (10-15hours). A communication will be sent to CSMs and Practice Managers to raise awareness that nurses new to immunisation should undertake the NES module plus any nurses who have been involved in an immunisation incident should undertake the course. -A formal system to support communications between the Children and Families Team and Practice is to be agreed -PGD folders to be audited to ensure all staff have signed copies of all PGDs they are working to and that up to date copies are available in the Practice folder(s) -A memo has been circulated underlining

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Incident Summary SER meeting date Stage SERs declared in Q2 that all staff (including GPs) must adhere to the NHSH Medicines Cold Chain (Refrigeration and Cold Storage Policy) Patient transfer from home to Lorn 26.11.14 Report and Action Plan to be approved and Islands Hospital, ambulance diverted to MACHICC, patient died following admission. Cross- Border transfer of patient 8.12.14 Investigation from Argyll and Bute Hospital to Liverpool hospital Mental Health patient waiting for Was scheduled for Investigation transfer from Victoria Hospital, 01/12/14 but had to be Rothesay postponed - TBC Water test (TVC) results for steelco TBC Investigation endoscopy reprocessors at Lorn and Islands Hospital came back as substantially higher than the required parameters. Contingency arrangements put in place for decontamination of equipment.

3. FEEDBACK

3.1 Complaints

TABLE 2: ARGYLL AND BUTE COMPLAINT PERFORMANCE REPORT

ARGYLL AND BUTE Expected Number AMBER RED JUNE JULY AUGUST SEPT OCT NOV No complaints received 7 8 - 9 10 and over 6 11 7 3 4 4 Withdrawn 1 2 0 1 Number simple 3 6 4 2 Simple - achievement against 70 - 79 69 % and 20 days 80% % under 67% 17% 0% 0% Simple - achievement against 90 - 99 89 % and 40 days 100% % under 67% 33% 50% 0% Number complex 2 3 3 0 Complex - achievement against 90 - 99 89 % and 40 days 100% % under 100% 0% 67% n/a Number further correspondence received 1 0 0 0 Further correspondence - 70 - 79 69 % and achievement against 20 days 80% % under 0% n/a n/a n/a Number of high risk complaints received 2 3 4 and over 0 0 0 0

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FIGURE 19: NUMBER OF COMPLAINTS RECEIVED NOV 2013 – NOV 2014

FIGURE 20: GRADE OF COMPLAINTS FROM NOV 2013- NOV 2014

FIGURE 21: TOP 3 COMPLAINTS ISSUES NOV 2013- NOV 2014

The overall number of complaints received in Argyll and Bute remains relatively low and the grades of the majority of complaints are either low or medium. The top three issues which are identified in complaints are related to staff attitudes/behaviours, procedural issues and clinical treatment.

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Our performance in Argyll and Bute in responding to complaints within the target timescales requires improvement. While we have improved both the quality of the investigation and the written response to complaints, the timescales in which the process is completed have lengthened. In order to address this and to identify actions which will enable speedier responses we will hold an improvement workshop for managers and those who undertake investigations in January/February 2015.

4 QUALITY AND SAFETY

4.1 Clinical Quality Indicators (CQIs)

Appendix 1 contains three tables showing the latest available results for the standards CQIs for Pressure Ulcers, Falls and Food, Fluids and Nutritional Care. The overall compliance set out for each of these indicators is very good.

4.2 Scottish Patient Safety Programme (SPSP)

Lorn and Islands Hospital

Appendix 2 contains the latest trend data related to SPSP outcomes in Lorn and Islands Hospital. The safety essentials are all being sustained. Issues with SEWs recording over the past few months are attributed to bank staff and students not recording the action on the SEWs charts. There is evidence within the patient records of actions being taken. The issue of correct recording is being addressed.

Work on the Sepsis and Venothromboembolism pathways continue with fairly good results.

Mortality reviews are up to date and summary report will be available for next CHP Committee. Further training in carrying out the mortality reviews will be provided by SPSP Lead Mary Anne Gillies for ANPs and consultants within the hospital.

Community Hospital Spread Plan

Due to capacity issues it has not yet been possible to progress the planned spread of SPSP bundles and improvement methodology to Mid Argyll Hospital. Meeting to identify how this can be progressed in both Mid Argyll Hospital and Victoria Hospital, Rothesay will be scheduled for January 2015. In the meantime there is shared learning across the community hospitals with a number of SPSP elements being adopted.

5. EXTERNAL REVIEW / INSPECTION

5.1 Healthcare Environment Inspectorate (HEI)

The 16 week progress report on the action plan which followed the HEI inspection of Mid Argyll Hospital was submitted to HEI on December 2 nd 2014. Most of the actions have now been completed.

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5.2 Older People in Acute Hospitals (OPAH)

Lorn and Islands Hospital in Oban had its first inspection (unannounced) by HEI of the standards for older people in acute hospitals. The inspectors spent two days in the hospital on December 3 rd and 4 th 2014 and visited each of the 3 inpatient wards as well as A&E. They carried out a range of observational and documentation audits as well as interviewing staff and patients across all areas.

The initial verbal feedback identified many areas of strength which included how well patients were cared for, the quality of staff interactions, the completion of assessments, protection of mealtimes and quality of food, access to pressure relieving equipment and patient feedback

Areas for improvement included completion of DNA CPR forms, awareness of Adults with Incapacity Act, care planning and completion of Medicines Reconciliation forms, better signage outside of the wards and implementation of the delirium care bundle.

The d raft report will be received on January 14 th 2015 ; the r eport and plan to be submitted by January 22 nd 2015 with the f inal report to be published on February 10 th 2015.

This was our first OPAH inspection in Argyll and Bute; we will take the opportunity to make sure that we learn from this and share the good practice and areas for improvement with all other hospitals.

5.3 Vale of Leven Hospital Public Inquiry Report http://www.valeoflevenhospitalinquiry.org/report.aspx

Aberdeen Royal Infirmary: Short Life Review of Quality and Safety http://www.healthcareimprovementscotland.org/our_work/governance_and_as surance/programme_resources/ari_review.aspx

Both of these recently published reports have been reviewed through the Argyll and Bute Clinical Quality and Patient Safety Group meeting in December and small review group will meet to identify improvement actions required in Argyll and Bute to address lessons learned through these reviews and recommendations.

6 HEALTH AND SAFETY

6.1 Argyll & Bute Operational Health and Safety Plan

CHP Health and Safety Managers in conjunction with NHS Head of Health and Safety have undertaken a review of the existing Operational Health and Safety Plans. The review focussed on realigning the reporting dates for monitoring the various work streams. The aim of this is to ensure that reporting dates are spread more uniformly through to the end of 2016, previously the Plan covered the period to the end of 2015. In addition a number of targets have been incorporated into the plan, these will be reported to the Health and Safety Committee, and the targets are:

• Completion of the sharps safety training module on LearnPro • Monitoring the extent of risk assessment completion and implementation

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6.2 Monitoring of Risk Assessments

A risk assessment monitoring exercise has been undertaken across the Operational Unit. The purpose of this exercise was to identify if the team leads within the various localities had produced risk assessments for their team activities.

To facilitate the capture of this information Smartsheet, an online work collaboration tool, was utilised, which enabled team leads to directly input the monitoring information The monitoring has been ongoing since July, a final deadline of the 19th December 2014 has been set for completion of the exercise.

To date, 68% of respondents indicated that they had risk assessments and the remaining 32% indicated that they had no risk assessments completed.

The information gathered will assist in identifying where risk assessments have not been undertaken and support the sharing of existing risk assessments.

7.0. FIRE SAFETY

7.1 Fire Risk Assessments

Fire risk assessments carried out by the CHP Risk Advisor, Fire Safety, using the 3i system continue to progress. Garelochhead, Kilcreggan, Campbeltown, Islay, Lorn and Islands, Dunoon, Rothesay, Mid Argyll, Mull and Iona Community Hospital, Helensburgh VICC, Rothesay Annexe, Rothesay GP Practice, Dalmally, Taynuilt, Inveraray, Furnace , Tarbert Muasdale, Coll, Colonsay, Port Appin, A&B IPCU & Succoth, Aros & Residencies are now complete and have been issued. Action plans are being prioritised locally.

Annual audits have been completed for Garelochhead and Kilcreggan Health Centres & Campbeltown, Islay, Lorn & Islands and Cowal Hospitals. A number of action plans still require to be completed by duty holders

7.2 Compartmentation Survey (Interim works)

Interim compartmentation work has been completed at Cowal Community Hospital, which has reduced the inpatient risk considerably. Compartmentation work at Lorn & Islands Hospital is being scheduled. Funding for work in Campbeltown & Islay has been agreed.

7.3 Training

Classroom fire safety training is being delivered across the CHP, in addition to the on-line LearnPro fire safety module.

During 2014, classroom training has been delivered in Islay, Lorn & Islands, Argyll and Bute, Cowal and Rothesay Hospitals.

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7.4 Fire Incidents

In October there were 4 fire alarm attendances reported by Scottish Fire and Rescue Service (SFRS), all unwanted fire alarm signals (UFAS), 2 at Argyll and Bute Hospital and 2 at Lorn and Islands Hospital. All UFAS are reported via Datix, investigated and actions identified to minimise recurrence. From the 01 December the fire service will be conducting more detailed root cause analysis reports for all UFAS.

7.5 Fire Service Audits

The SFRS enforcing officer has carried out recent audits of A&B, Cowal, Islay, Campbeltown & Lorn & Islands hospitals. Letters detailing improvements required have been sent to the relevant duty holders.

8. Integration of Health and Social Care in Argyll and Bute

Initial guidance has been issued by Scottish Government to provide Integration Authorities with an overview of the key elements and principles that should be reflected in the clinical and care governance processes implemented by Integration Authorities. The guidance will help determine how best to integrate the governance mechanisms in place for services within the partnership, highlighting areas where revised and new processes will be needed to deliver requirements across all of the dimensions outlined. Workshop session will take place on December 15 th 2014 to begin the development of framework and mechanisms to deliver clinical and care governance in the new Argyll and Bute Health and Social Care Partnership.

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APPENDIX ONE: CLINICAL QUALITY INDICATOR COMPLIANCE SCORES

Table 3: CQI Rates: % compliance with standards for Pressure Ulcer Prevention

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Table 4: CQI rates: % compliance with Standards for Falls Prevention

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Table 5: CQI Rates: %compliance with Standards for Food, Fluids and Nutritional Care

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APPENDIX TWO: SCOTTISH PATIENT SAFETY PROGRAMME, LORN AND ISLANDS HOSPITAL, OBAN

FIGURE 22: PATIENT SAFETY ESSENTIALS

Shows variance from 95% target. Blue >= 95% compliance Red < 95% Compliance The higher the peak/ darker the shade of red, the worse the performance.

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LORN AND ISLANDS HOSPITAL SPSP OUTCOME MEASURES

FIGURE 23: RAW INPATIENT MORTALITY FIGURE 24: ADVERSE EVENTS RATE

FIGURE 25: MEDICINES RECONCILIATION FIGURE 26: CRASH CALL RATES

18 Argyll & Bute CHP Committee 17 December 2014 Item : 7.2 INFECTION CONTROL REPORT

Report by Pat Tyrrell, Lead Nurse, Argyll and Bute CHP

The CHP Committee is asked to:

• Note the contents of the report.

1. Aim

The purpose of this paper is to update CHP Committee members of the current status of Healthcare Associated Infections (HAI) and infection control measures in Argyll and Bute CHP and NHS Highland.

2. Contribution to Board Objectives

One of the Board key objectives is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean”. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board.

3. Summary

TABLE 1 SHOWS NHS HIGHLAND INFECTION PREVENTION & CONTROL TARGETS AND PERFORMANCE DATA

Group Target NHS NHS Highland Scotland Clostridium Age 15 and over New Target 33.4 40.8 Apr - Red difficile 32.0 (100,000 Apr-Jun Jun 2014 OBDs) to be 2014 achieved by 03/15 42.5 July - Red (not yet Sep 2014 validated) (not yet HPS validated data)

Staphylococcus Age 15 and over 24.0 30.7 Apr- 20.4 Green aureus (100,000) Jun 2014 Apr-June bacteraemia AOBDs 2014

Group Target NHS NHS Highland Scotland 25.05 Red (not yet July – Sep validated) 2014 (not yet HPS validated data) Hand Hygiene 95% 95% 98% Green

Cleaning 90% 95% 96% Green

Estates 90% 97% 96% Green

Antimicrobial Total antibiotic 50% of GP 61% Green prescribing prescribing practices at or (includes data measure moved from Q1 (Jan – towards target Mar) of calendar year Source: – Health Protection Scotland/ISD/Local data.

NHS Highland Clostridium difficile case data (not yet validated by HPS) identifies the position as of 31 st October 2014 as 55 cases against target of 78 by end of March 2015. NHS Highland SAB case data (not yet validated by HPS) identifies our position as of 31 st of October 2014 as, 35 cases against target of 60 by end of March 2015.

NHS Highland is currently off trajectory to meet the Clostridium difficile target but on trajectory to meet SAB target; this position remains changeable.

It should also be noted that currently we are on “red” in terms of our SAB quarterly report but “green” in terms of this year’s number of infections against the trajectory.

4. Challenges

• To support all clinical staff in hospitals and the community in the prevention and reduction of Clostridium difficile infections.

• The Infection Control and Prevention team and the Health and Safety team are working in collaboration with other key members to ensure NHS Highland is prepared to care for a potential Ebola case. This is a high priority and as a result is creating a significant pressure on team resources. In order to mitigate some of the pressure, a nurse from the re-deployment register has been appointed to assist with this work.

• To reduce MSSA bacteraemias by engaging all clinical staff in hospitals and the community in initiatives to prevent and reduce invasive device/healthcare related infections.

• ICNET (infection control software programme) integration with Argyll and Bute, and Greater Glasgow and Clyde has not yet occurred due to ongoing discussions around governance. Work is underway to move this work forward however whilst we await the integration there is a risk that human factors might result in errors due to the transfer of manual date.

2 5. Risks

• Achieving the Clostridium difficile and SAB HEAT targets.

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Argyll and Bute CHP Healthcare Associated Infection Report – October 2014 Section 1 – NHS Highland Board Wide and Argyll and Bute Issues

1. Staphylococcus aureus (including MRSA)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus ), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252 NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

1.1 Staphylococcus aureus bacteraemia target

NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, S taphylococcus aureus bacteraemia (including MRSA) cases are 24.0 cases or less per 100,000 acute bed days. For NHS Highland this means no more than approximately 60 cases in year April 2014 ending March 2015.

1.2 Trends

National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate April to June 2014 was 30.7 per 100,000 acute occupied bed days (AOBDs). NHS Highland’s rate for the same period was 20.4 per 100,000 AOBDs (13 cases of which there were 11 MSSAs and 2 MRSAs).

The not yet validated figures for NHS Highland for July-September 2014 show a rate of 25.05 per 100,000 acute bed days – this is above the national target of 24.0 cases per 1000 acute bed days. However, overall, NHS Highland remains on course to achieve the national target for SAB by the end of March 2015.

Based on annual data, NHS Highland remains the second best performing Board in Scotland for Staphylococcus Aureus bactereamias against comparable Boards (excluding National Waiting Times Centre and non-mainland Boards).

4 FIGURE 1: NHS HIGHLAND STAPHYLOCOCCUS AUREUS BACTERAEMIA (MRSA AND MSSA) CUMULATIVE CASE NUMBERS YEAR ON YEAR SINCE 2010.

FIGURE 2: QUARTERLY ROLLING YEAR STAPHYLOCOCCUS AUREUS RATES PER 100,000 ACUTE OCCUPIED BED DAYS FOR HEAT TARGET MEASUREMENT

Apr 12 - Jul 12 - Oct 12 - Jan 13 - Apr 113- Jul 13 - Oct 13 - Jan 14 - Apr 14 - Mar 13 Jun 13 Sept 13 Dec 13 Mar 14 Jun 14 Sept 14 P Dec 14 Mar 15 Actual Performance 21.8 21.4 25.0 25.1 25.4 23.4 22.9 Trajectory 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 Target 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0

TABLE 2 SHOWS THE CUMULATIVE TOTALS FOR SAB WITHIN ARGYLL AND BUTE CHP FOR THE YEARS SINCE 2009-2010 UNTIL SEPTEMBER 30 TH 2014

Hospitals 09/10 10/11 11/12 12/13 13/14 14/15 Lorn and Islands, Oban 8 3 0 5 5 0 Victoria Hospital, Rothesay 1 1 0 0 0 0 Mid Argyll Hospital, Lochgilphead 0 1 0 0 0 0 Argyll & Bute Hospital, Lochgilphead 0 0 0 0 0 0 Campbeltown Hospital 0 0 0 0 0 0 Mull and Iona Community Hospital 0 0 0 0 0 0 Islay Hospital, Bowmore 0 0 0 0 0 0 Cowal Community Hospital, Dunoon 0 0 0 0 0 0

There have been no further case of SAB since February 2014 in Argyll and Bute. 7 5

1.3 Current Initiatives

Current initiatives are concentrating on infections associated with vascular devices (lines) and catheters as well as working to reduce blood culture contamination rate.

As of the 1 st of October the Infection Control and Prevention Team have begun collecting data for the national enhanced Staph.aureus surveillance database. All NHS Boards will be providing data from their enhanced surveillance to this database, which will provide an epidemiological national perspective.

2. Clostridium difficile

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of Section 1 and for each hospital within the CHP in Section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

2.1 Clostridium difficile HEAT Target

NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, the rate of Clostridium difficile infections (CDI) in patients aged 15 and over is 32.0 cases or less per 100,000 total occupied bed days . For NHS Highland that means no more than approximately 78 cases in the year ending March 2015.

2.2 Trends

National data published by Health Protection Scotland identifies that NHS Scotland Clostridium difficile infection (CDI) in patients aged 15 and over April – June 2014 was 33.4 per 100,000 bed days, which remains within our expected levels. NHS Highland’s rate for the same period was 40.8 per 100,000 bed days (24 cases in total of which 18 cases were aged 65 years and over and 6 cases aged 15 - 64 years).

When comparing the year-ending June 2013 data with year-ending June 2014 data, the trend analysis for NHS Highland shows a statistical increase in the cases of CDI in the over 65 years age range, and a statistical decrease in the cases in the 15-64 years age range. Across NHS Scotland an overall incidence rate of 35.6 per 100 000 beds days was noted this quarter in patients aged 65 years and over, this is a statistically significant increase when compared to the previous quarter incidence rate of 29.2 per 100 000 bed days.

Based on annual data, overall since April 2009, rates of Clostridium difficile in NHS Highland have reduced from approximately 56 cases per 100,000 total occupied bed days (April 2009- March 2010) to approximately 30 cases per 100,00 total occupied bed days (April 2013-March 2014). This has been a 46% reduction.

6 FIGURE 3: FUNNEL PLOT OF CDI INCIDENCE RATES IN PATIENTS AGED OVER 65 YEARS FOR ALL NHS BOARDS IN SCOTLAND, APRIL – JUNE 2014.

HG = Highland

FIGURE 4: FUNNEL PLOT OF CDI INCIDENCE RATES IN PATIENTS AGED 15 – 64 YEARS FOR ALL NHS BOARDS IN SCOTLAND, APRIL - JUNE 2014.

HG = Highland

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FIGURE 5: NHS HIGHLAND QUARTERLY RATES OF C DIFF INFECTION IN THOSE OVER THE AGE OF 15 YEARS PER 1000 OCUPIED BED DAYS

FIGURE 6: QUARTERLY ROLLING YEAR CLOSTRIDIUM DIFFICILE INFECTION CASES PER 100,000 TOTAL OCCUPIED BED DAYS FOR HEAT TARGET MEASUREMENT

Apr 12 - Jul 12 - Oct 12 - Jan 13 - Apr 113- Jul 13 - Oct 13 - Jan 14 - Apr 14 - Mar 13 Jun 13 Sept 13 Dec 13 Mar 14 Jun 14 Sept 14 P Dec 14 Mar 15 Actual Performance 31.9 27.3 28.7 28.8 30.2 33.7 34.6 Trajectory N/A 37.0 37.0 37.0 37.0 37.0 37.0 34.0 32.0 Target N/A 32.0 32.0 32.0 32.0 32.0 32.0 32.0 32.0

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TABLE 3 SHOWS THE CUMULATIVE CD TOXIN POSITIVE CASES IN EACH ARGYLL AND BUTE CHP HOSPITAL FOR THE YEARS SINCE 2009 UNTIL NOVEMBER 30 TH 2014

Hospitals 09/10 10/11 11/12 12/13 13/14 14/15 Lorn and Islands Hospital, Oban 0 1 2 1 4 1 Cowal Community Hospital, Dunoon 3 1 2 2 4 0 Victoria Hospital, Rothesay 3 0 1 0 1 0 Mull and Iona Community Hospital 0 1 0 0 0 0 Argyll & Bute Hospital, Lochgilphead 0 0 0 0 1 0 Mid Argyll Hospital, Lochgilphead 0 0 1 0 0 0 Campbeltown Hospital 0 0 1 1 2 0 Islay Hospital, Bowmore 0 0 0 0 0 0

TABLE 4 SHOWS THE CUMULATIVE CD TOXIN POSITIVE CASES IN ARGYLL AND BUTE COMMUNITY FOR THE YEARS SINCE 2009 UNTIL NOVEMBER 30 TH 2014

09/10 10/11 11/12 12/13 13/14 14/15 North and West Unit 22 8 South and Mid Reported as CHPs 21 6 Argyll & Bute 9 CHP 2 4 2 2 7 (7 pts )

8 patients have been diagnosed with CDI in Argyll and Bute since April 2014. One of these patients developed CDI while an inpatient in Lorn & Islands Hospital. Review of antibiotic therapy was undertaken and assessed as appropriate. The remaining seven patients developed CDI in the community. One of these patients had 2 further positive tests outwith the 28 day period since the previous test and so had to be reported as new infections.

Work continues within the Infection Control group to review incidence of infection. The groups scrutinise the surveillance data from the individual patient case reviews in order to identify learning points, and trend analysis.

3. Hand Hygiene

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: http://www.washyourhandsofthem.com/ NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital and community hospitals within each CHP in section 2. Information on national hand hygiene monitoring can be found at: http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

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3.1 Hand Hygiene Reporting

Each Board is now responsible for monitoring and reporting hand hygiene compliance data. With effect from April 2014, percentage compliance of each staff group will be reported in the bimonthly report to the Board.

3.2 Trends

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining 99% compliance in September and 98% in October 2014.

The recent results from the Scottish Inpatient Survey 2014 now include the question “Hand- wash gels were available for patients and visitors to use’”. NHS Highland average score in response to this question is 97% which compares favourably to the NHSScotland percentage compliance figure of 95%.

Figures for Argyll and Bute are contained within the report cards in Section 2 –all areas are achieving the compliance target of 95%.

4. Cleaning and the Healthcare Environment

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on national cleanliness compliance monitoring can be found at: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

4.1 Current Rates

The monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 96% compliance in September and October 2014 for domestic monitoring and 96% for estates monitoring in September and 97% in October 2014.

The results for each hospital in Argyll and Bute are included within the charts in section 2 of the report.

5. Healthcare Environment Inspectorate (HEI)

The 16 week progress report on the action plan which followed the HEI inspection of Mid Argyll Hospital was submitted to HEI on December 2 nd 2014. This is attached as Appendix One to this report. Most of the required actions have been completed.

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6. Outbreaks/Incidents

6.1 Norovirus Norovirus is a highly infectious virus that causes outbreaks in the community, healthcare and care settings every year. To help reduce the risk of outbreaks in hospitals, care settings and the wider community, members of the public who think they have norovirus are again being asked to ‘Stay at Home’ until at least 48 hours after any symptoms have passed. As norovirus is so infectious, it is important that everyone plays their part in reducing outbreak risks. To do this, hospitals may suspend access to particular wards to protect patients, staff and visitors from norovirus.

There has been one confirmed outbreak of Norovirus in Argyll and Bute since the last report. This affected patients and staff in Cowal Community Hospital during November, resulting in closure of the hospital to admissions for five days. This has since resolved, all patients and staff have recovered. Another outbreak, causative organism unknown, affected residents and staff in a Care Home in Oban in early December. The Care Home has been closed to admissions but is due to re-open at the time of this report.

6.2 Ebola Outbreak in West Africa Viral haemorrhagic fevers (VHF) are severe and life-threatening diseases caused by a range of viruses. Most are endemic in a number of parts of the world, most notably Africa, parts of South America (Bolivia, Venezuela, and Brazil) and some rural parts of the Middle East, the Balkans, South Russia and Western China. Currently there is much attention on the VHF virus, Ebola. Ebola’s geographical distribution is Western, Central and Eastern Africa. Transmission to the index case is likely to have been through contact with infected animals. Person to person spread is through contact with infected blood and body fluids via a mucous membrane, open wound, or needlestick injury. There is no evidence either circumstantial or epidemiological that aerosol (through the air) transmission occurs. NHS Highland are working with the guidance produced by Health Protection Scotland, based on the Advisory Committee on Dangerous Pathogens guidance September 2014,on the ‘Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence’; to ensure key staff are aware of their role in the risk assessment of potential patients, and the subsequent actions to take.

An Ebola Preparedness Short life working group has been established and is meeting fortnightly. This meeting is chaired by Dr Mills, Lead Infection Control Doctor and has a wide range of members from business continuity, health and safety, operational units, and health and social care groups. Communication is being circulated centrally from Health Protection Scotland. All operational units have conducted a ‘walk through exercise’ to identify where potential Ebola patients would be cared for, and a ‘table top exercise’ has been conducted in Raigmore. Training for all relevant staff in management of patients with suspected viral haemorrhagic disease and application of Personal Protective Equipment is underway across all hospital A&E settings in Argyll and Bute. All staff have access to the policy and are clear about the pathways to be followed and where to access guidance and advice.

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7. Decontamination Issues affecting the water quality for the washer disinfector in the endoscopy decontamination unit in Lorn and Islands Hospital continue to cause problems. Water quality remains below required levels for decontamination of scopes used in sterile areas and arrangements are in place for cystoscopes to be decontaminated in Belford Hospital in Fort William. This is being addressed through the NHS Highland Decontamination Group and it is hoped that resolution is reached within the next two months.

8. Vale of Leven Hospital Inquiry Report Lord MacLean’s report of the inquiry into the occurrence of Clostridium Difficile infection at the Vale of Leven Hospital from January 2007 until June 2008 was published on November 24 th 2014. While many of the issues which affected the safety of patients at the Vale of Leven Hospital have been addressed across all NHS Boards in the intervening years the full findings and recommendations of this report will be reviewed within Argyll and Bute CHP to ensure that further areas for improvement are identified and any required actions are taken to address potential risks. The full report can be accessed via this link: http://www.valeoflevenhospitalinquiry.org/report.aspx

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Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ which provide information on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections. Hand hygiene and cleaning compliance completes the report card. This includes information for pan Highland, Lorn and Islands Hospital, Oban, Community Hospitals collectively for Argyll and Bute and NHS Highland out of hospital infections.

The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case Numbers

Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month and the community hospitals within each CHP. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139§ionID=1

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252§ionID=1

Understanding the Report Cards – Hand Hygiene Compliance

Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/

Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/CHP report card presents the percentage of hand hygiene compliance for all staff in both graph and table form.

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Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/

The Report Cards show the hospitals’ cleaning compliance percentage in both graph and table form.

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Abbreviations AMT Antimicrobial Prescribing Team AMAU Acute Medical Admissions Unit CHP Community Health Partnership CDI Clostridium difficile Infection CNO Chief Nursing Officer CVC Central Venous Catheter CSM Clinical Services Manager ECDC European Centre for Disease Prevention & Control GDP General Dental Practitioner HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HEAT Health Improvement, Efficiency, Access, Treatment HEI Healthcare Environment Inspectorate Hemi arthroplasty An operation used to treat fractured hip similar to a total hip replacement, but involves only half of the hip. ICU Intensive Care Unit JAG Joint Advisory Group MSSA Meticillin Sensitive Staphylococcus Aureus MRSA Meticillin Resistant Staphylococcus Aureus PICC Peripherally Inserted Central Catheter PPI Proton Pump Inhibitor PVC Peripheral Venous Catheter QUAD Quality Assurance Document RIDDOR Reporting of Injuries, Diseases and Dangerous Occupational Regulations 1995 SAB Staphylococcus aureus Bacteraemia SCN Senior Charge Nurse SHPN Scottish Health Planning note SHTM 64 Scottish Health Technical Memoranda – Sanitary assemblies. SPC Statistical Process Chart SAPG Scottish Antimicrobial Prescribing Group SICPs Standard Infection Control Precautions SPSP Scottish Patient Safety Programme VAP Ventilator Associated Pneumonia

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Staphylococcus Aureus Bacteraemia (SAB) criteria

• Staphylococcus aureus isolated from blood, and Contaminated blood • SAB diagnosis incompatible with clinical picture, i.e. no or minimal culture clinical signs and symptoms indicating SAB.

• Staphylococcus aureus isolated from blood cultures taken 48 hours Hospital acquired after admission or within 48 hours of discharge, and, infection • The presence of clinical signs and symptoms indicating SAB

• Staphylococcus aureus isolated from blood cultures taken <48 Community onset- hours after admission, and healthcare • The presence of clinical signs and symptoms indicating SAB, and associated infection • At least one of the following within the past 12 months: o Hospitalisation or invasive device management as an outpatient / community patient, or dialysis as an outpatient / community patient.

• Staphylococcus aureus isolated from blood, and True • No hospitalisation within the past 12 months community infection • No dialysis within the past 12 months • No community or outpatient healthcare for invasive device management in the past 12 months

26 011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Improvement Action Plan Declaration

It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that the actions are measurable, timely and will deliver sustained improvement. Actions should be implemented across the NHS board, and not just at the hospital inspected. By signing this d ocument, the NHS board Chief Executive and NHS board Chair are agreeing to the points above. A representative from Patient/Public Involvement within the NHS should be involved in developing the improvement action plan.

NHS board Chair NHS board Chief Executive

Signature: Signature:

Full Name: Garry Coutts Full Name: Elaine Mead

Date: 02/12/2014 Date: 02/12/2014

File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 27 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 27 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action Rec 1. NHS Highland must ensure a robust system in place December to action failed standard infection control 2014 precautions (SICPs) audits. This should include a system of quality assurance to oversee the audit process and ensure that failed results are leading to improvement, within an appropriate timescale (see page 9). Ensure that monthly reporting of SICP audits is carried September Clinical Services Rolling programme for each Sept 2014 out in each ward with results monitored by the Clinical 2014 Manager (Kate ward restarted in July with Services Manager and Infection Control Nurse MacAulay) baseline results all completed at end of August 2014. Results are now monitored by SCNs and also by the CSM. Rolling results are recorded on spreadsheet

Where compliance is below 90% ensure that corrective September Clinical Services Rolling programme with Sept 2014

File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 28 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 28 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action action is taken to address failures 2014 Manager (Kate actions taken to address non MacAulay) compliance. CSM reviews all audit results and any action plans at Heads of Departments’ meeting monthly.

Instigate SICP audit reporting for each hospital in Argyll November Infection Control Nurse All hospital wards in Argyll October and Bute through the Infection Control Group which 2014 (Sheila Ogilvie) and Bute are now reporting 2014 meets on a monthly basis their monthly results to the ICNs.

Spreadsheet with collated Due results for each hospital will December be reviewed at Argyll and 2014 Bute Infection Control meeting in December 2014. Original timescale for this File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 29 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 29 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action was November – spreadsheet was not quite completed for the IC meeting on November 4 th 2014 therefore action will be completed December Rec 2. NHS Highland must include Craignish ward in its October 2014 standard infection control precautions (SICPs) audit process (see page 9) Implement SICP audits in Craignish Community September Senior Midwife (Karen Audits in progress to meet 9 September Maternity Unit 2014 McAlpine) SICPs audits. Patient 2014 placement not required as this is not an in patient unit. Audits now also commenced in all other Community Maternity Units in Argyll and Bute. Rec 3. NHS Highland must demonstrate compliance with September the national infection prevention and control manual 2014

File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 30 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 30 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action in terms of the safe management of linen in Glassary ward at Mid Argyll Community Hospital and Integrated Care Centre (see page 11).

Replace all stained and torn bed linen from all beds in August 2014 Clinical Services All unfit linen continues to be August Mid Argyll Community Hospital and Integrated Care Manager (Kate removed from use. 2014 Centre MacAulay) Facilities manager is December organising meeting with 2014 managers from Hillingdon Laundry Services in NHS GGC to discuss issues with current service. Ensure that all staff understand that bed linen to be used August 2014 Clinical Services SCNs and senior staff are August must comply with the national standards Manager (Kate now vigilant in making sure 2014 MacAulay) that all staff are clear about the standards required. This is also being reviewed during weekly hospital ward reviews File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 31 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 31 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action by managers

Rec 4. NHS Highland must implement an effective system October 2014 throughout Mid Argyll Community Hospital and Integrated Care Centre for ensuring that patient beds are effectively decontaminated between each use. This will minimise the risk of infection to patients, staff and visitors (see page 14).

Decontaminate all beds in Mid Argyll Hospital, including July 2014 Senior Charge Nurses/ Completed immediately post July 2014 in patient beds, A&E beds and CMU beds Midwives inspection.

Instigate system of spot checking of beds within the September Clinical Services This has been instigated and 03/09/2014 hospital on fortnightly basis 2014 Manager (Kate CSM is spot checking beds MacAulay) and equipment on a weekly File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 32 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 32 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action basis

Ensure that Standard Operating Procedures for Mattress September Clinical Services This has been implemented August Checking are being used in each ward/department 2014 Manager (Kate in each ward and 2014 MacAulay) department using the SOP provided.

NHS Highland should review the access to alcohol October 2014 Rec.a hand gel on Cara ward. This will ensure that a practical solution is reached that addresses the needs of both patients and staff (see page 10).

File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 33 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 33 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action Completed, implementing Carry out risk assessment on use of hand gel within September Infection Control Nurse gels at exits and entrances 28/8/2014 Cara, Glassary and Knapdale units 2014 (Sheila Ogilvie) only with staff carrying personal gels across all dementia areas.

Develop and implement Standard Operating Procedure September Infection Control Nurse SOP has been developed Sept 2014 on placement and availability of hand gel in these units 2014 (Sheila Ogilvie) and is now in use within the hospital

NHS Highland should provide a risk assessment that October 2014 Rec b demonstrates the appropriate selection of hand hygiene products in the accident and emergency department (see page 10).

Carry out risk assessment on use of hand hygiene September Senior Charge Nurse Risk assessment carried out Sept 2014 products within A&E 2014 (Mary Anne Douglas) and choice of Hand Hygiene File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 34 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 34 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action products now available at each sink in A&E

Ensure that all staff working in A&E are clear about use September Senior Charge Nurse Staff have been reminded Sept 2014 and have access to appropriate products 2014 (Mary Anne Douglas) about the Hand Hygiene guidance and are clear about which products to use.

Rec c NHS Highland should implement an assurance October 2014 system for nursing cleaning duties across all wards and departments in Mid Argyll Community Hospital and Integrated Care Centre (see page 12).

Implement Standard Operating Procedures for each September Senior Charge SOPs implemented in each Sept 2014 ward/department to ensure that cleaning of nursing 2014 Nurses/Midwife department equipment is carried out and recorded according to requirements File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 35 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 35 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action

Carry out spot checks of nurse cleaning schedules within September Clinical Services Spot checks are undertaken September the hospital on monthly basis 2014 Manager (Kate as part of CSM wards 2014 MacAulay) reviews

Rec d NHS Highland should review the current method of Octo ber 2014 input from the infection control team at Mid Argyll Community Hospital and Integrated Care Centre to provide assurance that infection control standards are being consistently implemented (see page 15). September Lead Nurse (Pat Review undertaken. Review the role and function of the Infection Control 2014 Tyrrell) Feedback sought from October Nurses to ensure that there is planned programme of CSMs and SCNs across 2014 regular visits to each hospital which will include ongoing Argyll and Bute. ICNs now reviews of all assurance systems that are in place visit each hospital in Argyll File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 36 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 36 of 37 Review Date: Circulation type (internal/external): Internal & External

011214 – 16 week plan

Improvement Action Plan

NHS Highland

Mid Argyll Community Hospital and Integrated Care Centre

Healthcare associated infection inspection

Inspection Date: 29 and 30 July 2014

16 week review

Ref: Action Planned Timescale Responsibility for Progress Date to meet taking action Completed action and Bute on a minimum of fortnightly basis. This visit will always encompass visit to clinical areas and will include reviews of SICPs, spot auditing, staff discussion and brief education sessions.

File Name: 2014 Mid-argyll Community Hospital Integrated Care centre action plan16 week review Version: 1 Date: December 1 st 2014 37 Produced by: Healthcare Improvement Scotland/ HEI//NHS Highland Page: Page 37 of 37 Review Date: Circulation type (internal/external): Internal & External

Argyll & Bute CHP Committee 17 December 2014 Item 7.3

Public Health

Elaine Garman, Public Health Specialist including contribution from Craig McNally, Senior Health Improvement Specialist

The CHP Committee is asked to:

• Note the positions on alcohol brief interventions and violence against women

1 Background and Summary This paper considers the two areas of Alcohol Brief Interventions (ABI) and Violence Against Women (VAW). Whilst there has been much coordinated work on ABIs over the years there has been less so on violence against women within Argyll & Bute which is currently being rectified.

The HEAT 4 target (now standard) for Alcohol Brief Interventions (ABI) was introduced across Scotland in 2008 as a result of the recognised harms associated with the higher levels of alcohol consumption across the population by comparison to the rest of the UK. ABI are aimed at reducing the consumption of hazardous and harmful drinkers. The annual target for ABI delivery in Argyll & Bute is 1066. A minimum of 90% of the target delivery must come from the priority settings of Primary Care (GP practices and NHS), Maternity and A&E. A maximum of 10% of delivery can be counted from non-priority settings.

At present the vast majority of the ABI delivery in Argyll & Bute is undertaken by GP practices under the LES agreement.

The HEAT standard is due to end in March 2015 but there will continue to be a requirement to report ABI delivery through Health Promoting Health Service returns and possibly through a separate return.

There is no Government target for VAW work. It is most clearly a partnership issue although there are specific actions that individual organisations need to do to improve response to women at risk from harm.

2 Main body of paper

2.1 Alcohol Brief Interventions

At present Argyll & Bute ADP is significantly below trajectory for the HEAT 4 target. The figures have been affected by the fact that one of the largest GP practices in A&B has been unable to deliver ABIs for the first five months of the year. They have now started delivery of ABIs (as have a few other GP practices) but they are substantially below their level of delivery in previous years. See Table 1 below.

Description No. of ABI GP ABIs 233

Priority Settings - Non GP, A&E, Antenatal & 22 Primary Care ABIs Wider Settings - Non GP ABIs 12 (Wider settings includes any ABI deliver by trained members of staff including staff from all other NHS settings, Local Authorities, Third Sector, Police and other emergency services) Total Actual Alcohol Brief Interventions 267

Trajectory 533

Annual Target 1066

Table 1: ABI performance against target

Between 2011 and 2014 a total of 279 people have been trained to deliver ABI within Argyll & Bute (see Table 2 below). In addition there were a significant number of staff trained prior to 2011 and several staff have been trained online or outside A&B. If each trained member of staff delivers only four ABI we will exceed our target.

NHS staff (priority and non-priority areas) 169 GP practice staff (inc. GPs & nurses) 47 Non-NHS service providers 63 (inc. Council/ 3 rd Sector) Total staff trained 279 Table 2: Staff trained in Argyll & Bute 2011 – 2014

Main Challenges

• Encouraging each trained member of staff to deliver ABIs and report delivery. • Encouraging GP practices to increase their delivery in the final quarter of the year. • Developing an appropriate reporting system. • Ensuring all ABIs reported can be counted.

2.2 Violence against Women

During this year, the Violence Against Women Partnership has been renewed. However it still needs more capacity to promote this work in the partnership organisations. Social work services in Argyll & Bute Council have identified a member of staff to support some of this work for a six month period. The public health department has been able to redirect a very small number of hours to contribute and may, dependent on recruitment controls in 2015/16, be able to divert some further hours next year.

Meanwhile work has been undertaken in developing a number of policies and guidelines: • Multiagency guidelines – Broad overarching guidelines to raise awareness of VAW, set out the overarching partnership policy on responding to VAW and to incorporate pointers to relevant specific departmental or agency guidelines (e.g. housing policy in relation to survivors of Domestic Abuse)

2

• Employee/Employer policies – Policy to support and guide managers to respond appropriately to staff who disclose that they are experiencing VAW and to staff identified as being perpetrators of VAW. • Briefing on responding to Forced Marriage – Briefing on identifying possible signs of or responding to disclosure of forced marriage • Guidance on responding to Female Genital Mutilation – Specific guidance on responding to women/girls who have been subject to FGM or to high risk individual girls • (Guidance on responding to disclosure of VAW – Specific step by step guidance on responding to disclosure. Will depend on timescale for roll-out of multi-agency approach to Effective and Early Intervention (EEI) and timescale for national guidance on Multi Agency Risk Assessment Conferences (MARAC)).

Extensive work has also been carried out to identify options for training which is key to rolling out the policies and guidelines above.

3 Contribution to Board Objectives

This contributes to two parts of NHS Highland’s vision: • Provide quality care at all times; • Support people and communities to maximise their own health

And to one of the quality objectives: • Ensure that the Board continues to improve the health of the population and that of its own staff, so that more people take responsibility for their own health and care and enjoy good health for longer. Ensure that the focus on reducing the inequality gap is maintained and resources prioritised appropriately in supporting disadvantaged groups.

4 Governance Implications

• Staff Governance: Encourages performance on health promoting health service • Patient and Public Involvement: Encourages patients to take action for their own health • Clinical Governance: Staff take up and use training offered on this area of care • Financial Impact: Effective use of resource allocated for this purpose

5 Risk Assessment

The risk exists for the CHP not to meet its required performance.

6 Planning for Fairness

Equality and diversity impact assessments have not been carried out.

Craig McNally, Senior Health Improvement Specialist Elaine Garman, Public Health Specialist

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Argyll & Bute CHP Committee 17 December 2014 Item : 8.1 FINANCE REPORT REPORT BY GEORGE MORRISON

The CHP Committee is asked to;

• Note the year-to-date financial position

• Note the requirement for management action to support the Board in achieving a year-end break-even position

1. Year-to-date Position

For the seven months ended 31 st October 2014, Argyll & Bute CHP recorded an overspend of £264,000. This is an improvement of £160,000 on the overspend of £424,000 recorded at the end of September. The favourable movement in month 7 has been caused largely by the efforts of managers to contain and reduce expenditure, where appropriate and safe to do so.

Table 1 below provides details of budgetary performance across Argyll & Bute CHP for the first seven months of this financial year.

Table 1: Financial performance by budget at 31 st October 2014 Year to Date Annual Budget Actual Variance Forecast Budget Budget £’000 £’000 £’000 Outturn £’000 Oban, Lorn & Isles Locality 19,928 11,548 11,916 (368) (554) Mid Argyll, Kintyre & Islay Locality 17,258 10,016 10,211 (195) (369) Mental Health In-Patient Services 7,593 4,332 4,320 12 100 Cowal & Bute Locality 12,782 7,436 7,381 55 50 Helensburgh & Lomond Locality 4,760 2,791 2,809 (18) 0 Salaried Dental Service 3,750 2,188 2,051 137 200 Other Clinical Services 5,857 2,852 2,811 41 (9) General Medical Services 15,786 8,979 9,097 (118) (200) Prescribing 17,207 10,170 10,371 (201) (260) Dental, Ophthalmic & Pharmacy 7,886 4,817 4,817 0 0 Services from NHS GG & C 51,602 29,165 29,165 0 0 Commissioned Services 4,342 2,520 2,531 (11) (170) Resource Release 4,609 2,689 2,689 0 0 Depreciation 2,682 1,549 1,549 0 0 Management & Corporate 9,069 5,637 5,560 77 95 Budget Reserves 1,584 300 0 300 850 Total Expenditure 186,695 106,989 107,278 (289) (267) Income (1,272) (794) (819) 25 17 Net Budget Position 185,423 106,195 106,459 (264) (250) Expected Yield from Management Action 500 Forecast year-end outturn 250

In discussion with the Health Board, the CHP has agreed to take action to further reduce planned spending over the remainder of the financial year. In table 1 above, I have indicated that the expected yield from this action will be £0.5m which, if achieved, will result in Argyll & Bute CHP achieving a year-end position of £0.25m underspent.

2. Significant budget variances

In addition to pressure on budgets from savings targets, there are a number of in-year cost pressures causing budget overspends. The most significant are:

i) Oban, Lorn & Isles Locality

Medical consultants - £234k due to locum costs arising from vacancies and sickness absence

Surgical consultants - £59k due to locum costs arising from a vacancy

Laboratory services - £24k due to increased pay, diagnostic reagent, quality control materials and service contract costs

Audiology Services - £21k use of agency staff to cover sickness absence

Mull Community nursing - £20k excess pay costs – due to maternity leave cover

Integrated Equipment Service - £19k excess cost of service manager being employed through Hays Agency. This issue is now resolved.

Tiree Community nursing - £17k excess pay costs – due to additional on call

ii) Prescribing

GP Prescribing - £201 k prescribing costs have risen by 3.7% in comparison to the same period in 2013. The budget uplift for 2014/15 was an increase of 1.0%, net of efficiency savings. The excess cost increase is creating an overspend on the prescribing budget. iii) MAKI Locality

Islay Hospital Nursing - £47k significant use of bank nursing due to a long-term suspension, maternity leave and sickness absence.

Kintyre Medical Group - £25k use of agency doctors

Islay Catering - £21k excess staffing costs

Campbeltown Hospital - £12k near patient testing consumables

2 iv) General Medical Services

Locum GPs - £118k excess cost of locums covering vacant practices in Inveraray, Port Charlotte and Bunessan plus maternity leave cover in several practices.

v) Commissioned Services

Huntercombe/The Priory - £65k due to increased referrals for the treatment of mood & eating disorders.

Golden Jubilee Hospital - £35k increased activity for cardiac bypass procedures

vi) Mental Health Service

Medical Staffing -£58k use of agency doctors due to vacancies (£175k year to date spend)

Argyll & Bute Hospital IPCU - £49k due to sickness absence and exceptional one to one Nurse staffing nursing requirements

vii) Other Clinical Services

ABAT -£11k appointment of two new nursing posts

viii) Cowal & Bute Locality

Rothesay Victoria Hospital -£52k excess staffing costs due to bank nurse usage and Nurse staffing unfunded displaced member of staff

Cowal Community Hospital -£31k use of agency doctors to staff rota (£222k year to date Medical staffing spend)

Cowal & Bute Community -£20k use of agency nurses (£69k year to date spend) Mental Health Team

ix) Management & Corporate

Removal Expenses -£12k payment for medical staff

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3. Cost Improvement Programme

To achieve a balanced budget, Argyll & Bute CHP approved a £3.4m cost improvement programme for 2014/15. This is proving to be very challenging and the level of recurring savings being achieved is likely to fall short of the target by at least £1m. Although the forecast shortfall against the recurring savings target can be compensated for by non-recurring measures, e.g. vacancies and budget underspends, it does create a recurring funding gap which will need to be addressed through budget setting for 2015/16.

Details of savings targets, and progress towards their achievement, are shown in table 2 below.

Table 2: Argyll & Bute CHP Cost Improvement Programme 2014/15 Declared Forecast Likely Responsible Target Achieved Outstanding Achievement Shortfall Recurring Savings Targets Manager £' 000 £' 000 £'000 £'000 £'000 Oban, Lorn & Isles V Kennedy 575 69 506 150 425 Mid Argyll, Kintyre & Islay C West 514 151 363 264 250 Mental Health Services J Dreghorn 219 169 50 219 0 Cowal & Bute V Hamilton 381 20 361 181 200 Helensburgh & Lomond V Hamilton 147 58 89 100 47 CAMHS J Dreghorn 13 0 13 13 0 Child Health C West 5 5 0 5 0 Learning Disabilities J Dreghorn 16 0 16 16 0 Community Dental Services E Reilly 20 0 20 20 0 Prescribing F Thomson 511 380 131 511 0 Lead Nurse P Tyrell 30 0 30 30 0 Public Health E Garman 32 32 0 32 0 Practitioner Services J Robinson 6 0 6 0 6 Director of Operations C West 23 23 0 23 0 Finance & Procurement G Morrison 21 21 0 21 0 Human Resources G Boyd 15 0 15 5 10 E-Health S Whiston 34 0 34 17 17 Planning & Performance S Whiston 10 6 4 10 0 Pharmacy Management F Thomson 11 0 11 11 0 Commissioned Services C West 121 121 0 121 0 Displaced Staff C West 69 0 69 24 45 Depreciation G Morrison 590 590 0 590 0 Income G Morrison 37 37 0 37 0 Totals 3,400 1,682 1,718 2,400 1,000

Declared recurring savings to date are only £1.682m which is 49% of the agreed £3.4m target.

4. Forecast Outturn

In response to discussions with the Health Board, I am now forecasting a year-end underspend of £250,000. However, this is dependent on management action to reduce spending over the remainder of the financial year.

George Morrison Head of Finance Argyll & Bute CHP 4th December 2014

4 Argyll & Bute CHP Committee 17 December 2014 Item : 9 Highland NHS Board 2 December 2014 Item 5.1 ARGYLL AND BUTE HEALTH AND CARE PARTNERSHIP – UPDATE

Report by Christina West, Interim Director of Operations on behalf of Deborah Jones, Chief Operating Officer

The Board is asked to:

 Note the appointment of the Chief Officer for Argyll and Bute HSCP.  Consider and approve for consultation the Argyll and Bute HSCP Integration Scheme.  Note the approval timeline of the Scottish Government for the Integration Scheme  Remit the Chair, Chief Executive of the Board with the Chief Officer together with the Leader of the Council and Chief Executive to finalise the Integration Scheme for submission to the Scottish Government.  Note planning for the next round of staff sessions and community events relating to Integration have commenced and will be completed in December 2014.

1 Background and Summary

The purpose of this paper is to provide NHS Highland Board with a progress report on the action undertaken to establish the Argyll and Bute Health and Social Care partnership (HSCP) since its last meeting.

The Board at its 1 April 2014 meeting endorsed the integration model as “Body Corporate” for the Argyll and Bute Health and Social Care partnership and confirmed the scope of service inclusion at its 5 June 2014 meeting.

2 Argyll and Bute HSCP Establishment Update

2.1 Chief Officer

Christina West, Interim Director of Operations in Argyll and Bute, has been appointed to the post of Chief Officer for the Argyll and Bute Health and Social Care Partnership.

2.2 Integration Scheme

 The Public Bodies (Joint Working) (Scotland) Act 2014 requires that an Integration Scheme is prepared jointly by the NHS Board and the Council in respect of each Integration Authority, known as the Integration Joint Board. The scheme sets out the formal agreement between the NHS Board and Council on a range of matters as prescribed in the regulations in support of the Act, including the delegation of functions and services to the partnership.

 The Integration Scheme must be approved by Scottish Ministers before the Integration Joint Board may legally form. Scottish Ministers will restrict their approval to those matters which are prescribed for inclusion in the scheme and any changes to the scheme in future will require the scheme to be resubmitted following further consultation. Matters that are not prescribed but which will provide assurance that the necessary arrangements are in place for the partnerships to function effectively will be included in supporting local protocols and guidance. In line with advice from the Scottish Government, the draft Integration Scheme (Appendix 1) is therefore a high level document and areas of detail that would be subject to regular change are not included.

 The draft Integration Scheme is based on the national Model Integration Scheme template provided by the Scottish Government and reflects the draft Regulations.

 The Act requires the NHS Board and Council to consult on the content of the draft Integration Scheme and the stakeholders to be involved are set out in the Regulations.

 These comprise stakeholders represented in the Shadow Integration Board, Health Board staff and Council staff and other stakeholders. To comply with the Scottish Government timescale for approval (Appendix 2). It is proposed that the consultation is for a period of 4.5 weeks following approval by NHS Highland Board. The draft Integration Scheme is scheduled to be submitted to the Scottish Government early January 2015 for approval.

2.3 Other Action

 The Scottish Government has also recently issued draft guidance in relation to 3 year strategic plans and is requesting feedback from partnerships in relation to the content of the guidance which the programme board is considering at its next meeting.

 The Scottish Government has recently provided guidance on the disestablishment of CHPs (Appendix 3). Health Boards and local authorities need to consider what interim arrangements they will put in place to oversee the services that CHPs have been made accountable for locally and how they will ensure the continued involvement of stakeholders in service planning and delivery.

 In terms of current work stream activity the communications and public involvement group are finalising materials for the forthcoming events for staff and the Public relating to integration which are planned for early December 2014. A set of frequently asked questions have been developed to help staff and the public understand the drivers behind integration and the focus on person centred healthcare. These series of meetings will also be used to consult on the Integration Scheme.

These events/sessions will give staff and members of our communities the opportunity to have an informed “local conversation” about current services and issues and the benefits and outcomes to be achieved (see inserted national outcome indicators) as a result of integration, to inform the local transformation in health and care service delivery required.

Supporting the Communications and Engagement process a dedicated Integration programme website has now been set up hosted by Argyll Voluntary Action and this can be found at http://www.healthytogetherargyllandbute.org.uk/

2 National Outcome Indicators

 Healthier living - Individuals and communities are able and motivated to look after and improve their health and wellbeing, resulting in more people living in good health for longer, with reduced health inequalities.

 Independent living - People with disabilities, long term conditions or who become frail are able to live as safely and independently as possible in the community, and have control over their care and support.

 Positive experiences and outcomes - People have positive experiences of health, social care and support services, which help to maintain or improve their quality of life.

 Carers are supported - People who provide unpaid care to others are supported and able to maintain their own health and wellbeing including by having a life outside of caring.

 People are safe - People using health, social care and support services are safe- guarded from harm and have their dignity and human rights respected.

 Engaged workforce - People who work in health and social care services are positive about their role and supported to improve the care and treatment they provide.

 Resources - The most effective use is made of resources across health and social care services, avoiding waste and unnecessary variation.

3 Contribution to Board Objectives

This is a significant area of policy development for both the Council and NHS Highland as it is a legislative requirement which both partners will need to comply with fully.

4 Governance Implications

4.1 Corporate Governance

The new Partnership will be established by a statue agreement. In particular the governance and accountability arrangements will impact on the current arrangements and standing orders of both partners. Dependent on the detail within the Integration Scheme there may be further corporate and legal implications for both partners.

4.2 Financial

The revenue and capital budgets of the specified council and NHS services will form part of an integrated budget for the new Health and Social Care Partnership to manage.

The exact details regarding management and accountability etc will be defined in the course of the integration programme.

3 4.3 Staff Governance

If the anticipated model of integration is taken forward, the majority of staff contract arrangements will be unaffected however there will be substantial changes to the operational and strategic management arrangements for all staff.

Staff are integral to the success of the new Health and Social Care partnership and significant effort will be made to ensure staff are fully involved and engaged in the process

Looking forward there are implications for a variety of staff roles and responsibilities, notably management and support services. Some of this is a continuum of the work already underway but others are also opportunities as identified by the Christie report regarding rationalisation, redesign and review of service as a consequence of integration of health and social care. There are also opportunities for staff co-location and professional and team development.

Organisational Change Policy will underpin the approach to be taken supported by workforce planning and development strategies. Presentations to key Committees such as Staff Governance Committee, Area Clinical Forum and Professional Executive Committee will be scheduled into the engagement and consultation process in both organisation, as well as face to face discussions and awareness sessions for staff providing them with opportunities to influence and shape partnership arrangements.

4.4 Planning for Fairness:

EQIA scoping exercise will be undertaken if required once the service model and its operational arrangements have been identified. Once again lessons learned from North Highland partnership process will be applied.

4.5 Risk

The process of integration introduces a large number of risks for the partners. The project is reviewing and updating its formal risk register:

- Governance - Finance and Resources - Performance Management and Quality - Human Resources - Integrated IT - Engagement and Communications - Organisational Development - Equity - Programme and timescale

The risks around integration are formally recorded on NHS Highlands SBAR and the integration programme will put in place a formal action plan to address and mitigate these risks.

4.6 Clinical Governance

There are a number of implications including clarification over pathways, roles and accountabilities in the new structure which will require to be detailed and implemented through the course of the integration programme.

4 Notwithstanding this the integration model will be required to be safe, effective and evidence-based. There will be a need to build significant clinical engagement and consensus across the localities in the partnership catchment area.

5 Engagement and Communication

This major service change will require the Partnership to put in place a comprehensive public involvement and engagement process in establishing the new arrangements for PFPI in the partnership.

The intention of the communication and engagement approach is to focus on Person Centred Care and outcomes demonstrating how services will improve by integration. This will be the core of both public and staff engagement and consultation.

A comprehensive communication and engagement has been developed and will be a discrete project work stream with members drawn from staff, the public and management, supported by SGHD designated funding for communication and engagement.

Christina West Interim Director of Operations Argyll and Bute CHP

21 November 2014

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APPENDIX 1 CONSULTATION DRAFT

INTEGRATION SCHEME

(BODY CORPORATE)

BETWEEN

ARGYLL & BUTE COUNCIL

AND

NHS HIGHLAND

Consultation Draft – December 2014

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1. Introduction

1.1 The Public Bodies (Joint Working) (Scotland) Act 2014 (the Act) requires Health Boards and Local Authorities to integrate planning for, and delivery of, certain adult health and social care services. They can also choose to integrate planning and delivery of other services – additional adult health and social care services beyond the minimum prescribed by Ministers and children’s health and social care services. The Act requires them to prepare jointly an integration scheme setting out how this joint working is to be achieved. There is a choice of ways in which they may do this: the Health Board and Local Authority can either delegate between each other (under s1(4)(b), (c) and (d) of the Act), or can both delegate to a third body called the Integration Joint Board (under s1(4)(a) of the Act). Delegation between the Health Board and Local Authority is commonly referred to as a “lead agency” arrangement. Delegation to an Integration Joint Board is commonly referred to as a “body corporate” arrangement.

1.2 This integration scheme describes how the joint working arrangements will be achieved in Argyll and Bute. It describes the ‘body corporate’ arrangement agreed between NHS Highland and Argyll and Bute Council (The Parties).

1.3 This document sets out a model integration scheme to be followed where the “body corporate” arrangement is used (i.e. the model set out in s1(4)(a) of the Act) and sets out the detail as to how the Health Board and Local Authority will integrate services. Section 7 of the Act requires the Health Board and Local Authority to submit jointly an integration scheme for approval by Scottish Ministers. The integration scheme should follow the format of the model and must include the matters prescribed in Regulations. Once the scheme has been approved by the Scottish Ministers, the Integration Joint Board (which has distinct legal personality) will be established by Order of the Scottish Ministers.

1.4 The Parties have agreed to delegate the maximum allowable range of health and social care service to a third body, described in the Act as the Integration Joint Board

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(IJB). The Integration Joint Board for Argyll and Bute shall be referred to as the Argyll and Bute Integration Joint Board.

1.5 The Argyll and Bute Integration Joint Board is responsible for the strategic planning of the functions delegated to it and for ensuring the delivery of its functions through the locally agreed operational arrangements set out within the integration scheme in Section 5. Further, the Act gives the Health Board and the Local Authority, acting jointly, the ability to require that the Integration Joint Board replaces their strategic plan in certain circumstances. In these ways, the Health Board and the Local Authority together have significant influence over the Integration Joint Board, and they are jointly accountable for its actions.

1.6 The Act requires NHS Highland and Argyll and Bute Council to submit this Integration Scheme for approval by Scottish Ministers. When the scheme is approved the Argyll and Bute Integration Joint Board will be established by order of the Scottish Ministers as an entity which has a distinct legal personality.

1.7 Argyll and Bute Integration Joint Board will be responsible for the strategic planning and delivery of the functions delegated to it; and for ensuring the discharge of those functions through the partnership between the Health Board and the Council, which will be formally referred to as Argyll and Bute Integration Joint Board.

2. Aims and Outcomes of the Integration Scheme

2.1 The main purpose of integration is to improve the wellbeing of people who use health and social care services, particularly those whose needs are complex and involve support from health and social care at the same time. The Integration Scheme is intended to achieve the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Act.

2.2 The Argyll and Bute Integration Joint Board will set out within its 3 Year Strategic Plan how it will effectively use allocated resources to deliver the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in regulations under section 5(1) of the Act, namely that:

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 People are able to look after and improve their own health and wellbeing and live in good health for longer.

 People, including those with disabilities or long term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

 People who use health and social care services have positive experiences of those services, and have their dignity respected.

 Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services.

 Health and social care services contribute to reducing health inequalities.

 People who provide unpaid care are supported to look after their own health and wellbeing, including reducing any negative impact of their caring role on their own health and wellbeing.

 People using health and social care services are safe from harm.

 People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.

 Resources are used effectively and efficiently in the provision of health and social care services.

2.3 The Argyll and Bute Health and Social Care Partnership’s Vision is that people in Argyll and Bute will live longer, healthier, happier, independent lives.

2.4 The Purpose of the Argyll and Bute Integration Joint Board is to plan for and deliver high quality health and social care services to and in partnership with the communities of Argyll and Bute.

2.5 NHS Highland and Argyll and Bute Council have agreed that Children and Families social work services and Criminal Justice services should be included within

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2.5.1 The national outcomes for Children are:-  Our children have the best start in life and are ready to succeed;  Our young people are successful learners, confident individuals, effective contributors and responsible citizens; and  We have improved the life chances of children, young people and families at risk.

2.5.2 National outcomes and standards for Social Work Services in the Criminal Justice System are:-  Community safety and public protection;  The reduction of re-offending; and  Social inclusion to support desistance from offending.

2.6 The geography and demographics of the area pose significant challenges to this vision and purpose and the Partnership recognises that success can only be guaranteed if: people are at the centre of the process and are empowered and encouraged to take responsibility for their own health and well-being; communities are vibrant and resilient, providing natural supports amongst themselves; localities are at the heart of integration, informing and driving forward local solutions and innovations to meet a diverse range of needs and preferences; staff are recognised as our greatest asset, are valued, developed, trained and supported to enjoy fulfilling careers supporting and caring for people who are in need of services.

2.7 The core values of the Argyll and Bute Integration Joint Board are: a person centred approach; compassion; respect; equality; fairness; transparency; efficiency; improvement; involvement and co-production.

2.8 Localities are recognised as being at the heart of integration. Argyll and Bute has many small and diverse communities with varying demographics, challenges and requirements. Over a number of years services have been delivered, managed and monitored across the four administrative areas, Mid Argyll, Kintyre and Islay;

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Oban, Lorn and the Isles; Bute and Cowal and Helensburgh and Lomond. The Argyll & Bute Integration Joint Board will commence integrated service delivery utilising these four existing areas. The Argyll & Bute Integration Joint Board retains the option to revise these locality arrangements.

3. Model Integration Scheme

The parties:

The Argyll & Bute Council, established under the Local Government (Scotland) Act 1994 and having its principal offices at, Kilmory, Lochgilphead, Argyll, PA31 8RT (“the Council”);

And

NHS Highland Health Board, established under section 2(1) of the National Health Service (Scotland) Act 1978 (operating as “Argyll & Bute CHP“) and having its principal offices at [AROS, Lochgilphead, Argyll PA31 8LB] (“NHS (Highland)”) (together referred to as “the Parties”).

4. Definitions and Interpretation

4.1 “The Act” means the Public Bodies (Joint Working) (Scotland) Act 2014.

4.2 “Integration Joint Board” means the Integration Joint Board to be established by Order under section 9 of the Act.

4.3 “Outcomes” means the Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Act.

4.4 “The Integration Scheme Regulations” means the Public Bodies (Joint Working) (Integration Scheme) (Scotland) Regulations 2014.

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4.5 “Integration Joint Board Order” means the Public Bodies (Joint Working) Integration Joint Boards (Scotland) Order 2014.

4.6 “Scheme” means this Integration Scheme.

4.7 “3 Year Strategic Plan” means the plan which the Integration Joint Board is required to prepare and implement in relation to the delegated provision of health and social care services to adults [and children] in accordance with section 29 of the Act.

In implementation of their obligations under the Act, the Parties hereby agree as follows:

In accordance with section 1(2) of the Act, the Parties have agreed that the integration model set out in sections 1(4)(a) of the Act will be put in place for [Argyll & Bute Health and Social Care Partnership], namely the delegation of functions by the Parties to a body corporate that is to be established by Order under section 9 of the Act. This Scheme comes into effect on the date the Parliamentary Order to establish the Integration Joint Board comes into force.

5. Local Governance Arrangements

5.1 In accordance with the Act, the Integration Joint Board has a legal personality distinct from the Council and Health Board, with the consequent autonomy to manage itself. There is no role for either Party to independently sanction or veto decisions of the Argyll & Bute Integration Joint Board.

5.2 The Argyll & Bute Integration Joint Board is recognised as having formal status for strategic planning for Argyll and Bute within both the Council and the Health Board, contributing to and operating within the wider context of their respective corporate strategies. The Argyll & Bute Integration Joint Board will communicate and interact with both parties to ensure the delivery of the National Outcomes for the people of Argyll and Bute.

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5.3 In exercising its functions the Argyll & Bute Integration Joint Board will take into account the respective statutory obligations of The Parties. Apart from those functions delegated by virtue of this Scheme, the Parties retain distinct statutory responsibilities and thus they also retain their formal decision making roles for functions not delegated.

5.4 The remit and constitution of the Argyll & Bute Integration Joint Board is established through legislation, with the Parties having agreed:

5.4.1 NHS Representation – 4 members of the NHS Highland Health Board (executive or non-executive); The Chief Executive Officer, NHS Highland; 3 NHS Officers; 1 Doctor (who is not a GP); 1 General Practitioner; 1 Registered Nurse and other Officers to be co-opted or in attendance as required by the Integration Joint Board.

5.4.2 Argyll & Bute Council Representation: 4 Elected Members of the Council; The Chief Executive Officer, Argyll & Bute Council; 3 Argyll & Bute Council Officers; 1 Section 95 Finance Officer; other Officers to be co-opted or in attendance as required by the Integration Joint Board.

5.4.3 Joint Representation: Chief Officer, Health & Social Care; 2 Trades Union/NHS Staff side Representatives; 2 Public Representatives; 1 Scottish Health Council Representative; 1 Carers Representative; 1 Patient Representative; 1 Independent Sector Representative; 1 Third (Voluntary) Sector Representative; other representatives co-opted or in attendance as required by the Integration Joint Board.

5.4.4 The Parties have decided, by democratic nomination and voting, the identities of the Chair and Vice Chair of the Argyll and Bute Integration Joint Board. It has been unanimously agreed that the Chair (who is the nominee of Argyll & Bute Council) will hold office for a period of two years. Thereafter, the Vice Chair (who is the nominee of NHS Highland) will assume office for a period of two years. The Chair and Vice Chair may agree between them the delegation of duties e.g. in the case of the Chair being unavoidably absent.

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5.4.5 The identified Integration Joint Board members are the voting representatives. Any co-opted representatives or representatives in attendance shall not have voting rights. Quoracy has been agreed at 50% attendance, with representatives from both parties present in equal number.

5.4.6 All voting and non-voting members of the Argyll & Bute Integration Joint Board will be obliged to behave in accordance with Ethical Standards in Public Life framework. This will include declaring relevant financial and non- financial interests, both within an annual register and at meeting in response to agenda items.

5.4.7 A voting member of the Argyll & Bute Integration Joint Board shall cease to be a voting member if he/she resigns or is removed from office. A Health Board member shall cease to be a member if he/she no longer holds his/her membership with the Health board. An Elected Member of the Council shall cease to be a member if he/she no longer holds the office of Elected Member. All members of the Argyll & Bute Integration Joint Board are members ex officio (by nature of their other appointment).

5.4.8 A voting member of the Argyll & Bute Integration Joint Board shall also cease to be a voting member of he/she fails to attend 3 consecutive meetings of the Argyll & Bute Integration Joint Board, provided the absences were not due to illness or other reasonable cause (which shall be decided by the Argyll & Bute Integration Joint Board). In this event the Argyll & Bute Integration Joint Board shall give the member one month’s written notice of his/her removal and the Argyll & Bute Integration Joint Board will, at the same time, request that a replacement is nominated by the relevant organisation and a new member will be appointed within a practicable timescale.

5.5 The Argyll & Bute Integration Joint Board covers only one Local Authority, therefore no additional arrangements are required. 5.6 The Parties will share targets, measures and other arrangements that will be devolved to the Integration Joint Board, in full. These will take into account national

Draft v 1.1 20.11.2014 Page 9 CONSULTATION DRAFT guidance on the core indicators for integration, as well as local targets and indicators and this information will be made available to the Integration Joint Board for consideration. Data in respect of the national indicators will be collected from April 1st 2015. Local targets and indicators are expected to change and evolve during 2015/16 and beyond, in line with the 3 year Strategic Plan.

5.7 The Argyll and Bute Integration Joint Board will as per as specified schedule and frequency receive for consideration, approval and agreement the following:

5.7.1 Public Health and Wellbeing Status reports including analysis of Argyll and Bute population, at macro, demographic specific and locality level.

5.7.2 Clinical and Care Governance reports to be assured of the quality, safety and effectiveness of services.

5.7.3 Staff Governance reports to be assured of compliance and best practice in workforce relations, workforce planning and organisational development.

5.7.4 Patient and User of Care Services Involvement and Community Engagement reports ensuring their involvement in the shaping, delivery and evaluation of service performance.

5.7.5 Financial Governance reports including financial management, budget setting recommendation, expenditure reporting and cost improvement plans for consideration and approval.

5.7.6 Performance Management reports to ensure that all services within scope are assessed for compliance and achievement against targets and improvement measures.

5.7.7 Risk and Health and Safety Management reports ensuring that all operational and strategic risks are identified with mitigation actions and plans identified.

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5.8 Public Health & Social Care Profile of HSCP

5.8.1 Multi-purpose high level and/or key demographic population health and social indices information:

 Planning info – life expectancy & at birth, morbidity mortality rates, suicides rates.

 Inequality markers – birth weight, breast feeding rates, dental carries in young children, rate of looked after children, school leavers in positive and sustained destinations.

 Life span indicators child healthy weight, alcohol use aged 15, drug use aged 15, strengths and difficulties score (young people), mental health and well- being (WEMWBS) young people, people (65+) receiving free personal care at home.

 National social care key performance reporting, relating to adults, children and young people. (Self-Directed Support (Direct Payments),Social Care Survey, Homecare Census, Telecare Census, Annual Respite Return , Eligibility Criteria & Waiting Times Census, Social Care Benchmarking, Mental Health Benchmarking, eSAY (LDSS), Adult Protection Reshaping Care for Older People, Delayed Discharge, Substance Misuse, Emergency Admission, Joint Integrated Community Teams, Carers, Child Protection, Early Years, Children Looked After Scotland (CLAS) and Criminal Justice )Disease prevalence rates- Diabetes. Lifestyle Behavioural indicators – smoking, weight physical activity, and alcohol assumption related admissions.

 Customer Service Reporting

 Economic data – income

5.9 National outcome indicators and measures

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5.9.1 Healthier living Individuals and communities are able and motivated to look after and improve their health and wellbeing, resulting in more people living in good health for longer, with reduced health inequalities.

 Premature mortality (National Performance Framework)  Emergency admissions to hospital (National Performance Framework) and Emergency inpatient bed day rates 75+ (NHS HEAT)  % of people who say they are able to look after their health or who say they are as well as they can be  % of people receiving any care or support who say they are able to live where they want

5.9.2 Independent living People with disabilities, long term conditions or who become frail are able to live as safely and independently as possible in the community, and have control over their care and support.  % of last 6 months of life spent in community  % people receiving personal care at home, rather than in a care home or hospital (National Performance Framework )  Emergency admissions to hospital (National Performance Framework ) and Emergency inpatient bed day rates 75+ (NHS HEAT)  % of people receiving care and support who said that people took account of what was important to them  % of people receiving any care or support who say they have a say in the way it is provided

5.9.3 Positive experiences and outcomes People have positive experiences of health, social care and support services, which help to maintain or improve their quality of life.  Number of bed days due to delayed discharge (NHS HEAT)  % who said that the care and support services they received had a positive impact in improving or maintaining their quality of life

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 % of people receiving care and support who said that people took account of what was important to them  % of people receiving any care or support who say they are able to live where they want  % of people receiving any care or support who say they have a say in the way it is provided

5.9.4 Carers are supported People who provide unpaid care to others are supported and able to maintain their own health and wellbeing including by having a life outside of caring.  % of carers who feel supported to continue in their caring role  Carer wellbeing, or self-assessed health

5.9.5 People are safe People using health, social care and support services are safe-guarded from harm and have their dignity and human rights respected.  Number of bed days due to delayed discharge (NHS HEAT)  % of people receiving care and support who said that they felt safe

5.9.6 Engaged workforce People who work in health and social care services are positive about their role and supported to improve the care and treatment they provide.  % of staff survey respondents who would recommend as a good place to work

5.9.7 The most effective use is made of resources across health and social care services, avoiding waste and unnecessary variation.  Balance of spend across institutional and community settings (Integrated Resource Framework)

5.10 Service delivery performance measures  HEAT targets and NHS performance measures i.e. RTT. Waiting times and targets  National social care indicators and measures for adult and children and family services

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 National social care benchmarking indicators and measures for adult and children and family services  Pyramid social care performance measures Joint Pyramid performance measures  LDP outcomes and objectives  SOA outcomes and objectives  Joint Health and Social Care Inspection reports  Patient/client feedback – complaints  Social Care Freedom of Information Requests  Patient/client feedback – complaints  Other

5.11 Where responsibility for a target or indicator is shared the Parties will agree in writing the accountability and responsibility of each Party.

6. Delegation of Functions

6.1 The functions that are to be delegated by the Health Board to the Integration Joint Board are set out in Part 1 of Annex 1. The services to which these functions relate, which are currently provided by the Health Board and which are to be integrated, are set out in Part 2 of Annex 1.

6.2 The functions that are to be delegated by the Local Authority to the Integration Joint Board are set out in Part 1 of Annex 2. The services to which these functions relate, which are currently provided by the Local Authority and which are to be integrated, are set out in Part 2 of Annex 2.

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7. Local Operational Delivery Arrangements

The local operational arrangements agreed by the Parties are:

7.1 The Argyll & Bute Integration Joint Board will be responsible for the strategic planning and delivery of the functions delegated to it. It will discharge those delegated functions through the partnership between the Council and the Health Board known as the Argyll and Bute Health and Social Care Partnership.

7.2 The Partnership comprises all the necessary resources and staff allocated by The Parties, for the purpose of undertaking the functions delegated to the Argyll & Bute Integration Joint Board.

7.3 The Parties have agreed that the Argyll & Bute Integration Joint Board will:

7.3.1 Appoint a Chief Officer, who by virtue of appointment will also be the Chief Officer of the Integration Joint Board.

7.3.2 Identify a Chief Financial Officer, to be termed the Section 95 Officer, who by virtue of appointment will also be the Chief Financial Officer of the Integration Joint Board.

7.3.3 Convene a Strategic Planning Group as required in terms of Section 32 of the Act to enable the preparation of Strategic Plans in accordance with Section 29 of the Act; inform significant decisions outside the Strategic Plan in accordance with section 36 of the Act. The membership of the Strategic Planning Group will be refreshed by the Argyll & Bute Integration Joint Board at the beginning of each strategic planning cycle.

7.3.4 Prepare, approve and implement a Strategic Plan for all of its delegated functions, in accordance with the Act and supported by an integrated workforce and organisational development plan. Strategic plans will detail how the Argyll & Bute Integration Joint Board will deliver on its responsibilities for children’s services planning and delivery as described in section 58 of the Act.

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The first Strategic Plan will be presented by the Chief Officer for approval, within the timeline set out by the Scottish Government, in accordance with section 29(5) of the Act.

7.3.5 Establish a process to identify and put in place the corporate support required by the Integration Joint Board to fulfil its duty and functions. The Parties will agree via the established Integration Programme Board an arrangement whereby professional, technical and administrative services will be made available to the Integration joint Board for the purpose of preparing a 3 year Strategic Plan and carrying out the delegated functions. The Partnership will, by April 1st 2015:

 Identify the corporate resources currently utilised to deliver the delegated functions.

 Agree with the Integration Joint Board the corporate support services required to fully discharge its duties under the Act.

 NHS Highland and Argyll and Bute will review, in 2015/16, that the provision of corporate support is adequate to the needs of the Integration joint Board and the delegated functions.

 NHS Highland and Argyll and Bute Council will agree how the provision of corporate support services is integrated within the annual budget.

7.3.6 Establish a standing Health and Care Sub Committee to focus on clinical and care governance, including (where necessary) to make recommendations to either or both Parties.

7.3.7 Establish a standing Audit Committee to focus on financial and internal audit, including (where necessary) to make recommendations to either or both Parties.

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7.3.8 Establish a standing Staff Partnership/Trade Union Forum to focus on applying the principles of staff governance across services in partnership with Trade Unions and where necessary to make recommendations to either, or both Parties.

7.3.9 Establish arrangements for locality planning in support of key outcomes for Argyll and Bute.

7.3.10 Agree an annual work plan, setting out key objectives for the year.

7.3.11 Maintain and routinely review an integrated strategic risk register.

7.3.12 Prepare and implement a Communication and Involvement Strategy that is supported by and contributes to local Community Planning Partnership arrangements.

7.3.13 Approve the allocation of resources to deliver the 3 Year Strategic Plan within the specific revenue and capital budgets as delegated by The Parties (in accordance with the standing financial instructions/orders of both Parties), and where necessary make recommendations to either or both Parties.

7.3.14 Prepare and publish an annual financial statement that sets out, in relation to the 3 Year Strategic Plan to which it relates, the amount that the Argyll & Bute Integration Joint Board intends to spend in implementing the Strategic Plan, in accordance with section 42 of the Act.

7.3.15 Prepare an annual performance report on the delivery of the Strategic Plan in accordance with section 42 of the Act.

7.3.16 Receive and act upon an annual report from the Chief Social Work Officer.

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7.3.17 Receive and act upon quarterly reports in respects of Performance, Clinical and Care Governance, Communication and Public Involvement, Workforce Planning and Staff Governance and Quality Improvement.

7.4 The Parties will retain responsibility for assuring the quality and safety of services commissioned from the Third and Independent sectors in accordance with the Strategic Plan.

8. Clinical and Care Governance

The arrangements for clinical and care governance agreed by the Parties is:

8.1 The Parties agree that patients and service users are the primary priority in everything that the Argyll & Bute Integration Joint Board plans and does and that, within available resources they will receive effective care that takes account of their expressed personal outcomes. Unpaid/family carers are recognised as central to achievement of the Argyll and Bute vision and will receive support within available resources. Services will be delivered by compassionate and committed staff, working within a common organisational culture and who are protected from avoidable risk of harm and any deprivation of their basic rights.

8.2 Clinical and care governance is the organisational framework through which the Argyll & Bute Integration Joint Board is responsible and accountable for the continuous improvement of the quality of the delegated functions (see annex 4). The process of clinical and care governance will safeguard quality standards by creating and maintaining an environment where excellence is expected. The Health and Care Sub Committee will agree the approach to measuring quality of service delivery; addressing organisation and individual care risks; promoting continuous improvement and ensuring that all professional and clinical standards, legislation and guidance are met.

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8.3 The Argyll & Bute Integration Joint Board will establish a clinical and care governance framework which will cover all health and social work services and encompass the following:

8.3.1 Quality and Safety

8.3.2 Standards and Guidelines

8.3.3 Incident and Risk Management

8.3.4 Audit and Self Evaluation

8.3.5 Inspections

8.3.6 Feedback and Complaints

8.3.7 Learning Organisation

8.3.8 Research and Development

8.3.9 Professional Leadership and Accountability (including regulation and registration).

8.4 The Chief Officer is accountable to the Argyll & Bute Integration Joint Board for clinical and care governance in relation to the staff and resources that constitute the delegated functions of the Partnership. The Chief Officer will be formally supported in this by staff in senior management and lead professional roles, employed by either of the Parties.

8.5 The Argyll & Bute Integration Joint Board will establish a Health and Care Governance Sub Committee. The Integration Joint Board will appoint a number of its voting members to serve on this Committee. It will be advised by the Chief Officer, the Clinical Director, Lead Nurse and Chief Social Work Officer and other appropriate representatives. These nominated professionals will continue to be the

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8.6 The Health and Care Governance Sub Committee will be chaired by the Chief Officer who will ensure that its membership includes appropriate senior managers and lead professionals. The Parties will ensure that the Health and Care Governance Sub Committee is able to call upon technical support in relation to its remit.

8.7 The professional leads of NHS Highland will be enabled to raise issues directly with the Integration Joint Board, in writing, or through the representatives who Board members. The Chief Social Work Officer as a member of the Integration Joint Board will be enabled to directly raise issues as appropriate.

8.8 This Scheme accepts that the Chief Officer and the Chief Social Work Officer is not the same individual. The two roles will have a non-hierarchical, mutually supportive relationship, with the Chief Social Work Officer continuing to discharge a statutory duty to Argyll and Bute Council. The Chief Social Work Officer shall also be obliged to support the Chief Officer and the Argyll & Bute Integration Joint Board. The Chief Social Work Officer will be a non-voting member of the Argyll & Bute Integration Joint Board (as per the Act) and a member of the Health and Care Sub Committee.

8.9 The relevant Corporate Directors/Lead Professionals of the NHS Highland Board (i.e. The Clinical Director, Lead Nurse, and Lead Allied Health Professionals) will support the Chief Officer and the Argyll & Bute Integration Joint Board. They will be non-voting members of the Argyll & Bute Integration Joint Board. They may agree with the Chief Officer for appropriately qualified and specified members of Health Board staff to act as a proxy for them, in their advisory role. The identified and agreed individuals will attend the Health and Care Sub Committee in an advisory capacity and provide professional support to the development of the Strategic Plan and within locality planning.

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8.10 The Chief Social Work Officer will formally present his/her annual report to the Argyll & Bute Integration Joint Board, as well as presenting it to Argyll and Bute Council and NHS Highland.

8.11 Representatives from General Practice and other external NHS contractors will be encouraged to work as an integral part of the Partnership, to support the development of multi-professional locality planning. Annual priorities for development will be identified for each locality and agreed by the Argyll & Bute Integration Joint Board, who will monitor progress.

9. ChiefOfficer

9.1 The Argyll & Bute Integration Joint Board shall appoint a Chief Officer in accordance with section 10 of the Act, who by virtue of that appointment shall also be the Chief Officer of the Partnership. This Scheme does not allow for the Chief Officer to be the same individual as the Chief Social Work Officer.

9.2 The Chief Officer has both strategic and operational responsibility for all delegated functions. The post holder is directly responsible to and line-managed by the Chief Executive Officers of both Parties and via the Chief Executive Officers is responsible to the NHS Highland Board and Argyll and Bute Council. The Chief Officer is also accountable to the Argyll & Bute Integration Joint Board. The Chief Officer’s contract of employment will be with one of the Parties, who will then second the Chief Officer to the Argyll & Bute Health and Social Care Partnership.

9.3 The Chief Officer will be accountable directly to the Argyll & Bute Integration Joint Board for the preparation, implementation of and reporting on the 3 Year Strategic Plan. The Chief Officer will also be responsible for operational delivery of services and the appropriate management of staff and resources.

9.4 The Chief Officer will establish a Senior Management Team, equipped to direct and oversee the structures and procedures necessary to carry out all functions in accordance with the 3 Year Strategic Plan. Relevant individuals and sub groups of

Draft v 1.1 20.11.2014 Page 21 CONSULTATION DRAFT the Senior Management Team will be tasked with specific strategic or operational tasks.

9.5 In the event that there is a prolonged period when the Chief Officer is unable or unavailable to fulfil his/her functions interim arrangements will be required to temporarily replace the Chief Officer. The Parties will nominate a suitably qualified and experienced senior officer to carry out the functions of the Chief Officer, for the duration of the interim period and submit the said nominations for approval by the Argyll & Bute Integration Joint Board’s Chair and Vice Chair.

9.6 The Chief Officer’s objectives will be set annually and performance appraised by the Chief Executive Officers of both Parties, in consultation with the Chair and Vice Chair of the Argyll & Bute Integration Joint Board.

9.7 Subject to the prior written consent of the other Party (acting reasonably) and with the consent of the Chair and Vice Chair of the Argyll & Bute Integration Joint Board, the Chief Executive Officer of either Party may direct the Chief Officer to be managerially responsible for functions or services which are not delegated under this Scheme. The Chief Officer’s accountability for such services shall be directly to the Chief Executive Officer of the Party making the request. That Party shall be entitled to revoke the direction, upon giving 12 weeks written notice to the Chief Officer.

9.8 The Chief Officer will be a full member of both the Council and Health Board’s corporate management teams, as well a non-voting member of the Argyll & Bute Integration Joint Board.

9.9 The Chief Officer will chair the Health and Care Sub Committee.

9.10 The Chief Officer will jointly chair the Staff Partnership Forum with the trades unions, or will nominate a Lead Officer to whom this responsibility will be delegated.

9.11 The Chief Officer will ensure the maintenance of up to date strategic risk register in respect of all functions delegated to the Argyll & Bute Integration Joint Board.

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9.12 The Chief Officer will routinely liaise with appropriate officers of the Health Board in respect of the Argyll & Bute Integration Joint Board’s role in informing and contributing to the strategic planning of acute NHS healthcare services and provision (in accordance with the Act) and delivery of agreed targets that have mutual responsibility.

9.13 The Chief Officer will routinely liaise with the relevant Executive Director(s) of the Council in respect of the Argyll & Bute Integration Joint Board’s role in informing strategic planning for local housing and the delivery of housing support services.

9.14 The Chief Officer will develop close working relationships with Elected Members of Argyll and Bute Council and Executive and Non-Executive members of the NHS Highland Board.

9.15 The Chief Officer will establish and maintain effective relationships with a range of key stakeholders across, the Scottish Government, Health, Council, Independent and Third sectors, service users, Trades Unions and professional organisations.

10. Workforce

The arrangements in relation to their respective workforces agreed by the Parties are:

10.1 The Chief Officer will appoint a Senior Management Team whose portfolios reflect the full range of the Argyll & Bute Integration Joint Board’s delegated functions and responsibilities for Strategic Planning and delivery of services, as well as any agreed corporate roles and/or hosted service responsibilities. The members of the Partnership’s Senior Management Team will all be contracted employees of one of the Parties and by inference will have a responsibility to both of the Parties, in respect of the Partnership.

10.2 Staff directly managed within the Partnership will either be employees of NHS Highland or Argyll and Bute Council and will be subject to the relevant terms and

Draft v 1.1 20.11.2014 Page 23 CONSULTATION DRAFT conditions specified within their contract of employment (including adherence to the corporate policies of their employing organisation). Staff working within the delegated functions of the Partnership will be solely line managed within its structures and ultimately accountable to the Chief Officer for the discharge of their responsibilities. No member of staff will be required to transfer their contract of employment to the other Party as a result of the establishment of the Argyll & Bute Health and Social Care Partnership.

10.3 The Argyll & Bute Integration Joint Board will establish a standing Staff Partnership Forum to focus on applying the principles of staff governance across services. This will be jointly chaired by the Chief Officer or a nominated Lead Officer and a nominated officer of the Trades Unions.

10.4 The Staff Partnership Forum will provide the collaborative vehicle by which the Partnership’s Integrated Workforce and Organisational Development Strategy will be agreed with staff and the Trades Unions, before incorporation into the Strategic Plan. It is envisaged that as far as possible Independent and Third Sector workforces will also be included in the plan, although they are not employees of the Partnership.

10.5 Workforce and organisational development will be key elements of the first 3 year Strategic Plan presented to the Argyll & Bute Integration Joint Board for approval.

10.6 The partnership is fully committed to providing continuous professional development for all members of staff and to engaging staff members in a robust and healthy organisational culture, where change and growth can flourish. This will be fully reflected in the 3 year Strategic Plan, produced during 2015.

10.7 The partnerships transitional Organisational Development Plan will evolve into a full Organisational Development Strategy agreed by the Argyll & Bute Integration Joint Board. This will set out priorities and arrangements for involvement and on- going support for staff and user/public members of the Argyll & Bute Integration Joint Board.

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10.8 Any future changes within the workforce, or changes to working practices will be developed and agreed on a planned and co-ordinated basis, in accordance with established policies and procedures. Trades Unions and staff affected by any proposed changes will be fully involved.

10.9 Argyll and Bute Council and NHS Highland will make arrangements regarding any future jointly appointed positions. The recruitment process may be run jointly; ‘hosted’ by either Party using their normal recruitment procedures or via new processes agreed by the Partnership. Representation on appointment panels will be agreed by the Argyll & Bute Integration Joint Board.

10.10 The Partnership will design and agree an integrated management structure for the future. It is recognised that integrated teams may have individuals reporting through a person employed by the other Party. The Parties agree to this as a proposed option and are both strongly committed to ensuring that clear lines of professional leadership and strong professional governance will be maintained within all integrated management structures.

10.11 There will be a jointly developed Organisational Development strategy, which includes engagement, leadership and workforce development for the integrated workforce. The strategy will continue to evolve and will regularly be reviewed in partnership with the stakeholders as the integration of Health and Social Care progresses. The strategy will be agreed by the Integration Joint Board.

10.12 NHS Highland and Argyll and Bute Council are committed to the continued development of positive and constructive relationships with recognised Trade Unions and professional organisations involved in Health and Social Care integration. Representatives of Trades Unions and professional organisations are and will continue to be fully involved in the process of Health and Social Care integration at all levels. They are represented on the Argyll & Bute Integration Joint Board.

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11. Finance

11.1 General Principles

11.1.1 The Argyll and Bute Integration Joint Board will determine its own internal financial governance arrangements, and the Chief Financial Officer will be responsive to the decisions of Argyll and Bute Integration Joint Board and the principles of financial governance that have been set out in this Integration Scheme.

11.1.2 Argyll and Bute Council and NHS Highland recognise that they each have continuing financial governance responsibilities, and have agreed to establish the Partnership as a “joint operation” as defined by IFRS 11.

11.1.3 Argyll and Bute Council and NHS Highland will work together in the spirit of openness and transparency.

11.1.4 Argyll and Bute Council and NHS Highland will ensure their payments to the Integration Joint Board are sufficient to fund the delegated functions. The Council and NHS agree to the establishment of an integrated budget for the Integration Joint Board that will be managed by the Chief Officer. Both Partners agree to make a revenue contribution to the Integration Joint Board representing the level of resources available for the service areas delegated to the Partnership.

11.1.5 Argyll and Bute Council and NHS Highland payments to the Integration Joint Board derive from a process that recognises that both organisations have expenditure commitments that cannot be avoided in the short to medium term. Argyll and Bute Council and NHS Highland will prepare and maintain a record of what those commitments are and provide this to the Integration Joint Board.

11.1.6 Argyll and Bute Integration Joint Board will monitor its financial position and make arrangements for the provision of regular, timely, reliable and

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relevant financial information on its financial position. Argyll and Bute Integration Joint Board, Argyll and Bute Council and NHS Highland will share financial information to ensure all parties have a full understanding of their current financial information and future financial challenges and funding streams.

11.1.7 Argyll and Bute Integration Joint Board will develop its own financial regulations. These will be reviewed periodically by the Chief Financial Officer and with a report on the review and proposed changes submitted to the board.

11.1.8 The existing financial regulations of Argyll and Bute Council and NHS Highland will apply to resources transferred from Argyll and Bute Integration Joint Board.

11.1.9 Argyll and Bute Integration Joint Board will comply with finance guidance in relation to health and social care integration issued by Scottish Government.

11.2 Chief Financial Officer

11.2.1 Argyll and Bute Integration Joint Board will make arrangements for the proper administration of its financial affairs and appoint a Chief Finance Officer with this responsibility. The Chief Financial Officer will be expected to work closely with the Chief Officer of the Partnership, the Section 95 Officer of the Council, Director of Finance of NHS Highland, the Board and the Audit Committee to ensure effective management of the financial resources of Argyll and Bute Integration Joint Board. The Chief Financial Officer will be employed by the Council or NHS Highland and seconded to Argyll and Bute Integration Joint Board. The post of Chief Financial Officer cannot be held by the same person as the Chief Officer.

11.2.2 Argyll and Bute Integration Joint Board will have regard to the current CIPFA guidance on the role of the Chief Financial Officer in Local

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Government and any Scottish Government or professional guidance in the operating parameters of the Chief Financial Officer and also in the appointment of a Chief Financial Officer. A job description will set out the requirements of the post.

11.3 Roles and Responsibilities - Finance

11.3.1 The Chief Financial Officer will be responsible for preparing the Argyll and Bute Integration Joint Board accounts and ensuring compliance with statutory reporting requirements as a body under the relevant legislation.

11.3.2 The Chief Financial Officer will be responsible for producing regular finance reports to the Argyll and Bute Integration Joint Board and managers ensuring that those reports are timely, relevant and reliable.

11.3.3 The Chief Financial Officer is accountable for financial management of delegated budgets in Argyll and Bute Integration Joint Board.

11.3.4 The Argyll and Bute Council Section 95 Officer and NHS Highland Accountable Officer are responsible for the resources that are allocated by the Integration Joint Board to their respective organisations for operational delivery.

11.3.5 The Chief Financial Officer will work with the Argyll and Bute Council Section 95 Officer and NHS Highland Director of Finance to ensure both organisations work together to develop systems which will allow the recording and reporting of Argyll and Bute Integration Joint Board financial transactions.

11.4 Management of Revenue Budget

11.4.1 The Argyll and Bute Integration Joint Board's 3 Year Strategic Plan will incorporate a medium term financial plan for its resources. On an annual basis a financial statement will be prepared setting out the amount the Integration Joint Board intends to spend to implement its 3 Year Strategic

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Plan. This will be known as the annual budget. The medium term financial strategy will be prepared for the Integration Joint Board following discussions with Argyll and Bute Council and NHS Highland who will provide a proposed budget based on payment for year 1, indicative payments for year 2 and 3 and outline projections for later years. The medium term financial strategy will be used in conjunction with the Strategic Plan to ensure the commissioned services by Argyll and Bute Integration Joint Board are delivered within the financial resources available.

11.4.2 Argyll and Bute Integration Joint Board is able to hold reserves. There is an expectation that they will achieve a break-even position each year unless there are clear plans to utilise reserves. The Board cannot budget a position which would result in the reserves moving into a deficit.

11.4.3 The term payment is used to maintain consistency with Legislation and does not represent physical cash transfer. As the Partnership does not operate a bank account, the net difference between payments into and out of the Integrated Joint Board will result in a balancing cash payment between the Council and the NHS. An initial schedule of payments will be agreed within the first 40 working days of each new financial year and may be updated taking into account any additional payments in-year.

11.4.4 Argyll and Bute Council and NHS Highland will establish a core baseline budget for each function and service that is delegated to the Integration Joint Board to form an integrated budget.

11.4.5 The budgets will be based on recurring baseline budgets plus anticipated non-recurring funding for which there is a degree of certainty for each of the functions delegated to Argyll and Bute Integration Joint Board and will take account of any applicable inflationary uplift, planned efficiency savings and any financial strategy assumptions. These budgets will form the basis of the payments to Argyll and Bute Integration Joint Board. These budgets will be reviewed against actual levels of expenditure for the previous 3 financial years.

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11.4.6 Information will be provided by Argyll and Bute Council and NHS Highland on the financial performance of the delegated services against budget in their respective areas for the last 3 years to enable all parties to undertake due diligence to gain assurance that the delegated resources are sufficient to deliver the delegated functions.

11.4.7 Argyll and Bute Council and NHS Highland will each prepare a schedule outlining the detail and total value of the proposed initial payment, the underlying assumptions behind that initial payment and the financial performance against budget for the delegated services in the shadow year for their respective areas. These schedules will identify any amounts included in the payments that are subject to separate legislation or subject to restrictions stipulated by third party funders. These documents must be approved by the Director of Finance for NHS Highland and the Section 95 Officer for Argyll and Bute Council prior to submission to the Partnership.

11.4.8 The Argyll and Bute Integration Joint Board Chief Financial Officer will review these documents and reach agreement with both parties on the value of the initial payment. The Chief Financial Officer then prepares a schedule that describes the agreed value of the payments. The Argyll and Bute Council Section 95 Officer, NHS Highland Director of Finance and Argyll and Bute Integration Joint Board Chief Officer must sign this schedule to confirm their agreement.

11.4.9 The process for agreeing the subsequent payments to Argyll and Bute Integration Joint Board will be contingent on the corporate planning and financial planning processes of Argyll and Bute Council and NHS Highland. The funding available to the Integration Joint Board will be dependent on the funding available to Argyll and Bute Council and NHS Highland and the corporate priorities of both. Both parties will provide indicative three year allocations to the Integration Joint Board subject to annual approval through the respective budget setting processes. These indicative allocations will take account of changes in NHS funding and changes in local authority funding.

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11.4.10 A report should be submitted to Argyll and Bute Integration Joint Board each year setting out the process, timetable and key assumptions to be adopted in drafting the budget.

11.4.11 Each year the Chief Financial Officer and Chief Officer of the Partnership should prepare a draft budget for the Integration Joint Board based on the three year strategic plan and present this to Argyll and Bute Council and NHS Highland.

11.4.12 The draft annual budget should be prepared to take account of the matters set out above and uses the previous year payment as a baseline that will be adjusted to take account of:  Activity Changes arising from the impact on resources in respect of increased demand (e.g. demographic pressures and increased prevalence of long term conditions) and for other planned activity changes.  Cost inflation on pay and other costs.  Efficiency savings that can be applied to budgets.  Performance on outcomes. The potential impact of efficiencies on agreed outcomes must be clearly stated and open to challenge by the Council and NHS.  Legal requirements that result in additional and unavoidable expenditure commitments.  Transfers to/from the set aside budget for hospital services set out in the 3 Year Strategic Plan.  Budget savings required to ensure budgeted expenditure is in line with funding available including an assessment of the impact and risks associated with these savings.

11.4.13 The Council and NHS will each prepare a schedule outlining the detail and total value of the proposed payment and the underlying assumptions behind that initial payment.

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11.4.14 The Director of Finance of NHS Highland, the Section 95 Officer of Argyll and Bute Council and the Chief Financial Officer of Argyll and Bute Integration Joint Board will ensure a consistency of approach and application of processes in considering budget assumptions and proposals.

11.4.15 Due diligence of Argyll and Bute Council and NHS Highland contributions will be undertaken annually and the Chief Financial Officer of Argyll and Bute Integration Joint Board will prepare a schedule outlining the agreed value of the payments. The schedule must be approved by the Argyll and Bute Integration Joint Board Chief Officer, Argyll and Bute Council Section 95 Officer, NHS Highland Director of Finance to confirm their agreement.

11.4.16 The allocations made from Argyll and Bute Integration Joint Board to Argyll and Bute Council and NHS Highland for operational delivery of services will be approved by the Partnerships Board. The value of the payments will be as set out in the 3 Year Strategic Plan and supporting financial plan.

11.4.17 The direction from the Argyll and Bute Integration Joint Board to Argyll and Bute Council and NHS Highland will take the form of a letter from the Chief Officer referring to the arrangements for delivery set out in the 3 Year Strategic Plan and will include information on:  The delegated function/(s) that are being directed.  The outcomes and activity levels to be delivered for those delegated functions.  The amount of and method of determining the payment to carry out the delegated functions.

11.4.18 Once issued these can be amended or varied by a subsequent direction by the Argyll and Bute Integration Joint Board.

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11.4.19 Any potential deviation from a break even position should be reported to the board of Argyll and Bute Integration Joint Board and Argyll and Bute Council and NHS Highland at the earliest opportunity.

11.4.20 Where it is forecast that an overspend will arise then the Chief Officer and Chief Financial Officer of Argyll and Bute Integration Joint Board will identify the cause of the forecast overspend and prepare a recovery plan setting out how they propose to address the forecast overspend and return to a breakeven position. The Chief Officer and Chief Financial Officer of Argyll and Bute Integration Joint Board should consult the Section 95 Officer of Argyll and Bute Council and Director of Finance of NHS Highland in preparing the recovery plan. The recovery plan should be approved by the board of Argyll and Bute Integration Joint Board.

11.4.21 A recovery plan should aim to bring the forecast expenditure of Argyll and Bute Integration Joint Board back in line with the budget within the current financial year. Where an in year recovery cannot be achieved then any recovery plan that extends into later years should ensure that over the period of the strategic plan forecast expenditure does not exceed the resources made available. Any recovery plan extending beyond in year will require approval of Argyll and Bute Council and NHS Highland in addition to Argyll and Bute Integration Joint Board.

11.4.22 Where are a recovery plan extends beyond the current year any shortfall (the amount recovered in later years) will be charged to reserves held by Argyll and Bute Integration Joint Board.

11.4.23 Where such recovery plans are unsuccessful and an overspend occurs at the financial year end, and there are insufficient reserves to meet the overspend, then the partners will be required to make additional payments to the Integrated Joint Board. Any additional payments by Argyll and Bute Council and NHS Highland will then be deducted from future years funding/payments.

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11.4.24 Argyll and Bute Integration Joint Board may retain any underspend to build up its own reserves and the Chief Financial Officer will develop a reserves policy for Argyll and Bute Health and Social Care Partnership.

11.4.25 There will be arrangements in place to allow budget managers to vire budgets between different budget heads set out in the financial regulations.

11.4.26 Redeterminations to payments made by Argyll and Bute Council and NHS Highland to Argyll and Bute Integration Joint Board would apply under the following circumstances:  Additional one off funding is provided to Partner bodies by the Scottish Government, or some other body, for expenditure within a service area delegated to Argyll and Bute Health and Social Care Partnership. This would include in year allocations for NHS and redeterminations as part of the local government finance settlement. The payments Argyll and Bute Integration Joint Board should be adjusted to reflect the full amount of these as they relate to the delegated services. Partner bodies agree that an adjustment to the payment is required to reflect changes to demand and activity levels.

11.4.27 Where payments by Argyll and Bute Council and NHS Highland are agreed under paragraphs 11.4.3 to 11.4.21 above they should only be varied a result of the circumstances set out in paragraphs 11.4.23 to 11.4.31. Any proposal to amend the payments out with the above, including any proposal to reduce payments as a result of changes in the financial circumstances of either Argyll and Bute Council or NHS Highland requires a justification to be set out and the agreement of both parties.

11.5 Financial Systems

11.5.1 The Chief Financial Officer will work with the Section 95 Officer of Argyll and Bute Council and Director of Finance of NHS Highland to ensure appropriate systems and processes are in place to:

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 Allow execution of financial transactions.  Ensure an effective internal control environment over such transactions.  Maintain a record of the income expenditure, assets and liabilities of Argyll and Bute Health and Social Care Partnership.  Enable reporting of the financial performance and position of Argyll and Bute Health and Social Care Partnership.  Maintain records of budgets, budget savings, forecast outturns, variances, variance explanations, proposed remedial actions and financial risks.

11.6 Financial reporting to Argyll and Bute Integration Joint Board

11.6.1 Prior to the start of each financial year the Board of Argyll and Bute Integration Joint Board will consider a report setting out the budget proposals for the coming financial year. This report will also set out for consideration by the board the proposal to achieve any budgetary savings required.

11.6.2 Throughout the financial year the board of Argyll and Bute Integration Joint Board will receive comprehensive financial monitoring reports on at least a quarterly basis. The reports will set out information on actual expenditure and budget for the year to date and forecast outturn against annual budget together with explanations of significant variances and details of any action required. These reports will also set out progress with achievement of any budgetary savings required.

11.6.3 The Chief Financial Officer will keep the board advised of key financial risks for Argyll and Bute Health and Social Care Partnership.

11.6.4 Following the end of the financial year the Chief Financial Officer will report to the board on actual outturn income and expenditure compared to budget for the preceding financial year with an explanation of significant variances.

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11.6.5 The Board of Argyll and Bute Integration Joint Board will review at least annually the level of reserves and the policy in relation to reserves for the Partnership.

11.6.6 The Board will review at least annually a report setting out the medium and longer term financial position of Argyll and Bute Integration Joint Board and the implications for the strategic plan of the Partnership.

7.7 Financial Reporting to Chief Officer

7.7.1 The Chief Financial Officer will support the Chief Officer by providing financial information, advice and support, where appropriate liaising with the Section 95 Officer of Argyll and Bute Council and Director of Finance of NHS Highland. This will include information, support and guidance in relation to:  Preparation and review of the 3 year strategic plan.  Developing a medium and longer term financial strategy to support delivery of the 3 year strategic plan.  Preparation and review of the annual budget.  Collating and reviewing budget savings proposals.  Information on actual income and expenditure.  Information on forecast outturns and annual budget.  Collating and reviewing explanations of significant variances.  Collating and reviewing action required in response to significant variances.  Identifying and analysing financial risks.  Considering the proposals in relation to reserves.

11.8 Financial Reporting to Management

11.8.1 The Chief Financial Officer will work with the Section 95 Officer of Argyll and Bute Council and Director of Finance of NHS Highland to ensure:

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 Managers are consulted in preparing the budget of Argyll and Bute Health and Social Care Partnership.  Managers are supported in identifying budgetary savings.  Managers are made aware of the budget they have available.  Managers are provided with information on actual income and expenditure.  Managers are provided with information on previous forecast outturns.  Managers are supported to provide up to date information on forecast outturns.  Managers are supported to provide explanations of significant variances.  Managers are supported to identify action required.  Managers are supported to identify and assess financial risks.  Managers are supported to identify and assess future medium to longer term budget implications.

11.9 Financial Statements

11.9.1 The legislation requires that Argyll and Bute Integration Joint Board is subject to the audit and accounts provisions of a body under Section 106 of the Local Government (Scotland) Act 1973 (Section 13). This will require audited annual accounts to be prepared with the reporting requirements specified in the relevant legislation and regulations (Section 12 of the Local Government in Scotland Act 2003 and regulations under section 105 of the Local Government (Scotland) Act 1973).

11.9.2 Unaudited financial statements will be prepared and circulated to members of the board in accordance with relevant legislation. The audit of financial statements will be completed and audited financial statements approved by the board and circulated to members of the board in accordance with legislative requirements and professional guidance.

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11.9.3 Financial statements will be prepared to comply with Code of Practice on Local Authority Accounting and other relevant professional guidance.

11.9.4 The financial statements will be signed in line with the governance arrangements for the integrated joint boards and as specified in the Regulations under section 105 of the Local Government (Scotland) Act 1973.

11.9.5 The Chief Financial Officer of Argyll and Bute Integration Joint Board will supply any information required to support the development of the year- end financial statements and annual report for both Argyll and Bute Council and NHS Highland.

11.10 Audit Committee

11.10.1 Argyll and Bute Integration Joint Board will establish an Audit Committee to be responsible for overseeing the system of corporate governance and internal controls. The Audit Committee should operate in accordance with professional guidance for Audit Committees. The board of Argyll and Bute Integration Joint Board will approve a terms of reference for the Audit Committee. The Audit Committee will ensure effective liaison and co-ordination between internal and external audit activity.

11.11 Internal Audit

11.11.1 It is the responsibility of the Argyll and Bute Integration Joint Board to establish adequate and proportionate internal audit arrangements for review of the adequacy of the arrangements for risk management, governance and control of the delegated resources.

11.11.2 Argyll and Bute Integration Joint Board will appoint an Internal Audit Section to provide internal audit services to the board. The Chief Internal Auditor will fulfil the role of Chief Internal Auditor of Argyll and Bute Health and Social Care Partnership. The Chief Internal Auditor will report to both the Audit Committee and Chief Officer of Argyll and Bute Health and Social Care

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Partnership. The Chief Internal Auditor of Argyll and Bute Integration Joint Board will liaise effectively with the Chief Internal Auditors of Argyll and Bute Council and NHS Highland to ensure effective delivery of internal audit that is risk based, proportionate and proportionate and avoids duplication of effort.

11.11.3 An annual internal audit programme will be prepared for approval by the Audit Committee. Progress against the internal audit plan, the outcome of each audit review and progress against implementation of audit recommendations will be reported to the Audit Committee.

11.11.4 The Chief Internal Auditor will liaise with the Chief Internal Auditors of Argyll and Bute Council and NHS Highland in relation to internal audits within the partners that have implications for Argyll and Bute Integration Joint Board and bring to the Audit Committee a summary of the relevant issues from these reports. It will be the responsibility of Argyll and Bute Council and NHS Highland to ensure an effective, risk based and proportionate internal audit of activities that fall within Argyll and Bute Integration Joint Board and which are delegated back to either Argyll and Bute Council or NHS Highland. The Chief Internal Auditor of Argyll and Bute Council and NHS Highland will liaise with the Chief Internal Auditor of Argyll and Bute Integration Joint Board in developing and delivery of their programmes of internal audit activity.

11.11.6 Following the end of the financial year the Chief Internal Auditor will report to the Audit Committee with an annual report on delivery of the plan including an overall audit opinion. The Audit Committee will prepare a report for submission to the board at the end of each financial year summarising the work of the Audit Committee during the year and the Audit Committees opinion on the effectiveness of Argyll and Bute Integration Joint Board internal controls. The annual reports of the Chief Internal Auditor and Audit Committee will be shared with both Argyll and Bute Council and NHS Highland.

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11.12 External Audit

11.12.1 The Accounts Commission will appoint the external auditors to the Integrated Joint Board. The external auditor will submit an annual external audit plan to the Audit Committee prior to the start of each financial year. All reports prepared by the external auditor will be submitted to the Audit Committee.

11.13 Capital Expenditure and Non-Current Assets

11.13.1 The Argyll and Bute Integration Joint Board will not receive any capital allocations, grants or have the power to invest in capital expenditure nor will it own any property or other non-current assets. Argyll and Bute Council and NHS Highland will:  Continue to own any property or non-current assets used by Argyll and Bute Health and Social Care Partnership.  Have access to sources of funding for capital expenditure.  Manage and deliver any capital expenditure on behalf of Argyll and Bute Health and Social Care Partnership.

11.13.2 The Chief Officer of Argyll and Bute Integration Joint Board will work with the relevant officers in Argyll and Bute Council and NHS Highland to prepare and maintain an asset register of property and noncurrent assets used by Argyll and Bute Health and Social Care Partnership.

11.13.3 The Chief Officer of Argyll and Bute Integration Joint Board will work with the relevant officers in Argyll and Bute Council and NHS Highland to prepare an asset management plan for Argyll and Bute Integration Joint Board to be approved by the board of Argyll and Bute Integration Joint Board within a timescale to be agreed annually by Argyll and Bute Council and NHS Highland (it is expected this would normally be 30 September). The asset management plan will set out suitability, condition, risks, performance and

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investment needs related to existing property and other non-current assets identifying any new or significant changes to the asset base.

11.13.4 Alongside the asset management plan the Chief Officer of Argyll and Bute Integration Joint Board will work with the relevant officers in Argyll and Bute Council and NHS Highland to prepare a bid for capital funding for property and other non-current assets used by Argyll and Bute Health and Social Care Partnership. This should be approved by the board of Argyll and Bute Integration Joint Board within a timescale to be agreed annually with Argyll and Bute Council and NHS Highland (it is expected this would normally be 30 September). A business case approach should be adopted to set out the need and assess the options for any proposed capital investment. Any business case will set out how the investment will meet the strategic objectives of the Integrated Joint Board and set out the associated revenue costs.

11.13.5 Whilst responsibility for managing and delivery of capital expenditure remains the responsibility of Argyll and Bute Council or NHS Highland the relevant officers in Argyll and Bute Council and NHS Highland will work with the Chief Officer of Argyll and Bute Integration Joint Board to report regularly (or quarterly) on progress with capital expenditure related to property or other non-current assets used by Argyll and Bute Health and Social Care Partnership.

11.13.6 The Argyll and Bute Health and Social Care Partnership, Argyll and Bute Council and NHS Highland will work together to ensure capital expenditure and property or other non-current assets are used as effectively as possible and in compliance with the relevant legislation on use of public assets.

11.13.7 Legacy projects will be managed by the relevant partner – either Argyll or Bute Council or NHS Highland with reporting of progress as set out above.

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11.13.8 Depreciation of property and other non-current assets used in the services within scope of Argyll and Bute Integration Joint Board will be charged to the accounts of Argyll and Bute Integration Joint Board and incorporated in the budgets and payments to Argyll and Bute Health and Social Care Partnership.

11.13.9 Revenue costs from property and other non-current assets used in the services within scope of Argyll and Bute Integration Joint Board will be charged to the accounts of Argyll and Bute Integration Joint Board and incorporated in the budgets and payments to Argyll and Bute Health and Social Care Partnership.

11.13.10 Any gains or losses on disposal of property and other non-current assets used in the services within scope of Argyll and Bute Integration Joint Board will be retained within the accounts of Argyll and Bute Council or NHS Highland and not charged to Argyll and Bute Health and Social Care Partnership.

11.13.11 Capital receipts will be retained by Argyll and Bute Council or NHS Highland.

11.14 VAT

11.14.1 The Argyll and Bute Integration Joint Board will not be required to be registered for VAT, on the basis it is not delivering any supplies that fall within the scope of VAT. The actual delivery of functions delegated to Argyll and Bute Integration Joint Board will continue to be the responsibility of the Argyll and Bute Council and NHS Highland.

11.14.2 Both the Argyll and Bute Council and NHS Highland will continue to adhere to their respective VAT arrangements which will be accounted for through respective financial ledgers and statements. The Argyll and Bute Integration Joint Board will consult HMRC regarding any VAT issues arising

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from proposed transfer of services between partner organisations (e.g. VAT leakage) taking specialist external VAT advice beforehand if necessary.

12. Participation and Engagement

12.1 The core value of the Argyll and Bute Health and Social Care Partnership is a person centred approach, ensuring compassion, respect, equality and fairness. Community and staff involvement and engagement remains crucial to planning and implementing effective service change and service development, as well as realising continuous improvement in quality, effectiveness and efficiency in service delivery and outcomes.

12.2 Building on the existing solid foundation, Argyll and Bute Health and Social Care Partnership’s intent for participation and engagement is that it is part of our normal business is delivered via a coproduction approach, achieving a positive relationship with our communities, those who use our services but also the staff who provide them.

12.3 To inform this, the Argyll and Bute Integration Joint Board, will take account of current Statutory Guidance CEL 4 (2010) Informing, Engaging and Consulting with People in Developing Health and Community Care Services, other Participation Standard and National Standards for Community Engagement and any future guidance or standards as well as implementing its own best practice and direction from the Scottish Health Council.

12.4 The Argyll and Bute Health and Social Care Partnership will establish a Communications and Engagement Group to lead and govern its approach. Its membership will include Public Involvement and Communications staff, community representatives covering the geographical area, as well as representation from Trades Unions / Staff Side and the Third sector. The Group will be responsible for developing, implementation and monitoring of the Communications and Engagement Strategy.

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12.5 In line with existing Statutory Guidance CEL 4 (2010) or any subsequent guidance, the Communications and Engagement Strategy will include media, public relations and marketing, participation / engagement methodologies for staff and communities (including seldom heard groups taking into account the Equalities Act 2010), feedback to communities and staff, how this has influenced developments / governance arrangements, and mechanisms to ensure community representatives receive the level of support they require to enable their full participation. This will be developed post April 2015 and will be an ongoing iterative strategy.

12.6 Feedback from our communities and staff on their experiences of our services is absolutely fundamental to the work of the Partnership. It is crucial to ensuring continuous improvements in quality, efficiency and effectiveness and is a key performance indicator for services. This will improve service delivery by ensuring patients/care users are at the centre of the process and equal partners in making decision about the care they receive. Of equal importance are the views of our staff, communities, service users and communities to contribute to policy and service review and development. Key principles of the Communications and Engagement Plan demonstrate the value of feedback and the way it influences improvement - “You Said, We Did” philosophy. A range of methodologies will be employed to capture this including social media and web based technology e.g. Patient Opinion.

12.7 The Argyll and Bute Public Partnership Forum (PPF), established in 2006’ is recognised as an approach which has been effective to date. It is a “Hub and Spoke” model of Seven Locality PPFs, reporting to and feeding into local operational management in the NHS. They were developed to ensure local people could work with local staff to develop and improve local services. Localities are the engine room of integration and transformation of services and our intent is to continue, strengthen and develop locality PPFs to support this. Participation and involvement in the PPF is open to all members of the public across Argyll and Bute.

12.8 The elected Chair and Vice Chair of the Argyll and Bute Public Partnership Forum will be members of the Joint Integration Board. .

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12.9 Whilst formal arrangements are essential for the Argyll and Bute Health and Social Care Partnership, they need not be constraining. There is a history in Argyll and Bute of involving community representatives on review and project groups and using the co-chair model to advantage. Our aim is to maintain this inclusive approach, keeping communities at the heart of the process, within the framework of robust organisational arrangements. . 12.10 Positive relationships with Argyll Voluntary Action, specialist organisations, care groups, independent care providers, and other health and social care related community and voluntary groups support the Partnership. This is crucial in facilitating improvements to and developments in services. The localities PPF work within existing arrangements with other public sector organisations e.g. Argyll and Bute Community Planning Partnership and Community Councils to strengthen and develop participation and engagement across all partners.

12.11 In involving the public and people as individuals, we will engage with our whole community and make sure that we reflect its diversity. We know that people living in the most deprived communities and those with disabilities, or from different ethnic backgrounds, faiths and sexual orientation, have specific health and care issues and may face additional barriers in accessing services. This will influence the process of community engagement. The Partnership will ensure that those who are vulnerable, disadvantaged or in a minority have equal opportunity to influence the shape of services or the provision of their own care and the Joint Integration Board will continue to work with the PPF and Scottish Health Council to put in place appropriate involvement mechanisms and processes which will be reflected in the Communications and Engagement Strategy.

12.12 The Parties will carry out Equality Impact Assessments (EQIAs) / Planning for Fairness Assessments (PFFs), in line with legislation, to ensure that services and policies do not disadvantage communities and staff.

12.13 Ensuring local public and staff involvement and communication will be the specified responsibility of the locality senior managers and their teams. The Argyll and Bute Health and Social Care Partnership will provide leadership and support for

Draft v 1.1 20.11.2014 Page 45 CONSULTATION DRAFT involvement / engagement / participation and communications by designated staff across the catchment area for example a Public Involvement and communications Manager. The Argyll and Bute Health and Social Care Partnership will also lead on formal consultation on major service change either within its catchment area or in support of service change out with its area where Argyll and Bute residents access services.

12.14 Effective public involvement and engagement requires skilled support and resources. The Argyll and Bute Health and Social Care Partnership will undertake an analysis to identify what kinds of skills and resources are needed, and how capability and capacity can be accessed and developed. This will include not only statutory agency resources but independent sector and voluntary sources including where necessary impartial support. Synergy and coproduction offer the greatest opportunity to make best use of skills and resources

12.15 The Argyll and Bute Health and Social Care Partnership recognises that designated financial and other resources are required to deliver its stated participation and engagement intent. Its current arrangements supporting volunteer involvement will remain with operational services i.e. repayment of volunteer's expenses, in accordance with current NHS Highland Expenses Policy for Volunteers. There will also remain dedicated management input by an Argyll and Bute based Public Involvement Manager to lead and promote participation and engagement, with a specified budget for development and administration. Specific resources for dedicated projects / initiatives will be assessed and identified on a case by case basis. The level of resourcing and impact of engagement and communication activities will be assessed by the Communications and Engagement group as part of its annual report of participation and engagement to the Joint Integration Board.

13. Information Sharing and Data Handling

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13.1 The Parties agree to be bound by the Data Sharing Protocol and to continuance of the existing agreement to use the Scottish Accord on the Sharing of Personal Information (SASPI), in respect of Information Sharing.

13.2 The Argyll & Bute Integration Joint Board will confirm their commitment to the Data Sharing Protocol and the Information Sharing Agreement and will be able to comment on the data and information sharing arrangements and associated procedures.

13.3 The Chief Officer will ensure appropriate arrangements are in place in respect of information governance and the requirements of the Information Commissioner’s Office.

13.4 All staff managed within the Partnership will be contractually required to comply with the data confidentiality policies of their employing organisations and the requirements of the Data Sharing Protocol that is agreed by the Argyll & Bute Integration Joint Board.

13.5 The Parties will establish a Data and Information Group to agree a high-level information sharing agreement. The existing Data Sharing Agreement in place between NHS Highland and Argyll and Bute Council will be developed to reflect the new Integration Joint Board arrangements and be implemented by the 31st March 2015.

13.6 With regard to individually identifiable material, data will be held in both electronic and paper formats and only be accessed by authorised staff, in order to provide the patient or service user with the appropriate service. In order to provide fully integrated services it may be necessary to share information within the Partnership and with external agencies, where this is the case the Partnership will seek the consent of the service user for the sharing of data, unless a statutory requirement exists. In order to comply with the Data Protection Act 1998, the Partnership will always ensure that personal data it processes will be handled fairly, lawfully and within justification.

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13.7 In order to comply with the Data Protection Act 1988, the Partnership will ensure that any personal data that it holds will be processed in line with the Data Protection Principles contained within Schedule 1 of the Act.

14. Complaints

The Parties agree the following arrangements in respect of complaints by service users and those complaining on behalf of service users.

14.1 Both of the Parties will retain separate complaints policies reflecting distinct statutory requirements. The Patient Rights (Scotland) Act 2011 makes provision for patients to complain about NHS services and the Social Work (Scotland) Act 1968 makes provision for complaints about social work services.

14.1.1 There will be a single point of contact within the partnership to co- ordinate the complaints function specific to Partnership issues. This will ensure that the requirements of existing legal/prescribed elements of health and social work complaints processes are met (including SPSO). This will also enable the Partnership to develop consistent high standard processes to include investigation, response and learning measures.

14.1.2 Partnership staff will apply the complaints policy of the relevant Party, depending on the nature of the complaint made. Where a complaint could be dealt with by the policies of both Parties, the appropriate Partnership manager will determine whether both need to be applied separately or a single joint response is appropriate. Where a joint response to such a complaint is not possible or appropriate, the material issues will be separated and progressed through the respective Party’s procedures.

14.2 In the first instance all complaints will be handled by front line staff. If they are unresolved they will then be passed to a relevant senior manager and thereafter to the Chief Officer.

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14.3 If the complaint remains unresolved it will be passed to the SPSO for health or the complaints review committee and then the SPSO for social care.

14.4 All complaints procedures will be clearly explained, well publicised, accessible, will allow for timely recourse and will sign-post independent advocacy services.

14.5 The person making the complaint will always be informed which policies are being applied to their complaint.

14.6 Complaints management will be a standing item on the agenda of the Health and Care Sub Committee, whose remit will include identifying learning from upheld complaints across all delegated functions.

15. Claims Handling, Liability & Indemnity

The Parties agree the following arrangements in respect of claims handling, liability and indemnity:

15.1 The Argyll & Bute Integration Joint Board, whilst having a legal personality in its own right has neither assumed nor replaced the rights or responsibilities of either the Health Board or the Council as the employers of staff who are managed within the Partnership, or for the operation of buildings or services under the operational remit of those staff.

15.2 The Parties will continue to indemnify, insure and accept responsibility for the Partnership staff that they employ; their particular capital assets that the Partnership uses to deliver services with or from; and the respective services themselves, which each Party has delegated to the Argyll & Bute Integration Joint Board.

15.3 Liabilities arising from decisions taken by the Argyll & Bute Integration Joint Board will be equally shared between the Parties.

16. Risk Management

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16.1 The Argyll & Bute Integration Joint Board will:

16.1.1 Establish risk monitoring and reporting as set out in the risk monitoring framework as developed by the Parties.

16.1.2 Maintain the risk information and share with the Parties within the timescales specified.

16.2 The Chief Officer will ensure that his/her work with the Partnership’s Senior Management Team includes a focus on risk monitoring and risk management. The Chief Officer and the Partnership’s Senior Management Team will undertake an annual review of the Partnership’s integrated strategic risk register. This will identify, assess and prioritise risks related to the planning and delivery of delegated functions, particularly any which are likely to affect the delivery of the 3 Year Strategic Plan and identify and describe processes for mitigating those risks. This process will also take due cognisance of the overall corporate risk registers of both Parties.

16.3 A Strategic risk register will be presented to the Audit Committee for scrutiny and the Argyll & Bute Integration Joint Board for approval on an annual basis. The Chief Officer is responsible for bringing to the attention of the Argyll & Bute Integration Joint Board any substantive developments in-year that lead to a significant change to the strategic risk register, out with the routine review process.

16.4 The approved strategic risk register will be shared with both of the Parties on an annual basis to contribute to their individual risk management strategies.

17. Dispute resolution mechanism

17.1 Where either of the Parties fails to agree with the other or with the Argyll & Bute Integration Joint Board on any issue related to this Scheme, then they will follow a process which comprises:

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17.1.1 The Chief Executives of the Health Board and the Local Authority, and the Chief Officer, will meet to resolve the issue.

17.1.2 If unresolved, the Health Board, the Local Authority and the Argyll & Bute Integration Joint Board will each prepare a written note of their position on the issue and exchange it with the others.

17.1.3 In the event that the issue remains unresolved, representatives of the Health Board, the Local Authority and the Argyll & Bute Integration Joint Board will proceed to non-binding mediation with a view to resolving the issue.

17.2 With regard to the process of appointing a mediator, a representative of NHS Highland and a representative of Argyll and Bute Council will meet with a view to appointing a suitable independent mediator. If agreement cannot be reached a referral will be made to the President of The Law Society of Scotland inviting the President to appoint a mediator.

17.3 Where an issue remains unresolved following the process of mediation, the Chief Executive Officers of NHS Highland and Argyll and Bute Council will communicate in writing with Scottish Ministers, on behalf of the Parties, informing them of the issue under dispute and that agreement cannot be reached.

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Annex 1 Part 1 Functions delegated by the Health Board to the Integration Joint Board

Set out below is the list of functions that must be delegated by the Health Board to the Integration Joint Board as set out in the Public Bodes (Joint Working) (Prescribed Health Board Functions) (Scotland) Regulations 2014. Further health functions can be delegated as long as they fall within the functions set out in Schedule One of the same instrument;

SCHEDULE 1 Regulation 3

Functions prescribed for the purposes of section 1(8) of the Act Column A Column B The National Health Service (Scotland) Act 1978

All functions of Health Boards conferred by, or Except functions conferred by or by virtue of— by virtue of, the National Health Service (Scotland) Act 1978 section 2(7) (Health Boards); section 2CA(1) (Functions of Health Boards outside Scotland); section 9 (local consultative committees);

section 17A (NHS Contracts);

section 17C (personal medical or dental services); section 17I(2) (use of accommodation); section 17J (Health Boards’ power to enter into general medical services contracts); section 28A (remuneration for Part II services); section 38(3) (care of mothers and young children);

(1) Section 2CA was inserted by S.S.I. 2010/283, regulation 3(2). (2) Section 17I was inserted by the National Health Service (Primary Care) Act 1997 (c.46), Schedule 2 and amended by the Primary Medical Services (Scotland) Act 2004 (asp 1), section 4. The functions of the Scottish Ministers under section 17I are conferred on Health Boards by virtue of S.I. 1991/570, as amended by S.S.I. 2006/132. (3) The functions of the Secretary of State under section 38 are conferred on Health Boards by virtue of S.I. 1991/570.

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section 38A(4) (breastfeeding);

section 39(5) (medical and dental inspection, supervision and treatment of pupils and young persons); section 48 (provision of residential and practice accommodation); section 55(6) (hospital accommodation on part payment); section 57 (accommodation and services for private patients); section 64 (permission for use of facilities in private practice); section 75A(7) (remission and repayment of charges and payment of travelling expenses); section 75B(8)(reimbursement of the cost of services provided in another EEA state); section 75BA (9)(reimbursement of the cost of services provided in another EEA state where expenditure is incurred on or after 25 October 2013);

section 79 (purchase of land and moveable property); section 82(10) use and administration of certain endowments and other property held by Health Boards); section 83(11) (power of Health Boards and local health councils to hold property on trust);

(4) Section 38A was inserted by the Breastfeeding etc (Scotland) Act 2005 (asp 1), section 4. The functions of the Scottish Ministers under section 38A are conferred on Health Boards by virtue of S.I. 1991/570 as amended by S.S.I. 2006/132. (5) Section 39 was relevantly amended by the Self Governing Schools etc (Scotland) Act 1989 (c.39) Schedule 11; the Health and Medicines Act 1988 (c.49) section 10 and Schedule 3 and the Standards in Scotland’s Schools Act 2000 (asp 6), schedule 3. (6) Section 55 was amended by the Health and Medicines Act 1988 (c.49), section 7(9) and Schedule 3 and the National Health Service and Community Care Act 1990 (c.19), Schedule 9. The functions of the Secretary of State under section 55 are conferred on Health Boards by virtue of S.I. 1991/570. (7) Section 75A was inserted by the Social Security Act 1988 (c.7), section 14, and relevantly amended by S.S.I. 2010/283. The functions of the Scottish Ministers in respect of the payment of expenses under section 75A are conferred on Health Boards by S.S.I. 1991/570. (8) Section 75B was inserted by S.S.I. 2010/283, regulation 3(3) and amended by S.S.I. 2013/177. (9) Section 75BA was inserted by S.S.I. 2013/292, regulation 8(4). (10) Section 82 was amended by the Public Appointments and Public Bodies etc. (Scotland) Act 2003 (asp 7) section 1(2) and the National Health Service Reform (Scotland) Act 2004 (asp 7), schedule 2. (11) There are amendments to section 83 not relevant to the exercise of a Health Board’s functions under that section.

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section 84A(12) (power to raise money, etc., by appeals, collections etc.); section 86 (accounts of Health Boards and the Agency);

section 88 (payment of allowances and remuneration to members of certain bodies connected with the health services); section 98 (13) (charges in respect of non- residents); and paragraphs 4, 5, 11A and 13 of Schedule 1 to the Act (Health Boards); and functions conferred by— The National Health Service (Charges to Overseas Visitors) (Scotland) Regulations 1989 (14); The Health Boards (Membership and Procedure) (Scotland) Regulations 2001/302; The National Health Service (Clinical Negligence and Other Risks Indemnity Scheme) (Scotland) Regulations 2000/54;

The National Health Services (Primary Medical Services Performers Lists) (Scotland) Regulations 2004/114; The National Health Service (Primary Medical Services Section 17C Agreements) (Scotland) Regulations 2004;

The National Health Service (Discipline Committees) Regulations 2006/330;

The National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006/135; The National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009/183;

The National Health Service (General Dental Services) (Scotland) Regulations 2010/205; and

(12) Section 84A was inserted by the Health Services Act 1980 (c.53), section 5(2). There are no amendments to section 84A which are relevant to the exercise of a Health Board’s functions. (13) Section 98 was amended by the Health and Medicines Act 1988 (c.49), section 7. The functions of the Secretary of State under section 98 in respect of the making, recovering, determination and calculation of charges in accordance with regulations made under that section is conferred on Health Boards by virtue of S.S.I. 1991/570. (14) S.I. 1989/364, as amended by S.I. 1992/411; S.I. 1994/1770; S.S.I. 2004/369; S.S.I. 2005/455; S.S.I. 2005/572 S.S.I. 2006/141; S.S.I. 2008/290; S.S.I. 2011/25 and S.S.I. 2013/177.

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The National Health Service (Free Prescription and Charges for Drugs and Appliances) (Scotland) Regulations 2011/55(15). Disabled Persons (Services, Consultation and Representation) Act 1986 Section 7 (Persons discharged from hospital)

Community Care and Health (Scotland) Act 2002

All functions of Health Boards conferred by, or by virtue of, the Community Care and Health (Scotland) Act 2002.

Mental Health (Care and Treatment) (Scotland) Act 2003 All functions of Health Boards conferred by, or Except functions conferred by— by virtue of, the Mental Health (Care and Treatment) (Scotland) Act 2003. section 22 (Approved medical practitioners);

section 34 (Inquiries under section 33: co- operation)(16);

section 38 (Duties on hospital managers: examination notification etc.)(17);

section 46 (Hospital managers’ duties: notification)(18);

section 124 (Transfer to other hospital);

section 228 (Request for assessment of needs: duty on local authorities and Health Boards);

section 230 (Appointment of a patient’s responsible medical officer);

section 260 (Provision of information to patients); section 264 (Detention in conditions of excessive security: state hospitals);

(15) S.S.I. 2011/55, to which there are amendments not relevant to the exercise of a Health Board’s functions. (16) There are amendments to section 34 not relevant to the exercise of a Health Board’s functions under that section. (17) Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards under that Act. (18) Section 46 is amended by S.S.I. 2005/465.

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section 267 (Orders under sections 264 to 266: recall); section 281(19) (Correspondence of certain persons detained in hospital); and functions conferred by—

The Mental Health (Safety and Security) (Scotland) Regulations 2005(20);

The Mental Health (Cross Border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2005(21);

The Mental Health (Use of Telephones) (Scotland) Regulations 2005(22); and

The Mental Health (England and Wales Cross border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2008(23).

Education (Additional Support for Learning) (Scotland) Act 2004 Section 23 (other agencies etc. to help in exercise of functions under this Act) Public Services Reform (Scotland) Act 2010

All functions of Health Boards conferred by, or Except functions conferred by— by virtue of, the Public Services Reform (Scotland) Act 2010 section 31(Public functions: duties to provide information on certain expenditure etc.); and section 32 (Public functions: duty to provide information on exercise of functions). Patient Rights (Scotland) Act 2011

All functions of Health Boards conferred by, or Except functions conferred by The Patient by virtue of, the Patient Rights (Scotland) Act Rights (Complaints Procedure and 2011 Consequential Provisions) (Scotland) Regulations 2012/36(24).

(19) Section 281 is amended by S.S.I. 2011/211. (20) S.S.I. 2005/464, to which there are amendments not relevant to the exercise of the functions of a Health Board. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (21) S.S.I. 2005/467. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (22) S.S.I. 2005/468. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (23) S.S.I. 2008/356. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (24) S.S.I. 2012/36. Section 5(2) of the Patient Rights (Scotland) Act 2011 (asp 5) provides a definition of “relevant NHS body” relevant to the exercise of a Health Board’s functions.

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Part 2 Services currently provided by the Health Board which are to be integrated

Set out below is the list of services that the minimum list of delegable functions is exercisable in relation to. Further services can be added as they relate to the functions delegated.

 Hospital inpatient (scheduled and unscheduled)  Rural General Hospitals  Mental Health  Paediatrics  Community Hospitals  Hospital Outpatient Services  NHS Community Services (Nursing, Allied Health Professionals, Mental Health Teams, Specialist End of Life Care, Homeless Service, Older Adult Community Psychiatric Nursing, Re-ablement, Geriatricians Community/Acute, Learning Disability Specialist, Community Midwifery, Speech and Language Therapy, Occupational Therapy, Physiotherapy, Audiology  Community Children's Services (Child and Adolescent Mental Health Service Primary Mental Health workers Public Health Nursing Health visiting Public Health Nursing School Nursing Learning Disability Nursing Child Protection Advisors Speech and Language Therapy Occupational Therapy Physiotherapy and Audiology, Specialist Child Health Doctors and Service, Community Paediatricians  GP Services  GP Prescribing  General Dental, Opticians and Community Pharmacy  Support Services  Contracts and Service Level agreements with other NHS boards covering adults and children

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SCHEDULE 2 Regulation 3 Part 1 Functions delegated by the Local Authority to the Integration Joint Board

Set out below is the list of functions that must be delegated by the local authority to the Integration Joint Board as set out in the Public Bodes (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Regulations 2014. Further local authority functions can be delegated as long as they fall within the relevant sections of the Acts set out in the Schedule to the Public Bodies (Joint Working) (Scotland) Act 2014;

SCHEDULE Regulation 2

PART 1

Functions prescribed for the purposes of section 1(7) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Column B Enactment conferring function Limitation

National Assistance Act 1948(25)

Section 48 (Duty of councils to provide temporary protection for property of persons admitted to hospitals etc.)

The Disabled Persons (Employment) Act 1958(26) Section 3 (Provision of sheltered employment by local authorities)

(25) 1948 c.29; section 48 was amended by the Local Government etc. (Scotland) Act 1994 (c.39), Schedule 39, paragraph 31(4) and the Adult Support and Protection (Scotland) Act 2007 (asp 10) schedule 2 paragraph 1. (26) 1958 c.33; section 3 was amended by the Local Government Act 1972 (c.70), section 195(6); the Local Government (Scotland) Act 1973 (c.65), Schedule 27; the National Health Service (Scotland) Act 1978 (c.70), schedule 23; the Local Government Act 1985 (c.51), Schedule 17; the Local Government (Wales) Act 1994 (c.19), Schedules 10 and 18; the Local Government etc. (Scotland) Act 1994 (c.49), Schedule 13; and the National Health Service (Consequential Provisions) Act 2006 (c.43), Schedule 1.

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Column A Column B Enactment conferring function Limitation

The Social Work (Scotland) Act 1968(27) Section 1 So far as it is exercisable in relation to another (Local authorities for the administration of the integration function. Act.)

Section 4 So far as it is exercisable in relation to another (Provisions relating to performance of functions integration function. by local authorities.)

Section 8 So far as it is exercisable in relation to another (Research.) integration function.

Section 10 So far as it is exercisable in relation to another (Financial and other assistance to voluntary integration function. organisations etc. for social work.)

Section 12 Except in so far as it is exercisable in relation to (General social welfare services of local the provision of housing support services. authorities.)

Section 12A So far as it is exercisable in relation to another (Duty of local authorities to assess needs.) integration function.

(27) 1968 c.49; section 1 was relevantly amended by the National Health Service (Scotland) Act 1972 (c.58), schedule 7; the Children Act 1989 (c.41), Schedule 15; the National Health Service and Community Care Act 1990 (c.19) (“the 1990 Act”), schedule 10; S.S.I. 2005/486 and S.S.I. 2013/211. Section 4 was amended by the 1990 Act, Schedule 9, the Children (Scotland) Act 1995 (c.36) (“the 1995 Act”), schedule 4; the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13) (“the 2003 Act”), schedule 4; and S.S.I. 2013/211. Section 10 was relevantly amended by the Children Act 1975 (c.72), Schedule 2; the Local Government etc. (Scotland) Act 1994 (c.39), Schedule 13; the Regulation of Care (Scotland) Act 2001 (asp 8) (“the 2001 Act”) schedule 3; S.S.I. 2010/21 and S.S.I. 2011/211. Section 12 was relevantly amended by the 1990 Act, section 66 and Schedule 9; the 1995 Act, Schedule 4; and the Immigration and Asylum Act 1999 (c.33), section 120(2). Section 12A was inserted by the 1990 Act, section 55, and amended by the Carers (Recognition and Services) Act 1995 (c.12), section 2(3) and the Community Care and Health (Scotland) Act 2002 (asp 5) (“the 2002 Act”), sections 8 and 9(1). Section 12AZA was inserted by the Social Care (Self Directed Support) (Scotland) Act 2013 (asp 1), section 17. Section 12AA and 12AB were inserted by the 2002 Act, section 9(2). Section 13 was amended by the Community Care (Direct Payments) Act 1996 (c.30), section 5. Section 13ZA was inserted by the Adult Support and Protection (Scotland) Act 2007 (asp 10), section 64. Section 13A was inserted by the 1990 Act, section 56 and amended by the Immigration and Asylum Act 1999 (c.33), section 102(2); the 2001 Act, section 72 and schedule 3; the 2002 Act, schedule 2 and by S.S.I. 2011/211. Section 13B was inserted by the 1990 Act sections 56 and 67(2) and amended by the Immigration and Asylum Act 1999 (c.33), section 120(3). Section 14 was amended by the Health Services and Public Health Act 1968 (c.46), sections 13, 44 and 45; the National Health Service (Scotland) Act 1972 (c.58), schedule 7; the Guardianship Act 1973 (c.29), section 11(5); the Health and Social Service and Social Security Adjudications Act 1983 (c.41), schedule 10 and the 1990 Act, schedule 9. Section 28 was amended by the Social Security Act 1986 (c.50), Schedule 11 and the 1995 Act, schedule 4. Section 29 was amended by the 1995 Act, schedule 4. Section 59 was amended by the 1990 Act, schedule 9; the 2001 Act, section 72(c); the 2003 Act, section 25(4) and schedule 4 and by S.S.I. 2013/211.

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Column A Column B Enactment conferring function Limitation Section 12AZA So far as it is exercisable in relation to another (Assessments under section 12A - assistance) integration function.

Section 12AA (Assessment of ability to provide care.)

Section 12AB (Duty of local authority to provide information to carer.)

Section 13 (Power of local authorities to assist persons in need in disposal of produce of their work.)

Section 13ZA So far as it is exercisable in relation to another (Provision of services to incapable adults.) integration function.

Section 13A (Residential accommodation with nursing.)

Section 13B (Provision of care or aftercare.)

Section 14 (Home help and laundry facilities.)

Section 28 So far as it is exercisable in relation to persons (Burial or cremation of the dead.) cared for or assisted under another integration function. Section 29 (Power of local authority to defray expenses of parent, etc., visiting persons or attending funerals.)

Section 59 So far as it is exercisable in relation to another (Provision of residential and other integration function. establishments by local authorities and maximum period for repayment of sums borrowed for such provision.)

The Local Government and Planning (Scotland) Act 1982(28) Section 24(1) (The provision of gardening assistance for the disabled and the elderly.) Disabled Persons (Services, Consultation and Representation) Act 1986(29)

(28) 1982 c.43; section 24(1) was amended by the Local Government etc. (Scotland) Act 1994 (c.39), schedule 13. (29) 1986 c.33. There are amendments to sections 2 and 7 which are not relevant to the exercise of a local authority’s functions under those sections.

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Column A Column B Enactment conferring function Limitation Section 2 (Rights of authorised representatives of disabled persons.) Section 3 (Assessment by local authorities of needs of disabled persons.) Section 7 In respect of the assessment of need for any (Persons discharged from hospital.) services provided under functions contained in welfare enactments within the meaning of section 16 and which have been delegated.

Section 8 In respect of the assessment of need for any (Duty of local authority to take into account services provided under functions contained in abilities of carer.) welfare enactments (within the meaning set out in section 16 of that Act) which are integration functions. The Adults with Incapacity (Scotland) Act 2000(30)

Section 10 (Functions of local authorities.)

Section 12 (Investigations.)

Section 37 Only in relation to residents of establishments (Residents whose affairs may be managed.) which are managed under integration functions.

Section 39 Only in relation to residents of establishments (Matters which may be managed.) which are managed under integration functions.

Section 41 Only in relation to residents of establishments (Duties and functions of managers of authorised which are managed under integration functions establishment.) Section 42 Only in relation to residents of establishments (Authorisation of named manager to withdraw which are managed under integration functions from resident’s account.) Section 43 Only in relation to residents of establishments (Statement of resident’s affairs.) which are managed under integration functions

Section 44 Only in relation to residents of establishments (Resident ceasing to be resident of authorised which are managed under integration functions establishment.)

(30) 2000 asp 4; section 12 was amended by the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13), schedule 5(1). Section 37 was amended by S.S.I. 2005/465. Section 39 was amended by the Adult Support and Protection (Scotland) Act 2007 (asp 10), schedule 1 and by S.S.I. 2013/137. Section 41 was amended by S.S.I. 2005/465; the Adult Support and Protection (Scotland) Act 2007 (asp 10), schedule 1 and S.S.I. 2013/137. Section 45 was amended by the Regulation of Care (Scotland) Act 2001 (asp 8), Schedule 3.

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Column A Column B Enactment conferring function Limitation Section 45 Only in relation to residents of establishments (Appeal, revocation etc.) which are managed under integration functions

The Housing (Scotland) Act 2001(31)

Section 92 Only in so far as it relates to an aid or (Assistance to a registered for housing adaptation. purposes.)

The Community Care and Health (Scotland) Act 2002(32) Section 5 (Local authority arrangements for of residential accommodation outwith Scotland.) Section 14 (Payments by local authorities towards expenditure by NHS bodies on prescribed functions.)

The Mental Health (Care and Treatment) (Scotland) Act 2003(33) Section 17 (Duties of Scottish Ministers, local authorities and others as respects Commission.)

Section 25 Except in so far as it is exercisable in relation to (Care and support services etc.) the provision of housing support services.

Section 26 Except in so far as it is exercisable in relation to (Services designed to promote well-being and the provision of housing support services. social development.)

Section 27 Except in so far as it is exercisable in relation to (Assistance with travel.) the provision of housing support services.

Section 33 (Duty to inquire.)

Section 34 (Inquiries under section 33: Co-operation.)

Section 228 (Request for assessment of needs: duty on local authorities and Health Boards.)

(31) 2001 asp 10; section 92 was amended by the Housing (Scotland) Act 2006 (asp 1), schedule 7. (32) 2002 asp 5. (33) 2003 asp 13; section 17 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), section 111(4), and schedules 14 and 17, and by the Police and Fire Reform (Scotland) Act 2012 (asp 8), schedule 7. Section 25 was amended by S.S.I. 2011/211. Section 34 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedules 14 and 17.

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Column A Column B Enactment conferring function Limitation Section 259 (Advocacy.)

The Housing (Scotland) Act 2006(34)

Section 71(1)(b) Only in so far as it relates to an aid or (Assistance for housing purposes.) adaptation.

The Adult Support and Protection (Scotland) Act 2007(35)

Section 4 (Council’s duty to make inquiries.)

Section 5 (Co-operation.)

Section 6 (Duty to consider importance of providing advocacy and other.) Section 11 (Assessment Orders.)

Section 14 (Removal orders.)

Section 18 (Protection of moved persons property.)

Section 22 (Right to apply for a banning order.)

Section 40 (Urgent cases.)

Section 42 (Adult Protection Committees.)

Section 43 (Membership.) Social Care (Self-directed Support) (Scotland) Act 2013(36) Section 3 Only in relation to assessments carried out (Support for adult carers.) under integration functions.

(34) 2006 asp 1; section 71 was amended by the Housing (Scotland) Act 2010 (asp 17) section 151. (35) 2007 asp 10; section 5 and section 42 were amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedules 14 and 17 and by the Police and Fire Reform (Scotland) Act 2012 (asp 8), schedule 7. Section 43 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedule 14. (36) 2013 asp 1.

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Column A Column B Enactment conferring function Limitation Section 5 (Choice of options: adults.)

Section 6 (Choice of options under section 5: assistances.) Section 7 (Choice of options: adult carers.)

Section 9 (Provision of information about self-directed support.) Section 11 (Local authority functions.)

Section 12 (Eligibility for direct payment: review.)

Section 13 Only in relation to a choice under section 5 or 7 (Further choice of options on material change of the Social Care (Self-directed Support) of circumstances.) (Scotland) Act 2013 . Section 16 (Misuse of direct payment: recovery.)

Section 19 (Promotion of options for self-directed support.)

PART 2 Functions, conferred by virtue of enactments, prescribed for the purposes of section 1(7) of the Public Bodies (Joint Working) (Scotland) Act 2014

Column A Column B Enactment conferring function Limitation The Community Care and Health (Scotland) Act 2002 Section 4(37) The functions conferred by Regulation 2 of the Community Care (Additional Payments) (Scotland) Regulations 2002(38)

Part 2

(37) Section 4 was amended by the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13), schedule 4 and the Adult Support and Protection (Scotland) Act 2007 (asp 10), section 62(3). (38) S.S.I. 2002/265, as amended by S.S.I. 2005/445.

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Services currently provided by the Local Authority which are to be integrated

Scottish Ministers have set out in guidance that the services set out below must be integrated. Further services can be added where they relate to delegated functions;

 Social Work Services for Adults and Older People  Social Work Services for Children and Families including Criminal Justice  Services and Support for Adults with Physical Disabilities and Learning Disabilities  Mental Health Services  Drug and Alcohol Services  Adult Protection and Domestic Abuse  Child Protection  Carers Support Services  Community Care Assessment Teams  Support Services  Care Home Services  Adult Placement Services  Health Improvement Services  Aids and Adaptions  Day Services  Local Area Co-ordination  Respite Provision  Occupational Therapy Services  Re-ablement Services, Equipment and Telecare

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Annex 3

Hosted Services

Where a Health Board spans more than one Integration Joint Board, one of them might manage a service on behalf of the other(s). This Annex sets out those arrangements which the Parties wish to put in place. Such arrangements are subject to the approval of the Integration Joint Board but will not be subject to Ministerial approval.

This would include –  The hosting of services by one Integration Authority on behalf of others within the same Health Board areas.  The hosting of services by on Health Board on behalf of one or more Integration Authority.  Additional duties or responsibilities of the Chief Officer.

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Argyll and Bute Health and Social Care ANNEX 4

System Governance Schematic

NHS Highland Board Argyll & Bute Council

Integration Joint Board Community Planning Partnership

Audit Strategic Area Clinical Committee Planning Group Chief Officers’ Group Forum

Managed Care Health & Care Networks Communications & Governance Child Protection Adult Protection Public Involvement Sub Group Committee Committee Public Group Partnership Forums

Locality Planning Groups x 4 (Oban, Lorn & The Isles; Helensburgh & Lomond; Bute & Cowal; Mid Argyll, Kintyre & Islay) underpin and direct the planning structure

Draft v 1.1 20.11.2014 Page 67 APPENDIX 2 Health and Social Care Integration Example INTEGRATION SCHEME APPROVAL HIGH LEVEL TIMELINE

Integration Schemes must be submitted by 1 April 2015

Integration IJBs schemes legally submitted Cabinet constituted Secretary approval sought  SG Officials to undertake analysis, scrutiny, Order laid assurance checks against the regulations/model. Order cleared Parliamentary Recess Dates with Scottish  Consultation SG Officials e.g. Finance,Statutory Cabinet 7 – 15 February 2015 Workforce, e-Health, PerformanceInstrument Secretary 4 – 19 April 2015 Sign-off Management, Social Care Policy.(SSI) Unit 27 June – 30 August 2015

 Liaison with Partnerships to obtain additional information, clarity.

 Scottish Government Legal Directorate to develop Order. Order laid for 28 days (excluding recess)

Week 1 2 3 4 5 6 7 8 9 10 11 12

Email: [email protected] Visit: www.scotland.gsi.gov.uk/hsci APPENDIX 3

Health and Social Care Integration

Disestablishment of Community Health Partnerships (CHPs)

17 November 2014 Final version

Scottish Government 17 November 2014 Disestablishment of Community Health Partnerships (CHPs) 1. As of 1 April 2015, the statutory provisions which provide authorisation for CHPs to exercise functions of Health Boards will be repealed, and CHPs will be disestablished following the commencement of section 71 of the Public Bodies (Joint Working) (Scotland) Act 2014 (“the 2014 Act”). Under arrangements to be made under the 2014 Act, community health and social care planning will be provided by integration authorities, to which Health Boards and local authorities will delegate their statutory functions. The delegation of functions to an integration authority must take place on or before 1 April 2016. The date on which functions and resources are delegated to the integration authority is established in the strategic plan, which is subject to the approval of the integration authority. The sequence of approval is as follows:

By 31 March 2015 Integration schemes submitted to Ministers for approval Once Ministers approve Orders laid in Parliament to establish IJBs, once an integration Scheme integration schemes approved by Ministers (each IJB is established by Order, which will be laid as soon as they are ready for Parliamentary approval) Once IJBs established by Each IJB appoints its Chief Officer and approves its Parliamentary Order strategic plan, which contains the date on which functions and resources are to be delegated to the IJB On the date in the The IJB is fully functional strategic plan By01 April 2016 IntegrationAuthoritiesmusthave appointed their chief officers and signed off strategic plans. Health Boards and local authorities must have delegated their functions and resources.

2. While the progress of shadow integration arrangements will vary across different areas by April 2015, it is anticipated that, for many areas at least, there will be an interim period between the disestablishment of CHPs and the establishment of integration arrangements. As a consequence, Health Boards and local authorities need to consider what interim arrangements they will put in place to oversee the services that CHPs have been made accountable for locally and how they will ensure the continued involvement of stakeholders in service planning and delivery. Options

3. Health Boards cannot delegate responsibility for their statutory functions during the interim period between the removal of the legal basis for delegation to a CHP and the commencement of their integration arrangements under the 2014 Act. However, there are a number of possible solutions to ensure continuity in arrangements and manage any risk of a gap in provision. We would recommend, for instance, one of the following options:  Where a shadow board is operational, the shadow board acts in an advisory capacity to advise or assist the Health Board and local authority, who will remain legally accountable for delivery until the IJB is fully functional (on the date in the strategic plan); or  A non-formal CHP remains in place until the integration arrangements are finalised, acting in an advisory capacity to assist the Health Board and local authority, as per the previous bullet point; or  An alternative locally agreed arrangement is put in place.

4. Scottish Ministers expect that the interim arrangements that are put in place will involve the same key stakeholders who the Health Board and local authority plan to include in their statutory integration arrangements under the 2014 Act. It is important that Health Boards, local authorities and their key stakeholders are confident that persons involved in the interim arrangements will work together, and with relevant professions/agencies, in the interests of the people they serve.

Argyll & Bute CHP Committee 17 December 2014 Item: 10 Modernisation of Mental Health Services Update Report - December 2014

Report by John Dreghorn

The meeting is asked to:
Note current key issues and progress against the action plan

1. Background The following report provides an update on the implementation of the modernisation of mental health services in Argyll & Bute.

2. Progress Report

Project Governance The MH Programme Board last met on 17 October. Next meeting is on 12 December. The Capital Project (Bundle) Board met on 21 November. Next meeting is on 2 February 2015.

• Project Management As the capital project proceeds towards the completion of hub stage 1 and the completion of the OBC, the need for additional project management support to deliver the OBC by mid January has been identified. Options to support the project team are currently being explored.

Inpatient Services Current staffed bed compliment is 26. Recent pressure on beds noted.

Patient numbers in the IPCU continue to fall – currently 4 patients. As resettlement plans progress this is likely to reduce to 2 by January, assuming no new admissions in the meantime. This has further highlighted pre-existing concerns regarding the viability of IPCU as a stand- alone unit, leading to a review of the options available and the decision to merge IPCU with Succoth Ward. NHS Highland’s Asset Management Group met in November and approved £295k capital funding to convert an area within Succoth to function as the IPCU. The work will be tendered in January and commencement in Feb/March. Work is expected to be completed by end of May 2015.

The expected non financial benefits are as follows: Improved clinical environment which will be safer and HEI compliant; will provide access to safe enclosed outdoor space; has all en-suite bedrooms; and allows for more flexible deployment of staff across the 2 clinical areas. In addition it is expected that the new working arrangements will reduce costs by approx £200k per year.

New Posts Nil new to report

Vacancies/Recruitment There is currently 1 Consultant Psychiatrist vacancy (Dementia/Old Age Psychiatry). This post has proven very difficult to recruit to as there have been no applicants from the last 2 adverts. This post is currently covered by a locum.

The Cowal & Bute locality continues to face a number of challenges in the provision psychological therapies with vacancies in Clinical Psychology, and Primary Mental Health Care Worker posts. The CBT post was filled in November.

Budget: The inpatient mental health service has now achieved its cost improvement target for 2014/15, and is expected to end the year within budget, despite some significant cost pressures in IPCU nursing and Psychiatry.

Resettlement Group The resettlement planning group met November. Work is progressing well to find suitable placements for the remaining long terms patients. Two are expected to leave hospital within the next few weeks.

New Hospital Project
“The Bundle”: It is now anticipated that the stage 1 report will be available by the end of December. This will allow the OBC to be completed during January for approval though the Asset Management Group, NHS Highland Board, and the SG Capital Investment Group, during February and March.

Enabling Funds: As previously reported £195k has been allocated by the Scottish Government to support works which require to be undertaken before the new hospital construction work commences. Plans for the demolition of Tigh na Linne and the Estates Department outbuildings earlier in the year were delayed due to the need to review the estimated costs to complete this work as submitted by hubco. This review was completed and a pre-start meeting with the contractor took place in October. The works are due to start in January 2015 if all of the planning conditions have been met, including: a further ecology report; and confirmation from Historic Scotland that no further survey work is required prior to work commencing. Scottish Water have undertaken a “water impact assessment” of the site, taking into account the potential housing and other developments on the site following disposal. The report is expected by the end of the year. At this stage it appears likely that we will be required to replace the main water holding tank and upgrade the pipe work before Scottish Water will agree to adopt the system. This will require further capital investment.

Art in Mind: The arts strategy group, which is chaired by Dr Grace Fergusson (now retired), continues to meet. As previously reported we are working with Green Space, a national organisation which promotes and supports projects which improve the environment around public buildings in Scotland. The link between the internal and external environments being a key feature of this project. Recent developments associated with this include successful application for Commonwealth Games Legacy status which allows us to use the logo to promote developments such as the “green gym”. The Coop are also fund raising to support the work of NHS staff with Blarbuie Woodland Enterprise to promote health and wellbeing.

Supported Transfer of Detained Patients An audit of patient transfers from January 2014 is due to be reported at the Programme board on 12 th December. The initial report produced in September showed a significant increase in the number of patients detained and requiring supported transfer when compared to 2013. A review of the incident reports associated with this service shows a high number of incidents from 2 areas and the majority being due to transport problems (mainly SAS). Further work including a review of activity from July to November, plus an analysis of questionnaires received from staff, partner organisations; service users and carers, will add move evidence to this review. It is anticipated that a range of options to improve this service will be developed once the evidence from the review has been considered by the Programme Board

Service User & Carer Involvement Regular meetings of the Service User and Carers Reference Groups continue on a two monthly basis.

3. Summary This month’s report highlights the need for us to continually review and invest in our existing service while progress is being made on the capital project; which is now moving rapidly towards the end of hub stage 1 and submission of the OBC for approval early in 2015. The ongoing challenge of providing a safe and effective patients transfer service will be discussed at the next Programme Board and the service options that emerge from that will be reported in a future update report.

10 MH Service Modernisation Update 08/12/2014 J. Dreghorn Page 2 of 2

Argyll & Bute CHP Committee 17 December 2014 Item : 11.1

PDP/R AND e-KSF IMPLEMENTATION 2014/15 Report by : Gaye Boyd, Interim Head of HR

The CHP Committee is asked to:

• Note the current position which shows an overall decline in PDP & R meetings taking place • Note the need to re-invigorate this in practice and use it to support and direct staff development in line with CHP and NHS Highland objectives • Note the need to ensure that regular annual reviews and PDPs continue for all staff, including bank staff • Note that the eKSF software licence has been extended to March 2016

1. BACKGROUND AND SUMMARY

The Argyll and Bute CHP has progressed over previous years in working towards achieving the NHS Highland target that ALL Agenda for Change staff have a review against a Knowledge and Skills Framework (KSF) post outline, with at least 80% of reviews being carried out and recorded online using the web based system, e-KSF.

However, in this current period there is a marked decline in the number of reviews recorded and actions require to be taken within the CHP to recover and improve on this position.

It should be noted that prior to implementation of e-KSF, there was no systematic way of knowing which staff had a regular review. NHS Highland is now in the position to be able state exactly the number of staff who have had reviews, that these follow the same process, and that staff are actively involved. The evidence is being used by staff as support for Continuous Professional Development (CPD) and re-registration. In addition it allows for Mandatory and Statutory training to be included in every staff members’ PDP, which raises the profile and acts as a record enabling measurement of the levels of completion of required training across the organisation.

It is important to recognise that staff development can include a wide range of options and experience, and is not necessarily a training course, but can include sharing good practice, working in other areas, shadowing, study/library groups, learning sets etc.

The target remains that 80% of all staff have a KSF review completed and recorded on e-KSF at least annually.

2. MONITORING PROGRESS 2014/15

The position across NHS Highland at 30 November 2014 is as follows ( Extract from e-KSF 30-11-14):

Area All AfC Reviews % of AfC % of AfC % of AfC %of AfC staff staff signed off staff (all) staff staff(all) in last 12 (excl bank) In last 12 months (Excl months bank)

Argyll and Bute 1972 284 14.40 19.19 42.49 56.62 CHP Corporate Services 756 83 10.98 11.48 48.41 50.62 West 955 59 6.18 8.48 36.96 50.72 Mid Highland 535 73 13.64 16.63 37.76 46.01 North Highland 893 138 15.45 20.32 45.91 60.38 Raigmore Hospital 3328 360 10.82 14.84 40.75 55.89 South Highland 650 68 10.46 12.88 38.77 47.73 I

• The CHP currently has 14.40% of all staff (19.19% excl bank) with reviews and personal development plans signed off in e-KSF for this financial year. • The total percentage for NHS Highland is 11.64% (15.01 % excl bank posts). • The rolling 12 month figures for A&B CHP (from 1 October 2013 to 30 November 2014) show that 42.49 % of all staff have had reviews completed (56.62% excl bank). This should be 80% and be maintained at that level. • This time last year the CHP had 18.70% signed off within the financial year.

3. PLAN FOR 2014/15

To recover the previously higher percentage of staff who had reviews recorded, and move towards the 80% target, considerable efforts will have to be made across the CHP to raise the level of activity of reviews. Firstly, the reviews need to be viewed as worthwhile by staff and managers/reviewers and the focus will be on managers/reviewers ensuring quality of the process. This directly supports Professional Registration and the Health Care Support Workers (HCSW) Standards ensuring safe and effective care and the maintenance of professional standards within our workforce.

Historically the period from December – March usually records higher activity than other months but managers are encouraged to schedule reviews in a planned manner throughout the year to spread the workload and ensure higher proportion of staff have reviews carried out.

Discussions with staff and staff side representatives have also highlighted the continuing concerns of a number of staff, particularly those on low hours, or on bank contracts, who have difficulty in accessing the eKSF software and their records due to either a low level of confidence on computer use, or difficulty in being able to find a suitable computer in their workplace on which they can log-in. Further work will have to be carried out in operational units to identify and provide PCs for access, and also to address training needs.

The quality of reviews has been the focus this year and is considered by the Staff Governance Committee. A quality survey trialled in September (using survey monkey) indicated good levels of satisfaction in relation to the review process (by reviewees), the survey will be conducted pan Highland in April 2015.

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4. NATIONAL SUPPORT ACTIVITIES

From March to July 2014 40 focus groups were held across Scotland (with NES) to discuss views about how the NHS KSF and Personal Development and Review (PDPR) supports them in their jobs. A short report highlighted that:-

‘Common themes emerged throughout regardless of the job family and pay band of participants and a key success factor in ensuring that the experience was positive and perceived by staff to be meaningful and worthwhile was the level of knowledge and skill of the team leader or manager and the value and priority he or she placed on staff development . ‘

NES ‘Reviewing the KSF in NHS Scotland – Report on Focus Group Findings’ Nov 2014 (Appendix 3)

In the areas of good practice identified via the focus groups:-

‘objective and goal setting were standard practice , and regular conversations between managers and staff members took place throughout the year to discuss progress, development needs and service priorities. Dedicated time was allocated or scheduled to facilitate the process.’

Staff suggestions for improvement will inform the review which were :

• Review and simplify the content of the core dimensions • Develop consistent guidance and resources with an ‘improvement focus’ • more clarity on links with appraisal including values, behaviours and service led objectives

This work will be carried forward nationally and be completed by 31 March 2015.

5. 2015/16 e-KSF AND e:ESS

The contract to deliver the e-KSF system was due to end in March 2014 pending the introduction of the replacement system Oracle Performance Management (OPM), hosted within eESS (employee information system). Due to delays with the new system, e-KSF has continued to be used and will continue until March 2016.

Boards have been asked to prepare for a transition to the Oracle Performance Management which will include a roll out plan, guidance and training packages but until then the existing e-KSF system should continue to be used for the planning and process of reviews and personal development planning until OPM is ready .

6 CONTRIBUTION TO BOARD OBJECTIVES

The achievement of the target is in line with the NHS Highland Board objectives.

7 GOVERNANCE IMPLICATIONS

Staff Governance

KSF and e-KSF are vital components of meeting Staff Governance standards.

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Patient focus and public involvement

The KSF process enables performance management to assist with improved patient focus and public involvement where appropriate for roles.

Clinical Governance

KSF process provides the opportunity to monitor development activities of staff including clinical skills and ensures that staff develop and apply the appropriate knowledge and skills in order to be effective in their work.

Financial Governance

This is part of normal management processes. In addition, workforce costs are a large proportion of the allocated budget. KSF PDP/R and e-KSF support the effective use of staff, in particular through service change and redesign.

8. IMPACT ASSESSMENT The KSF and e-KSF processes are impact assessed at National level and will be monitored as part of overall staff engagement measures.

Gaye Boyd Interim Head of HR Argyll and Bute CHP NHS Highland

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Item : 11.1a e-KSF Reviews Report by Operational Unit For Period 01/04/2014 - 31/03/2015

Reviews 'Completed & Signed Reviews 'Completed & Signed th 1 e-KSF Reviews 30 November Total Reviews 'Completed 1 Reviews at all stages 1 Reviews 'Started'1 Off' (01/04/2014-30/11/2014) Off' (12 month rolling) 2014 Posts1 & Not Signed Off'1 All Staff Non Bank All Staff Non Bank NHS Highland 9912 1225 12.36% 149 1.50% 1154 11.64% 15.01% 2528 25.50% 4232 42.70% 55.03% A&B Mental Health Services 214 14 6.54% 3 1.40% 23 10.75% 16.55% 40 18.69% 60 28.04% 43.17% Argyll & Bute Central Services 145 10 6.90% 5 3.45% 13 8.97% 9.42% 28 19.31% 62 42.76% 44.93% Cowal and Bute Area 330 69 20.91% 8 2.42% 66 20.00% 23.40% 143 43.33% 132 40.00% 46.81% Dental Service (Argyll & Bute) 73 18 24.66% 3 4.11% 17 23.29% 23.61% 38 52.05% 53 72.60% 73.61% Helensburgh and Lomond Area 96 5 5.21% 1 1.04% 6 6.25% 7.79% 12 12.50% 37 38.54% 48.05% Mid Argyll Kintyre & Islay 533 71 13.32% 11 2.06% 89 16.70% 24.79% 171 32.08% 248 46.53% 69.08% Oban Lorn & Isles Area 581 58 9.98% 1 0.17% 70 12.05% 16.95% 129 22.20% 246 42.34% 59.56% Argyll and Bute CHP 1972 245 12.42% 32 1.62% 284 14.40% 19.19% 561 28.45% 838 42.49% 56.62% Notes 1 From e-KSF - does not include Adult Social Services data (unless Agenda for Change) Current position if Bank Posts are removed from 'Total Posts' - data from Workforce Information Staff List

Page 1 of 1 01/12/2014 Item : 11.1b e-KSF Reviews Report by Operational Unit For Period 01/04/2014 - 31/03/2015

Reviews 'Completed & Signed Reviews 'Completed & Signed e-KSF Reviews 30th November Total Reviews 'Completed Reviews at all stages1 Reviews 'Started'1 Off'1 (01/04/2014-30/11/2014) Off'1 (12 month rolling) 2014 Posts1 & Not Signed Off'1 All Staff Non Bank All Staff Non Bank NHS Highland 9912 1225 12.36% 149 1.50% 1154 11.64% 15.01% 2528 25.50% 4232 0.00% 0.00% Argyll and Bute CHP 1972 245 12.42% 32 1.62% 284 14.40% 19.19% 561 28.45% 838 42.49% 56.62% Corporate Services 756 88 11.64% 11 1.46% 83 10.98% 11.48% 182 24.07% 366 48.41% 50.62% Raigmore Hospital 3328 418 12.56% 50 1.50% 360 10.82% 14.84% 828 24.88% 1356 40.75% 55.89% West Area 955 67 7.02% 17 1.78% 59 6.18% 8.48% 143 14.97% 353 36.96% 50.72% Mid Area 535 64 11.96% 5 0.93% 73 13.64% 16.63% 142 26.54% 202 37.76% 46.01% North Area 893 123 13.77% 14 1.57% 138 15.45% 20.32% 275 30.80% 410 45.91% 60.38% S+M Grouped Services 823 117 14.22% 13 1.58% 89 10.81% 12.38% 219 26.61% 455 55.29% 63.28% South Area 650 102 15.69% 8 1.23% 68 10.46% 12.88% 178 27.38% 252 38.77% 47.73%

Adult Social Care Services 1937 125 6.45% 5 0.26% 19 0.98% 1.34% 149 7.69% 24 1.24% 1.70% Children's Services 218 16 7.34% 7 3.21% 41 18.81% 18.81% 64 29.36% 109 50.00% 50.00% Notes 1 From e-KSF - does not include Adult Social Services data Current position if Bank Posts are removed from 'Total Posts' - data from Workforce Information Staff List

Page 1 of 1 01/12/2014 Item : 11c Reviewing the KSF in NHSScotland Report on Focus group Findings

1. Introduction

This report presents a summary of the findings from a series of focus group discussions held as part of the first phase of the national project established to review and refresh the content of the NHS Knowledge and Skills Framework (KSF) Core Dimensions and existing guidance.

Over the period March to July 2014, forty focus groups were held with 300 staff from different pay bands and job families to listen to their views about how the NHS KSF and Personal Development Planning & Review (PDPR) supports them in their jobs and career aspirations. Staff were asked about their experiences with PDPR - what worked well and what the barriers and issues were. They were also asked to give their views on what could make the process better. Some positive examples of good practice surfaced through the discussions, mainly in mental health and community settings, however most of the feedback highlighted key issues and barriers to effective PDPR. Common themes emerged throughout regardless of the job family and pay band of participants and a key success factor in ensuring that the experience was positive and perceived by staff to be meaningful and worthwhile was the level of knowledge and skill of the team leader or manager and the value and priority he or she placed on staff development.

2. Emergent themes from the discussion

2.1 What is working well?

Identified areas of good practice were mainly in Mental Health and Community Nursing teams and also in a number of Support Services departments. Staff from these areas acknowledged the importance of managers seeing the value in making time available to invest in staff development. Objective and goal setting were standard practice and regular conversations between managers and staff members took place throughout the year to discuss progress, development needs and service priorities. Dedicated time was allocated or scheduled to facilitate the process.

2.2 What are the Barriers and Issues to Effective PDPR?

Purpose, Value and Benefit to staff - Staff expressed the view that the PDPR process seemed to be target driven and it felt to them that PDPR was merely a tick box exercise. Often shortcuts were taken to ensure targets were met leaving staff feeling that the onus was on them to put evidence in e-ksf for sign-off with no time for a face to face discussion with their manager. Those who reviewed staff reported being put under pressure to achieve the target at the expense of having quality discussions. Participants with managerial responsibilities were often not having PDPR discussions with their own more senior managers

Discussions highlighted that many staff and managers struggled to see the relevance of the process. In particular staff at the top of their pay band were of the belief that the process had nothing to offer them. They felt there was nowhere else for them to go, so what was the point of a PDP. The theme was echoed by staff who had been told or who believed that there was no funding for learning and development. The view was expressed that the PDPR process involved lots of time and effort for no (seemingly) meaningful purpose.

Some reviewers felt that they had received little or no training and support to carry out reviews and that they lacked the right knowledge and skills to support staff in identifying potential development opportunities.

Regulated professional staff discussed the links of PDPR with their CPD requirements – while some people saw the links quite clearly and recognised how one could support the other, there were a considerable number of staff who felt that either these requirements were completely separate or an unnecessary duplication.

Many staff felt that the need to gather evidence from one year to the next was an exercise in ‘justifying ’ their role. Anxiety levels of staff increased before a review meeting and some felt overwhelmed by everything that needed to be updated. In some areas the KSF review meeting is considered to be “about saying what is bad rather than what are we doing well and what can we do better .”

Technology – eksf Some staff and managers were relatively comfortable with the tool and felt that despite some of its presentational deficiencies it was relatively easy to use and provided a good means to store a record of an individual’s achievements and development. However the majority of opinion was that e-ksf was a barrier to PDPR, however others felt that this was often used as an excuse and that other electronic clinical systems were used on a daily basis by the same staff.

There are issues for staff who are not required to use IM&T in their day to day job, mainly those in Estates and Facilities roles, and who find the need to use e-ksf daunting even although they may be familiar with social media or on-line shopping. They regard work based IM&T as something more threatening and unfamiliar.

Staff who work in laboratory areas felt that e-ksf caused unnecessary duplication. The requirements of laboratory accreditation processes do not appear to be supported by the functionality in e-ksf – particularly in the reporting capabilities – and this results in the need to duplicate staff training information.

Access to suitable IM&T provision was often cited as a problem. Staff reported that although there may be several PCs available in an area, there were competing demands made on the use of these for other necessary systems eg clinical reporting systems and e-learning. It may also be the case that the area in which the technology is housed is not conducive in terms of privacy for the purpose of recording PDPR outcomes.

Dedicated/Protected time – participants identified key issues around the lack of protected time to be able to participate in PDPR processes and in development activities. Some staff described their intention to regularly update information around evidence and PDP entries but were not always able to fulfil those intentions and then felt under pressure as the time for their PDPR discussion grew close. Managers and reviewers spoke of the pressures of releasing staff to undertake mandatory training and admitted that conflicting service pressures often got in the way of providing adequate time for PDPR. Staff shortages and recruitment freezes added to the difficulties.

Lack of quiet space in the workplace – difficulty in finding a suitable area to hold PDPR discussions is an issue in some workplaces. Offices are often shared and there are high demands for available quiet spaces or meeting rooms for mandatory e-learning and other requirements.

2 AC/Nov 14

Reviewers stated that this issue presented yet another practical organisational barrier faced when trying to ensure quality conversations are held.

2.2 The NHS KSF – How helpful is it?

Positive views tended to be expressed where the teams had made the framework work for them and related their own team goals or service standards to the core dimensions – they placed less focus on the detail of the indicators but used the KSF to identify areas for development to help staff achieve their goals or objectives.

However many staff and reviewers reported that the framework was difficult to understand and felt that the dimensions, levels and indicators all contributed to confusion. Most participants admitted that it was difficult to relate the language to the job that they did on a daily basis. Staff working in large production areas such as Catering, Laundry and Decontamination Units had particular difficulties in relating the dimensions to their daily job.

Those staff who worked in specialist areas such as IM&T support or Finance also felt that it was difficult to relate the indicators in the dimensions to their industry or professional standards.

The idea of having a ‘one size fits all’ framework was a point of discussion and participants felt that the language had to be more relevant to their occupational or professional areas.

3. How do we make PDPR conversations more effective and meaningful for staff?

3.1 Focus on the conversation

Ensuring that the importance of the PDPR conversation comes first as opposed to the target driven focus is a key step in engaging staff in the process and encouraging them to take more ownership of their own development. Staff want to feel that there is value, purpose and a benefit to participating in the PDPR process rather than feeling that it is only an exercise in ticking boxes. ‘My PDPR should relate to me, my job and my progress’. Staff also said that there would be a benefit to having more explicit links with career planning – “Where do I want to be in 5 years ”.

Also staff felt that it was important to create a more developmental or improvement based focus for KSF. Using the process to look forward and support staff to set goals for service and quality improvements was presented as an important factor in making PDPR more effective rather than the current focus on the need to continually provide evidence of meeting knowledge and skills requirements.

3.2 Keep it Simple (and Jargon-free)

Reducing the bureaucracy of the process was a common suggestion from the groups. Groups felt that getting rid of ‘clutter’ would reduce the duplication and help streamline the process making it more effective. In terms of the KSF language and dimension structure, staff suggested that the indicators should be removed and replaced with clear descriptive statements about the focus of the dimension. The level of jargon used should be reduced with language that staff are more familiar with to be used. The majority of participants felt that the Core dimensions were sufficient although there were some comments that the language used in the specific dimensions was more relevant to individual staff groupings.

The technology aspect was also picked up in this area with a plea from all staff to keep the replacement recording tool as simple, accessible and as easy to use as possible. Establishing links 3 AC/Nov 14

with e-portfolio would help reduce the duplication and regulated staff suggested the inclusion of a reflective section to support the provision of evidence of learning in practice.

Guidance should be revised to provide better clarity and consistency around PDPR. Examples of good practice that are more related to the wide variety of jobs in the NHS should be developed and shared. Staff should be able to see examples or scenarios around PDPR that relate to their specific roles. The guidance should be clearer about the links with appraisal and professional or regulatory standards and CPD.

3.3 Management Development

Improved development and support for Managers was seen as a key priority – recognising that staff in bands 3 to 5 can have supervisory responsibilities. They should have the skills to provide feedback on what is being done well and what needs to be improved, be able to help staff set challenging goals and access relevant and appropriate learning and development opportunities including learning through work. They also need to be supported by the senior leaders in the organisation who are the role models for the reflecting the values and behaviours expected in NHSScotland.

4. Conclusion and Recommendations

4.1 Staff who participated in the focus group said they appreciated the opportunity to express their views around KSF and PDPR and that their ideas for improvement were being listened too. It is important therefore that they see action taken in regard to the points they raised. Their feedback resonates with the broader intentions within Everyone Matters. The content of this report therefore should be shared widely among those with responsibility for implementing the relevant actions in Everyone Matters.

4.2 The reliance on the quantitative monitoring of completed PDPRs recorded on e-ksf as a sole measure should be reduced. Supplementary qualitative monitoring should be developed around the quality and impact of effective PDPR – iMatter offers the potential for this.

4.3 Staff suggestions from the focus groups validated the intended approach for the review. Namely the intention to

• review and refine the content of the core dimensions using less complex and more relevant language developed for specific staff groups. • Develop revised consistent guidance, case studies and resources supporting an ‘improvement focus’ and more clarity on the links with appraisal including incorporating values and behaviours and setting personal and service-led objectives.

This work will be progressed through phase two of the project with key pieces of work completed by 31 March 2015 and published on KSF website www.ksf.scot.nhs.uk .

5. Acknowledgements

The national NES KSF team would like to express their thanks to those colleagues in NHS Boards who helped to facilitate access to the wide range of staff who participated in the focus groups. We would also very much like to thank all of the staff who gave up their time to meet with us, sometimes having to travel to venues and who were open and honest in providing feedback on their experience and views of PDPR and KSF. 4 AC/Nov 14

Argyll & Bute CHP Committee 17 December 2014 Item : 13a The Vale of Leven Hospital Inquiry Report Executive Summary

The Vale of Leven Hospital Inquiry Report The Rt Hon Lord MacLean Chairman

© Crown copyright 2014

ISBN: 978-1-78412-844-9

Published on behalf of The Vale of Leven Hospital Inquiry by APS Group

An online version of the Report is available at www.valeoflevenhospitalinquiry.org email: [email protected] Executive Summary APS Group Scotland DPPAS23140 (11/14) The Vale of Leven Hospital Inquiry Report The Rt Hon Lord MacLean Chairman

Executive Summary Laid before the Scottish Parliament by the Scottish Ministers under section 26 of the Inquiries Act 2005.

November 2014 SG/2014/211

© Crown copyright 2014

ISBN: 978-1-78412-844-9

Published on behalf of The Vale of Leven Hospital Inquiry by APS Group

An online version of the Report is available at www.valeoflevenhospitalinquiry.org email: [email protected]

APS Group Scotland DPPAS23140 (11/14) Contents

Page

Chairman’s letter to the Cabinet Secretary 1

Foreword 2

Introduction 5

Conclusion 21

Key findings 23

Recommendations 57 Executive Summary

Chairman’s letter to the Cabinet Secretary

The Vale of Leven Hospital Inquiry

Third Floor, Lothian Chambers, George IV Bridge, Edinburgh, EH1 1RN Website: valeoflevenhospitalinquiry.org Email: [email protected] Phone: (0131) 240 6809 Fax: (0131) 225 6710

Cabinet Secretary for Health and Wellbeing St Andrew's House Regent Road EDINBURGH EH1 3DG

November 2014

On 21 August 2009, I was appointed by the then Cabinet Secretary for Health and Wellbeing to hold a public inquiry into the occurrence of Clostridium difficile infection at the Vale of Leven Hospital from 1 January 2007 onwards, in particular between 1 December 2007 and 1 June 2008, and to investigate the deaths associated with that infection.

The Terms of Reference were very wide-ranging and I have addressed these, I hope, comprehensively, as can be seen from the Report which I now present to you.

Yours sincerely,

Rt Hon Lord MacLean Chairman

1 The Vale of Leven Hospital Inquiry Report

Foreword

The evidence adduced by the Inquiry was concluded on 28 June 2012. In July 2012 I entered hospital for what was then regarded as a fairly routine operation. The operation itself was concluded successfully but shortly thereafter my condition began to deteriorate as a result of an infection of unknown aetiology which necessitated a prolonged period of intensive care and hospitalisation for a total of five months. I may say that the irony of this was not lost on me during the time I remained in hospital. The experience did, however, enable me better to understand the plight of those who suffered from C. difficile infection and in some cases died from it, in the Vale of Leven Hospital.

I narrate all this, not in anyway to evoke sympathy for myself but in order to pay tribute to the Inquiry team who responded so superbly to the crisis they then had to face, namely carrying on the work of the Inquiry effectively without its Chairman. A central core of the staff, made up of the Secretary, leading Counsel to the Inquiry, and its Principal Solicitor, visited me regularly in hospital, consulted me there, and received instructions from me. After my discharge from hospital the same work was carried on during my convalescence at home. In order to ensure that Mr Neil, the Cabinet Secretary who succeeded Ms Sturgeon, was aware of the predicament I was in, I wrote a personal letter to him on 17 January 2013. He replied to this letter on 21 March 2013 and from the terms of that letter I believe he ultimately came to understand the problems I had had.

On 29 July 2009 I met the then Cabinet Secretary for Health and Wellbeing, Ms Nicola Sturgeon, in Glasgow. She thanked me for taking over from Lord Coulsfield. We discussed the terms of the remit. She was very keen on a time limit because, as she said, she wanted a short and sharp inquiry. She expected a report and recommendations on her desk by October 2010. In light of my previous experience as Chairman of two other Inquiries and membership of another (none of which had any time restriction) I demurred to such a time limit and explained that I did not consider it possible to fulfil the terms of such a wide remit within that time scale. I preferred a time limit of “as soon as possible”. The Cabinet Secretary, however, insisted, with the qualification that the Inquiry could always apply for an extension. I am clear that this was a mistake, for the reasons that are given more fully in the Report itself and summarised in the Introduction.

2 Executive Summary

The result was that, as each so-called deadline approached and was not fulfilled, there was a familiar chorus of criticism from certain quarters. Significantly, none of it came from any representatives of Core Participants. Nevertheless, the Inquiry team had to face this criticism and respond to it as best they could, when, in my opinion, they were absolutely blameless.

If anything, the whole experience shows the futility of imposing time constraints on an Inquiry like this, simply because one cannot at the outset know what lies ahead of an Inquiry’s investigation. My illness was just one aspect of this. Indeed, I doubt whether, unless in wholly exceptional circumstances, an Inquiry set up under the Inquiries Act should be limited in point of time.

I should add that, in my not inconsiderable experience, it is very rare to have such a cohesive and united unit as the entire Inquiry team. That is probably due to the quite exceptional skills of leadership demonstrated by the Secretary, Julie-Anne Jamieson who kept the show on the road, as it were, and maintained in the face of considerable difficulties, the high level of morale which has persisted to the end. She was exceptional.

I take this opportunity to express my gratitude to my single-minded and devoted Inquiry team. I am grateful to all those in the team who so faithfully assisted me.

Lord MacLean November 2014

3 Introduction The Vale of Leven Hospital Inquiry Report

Summary 1 June 2008. Many patients were exposed unnecessarily to CDI and had to suffer the Serious failures humiliation and distress often associated with Between 1 January 2007 and 1 June 2008, the infection. 131 patients who were or had been patients in the Vale of Leven Hospital (VOLH) tested Scottish Ministers have a duty to promote positive for Clostridium difficile Infection the improvement of the physical and (CDI). Of that number, 63 patients tested mental health of the people of Scotland. positive in the period from 1 December The Scottish Government is the executive 2007 to 1 June 2008. During that particular branch of government in Scotland. The period 28 of those 63 patients died with duty to promote the health of the people of CDI as a causal factor in their deaths, either Scotland is discharged through Health Boards, as the underlying cause of death or as a particularly within the context of healthcare contributory cause of death. Another three acquired infections such as CDI. There was a patients who died in the course of June failure to have in place an inspection regime 2008 also had CDI as a causal factor in that could provide the necessary assurance their deaths. In the period 1 January 2007 that infection prevention and control was to 31 December 2008 the total number of being properly managed and important deaths identified by the Inquiry in which CDI policies and guidance implemented. was a causal factor was 34. These figures are particularly damning when considered in the Inadequate attention was given by the context of the VOLH, a hospital with around Scottish Government and NHSGGC to 136 beds in 2008. the reports about other outbreaks in the United Kingdom. These identified failures CDI can be a devastating illness, particularly similar to many of the failures at the VOLH in the frail and elderly. It can lead to discovered in the course of the Inquiry. malnutrition and dehydration unless carefully Repeated warnings over a number of years managed. The frequency of diarrhoea, about the importance of prudent antibiotic the impact upon patient dignity, and the prescribing had no apparent impact. The challenges presented to staff are some of the Scottish Government failed to monitor the factors that highlight the absolute necessity implementation of the prudent prescribing of treating CDI as a serious illness. Sadly, for message and to remedy the failure by reasons I set out in detail in this Report, there NHSGGC to implement that message. were deficiencies in medical and nursing care at the VOLH that seriously compromised the Prolonged uncertainty over the future of the care of this group of patients. Furthermore, VOLH had damaging effects on recruitment, the infection prevention and control practices staff morale, and the physical environment and systems were seriously deficient. of the VOLH. The hospital environment was not conducive to good patient care. It is Governance and management failures resulted hardly credible that in 2007 and 2008 a care in an environment where patient care was environment existed in which gaps in floor compromised and where infection prevention joints were covered in adhesive tape. There and control was inadequate. The important was a lack of wash‑hand basins in wards principle of Board to ward and ward to Board and toilets, and commodes were not fit for means that there must be an effective line of purpose. reporting, accountability, and assurance. This was lacking for the VOLH. There were failures A lack of strong management as well as by individuals but the overall responsibility personal and system failures contributed has to rest ultimately with NHS Greater to the development of a culture in the Glasgow and Clyde (NHSGGC). VOLH that had lost sight of what is of the very essence of a hospital – a caring and It is highly likely that there were a number compassionate environment dedicated to of undeclared outbreaks of CDI transmission the provision of the highest possible level of in the VOLH between 1 January 2007 and care.

6 Executive Summary

Background to the Inquiry Terms of Reference has therefore been my sole responsibility. In carrying out that Creation of the Inquiry responsibility I have been greatly assisted On 22 April 2009 the then Cabinet Secretary by my Assessors and the members of the for Health and Wellbeing, Nicola Sturgeon, Inquiry Team. announced to the Scottish Parliament that a Public Inquiry would be held into the Appointment of Assessors “outbreak” of Clostridium difficile at the VOLH. To assist me in my task I appointed two She explained that this would commence Assessors, under a power granted to me at the conclusion of ongoing investigations under section 11 of the 2005 Act. A summary by the police and the Health and Safety of their qualifications and experience is set Executive, and of any prosecutions resulting out in Appendix 2. The purpose behind their from those investigations. At the same time appointment was that of providing me with the Cabinet Secretary announced that the Rt advice on matters within their own areas Hon Lord Coulsfield had agreed to chair the of professional expertise, which included Inquiry. nursing and medical expertise and also The C.diff Justice Group, which represents a expertise in infection prevention and control. number of surviving and deceased patients, was influential in the establishment of the The Assessors were appointed on 14 October Inquiry. In January 2009 the Group lodged a 2009. They participated in the preparations petition with the Scottish Parliament Public for the oral hearings and attended the oral Petitions Committee calling for a public hearings, and I was able to rely on their inquiry to ensure that lessons were learned advice in the course of the drafting of the across the NHS and that further deaths from Report. Their joint contribution to the Inquiry C. difficile were minimised. The petition was process proved invaluable, as nursing and considered by the Petitions Committee on medical matters and issues of infection 27 January 2009 and formally closed on prevention and control became central to 1 November 2011. the work of the Inquiry. I am extremely grateful to them for that contribution and The Group’s determination to have a public for the commitment they continued to make inquiry has been fully vindicated by the to an Inquiry process that took longer than Inquiry’s findings of significant failures from anticipated. which important lessons must be learned. Meeting with NHS Greater Glasgow and Clyde In June 2009 the Lord Advocate intimated Board members that there would be no criminal proceedings Lord Coulsfield and the Secretary to the and steps were then taken to establish Inquiry met with NHSGGC Board members on an Inquiry Team and define its Terms of 11 June 2009. That was an informal meeting Reference. The statements obtained by the and was not part of the evidence gathering police were passed on to the Inquiry Team. process. It was agreed at that meeting that there could be a single point of contact within Lord Coulsfield subsequently withdrew the Board for the Inquiry. I, however, did from the Inquiry for health reasons, and my not consider it necessary to have a further appointment was announced in his place on meeting with Board members. 21 August 2009.

The Inquiry was formally set up on 1 October Meeting with patients/relatives 2009. The procedure of the Inquiry was Lord Coulsfield met patients and relatives subject to the Inquiries Act 2005 (the 2005 on 12 June 2009, and following my own Act) and the Inquiries (Scotland) Rules 2007 appointment as Chairman I decided that it (the 2007 Rules). would also be appropriate for me to have a similar meeting. That meeting took place No other person was appointed to sit with on 25 September 2009, and was attended me. The important task of fulfilling the by one former patient and 17 relatives of

7 The Vale of Leven Hospital Inquiry Report

patients. I found the meeting to be highly e) To investigate the governance productive, and I gained the clear impression arrangements of NHS Greater Glasgow that the patient and relative group as a whole and Clyde in relation to, and the was anxious to be as helpful as possible priority given to, the prevention and to the Inquiry. Quite understandably they control of the infection. wanted to find out why CDI became such a problem in the VOLH. f) With reference to experience within and beyond Scotland of C. difficile, The scope of the Inquiry to establish what lessons should be learnt and to make recommendations. Terms of Reference The Terms of Reference agreed with the g) To report by 30 September 2010 Cabinet Secretary were in the following terms: unless otherwise provided by the Cabinet Secretary for Health and a) To investigate the circumstances Wellbeing. contributing to the occurrence and rates of C. difficile infection at the Vale The Cabinet Secretary granted several of Leven Hospital from 1 January extensions to the reporting date in 2007 onwards, and any increases in accordance with paragraph (g) of the remit. such rates during that period and in particular between 1 December 2007 The breadth of the Terms of Reference and 1 June 2008, with particular What is significant about the Terms of reference to the circumstances which Reference is their breadth. I have already gave rise to deaths associated with made the point in the Foreword that I that infection. did not consider it possible to report by b) To investigate the management and a specified date, initially 30 September clinical response at the Vale of Leven 2010. The Cabinet Secretary’s response was Hospital to the C. difficile infection the addition of the provision in paragraph rates during that period and to any (g) for extending the time limit. That did such increases, and the steps taken to not allay my concerns. While it is readily prevent or reduce the risk of spread understandable that the responsible Minister or recurrence of the infection. should wish an inquiry to report at the earliest reasonable opportunity, until the c) To investigate the systems in place at work of an inquiry is well under way any the Vale of Leven Hospital to identify prediction about a time limit cannot be and notify cases, increased rates accurate and may be totally unrealistic. of infection outbreaks and deaths The Inquiry Team must conduct an initial associated with C. difficile infection, investigation. Only once that initial stage including the action taken to inform is substantially complete will it become patients, their relatives and the public apparent what further investigation is and the steps taken at the Vale of necessary. A further factor that could not Leven and in NHSScotland generally have been foreseen at the outset was that for recording such incidents including of the problems encountered in the recovery for the purposes of death certification. of documents, discussed later in the Report. These problems became a running sore that d) To investigate the actions of NHS bedevilled the work of the Inquiry even into Greater Glasgow and Clyde in 2012. response to the occurrence of C. difficile infection at the Vale of For reasons set out in this Report, including Leven Hospital, including informing the nature and extent of the Terms of patients and their relatives of the Reference and the size of the task that risks of such infection and the emerged, the successive deadlines were measures that should be taken to impossible to meet. When that was apparent assist prevention and control. to me, I notified the Cabinet Secretary at the

8 Executive Summary

earliest opportunity. As it turned out, because “On the ground of fairness specified of the amount of work involved in the initial in s.17 of the Inquiries Act 2005 (“the investigation, the first phase of oral hearings 2005 Act”), and also in reference to the did not take place until June 2010, just four need (s.17(3) of the 2005 Act) to avoid months before the original latest reporting any unnecessary cost (whether to public date of September 2010. funds or to witnesses or others), GGHB respectfully submits that no evidence The first application for an extension of time should be allowed or taken into account was in fact made on 10 December 2009, and concerning various aspects of the quality following that the reporting date was of nursing care (“the aspects objected to”) extended to 31 May 2011. Subsequent at the Vale of Leven Hospital in the period extensions were necessary to allow the to date, namely hydration of patients; Inquiry to carry out as thorough an preparation of fluid balance charts and investigation as possible into the terms of the completion of these; nutrition of patients; remit. The final phase of oral hearings was completion of nutrition assessments and not completed until June 2012. food charts, and the need to involve a dietician; weighing of patients; guarding The lesson to be learned from this experience against and dealing with skin and is that, except in circumstances where the pressure damage, and taking tissue issue is clear and the remit is a relatively viability precautions; carrying out manual narrow one, specific deadlines should not handling risk assessments; carrying out be imposed on public inquiries of this kind. falls risk assessments; avoiding patients A formula “as soon as possible” or even “as being injured through falling; providing soon as practicable” should be seen as a proper pain relief; completion of care much better option. No inquiry Chairman plans (except for care plans relevant to would fail to respond to that form of remit the contraction of Clostridium difficile in a timeous manner. Unrealistic deadlines of illness or the mortality rate there from); the kind contained in the Terms of Reference assessing the mental state of patients create unrealistic expectations in the and meeting their mental health needs; minds of those waiting for the Report to be the quality of the personal care given to published. They also create undue and unfair patients; Do Not Attempt Resuscitation pressure on the Inquiry Team. (“DNAR”) decisions; and providing end of life care pathways”.1 The broad nature of the remit as set out in paragraphs (a) to (g) of the Terms of Ruling on NHS Greater Glasgow and Clyde’s Reference reflects the Cabinet Secretary’s objection intention, when the setting up of the Inquiry With little hesitation I repelled the objection was announced in the Scottish Parliament on taken on behalf of NHSGGC. The solicitor 22 April 2009, that relevant lessons “must be to NHSGGC was advised of my ruling and learned by everyone in the NHS”. my reasons by letter dated 12 May 2011.2 I concluded that the issues of concern raised Interpretation of the Terms of Reference by in the nursing expert reports were in areas NHS Greater Glasgow and Clyde of nursing care which might be directly On 11 May 2011 the NHS Central Legal Office relevant to the circumstances contributing to (CLO), acting on behalf of NHSGGC, delivered the occurrence and rates of CDI at the VOLH. a Note to the Inquiry intimating an objection It has to be emphasised that good nursing to evidence being led on aspects of the care lies at the very heart of the appropriate quality of nursing care provided to patients management of patients who contract covered by the remit. That Note was revised CDI. That care does not just begin when on 12 May 2011. The principal thrust of the the diagnosis of CDI has been confirmed. objection was in the following terms: Patient care has to be seen as a dynamic

1 INQ05480002‑03 2 INQ05610001

9 The Vale of Leven Hospital Inquiry Report

process that involves regular assessment Furthermore, I was satisfied that the issue of and reassessment. A patient who develops whether any aspects of patient management CDI may require to be managed not just for were outwith the Terms of Reference was a the direct effects of the infection itself, for matter that could be determined at the end example by the administration of antibiotics, of the evidence without causing any material but also for other aspects of care on which delay to the progress of the Inquiry. In CDI might have an impact, such as hydration, addition, most of the nursing expert evidence nutrition, pressure management, and the having been led, I was of the view that, in risk of falls and impaired mobility due to the fairness to nurses whose standard of care debilitating nature of the condition. While Do had been criticised, they should be given the Not Attempt Resuscitation (DNAR) decisions opportunity to respond to that criticism. may be only indirectly linked, these decisions can be relevant to the care of patients The focus and early period division suffering from CDI. The Terms of Reference stipulate in paragraph (a) that the starting date for my investigation Renewal of the objection of the circumstances contributing to the At the oral hearing on 23 August 2011 occurrence and rates of CDI is 1 January Counsel for NHSGGC renewed the objection to 2007. There is no specified end date, but that the leading of evidence on certain aspects of same paragraph does provide that particular care.3 By this time almost all the evidence of attention is to be directed to the period the nursing experts had been led. At this point from 1 December 2007 to 1 June 2008. the challenge was more restricted in nature, This period had been looked at by other with the focus now only on some aspects Inquiries. In this Report I have labelled the of care. For example, it was not now being period from 1 January 2007 to 30 November suggested that the nursing management of 2007 the “early period”, and the period from hydration and nutrition was not relevant to 1 December 2007 to 1 June 2008 the “focus the issues that I required to examine.4 period”.

Having heard the argument on this renewed objection I again refused to sustain it. It was Clostridium difficile infection in principle the objection that had been taken Clostridium difficile earlier and repelled, and no good reason was Clostridium difficile (C. difficile) is a bacterium advanced for its renewal after almost all the that can cause infection in the colon. Up to nursing evidence had been led. It had been 4% of healthy adults carry C. difficile in the clear in advance from the nursing expert colon.6 That percentage may increase to 50% reports what evidence was going to be led. in hospital, particularly in the elderly and As I have already explained, there are aspects newborn infants. These patients may not of nursing care that cannot be divorced from have the infection, but clearly the risk of the consideration of how a patient suffering infection developing increases significantly in from CDI is being managed. Hydration a hospital environment. There are numerous and nutrition are clear examples, and no different strains of C. difficile, and some strains doubt that is why NHSGGC did not renew are said to be more virulent than others. its objection to those aspects of care at the These strains are normally referred to as oral hearing. Counsel for NHSGGC argued “hypervirulent” strains because they produce that the Inquiry should focus only on the high levels of toxins. It has to be stressed, care planning relevant to the contraction or however, that any strain of C. difficile has the persistence of CDI,5 but the fallacy underlying potential to cause severe infection. that argument is the assumption that the care planning for a patient who is suffering from To acquire the organism, spores must enter CDI can be properly managed without regard the mouth and be swallowed. Many people to all that patient’s problems. are exposed to spores, but C. difficile generally

3 TRA00290073‑109 does not colonise in healthy people and 4 TRA00290100 5 TRA00290081 6 TRA00090019

10 Executive Summary

cause infection. This is because the normal “C. difficile is very unpleasant for patients. healthy bacteria in the colon protect against It is exceedingly unpleasant and distressing the development of the infection. It is when for relatives to see an old, loved patient in these protective mechanisms are disrupted a bed in a pool of faeces. It is very difficult that C. difficile can colonise in the colon and for nursing staff to have to clean a patient result in infection. This disruption is usually nine, ten times a day who is demented, caused by the administration of antibiotics immobile, (and) can’t help the nurse with in the treatment of another infection, for moving”.7 example, a urinary tract infection. This is particularly so when patients are treated with For a patient to contract CDI in a hospital broad spectrum antibiotics, because these setting, a setting where the patient expects antibiotics eradicate many normal bacteria in to be protected and safe, is especially tragic. the colon, making the colon more susceptible CDI can deny an elderly patient a peaceful to the development of CDI. This is why and uncomplicated death, and that is one prudent antibiotic prescribing is so important particular reason, among others, why what in patient management. An infected patient was allowed to happen in the VOLH should will normally develop diarrhoea, and in a never be allowed to happen again. hospital there is the risk of the environment being contaminated, with other patients being put at risk. Good hand hygiene is The Vale of Leven Hospital important as a preventative measure. Changes in hospital management From an infection prevention and control The Vale of Leven District General Hospital perspective, the isolation of a symptomatic (this is its full title) is one of the smaller patient from other patients is important. hospitals in the National Health Service Unfortunately, as set out in the Report, in Scotland. It is located in the town of the general practice in the VOLH was not Alexandria, West Dunbartonshire. In 2002 to isolate patients until the infection was the VOLH delivered a broad range of acute actually diagnosed by means of a positive hospital services, and the bed complement laboratory result. This practice meant that was in the region of 234, but by 2008 this other patients continued to be placed at risk had been reduced to around 136. of cross infection. Prior to 1 April 2006 the VOLH was managed by NHS Argyll and Clyde. By 2005 NHS Argyll CDI symptoms and Clyde had incurred a cumulative budget There are a variety of symptoms associated deficit of £82 million, and on 19 May 2005 with CDI. I have already mentioned the then Minister for Health and Community diarrhoea, which when caused by CDI is Care announced in a statement to the Scottish often described as “explosive”. Symptoms Parliament that NHS Argyll and Clyde was to can also include abdominal pain, fever and be dissolved. The administrative boundaries nausea. In some cases the colon can become of Greater Glasgow Health Board (GGHB), also severely inflamed, a condition known as then known as NHS Greater Glasgow, and of pseudomembranous colitis. This can become NHS Highland were to be changed to allow acute, resulting in toxic megacolon ‑ acute them to take over responsibility for managing distension of the colon. CDI must therefore the delivery of the health services in Argyll be regarded as a serious illness that can be and Clyde. life‑threatening, and I have already set out the number of patients covered by my remit Following upon an integration process who died with CDI involved in the death. The NHS Argyll and Clyde was dissolved on elderly are particularly vulnerable. Professor 1 April 2006. From that date a number of George Griffin, Professor of Infectious hospitals, including the VOLH, became the full Diseases Medicine at St George’s University, responsibility of GGHB, which became known London, whose evidence is considered later, as NHS Greater Glasgow and Clyde (NHSGGC). provided the following graphic description of the impact of CDI: 7 TRA00730030‑31

11 The Vale of Leven Hospital Inquiry Report

Full integration of services did not, however, during that period9 made it clear that an take place immediately, and a Clyde Acute outbreak consisted of two or more linked Directorate was created to manage services cases of the same illness, yet no outbreak in the former Argyll and Clyde hospitals now was declared. The reasons for the failure to managed by NHSGGC, including the VOLH. identify a problem include the dysfunctional Mrs Deborah den Herder was appointed as nature of the Infection Control Team, the the Director of the Clyde Acute Directorate, inadequacy of reporting systems and the although she did not take up her post failure of committee structures. Nevertheless, formally until 1 October 2006. it is surprising that such a problem could effectively remain undiscovered for so long Reduction in services even in the face of such failures. In the years up to 2007 and 2008 a significant reduction in the services provided at the Levels of infection and fatality rates VOLH had taken place. These are set out in As I set out at the beginning of this summary, Chapter 8. By then the future of the hospital in the period from 1 January 2007 to 1 June had been uncertain over a prolonged period 2008 131 patients who were or had been in of time. This uncertainty had a damaging the VOLH tested positive for CDI. Although impact on recruitment and morale as well as the focus of the Inquiry has been on the on the hospital’s physical environment. It also period up to 1 June 2008, patients continued compromised patient care. to suffer from CDI until the end of 2008, but the rate was lower. The total number of CDI at the VOLH patients covered by the Inquiry’s remit who contracted CDI between 1 January 2007 and Discovery and extent of the problem 31 December 2008 was 143. The problem with CDI in the VOLH was not apparent until May 2008. Those who worked I did not engage in a comparative exercise in the VOLH did not appear to identify CDI of CDI rates in Scottish hospitals, for such an as a particular problem over the period from exercise was outwith my remit. It is perfectly 1 January 2007 to May 2008, even although clear, however, that for a hospital the size a significant number of patients suffered from of the VOLH the number of patients infected the illness during that period. As set out in reveals that CDI had become a serious the Report, the discovery of the extent of the problem in the VOLH, even although that problem was partly due to a press enquiry problem was not identified. The problem was by a local newspaper requesting information compounded by the number of patients who on the number of cases of CDI at the VOLH in died with CDI as the underlying cause or a the six months prior to June 2008. Dr Brian contributory factor. In the six-month period Cowan, Medical Director and Acute Services from 1 December 2007 to 1 June 2008, CDI Division Medical Director of Greater Glasgow played a role in the deaths of 28 patients. and Clyde described his understanding of the position in the following way: Death certification “Here was an outbreak which raged, or a series of outbreaks that raged, for a long Accuracy period of time with a significant, highly Accuracy in death certification is important significant, number of deaths”.8 because it provides an understanding of the health needs of the population. There is also In the period from 1 January 2007 to June a personal need for family members to know 2008 there were 199 positive test results why a relative has died. Of the 28 patients for C. difficile toxin from 131 patients in the who died between 1 December 2007 and VOLH, and in different wards at different 1 June 2008 with CDI as the underlying times throughout that period there were cause or contributory factor, CDI was not patients suffering from CDI who were linked mentioned in the death certificates of seven in time and place. Outbreak Policies in force of these patients.

8 TRA01230015 9 GGC00780145; GGC27390001

12 Executive Summary

Death certification involves the exercise of of members of the Inquiry Team and my professional judgement. Yet although in 2007 Assessors, that certain recurrent themes and 2008 the available guidance provided emerged. In order to explore those issues that it was “best if a consultant, general more fully, experts were commissioned in practitioner or other experienced clinician a number of disciplines so that the Terms certifies the death”,10 it seems that in practice of Reference could be properly complied in Scotland consultants were rarely involved in with. The timescales involved in that process death certification at that time.11 Certainly in are set out in Chapter 2. I have already set the cases examined from the VOLH the out my reasoning for the division of cases majority of the death certificates were signed into the early period and the focus period. by junior doctors without any recorded Accordingly, expert reports were instructed consultation with more senior medical staff. on 1. medical care; 2. nursing care; 3. the prescription of antibiotics; 4. infection New guidance prevention and control; and 5. death New guidance was issued on death certification for all patients who fell within certification after the emergence of the CDI the focus period. Patients for whom expert problem at the VOLH. The most up‑to‑date reports were obtained are listed in Appendix guidance provides that death certificates for 1. Those patients and relatives who were patients who have died in hospital should core participants had an opportunity through only be completed after discussion with a their legal representatives to see these consultant. Ideally this should be the patient’s detailed reports. named consultant.12 Boards also have to ensure that there are systems in place to A more restricted approach was taken in the identify C. difficileassociated deaths.13 early cases, but I still considered it necessary that, insofar as patient records were Scotland should not have developed the available, a nursing expert should examine practice of consultants generally not being these records to see whether trends apparent involved in the death certification of their in the course of the focus period also existed patients. Consultants are best placed to in that early period. accurately assess why a patient has died. I certainly endorse the mandatory duty now Detailed examination of patient records, imposed to involve consultants. Furthermore, expert reports and all other evidence relevant if a patient dies with CDI either as a cause of to each patient’s care was undertaken during death or as a contributing condition, relatives the Inquiry’s work in preparation of this should be provided with a clear explanation Report. This approach reflected the approach about the role played by CDI in the patient’s taken during the oral hearings which involved death. detailed examination of patient care.

The results of that whole exercise are Patient records discussed in the Report. Suffice to say at this point that the unacceptable levels of care Examination of patient records by experts discovered were not the levels of care which In the interpretation of my remit I took I would have expected to find in any hospital the decision that the patient records of in Scotland. That is why I have made firm the patients who suffered CDI in the focus recommendations in the Report which should period should be subjected to careful be seen as fundamental to patient care. scrutiny. This scrutiny had not been carried Ultimate responsibility for patient care in out during other investigations into the Scotland rests with the Scottish Ministers. To VOLH CDI problem. From that exercise it discharge that duty the necessary inspection became apparent to me, with the assistance and implementation systems must be capable of providing real assurance that patient 10 INQ00790002 care in Scotland is not at any risk of being 11 TRA01070009‑10 compromised. 12 INQ02980003 13 INQ02980005

13 The Vale of Leven Hospital Inquiry Report

NHS Greater Glasgow and Clyde’s position on I was surprised that NHSGGC had not taken the examination of patient records steps to examine the patient records to In the course of submissions made on evaluate the nature of care afforded to CDI behalf of NHSGGC at the oral hearing on patients, particularly the records of patients 13 June 2011 in connection with the legal who died with CDI as a cause, or contributory representation of nurses, an issue addressed cause, of death, in order to satisfy itself that in Chapter 2, Counsel for NHSGGC made the there were no apparent deficiencies in care. following statement in connection with the I would regard such an examination as one reports of the nursing experts: that should be at the forefront of the thinking of any Health Board in the circumstances “The content of the reports came as that had emerged in the VOLH by June 2008. somewhat of a surprise to Greater Mr Robert Calderwood, Chief Executive of Glasgow Health Board”.14 NHSGGC, did explain in his evidence that once the Independent Review was set up on As discussed in Chapter 17, the remit of the 18 June 2008 NHSGGC was invited to assist Internal Investigation set up by NHSGGC in with that Review and discontinue its own June 2008 did not cover an examination of investigation,20 but as already mentioned the patient care with particular reference to the Independent Review did not examine patient medical records. Nor did the Independent care in any detail. Review chaired by Professor Cairns Smith, Professor of Public Health at the University of Aberdeen. That was not part of the remit Management of either investigation. The importance of questioning It was surprising how managers at different Limited reviews of patient records were levels within an organisation like NHSGGC undertaken during the Internal Investigation. failed in one of the most fundamental aspects A case note review of 45 patient records was of management, namely to ask questions. also carried out by senior nurses as part of the Outbreak Control Team’s investigations that commenced in June 2008 to obtain The culture certain data in relation to matters such as Quite apart from a number of individual age, date of admission and to which wards failures to investigate and be aware of what patients were admitted.15 So far as the was actually happening in the VOLH, it Outbreak Control Team report discloses, became apparent that there was a systemic the purpose of that review was to make failure. Ultimately this can only be described a comparison between the status of the as a management culture that relied upon patients who died and the status of patients being told of problems rather than actively who survived. The report’s conclusion was seeking assurance about what was in fact that patients who died were, on average, happening. To take an example from the older than those who survived.16 In addition, evidence, a manager who has a responsibility on 16 June 200817 two senior Consultant to ensure the delivery of high quality care Physicians from outwith the Clyde division cannot fulfil that duty simply by relying on undertook a case review of 15 patient being told when a specific problem emerges records where C. difficile had appeared on and then reacting to the problem. Some the death certificates to consider whether managers with responsibilities for the VOLH the death certification was appropriate.18 The also had responsibilities for other hospitals Outbreak Control report describes this as a operated by NHSGGC, but the Inquiry’s “brief review”.19 focus, of course, was only on the VOLH, and in consequence I cannot comment on their broader performance. Nor do I know how 14 TRA00180010 prevalent this style of management would be 15 TRA01140044‑46; GGC01480004 generally within NHSScotland. Nevertheless, 16 GGC00600047 the clear lesson to be learned is that an 17 GGC07260001 18 GGC07280001; GGC0060058‑59 19 GGC00600059 20 TRA01240116

14 Executive Summary

important aspect of management is to be Poor communication proactive and obtain assurance that systems Relatives were critical of poor levels of and personnel are functioning effectively. communication. This was particularly the case in relation to the presence and nature of CDI. One witness only became aware that Patients and families his mother had been diagnosed with CDI Full co‑operation when he saw C. difficile mentioned on her A Chapter in the Report has been devoted to death certificate. Some relatives were told the views of patients and families and their that it was a “wee bug”. That is not an apt experiences at the VOLH. The oral evidence description of what can be a life‑threatening at the hearings from this group of witnesses infection. Mixed messages were provided to was given in a measured and unexaggerated relatives who took patients’ soiled laundry way. Those who provided written statements home to wash. Good communication and but were not called to give oral evidence candour are important aspects of care. co‑operated fully with the Inquiry. These witnesses recognised the importance of having a local hospital and as a group wanted Nursing and medical care to support its continued existence. Nursing failures In the Report it has been necessary to mention The Inquiry’s oral hearings began with the nursing failures. There were individual failures evidence of this group of witnesses. I was caused by a number of factors, including anxious that they should have an opportunity pressures of work, lack of training, and as early as possible to have their views inadequate support. Poor leadership also expressed publicly. Much of the Inquiry’s contributed to an inadequate standard of work was still to be done at that time, nursing care. The individual nurses concerned and that meant that when they gave their may have been doing their best. What I evidence they were not aware of the extent have sought to identify is how, in a care and range of criticisms that were to be made environment that does not promote good subsequently by the experts. quality care, nursing standards can deteriorate and become unacceptable. The message to be A common theme conveyed on this issue is one of the absolute A common theme from this group’s evidence importance of good quality nursing care. was the desire to have answers to what went wrong at the VOLH. A significant number of There were a significant number of cases in this group of witnesses had been actively which there were delays of over 24 hours engaged in a campaign for a public inquiry, between the taking of a specimen for and it became clear during the evidence that laboratory analysis and the commencement fundamental to their thinking was the desire of treatment. What was totally unacceptable that others should not be made to suffer in were the delays in the commencement of the same way that patients suffered in the treatment after the ward was aware of the VOLH as a result of contracting CDI. Although positive result. Delay in the commencement of this group of witnesses was reluctant to be treatment in such circumstances represents an critical of the care provided to patients, many inexcusable level of patient care. Such failures of the descriptions provided did show that would inevitably compromise patient care. there were failures in basic nursing care. Some witnesses attributed poor care to the Medical care nursing staff being too busy to render the The deficiencies that existed in relation to necessary quality of care. Being busy is not medical staffing are set out in Chapter 14. an excuse. If the right kind of care requires In effect, there was a layer of middle grade more staff, then arrangements should be in medical staffing missing, with the result that place to have an adequate number of staff the brunt of the day to day care had to be available. borne by inexperienced junior doctors and that consultants were overstretched. The

15 The Vale of Leven Hospital Inquiry Report

medical review of patients suffering from Dr Biggs was under a duty to take a lead CDI was inadequate, and for many patients role in the effective functioning of the there was no evidence that a proper clinical Infection Control Team. It is clear that Dr assessment of the patient’s condition had Biggs was unhappy with her general position been made. Scrutiny of antibiotic prescribing and lacked professional line management disclosed that many aspects of practice were support, but that does not excuse her poor. There were instances of antibiotics attitude. Dr Biggs’ attitude to her role as being prescribed when no antibiotic was Infection Control Doctor for the VOLH was necessary, and of the continued prescribing wholly inappropriate and professionally of antibiotics in cases where a laboratory test unacceptable. demonstrated that the organism was resistant to that choice of antibiotic. Failure to address Dr Biggs’ behaviour Dr Biggs had raised issues in a number Overall it is likely that patient care was of emails and failure to address these, compromised by the inadequate standard of and to ensure an effective leader of the medical care. Infection Control Team was in place, was a serious management failure. One witness Infection prevention and control described Dr Biggs’ behaviour as “accepted behaviour”.21 Such an attitude is to be Significant failures deplored. Accepted behaviour that puts Clearly infection prevention and control patients at risk has no place in any Health practices and systems had to be fully Board’s philosophy. investigated by the Inquiry. Again experts were commissioned to assist the Inquiry in this System failures task. The Chapter in the Report on infection The failure to meet of committees within the prevention and control is one of the major infection control structure meant that the Chapters, and there can be little doubt that the structure became unfit for purpose. This was significant deficiencies in infection prevention compounded by the fact that the reporting and control practices and systems discovered systems within the infection control system by the Inquiry had a profound impact on the itself and under the clinical governance care provided to patients in the VOLH. arrangements in place at the time were inadequate. Adequate reporting systems must Local failures ensure that there is ward to Board and Board There were personal failures by the senior to ward accountability. Appropriate systems nurse responsible for infection prevention would have identified the local failures at and control in the VOLH. The failure not to the VOLH and the failure of Dr Biggs to consider as a real possibility that the number carry out her duties. That in turn would of cases with CDI was a result of cross have identified the problem with CDI in the infection was inexplicable. Over the period VOLH much sooner and saved many patients from 1 January 2007 to 1 June 2008 there from suffering from the infection and its were a number of opportunities presented consequences. when cross infection should have been actively considered. National structures and systems The Infection Control Doctor Structures Dr Elizabeth Biggs was the Infection Control In order to orientate the reader of the Report, Doctor for the VOLH at least from 1 January some information is provided in Chapter 6 2007 up to early February 2008. Dr Biggs on how the National Health Service in was based at the Inverclyde Royal Hospital Scotland has been structured. In summary, (IRH) but was responsible as Infection Control ultimate responsibility for the promotion Doctor for that hospital, the Royal Alexandria and improvement of the physical and mental Hospital (RAH) and the VOLH. The main thrust of the evidence was that she did not attend the VOLH during that period. 21 TRA01260022

16 Executive Summary

health of the people of Scotland rests with for example, effective infection prevention the Scottish Ministers. The Scottish Ministers and control methods in place. CDI was only discharge that duty through Health Boards. made a HEAT Target in 2009 in response The Scottish Government is the executive to the discovery of the CDI problem at the branch of government in Scotland. There VOLH. Had CDI been a HEAT Target earlier, are a number of organisations that provide that might have raised awareness of the support including NHS National Services infection, but it is to be stressed that the Scotland (NSS) of which Health Protection HEAT Target system was not designed to be Scotland (HPS) forms part. The Scottish a surveillance system of the kind that Boards Government Health Directorate (SGHD) had to have in place. Although there was no provides the central management of the NHS evidence that in the period prior to 1 June in Scotland. The Cabinet Secretary for Health 2008 any consideration was being given and Wellbeing is the Minister responsible for to making CDI a HEAT Target, that is not a the SGHD. criticism because it was necessary to have adequate data available for comparative Systems purposes, and as I have already indicated the The impact of healthcare acquired infections system for mandatory surveillance did not (HAIs) on patients has been well recognised come into operation until September 2006. since at least the 1990s. The HAI Task Force The introduction of CDI as a HEAT Target in was created in January 2003 in recognition 2009 was an appropriate response by the of the ongoing challenges presented by HAI. Scottish Government to the emergence of the Its primary responsibility is to advise on CDI problem at the VOLH. the development and delivery of Scottish Healthcare Environment Inspectorate Government policy in order to minimise HAIs. There is no doubt that the HAI Task Prior to June 2008 there was no system of Force has carried out some excellent work, independent inspection dedicated to the including the implementation of the system infection prevention and control of HAI. of mandatory reporting of all positive tests Following upon the discovery of the CDI for C. difficile toxins to HPS on a weekly problem in VOLH the Cabinet Secretary had a basis since September 2006. This is in effect number of meetings with family members of a national surveillance system in Scotland patients who had contracted CDI who made that provides information on the extent clear to her the view that there should be an of CDI at a national level and allows a independent inspectorate in place to review comparison to be made of trends and data the actions taken in hospitals in relation to over time and between Health Boards. It HAIs. This led to the establishment of the is to be emphasised that the system is not Healthcare Environment Inspectorate (HEI) designed to identify the prevalence of CDI in in April 2009. The HEI carries out announced a particular hospital. and unannounced inspections and publishes inspection results on its website. The The Scottish Government also set inspection team measures hospitals against performance targets that Health Boards standards that are designed to minimise are expected to meet. These are known as the risk of infection to patients, visitors and Health Improvement, Efficiency, Access and staff, based on evidence, best practice and Treatment (HEAT) Targets. In November 2006 expert opinion. The Health Board concerned the Scottish Government announced a HEAT must respond to any issues raised by the Target for Staphylococcus aureus bacteraemia inspection process. (including MRSA and MSSA). The target was an overall reduction of 30% in such cases Inspections of the VOLH in 2011 and 2012 by 2010, and that target was achieved by It is worthy of note that an announced September 2009. inspection of the VOLH took place on 10 and 11 August 2011, and that an unannounced The importance of the HEAT Target system inspection took place there on 7 June 2012. lies in the fact that it places an onus on The unannounced inspection in June 2012 Health Boards to meet the targets by having, concluded that the hospital was clean and

17 The Vale of Leven Hospital Inquiry Report

well maintained and that education in of antibiotics published in 200524 highlighted infection prevention and control was being as a challenge the inadequate supervision of well promoted. There is no doubt that had prescribing and the inappropriate choice of there been an inspection regime of that kind antibiotics by junior doctors. Even as late as in 2007 and 2008, and had an inspection of March 2008, shortly prior to the emergence the VOLH been carried out over that period, of the problem with CDI at the VOLH, another the conclusions would have been very Action Plan was launched by the then Cabinet different to the conclusions arrived at in Secretary for Health and Wellbeing.25 This 2012. echoed the theme that had emerged in Scotland at least by 1999, and had been The absence of an inspection system – a repeated over the years, that antibiotic failure prescribing was not being carried out in a Since devolution the SGHD and other prudent way. agencies have produced a significant amount of material for Health Boards on HAIs. For Inadequate response to the prudent example, the Scottish Infection Manual prescribing message published in July 1998 sent out a clear Reference has already been made to the message on the importance of good infection failures in the prescribing of antibiotics prevention and control. Furthermore, the in the VOLH, failures that persisted until importance of prudent antibiotic prescribing the emergence of the CDI problem in May had been well known at least since the 2008. The repeated messages on prudent 1990s. There was no doubt that the message prescribing had not had an effective impact on the importance of having sound systems in the VOLH by June 2008. Dr Andrew in place to combat HAIs was a message that Seaton, a Consultant Physician in Infectious had been repeated many times over the Diseases and General Medicine in NHSGGC, years because of the importance attached said in evidence that what was happening in to it. In such circumstances it is surprising the VOLH in relation to antibiotic prescribing and indeed regrettable that an effective “was applicable to all our hospitals in Greater inspectorate system had not been put in place Glasgow and Clyde and, indeed, almost prior to 1 June 2008. This is dealt with in certainly all our hospitals in Scotland”.26 detail in the Report, and represents a failure It is not within my remit to consider the on the part of the Scottish Government. position of other hospitals in Scotland, but what was perfectly apparent to me was that there had been what I describe in the Antibiotic prescribing Report as a mismatch between expectation Prudent prescribing and implementation. There are two targets for criticism here – NHSGGC for failing to The importance of prudent antibiotic respond to the messages being sent on the prescribing had been recognised in Scotland importance of prudent prescribing, and the for many years prior to 2007 to 2008. In a Scottish Government for failing to identify letter dated 21 May 199922 addressed to a and remedy the failure to comply with the number of people, including Health Board prudent prescribing messages. General Managers and Chief Executives, the Scottish Office Department of Health included prudent antibiotic prescribing as Outbreaks elsewhere an important goal in the reduction of ill health from hospital acquired infection. That Paragraph (f) of the Terms of Reference message was subsequently repeated over a did permit the Inquiry to see what lessons number of years. An Action Plan23 published could be learned from experience of CDI in in 2002 by the then Scottish Executive and beyond Scotland. I was, however, of the again emphasised the importance of prudent view that that paragraph did not provide antimicrobial use. A guide on the prudent use

24 GOV00360003 22 INQ04540001 25 GOV00360040 23 GOV00360072 26 TRA01150114

18 Executive Summary

an open ended platform from which to necessary, re‑examined. The judge presiding look at the detail of how outbreaks of CDI over the case has no direct part to play in were handled in other hospitals. That would that process. The judge’s role is to ensure that have been an enormous task. In light of the parties conduct the case in accordance with Terms of Reference as a whole I was of the the rules and the judge only intervenes in clear view that it would be outwith their the evidence to seek clarification or further scope to embark upon a critical analysis explanation. At the end of a case parties of the infection control policies of other make submissions on the facts and the law organisations, the governance arrangements to advance their respective positions and, of such organisations and the handling of any ultimately, the judge decides the case by outbreaks. What I did find useful was to have making findings in fact and law. regard in particular to the available reports on CDI outbreaks in England, and compare the The purpose of an inquiry of this kind is conclusions arrived at with the conclusions I quite different. The process is an inquisitorial have arrived at in connection with the VOLH. one. Section 17 of the 2005 Act provides as What was striking was the similarity of the follows: problems identified in these reports and the problems identified by this Inquiry. Lessons “(1) Subject to any provision of this Act or had not been learned from these reports. This rules under Section 41, the procedure and is considered in Chapter 18. conduct of an inquiry are to be such as the Chairman of the inquiry may direct. Scrutiny of other hospitals “(3) In making any decision as to the procedure or conduct of an inquiry the There was regular traffic of patients to the Chairman must act with fairness and VOLH from other hospitals. In particular, with regard also to the need to avoid any patients covered by the remit were unnecessary cost (whether to public funds transferred from the RAH, or transferred or to witnesses or to others)”. from the VOLH to the RAH. For that reason it became necessary for the Inquiry to examine In an inquiry of the kind that I have some aspects of the treatment of those conducted it was for me to decide who would patients at the RAH. As discussed later in the give evidence to the Inquiry and what areas Report, I concluded that the prescription and should be subject to investigation, all within administration of antibiotics to patients prior the parameters of the Terms of Reference. to admission to the VOLH were relevant to It was not in any way part of my function my remit whether that occurred at another to resolve issues as a judge might resolve hospital or in the community under the issues between parties in a litigation. The role authorisation of general practitioners. That of Core Participants is quite different to the did not mean, however, that I considered role played by parties to litigation. Indeed it to be within my remit to conduct an their role should be seen as being one where examination of practices, policies and they are under a duty to assist the Inquiry patient care at any other hospital, or in the in responding to its Terms of Reference. community. As I said at the preliminary hearing on 1 February 2010, the focus of the Inquiry was on investigating, and the Inquiry’s questions The proceedings were to be about finding out what happened, Inquisitorial proceedings why it happened and, importantly, how to In Scotland, legal proceedings are generally make a difference for the future. conducted by way of adversarial process. For example, in a civil litigation the parties to Furthermore, the extent to which Core the litigation identify the issues that are of Participants may question witnesses is concern to them and decide what evidence to significantly constrained by the 2007 Rules. lead in support of their respective positions. Rule 9 provides: Generally a witness led by one party can then be cross‑examined by the other party and, if

19 The Vale of Leven Hospital Inquiry Report

“(1) Subject to paragraphs (2) to (5), where Expert assistance a witness is giving oral evidence at an The contribution made by all the experts inquiry hearing, only – commissioned by the Inquiry cannot (a) the inquiry panel; be overstated. An inquiry of this kind, with Terms of Reference that required (b) counsel to the inquiry; investigation of a range of different factors (c) if counsel has not been appointed, leading to the development of the problem the solicitor to the inquiry; or with CDI, could not perform its function (d) persons entitled to do so under without expert input from a number of paragraphs (2) to (4),may examine different disciplines. I am extremely grateful that witness. to all the experts who assisted the Inquiry. Details of the experts are provided in (2) Where a witness, including a Core Appendix 4. Participant, is being examined at an inquiry hearing, the Chairman may direct that the recognised legal representative of that witness may examine the witness”.

There are other provisions in the 2007 Rules regulating the examination of witnesses, but the clear message is that it is for the Chairman to decide whether a witness should be examined by a Core Participant or any other party representing a person.

Standard of proof The 2005 Act and the 2007 Rules are silent on the standard of proof an inquiry under the 2005 Act should apply when making its findings. I have already mentioned Section 17, which provides that the procedures and conduct of the Inquiry are to be such as I may direct. Furthermore, as I have explained, I must act with fairness. It is worth pointing out that Section 2 of the 2005 Act provides that “an inquiry panel is not to rule on and has no power to determine, any person’s civil or criminal liability”. It is not the function of an inquiry under the 2005 Act to determine the rights and obligations of any parties. In the light of these provisions I considered it to be appropriate to apply the civil standard of proof, a standard of proof on the balance of probabilities.

20

Conclusion The Vale of Leven Hospital Inquiry Report

Conclusion fluid monitoring, care planning, and the prevention and management of pressure This was a lengthy and complicated Inquiry. damage. I note from the important inspection It was necessary to examine a wide range of work being carried out by Healthcare topics in order to comply with the terms of Improvement Scotland that these aspects the remit. I was determined to carry out as of care still feature as sources of criticism, comprehensive an investigation as possible and I make no apology for including so that a full account could be provided of recommendations on these issues to reinforce why the CDI problem at the VOLH was so how critical they are to good quality care. persistent and devastating. Patients and Such basic care is integral to compassionate families had to relive painful experiences care. The recommendations are not directed in providing statements and giving oral against individuals although they will have an evidence and then had to wait for some impact on individual behaviour. Nevertheless, considerable time for the publication of the it is important for individuals such as nurses Report. I consider that wait to be highly and doctors to realise that they have a regrettable but I do firmly believe that the professional responsibility to comply with timescales identified throughout the Inquiry what is laid down as proper practice by their process were unrealistic. The extent of the professional bodies. work required to undertake a thorough examination of the many relevant issues There may be some recommendations that cannot be overemphasised. In the event have been overtaken by events. For example, the Inquiry has unearthed serious personal as set out in Chapter 15, NHSGGC did and systemic failures. Patients who suffered introduce more effective reporting systems from CDI at the VOLH were badly let down for CDI after June 2008, but again the by people at different levels of NHSGGC message should be reinforced that systems who were supposed to care for them. The must ensure that important information is Scottish Ministers bear ultimate responsibility relayed from ward to Board. for NHSScotland and even at the level of the Scottish Government the systems were I am convinced that the adoption of the simply not adequate to tackle effectively an recommendations proposed will result in a HAI like CDI. The major single lesson to be significantly improved focus on patient care, learned is that what happened at the VOLH and in particular on the care of patients to cause such personal suffering should never who contract a hospital infection such as be allowed to happen again. CDI. CDI has been the focus of the Inquiry, but I am in no doubt that, although it was The Report and the recommendations are the failures in how CDI was managed at the informed by all the relevant documentation VOLH that governed the work of the Inquiry, gathered by the Inquiry, the evidence the recommendations should have a more contained in written statements, and the far-reaching impact. Indeed the express evidence at the oral hearings, including intention of the Cabinet Secretary when the evidence of the experts who were announcing the setting up of the Inquiry commissioned to assist the Inquiry. The was that lessons should be learned across lessons to be learned are contained within Scotland. The recommendations are designed the narrative of the Report and reflected in to encapsulate a concept of patient care that the recommendations. includes skilled and considerate medical and nursing care, transparency, candour, effective Some of the recommendations are directed systems of infection prevention and control, to aspects of basic nursing care, for example and strong and dedicated leadership.

22 Key findings The Vale of Leven Hospital Inquiry Report

Key findings 3.4 How C. difficile is spread C. difficile is able to remain in the environment The key findings are short summaries of in the form of resistant spores, a vast number issues identified in the main body of the of which can be shed by a symptomatic Report. For a proper understanding of these patient. Ingestion of spores by a patient who issues the reader should read the main text. is receiving antibiotics can result in infection. Although any antibiotic may result in CDAD The numbering of the introductory and the particular antibiotics associated with subsequent headings identifies the Chapter CDAD are the cephalosporins, co‑amoxiclav and Section numbers upon which the findings (and other broad spectrum penicillins) are based. clindamycin and ciprofloxacin (and other fluoroquinolone antibiotics). 3. Healthcare Associated There are hypervirulent strains of C. difficile Infection and C. difficile that produce high levels of toxins. The 027 3.1 Healthcare Associated Infection strain has been described as a hypervirulent strain but any strain of C. difficilecan produce Healthcare Associated Infection (HAI) is an severe CDAD. infection acquired as a result of a healthcare intervention either in hospital or in the C. difficile community. HAIs are a major public health 3.5 Laboratory diagnosis of problem. Good infection prevention and infection control practices can prevent HAIs. There are a number of tests presently available for laboratory testing for CDAD. It is 3.2 Antibiotics and the bowel flora important to appreciate, however, that there is no test that is both 100% sensitive and also The undoubted potential therapeutic benefit 100% specific. The laboratory must be aware of antibiotics in certain circumstances has of the risk of false positive and false negative to be balanced against the risks associated results. with antibiotic use. Antibiotics can affect the bacteria that make up the normal bowel flora of humans. Because it is unusual for a 3.6 Precautions against occurrence and specific antibiotic to be active only against spread of C. difficile infection one particular bacterial species or group of Because C. difficile can be transmitted to species, treatment of a specific infection with individuals by a number of routes, including an antibiotic will be likely to have an effect direct hand to mouth spread, good and on other bacteria in the bowel. appropriate hand hygiene is essential. So too is good maintenance of the healthcare 3.3 C. difficile – what is it? environment. The main way to prevent C. difficile is an organism carried in the bowel cross‑contamination is to isolate the of up to 4% of healthy adults. Under normal potentially infectious patient in a single room. circumstances it does not cause symptoms Cohorting of infected patients under strict because it is in relatively small numbers and infection control conditions must be seen constrained by other bacterial flora that make as a last resort where single rooms are not up the normal bowel flora of the healthy available. adult. Multiplication of the organism can be triggered by the use of broad spectrum An unexplained incident of loose stools antibiotics administered for some other should be assumed to be infectious until an suspected bacterial infection. C. difficile alternative cause is confirmed. In the VOLH produces toxins that set in motion a process in 2007 to 2008 a potential outbreak could that causes C. difficile associated diarrhoea include two cases of potentially infectious (CDAD). In severe cases the infection can be diarrhoea linked in time and place. life‑threatening.

24 Executive Summary

3.7 Treatment of C. difficile infection upon a press enquiry in early June 2008, a Treatment includes the administration of the look‑back exercise covering the six‑month antibiotics metronidazole or vancomycin, period from 1 December 2007 to 31 May depending upon the duration or severity of 2008 disclosed that there had been a the infection. Any existing antibiotic treatment persistent CDI problem and associated deaths must be reviewed urgently. Good hydration is during that period. That exercise identified essential. The importance of ensuring that the 55 patients who had suffered from CDI and patient’s comfort and dignity are preserved 18 CDI associated deaths. Those figures were cannot be overemphasised. an underestimate of the true position. The CDI problem was identified as a result of a 3.8 Conclusion combination of external factors including a coincidental research project and the press CDAD is a significant cause of morbidity and enquiry. mortality in the elderly, the immunosuppressed and severely ill patients on broad spectrum 4.2 Number of CDI cases antibiotic chemotherapy. Diarrhoea in these In the period from 1 January 2007 to groups of patients must be taken seriously and 31 December 2008, 143 patients who were urgent steps taken to establish whether or not or had been patients in the VOLH tested infection is involved. Patients with diarrhoea positive for CDI. must be isolated as soon as possible. As soon as the diagnosis is confirmed appropriate In the period from 1 January 2007 to antibiotic treatment must be started. Other 30 November 2007 (the early period) antibiotics must be reviewed and stopped 68 patients tested positive for CDI. In unless there are overriding clinical reasons to the period from 1 December 2007 to continue with them. 1 June 2008 (the focus period) there were 63 patients who tested positive for CDI. 4. The number of patients with In the period from 1 June 2008 to 31 December 2008 a further 12 patients at C. difficile and those who died the VOLH tested positive for CDI. Furthermore, 4.1 Discovery of the problem in addition, a number of patients who had The ongoing problem with CDI in the VOLH tested positive prior to 1 June 2008 tested began to emerge in mid‑May 2008. Following positive again after 1 June 2008.

Figure 4.1 Patients with CDI

1/01/07 – 31/12/08 TOTAL 143

01/01/07 - 30/11/07 01/12/07 – 01/06/08 01/06/08 – 31/12/08 68 patients 63 patients 12 patients “Early period” “Focus period”

25 The Vale of Leven Hospital Inquiry Report

4.3 Number of C. difficile deaths Of the patients considered by the Inquiry, Many of the patient records of the 68 CDI was a causal factor in the deaths of 34 patients who contracted CDI in the early of those patients. In addition an examination period (1 January 2007 to 30 November of the death certificates of patients who died 2007) were not available. It was possible to prior to 30 November 2007 revealed that conclude that CDI played a part in the deaths CDI was mentioned in the death certificates of at least six patients during that period. of three of those patients. The figure for the number of deaths is an underestimate, since In the focus period (1 December 2007 to many patient records for the early period 1 June 2008) 28 patients died with CDI (1 January 2007 to 30 November 2007) as a causal factor in their deaths either were unavailable. Most of the patients who as the underlying cause of death or as a died were elderly and suffered from other contributory cause of death. conditions. These were patients who were clinically very vulnerable and in whom an Ten patients died after 1 June 2008. CDI was infection such as CDI could have profound a causal factor in five of those deaths. Three effects. What CDI caused was unnecessary of those five patients died in June 2008. suffering and lack of dignity to patients and enormous distress to relatives.

Figure 4.2 Deaths related to CDI

TOTAL DEATHS 43 DEATHS RELATED TO CDI: 34

01/01/07 – 30/11/07 01/12/07 – 01/06/08 01/06/08 – 31/12/08 2 deaths 31 deaths 10 further deaths (full analysis of 28 related to CDI 5 related to CDI deaths not possible) 1 confirmed CDI related (3 further references on death certificates)

26 Executive Summary

4.4 Conclusion In April 2007 there were several patients The fact that many of the patients were who tested positive in ward 14 over a vulnerable and frail made the suffering period of three to four days. In March 2007 inflicted by CDI particularly devastating. The two patients were positive in ward F on lack of dignity suffered by patients in the the same day, and around two days later final period of their lives and the enormous another patient tested positive. These are distress caused to relatives underline the examples of early opportunities in 2007 for importance of recognising CDI as a serious full investigation of the real possibility of infection. cross‑contamination. Although no ribotyping of specimens took place during that period because the nature of the problem was not 5. C. difficile infection rates and properly identified, it is inconceivable that undeclared outbreaks there were not a number of outbreaks. The C. difficile problem was not confined to one 5.1 Definition of an outbreak ward. A number of the wards in the VOLH An outbreak of CDI includes two or more were affected. linked cases of CDI, by which is meant that the patients are suffering from the same strain of 5.4 Wards with CDI patients – the focus C. difficile toxin due to cross contamination. period C. difficile Different strains can be identified by There were several occasions during the C. difficile ribotyping, and if the strain of is the focus period (1 December 2007 to 1 June same in two linked patients then that would 2008) when at least two patients were indicate that a single ribotype was being suffering from CDI in the same ward in the transmitted between patients. The Infection VOLH. In ward 6 there were patients closely Control Nurses in the VOLH were well aware associated in time and place who tested of what constituted an outbreak. positive in December 2007 and February 2008. In ward F the ward was aware of five When an outbreak is suspected, a number of patients testing positive between 9 and people including the Medical Director have to 25 January 2008. Several patients remained be notified and, if an outbreak is confirmed, positive in ward F in February 2008. an Outbreak Control Team requires to be set up. An NHSGGC requirement is that the Chief 5.5 Conclusion Executive and/or the Chairman need to be informed. If the outbreaks that occurred in 2007 had been identified at the time, and the proper procedures followed, the persisting CDI 5.2 The number of CDI results problem that continued up to June 2008 In the period from 1 January 2007 to 1 June would have been significantly reduced and 2008 there were 199 positive results for many patients would have been spared C. difficile toxin at the VOLH. Ninety of these the devastating impact of the infection. positive results were in the focus period. For CDI would not have been a causal factor in a hospital the size of the VOLH (136 beds in so many deaths. The omissions to identify 2008) this represents a significant level of potential outbreaks represented serious activity. failures.

5.3 Wards with CDI patients – the early period 6. National structures and In the early period (1 January 2007 to 30 November 2007) there were several systems occasions when the number of patients 6.1 Relevant parties and agencies suffering from CDI in different wards in the Scottish Ministers have ultimate VOLH should have been fully investigated. responsibility to promote the improvement As early as February 2007 there were two of the physical and mental health of the patients in ward 6 who tested positive for people of Scotland. It is through Regional C. difficile toxin within a day of each other. and Special Health Boards that Scottish

27 The Vale of Leven Hospital Inquiry Report

Ministers discharge many of their duties. 6.3 Accountability and monitoring The Scottish Government is the executive The system of direct accountability of Health branch of government in Scotland. Healthcare Boards to the Scottish Government included Improvement Scotland (HIS) has a general monthly meetings, two‑monthly meetings, duty of furthering improvement in the and an Annual Review. The Annual Review quality of healthcare in Scotland. There is of particular importance, and is attended are other agencies such as NHS National by the Cabinet Secretary, senior officials Services Scotland (NSS) and Health Protection and Board members. There is a public Scotland (HPS), a division of NSS, that provide session, and members of the public have strategic support and expert input. HPS has a the opportunity of questioning the Cabinet particular responsibility for HAIs. Secretary and the Chair of the Health Board. In the course of the Annual Reviews in NHSScotland is a generic description that August 2006 and October 2007 the Cabinet encompasses the Health Boards and HIS. Secretary did receive assurances from the NHSGGC regarding compliance with infection The central management of the NHS in prevention and control standards. Scotland is undertaken by the Scottish Government Health Directorate (SGHD). The As part of the Scottish Government’s annual Cabinet Secretary for Health and Wellbeing is auditing process of Health Boards, Chief the Minister responsible for the SGHD. Executives are required to sign a Statement of Internal Control to confirm that effective 6.2 Systems processes are in place for clinical governance, The recognition of the growing challenges including appropriate mechanisms in place around HAI led to the creation of the HAI for HAI. Task Force in January 2003. This is a multi‑agency body responsible for advising 6.4 Health Improvement Efficiency, Access on the development and delivery of Scottish and Treatment (HEAT) Targets and CDI Government policy to minimise HAIs. The Task guidance Force membership is drawn from a wide range The Scottish Government sets performance of expertise including medical directors, nurse targets, Health Improvement, Efficiency, directors and consultant microbiologists. Much Access, and Treatment (HEAT) Targets that of the HPS work on HAIs is carried out in Health Boards are expected to meet. CDI conjunction with the Task Force. was not a HEAT Target in 2007 and 2008. In November 2006 MRSA was made a HEAT The Task Force and HPS were instrumental in Target with a 30% reduction target by 2010, the development of a mandatory reporting one that was in fact achieved by September system of C. difficiletoxin specimens. Since 2009. CDI was made a HEAT Target in 2009 1 September 2006 specimens of diarrhoea in the aftermath of the discovery of the from patients aged 65 years or over have problem with CDI at the VOLH. It was only to be tested for C. difficile toxin and the then that the reporting regime set up in results of all positive results have to be September 2006 had produced adequate data sent to HPS on a weekly basis. From 1 April that could be used for comparative purposes. 2009 surveillance for CDI has included the collection of data for those aged 15 and over. 6.5 The review system This regime provides a national surveillance The Clinical Standards Board for Scotland system for CDI in Scotland. The system is not (CSBS) (later subsumed under NHS QIS, designed to monitor the prevalence of CDI and since 1 April 2011 under HIS), was in a particular hospital. As part of the work established as a Special Health Board in April of the Task Force, since November 2007, the 1999 to develop and run a national system Scottish Salmonella, Shigella and C. difficile of quality assurance of clinical services. In Reference Laboratory at Stobhill Hospital, December 2001 CSBS published standards Glasgow, has been able to ribotype isolates to designed to ensure that the risk of infection identify outbreaks and the emergence of new was controlled. A revision of these standards strains of C. difficile. was published in March 2008.

28 Executive Summary

Following the publication of the standards 7. National policies and CSBS undertook a process of review of all Trusts and Boards. The Argyll and Clyde guidance Acute Hospitals NHS Trust was reviewed in 7.1 National guidance on the prevention and July 2002. The Trust met only 24 out of 69 control of C. difficile before 2008 criteria. An update review on 12 May 2004 There was a considerable range of policies disclosed that 27 out of 69 criteria were met. and guidance on HAI available to Boards No further reviews or assessments took place in Scotland from the 1990s onwards. prior to June 2008. The Scottish Government and national organisations regarded infection prevention The review process conducted by CSBS did and control as an important priority. UK include an investigatory process but it was national guidance on the prevention and not an inspection system. Nonetheless, in management of C. difficile was published 2002 and 2004 significant failures in infection in 1994. Launched in September 2003 the prevention and control were identified in the Cleanliness Champions Programme was former Argyll and Clyde Trust. designed to provide education in the basic principles of infection prevention and 6.6 Healthcare Environment Inspectorate control with hand hygiene at the heart of the In 2007 and 2008 there was no inspection programme. system to provide independent scrutiny of the state of the healthcare environment 7.2 The role of Health Protection Scotland in in hospitals, including infection control, developing guidance on C. difficile cleanliness and hygiene. An inspection Health Protection Scotland (HPS) was charged regime was introduced by the establishment with delivering many aspects of plans of the HEI in April 2009 in response to the devised to address HAI. This included the emergence of the VOLH CDI problem. It was issuing of guidance on HAI. The publication a highly appropriate response. The focus of by HPS of the Clostridum difficile associated the HEI is on reducing the HAI risk to patients disease (CDAD) bundle in March 2008 was through a rigorous inspection framework guidance directed at CDI. that includes unannounced inspections of hospitals across NHSScotland. In the years 7.3 Developments from June 2008 onwards since its establishment the HEI has identified A number of C. difficile related guidance a number of hospitals where there were documents were being developed in early deficiencies in infection prevention and 2008 but were not available prior to 1 June control. 2008. This included Scottish guidance on CDI and a checklist for preventing and controlling 6.7 Conclusion C. difficile associated disease. The introduction of CDI as a HEAT Target in 2009 was an appropriate and timely 7.4 Was the guidance on HAI adequate? response by the Scottish Government to the On 27 June 2008, after the VOLH CDI disclosure in June 2008 of the CDI problem problem emerged, the Director General and at the VOLH. Chief Executive of NHSScotland wrote to Health Board Chief Executives reminding A rigorous inspection system of infection them of their responsibilities for HAI. The prevention and control should have been in six‑page Appendix to that letter lists guidance place prior to 1 June 2008. This represents relevant to HAI, a clear indication of the a failure on the part of the Scottish extent of the information available. There Government. Had such a system existed in was adequate guidance available and the the period from 1 January 2007 to 1 June message on the importance of managing HAI 2008, its existence would at the very least had been repeated over several years. have raised awareness of HAI throughout Scotland. If the VOLH had been inspected Guidance in the form of a checklist was during that period the CDI problem would issued by HPS in August 2008. The first have been identified. version of national guidance on CDI

29 The Vale of Leven Hospital Inquiry Report

was not published until October 2008. including A&E services, being transferred Notwithstanding the absence of specific from the VOLH to the RAH. This reduction in C. difficile guidance there were policies in services meant that the anaesthetic service place which informed Health Boards of was not sustainable beyond the short term, how to respond to cases and outbreaks of because the volume of work available was CDI. The guidance issued in October 2008 not sufficient to allow anaesthetists to strengthened aspects of the guidance that maintain their skills or provide a basis to already existed. sustain training accreditation. This state of affairs cast doubt on the sustainability 7.5 The provision of C. difficile guidance of unscheduled admissions at the VOLH. Specific Scottish guidance on C. difficile This prolonged uncertainty had a damaging was not available until October 2008. The effect on staff morale, equipment and on the publication of that guidance was originally physical environment of the hospital. planned for 2009 as part of a two year programme. Publication was brought forward 8.2 Shaping the Future as a result of emerging 027 outbreaks. In 2004 NHS Argyll and Clyde produced a public consultation paper, “Shaping 7.6 The monitoring of the implementation of the Future”, setting out proposals for the guidance reconfiguration of services substantially Although there was a range of guidance to be carried out by the end of April 2007. available at national level, the persisting CDI Significant changes were proposed across problem at the VOLH showed that not enough the whole Argyll and Clyde area. The attention was paid to the implementation of proposals proved to be highly controversial, guidance. and there was no final strategy before the announcement in May 2005 that NHS Argyll After the discovery of the CDI problem at and Clyde was to be dissolved. the VOLH in June 2008 a more prescriptive approach was adopted by SGHD with a specific 8.3 The Lomond Integrated Care Model action plan produced for NHSGGC and a more The Lomond Integrated Care Model was general action plan for all Health Boards. developed as a specific measure to address the fragility of the anaesthetics service and 7.7 Conclusion to manage emergency admissions at the The considerable range of policies available VOLH without the support of anaesthetists. on HAI and C. difficile from the 1990s This model envisaged that 85 to 88% of showed that the Scottish Government and medical admissions would continue. national organisations took the threat of HAIs On the dissolution of NHS Argyll and Clyde seriously. The weakness in the system was on 1 April 2006 this model had not been inadequate external scrutiny. fully implemented. On‑site anaesthetic cover was still available at the VOLH. The Board of NHSGGC intended to fully implement the 8. Changes in services at the model, but medical consultants in the Clyde Vale of Leven Hospital from sector concluded that providing unscheduled 2002 care at the VOLH without anaesthetic cover would not be a safe system of work. This 8.1 Prolonged uncertainty meant that the model could not proceed as For some years there was real uncertainty originally conceived. The Health Minister over the range of services to be provided was made aware of this at a meeting in at the VOLH and indeed over the future September 2006. At a subsequent meeting of the hospital itself. Attempts had been in October 2006 attended by Health made to develop a sustainable strategy for Department representatives and the Chief the VOLH, and between 2002 and 2004 a Executive of NHSGGC, the Chief Executive significant service reconfiguration took place was told to carry out a full option appraisal in Argyll and Clyde resulting in services, of the proposed change.

30 Executive Summary

8.4 A new strategy medical admissions. At a meeting on In June 2007 NHSGGC produced a paper: 24 February 2009 the NHSGGC Board “Clyde Health and Service Strategies: Outcome approved a plan that retained unscheduled of Reviews and Proposals for Consultation”. medical admissions at the VOLH at a level of The extensive programme for change set out about 70% of the current level without the in that paper included the withdrawal of the need for anaesthetic cover. The uncertainty Lomond Integrated Care Model at the VOLH surrounding the level of unscheduled medical and the transfer of unscheduled medical care care and the level of services necessary was to the RAH. At its meeting on 26 June 2007 therefore resolved after many years. the NHSGGC Board approved the proposals set out in the paper as the basis for formal public 8.6 Conclusion consultation and external review. The need for Prolonged uncertainty over the range public consultation and external review arose of services to be provided at the VOLH, because of the policy of independent scrutiny including anaesthetic cover, and over the and public consultation introduced by the new future of the VOLH itself, had a damaging Scottish Government elected in May 2007. effect on recruitment, on staff morale and on the physical environment of the hospital. The external review was carried out by an This state of affairs should not have been Independent Scrutiny Panel. In its report permitted to continue for as long as it did. published on 30 November 2007 the Independent Scrutiny Panel put forward a number of options for public consultation 9. The creation, leadership and including the retention of the status quo. management of the Clyde Subsequently, having initially rejected the Directorate need for public consultation at a Board meeting on 18 December 2007, NHSGGC 9.1 The dissolution of NHS Argyll and Clyde reversed its previous decision under Financial mismanagement in NHS Argyll instruction from the Cabinet Secretary and, and Clyde resulted in the then Minister for at a meeting on 22 January 2008, agreed Health and Community Care announcing on to initiate a period of public consultation as 19 May 2005 in a statement to the Scottish soon as possible. Parliament that NHS Argyll and Clyde was to be dissolved. The administrative boundaries That consultation process was still ongoing of NHS Greater Glasgow and NHS Highland in June 2008 when the CDI problem at were to be changed to allow these Boards the VOLH emerged. In June 2008 the to take over responsibility for managing the Cabinet Secretary for Health and Wellbeing delivery of health services in the relevant commissioned an Independent Review into areas of Argyll and Clyde. the sustainability of anaesthetic services at the VOLH. That review concluded, as had NHS Argyll and Clyde was dissolved on been the conclusion in 2006, that anaesthetic 1 April 2006. From that date NHS Greater services were not sustainable at the VOLH, Glasgow took over responsibility for a but that selected unscheduled admissions significant part of the Argyll and Clyde area, could be retained at the VOLH with including the VOLH, the IRH and the RAH. unscheduled medical admissions diverted to Since then the Board has used the descriptive a suitably equipped hospital such as the RAH. name of NHS Greater Glasgow and Clyde (NHSGGC). 8.5 The Vision for the Vale In September 2008 NHSGGC approved 9.2 Integration and published its consultation document The options open to NHS Greater Glasgow “Vision for the Vale of Leven Hospital”, were either full integration when NHS with the consultation period running from Argyll and Clyde was dissolved or phased 31 October 2008 to 30 January 2009. The integration. NHS Greater Glasgow was itself recommendations of the Independent Review already in the process of restructuring, and were adopted as the model for unscheduled the decision was made that full integration

31 The Vale of Leven Hospital Inquiry Report

should not be completed for a further three 9.4 Leadership of the Clyde Directorate years. Acute Services within the Argyll and The new Clyde Acute Directorate required Clyde area that were to be the responsibility highly experienced leadership and strong of NHSGGC were therefore initially management in order to achieve successful incorporated as a single directorate of the integration. Yet the recruitment process for Acute Division of Greater Glasgow. the appointment of the Director was delayed. Mrs den Herder was not interviewed for the The integration process after April 2006 was post until 19 June 2006 and only took up managed by the Clyde Transition Steering the post formally on 1 October 2006. From Group, chaired by the Chief Executive. The 1 April 2006 to 31 July 2006 an interim final meeting of this Group took place in Director was appointed. After 31 July 2006, November 2006. responsibilities for the Clyde Directorate The creation of the Clyde Acute Directorate were passed to individual Directorate General was a sound decision. A significant amount Managers until Mrs den Herder was in post. of planning and expertise was involved in ensuring that the transition of the Argyll and 9.5 The leadership of Mrs den Herder Clyde Board’s responsibilities to NHSGGC The Clyde Acute Directorate was not directly was as smooth as possible. Nevertheless, comparable with other directorates within integration took place against a background of NHSGGC, as it was geographically defined mismanagement of NHS Argyll and Clyde and rather than service‑based. The range of of glaring deficiencies in infection prevention services for which Mrs den Herder was and control previously identified in Argyll and responsible proved to be a considerable Clyde. Extensive transitional arrangements burden for her, and it is not surprising had been put in place for what was a major that Mrs den Herder did not initially give organisational change. Given this history, priority to infection prevention and control and notwithstanding the care taken in the at the VOLH. Nevertheless in the course of planning of the integration process and the 2007 she should have been in a position appropriateness of the establishment of the to acquaint herself with the outstanding separate Clyde Acute Directorate as part of deficiencies in the management of infection that process, it would have been desirable for prevention and control. a post‑implementation audit or review by an independent party to have been carried out. Mrs den Herder failed to give sufficient priority to infection prevention and control. 9.3 Impact of integration on the Vale of Leven There is no doubt that in this, as well as Hospital (VOLH) in other aspects of her work, Mrs den Although no criticism is made of the decision Herder was let down by other members to establish the Clyde Acute Directorate, the of her management team, but given her decision did mean that infection prevention responsibility for infection prevention and and control management within that control she should have exercised greater Directorate initially remained separate from scrutiny of the structures that were in the rest of Greater Glasgow. Full integration place. She should have been in a position to at an earlier stage would have resulted in identify that there were system failures. She earlier recognition that the Clyde infection resigned her post in July 2008, at least in 27 prevention and control system was defective. part because of “stress and burnout”. There can be little doubt that her stress levels As part of the continuing process of would have impacted upon her performance integration, in September 2007 the as Director of the Clyde Acute Directorate. rehabilitation and assessment areas of the Clyde Acute Directorate were integrated 9.6 Other managers in the Clyde Directorate into NHSGGC Rehabilitation and Assessment Other managers in the Clyde Directorate were Directorate (RAD) but line management for insufficiently proactive, with the result that infection prevention and control for the system failures, and in particular the failure rehabilitation and assessment areas in the

VOLH did not change. 27 INQ04240005‑06

32 Executive Summary

of the Infection Control Doctor to fulfil her governance responsibilities were a specific duties, were not identified. part of the role of senior staff, directors and other general managers, with the Chief The management approach to infection Executive having overall responsibility. prevention and control in the Clyde NHSGGC also produced more detailed Directorate was a manifestation of a culture guidance on clinical governance in December that viewed infection prevention and control 2006 in recognition of its importance. as being of low priority. NHSGGC has to bear ultimate responsibility for the existence of 10.3 Clinical governance structures at this culture notwithstanding the difficulties divisional level it encountered in inheriting the problems of In NHSGGC an appropriate clinical governance NHS Argyll and Clyde and in the integration committee structure was in place at divisional process. level. A Clinical Governance Committee (CG Committee) had responsibility to oversee the 9.7 Conclusion Clinical Governance Framework and assure The decision to establish a separate Clyde NHSGGC that it was working effectively. Acute Directorate was, in principle, a sound There was a reporting line from the infection one. A post‑implementation audit or review prevention and control committee structure would have been desirable. There was a through the Board Infection Control lack of continuity of leadership in the initial Committee (BICC) to the CG Committee. stages, although it is by no means certain that the clinical governance and infection The infection prevention and control prevention and control issues would have reporting line to the BICC did not, however, been recognised at an early stage given Mrs identify the system and personal failures den Herder’s failure to identify them in the that resulted in the infection prevention months after she took up post. Generally, and control system for the VOLH becoming infection prevention and control was viewed dysfunctional. The CG Committee did not as low priority by other managers. become aware of the CDI problem in the VOLH prior to June 2008.

10. Clinical governance 10.4 Clinical governance in the Clyde Acute Directorate 10.1 National policy At the level of the Clyde Acute Directorate Clinical governance is the system through (after 1 October 2006) Mrs den Herder, which NHS organisations across the UK are as Director, bore responsibility for accountable for continuously monitoring leading the clinical governance agenda. and improving the quality of their services That responsibility included ensuring the and safeguarding high standards of achievement of the highest possible quality patient‑focused care and services. Monitoring of care. That responsibility for high quality is a key element of effective clinical care included HAI. As Director, Mrs den governance. Herder chaired the senior committee in the Directorate with responsibility for clinical 10.2 Clinical governance in NHS Greater governance. Glasgow and Clyde In December 2006 NHSGGC produced its own Mrs den Herder failed to ensure that the Clinical Governance Framework in recognition clinical governance arrangements for of the importance of having effective infection prevention and control were arrangements in place to improve public and operating effectively. The clinical governance staff confidence in the safety and quality of arrangements for which she has to bear the healthcare provided. That Framework ultimate responsibility were not geared document also recognised the importance to ensuring the highest possible quality of monitoring arrangements to improve of patient care in relation to HAI, and in the quality of healthcare provided. Clinical particular CDI. She was not provided with routine infection prevention and control

33 The Vale of Leven Hospital Inquiry Report

information. Infection prevention and and control issues was provided to the CG control was largely ignored as an element of Committee from other sources, but because importance to clinical governance. of the size of NHSGGC the information made available to the CG Committee was limited Had clinical governance within the Clyde to issues deemed to be of importance. The Acute Directorate been effective, the infection CG Committee should have been alerted prevention and control failings set out in this to the CDI problem in the VOLH, but the Report would have been identified. Although clinical governance arrangements within the precise impact of earlier detection cannot the Clyde Sector were not sufficiently be measured, the identification of these effective to provide the necessary assurances failings would have prevented many cases of that the infection prevention and control CDI. arrangements at the VOLH were operating properly. 10.5 Clinical governance in the Rehabilitation and Assessment Directorate 10.8 Changes in clinical governance since The rehabilitation and assessment areas of 2008 Clyde were fully integrated with NHSGGC Important changes in reporting practices in September 2007. Ms Anne Harkness, have been put in place by NHSGGC since June the Director of the Greater Glasgow 2008. Infection prevention and control is Rehabilitation and Assessment Directorate now a standing item on the CG Committee’s (RAD), became the Director of the extended agenda. The Board Infection Control RAD, with wards 14, 15 and F at the VOLH Committee reports to each meeting of the CG being included in her responsibilities. Ms Committee instead of annually. Harkness was responsible for leading the clinical governance agenda in the RAD, as 10.9 No non‑executive director for Clyde was Mrs den Herder for the Clyde Acute The membership list for the CG Committee Directorate. discloses an intention to appoint a designated non‑executive director for Clyde to the Prior to June 2008 Ms Harkness was not committee. That did not happen. It would aware of the CDI problem at the VOLH. There have been highly desirable to have a were patients suffering from CDI in wards non‑executive director on that committee for which she was responsible, particularly with a specific responsibility for Clyde during in ward F in January/February 2008. The a period of extensive organisational change. clinical governance arrangements were not sufficiently effective to alert her to the problem. 10.10 Conclusion NHSGGC’s clinical governance system was 10.6 Reporting from the Clyde Sector not operating effectively. An effective clinical governance system would have identified the The NHSGGC CG Committee was unaware infection prevention and control failures that of the persistent CDI problem in the VOLH occurred in connection with the VOLH. notwithstanding appropriate links being in place in the Clyde Sector. This was due to a lack of focus in the Clyde Sector on infection prevention and control as an integral part of 11. The experiences of patients clinical governance. and relatives 11.1 Sources of evidence 10.7 The Clinical Governance Committee and NHS Greater Glasgow and Clyde A total of 71 patients and relatives provided written statements to the Inquiry, eight of Above the level of the Clyde Sector, clinical whom were patients. governance committee structures were in place, with a reporting line on infection The patients and relatives who gave oral prevention and control from the Board evidence to the Inquiry were asked to Infection Control Committee (BICC) to the CG recall events that for many had been highly Committee. Input on infection prevention

34 Executive Summary

distressing. They gave their evidence with 11.5 Communication candour and with great dignity. In the oral Relatives expressed a real concern about a evidence and in the evidence provided in general lack of communication by nursing and statements to the Inquiry many witnesses medical staff. Difficulties were encountered did not directly criticise the care given in speaking to nursing staff and in obtaining by nursing staff. They described care that information from medical staff. The fact was deficient but that they believed could that the nursing shift change coincided with be explained by the nursing staff being evening visiting caused a particular problem. overworked and understaffed. The evidence One area where there was a lack of proper of these witnesses was provided prior to the discussion was that of decisions not to evidence of the nursing and medical experts resuscitate patients in the event of cardiac and the criticisms made by these experts. arrest.

11.2 The patients’ and relatives’ expectations There was also a lack of communication over A common theme in the evidence of the CDI. A number of witnesses were not aware patient and relative group was a desire for of relatives having contracted CDI until the answers to two questions: firstly, why there relative had died. One witness only became were so many deaths in which CDI was aware that a patient had been diagnosed with implicated, and secondly, why the problem CDI when he saw “C. difficile” on the death with CDI was not identified prior to June certificate. 2008. The other main theme that emerged from their evidence was the desire that Good communication should be seen as an others should not be made to suffer in the important element of patient care so that way that patients suffered in the VOLH. patients, and where appropriate relatives, can be involved in decisions about care. 11.3 Patient care While many of the patients and relatives 11.6 Ward fabric and cleanliness did not criticise the nursing staff directly, It was obvious to patients and relatives that incidents described by them did represent the VOLH was run down. There was some examples of failures in basic nursing care. evidence that the hospital environment was Patients in different wards were described not particularly clean. Storage was an obvious by relatives as having dirty fingernails. problem, with items stored within patient Faeces were found under fingernails. One bays. Faeces were seen on items of patient patient, whose catheter bag was seen to clothing. Urine on the floor of one ward had be full at visiting times, had puddles at the not been properly cleaned and produced a side of the bed on the floor in the vicinity stench that was described as “disgusting”.28 of the catheter bag. The catheter bag was Commodes were seen to be dirty. strapped to the patient’s leg, and the patient developed sores on her leg where the bag 11.7 Infection prevention and control issues was located. There were unacceptable failures In a number of wards inadequate information in basic nursing care. was given on hand washing, and many visitors were not advised of the importance 11.4 The patients’ and relatives’ view on of using soap and water when a patient staffing was diagnosed with CDI. Heavily soiled The clear impression gained by these laundry was taken home by some relatives witnesses was that there was a shortage of of patients suffering CDI with inadequate and staff on the wards and that the nurses were conflicting information on how the laundry overworked. It was that belief that convinced should be managed. Most witnesses said that them that members of the nursing staff nursing staff did wear aprons and gloves were doing the best they could in difficult when dealing with patients, but a number circumstances. Staff morale was perceived as of witnesses did not recall seeing a notice low.

28 TRA00040030‑31

35 The Vale of Leven Hospital Inquiry Report

outside an isolation room when a patient was restricted to one particular ward or limited to suffering from CDI. Isolation practices were a particular period of time. It was apparent seen to be carelessly managed, with doors of that standards of nursing care had been isolation rooms left open. permitted to lapse over a period of time.

11.8 Conclusion 12.4 Record keeping The patient and relative group pressed for a The record of a patient’s stay in hospital public inquiry because they wanted a full is an essential clinical tool. Nursing is not examination of why the CDI problem had a memory game. The standard of record persisted for as long as it did and why there keeping by the nursing staff in the VOLH were so many deaths in which CDI was was poor. It was clear that a culture had implicated. The descriptions of care provided developed in which record keeping was did identify serious failures in patient care. not considered to be a priority. Nurses maintained in evidence that with small wards 12. Nursing care they were fully aware of the needs of the individual patients without having detailed 12.1 The Nursing and Midwifery Council Code and complete records. This was a seriously of Conduct flawed approach and must have contributed The Nursing and Midwifery Council (NMC) to failures in patient care. sets standards for nurses and midwives for The NMC Guidance emphasises that auditing the provision of safe and appropriate care. plays a vital part in ensuring that good quality care is being provided to patients. The NMC, through its Code of Conduct Deficiencies identified through auditing and other advice, emphasises that record can be responded to by staff training and keeping is an integral part of nursing care. development. No auditing of records was If widespread failures in record keeping are carried out from 1 January 2007 to April or identified there can be little doubt that care May 2008. Peer audits of patient records had has been compromised. taken place in the past, but none had been carried out in the VOLH since 2003. 12.2 Use of nursing experts Seven independent nursing experts were 12.5 Nursing aspects of infection prevention commissioned by the Inquiry to provide and control professional opinions on the quality of Nurses are at the frontline of the delivery nursing care given to patients who suffered of care. To deliver care to an acceptable from CDI during the focus period (1 standard to patients with CDI nurses must December 2007 to 1 June 2008). They were have the relevant knowledge and skills. instructed to review the patient records and Infection Control Cards and asked to use Prior to June 2008 the majority of nursing the professional standards of the NMC as a staff in the VOLH had no formal training on benchmark for the standard of care expected CDI. Some nurses in the VOLH had completed from nursing staff. Cases from different the Cleanliness Champions Programme prior wards were allocated to each expert. An to 1 June 2008 but the uptake was poor. infection control nursing expert was asked Infection Control Nurses at the VOLH did visit to review some aspects of nursing care in wards to provide advice, but there was little that period. The available patient records evidence in the nursing records on the advice for the early period (1 January 2007 to 30 given because generally no record was made. November 2007) were also reviewed by one of the nursing experts. Evidence of the nurses’ knowledge of the seriousness of CDI as an infection was 12.3 Overall view of nursing experts somewhat mixed. There was evidence that There was a catalogue of failures in it was seen as a serious infection, but there fundamental aspects of nursing care. was also evidence of a lack of awareness of Deficiencies in nursing care were not the significance of the infection. A review

36 Executive Summary

of nursing records disclosed that there was baseline observations of temperature, pulse, little to suggest that nurses were aware of respiration and blood pressure, was regularly the seriousness of CDI as an illness. The omitted from the assessments. importance of fundamental aspects of care, including fluid balance management and Pro forma nutritional assessment nutrition, was not recognised. Delays in the documentation was available but had not administration of antibiotics for patients who been distributed to all wards. Where available tested positive for CDI represented a wholly there were deficiencies in the assessments unacceptable level of care for patients who including a failure to regularly reassess the in the main were elderly and vulnerable and position and delays in patients being referred exposed to serious risk by contracting CDI. to a dietician. Other assessments like moving and handling and falls risks assessments Although the Loose Stools Policy quite were often either not completed at all or rightly provided that a patient who could incorrectly completed with no evidence of contaminate the environment with faeces reassessment. should be isolated unless the patient was clinically unsuitable for isolation, the practice Care planning is a term used to describe in the VOLH was not to isolate patients until the process of assessing a patient’s needs. a positive laboratory result of the diagnosis It is a prescription for care. The ability to was obtained. This practice was to an extent prepare an appropriate care plan is a core influenced by a shortage of isolation rooms skill, and the absence of an appropriate but because it was usually possible to isolate care plan makes it difficult for nurses and once the diagnosis was confirmed it was clear other members of the healthcare team to that isolation could have occurred earlier. deliver consistent and coordinated care. Care The practice was an unsafe one and put planning should be seen as a mandatory asymptomatic patients at risk. professional responsibility.

12.6 Isolation issues specific to ward F Care plans were poorly completed and did The admission of a patient to ward F in not reflect all of the patient’s problems. In February 2008 was badly managed. The one ward the well recognised nursing model patient was not symptomatic for CDI, but for care planning had been abandoned was admitted into a bay where there was at in favour of a medical model that simply least one symptomatic patient. This patient consisted of listing the medical instructions later contracted CDI. The investigation into a on the care plan documentation. This was a complaint by this patient’s family was poorly wholly inappropriate model of care planning. carried out with the result that the Chief For many of the patients who contracted CDI Operating Officer was misled and provided no care plans had been prepared. inaccurate information in response to the complaint. 12.8 Nursing notes and charts in the focus period 12.7 Nursing assessments and care planning The nursing evaluation records are an in the focus period important part of the patient records and are Effective patient assessment on admission to the direct responsibility of the nurses caring hospital is integral to the safety, continuity for the patients. and quality of patient care. The assessment provides baseline information on which to There were serious failures in the recording plan care. of patient information in the nursing evaluation records. There were unacceptable In the admission assessment documentation gaps in some records. The handover practices available in the VOLH many basic details adopted at the VOLH included information were often not recorded. Some sections were obtained by the nurse during the shift not completed at all. Important information being noted on a handover sheet for use such as the patient’s weight, assessment during handovers. On many occasions this of the risk of pressure damage, and the information had not been entered into the

37 The Vale of Leven Hospital Inquiry Report

patient records. The handover sheets were it is not possible to say how many patients not retained. might have suffered some pressure damage prior to admission. There were serious failures in the recording of observations in patients who were ill with Between January 2007 and June 2008 CDI and in the nursing management of pain. the VOLH did not have a dedicated Tissue In general there was no proper recording of Viability Nurse (TVN). That task was stools in patients with unexplained diarrhoea being carried out by one of the Senior and also when there had been a diagnosis of Charge Nurses (SCNs), which placed her CDI. The recording of fluid balance, of obvious in a very difficult position because of her importance to patients suffering from CDI and responsibility for a busy medical ward. Given at real risk of dehydration, was poor. the importance of tissue viability a nurse who was an SCN on a busy ward should not 12.9 Pressure damage in the focus period have been selected as the TVN for the VOLH. Immobile, sick and weak patients are unable to move effectively and are dependent 12.10 Nursing care in the early period upon their carers to assist them. They are at The nursing expert who examined the patient particular risk of sustaining pressure damage. records for the early period (1 January Patients who are suffering from CDI with 2007 to 30 November 2007) had access to profuse diarrhoea are particularly vulnerable 33 sets of patient records out of a total of to skin damage. That is one reason why 68 patients who tested positive for CDI. The moving and handling techniques are important trends evident on basic aspects of nursing in the management of these patients. care in the focus period were also present in the early period. Effective nursing care should prevent pressure damage where possible. Early 12.11 Staffing issues and care assessment of the risk to the patient is Adequate staffing of nurses on wards is imperative so that appropriate measures can dependent not only on having the correct be put in place to prevent pressure damage number of nurses, but also on having or at least reduce the risk. the correct skill mix to carry out the care appropriate to the level of patient In the VOLH the intention was that the risk dependency. Adequate nursing staffing levels of pressure damage should be assessed on are important for ensuring patient safety admission by using the established criteria and quality of care. The staffing ratios for contained in the Waterlow Scoring system. all the wards in the VOLH were acceptable The appropriate documentation for the for the number and nature of patients for implementation of this system was available these wards. Similarly the ratio of registered/ to nurses in the VOLH. The Waterlow Scoring trained to untrained staff on the medical system documentation was not, however, wards was appropriate. The use of bank and being used in ward 6. agency staff was at an expected level.

There were serious deficiencies in pressure What the staffing ratios do not do, however, management. There were failures to assess is take account of a number of patients patients and failures in documentation of becoming unwell with profuse diarrhoea and the risk which included incorrect scoring. In requiring additional nursing input. Nor do the cases where initial assessments were made, ratios for the Rehabilitation and Assessment there were failures to review assessments wards take account of the fact that some appropriately and to prepare appropriate patients in those wards may be medically care plans. On the whole pressure and unwell and may require nursing rather than tissue management at the VOLH was poor. rehabilitation care. The nurses’ evidence Inevitably this would have had an impact was that they were extremely busy on the on care. So far as the Inquiry can ascertain wards, and that was regularly advanced as a at least 37 patients in the focus group of 63 reason why nursing records were incomplete. patients suffered pressure damage, although It is highly likely that, with patients in a

38 Executive Summary

rehabilitation ward being acutely unwell antibiotics. Subsequently in 2005 a guide and patients in different wards suffering on the use of antibiotics for NHSScotland: from CDI, staffing levels were inadequate “Antimicrobial Prescribing Policy and Practice at times between January 2007 and June in Scotland” (the 2005 guide) highlighted the 2008. Activity levels on wards may very well challenges faced in antimicrobial prescribing, at least partially explain why the nursing including concern about inadequate records were not kept as they should have supervision of prescribing and inappropriate been, but that does not in any way excuse choice, duration of treatment and records the significant deficiencies found. Having of administration by junior doctors. One of regard to the serious failures identified, it is the key recommendations of the 2005 guide simply not tenable to maintain, as nurses did was that a multi‑disciplinary Antimicrobial in evidence, that the care was in fact given. Management Team (AMT) should be formed by each Health Board to be responsible 12.12 Overall conclusions on nursing care for implementing antimicrobial policy and There were failures in fundamental aspects practice. of nursing care of patients who suffered CDI. The SCNs must be primarily to blame for the 13.2 The 2008 Action Plan deficiencies in their own wards. In March 2008 the then Cabinet Secretary for Health and Wellbeing launched the “Scottish Nursing Management was unaware of the Management of Antimicrobial Resistance extent of the problem with fundamental Action Plan” (the 2008 Action Plan) which aspects of care. A functioning system of was to replace the 2002 Action Plan. The audit would have identified failures of the 2008 Action Plan echoed the theme that kind identified here and would have allowed had emerged in Scotland at least by 1999, remedial action to be taken. Effective Nursing and had persisted over the years, that it was Management would have identified the known that antibiotic prescribing was not deficiencies in nursing care. being carried out in a prudent manner.

Ultimately NHSGGC must accept responsibility 13.3 Significant failures in implementation for the failures in nursing care identified in and monitoring Chapter 12 of the Report. Prior to June 2008 the message on the importance of prudent antibiotic prescribing had certainly not reached the VOLH, where 13. Antibiotic prescribing prescribing was far from prudent. The discovery of the CDI problem in the VOLH 13.1 Antimicrobial policy and prudent in May and June 2008 was a catalyst for prescribing change, but change in antimicrobial practices By letter dated 21 May 1999 addressed to should have happened long before that time. Health Board General Managers and Chief Furthermore, reports into CDI outbreaks Executives of NHS Trusts, among others, the at the Stoke Mandeville and Maidstone Scottish Office Department of Health set out and Tunbridge Wells hospitals published in a wide range of actions aimed at reducing 2006 and 2007 should have prompted an the emergence and spread of antimicrobial examination of antibiotic prescribing practice. resistance and its impact on the treatment of A culture had developed in which clinicians, infection. One of the key elements identified were using broad spectrum antibiotics in was prudent antimicrobial use. situations where they were no more effective against those infections that were sensitive to In the years that followed this message was narrow spectrum antibiotics. repeated. In 2002 the then Scottish Executive produced the “Antimicrobial Resistance The recognition at national level of the Strategy and Scottish Action Plan” (the need for prudent antibiotic prescribing and 2002 Action Plan). This was a three‑year implementation of that policy produced plan with aims that included the reduction an ineffective response by NHSGGC over of unnecessary and inappropriate use of a period of several years. The failure to

39 The Vale of Leven Hospital Inquiry Report

implement the prudent prescribing message doctors should keep clear, accurate and should have been identified and remedied at legible records, reporting the relevant clinical an earlier stage by the Scottish Executive and findings, the decisions made, information later the Scottish Government. There was an given to patients, and any drugs prescribed obvious mismatch between expectation and or other investigation or treatment. The implementation. message for doctors who want to show that care of the necessary quality has been given 13.4 The Antimicrobial Management Team is to make an accurate and complete record The recommendation that Antimicrobial of that care. As with nurses, good record Management Teams (AMTs) should be set up keeping by doctors is an integral aspect of was contained in the 2005 guide available to good care. Health Boards from 5 September 2005. The Records made by the consultants at the VOLH NHSGGC AMT was not established until June were generally adequate, but the recording 2007, but in circumstances that involved of a patient’s condition and assessment made planning and financial support there was by junior doctors was poor. There was a real no undue delay by NHSGGC in setting up problem in identifying from some of the the AMT. A number of other Boards had not records why a particular antibiotic was being set up AMTs prior to June 2008, and were prescribed. instructed by the Scottish Government to do so immediately after the problem with CDI at the VOLH came to light. 14.3 Medical staffing Years of uncertainty over the future of the The NHSGGC AMT reacted swiftly and VOLH had a significant impact upon the effectively to the emergence of the CDI recruitment of medical staff. problem at the VOLH. Steps taken to improve prudent prescribing had a dramatic impact on The departure of different specialist services the number of CDI cases in the NHSGGC area from the VOLH over the years meant that even in the relatively short term. the VOLH was regarded less and less as a potential source of senior education. Between 13.5 Conclusion January 2007 and June 2008 there were The importance of prudent antibiotic no middle grade doctors such as registrars prescribing had been recognised in Scotland in the VOLH. As a result a significant burden for many years prior to June 2008. of managing patients was borne by junior Important guidance was available but there doctors and added to the pressures on the was a mismatch between expectation and senior medical staff. There was a lack of implementation that should have been continuity of care. The pressure imposed addressed prior to June 2008. upon one senior doctor because of his on‑call duties had a significant impact upon his 14. Medical care ability to conduct ward rounds. 14.1 Inquiry medical experts The rehabilitation wards should have been Medical experts commissioned by the Inquiry mainly geared towards rehabilitation and were given the patient records and Infection not to looking after acutely ill patients. Control Cards of the patients allocated to Between January 2007 and June 2008, them. Patient records from different wards however, acutely ill patients were in these were considered by each medical expert. wards, which increased the pressure on the The professional standards issued by the doctors with responsibilities for these wards General Medical Council (GMC) were used by and impacted on care. This was recognised the medical experts as a benchmark for the to an extent by management, and by at least standard of care expected from medical staff. February 2008 steps were being taken to monitor the provision of care at the VOLH 14.2 Record keeping while a decision on the future of the VOLH The GMC’s “Guidance for Doctors” effective was awaited. Morale was low because of the from 13 November 2006 provided that uncertainty over the future of the hospital.

40 Executive Summary

On inheriting the VOLH, NHSGGC took over 14.6 Antibiotic prescribing a hospital that for a number of years had In the period from 1 January 2007 to suffered losses of services and serious 1 June 2008 a variety of guidelines on mismanagement. Uncertainty over the future antibiotic prescribing was being used at the of the VOLH and recruitment problems placed VOLH. In the main there was consistency NHSGGC in a difficult position. among the junior medical staff in the use of antibiotic prescribing guidelines. There was, 14.4 Medical management of CDI however, a lack of uniformity in the use of A patient who tests positive for CDI should guidelines among the senior medical staff, be reviewed that same day. That review and there were some differences between should include a clinical assessment of the the guidelines. This situation should not patient’s condition to assess the severity of have developed. In a hospital like the VOLH the condition. The patient records disclosed, clinicians should have been following one however, that there were delays in medical common agreed policy. intervention with patients who had tested positive for CDI, suggesting that the severity The patient records disclose that 60 of the of CDI as an illness was not properly 63 patients in the focus group did receive recognised. Subsequent review should also be antibiotics while in the VOLH. At least 24 regular, which could mean on a daily basis. of those patients received antibiotics in the Even if it is accepted that there might have community which may have predisposed been more regular reviews than have been them to CDI, and at least three further recorded in the patient records, it is clear that patients had been prescribed predisposing there were a significant number of instances antibiotics at the RAH before admission to where there was no review. Because junior the VOLH and before receiving antibiotic doctors were at the forefront of care, their treatment in the VOLH. Nevertheless, more inexperience resulted in failures to notify than half of the patients in the focus group senior medical staff when senior medical were first prescribed antibiotics which involvement was necessary. predisposed them to CDI while they were in the VOLH. The antibiotics involved The inadequacy of medical reviews and in the VOLH included third generation assessment compromised patient care. The cephalosporins, quinolones and broad lack of proper supervision of junior doctors spectrum penicillins such as amoxicillin and was simply the result of the uncertain future co‑amoxiclav (Augmentin). The prescribing of the VOLH as a hospital. Senior medical of antibiotics in the VOLH therefore played a staff were exposed to pressures that limited significant role in many of the patients in the their ability to provide the necessary focus group contracting CDI. supervision. It may not be easy for a Board to scrutinise the levels of medical care provided Poor documentation of the reasons for but assurance can be obtained that the the choice of certain antibiotics made it quality and safety of care meet the requisite difficult to ascertain whether or not the standard through appropriate systems. choice was appropriate. There were many Ultimate responsibility for standards of care examples of appropriate prescribing for not being adequate rests with NHSGGC. conditions other than CDI. Nevertheless, it was evident that there were instances where 14.5 Do Not Attempt Resuscitation orders the choice of antibiotic was inappropriate A Do Not Attempt Resuscitation (DNAR) order or where antibiotics were prescribed when is a written record of a decision that if the unnecessary. There were also instances of patient suffers a cardiac arrest he or she will the continued prescription of antibiotics in not be resuscitated. A significant number of cases where a laboratory test demonstrated DNAR orders had been incorrectly completed, the organism was resistant to that antibiotic. for example by failure to record a date for After stricter controls were introduced in review. There was no evidence that the June 2008 there was a significant reduction auditing envisaged by the DNAR Policy ever in the use of co‑amoxiclav in hospitals in took place. NHSGGC, including the VOLH.

41 The Vale of Leven Hospital Inquiry Report

In most cases of CDI, once the treatment was failures in carrying out proper medical started, appropriate antibiotic treatment assessments and review, inappropriate by the prescription of metronidazole or prescribing and unacceptable delays in the vancomycin was given, although there were commencement of appropriate antibiotic instances where ongoing monitoring should treatment after positive results were have led to a reassessment of treatment with available, compromised patient care. greater input from a microbiologist.

14.7 The process for testing for C. difficile 15 Infection prevention and toxin control Delay in the prescription and administration of appropriate antibiotic therapy for 15.1 The constitution of an Infection Control CDI can have a significant impact on the Team management of the condition, and tends to Clear guidance has been in place on the make the outcome worse, particularly if the constitution of an Infection Control Team patient continues to receive broad spectrum (ICT) since 2001. The ICT should include an antibiotics. The general practice adopted in Infection Control Doctor (ICD) and properly the VOLH (with few exceptions) was that trained Infection Control Nurses (ICNs). The treatment for CDI was not started until a ICD should be the leader of the ICT. NHSGGC positive result was communicated by the had ICTs in place for the sectors that made up Laboratory. This was in accordance with the NHSGGC area. The VOLH was in the Clyde normal practice, but it does mean that there Sector as was the RAH and the IRH. must be no undue delay between the taking of the specimen and the commencement of 15.2 The Infection Control Team for the VOLH treatment. During most of the period from 1 January 2007 to 1 June 2008 there were two There were a significant number of cases Infection Control Nurses based at the VOLH. where there were either delays in the The senior Infection Control Nurse, Mrs Jean processing of specimens or delays in the Murray, became interim Lead Nurse for commencement of treatment after the ward infection control for the Clyde Directorate was aware of the result. There were also in July 2007, which involved taking on cases where there was a combination of additional responsibility for infection processing and treatment delays, and these prevention and control outwith the VOLH. combined delays resulted in treatment She began a period of phased retirement in being delayed for periods ranging from January 2008 and stopped work on 17 March two to seven days. The delays identified 2008. The other Infection Control Nurse, Mrs in the commencement of treatment after Helen O’Neill, did not have a qualification in positive results were known by the ward infection prevention and control. Particularly were inexcusable. The patients concerned during Mrs Murray’s phased retirement continued to be unnecessarily exposed to any Mrs O’Neill bore the brunt of the infection existing antibiotic treatment that they were prevention and control duties at the VOLH. receiving and to an untreated serious and potentially life‑threatening infection. The ICD for the Clyde Sector for the period from 1 January 2007 to early February 2008 No doubt there were failures by individuals was Dr Elizabeth Biggs. She was based at in relation to antibiotic prescribing and for the IRH. Dr Biggs was under a duty to take a the delays in the treatment of CDI patients, lead role in the effective functioning of the but the ultimate responsibility for standards Infection Control Team. Dr Linda Bagrade having become unacceptable must rest with took over as ICD in February 2008. NHSGGC. No formal appraisals of the Infection Control 14.8 Conclusion Team members were carried out in the period The medical care of patients suffering from 1 January 2007 to 1 June 2008. At that time CDI was inadequate. Poor record keeping, there was no functioning formal system of

42 Executive Summary

appraisals in place at the VOLH, a situation Policy. The Outbreak Policy defined the action that had existed for several years. to be taken if an outbreak was suspected or confirmed. The Loose Stools Policy identified 15.3 The infection prevention and control the importance of patients suffering from management structure loose stools being placed in a single room. Ms Marie Martin had been the General In the main this was not the practice in Manager of Diagnostic Services for the Clyde the VOLH prior to 1 June 2008, with the Sector since April 2006, with a remit that result that the risks of cross‑contamination also included responsibilities for infection were greatly increased. In a significant prevention and control. Within the infection number of cases delays in isolation after control structure for the Clyde Sector Ms the result was known increased the risks of Martin was the designated line manager cross‑contamination even more. The C. difficile for Dr Biggs and for Dr Biggs’ successor, Dr Policy highlighted the importance of hand Bagrade. Ms Martin had a duty to ensure that hygiene and the fact that soap and water had there was adequate staff in place and that to be used in conjunction with alcohol hand the staff had the resources and assistance in rub before and after direct patient contact. place to allow them to do their job. Ms Martin reported to Mrs den Herder. Within the Clyde The message contained in guidance issued Directorate Mrs den Herder had overall line by the Scottish Executive and subsequently management responsibility for infection by the Scottish Government that infection prevention and control, with a reporting line control was everyone’s business had not to the Chief Operating Officer of the Acute reached the medical staff at the VOLH, and Services Division. was not practised by the nursing staff in a number of respects, including the failure to Ms Martin failed to address the obvious isolate potentially infectious patients, and and significant gap created by Mrs Murray’s failures in stool charting and care planning. phased retirement, particularly when Mrs O’Neill was an unqualified ICN and required 15.5 The Infection Control Manager supervision. This was at a time when a Mr Thomas Walsh, the Infection Control significant problem with CDI had developed Manager for NHSGGC from 25 June 2007, did in the VOLH. not have any operational or line management responsibilities for infection prevention and 15.4 Implementation of policies and training control. The reference to management in his The Infection Control Manual available in the job description related to “management of the VOLH contained appropriate policies relevant processes rather that than the management to infection prevention and control. Medical of human resources involved …”. The Infection staff had not received training in infection Control Manager’s role was based on the prevention and control (other than as part of then Scottish Executive Health Department their undergraduate training) and had little guidance, but after June 2008, and following awareness of the policies contained in the upon the events at VOLH, in January 2009 Infection Control Manual. Nursing staff did the role of the Infection Control Manager have an awareness of the Infection Control was changed so as to incorporate operational Manual. The relatively small number of and line management responsibilities. That nurses who had undertaken the Cleanliness was a highly desirable change as the role Champions Programme would have gained created by NHSGGC for the Infection Control some insight into aspects of infection Manager, as understood by Mr Walsh, was prevention and control. Evidence from the not one that produced a system providing nurses, however, suggested that prior to June effective leadership of infection prevention 2008, they had received no formal training in and control. CDI. 15.6 The Nurse Consultant Important policies contained in the Infection The Nurse Consultant for Infection Control Control Manual included the Outbreak Policy, in the period from1 January 2007 to the Loose Stools Policy and the C. difficile 1 June 2008, Ms Sandra McNamee, had a

43 The Vale of Leven Hospital Inquiry Report

job description that required her to provide issues. It was chaired by Dr Biggs. At the “strong strategic and clinical leadership meeting of the Support Group of 10 July 2007 across NHSGGC”. Like the Infection Control Dr Biggs indicated that she felt that the ICD Manager, the Nurse Consultant did not have should not be the person to chair the Support line management or operational responsibility Group. The next planned meeting on 9 October for the Infection Control Teams. Ms McNamee 2007 therefore did not take place, and indeed did take over managerial and operational the Support Group did not meet again. The responsibility for the Infection Control Nurses combined failures of the Support Group and of NHSGGC from 2009 as Assistant Director of the Working Group resulted in a significant Nursing for Infection Prevention and Control, gap in the reporting chain that was designed and again this was an important change of to report from ward to Board. remit that could only serve to strengthen the infection prevention and control system. If the The reporting line for the Support Group was Nurse Consultant had had more operational to the Acute Control of Infection Committee responsibility for the infection prevention and (ACIC). In the period from 1 January 2007 control structures, she would have been in a to 1 June 2008 the ACIC was chaired by better position to identify deficiencies in those Dr Robin Reid, Associate Medical Director structures. Diagnostics. In addition to the Clyde Sector, all other NHSGGC areas reported to the ACIC. 15.7 The infection control committee The ACIC reported to the NHSGGC Board structure Infection Control Committee (BICC) chaired NHSGGC had in place a committee structure by Dr Syed Ahmed, Consultant in Public designed to report infection control issues Health Medicine. The BICC reported to the from the VOLH to the Board. Chief Executive and also to the Board CG Committee. Dr Biggs was a member of the Within the VOLH itself, there was a link nurse BICC but did not attend any meeting from system in place. There was no reporting line January 2007 to 1 June 2008. from the meetings of this Group, its apparent purpose being to increase awareness of 15.8 Reporting within the infection control infection prevention and control issues at committee structure ward level. The meetings of this Group were From 1 January 2007 to June 2008 the poorly attended, and there was no evidence reporting of issues about infection prevention before the Inquiry that it made any effective and control was carried out within an contribution to infection prevention and established system of “exception reporting” control in the VOLH in the period from designed to control the flow of information 1 January 2007 to 1 June 2008. through the hierarchy of committees. This meant that at the levels of the ACIC and the The VOLH Infection Control Working Group BICC an issue would only be reported if, for (the Working Group) was also a local Group example, there was a concern that it was based at the VOLH, and was chaired by outwith normal parameters. An outbreak of Mrs Murray. Meetings of the Working CDI would qualify for exception reporting, Group were also poorly attended, and the although in practice any outbreak ought to meeting planned for December 2007 did be identified and responded to before any not take place because so many apologies meeting took place. for non‑attendance were received. The next meeting should have been in March 2008, The system of exception reporting provided but again no meeting took place. an important filter of information within an organisation as large as NHSGGC. It The Working Group had a reporting line to the was important that senior management Clyde Acute Infection Control Support Group was not inundated with matters that could (the Support Group). The Support Group was be managed adequately at levels further supposed to be the main Group within the down the chain. Such a system, however, Clyde Sector for identifying, responding to does depend upon individuals recognising and reporting infection prevention and control and reporting exceptional events. Because

44 Executive Summary

there were significant individual failures aware that it had ceased to meet. She too had within the Infection Control Team for the opportunities to raise the issue, particularly VOLH, important information on the nature at meetings of the ACIC at which she was in and extent of the CDI problem in the VOLH attendance. Although Mrs den Herder has was not being transmitted to the ACIC. maintained in correspondence that she did Consequently there was no discussion at the not know the Support Group had ceased to ACIC level about the prevalence of CDI in the meet, she did receive the minutes of the period from January 2007 to June 2008. Support Group and it should have become Similarly, the BICC was not made aware of apparent to her that that Group had stopped the persisting problem with CDI at the VOLH. functioning.

The exception reporting system therefore The respective chairs of the BICC and the failed to identify the CDI problem that ACIC, Dr Ahmed and Dr Reid, were not made existed in the VOLH throughout most of 2007 aware of the failure of the Support Group. and up until its discovery in May 2008. It is Nor was the Infection Control Manager, Mr undoubtedly the case that, if the infection Walsh. control structure had worked in the way it was intended to work, the problem with CDI 15.10 Surveillance systems at the VOLH would have been discovered and Effective surveillance is a necessary responded to. prerequisite of a properly functioning infection prevention and control system. Infection prevention and control is a core part of patient safety, and senior management In the VOLH the Infection Control Nurses ought to have been made aware of the rates operated a T‑card monitoring system. This and trends of a hospital associated infection system involved identifying a patient who such as CDI. The principle of Board to ward had been diagnosed with CDI by entering and ward to Board means that there must be information onto a yellow T‑card which an unbroken line of reporting, accountability was then placed in a rack by reference and assurance. The failure to have a system to the ward in which the patient was in place whereby rates and trends of CDI in accommodated. If there were two or three hospitals such as the VOLH were being made CDI cases in a particular ward at the same available at least to meetings of the ACIC and time there would be two or three yellow subsequently reported to the Board, was a cards in a line to display that information. system failure and one that contributed to In that way the system could provide the CDI problem persisting up to June 2008. contemporary information on the number of This is a failure for which NHSGGC has to positive cases and alert the Infection Control bear ultimate responsibility. Nurses to a potential problem with CDI. As disclosed by an examination of the T‑cards, 15.9 The failure of the committee structure the Infection Control Nurses’ record keeping As the chair of the Working Group, Mrs was totally inadequate. Murray was directly responsible for its failure to meet after 28 September 2007. Dr Biggs The VOLH also had an Access database was directly responsible for the failure of system. The Infection Control Nurses entered the Support Group to meet after 10 July information into the system on patients who 2007. Ms Martin knew the Support Group had tested positive for CDI. It was then possible ceased to meet and had direct responsibility to access data in different forms from the to tackle the problem created by Dr Biggs’ database and extract those data to create failure to convene the Support Group. Ms reports and identify trends. Annette Rankin, Infection Prevention and Control Head Nurse, was aware that the The Infection Control Nurses at the VOLH Support Group had ceased to meet and should have been able through regular visits failed to raise this issue at meetings of the to wards to identify the extent of the CDI ACIC that she attended. Mrs Murray, as a problem that persisted in the VOLH during member of the Support Group, was also the period from 1 January 2007 to 1 June

45 The Vale of Leven Hospital Inquiry Report

2008. In any event the systems available Mrs Murray, as the Senior Infection Control were themselves perfectly adequate to Nurse at the VOLH, repeatedly failed to enable the Infection Control Nurses to recognise that the most likely explanation discover the existence of potential outbreaks for the presence of two or more patients of CDI. suffering CDI in the same ward and closely linked in time was cross infection. She 15.11 Failure to identify outbreaks excluded cross infection because in her view The failures at local level to appreciate the there were other risk factors that could lead nature of the persisting CDI problem at the to patients developing C. difficile diarrhoea. VOLH were serious and had a profound effect Her position was completely illogical, on patient care. At different points in time particularly when the great majority of the during the period from 1 January 2007 to cases of CDI were described in the Access 1 June 2008 it was apparent in different database system as “hospital related”. Her wards that there were patients suffering failures were serious failures and contributed from CDI who were linked in time and place. in a significant way to the persisting CDI The medical staff seemed oblivious to the problem at the VOLH. The failures meant that persisting CDI problem. Any focus given to the outbreak procedures contained in the CDI patients by nursing staff was influenced Infection Control Manual were never invoked. by Mrs Murray’s perspective that the If they had been, other levels of management problem could be explained by factors other within the infection control structure would than cross‑contamination. have been alerted to the CDI problem.

At the meeting of the Support Group on 9 May 15.12 Role of the Microbiologists 2007 a report was presented by Dr Biggs By 2005 there was real concern about containing important information on the the number of vacant microbiology posts status of CDI patients in the VOLH. The report in Argyll and Clyde, with two out of the disclosed that in April 2007 there were 22 five positions being vacant. The resident positive results for CDI in the VOLH. Another microbiologist in the VOLH had resigned in source of evidence in that report disclosed 2002 and another microbiologist had left that four patients tested positive for CDI in her post at the RAH in 2005, with neither ward 14 in the week beginning 13 April 2007. post being filled. Arrangements were made This was a relatively early opportunity to to provide some microbiology cover for the identify the extent of the problem with CDI in VOLH which were intended as a stopgap the VOLH, but it was an opportunity that was pending the appointment of additional completely missed. An appropriate response microbiologists. Dr François de Villiers, to the information contained in the report Consultant Microbiologist at the IRH, and Dr would almost certainly have identified the Barbara Weinhardt, Consultant Microbiologist CDI problem and saved a significant amount at the RAH, were involved in these of further suffering. Dr Biggs’ response, arrangements, under which limited on‑site as Infection Control Doctor, was totally clinical microbiology cover was provided inadequate and professionally unacceptable. at the VOLH by Dr de Villiers. Difficulties in recruitment meant that the vacant posts In the period from 1 January 2007 to 1 June were not filled until early 2008, with the 2008 there were a number of opportunities result that the staffing arrangements for to carry out a proper investigation into consultant microbiologists in the Clyde Sector why there were patients suffering from CDI were unsatisfactory throughout the period in different wards in the VOLH. Because from January 2007 to January 2008. The no proper investigations were carried out unsatisfactory nature of the arrangements no ribotyping of the positive C. difficile was compounded by Dr Biggs’ failures in her toxin samples was conducted which would duty as ICD. have established whether the same strain of infection was involved. However, it is C. difficile toxin positive results required to inconceivable that there were no outbreaks be authorised by a consultant microbiologist. during that period. Although on occasion that did not happen, the

46 Executive Summary

number of positive reports being authorised Although Dr Biggs did not receive a job in December 2007 and into early 2008 did description providing details of her role make consultant microbiologists in Clyde until 19 September 2007, she could have aware of an increased incidence of CDI. One been under no misapprehension as to what of these consultant microbiologists raised her duties were as Infection Control Doctor. the issue with Dr Biggs, suggesting that she She did not question the terms of the job should investigate the position in hospitals for description once she received it. which she was the Infection Control Doctor. There is no evidence that Dr Biggs carried Ms Martin had line management out any investigation into the prevalence (non‑professional) responsibilities for of CDI at the VOLH. In December 2007 and infection prevention and control and was the January 2008 there were patients suffering line manager for Dr Biggs and Dr de Villiers. from CDI in a number of wards in the VOLH, The suggestion by her that Dr de Villiers was and an investigation at that time would have to cover Dr Biggs’ ICD responsibilities at the disclosed the likelihood of an outbreak. VOLH when he went there is not accepted by the Inquiry. This simply highlights the Prior to the appointment of the two dysfunctional nature of the arrangements for additional microbiologists in early 2008, the infection prevention and control at the VOLH. system in place meant that a co‑ordinated, In a series of emails in 2007, mainly to Ms integrated microbiology service was not Martin, Dr Biggs raised a number of issues in being provided to the VOLH. relation to her position as ICD. Dr Biggs made it clear that she had no intention of carrying 15.13 The Infection Control Doctor out her responsibilities as ICD, an attitude Dr Biggs was the designated ICD for the that demanded a prompt and effective Clyde Sector, which included the VOLH. This response. was a responsibility that certainly spanned the period from1 January 2007 to early Dr Biggs’ attitude to her role as ICD so far as February 2008, when Dr Bagrade took the VOLH was concerned was inappropriate over as ICD. Dr Biggs was unable on health and professionally unacceptable. She was the grounds to provide a written statement or leader of the Infection Control Team. She was give oral evidence to the Inquiry. not performing her duties as ICD at the VOLH. She had minimal contact with the Infection Professional line management has an Control Nurses there and provided little important role to play in providing advice support or leadership. Her attitude to Ms and support, but there seems to be Annette Rankin, Head Infection Control Nurse some confusion over who was Dr Biggs’ for NHSGGC, was unprofessional. professional line manager after April 2006. Dr Elizabeth Jordan, the Associate Medical Dr Biggs’ self‑imposed restriction on her role Director, should have been Dr Biggs’ as ICD for the VOLH was without justification, professional line manager until she left whatever reservations she may have her post in August 2007, and there was a had over changes to the infection control suggestion in the police statement Dr Biggs structure. Her failure to carry out her duties provided in September 2009 that Dr Jordan as ICD for the VOLH was a serious failure was her line manager at least up to May on her part and would have contributed 2007. In any event there is no evidence significantly to the ongoing CDI problem that any real professional line management there and to unnecessary suffering to support was provided to Dr Biggs in 2007, patients. and this is a factor that must be taken into account when considering Dr Biggs’ attitude 15.14 Knowledge of Dr Biggs’ failure as to her role as ICD. She was unhappy with Infection Control Doctor her role and with changes implemented by Clearly Mrs Murray and Mrs O’Neill knew NHSGGC, and a higher level of support should that Dr Biggs was not attending to her ICD have been available to her. responsibilities at the VOLH. Mrs Murray had discussions with Ms Rankin about Dr

47 The Vale of Leven Hospital Inquiry Report

Biggs’ failure to carry out her ICD duties, Ms Martin complained to Mrs den Herder and Ms Rankin did pass on her concerns about the pressure she was under due to about Dr Biggs to Mr Walsh. Mr Walsh may the extent of her responsibilities. Mrs den not have been aware of the extent of the Herder should have responded positively to problem, but he could not avoid being aware these complaints but she failed to do so. Ms that there was a problem, and he should Martin’s complaints of overwork should have have conducted some enquiries to see if the alerted Mrs den Herder to the real possibility problem had been resolved. that the management of infection prevention and control was being neglected. Ms Martin knew that Dr Biggs did not attend the VOLH. She had no proper basis in fact to 15.16 The reporting of C. difficile data to believe that Dr de Villiers was covering as Health Protection Scotland and the Public ICD for Dr Biggs. As Dr Biggs’ line manager Health Protection Unit (non‑professional) Ms Martin failed to deal Mandatory reporting of C. difficile toxin with the problems created by Dr Biggs in her positive cases was required as part of attitude to her role as ICD. Mrs den Herder the national surveillance system from did not know that Dr Biggs was not fulfilling 1 September 2006. Reports providing her role as ICD, but she ought to have been details of C. difficile toxin cases are sent made aware of the problem. Ms Martin in to Health Protection Scotland (HPS). This particular ought to have made her aware reporting system was never designed to be of the problems with Dr Biggs. Ms Martin’s a surveillance tool; it is simply a method of failure to address the problems created by Dr identifying how many patients had been Biggs was a serious failure. diagnosed with CDI as part of the national surveillance programme. The system of The reality is that in the latter part of 2007 national surveillance was not intended to no‑one was prepared to tackle the issues replace effective systems of local surveillance associated with Dr Biggs. By then there and reporting. was a plan to replace Dr Biggs after the appointment of the two new consultant microbiologists but that does not excuse the Copies of the reports sent to HPS were also failure to deal at the time with an ICD who sent to the NHSGGC Public Health Protection was not carrying out her infection prevention Unit (PHPU) on a weekly basis. This system and control responsibilities for the VOLH. of reporting did allow the PHPU to perform a surveillance function in connection with 15.15 The secondment issue certain diseases in the community, but this did not constitute a surveillance system of Ms Martin claimed that she was on full‑time CDI that was hospital acquired. The PHPU secondment to the Picture Archiving could not have been expected to identify the Communication Systems (PACS) project from CDI problems at the VOLH. August 2007 to April 2008 and that when on secondment her responsibilities for infection prevention and control ceased. 15.17 Statistical Process Control Charts The Statistical Process Control (SPC) Chart Both these claims are incorrect. In September is a surveillance tool that can provide 2007 there had been some discussion about retrospective information on a monthly basis the possibility of early integration through on the number of C. difficile toxin positive which managerial responsibility for infection patients and trends. Although available in prevention and control for the Clyde Sector 2007 in some NHSGGC areas, SPC Charts would be integrated within Greater Glasgow were not introduced to the VOLH until April and Clyde but that was not pursued. The or May 2008. position in fact is that Ms Martin did remain responsible for infection prevention and Had the SPC Charts been in place in 2007, an control. Mrs den Herder recognised that Ms increased level of awareness would have been Martin would require support to provide her generated in relation to rates of CDI at the with sufficient time to undertake the PACS VOLH and the CDI problem would have been work. That support was not adequate and discovered sooner. That having been said, the

48 Executive Summary

dissolution of NHS Argyll and Clyde and the hospital level. NHSGGC implemented commencement of the process of integration a risk register policy on 1 April 2006, with GGHB only took place in April 2006, and acknowledging that the continuing the preparation for the introduction of the SPC development of a comprehensive risk register chart system to the VOLH was going to take was a core part of risk‑management activity. some time. It was therefore not unreasonable that the introduction of the SPC chart system A risk register specifically for infection to the Clyde Sector, and the VOLH in particular, prevention and control for the Acute suffered some delay in comparison to other Services Division was first discussed at areas of NHSGGC. In any event, SPC Charts are a meeting of the ACIC on 26 November not a substitute for acute observation in real 2006. Subsequently there was some further time. The surveillance systems in place at the discussion at meetings of the ACIC, but the VOLH should have alerted the Infection Control risk register for infection prevention and Team to the extent of the problem with CDI. control was not approved until the ACIC meeting held on 3 December 2008. Reference 15.18 The VOLH Laboratory accreditation to CDI did not feature in earlier drafts of the risk register and it was only at the meeting Following an inspection by the accrediting of 3 December that the decision was taken to body in January 2003 the VOLH laboratory include CDI. Having regard to a timescale that was granted conditional approval. That first began in November 2006 the approval remained the position until another of the risk register in December 2008, just inspection on 18 and 19 September 2007. over two years later, represents undue delay. The September 2007 inspection produced Account does, however, have to be taken a list of 43 non‑compliances, although the of the fact that when that process began it inspectors’ overview report described the was one of the many issues facing NHSGGC laboratory as well managed and well led. The at a time of significant change. Furthermore, numerous document control issues disclosed the emergence of the VOLH CDI problem by the inspection were explained by the did increase the level of attention paid to fact that the laboratory was in a transitional infection prevention and control. phase of migrating to an electronic system. The inspectors concluded that despite the number of non‑compliances the quality of 15.20 Hygiene, environment and audits the service being provided was not being National C. difficile guidance published in compromised. 1994 emphasised the importance of personal and environmental cleanliness in the Despite the conclusion of the overview report prevention and control of CDI. Hand hygiene the extent of non‑compliances shows that in particular is of extreme importance in the general management of the microbiology the prevention of an infection like CDI but service did need to be improved. so too are environmental factors. Damaged surfaces make cleaning more difficult because 15.19 Risk registers it is harder to remove micro‑organisms from damaged or irregular surfaces than from Risk registers are an important strategy for smooth surfaces. the management of risk in the delivery of healthcare. The creation and maintenance The Cleanliness Champions Programme (CCP) of a risk register ensures that risks relevant was launched as part of the first HAI Task to a particular area of healthcare have been Force Plan in September 2003, and was identified. Where possible risks are removed, viewed as an important aspect of infection but otherwise the risk register ensures that prevention and control. The programme’s appropriate controls and precautions are in two main themes were safe practice and safe place to prevent those risks materialising. environment. The key to the creation of a risk register is risk assessment. Within an organisation In a letter dated 18 March 2005 addressed such as NHSGGC, risk registers should be to Chief Executives, NHS Boards and Nursing maintained at different levels including Directors, the Chief Nursing Officer reinforced

49 The Vale of Leven Hospital Inquiry Report

the importance of the CCP by requiring all 15.21 Changes after June 2008 G grade sisters/SCNs to undertake the CCP The NHSGGC Board responded promptly “forthwith” while adding that account should to the discovery of the failures that had be taken of workload and available access to occurred in the VOLH prior to June 2008. A the required IT resources. single management structure, with the Board Medical Director as the accountable executive By 15 May 2007 NHSGGC was officer reporting to the Chief Executive has underperforming generally on completion of been put in place. The Board Medical Director the CCP, an issue raised at the ACIC meeting is required to bring infection control and of that date. In the VOLH the completion HAI reports to every Board meeting. New rate for the CCP in the period prior to June posts have been created to strengthen the 2008 was extremely slow. The CCP did not management structure so that the principle receive the priority it should have received, of ward to Board and Board to ward and a more determined attitude to infection accountability is as effective as possible. prevention and control would have provided more impetus to the implementation of the The infection prevention and control programme. committee structure has been changed, with the VOLH now under the jurisdiction of the In the period leading up to June 2008 the North West Sector of NHSGGC. Governance, fabric of the VOLH was in a poor state. Areas accountability and reporting arrangements of flooring were damaged and covered in have been significantly changed with the adhesive tape. Inspections carried out in aim of producing an effective monitoring and May 2008, when the problem with CDI reporting system of HAIs such as CDI. was emerging, identified an unsatisfactory hospital environment that included a lack Infection prevention and control education of wash‑hand basins, commodes that were and training programmes have been not fit for purpose and required urgent implemented for all staff. NHSGGC pursues replacement, and storage problems. At a policy that treats patient experience and the dissolution of NHS Argyll and Clyde in involvement as an important element in the April 2006 NHSGGC inherited a hospital in infection prevention and control programme. which underinvestment in maintenance and NHSGGC has also established an inspection infrastructure had existed for a number of regime in which multi‑disciplinary teams years. The environmental deficiencies had inspect hospitals following methodology existed in the years prior to dissolution and adopted by the Healthcare Environment persisted afterwards without resolution. Inspectorate. There was an acceptance that because of the lack of investment, improvements were Between June 2008 and June 2012 a sum in not going to happen until a decision on the excess of £4.5m was invested in improving VOLH’s future could be made. healthcare and the general environment at the VOLH. This improvement programme included The infection control audit process the provision of additional wash‑hand basins did identify key areas of persistent and the creation of more single rooms. After non‑compliance, but there was no effective years of neglect there has been significant process of ensuring managerial awareness investment in the VOLH by NHSGGC. at a level where appropriate action could be taken. Environmental issues that had a clear 15.22 Conclusion impact on infection prevention and control The personal and system failures in infection were not addressed. Patients were put at risk. prevention and control identified in Chapter Staff morale was affected. Uncertainty led to 15 had a profound effect upon the care the acceptance of the unacceptable from the provided to patients at the VOLH. NHSGGC perspective of patient safety. must bear ultimate responsibility for these failures. NHSGGC did learn lessons from the failures by introducing significant changes after 1 June 2008.

50 Executive Summary

16. Death certification or not the death should be reported to the Procurator Fiscal. Guidance issued by the 16.1 Form of death certificate Crown Office and Procurator Fiscal Service The section of the death certificate which (COPFS) in November 1998 set out certain is devoted to the cause of death is divided categories of death that were to be reported into two parts. Part one deals with the direct to the Procurator Fiscal but did not make cause of death and any conditions giving rise any explicit reference to HAI or C. difficile to that direct cause. Part two deals with other infection. That guidance was updated in conditions which have contributed to death October 2008 to include HAI. but are not part of the main sequence of events leading to death. 16.3 Accuracy in death certification in the VOLH Death certification is a matter of professional Accuracy in death certification is crucial in judgement. The doctor needs to make order to allow collation of data to enable the a judgement as to what is the direct or identification of trends and the establishment immediate cause of death for entry into of public health measures to prevent Part 1 of the death certificate and also diseases. At a more personal level it is very a judgement as to which of the illnesses important for family members to know the suffered by the patient are relevant for entry cause or causes of death of a family member. in Part 2 of the death certificate. A number of patients who died in the VOLH 16.2 The 1999 guidance on death certification did not have CDI mentioned on their death and VOLH practice certificates when in fact CDI should have been mentioned. Guidance on the completion of death certificates was issued by the Registrar 16.4 Updated guidance General for Scotland in January 1999. That guidance provided that it was “best if a Guidance issued in September 2009 and consultant, general practitioner or other in October 2011 by the Chief Medical experienced clinician” certified the death. The Officer (CMO) of the Scottish Government guidance went on to provide that for a death emphasised the important role to be played in hospital an inexperienced doctor should by consultants in death certification. only certify the death if closely supervised and if the experienced clinician was content 16.5 Collation, analysis of data and future that the causes of death were accurately changes recorded. In the guidance issued in September 2009 the CMO envisaged that the reporting of Notwithstanding the guidance, in practice HAI related deaths to the Procurator Fiscal consultants in Scotland were rarely involved would allow the local Area Procurator Fiscal in death certification in 2007 and 2008. That to identify any clusters of HAI related practice was reflected in the VOLH where, of deaths. The COPFS does not in fact collate the 33 extracts from the register of deaths information on HAI related deaths. The examined, none of the death certificates had function of the COPFS is to investigate, and been signed by a permanent consultant and it does not have a surveillance function of in the majority of cases the death certificate the kind envisaged by the CMO. The Scottish was signed by junior doctors. There was Government should identify a national some evidence in the patient records that agency to monitor HAI mortality rates, and in some instances junior doctors did contact CDI deaths in particular. a consultant, but in the majority of cases the death certificate was signed by a junior 16.6 Conclusion doctor without any recorded consultation The guidance on death certification in place with senior medical staff. in 2007 to 2008 had been issued in January 1999 and was inadequate and outdated. Before issuing a death certificate the doctor Death certification was viewed as a low concerned is obliged to consider whether priority despite the important role it plays.

51 The Vale of Leven Hospital Inquiry Report

The Inquiry’s examination of the manner 17.3 Outbreak Control Team Investigation in which the deaths were certified in the The second investigation conducted by VOLH disclosed that there was a lack of NHSGGC was in the form of an Outbreak understanding of the way in which death Control Team (OCT) Investigation that began certification should be carried out. Doctors in June 2008 and reported in October need to be trained in the completion of death 2008. It had a broader remit that involved certificates. investigating all aspects of the “outbreak” and ensuring that all control measures were in 17. Investigations from May place. 2008 The OCT’s report identified the outbreak 17.1 The Independent Review period as 1 December 2007 to 31 May 2008. The number of cases of CDI in that period In June 2008 the Cabinet Secretary for Health was identified as 55, with CDI identified as and Wellbeing announced an Independent having caused or contributed to the death C. difficile Review of the cases of infection at of 18 of 28 patients who died. These were the VOLH. That was led by Professor William underestimates of the numbers of patients Cairns Smith, OBE, Professor of Public Health and deaths. at the University of Aberdeen. The report was published in August 2008, and an audit in The OCT concluded that the number of cases December 2008 of the implementation of its of CDI at the VOLH in the period examined recommendations concluded that rapid and was more than expected, and that the fatality very significant progress had been made in rate appeared to be higher than reported the VOLH. from elsewhere. 17.2 Vale of Leven Internal Investigation The OCT report identified the ‑T card system report as the surveillance system in place at the An Internal Investigation was commissioned time, but failed to mention the Access by Mr Calderwood, then the Chief Operating database that was capable of providing Officer, in June 2008 when he became aware regular surveillance reports. of CDI cases and associated deaths. As was the case with the Internal The remit of the Internal Investigation was Investigation, the OCT’s investigation was a narrow one and concerned with who somewhat truncated by the appointment knew about the C. difficile cases, what action of the Independent Review. Nevertheless was taken, and to whom matters were the OCT report did make a number of reported. The Internal Investigation team valuable recommendations, including the did not in fact limit its investigation to the review of roles and responsibilities and terms of its remit: the Internal Investigation the communication chain for HAI, the report proposed, for example, that each commencement of a programme of work to Directorate’s Clinical Governance Committee improve the structural environment of the should have a standing item on “Control of VOLH, the auditing of antimicrobial policy, Infection”. In response to its specific remit and education on infection control and HAI the Internal Investigation did not identify any issues. knowledge of the VOLH CDI problem within management. 17.4 Conclusion The setting up of the Internal Investigation The Internal Investigation and the OCT was an important and appropriate step, and investigation did not examine the nursing identified some learning opportunities at and medical care given to patients who an early stage. It did not identify errors or contracted CDI for the simple reason that their failures which must have been present to respective remits did not cover this issue. The allow outbreaks to occur and to go unnoticed, setting up of the Internal Investigation was but its remit was limited and its work was an appropriate step in the circumstances that overtaken by the Independent Review. emerged in May/June 2008.

52 Executive Summary

18. Experiences of C. difficile System failures were also identified. The report’s recommendations, as with the infection within and beyond recommendations of the Stoke Mandeville Scotland report, were of UK‑wide relevance. 18.1 The 027 strain 18.3 The NHS Greater Glasgow and Clyde At the time of the Stoke Mandeville and response to Stoke Mandeville and Maidstone Maidstone and Tunbridge Wells outbreaks, and Tunbridge Wells and in the aftermath of those outbreaks, the 027 strain was seen as a “hypervirulent” Within NHSGGC a number of people were strain because it caused more severe disease aware of the Stoke Mandeville report, in and more deaths. The hypervirulent nature particular those with some responsibility of the 027 strain was recognised by Health for infection prevention and control. The Protection Scotland in 2006, before the Infection Control Manager, Mr Walsh, discovery of the CDI problem at the VOLH, discussed the Maidstone and Tunbridge Wells as a strain capable of causing very severe report with the Nurse Consultant, and that disease and death. report was influential in CDI being considered for the SPC Chart system. 18.2 The Stoke Mandeville and Maidstone and Tunbridge Wells reports In the VOLH itself there was also a response to the Stoke Mandeville report. On In July 2006 the Healthcare Commission 16 February 2007 a meeting took place to in England published a report into two discuss facilities services. Several concerns, outbreaks of CDI at the Stoke Mandeville including storage issues, poor housekeeping Hospital, the first between October 2003 and poor maintenance of fabric and and June 2004 and the second between equipment were identified. A further review October 2004 and June 2005. Many of the in February 2008 concluded that a number of cases of CDI were due to the 027 strain. those problems had not been resolved. There The report identified many failures in the were also presentations early in 2007 and in management and care of patients suffering May 2007 on infection prevention and from CDI which were similar to the failures control by Dr Weinhardt and Mrs Murray. identified by the Inquiry at the VOLH. It These presentations covered what were poor highlighted the poor state of repair of the infection prevention and control practices buildings, failures to isolate patients with and the importance of prudent antibiotic diarrhoea, lack of facilities for hand washing prescribing. and low priority afforded to infection control. There were nursing failures where fluid 18.4 NHS Quality Improvement Scotland balance was given little attention and poor response care planning and nursing assessments. At the time of its investigations the Healthcare No guidance appears to have been issued, or Commission did, however, discover that the review conducted, by NHS QIS specifically in hospital policy on the use of broad spectrum light of the Stoke Mandeville or Maidstone antibiotics had already been changed in and Tunbridge Wells reports. response to the cases of CDI. 18.5 The response to the Stoke Mandeville In October 2007 the Healthcare Commission and Maidstone and Tunbridge Wells reports produced a report into outbreaks of C. difficile by Health Protection Scotland at Maidstone and Tunbridge Wells NHS The work of Health Protection Scotland Trust. That report identified a significant (HPS) in connection with HAIs is overseen by number of issues similar to the issues the HAI Task Force. In the Project Initiation identified by the Inquiry at the VOLH, Document produced in July 2007 for the including the unnecessary administration development of a programme for reduction of broad spectrum antibiotics, inadequate of healthcare associated CDI in Scotland, the fluid management and an inadequate HAI Taskforce did refer to the Healthcare level of training on infection control. Commission’s recommendations contained in

53 The Vale of Leven Hospital Inquiry Report

the Stoke Mandeville report. In October 2007, 18.7 The Northern Health and Social Care shortly after the publication of the Maidstone Trust, Northern Ireland and Tunbridge Wells report, the HAI Taskforce The Regulation and Quality Improvement considered that report. Thereafter the Chief Authority for Northern Ireland (RQIA) Nursing Officer wrote on 8 November 2007 published a review in August 2008 of the to Board Chief Executives asking each Board circumstances contributing to the rates of to undertake an immediate and thorough CDI in the Northern Health and Social Care review of its local infection control policies. Trust in 2007 and early 2008. The report of His expectation was that each Board would a Public Inquiry into the outbreak of CDI in make sure that the systems and processes Trust hospitals was published on 21 March were in place for effective infection 2011. The RQIA review identified failures prevention and control, although that similar to failures identified in this Report expectation was not spelled out in his letter. including structural reorganisation putting the monitoring of health infection prevention at National guidance on the prevention and risk, shortage of isolation beds, inappropriate control of CDI was published by HPS in use of antibiotics, poor quality of nursing October 2008. The production of national notes and general lack of care plans and guidance of that kind can take time. HPS needs assessments. also developed a checklist as a support tool to check control measures were in place, The RQIA review and the Public Inquiry prompted by the Stoke Mandeville and report suggest that there was also a lack of Maidstone and Tunbridge Wells reports. preparedness for an outbreak of CDI. This Although production of the checklist was simply reinforces the need for lessons to be accelerated following discovery of the CDI learned from other inquiries. problem at the VOLH it was not in fact produced until June 2008. If the publication 18.8 Ninewells Hospital, Dundee of the Stoke Mandeville report is taken as a starting point, it took some two years for the In October 2009 an outbreak of CDI was checklist to be produced. declared at Ninewells Hospital, Dundee in one ward following upon two patients testing The checklist highlighted 32 issues seen as positive for CDI where the 027 strain was important in the prevention and control of identified. Measures were taken in response to CDI, including data collection at ward level, the outbreak including a visit by HPS. In total, data review, and adherence to antibiotic between 31 July 2009 and 6 November 2009 policy. The advice contained in it was seven patients who had been in the ward designed to lead to an overhaul of practices concerned were found to be infected with the and to alert Boards to the dangers of the 027 027 strain. CDI caused or contributed to the strain. Earlier circulation of that advice would deaths of five of those patients. have been highly desirable. It could only have led to a more timely and comprehensive The Ninewells outbreak occurred after review of practice. It would have alerted discovery of the CDI problems at the VOLH Health Boards to the dangers of the 027 in an environment where there was an strain and the broader issues of patient increased awareness of the importance safety and infection prevention and control. of infection prevention and control. The identification of the outbreak and subsequent 18.6 The Scottish Government response management appeared to be in accordance The Scottish Government did not take any with good infection prevention and control action to draw the Stoke Mandeville case to practice. the attention of Health Boards. Prior to June 2008 Scottish Government had not received any advice from any source that any action was required.

54 Executive Summary

18.9 Comparison between the VOLH and 18.10 Conclusion Stoke Mandeville and Maidstone and There was a failure at national and NHSGGC Tunbridge Wells level to utilise the Stoke Mandeville and At least 20 issues identified in the Stoke Maidstone and Tunbridge Wells reports as a Mandeville and Maidstone and Tunbridge basis for timely guidance and for audit and Wells reports were also identified by review. There was undue delay on the part of the Inquiry as relevant to the VOLH. This HPS in producing the kind of advice set out in included the failure to isolate patients, the the checklist. inappropriate prescribing of antibiotics, and failures in basic nursing care. The findings and recommendations of the Stoke Mandeville report should have been The findings in the Stoke Mandeville and considered by NHSGGC in a more thorough Maidstone and Tunbridge Wells reports and systematic way prior to 2007, and contained important lessons on how the practices and implementation of policies management of CDI could go wrong and should have been reviewed in the light how it should be effectively managed. The of these findings and recommendations. recommendations in both reports provided Had that happened, many of the factors valuable guidance which was available in the contributing to the outbreaks at the VOLH one case from July 2006 and in the other would have been eliminated or at least from October 2007. reduced by June 2008.

It is important that effective systems are in place to enable lessons learned elsewhere to be applied in Scotland in a timely manner.

55

Recommendations The Vale of Leven Hospital Inquiry Report

Chapter 6 National structures and systems responsible for all patient services before Recommendation 1: Scottish Government the reorganisation takes place. Subsequent should ensure that the Healthcare to that reorganisation regular reviews of Environment Inspectorate (HEI) has the the process should be conducted to assess power to close a ward to new admissions if its impact upon patient services, up to the the HEI concludes that there is a real risk to point at which the new structure is fully the safety of patients. In the event of such operational. The review process should closure, an urgent action plan should be include an independent audit. devised with the Infection Prevention and Control Team and management. Recommendation 8: In any major structural reorganisation in the NHS in Scotland the Chapter 7 National policies and guidance Board or Boards responsible should ensure that an effective and stable management Recommendation 2: Scottish Government structure is in place for the success of the should ensure that policies and guidance project and the maintenance of patient safety on healthcare associated infection are throughout the process. accompanied by an implementation strategy and that implementation is monitored. Chapter 10 Clinical governance Recommendation 3: Health Boards should Recommendation 9: Health Boards should ensure that infection prevention and control ensure that infection prevention and policies are reviewed promptly in response to control is explicitly considered at all clinical any new policies or guidance issued by or on governance committee meetings from local behalf of the Scottish Government, and in any level to Board level. event at specific review dates no more than two years apart. Chapter 11 The experiences of patients and relatives Recommendation 4: Scottish Government Recommendation 10: Health Boards should should develop local Healthcare Associated ensure that patients diagnosed with CDI are Infection (HAI) Task Forces within each Health given information by medical and nursing Board area. staff about their condition and prognosis. Patients should be told when there is a Chapter 8 Changes in services at the Vale of suspicion they have CDI, and when there is Leven Hospital from 2002 a definitive diagnosis. Where appropriate, Recommendation 5: Scottish Government relatives should also be involved. should ensure that where any uncertainty Recommendation 11: Health Boards should over the future of any hospital or service ensure that patients, and relatives where exists, resolution of the uncertainty is not appropriate, are made aware that CDI is delayed any longer than is essential for a condition that can be life‑threatening, planning and consultation to take place. particularly in the elderly. The consultant in charge of a patient’s care should ensure that Recommendation 6: Scottish Government the patient and, where appropriate, relatives should ensure that where major changes in have reasonable access to fully informed patient services are planned there should medical staff. be clear and effective plans in place for continuity of safe patient care during the Recommendation 12: Health Boards should period of planning and change. ensure that when a patient has CDI patients and relatives are given clear and proper Chapter 9 The creation, leadership and advice on the necessary infection control management of the Clyde Directorate precautions, particularly hand washing and Recommendation 7: In any major structural laundry. Should it be necessary to request reorganisation in the NHS in Scotland a due relatives to take soiled laundry home, the diligence process including risk assessment laundry should be bagged appropriately and should be undertaken by the Board or Boards clear instructions about washing should be

58 Executive Summary

given. Leaflets containing guidance should be Recommendation 19: Health Boards should provided, and these should be supplemented ensure that where Infection Control Nurses by discussion with patients and relatives. provide instructions on the management of patients those instructions are recorded in Chapter 12 Nursing care the patient notes and are included in care Recommendation 13: Health Boards should planning for the patient. ensure that there is a clear and effective line of professional responsibility between the Recommendation 20: Health Boards should ward and the Board. ensure that where a patient has, or is suspected of having, C. difficile diarrhoea Recommendation 14: Health Boards should a proper record of the patient’s stools is ensure that the nurse in charge of each ward kept. Health Boards should ensure that audits compliance with the duty to keep there is an appropriate form of charting of clear and contemporaneous patient records. stools available to enable nursing staff to Health Boards should ensure that there is an provide the date, time, size and nature of effective system of audit of patient records, the stool. Stool charts should be continued and that there is effective scrutiny of audits after a patient has become asymptomatic by the Board. of diarrhoea in order to reduce the risk of cross infection. Health Boards should ensure Recommendation 15: Health Boards should that all nursing staff are properly trained ensure that nursing staff caring for a patient in the completion of these charts, and that with CDI keep accurate records of patient the nurse in charge of the ward audits observations including temperature, pulse, compliance. respiration, oxygen saturation and blood pressure. Recommendation 21: Health Boards should ensure that a member of nursing staff Recommendation 16: Health Boards should is available to deal with questions from ensure that the nurse in charge of each relatives during visiting periods. ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Recommendation 22: Health Boards should Control Team. ensure that any discussion between a member of nursing staff and a relative about Recommendation 17: Health Boards should a patient which is relevant to the patient’s ensure that where there is risk of cross continuing care is recorded in the patient’s infection, the nurse in charge of a ward notes to ensure that those caring for the has ultimate responsibility for admission patient are aware of the information given. of patients to the ward or bay. Any such decision should be based on a full report of Recommendation 23: Health Boards should the patient’s status and full discussion with ensure that a nurse appointed as Tissue site management, the bed manager, and a Viability Nurse (TVN) is appropriately trained member of the Infection Control Team. The and possesses, or is working towards, a decision and the advice upon which the recognised specialist post‑registration decision is based should be fully recorded qualification. Health Boards should ensure contemporaneously. that a trainee TVN is supervised by a qualified TVN. Recommendation 18: Health Boards should ensure that there is an agreed system of Recommendation 24: Health Boards should care planning in use in every ward with ensure that where a TVN is involved in the appropriate documentation available to caring for a patient there is a clear record nursing staff. Where appropriate they should in the patient notes and care plan of the introduce pro forma care plans to assist instructions given for management of the nurses with care planning. Health Boards patient. should ensure that there is a system of audit of care planning in place.

59 The Vale of Leven Hospital Inquiry Report

Recommendation 25: Health Boards should nursing staff complete fluid balance charts as ensure that every patient is assessed for risk accurately as possible and sign them off at of pressure damage on admission to hospital the end of each 24‑hour period. using a recognised tool such as the Waterlow Score in accordance with best practice Recommendation 31: Health Boards should guidance. Where patients are identified ensure that the staffing and skills mix is as at risk they must be reassessed at the appropriate for each ward, and that it is frequency identified by the risk scoring reviewed in response to increases in the level system employed. Compliance should be of activity/patient acuity and dependency monitored by a system of audit. in the ward. Where the clinical profile of a group or ward of patients changes, (due to Recommendation 26: Health Boards acuity and/or dependency) an agreed review should ensure that where a patient has a framework and process should be in place to wound or pressure damage there is clear ensure that the appropriate skills base and documentation of the nature of the wound resource requirements are easily provided. or damage in accordance with best practice guidance, including the cause, grade, size and Recommendation 32: Health Boards should colour of the wound or damage. The pressure ensure that there is a straightforward and damage or wound should be reassessed timely escalation process for nurses to report regularly according to the patient’s condition. concerns about the staffing numbers/skill Compliance should be monitored by a system mix. of audit. Recommendation 33: Health Boards should Recommendation 27: Health Boards should ensure that where a complaint is made about ensure that where a patient requires nursing practice on a ward this complaint positional changes nursing staff clearly is investigated by an independent senior record this on a turning chart or equivalent. member of Nursing Management. Compliance should be monitored by a system of audit. Chapter 13 Antibiotic prescribing Recommendation 34: Health Boards should Recommendation 28: Health Boards should ensure that changes in policy and/or ensure that all patients have their nutritional guidance on antimicrobial practice issued status screened on admission to a ward by or on behalf of Scottish Government are using a recognised nutritional screening tool. implemented without delay. Where nutritional problems are identified further assessment should be undertaken Recommendation 35: Scottish Government to determine an individual care plan. should monitor the implementation of Appropriate and timely referrals should be policies and/or guidance on antibiotic made to dieticians for patients identified prescribing issued in connection with as being in need of specialist nutritional healthcare associated infection and seek support. assurance within specified time limits that implementation has taken place. Recommendation 29: Health Boards should ensure that there is appropriate equipment Chapter 14 Medical care in each ward to weigh all patients. Patients should be weighed on admission and at least Recommendation 36: Health Boards should weekly thereafter and weights recorded. ensure that the level of medical staffing Faulty equipment should be repaired or planned and provided is sufficient to provide replaced timeously and a contingency plan safe high quality care. should be in place in the event of delays. Recommendation 37: Health Boards should Recommendation 30: Health Boards should ensure that any patient with suspected CDI ensure that where patients require fluid receives full clinical assessment by senior monitoring as part of their clinical care, medical staff, that specific antibiotic therapy

60 Executive Summary

for CDI is commenced timeously and that the Recommendation 44: Health Boards should response to antibiotics is monitored on at ensure that performance appraisals of least a daily basis. infection prevention and control staff take place at least annually. The appraisals of Recommendation 38: Health Boards should Infection Control Doctors who have other ensure that clear, accurate and legible patient responsibilities should include specific records are kept by doctors, that records are reference to their Infection Control Doctor seen as integral to good patient care, and that roles. they are routinely audited by senior medical staff. Recommendation 45: Health Boards should ensure that where a manager has Recommendation 39: Health Boards should responsibility for oversight of infection ensure that medical and nursing staff are prevention and control, this is specified in the aware that a DNAR decision is an important job description. aspect of care. The decision should involve the patient where possible, nursing staff, the Recommendation 46: Health Boards should consultant in charge and, where appropriate, ensure that the Infection Control Manager relatives. The decision should be fully has direct responsibility for the infection documented, regularly reviewed and there prevention and control service and its staff. should be regular auditing of compliance with the DNAR policy. Recommendation 47: Health Boards should ensure that the Infection Control Manager Recommendation 40: Health Boards should reports direct to the Chief Executive, or at ensure that the key principles of prudent least to an executive board member. antibiotic prescribing are adhered to and that implementation of policy is rigorously Recommendation 48: Health Boards should monitored by management. ensure that the Infection Control Manager is responsible for reporting to the Board on the state of healthcare associated infection in the Recommendation 41: Health Boards should organisation. ensure that there is no unnecessary delay in processing laboratory specimens, in reporting Recommendation 49: Scottish Government positive results and in commencing specific should re‑issue national guidance on the role antibiotic treatment. Infection control staff of the Infection Control Manager, stipulating should carry out regular audits to ensure that the Infection Control Manager must that there are no unnecessary delays in the be responsible for the management of the management of infected patients once the infection prevention and control service. diagnosis is confirmed. Recommendation 50: Health Boards should Chapter 15 Infection prevention and control ensure that there is 24-hour cover for Recommendation 42: Health Boards should infection prevention and control seven days ensure that all those working in a healthcare a week, and that contingency plans for leave setting have mandatory infection prevention and sickness absence are in place. and control training that includes CDI on appointment and regularly thereafter. Staff Recommendation 51: Health Boards should records should be audited to ensure that such ensure that any Infection Control Team training has taken place. functions as a team, with clear lines of communication and regular meetings. Recommendation 43: Health Boards should ensure that Infection Control Nurses and Recommendation 52: Health Boards Infection Control Doctors have regular should ensure that adherence to infection training in infection prevention and control, prevention and control policies, for example of which a record should be kept. the C. difficile and Loose Stool Policies, is audited at least annually, and that serious non‑adherence is reported to the Board.

61 The Vale of Leven Hospital Inquiry Report

Recommendation 53: Health Boards should Recommendation 60: Health Boards should ensure that surveillance systems are fit for ensure that programmes designed to improve purpose, are simple to use and monitor, and staff knowledge of good infection prevention provide information on potential outbreaks in and control practice, such as the Cleanliness real time. Champions Programme, are implemented without undue delay. Staff should be given Recommendation 54: Health Boards should protected time by managers to complete such ensure that the users of surveillance systems programmes. are properly trained in their use and fully aware of how to use and respond to the data Recommendation 61: Health Boards should available. ensure that unannounced inspections of clinical areas are conducted by senior Recommendation 55: Health Boards should infection prevention and control staff ensure that numbers and rates of CDI accompanied by lay representation are reported through each level of the to examine infection prevention and organisation up to the level of the Chief control arrangements, including policy Executive and the Board. Reporting should implementation and cleanliness. include positive reporting in addition to any exception reporting. The Chief Executive Recommendation 62: Health Boards should should sign off the figures to confirm that ensure that senior managers accompanied by there is oversight of infection prevention and infection prevention and control staff visit control at that level. clinical areas at least weekly to verify that proper attention is being paid to infection Recommendation 56: Health Boards should prevention and control. ensure that infection prevention and control groups meet at regular intervals and that Recommendation 63: Health Boards should there is appropriate reporting upwards ensure that there is effective isolation of any through the management structure. patient who is suspected of suffering from CDI, and that failure to isolate is reported to Recommendation 57: Health Boards should senior management. ensure that the minutes of all meetings and reports from each infection prevention Recommendation 64: Health Boards should and control committee are reported to the ensure that cohorting is not used as a level above in the hierarchy and include the substitute for single room isolation and is numbers and rates of CDI, audit reports, and only resorted to in exceptional circumstances training reports. and under strict conditions of dedicated nursing, with infected patients nursed in Recommendation 58: Health Boards should cohort bays with en‑suite facilities. ensure that there is lay representation at Board infection prevention and control Recommendation 65: Health Boards should committee level in keeping with local policy ensure that appropriate steps are taken to on public involvement. isolate patients with potentially infectious diarrhoea. Recommendation 59: Health Boards should ensure that attendance by members of Recommendation 66: Health Boards should committees in the infection prevention and ensure that the healthcare environment control structure is treated as a priority. does not compromise effective infection Non‑attendance should only be justified prevention and control, and that poor by illness or leave or if there is a risk of maintenance practices, such as the compromise to other clinical duties in acceptance of non‑intact surfaces that could which event deputies should attend where compromise effective infection prevention practicable. and control practice, are not tolerated.

62 Executive Summary

Recommendation 67: Health Boards should Chapter 18 Experiences of C. difficile infection ensure that, where a local Link Nurse system within and beyond Scotland is in place as part of the infection prevention Recommendation 74: Scottish Government and control system, the Link Nurses have (whether through HPS, HIS, the HAI Task specific training for that role. The role should Force or otherwise) should as a matter be written into job descriptions and job of standard practice ensure that reports plans. They should have clear objectives set published in the United Kingdom and in other annually and have protected time for Link relevant jurisdictions on infection prevention Nurse duties. and control and patient safety are reviewed as soon as possible, and that, as a minimum, Chapter 16 Death certification any necessary interim guidance is issued Recommendation 68: Health Boards should within three months. ensure that where a death occurs in hospital the consultant in charge of the patient’s Recommendation 75: Health Boards should care is involved in the completion of the review such reports to determine what death certificate wherever practicable, and lessons can be learned and what reviews, that such involvement is clearly recorded in audits or other measures (interim or the patient records. Regular auditing of this otherwise) should be put in place in the light process should take place. of these lessons.

Recommendation 69: Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the patient’s death.

Recommendation 70: Crown Office and the Procurator Fiscal Service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.

Recommendation 71: Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.

Chapter 17 Investigations from May 2008 Recommendation 72: Health Boards should ensure that a non‑executive Board member or a representative from internal audit takes part in an Internal Investigation of the kind instigated by NHSGGC.

Recommendation 73: Health Boards should ensure that OCT reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out, as recommended in the Watt Group Report.

63 The Vale of Leven Hospital Inquiry Report Executive Summary

The Vale of Leven Hospital Inquiry Report The Rt Hon Lord MacLean Chairman

© Crown copyright 2014

ISBN: 978-1-78412-844-9

Published on behalf of The Vale of Leven Hospital Inquiry by APS Group

An online version of the Report is available at www.valeoflevenhospitalinquiry.org email: [email protected] Executive Summary APS Group Scotland DPPAS23140 (11/14) Argyll & Bute CHP Committee 17 December 2014 Item : 13b

Aberdeen Royal Infirmary: Short-Life Review of Quality and Safety

December 2014

Healthcare Improvement Scotland is committed to equality. We have assessed the review process for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or email [email protected]

© Healthcare Improvement Scotland 2014 First published December 2014

The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document’s date and title specified. www.healthcareimprovementscotland.org

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Contents

List of figures 4 1 Executive summary 5 2 Recommendations 13 3 Context 18 4 The short-life review: structure, scope and methodology 22 5 Patient outcome 29 6 Patient experience data 39 7 Complaints management 43 8 Leadership and culture 52 9 Governance and accountability 65 10 Staff governance 75 Appendix 1 – Key lines of enquiry 93 Appendix 2 – Interviews and focus groups 94 Appendix 3 – Clinical areas visited 95 Appendix 4 – Review team 97 Appendix 5 – Expert advisory group 99 Appendix 6 – Unannounced inspection of the care for older people in acute hospitals: Aberdeen Royal Infirmary and Woodend Hospital – areas identified for improvement 100 Appendix 7 – Glossary 103

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List of figures

Figure 1: NHS Grampian executive structure. 20 Figure 2: Standardised Mortality Ratio for intensive care units and combined units. 2013 data. 30 Figure 3: Hospital Standardised Mortality Ratio (HSMR), for deaths within 30 days of admission to hospital. Data presented by hospital of admission. April–June 2014. 31 Figure 4: Hospital Standardised Mortality Ratio (HSMR), for deaths within 30 days of admission to hospital. Data presented for Aberdeen Royal Infirmary. October– December 2007 to April–June 2014. 31 Figure 5: Rate of Staphylococcus aureus bacteraemia infections. Data presented by NHS board. 1 April 2014–30 June 2014. 32 Figure 6: Incidence rate of Clostridium difficile infections in patients aged ≥65 years. Data presented by NHS board. 1 April 2014–30 June 2014. 32 Figure 7: Percentage of patients treated within 4-Hour Emergency Care Standard. Data presented for Aberdeen Royal Infirmary and Scotland. Data for July 2007– September 2014. 33 Figure 8: Percentage compliance with Treatment Time Guarantee. Data presented for NHS Grampian and Scotland. October 2012–June 2014. 34 Figure 9: Patient Service Score. Data presented for NHS Grampian. Data collected since July 2013. 40 Figure 10: Complaints sent to the Scottish Public Services Ombudsman prematurely: complaints upheld by the Scottish Public Services Ombudsman. 45 Figure 11: Overall Medical Engagement Scale results compared to other NHS organisations. 53 Figure 12: Specialties within the highest and lowest ranges of medical engagement. 53 Figure 13: Whole-time equivalent nursing staff and costs 2009–2010 to 2012–2013. 75 Figure 14: Ratio of hospital nursing staff in post (Agenda for Change bands 1-9) to average available staffed beds for all acute specialties. Data for NHS boards 76 Figure 15: Nursing whole-time equivalents for funded establishment, actual staff in post and assessed establishment. 77 Figure 16: Hospital nurse vacancies (all bands) as a percentage of establishment. Data for NHS boards. Data for January–March 2014. 80 Figure 17: Number of consultant vacancies as a percentage of establishment. Data for NHS board. January to March 2014. 83 Figure 18: Trainee rota monitoring. 87

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1 Executive summary

This executive summary presents the findings of the short-life review of quality and safety in Aberdeen Royal Infirmary.

The review team considered a large amount of evidence in reaching its findings and recommendations. We spoke with a wide range of staff, patients and carers, and drew on national data and information provided by NHS Grampian. A survey of medical staff and managers was also undertaken and considered alongside the results of recent surveys by the General Medical Council (GMC) and NHS Education for Scotland (NES) of doctors in training at Aberdeen Royal Infirmary.

We are extremely grateful for the openness of staff throughout the review. It is clear that most staff spoken with had a sense of pride regarding Aberdeen Royal Infirmary, but felt very concerned that the prevailing leadership, cultural and operational difficulties were eroding both the hospital’s effectiveness and the goodwill of staff. We are also grateful for the assistance of patients and carers in describing their experiences.

Introduction In March 2014, the chief executive of the NHS in Scotland invited the director of scrutiny and assurance of Healthcare Improvement Scotland to lead, alongside the medical director of NHS Lothian, a short validation exercise to review concerns that had been raised with the Cabinet Secretary for Health and Wellbeing.

The validation exercise identified a range of concerns and issues. These included:

• the relationship between some senior medical staff and the NHS Grampian senior leadership • the accountability, governance and performance management arrangements in acute services • follow-through in translating strategy into operational delivery, and • specific concerns about the quality and safety of key specialties.

The results from the validation visit were discussed with senior executives from NHS Grampian who subsequently invited Healthcare Improvement Scotland to undertake a detailed review of the leadership, culture, behaviours and values of Aberdeen Royal Infirmary. This included a review of how these factors impacted on the quality and safety of care. The review also looked at a number of specific areas including emergency medicine, general surgery, care of the elderly, obstetrics and gynaecology, and critical care.

Structure of review Members of the review team visited Aberdeen Royal Infirmary and NHS Grampian on three occasions and spoke with approximately 530 members of staff of all disciplines and grades. The team also reviewed the following:

• a substantial amount of evidence from NHS Grampian • a range of data from nationally available sources

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• a survey of medical staff and management using a validated Medical Engagement Scale questionnaire • feedback from patients and patient groups • 32 consecutive complaints records • the case records of 49 patients who had died within 30 days of admission to Aberdeen Royal Infirmary, and • 13 adverse events and their subsequent management.

An unannounced inspection of the care for older people in acute hospitals was undertaken at Aberdeen Royal Infirmary and Woodend Hospital from 6–10 October 2014.

The Royal College of Surgeons (England) (RCS) also undertook a review of general surgery in September 2014, at the invitation of NHS Grampian, and they shared their summary findings with us.

We are grateful to the many members of staff who took time to be interviewed or provided data and information to inform the review. We are also grateful to patients and their carers and visitors who shared their experiences with us.

While not exhaustive, the data, feedback from staff and patients, and direct observation has allowed us to form a comprehensive picture of the issues identified through the validation exercise in Aberdeen Royal Infirmary.

Findings Our primary purpose was to form an objective and independent view on the quality and safety of care delivered in Aberdeen Royal Infirmary.

We found sufficient evidence from national comparative audits and benchmarking to confirm that patients achieve broadly similar outcomes in Aberdeen Royal Infirmary compared to similar patients in other Scottish hospitals. We also noted from the recent national survey of inpatients that Aberdeen Royal Infirmary provides a quality of care that patients rate as highly as care delivered in any other Scottish hospital.

Through this review process we found examples of good and also poor patient care. We found dedicated and hard working individuals, particularly those in frontline roles, who are committed to delivering the highest standard of healthcare to the people of Grampian. However, we are concerned that many aspects of the current working arrangements, particularly those dependent upon goodwill, will be unable to meet future demands on the system. The potential for patient care and safety to be further compromised is overwhelmingly evident in the findings of this report.

We found a range of areas requiring improvement and have made a number of recommendations. The report outlines these recommendations and aims to help NHS Grampian to meet its ongoing commitment to providing a high quality and safe system of care.

Throughout the report, we have used examples that staff have provided us. These examples have only been included where they are representative of a general theme.

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Patient outcome data Patient outcome data did not show consistent or widespread concerns about patient safety at Aberdeen RoyaI Infirmary. However, there is a need to ensure effective action in addressing current shortcomings in systems and governance to prevent potential future harm to patients.

When viewed as a whole, the data do not highlight consistent or widespread concerns about the quality of patient care at Aberdeen Royal Infirmary. Aberdeen Royal Infirmary is not significantly different from the Scottish average for a range of established measures about the quality and safety of patient care.

It is recognised that high level data are not always sensitive to the underlying risks, and are retrospective. The Berwick report1 highlighted the danger of relying on aggregated data and the importance of understanding what is happening ‘on the frontline’. We found a range of issues that considerably reduce quality and safety, and that are mitigated through the actions of talented and dedicated frontline staff. The inspections carried out in departments during the unannounced inspection of the care of older people in acute hospitals identified sufficient incidents to raise concern about the system of care. Relying on individual dedication to compensate for poor systems is inappropriate and carries unacceptable risk.

Leadership and culture There have been weaknesses in the leadership and management of the Board, the executive team and the senior management team, in respect of Aberdeen Royal Infirmary. A small number of consultants have acted to undermine management and have exhibited poor behaviour.

We found a number of issues relating to leadership and culture which reduce the quality and safety of care. There is an urgent need for NHS Grampian to address these in order to ensure safe care. Some specific examples are listed below, but we have concerns about the leadership, culture and behaviours witnessed throughout the organisation.

• The Board was insufficiently aware of several of the problems facing Aberdeen Royal Infirmary, specifically in relation to the emergency department and the poor reports from doctors in training. • The culture within Aberdeen Royal Infirmary varies considerably from department to department. We saw good collaborative working within a number of departments, most notably in care of the elderly. However, in a number of other departments, we heard of low morale, disengagement from management, a forceful style of management which some staff perceived to be bullying, poor supervision and education for doctors in training. • We confirmed there are very poor relations between some senior medical staff and management at all levels. This is in part due to poor management visibility, communication and engagement with medical staff. But it is also a result of unprofessional behaviour of some medical staff which has not been resolved. We were particularly concerned about the behaviour of a minority of consultants in general surgery, a department we had specifically been asked to include in the review. The failure of management to resolve these issues has had an adverse effect on morale, team working and patient care.

1 Berwick review into patient safety (August 2013) 7

• There are serious issues within the emergency department, another area specifically included in the review. Concerns about staff behaviour, the lack of engagement from a small number of consultants, and a lack of confidence in the leadership’s ability to resolve the situation has compounded matters further. Whilst plans to address a number of these issues have been presented to the NHS Grampian Board at recent meetings, the present situation is not sustainable and the efforts to resolve it have so far been unsuccessful. • We also heard examples of unprofessional and unacceptable conduct which had not been addressed, open and aggressive criticism of the work of other staff and poor communication between professionals. There was a belief amongst some senior medical staff that hospital policies did not apply to them. Such behaviour is contrary to the values and behaviours expected of all staff employed within NHSScotland. • Annual job planning is a requirement of the 2004 Consultant Contract. The documentation supplied by NHS Grampian showed that only 60% of consultants had completed job plans at 15 July 2014 and this is a recurrent problem. We heard that senior consultants in general surgery had actively urged colleagues not to sign job plans. This is unacceptable and should have resulted in managerial action. • One of the surgical units is significantly dysfunctional and there are serious allegations about individual consultants which must be resolved. We heard of serious and specific allegations regarding the performance and behaviour of individual consultants in general surgery from other consultants within this department. The RCS also noted these concerns during their review carried out in September 2014. NHS Grampian has known about these concerns for several months, but has been unable to resolve them. It is not the role of Healthcare Improvement Scotland, nor we understand of the RCS, to investigate concerns about alleged misconduct by individuals. We have recommended that NHS Grampian undertakes an urgent investigation to establish the facts to inform the need for further action. • We also identified serious issues with the flow of patients through the hospital. Difficulties in transferring patients from the emergency department to wards was a recurrent theme in our interviews with staff. The most recent response from senior management to the serious problems that exist was to issue a letter to all consultants seeking to impose new and controversial arrangements, rather than consulting with them and by negotiation, gaining common agreement to an effective plan. • The issues with lack of clarity of management and leadership have made consultants reluctant to take on formal management roles. Those who have done so have sometimes been undermined by their peers. Failure to resolve this leads to increasing disengagement between clinicians and managers. • There is a need for senior managers to take concerns raised by clinicians seriously and to develop effective change management strategies. The majority of consultants in Aberdeen Royal Infirmary maintain high standards of conduct and professionalism, and are committed to continually improving standards within the hospital. This ‘silent’ majority needs to be listened to more and encouraged to participate. There is also a need for senior doctors to accept that managers have the right to manage and a legitimate expectation that clinicians co-operate with change. • The minutes of the medical staff committee suggest that this group sees itself as an alternative management structure rather than as an advisory body. This is not

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appropriate. It was also not clear if the medical advisory structure sought views from the wider medical staff body. In particular, the consultant sub-committee did not seem to have an appropriately representative number of younger or female doctors on the committee.

Governance and accountability Some systems of accountability, governance and performance management within Aberdeen Royal Infirmary are absent or weak and need to be improved.

• The executive team is seen as remote, except by some individuals who rely on personal contacts. The Aberdeen Royal Infirmary management team is also seen as remote by frontline staff. The system of leadership walkrounds did not remove this perception. The Aberdeen Royal Infirmary management team went four months without having a formal meeting. Minutes of the meetings which did take place suggested that the management team did not consider data or make meaningful decisions. There is little evidence of an effective performance management framework. All of this is of significant concern given the known issues with scheduled surgery, cancer waiting times, nurse staffing and the emergency department. • The uncertainty about management structure and accountability has led to a reduction in the effectiveness of managers. • A lack of clarity in the management structure is compounded by a lack of leadership at Board, executive and hospital management level. The executives gave the impression that they believe the problems that Aberdeen Royal Infirmary faces are in large part due to external factors and cannot be resolved by NHS Grampian management. We acknowledge the general challenges that face the NHS, and some particular challenges affecting NHS Grampian, but consider that the executive team should be leading work to mitigate these. This lack of leadership has contributed to the situation where a minority of staff have behaved poorly. • Staff told us that there had been repeated restructuring of management. Individual managers at junior level are often not in post long enough to understand the department and its issues. Junior managers, and most clinical managers, have little or no decision-making authority. There is a general belief that when decisions are escalated to hospital or Board level management, decisions are either not made or not communicated. We heard multiple comments about emails and letters to managers raising important concerns going unanswered and unaddressed. It was a frequently expressed view that actions were not taken until a crisis was imminent, and then senior managers were drawn in to “fire-fight” and that responses were “knee jerk”. • We heard concerns about the lack of learning from reviews of complaints, adverse events and the General Medical Council training reports. We felt there was minimal evidence that the clinical governance structures resulted in learning from these sources being spread across the organisation. We also heard about some mortality and morbidity meetings within general surgery being settings for clinicians to aggressively criticise others rather than forums to share learning. Individual behaviours of some consultants in these settings need to be addressed promptly. • There are further concerns about governance included in the staff governance section below.

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Staff governance There are considerable staffing difficulties, particularly medical staffing within the emergency department, that require urgent attention to maintain safety.

• Throughout Aberdeen Royal Infirmary and Aberdeen Maternity Hospital, we found dedicated and hardworking individuals who are committed to delivering the highest standard of healthcare to the people of Grampian. • However, there are considerable staffing difficulties, mostly relating to medical staffing within the emergency department at Aberdeen Royal Infirmary, that require urgent attention to maintain safety. These have been repeatedly raised by consultants in the department and to date the plans to address these have not been adequate. We acknowledge the difficulty nationally in recruiting at both consultant and senior trainee level in this specialty. The present arrangements, which depend on cover by registrars from other departments, who may not be trained in emergency or trauma medicine, are not sustainable and are considered by many staff to be unsafe. • Members of the Board appear to have been unaware of the depth of the developing crisis in the emergency department, and this raises serious concern about the adequacy of governance. • There are serious issues with nurse staffing, as evidenced by feedback from nurses and doctors that we spoke with and the findings from the care for older people in acute hospital inspection carried out in October 2014. As with some medical staff groups, there are national difficulties in recruitment, but NHS Grampian had planned reductions in nurse numbers over recent years (see Section 10). While NHS Grampian has tried to address recent issues through a prioritised investment programme, this has not yet produced the staffing levels and skills required. • For a number of years, the annual survey of training doctors has revealed very poor results in some departments (although some departments have produced creditable results). These deficiencies have been known about for some time and require to be addressed effectively. Board members seem to have been unaware and some consultants complacent. As a result of the failure to address issues so far, the emergency department has now been escalated to ‘Enhanced Monitoring’ by the General Medical Council. There is a real risk that if service pressures are used to justify poor training, then trainees may be withdrawn, or fail to apply, resulting in significant consequences. Many medical staff members mentioned increasing difficulties in recruiting consultants. It is unsurprising that doctors who experience poor training and an unsupportive atmosphere choose to find consultant jobs elsewhere and do not recommend Aberdeen as a place to work to their peers.

Complaints management The leadership and management of complaints is poor with evidence of defensiveness in some responses to complainants.

• We undertook a review of the handling of complaints to assess how NHS Grampian meets the expectations of legislation and related good practice guidance in ‘Can I Help You?’ Guidance for handling and learning from feedback, comments, concerns or complaints about NHS health care services’ (Scottish Government, 2012). The complaints review found poor and delayed management of complaints and evidence of

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defensiveness in some responses to complainants. Further training for those involved in addressing complaints would be helpful, as would a greater number of face to face meetings with complainants.

Unannounced inspection of the care of older people in acute hospitals The unannounced inspection of the care of older people in acute hospitals resulted in one area of strength and 22 areas for improvement. These included:

• Woodend Hospital has a person-centred approach to patient care, particularly at mealtimes where food was served in a manner that ensured dignity and respect • the management of patient flow and capacity in Aberdeen Royal Infirmary and Woodend Hospital is not fit for purpose and puts patient safety at risk • senior nurse and medical leadership must regain the confidence of staff by addressing the issues of staffing, staff motivation, and patient flow and capacity • ineffective discharge processes are affecting timely discharge • the care provided in Aberdeen Royal Infirmary is only possible because medical and nursing staff commitment and dedication in repeatedly covering gaps in the system, and • inconsistent documentation completed across the wards inspected relating to a number of key assessments.

The areas for improvement identified following this inspection are listed in Appendix 6 of this report. The full inspection report can be found at http://www.healthcareimprovementscotland.org/opah.aspx.

In conclusion • Patient outcome data did not show consistent or widespread concerns about patient safety at Aberdeen RoyaI Infirmary. However there is a need to ensure effective action in addressing current shortcomings in systems and governance to prevent future harm to patients. • A number of issues relating to staffing, leadership and management have the potential to impact on the quality and safety of care. They do not appear to have a detectable adverse impact at present, which is likely due to the hard work of dedicated and hard working frontline staff. The issues, which are outlined in detail in the report, are serious enough to warrant urgent attention to prevent any future adverse impact on patient care. • There have been significant deficiencies in leadership and management in relation to Aberdeen Royal Infirmary. • There is widespread disengagement of medical staff in Aberdeen Royal Infirmary and responsibility for this rests with both managers and doctors. There has been a lack of leadership within the organisation which has resulted in the failure to unite staff behind a common purpose. There is also disengagement among other professions in Aberdeen Royal Infirmary. • Some systems of accountability, governance and performance management in Aberdeen Royal Infirmary are absent or weak, and need to be improved.

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• NHS Grampian has great difficulty in translating strategy into change at Aberdeen Royal Infirmary, due in part to weaknesses in leadership and poor clinical engagement. • There are considerable medical and nursing staffing difficulties, particularly medical staffing within the emergency department, that require urgent attention to maintain safety. • National and locally collected data on patients and carers, report, on the whole, positive experiences of the care they received whilst at Aberdeen Royal Infirmary. This was supported through our work with the Scottish Health Council and through patient and carer conversations with public partners during the visits. • There is a lack of clarity in the management structure which compounds the lack of leadership at executive and hospital management level. • A small number of consultants have acted to undermine and disengage from management and have exhibited poor behaviour. It is unlikely that the optimum care for patients can be provided in the settings where this behaviour was most evident. • There are significant weaknesses in how patient complaints are managed and ultimately responded to.

We have identified recommendations (see Section 2) and we expect that these recommendations will be used to provide guidance and support for those working in NHS Grampian to help them to deliver the necessary improvements.

We expect NHS Grampian to develop an action plan to implement the recommendations. It is important that the recommendations are carefully considered and a detailed improvement plan developed, with appropriate timescales, ownership, accountability and measures incorporated.

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2 Recommendations

Patient outcome 1 NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a sustainable emergency department service that provides patients with safe, effective and person-centred care.

The plan should:

● be sustainable in terms of ability to recruit and retain medical staff

● recognise the reality that the emergency department requires senior input from specialist emergency medicine medical staff

● recognise that senior trainees will continue to be in short supply

● recognise that staff from other specialties whilst valuable in their own roles cannot be used to substitute for the expertise of senior emergency medicine medical staff

● recognise that senior trainees can make a valuable service contribution, but are also entitled to expect support and training that adheres to the appropriate GMC mandatory regulatory standards2

● explore the potentially valuable contribution that can be made by non-medical staff, such as advanced nurse practitioners, while recognising that senior doctors leading care will always be required, and

● be approved and progress monitored by the Board.

2 NHS Grampian executive team should work with senior clinical colleagues and local managers to review the management of unscheduled care across the hospital, with emphasis on the effective transfer of emergency patients from the emergency department to inpatient areas.

This will mean:

● recognising the complexity of the systems involved

● developing an effective system of flow of patients through the hospital that will improve patient care, reduce wastage of clinical time, and improve the quality of care for patients

● using visible leadership to ensure that all stakeholders involved sign up to agreed and defined protocols, and then work in line with the protocols, and

● working closely with health and social care partnerships to support effective discharge planning.

3 NHS Grampian should ensure that the escalation policy for patients whose Scottish Early Warning System score is high is understood and implemented by all relevant clinical staff.

2 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf 13

Patient experience data 4 NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently across the services.

This work should include the following:

● continue to use patient feedback as a resource for continuous improvement

● ensure that collated patient feedback is passed on to staff to encourage improvement, and

● monitor progress so that agreed improvements are initiated within a reasonable timescale.

Complaints management 5 NHS Grampian should improve the way it investigates, responds to and learns from complaints.

This improvement should include:

● clear, unambiguous and effective leadership on complaints at senior/executive level and ensure that appropriate priority is given to continuously improving the approach of listening to and learning from complaints consistently across NHS Grampian’s acute services

● clarity and consistency in decision-making about whether a complaint has been upheld or not

● a more robust approach to the quality assurance of complaints management

● more face to face meetings between staff, patients and relatives to resolve complex complaints

● confirmation that clinical aspects of responses address the questions posed and that responses are clear and empathetic, and

● a way in which to build on the positive impact of a nominated post in acute services who can liaise with the feedback service and managers or clinicians to support good practice in the handling of complaints and learning from these.

Leadership and culture 6 NHS Grampian should carry out a fundamental review of the acute sector leadership with the emphasis on ensuring clear accountability and a delivery focus in respect of acute services and Aberdeen Royal Infirmary in particular.

These arrangements should include:

● an appropriate balance between structural redesign and establishment of effective leadership, whilst securing a strong focus on delivery of key objectives

● reporting lines, remits and performance of committees and individuals that are clear, unambiguous and regularly measured

● executive level professional leadership for escalation and governance of concerns regarding the currently disjointed and unclear workforce data

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● opportunities for leaders and managers at all levels of the organisation to be supported through training, their peers and the managerial hierarchy to fulfil their respective roles

● a review and revision of the medical management structure (medical director, divisional clinical directors, clinical directors and clinical leads) to ensure there is clarity and consistency of job role and purpose and include job descriptions, contracts objectives and resource, and

● a review and revision of the medical advisory structure to ensure appropriate, representative, valued and effective engagement and contribution. The final structure should be integral to the overall multidisciplinary professional advisory structure, and should not appear to operate outwith that professional advisory structure.

7 NHS Grampian should take urgent action to engage fully with all clinical and non- clinical staff.

The plan should:

● build on recent work to address engagement of clinicians

● acknowledge the large positive contribution made by the majority of staff, whilst addressing behaviours that undermine the organisation and where applicable adhere to GMC mandatory regulatory standards3

● specifically include work to address the issues identified in the Medical Engagement survey, and

● include a consistent, fair and comprehensive approach to dealing with adverse staff behaviour in all groups of staff.

Governance and accountability 8 NHS Grampian should introduce strong and effective governance mechanisms for the clinical, operational and managerial control of services at Aberdeen Royal Infirmary.

These mechanisms should include the following:

● a thorough examination of the effectiveness of the clinical governance function ensuring that it meets the expected objectives of NHS Grampian’s clinical governance strategy

● defined and clear roles and responsibilities of the management and advisory structure (see recommendation 6) to ensure appropriate involvement in the clinical governance function

● sufficient capacity, for the NHS Grampian Board members, to constructively challenge and to assert their position as a body focused on securing improved health outcomes for the population of NHS Grampian

● defined and clear strategic organisational objectives which link to the objectives of leaders and management of the organisation

● a clear and prioritised operational plan for the delivery of strategic objectives across

3 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf (standard 6.18)

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the acute sector, with accountability for delivery expressed

● a robust performance management framework to monitor delivery of the operational plan. The performance management framework should be based on data which should be routinely collected, distributed and used. Data will come from a variety of sources and should allow managers to share and learn from emerging themes and improve services. For example, adverse incidents, patient experience data and complaints

● arrangements for the acute management team to have regular meetings focusing on delivery, accompanied by minutes and action tracking of progress, and

● arrangements for the medical director to have regular meetings with the associate medical directors and divisional clinical directors accompanied by minutes and action tracking of progress.

Staff governance 9 NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools.

These plans should include the following:

● detail on how to ensure that there are sufficient numbers of nurses with the appropriate skill mix at all times in all wards

● detail on how to fill the gaps, with defined dates and hierarchical ordering of wards

● be based on assessed priority. Through this process, nursing staff should be made aware of the most recent results of the national nursing workforce and workload tool

● consideration of the current bed model in the context of a 20% gap between staff establishment in-post and establishment-assessed-as-being-required, especially in the absence of a robust plan to successfully recruit and retain nursing staff, and

● opportunities to create learning and communication sessions with senior charge nurses regarding workforce requirements. This should include positive communication regarding the funded skill mix and patients-per-registered nurse- per-shift ratio.

10 NHS Grampian should develop and implement a robust medical workforce plan.

This plan should:

● have a significant focus on securing full recruitment, including anticipating retirals and proactively working to prevent gaps

● ensure that the experience of trainees in their training is consistently good so that they will be attracted to work in NHS Grampian after completing training

● ensure all consultants and specialty doctors complete a job plan review annually, and have an up-to-date job plan that explicitly and fairly outlines what is expected of them, and

● have a clear and consistent consultant appointment process that includes a list of desirable professional and behavioural characteristics for candidates.

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11 NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the General Medical Council and National Training Survey results are reviewed by the Board.

This arrangement should:

● ensure that adverse trainee survey results are noted and action plans produced to address them in line with the GMC’s mandatory regulatory standards4

● monitor the progress of such action plans

● ensure that particular attention is paid to the current training experience in general surgery and emergency medicine, and

● ensure that trainee rotas are monitored and that valid returns are produced.

Recommendations from the Royal College of Surgeons (England) and the unannounced Older People in Acute Hospitals inspection 12 NHS Grampian should ensure that the recommendations made by the Royal College of Surgeons (England) following their visit in September 2014 are implemented in full.

13 NHS Grampian should work to address the areas of improvement outlined following the unannounced inspection of the care for older people in acute hospitals at Aberdeen Royal Infirmary and Woodend Hospital on 6–10 October 2014.

● The areas for improvement indentified following the inspection are listed in Appendix 6 of this report. The full inspection report can be found at http://www.healthcareimprovementscotland.org/opah.aspx.

4 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf (Standards 7.2 and 7.3)

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3 Context

3.1 This chapter briefly describes the operating and strategic context in Aberdeen Royal Infirmary. Throughout this report when we refer to Aberdeen Royal Infirmary, we also include Aberdeen Maternity Hospital.

Operating context 3.2 Aberdeen Royal Infirmary is a major teaching hospital, for which NHS Grampian has responsibility. The focus of this report is on Aberdeen Royal Infirmary.

3.3 Aberdeen Royal Infirmary is the major acute hospital in the north east of Scotland and provides healthcare for the population of Grampian and the northern isles. As a teaching hospital, it also plays a key role with the University of Aberdeen in scientific research.

3.4 Aberdeen Royal Infirmary is within the Foresterhill campus. It has approximately 900 staffed beds and a complete range of medical and clinical specialties. In November 2012, the new purpose-built emergency care centre opened, bringing together emergency and urgent care facilities into one building. There are 353 inpatient and day beds in the emergency care centre.

3.5 From 1 October 2013 to 30 September 2014, NHS Grampian employed 4,500 staff (excluding bank staff) at Aberdeen Royal Infirmary and 500 staff (excluding bank staff) at Aberdeen Maternity Hospital. Aberdeen Royal Infirmary has a budget of £272.7 million and Aberdeen Maternity Hospital a budget of £28.1 million.

3.6 As well as providing specialist services to the region, the hospitals are also the major provider of most routine hospital care to the local population. This includes healthcare provided on an outpatient and day care basis. Aberdeen Royal Infirmary had 46,595 inpatient admissions, 30,967 day cases and 308,326 outpatients between 1 October 2013 and 30 September 2014. For the same period, Aberdeen Maternity Hospital had 10,705 inpatient admissions and 38,326 outpatients.

Leadership and management arrangements 3.7 It is important to provide the leadership and management context for Aberdeen Royal Infirmary.

3.8 The acute sector in NHS Grampian consists of Aberdeen Royal Infirmary, Aberdeen Maternity Hospital, the Royal Aberdeen Children's Hospital and Dr Gray's Hospital in Elgin. The acute sector is overseen by an acute sector management team.

3.9 The acute sector management team is led by the general manager (acute sector), associate director of nursing (acute sector) and the deputy medical director/clinical lead (acute sector). The acute sector management team oversees five operational divisions, each led by a similar team of divisional general manager, lead nurse and clinical director. The divisions have a management infrastructure consisting of unit operational managers, clinical nurse managers and specialty level clinical leads.

3.10 The general manager (acute sector) reports directly to the deputy chief executive. The deputy chief executive is the executive director responsible for the acute sector in NHS Grampian. The general manager (acute sector) has day to day operational management responsibility for Aberdeen Royal Infirmary. 18

3.11 The executive team led by the chief executive, is accountable for the management of the system of healthcare in NHS Grampian, which includes Aberdeen Royal Infirmary. The executive team includes the deputy chief executive, medical director, finance director, director of nursing and director of workforce. Figure 1 (see page 20) sets out the executive structure.

3.12 The executive team reports to the NHS Grampian Board. The Board, led by the non executive chair, has overall responsibility to ensure the efficient, effective and accountable governance of the local NHS system and in providing strategic leadership and direction for the system as a whole. The Board consists of non executives and executives appointed by the Cabinet Secretary for Health and Wellbeing. The Board operates within an assurance framework which delegates specific governance functions to Board sub-committees, including clinical governance, staff governance and audit.

Performance 3.13 Performance targets aim to ensure that NHS boards focus on making improvements in areas the Scottish Government has identified as priorities, to help to achieve its overall purpose and objectives. In recent years, the Scottish Government has reduced the number of HEAT targets and has committed to focusing more on outcomes. A number of HEAT targets continue to be monitored after their delivery date. These targets are then referred to as HEAT standards. Many of the HEAT targets relate to waiting times which over the past 10 years have been shortened to support patients being seen more quickly across a range of services. These targets have become more challenging for NHS boards recently.

3.14 The treatment time guarantee (TTG) was introduced on 1 October 2012 under the Patient Rights (Scotland) Act 2011. All eligible patients now have a legal right to receive planned inpatient or day case treatment within 12 weeks of the treatment being agreed. NHS Grampian has not met this target since December 2012, with performance below that of NHSScotland as a whole.

3.15 Urgent referral to first treatment for patients who are diagnosed with cancer should be no more than 62 days. For the year end to March 2014, NHS Grampian has not met this target, with performance below that of NHSScotland as a whole.

3.16 Since April 2013, NHS boards have been working to the target that no patient should wait in hospital for more than 28 days from when they are clinically ready for discharge (reduced from 42 days previously). From April 2015, this is due to reduce further, to 14 days. NHS Grampian did not meet this 28-day target at the end of April 2014 (only three NHS boards met this target by the end of April 2014).

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Figure 1: NHS Grampian executive structure.

Chief Executive

Director of Director of Director of Deputy Chief Director of Public Nurse Medical Director of Communications & Workforce Finance Executive Health Director Director Modernisation Board Secretary

General Manager General Manager General Manager General Manager General Civil General General Acute Aberdeen City CHP Aberdeenshire CHP Moray CHP Manager of Contingencies Manager Manager Facilities e-Health Mental Health

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Financial position 3.17 The majority of core funding for the NHS boards is allocated using the formula introduced in 2009 by the NHSScotland Resource Allocation Committee (NRAC). This covers funding for hospital and community health services and GP prescribing, which together cover around 70% of the NHS budget. The formula predicts a target share of the overall budget for each of the 14 territorial NHS boards. This target share is based on a weighted capitation that takes account of a number of factors that predict the need for healthcare including age, morbidity and life circumstances, and geographical factors that is aggregated across the entire NHS board population. Due to the combination of these factors in NHS Grampian relative to other NHS boards, the formula has consistently predicted a per capita share for NHS Grampian that is the lowest among NHS boards.

3.18 At the start of the financial year 2014/15 NHS Grampian’s core allocation was £34.7m less than the Board’s target NRAC share5. NHS Grampian has recently confirmed an agreement with the Scottish Government which will increase the NHS board’s financial allocation by a total of £43m over the next 3 years. This uplift will bring NHS Grampian to within 1% of NRAC parity by 2016/17. NHS Grampian has stated that whilst it welcomes the positive commitment from the Scottish Government towards this financial parity, it highlighted that even at parity its funding share relative to other NHS boards is impacted by further issues of weighting.

3.19 The self-assessment produced by NHS Grampian and published ahead of its annual review with the Cabinet Secretary for Health and Wellbeing (originally scheduled to take place on 17 November 2014 but postponed until early 2015) states that:

“NHS Grampian remains the lowest funded NHS board per capita under the NRAC formula and our funding level remains below the parity level suggested by the formula. Our performance as an NHS board has been significant in the context of our funding position relative to all other Boards. We very much welcome the plan we have agreed with the Scottish Government to move towards a parity level. The resources that this will provide will enable us to invest in key clinical services in order to bring service provision up to comparable levels with other parts of Scotland and will help us to provide healthcare for the ever expanding population of Grampian."

5 Financial Plan 2014/15 (update) paper to 1 August 2014 NHS Grampian Board meeting 21

4 The short-life review: structure, scope and methodology

4.1 The purpose of this report is to present the detailed findings against the issues and concerns highlighted to Healthcare Improvement Scotland. It also provides an agreed set of recommendations which NHS Grampian, with support, will implement over the coming months.

4.2 The findings and recommendations describe the consideration and verification of a range of sources of evidence including documents, statements, reports and conversations the review team had with the patients and staff at Aberdeen Royal Infirmary. The methods we employed during this review process allow us to be confident that what we have written reflects the beliefs of a number of staff throughout the organisation. It is vital that we sensitively include all of these views and perceptions in our report.

4.3 The review team is grateful for the welcome, hospitality and candour of patients, carers, members of the public and staff during this whole process.

Background 4.4 In March 2014, the chief executive of the NHS in Scotland invited the director of scrutiny and assurance of Healthcare Improvement Scotland to lead, alongside the medical director of NHS Lothian, a short validation exercise to review concerns that had been raised with the Cabinet Secretary for Health and Wellbeing.

4.5 The central approach to the validation exercise was to interview a range of individuals in NHS Grampian. Around 30 individuals were spoken with about their perceptions relating to the issues. On 31 March 2014, an initial verbal report was presented to the chief executive of the NHS in Scotland and other officials, and subsequently to the chair, chief executive and deputy chief executive of NHS Grampian.

4.6 The validation exercise identified a range of concerns and issues. These included:

• the relationship between some senior medical staff and the NHS Grampian senior leadership • the accountability, governance and performance management arrangements in acute services • follow-through in translating strategy into operational delivery, and • specific concerns about the quality and safety of key specialties.

4.7 The validation visit identified:

“A fracture between the senior leadership and a strong and influential clinical community in NHS Grampian’s acute services. The roles and accountabilities of clinical directors were unclear and the visibility and engagement between the management and clinical staff could be improved. In particular there was a loss of confidence in the senior medical management in NHS Grampian by some senior clinicians.

“The review team had identified a lack of clarity in the lines of accountability and governance in acute services. This was expressed, for instance, by the bypassing of

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structures and systems of governance by some individuals going directly to the chief executive to seek approval for their objectives. This sometimes led to a lack of clarity about who was actually ‘in charge’ and about how and why decisions were made. The management of waiting lists was a particular area that required improvement.”6

4.8 In addition, “The review team observed a lack of shared values which impacted on the culture that was necessary to facilitate the Board’s ambitions for quality and safety of care. The work on the 2020 vision in NHS Grampian was important but needed to be more broadly owned.”6

4.9 Given the short space of time, the validation visit did not examine in depth the range of issues raised. The team that conducted the validation visit believed that there were sufficient grounds to warrant a fuller and more considered examination of the issues raised.

4.10 Given the significance of the concerns identified, it was important that they were rigorously, systematically and independently followed up by the appropriate agencies. Therefore, NHS Grampian invited Healthcare Improvement Scotland to carry out a short-life review of the quality and safety of care in Aberdeen Royal Infirmary.

4.11 On 6 June 2014, the short-life review was announced and the terms of reference for the review were published on the Healthcare Improvement Scotland website7.

Scope of the short-life review 4.12 As the chief executive of NHS Grampian had invited a service review, the terms of reference were agreed between Healthcare Improvement Scotland and NHS Grampian. The focus of the short-life review was to:

• assess the leadership, culture, values and behaviours which support and ensure the quality and safety of care • identify the areas for improvement, and good practice, in relation to the specific services under review • advise if any additional support should be made available to NHS Grampian to help strengthen and accelerate their improvement programme, and • advise on any areas that may require further action, including improvement support.

4.13 The review broadly covered two main areas.

• The culture, leadership, values and behaviours which support and ensure the quality and safety of care. This report provides an independent assessment of the approach of leadership to support the delivery of a safe and high quality system of care. Leadership is defined as all levels of leadership in the organisation. The review considered the extent to which the Board leads the development of a safety culture that leads to improvement. The review also considered the

6 Extract from the minute of 31 March 2014 meeting between the Scottish Government, Healthcare Improvement Scotland and NHS Grampian 7http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/programme_resourc es/ari_review.aspx 23

opportunities to build stronger and more effective engagement with the clinical community in the design and operation of services. It also examined the skills and capacity to sustain future improvement. At the service level, we assessed the local leadership in supporting and driving the commitment to a safer health service.

• Quality and safety of care in a focused number of specialties and services. We considered the key issues relating to the quality and safety of care in a small number of services that were flagged as areas of concern in the validation visit in March 2014. These services were: - emergency department - surgical specialties – general surgery and trauma/orthopaedics - care of the elderly - obstetrics and gynaecology8, and - critical care9.

4.14 We focused on issues which are known to have a significant impact on the safety and effectiveness of the clinical care provided. These included:

• the patient and carer experience within Aberdeen Royal Infirmary • workforce issues within Aberdeen Royal Infirmary, such as staffing levels and skill mix • the operational effectiveness of Aberdeen Royal Infirmary, in particular the management of patient flow through the hospital • the leadership and culture in delivering a quality and safety of care within the individual services being reviewed, and • the capacity and capability within Aberdeen Royal Infirmary to both identify key quality and safety issues in a timely way and to then implement appropriate improvements.

4.15 Whilst the review was focused on Aberdeen Royal Infirmary, it also considered the overall leadership and accountability arrangements in NHS Grampian.

4.16 Where appropriate, we also investigated current clinical practice in relation to the safe provision of care and the effective implementation of the Scottish Patient Safety Programme (SPSP).

Review team and expert advisory group 4.17 The short-life review was conducted by a review team. The review team was chaired by the medical director of NHS Dumfries & Galloway. The review team included a wide range of experienced healthcare professionals from across the NHS in Scotland and members of the public. See Appendix 4 for the list of review team members.

4.18 The review team was supported by a separate expert advisory group chaired by the executive clinical director of Healthcare Improvement Scotland. See Appendix 5 for the list of expert advisory group members.

8 A decision was made on 22 August 2014 to extend the review to obstetrics and gynaecology 9 Critical care was not specifically included in the review terms of reference, but was subsequently taken into account given its key role 24

Structure of the short-life review 4.19 The short-life review consisted of three broad phases:

• gathering data and intelligence from June to August 2014, including a Medical Engagement Scale survey • assessing the quality and safety of care through a review team visit (12–15 August 2014), a follow-up service visit (16 September 2014 and 9 October 2014) and an unannounced inspection of care for older people in acute hospitals (6–10 October 2014), and • developing the short-life review report underpinned by the triangulation of data, intelligence and observing care provided to patients.

4.20 Throughout the short-life review process we:

• conducted meetings with or visits to a total of approximately 11 groups and clinical areas • spoke with approximately 530 members of staff working in NHS Grampian • received feedback through surveys and interviews from 362 patients and carers about their experience of the care received (see Appendix 2) • reviewed 32 complaints records from a sample of 50 consecutive records • reviewed the case records of 49 patients who had died within a set time period in Aberdeen Royal Infirmary, and • analysed 13 adverse events and their subsequent management.

Building the data and the intelligence for the review 4.21 In the first phase of the short-life review, we focused on assembling the data and intelligence on the quality and safety of care in Aberdeen Royal Infirmary. We drew on the experience and learning from a previous rapid review of NHS Lanarkshire to help determine the evidence that would be useful. We considered a range of data from nationally available sources.

4.22 On 22 August 2014, a data pack was circulated to the review team members.

4.23 We reviewed recent care for older people in acute hospitals inspection reports to identify any key themes where patient care could be improved and to consider how NHS Grampian had responded to the recommendations made. An inspection was undertaken at Aberdeen Royal Infirmary from 16–18 June 2013 which identified 11 areas for improvement and four areas for continuing improvement. After the inspection, NHS Grampian put in place an action plan to address the recommendations.

4.24 An unannounced inspection of the care for older people in acute hospitals was undertaken at Aberdeen Royal Infirmary from 6–10 October 2014 to assess progress against the action plan and to inform the short-life review. The inspection identified concerns with patient flow, a lack of co-operation between medical staff to resolve issues, lack of structure in general management resulting in continual short term fixing, evidence of weak leadership and lack of visibility from senior nursing staff and concerns regarding the skill mix of staff on wards. 25

Medical Engagement Scale 4.25 A major area of concern identified in the validation visit was the perceived poor engagement between senior management in NHS Grampian and an influential group of clinicians in Aberdeen Royal Infirmary. Medical engagement is related to clinical outcomes10. Healthcare Improvement Scotland commissioned a baseline assessment of the level of engagement between senior management and all medical staff at the Aberdeen Royal Infirmary site.

4.26 The Medical Engagement Scale survey has been used across the UK and has surveyed around 8,000 doctors. It provides a benchmark against which NHS hospitals can assess their level of medical engagement. The definition of engagement is:

“The active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation which itself recognises this commitment in supporting and encouraging high quality care.”

4.27 The survey was circulated to 960 staff in Aberdeen Royal Infirmary and was completed by 326 medical staff and 49 management staff (39% response rate).

4.28 The full survey report is available on the Healthcare Improvement Scotland website at: http://www.healthcareimprovementscotland.org/ari_review.aspx. The analysis of the results of the survey is included in Section 8.

4.29 The Medical Engagement Scale is only validated for use with medical staff. We considered the level of clinical and managerial engagement in Aberdeen Royal Infirmary across other staff groups during the visits. This included nursing, allied health professional and support or administrative staff.

4.30 We considered the output from this exercise with other strands of intelligence, such as surveys of the training experience of junior doctors undertaken by the GMC and NES.

Review team visit 12–15 August 2014 4.31 Members of the review team undertook an intensive 4-day visit to Aberdeen Royal Infirmary between 12–15 August 2014. During the visit, we spoke with a wide cross- section of staff working in NHS Grampian, and Aberdeen Royal Infirmary in particular.

4.32 We worked within the broad parameters of ‘key lines of enquiry’ (see Appendix 1). The key lines of enquiry sought to follow up on the concerns raised in the validation visit and queries arising from intelligence gathered since that visit.

4.33 The review visit consisted of:

• individual interviews • focus group meetings • visits to clinical areas, and • drop-in sessions for staff to share their experiences.

10 Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report (July 2013) (Keogh Report) 26

4.34 There was strong interest and participation in the drop-in sessions for staff. We met with around 130 people at these sessions and a significant number asked for a one to one session with members of the review team. Across the four days in August, we met over 300 members of staff through drop-in sessions, individual interviews, focus group meetings and visits to clinical areas.

4.35 We operated within an agreed protocol to feedback any areas of concern to the management team in NHS Grampian.

4.36 On 18 August 2014, the chair of the review team escalated a clinical governance matter in writing to the chief executive of NHS Grampian concerning serious allegations made by a small group of surgeons about the behaviour, competence and probity of colleagues.

4.37 The matters identified in this visit formed the basis for further investigation in the following weeks.

Service visits on 16 September 2014 and 9 October 2014 4.38 Members of the review team undertook further one-day service specific visits during September and October 2014. These visits followed up specific concerns initially identified in the validation visit in March 2014 and subsequently established by the review team. These visits covered the following areas:

• emergency medicine • surgical specialties – general surgery and trauma/orthopaedics • care of the elderly • obstetrics and gynaecology, and • critical care.

4.39 We visited emergency medicine, surgical specialties, care of the elderly and obstetrics and gynaecology at the Aberdeen Royal Infirmary site on 16 September 2014. The team met with 177 members of staff during visits to clinical areas and through requested one to one sessions with staff.

4.40 In response to issues identified on this visit, the chair of the review team escalated three serious clinical governance matters to the chief executive of NHS Grampian on 16 September 2014 and subsequently in writing on 23 September 2014: • the health and safety risk from a leaking roof • loss of dignity and privacy in respect of two patients, and • staffing levels in the emergency department.

We asked NHS Grampian to investigate these issues further. 4.41 We visited the critical care department at Aberdeen Royal Infirmary on 9 October 2014. The team met with approximately 35 members of staff during the visit to relevant clinical areas within critical care.

4.42 A member of the review team participated in the NES re-visit to the emergency department in October 2014. 27

Feedback and follow-up 4.43 We presented the initial findings of our report to NHS Grampian’s executive team on 28 October 2014. NHS Grampian received the draft report on 4 November 2014 for factual accuracy checking.

4.44 We expect NHS Grampian to develop an action plan to implement the recommendations contained within this report. It is important that the recommendations are carefully considered and a detailed improvement plan developed, with appropriate timescales, ownership, accountability and measures incorporated.

4.45 Healthcare Improvement Scotland, with other key stakeholders, will support the development of the NHS Grampian action plan to implement the recommendations set out in this report. Through this process, additional improvement support will be identified to help implement the actions.

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5 Patient outcome

5.1 To inform the short-life review, we assembled data and intelligence on the quality and safety of care in Aberdeen Royal Infirmary. We reviewed and analysed data from nationally available sources and also evidence provided by NHS Grampian. We reviewed patient outcome data through:

• compiling a data pack, and • a review of patient case notes.

Compiling a data pack 5.2 We prepared a data pack which helped us develop key lines of enquiry and to formulate conclusions. It is important to note that the data considered for the short- life review cannot be used as a sole basis for making reliable judgements about quality and performance at Aberdeen Royal Infirmary.

5.3 Preparation of the data pack involved identifying and prioritising key pieces of existing data, most of which were derived from Scotland-wide data sets and with some additional data provided by NHS Grampian. The data in the pack covered a wide range of issues relating to the quality of patient care (including clinical outcomes) and operational performance. The data pack can be found at http://www.healthcareimprovementscotland.org/ari_review.aspx.

5.4 Available data on patient experience were included, as were data on patient outcomes such as hospital-related deaths, healthcare associated infections, emergency admissions/readmissions, and length of stay. We also reviewed data for some relevant clinical specialties, for example analyses on emergency medicine, and national clinical audit data for intensive care, arthroplasty (joint replacement surgery) and stroke. NHS Grampian collects a range of data for the SPSP, and these were also considered. The data pack also contained data on the workforce (both nursing and medical), waiting times, bed occupancy, delayed discharges, and theatre utilisation.

5.5 When viewed as a whole, the data in the pack do not show consistent or widespread concerns about the quality of patient care at Aberdeen Royal Infirmary. Aberdeen Royal Infirmary is not significantly different from the Scottish average for a range of established measures about the quality and safety of patient care. However, the data for some measures, for example on specific aspects of operational performance, do highlight areas of potential concern. It should be noted that, when considering such a wide range of data, it might reasonably be expected that data drawing attention to potential areas of concern would be identified for any NHS board.

5.6 Some of the key pieces of data from the pack are presented or summarised below to illustrate the broad themes. Some specific items of data are also presented in subsequent chapters of this report, for example patient experience, complaints and staff governance.

5.7 The Information Services Division (ISD) of NHS National Services Scotland manages a number of national clinical audits, and data from three audits that are of particular relevance were considered as part of the review. Specifically, when reviewing the various measures reported for the Scottish Intensive Care Society Audit Group, the Scottish Arthroplasty Project and the Scottish Stroke Care Audit, the data for 29

Aberdeen Royal Infirmary are not significantly different from the national average. For example, the Standardised Mortality Ratio for the Intensive Care Unit at Aberdeen Royal Infirmary is not significantly different from the Scottish average (Figure 2).

Figure 2: Standardised Mortality Ratio for intensive care units and combined units. 2013 data11. The intensive care unit at Aberdeen Royal Infirmary is denoted ‘W’ on this chart.

Data source: Information Services Division, Scottish Intensive Care Society Audit Group

5.8 Data points within the control limits are said to exhibit common cause variation or to be ‘in control’. Data points outwith the control limits (sometimes called ‘outliers’) are said to exhibit something called ‘special cause variation’. This is where further investigation might be beneficial. Variations observed on an indicator may reflect a number of factors, such as characteristics of the patients being cared for (case-mix), the quality of clinical care, or errors in the data submitted.

5.9 ISD also publishes quarterly Hospital Standardised Mortality Ratios (HSMRs) for all hospitals taking part in the SPSP. The HSMR for Aberdeen Royal Infirmary is not significantly different from the Scottish average (Figure 3). However, an aim of the SPSP is to reduce the HSMR by 20% by December 2015, and the HSMR for Aberdeen Royal Infirmary has remained fairly constant (Figure 4).

11 The funnel plot allows comparisons to be made between each NHS board, hospital or unit and the average for Scotland. There are three key lines on the funnel plot. The first is the average for Scotland, which is the horizontal line through the chart. Plotted on either side of the average is a set of curved lines called control limits. The reason these lines are curved (and the limits are wider at the left hand side of the graph) is because the data points plotted at this side of the graph are made up of fewer observations and are therefore subject to greater variability. 30

Figure 3: Hospital Standardised Mortality Ratio (HSMR), for deaths within 30 days of admission to hospital. Data presented by hospital of admission. April–June 2014.

HSMR Funnel Plot; Apr-Jun 2014p

2.00

1.80

1.60

1.40 Aberdeen Royal Infirmary 1.20

1.00

.80

.60 Standardised mortality ratio

.40

.20

.00 0 100 200 300 400 500 600

Predicted deaths

Data source: Information Services Division’s SMR01 database linked with National Records of Scotland death records. Published 18 November 2014.

Figure 4: Hospital Standardised Mortality Ratio (HSMR), for deaths within 30 days of admission to hospital. Data presented for Aberdeen Royal Infirmary. October– December 2007 to April–June 2014.

HSMR Run Chart - Aberdeen Royal Infirmary Oct 2007 - Jun 2014p

smr base1 base2 shift base3 1.00

0.90

0.80

0.70

0.60

0.50 SMR 0.40

0.30

0.20

0.10

0.00

Data source: Information Services Division’s SMR01 database linked with National Records of Scotland death records. Published 18 November 2014.

5.10 Health Protection Scotland produces routine quarterly reports and data for the surveillance programmes it runs for Staphylococcus aureus, Clostridium difficile and surgical site infection, together with associated annual reports. When considering various measures about these healthcare associated infections, the data for NHS Grampian do not differ statistically from the Scottish average (Figures 5 and 6). 31

Figure 5: Rate of Staphylococcus aureus bacteraemia infections. Data presented by NHS board, with NHS Grampian denoted ‘GR’. 1 April 2014–30 June 2014.

Data source: Health Protection Scotland. Quarterly Scottish Staphylococcus aureus bacteraemia surveillance report, 1 April 2014 to 30 June 2014.

Figure 6: Incidence rate of Clostridium difficile infections in patients aged ≥65 years. Data presented by NHS board, with NHS Grampian denoted ‘GR’. 1 April 2014–30 June 2014.

Data source: Health Protection Scotland. Quarterly Surveillance Report on the Surveillance of Clostridium difficile infection in Scotland, 1 April 2014 to 30 June 2014. 32

5.11 Current data-led assessment under the acute adult programme for the SPSP does not indicate that NHS Grampian is performing significantly differently to other NHS boards. According to the programme’s new assessment process, NHS Grampian and primarily Aberdeen Royal Infirmary are on trajectory for all but two elements of the programme. Being on trajectory means that many sustained improvements have been made and that these are being spread throughout the NHS board around the ‘Essentials of Safety’.

5.12 There is an emergency care standard target for NHSScotland for 98% of patients to be treated within 4 hours. Performance against the 4-hour standard has decreased, both at Scotland-level and at Aberdeen Royal Infirmary (Figure 7). This is despite the number of attendances at Aberdeen Royal Infirmary’s emergency department remaining fairly constant in recent years. The recent performance at Aberdeen Royal Infirmary is not markedly different from other similar sized emergency departments.

Figure 7: Percentage of patients treated within 4-Hour Emergency Care Standard. Data presented for Aberdeen Royal Infirmary and Scotland. Data for July 2007– September 2014. Aberdeen Royal Infirmary is denoted by the red line on this chart.

100%

98%

96%

94%

92%

90%

88%

86% 4 hr emergency care standard

84%

82% Jul 07 Jul 08 Jul 09 Jul 10 Jul 11 Jul 12 Jul 13 Jul 14 Jul Oct 07 Apr 08 Oct 08 Apr 09 Oct 09 Apr 10 Oct 10 Apr 11 Oct 11 Apr 12 Oct 12 Apr 13 Oct 13 Apr 14 Jan 08 Jan 08 Jun 09 Jan 09 Jun 10 Jan 10 Jun 11 Jan 11 Jun 12 Jan 12 Jun 13 Jan 13 Jun 14 Jan 14 Jun Mar 08 Mar 09 Mar 10 Mar 11 Mar 12 Mar 13 Mar 14 Feb 08 Feb 09 Feb 10 Feb 11 Feb 12 Feb 13 Feb 14 Feb Nov 07 Nov 07 Dec 08 Nov 08 Dec 09 Nov 09 Dec 10 Nov 10 Dec 11 Nov 11 Dec 12 Nov 12 Dec 13 Nov 13 Dec Aug 08 Aug 08 Sep 11 Aug 11 Sep 14 Aug 14 Sep Aug 07 Aug 07 Sep 09 Aug 09 Sep 10 Aug 10 Sep 12 Aug 12 Sep 13 Aug 13 Sep May 08 May 09 May 10 May 11 May 12 May 13 May 14

Scotland 4 Hour Standard Compliance (Sep-14): 90.4% 4 Hour National Standard: 98.0%

Data source: Information Services Division Scotland. Scotland Monthly Management Report - September 2014

5.13 When considering a range of waiting times measures, the performance of NHS Grampian is below that of NHSScotland and/or deteriorating over time. For example, NHS Grampian’s performance against the treatment time guarantee is below target (which is 100%), with performance below that of NHSScotland as a whole (Figure 8).

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Figure 8: Percentage compliance with Treatment Time Guarantee. Data presented for NHS Grampian and Scotland. October 2012–June 2014.

Performance against TTG for a Inpatient or Day case admission, Completed waits for patients seen (Added to Waiting List from 1st Oct 2012 onwards) Data sourced from ISD Waiting Times Warehouse - Prior to this aggregate returns were supplied by NHS Boards while local systems and the ISD Waiting Times Warehouse were being developed to reflect legislation and revised 100 Waiting Times guidance.

99

98

97 24 December 2012 is the first day where TTG 96 patients could breach i.e. no patients could breach in 95 October or November as this is still within 12 weeks 94 (84 days).

93 Performance Against TTG (%) 92

91

90 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Month ending

NHS Scotland NHS Grampian Source: Figures prior to April 2014 are sourced from aggregate data supplied by NHS Boards while local systems and the ISD Waiting Time Warehouse were being developed to reflect legislation and revised Waiting Time guidance.

Data source: Information Services Division. Waiting Times Warehouse.

Review of patient case notes 5.14 A review of patient case notes was undertaken using the ‘A Matter of Life and Death’ (3x2 matrix tool) developed by the NHS Modernisation Agency. This tool was developed to identify problems with health and care systems rather than examine individual cases, with the aim of improving Hospital Standardised Mortality Rates and the quality of care for all patients. It states:

• “While death is a rare event, it is a useful lens to view the system as it is a clearly defined event, which is accurately recorded and is generally thought to be associated with the quality of health care. Furthermore, those patients who do die in hospital are likely to have accessed a significant section of hospital services and therefore their experience can shed light on a range of system issues. Overall, the objective is to develop a system level perspective of the care received and uncover system defects. We have found that the review demands a mindset to focus on system issues around the quality of care rather than identify individual causal factors that may or may not contribute towards death.” 5.15 A case note review is a tool to help identify areas for improvement and is not designed to be used to make judgements about levels of avoidable harm.

5.16 Two experienced reviewers undertook a review of the case notes of 49 consecutive patients who died at Aberdeen Royal Infirmary. The case notes reviewed related to 49 consecutive deaths within Aberdeen Royal Infirmary from 1 January 2014 to 11 January 2014. For patients identified as being admitted into a ward for treatment, the Global Trigger Tool (GTT) is then applied to the patient journey. The methodology used in this review used the same standardised approach that has been used in other NHS board areas within Scotland as part of the SPSP work to reduce HSMR.

5.17 The case notes of the patients reviewed suggest that reasonable care is being provided. Generally, the patients reviewed were elderly and frail with significant co- morbidities.

5.18 It is clear that there are areas where further improvements could be made to the 34

quality of care provision. The reviewers are of the opinion that there are likely to be similar areas for improvement within other Scottish hospitals.

5.19 The review of Aberdeen Royal Infirmary case notes found the following:

• average age at death was 79 years (median 80, interquartile range (IQR) or middle 50% between 68-88, range 53-109) • median length of stay was nine days (range 1-41) • seven patients reviewed were in hospital for only one day before they died • 11 patients were admitted for more than one month, and • the majority of patients were admitted as part of general medicine and geriatric medicine acute receiving.

Patient case note review conclusions 5.20 The reviewers identified the following areas of good practice.

• There was good reference to the Scottish Early Warning Score (SEWS) in nursing notes (a guide used by staff to quickly determine the degree of illness of a patient). The SEWS score was often recorded in the medical notes both at the time a doctor was called to review a patient and also at the time of regular ward rounds. Both medical and nursing staff paid attention to SEWS scores. • Patients were seen by experienced trainees and consultants early in their admission. • Patients were reviewed by consultants, and on a number of occasions, there was evidence of good interaction between consultants from different specialties, each contributing to the care of a patient. • Clear plans were made and documented. • Medical trainees had good access to consultant support. • When a patient was deteriorating, there was communication with the patient and relatives and this was clearly recorded in the medical records. Families were involved in decision-making. • An orthopaedic morning trauma meeting checklist was used to make sure that important points for preoperative preparation were completed. • In care of the elderly, staff used a ward round template note in the format of daily goals, and similar documentation was used in gastroenterology.

5.21 The reviewers identified the following areas (detailed below) that should be followed up and considered by NHS Grampian to bring about improvements:

• SEWS scoring • care to patients with sepsis • anticipatory care planning • patient flow, and • communication.

35

a) SEWS scoring 5.22 The policy for responding to elevated SEWS scores is unclear. For example, when and who to call for support when SEWS scores are high or increasing. In one case note that was reviewed, there was evidence of a document describing such a policy, but this was from an admission five years previously. No similar document was seen for current admissions. The reliability of SEWS scoring could also be improved.

5.23 It is important in addressing this issue to separate writing a document (a policy) from making change happen at the frontline (using improvement science).

b) Care to patients with sepsis 5.24 Sepsis is an extremely serious blood borne infection. Once sepsis is identified, antibiotics should be given within 60 minutes.

5.25 The case note review identified patients who received antibiotics within 60 minutes and other patients who received antibiotics later than 60 minutes after sepsis identification, suggesting variability.

5.26 There is a sepsis prompt sticker attached to many admission documents, this allows checking for systemic inflammatory response criteria and prompts the user to think about sepsis. It was rarely filled out.

5.27 Sepsis is a focus on the current SPSP work programme. Support from individuals with improvement skills and monitoring needs to be given to this important quality improvement work so that progress can be made. c) Anticipatory care planning 5.28 Several of the case notes reviewed involved elderly patients with severe co-existing health problems, who had a number of hospital admissions in the previous 12 months, and many were admitted from nursing homes. These individuals were in the last phase of life. The reviewers did not see any mention of pre-existing anticipatory care planning in this group of patients. This may have simply been due to the sample of case records that were reviewed.

d) Patient flow 5.29 There were examples of delay in transfers to other units due to unavailable beds. There were also examples of patients being held in a receiving ward for six to eight hours, then moved on (often late into the evening) to another ward where they were re-clerked. This highlights a patient flow issue and also repetition of clerking work already done.

e) Communication 5.30 There were examples of delay to treatment for patients. The provision of care to a patient involves multiple professionals and shift changes. Communication between healthcare professionals may benefit from standardisation, using a recognised tool such as the Situation, Background, Assessment and Recommendations (SBAR) tool.

5.31 In 3 out of 49 case notes reviewed, there was no evidence of a discharge summary.

36

Patient outcome conclusions 5.32 When viewed as a whole, the data do not highlight consistent or widespread concerns about the quality of patient care at Aberdeen Royal Infirmary. Aberdeen Royal Infirmary is not significantly different from the Scottish average for a range of established measures about the quality and safety of patient care. However, the data for some measures, for example, specific aspects of operational performance, do highlight areas of concern. It should be noted that, when considering such a wide range of data, it might reasonably be expected that data drawing attention to potential areas of concern would be identified for any NHS board.

5.33 It is recognised that high level data are not always sensitive to the underlying risks, and are retrospective. The Berwick report12 highlighted the danger of relying on aggregated data and the importance of understanding what is happening ‘on the frontline’. We found a range of issues that considerably reduce quality and safety, and that are mitigated through the actions of talented and dedicated frontline staff. The inspections carried out in departments during the unannounced Older People in Acute Hospitals inspection identified sufficient incidents to raise concern about the system of care. Relying on individual dedication to compensate for poor systems is inappropriate and carries unacceptable risk.

5.34 We expect NHS Grampian to develop an action plan to address the following recommendations.

Patient outcome recommendations

1 NHS Grampian executive team with senior staff in emergency department and other key stakeholders should develop a plan for a sustainable emergency department service that provides patients with safe, effective and person-centred care.

The plan should:

● be sustainable in terms of ability to recruit and retain medical staff

● recognise the reality that the emergency department requires senior input from specialist emergency medicine medical staff

● recognise that senior trainees will continue to be in short supply

● recognise that staff from other specialties whilst valuable in their own roles cannot be used to substitute for the expertise of senior emergency medicine medical staff

● recognise that senior trainees can make a valuable service contribution, but are also entitled to expect support and training that adheres to the appropriate GMC mandatory regulatory standards13

● explore the potentially valuable contribution that can be made by non-medical staff, such as advanced nurse practitioners, while recognising that senior doctors leading care will always be required, and

● be approved and progress monitored by the Board.

12 Berwick review into patient safety (August 2013) 13 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf 37

2 NHS Grampian executive team should work with senior clinical colleagues and local managers to review the management of unscheduled care across the hospital, with emphasis on the effective transfer of emergency patients from the emergency department to inpatient areas.

This will mean:

● recognising the complexity of the systems involved

● developing an effective system of flow of patients through the hospital that will improve patient care, reduce wastage of clinical time, and improve the quality of care for patients

● using visible leadership to ensure that all stakeholders involved sign up to agreed and defined protocols, and then work in line with the protocols, and

● working closely with health and social care partnerships to support effective discharge planning.

3 NHS Grampian should ensure that the escalation policy for patients whose Scottish Early Warning System score is high is understood and implemented by all relevant clinical staff.

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6 Patient experience data

6.1 We reviewed data and evidence to assess the quality of the patient experience. We did this through undertaking a review of the following:

• Scottish Inpatient Experience Survey • data provided by NHS Grampian • NHS Grampian approach to listening to patient experience, and • direct patient and carer feedback.

Introduction 6.2 There has been an increasing focus in NHSScotland on the need for complaints and feedback to be encouraged and valued as a vital source of intelligence about what is working well, or not working well, in NHS services. Genuinely listening to people and responding to their concerns is critical for improving the quality and safety of care and ensuring that services are person-centred. This also supports the identification of necessary improvements.

6.3 Complaints tend to happen after a service has been provided or in relation to failure to provide a service, and there is much to be learned from the experiences captured through complaints. There is also much to be learned from proactively gathering views from patients and carers at the time a service is provided, whether those views reflect positive or negative experiences.

6.4 In Scotland, there have been a number of developments that have placed greater emphasis on complaints and feedback including: the Patient Rights (Scotland) Act 2011; the Scottish Government guidance: ‘Can I help you? Guidance for handling and learning from feedback, comments, concerns or complaints about NHS health care services’ (April 2012); and the Listening and Learning report published in April 2014 by the Scottish Health Council.

6.5 Before beginning this review, Healthcare Improvement Scotland had received information from the Patient Action Co-ordination Team (PACT), a local patient action group, and from individual complainants that was extremely critical of NHS Grampian’s approach and attitude to handling complaints. They informed us that there was a culture of denial and dismissal in the way NHS Grampian manages complaints. Given the importance of complaints as a key indicator of service quality, we were keen to explore this further.

Scottish Inpatient Experience Survey 6.6 The fourth Scottish Inpatient Experience Survey was sent by Scottish Government, in January 2014, to a random sample of people aged 16 years or older who had an overnight hospital stay between April and September 2013. The national and local results were published on 26 August 2014.

6.7 The survey asked patients about seven aspects of care: admission to hospital; the hospital and ward; care and treatment; operations and procedures; staff; leaving hospital; and after leaving hospital.

6.8 The survey indicated that, in the majority of areas, the proportions of patients at 39

Aberdeen Royal Infirmary who reported a positive score were not significantly different compared to the Scottish average. The overall rating of care or support services after leaving hospital was the only area where a lower percentage of patients gave a positive score for Aberdeen Royal Infirmary compared to the Scottish average.

6.9 Some specific questions from the 2014 survey are pertinent to this review. For the questions on whether ‘Patients felt there were enough nurses on duty’ and on ‘How patients felt about the time they waited to be admitted to hospital after they were referred’, Aberdeen Royal Infirmary patients were similarly positive to other patients in Scotland. The question on ‘Overall rating of hospital admission process’ revealed that Aberdeen Royal Infirmary patients were significantly more positive than the Scottish average.

Data provided by NHS Grampian 6.10 Collecting and acting upon data on patient experience is of critical importance, yet health services generally face many challenges in this regard. NHS Grampian provided data on both patient and staff experience, collected from the national Person- Centred Health and Care Collaborative. NHS Grampian reports that it has collected real-time data on patient and staff experience since July 2013, and this has involved more than 50 clinical areas to date, primarily from secondary care. Of the patients which took part in this exercise, 96% rated the service they received as being good, very good, or excellent (Figure 9). However, it should be recognised that experience reported by patients at point of care is often more positive than that reported after a period of reflection.

Figure 9: Patient Service Score. Data presented for NHS Grampian. Data collected since July 2013.

Patient Service Score (N=865) 50% 41.8% 40% 36.4%

30%

20% 17.5%

10% 3.2% percentage of respondents 1.0% 0.0% 0% Excellent Very Good Good Fair Poor Very Poor How would you rate the service?

Data source: NHS Grampian

NHS Grampian approach to listening to patient experience 6.11 In common with other NHS boards, NHS Grampian receives feedback in a variety of ways including: feedback cards; letters and emails; telephone calls; social media such as Twitter and Facebook; and the national Patient Opinion website.

6.12 There is much to be learned from proactively gathering views from patients and 40

carers at the time a service is provided. We heard some good examples of how NHS Grampian is gathering real-time patient experience data and using this to make immediate improvements to services. Real-time patient surveys have been used and sessions have been held with some ward staff to identify ‘always events’ and to assist in making improvements to patient care. Staff have undertaken pilot initiatives using iPads to gather patient experience and using the electronic information management system, Datix, to speed up collection and turnaround of data. ‘Improvement trees’ have been introduced involving the use of wall stickers to gather patient, family and visitor feedback.

6.13 This demonstrates that progress is being made in gathering real-time patient experience at the point of care in a proactive way. However, we noted that this is not yet happening reliably and consistently across all services. The team also identified a lack of a fully joined-up approach between this activity, which sits in the quality, governance and risk unit, and complaints handling, which sits in the corporate communication and Board secretariat.

Direct patient and carer feedback 6.14 A vital element of the short-life review was to ensure that the voices of patients, carers and members of the public in Grampian were heard. Members of the public were an integral part of the review team, bringing their own experience and expertise. We had four public partners on the review team who provided a public perspective. The public partners spoke with a number of inpatients, carers and visitors and observed levels of care on wards on the visits to Aberdeen Royal Infirmary. We extend our grateful appreciation to our public partners for providing a valuable public perspective throughout the review.

6.15 We considered a range of existing data on patient and carer experience and we set up a variety of mechanisms to obtain direct feedback from patients, carers and public partners.

6.16 The Scottish Health Council, which is part of Healthcare Improvement Scotland, works to improve patient and public participation in NHSScotland. During the weeks beginning 4 August and 1 September 2014, the Scottish Health Council obtained feedback from patients and carers who had used the services of Aberdeen Royal Infirmary during the past year. Local staff carried out focus groups in Orkney, Shetland, Aberdeenshire and Aberdeen City. They also spoke with patients and carers within the Aberdeen Royal Infirmary concourse and rotunda area, received phone calls and emails, and conducted one to one interviews. A survey and a dedicated phone line with the Citizens Advice Bureau were also available to members of the public during the month of August.

6.17 A total of 362 patient or carer experiences were obtained during the review period. There was a diverse range of patients and carers engaged in the feedback process including representation from older people, young people, people with disabilities and people from ethnic minority communities.

6.18 Six focus groups were held during August and September 2014, through which a total of 35 individuals attended. Thirty-eight inpatients completed questionnaires and 289 individuals gave feedback through interviews, telephone calls and written correspondence. Before each focus group and interview session, a comprehensive introduction and outline of the purpose of the exercise was given. This included 41

advising patients and carers of the anonymity involved in providing information. Throughout the engagement process, a high number of individuals reported positive experiences of care with the service provided at Aberdeen Royal Infirmary. They indicated they valued the staff and quality of care that they experienced. In particular, the professionalism, working attitudes and care provided by all healthcare staff. Many of the individuals who did not provide direct comments stated that there were no areas they would recommend for improvement.

6.19 Patients and carers provided feedback on their experience of care and suggested key areas where improvements could be made. Feedback focused primarily on care of the elderly, emergency medicine, general surgery, and obstetrics and gynaecology areas. The information provided to patients and carers made it clear that we could not respond directly to issues raised or to investigate individual complaints. Instead the purpose of this exercise was to identify any key themes (both positive and negative) from the feedback to inform the focus of the review and the subsequent findings and recommendations of this report. The most common positive experiences included good communication between staff and patients, quality of care and friendly staff. Suggested areas for improvement included staff shortages and discharge procedures.

Patient experience data conclusions 6.20 We concluded that through the reviewed national and locally collected data, patients and carers reported, on the whole, positive experiences of the care they received whilst at Aberdeen Royal Infirmary. This was supported through our work with the Scottish Health Council and through patient and carer conversations with public partners during the visits.

Patient experience data recommendation

4 NHS Grampian should continue to build on collecting real-time patient experience data ensuring this is done reliably and consistently across the services.

This work should include the following:

● continue to use patient feedback as a resource for continuous improvement

● ensure that collated patient feedback is passed on to staff to encourage improvement, and

● monitor progress so that agreed improvements are initiated within a reasonable timescale.

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7 Complaints management

7.1 We undertook a review of the handling of complaints to assess how NHS Grampian meets the expectations of legislation and related good practice guidance in ‘Can I Help You? Guidance for handling and learning from feedback, comments, concerns or complaints about NHS health care services’ (Scottish Government, 2012). We did this through reviewing the following:

• NHS Grampian’s processes for handling complaints • complaints data and themes • review team audit of complaints • organisational culture • process and procedure • accessibility • quality of handling responses • learning from complaints, and • complaints handling performance.

7.2 An internal audit of NHS Grampian’s complaints process was carried out by PricewaterhouseCoopers (PwC) at NHS Grampian’s request in 2013–2014. The audit findings were presented to NHS Grampian in June 2014 and considered by the audit committee. Some steps have been taken by NHS Grampian to address the issues raised in the audit report, including increasing staff capacity within the feedback service. However, there are still issues to be addressed.

NHS Grampian’s processes for handling complaints 7.3 NHS Grampian’s feedback service handles all feedback, comments, concerns and complaints. It covers all NHS Grampian services except those provided by independent practitioners such as GPs, dentists and opticians. The feedback service was redesigned in early 2012. The redesign shifted responsibility for investigating and responding to complaints within the required timescales from the central team to individual clinical services. This was to encourage greater ownership of complaints at service level. The feedback service retained responsibility for central administration and performance reporting of complaints and feedback, as well as providing advice, support and training to staff.

7.4 NHS Grampian reported that it uses the Datix system to record all feedback and complaints. However, our review of complaints management did not provide assurance that this is done consistently and thoroughly.

7.5 Processes and procedures for handling complaints were provided to us in a number of separate documents. These processes and procedures were being revised by NHS Grampian at the time of this review.

7.6 All complaints responses are currently signed by the chief executive or another executive team member in the absence of the chief executive.

7.7 A number of performance reports are produced including: 43

• a twice yearly ‘Joint Incident, Feedback and Claims Report’ which is considered by NHS Grampian’s clinical governance committee and its patient focus and public involvement committee. This includes information on complaints reviewed by the Scottish Public Services Ombudsman (SPSO). • a monthly ‘highs and cats’ report on high and catastrophic risks, incidents and complaints, including cases considered by the SPSO, is considered at a meeting involving senior staff. This includes the deputy chief executive, director of corporate communications and Board secretariat, director of nursing and quality, director of workforce, feedback service manager, risk management advisor and nurse consultant for patient experience. Complaints trends, new complaints themes, complaints severity scoring, late complaints and complaints performance or situation reports are also considered at this meeting, and • reports to the Board such as the ‘Stakeholder Engagement’ report considered by the Board on 7 February 2014.

Complaints data and themes 7.8 ISD routinely publishes data on complaints for all NHS boards.

7.9 The number of complaints received by NHS Grampian has increased in each of the last three reporting periods (2011–2012, 2012–2013, 2013–2014). The increase in number of complaints is similar in other NHS boards across Scotland. There does not appear to be an abnormal number of complaints for NHS Grampian in respect of its size.

7.10 In 2013–2014, NHS Grampian had the lowest performance in acknowledging complaints within three days, at 68% compared to a national average of 94%.

7.11 In 2013–2014, NHS Grampian had the lowest performance in responding to complaints within 20 days, at 33% compared to a national average of 66%. NHS Grampian had a median response time of 25 days compared to the national figure of 18 days.

7.12 Evidence provided by NHS Grampian indicated that Aberdeen Royal Infirmary’s top three complaints themes for 2013–2014 were clinical treatment; attitude and behaviour; and date for appointment. These themes are similar to those of other NHS boards.

7.13 In October 2014, the SPSO wrote to NHS Grampian providing statistics about complaints to the SPSO in 2013–2014. The number of complaints received by the SPSO does not appear to be markedly high for NHS Grampian compared to the rest of NHSScotland. Specifically, 6% of all health sector complaints were about NHS Grampian. This is less than the percentage (11%) of the Scottish population who are resident in this region.

7.14 The profile of complaints to the SPSO about NHS Grampian was similar to that for the health sector as a whole. Specifically, 66% of complaints were about clinical treatment or diagnosis. The next three most frequent categories were: communication/staff attitude/dignity/confidentiality (9%); appointments/admissions (delay, cancellations, waiting lists) (5%); and policy/administration (4.%).

7.15 The level of NHS Grampian complaints that are sent to the SPSO prematurely 44

(referred before the local process was complete) and the proportion that are upheld were numerically higher than the health sector average in 2012–201314 and 2013–201415 (statistical tests have not been carried out to ascertain whether these differences are significant). A consistently high level of premature complaints tends to suggest people may be confused, lost or frustrated with the local complaints handling process. A consistently high level of complaints upheld by the SPSO may suggest that the local decision-makers (complaints handlers or senior managers) may not be making the right decisions in terms of their conclusions or responses.

Figure 10: Complaints sent to the Scottish Public Services Ombudsman prematurely: complaints upheld by the Scottish Public Services Ombudsman. Category NHS Grampian Health sector average Complaint sent to SPSO prematurely 43.8% 29.7% (before local process was complete) 2012–2013 Complaint sent to SPSO prematurely 40.8% 26.4% (before local process was complete) 2013-2014 Upheld rate (SPSO agree fully or partly with 64.7% 51.9% the complaint) 2012-2013 Upheld rate (SPSO agree fully or partly with 66.7% 55.4% the complaint) 2013-2014

Review team audit of complaints 7.16 To understand NHS Grampian’s approach to complaints, we considered the following:

• various papers received from NHS Grampian including the June 2014 PwC internal audit report • 32 complaints records and 20 pieces of feedback, comments, concerns and compliments relating to Aberdeen Royal Infirmary. We randomly selected complaints from a sample of 50 consecutive complaints dating from 1 January 2014. Our focus was on the quality of complaints handling rather than on the substance of the complaints and related responses, and • information obtained through interviews with staff in NHS Grampian, including some who have particular roles relating to complaints and feedback.

7.17 Our findings are set out below under six headings informed by a draft framework developed by the SPSO:

• organisational culture • process and procedure • accessibility • quality of handling responses

14 Annual letter 2012–13 from the Scottish Public Services Ombudsman to NHS Grampian http://www.spso.org.uk/sites/spso/files/communications_material/statistics/2012-13/Grampian.pdf 15 Annual letter 2013–14 from the Scottish Public Services Ombudsman to NHS Grampian http://www.spso.org.uk/sites/spso/files/communications_material/statistics/2013- 14/Annual_Letters/Health/GrampianSPSOLetter201314.pdf 45

• learning from complaints, and • complaints handling performance. a) Organisational culture 7.18 NHS Grampian’s ‘Handling and Learning from Feedback Annual Report 2013/14’ opens by stating: “NHS Grampian values all feedback and is committed to ensuring that the information and learning gathered from all our feedback systems informs the aspiration of continuous improvement and the further development of a person centred approach to planning.” The importance of listening to and engaging with patients, families and carers is also a key part of NHS Grampian’s organisational values – “caring, listening, improving”. Each Board meeting now incorporates a ‘patient story’.

7.19 Whilst NHS Grampian clearly recognises the importance of listening to people using its services and acting on what they say, this commitment is not being fully delivered in practice. The PwC internal audit report gives the complaints process an overall classification of ‘high risk’. It highlights a number of failures to comply consistently with expectations in legislation and guidance, such as time limits for complaints responses and lack of recording of lessons learnt. It also highlights weaknesses and deficiencies in NHS Grampian’s systems and processes, for example a lack of assessment of the severity of complaints scoring and poor working practices regarding re-opened cases. Our review confirmed the key findings in the PwC report and identified additional issues which are outlined below.

7.20 The PwC report states: “Approximately 18 months ago there was a significant redesign of the feedback team, which resulted in a significant reduction to the size of the core team and a consequent transfer of responsibility to sectors, with no reflection of the capacity required to deliver this model.” From our review, it appears that this redesign was poorly handled and implemented and had an adverse impact on the complaints handling performance in the acute sector and on some of the key staff who were affected by the change. A number of risks were identified at the outset in relation to the change, and there appears to have been insufficient management of these risks and lack of timely associated remedial action.

7.21 Our interviews with staff led us to conclude that leadership was not visible at senior and executive level. We also had serious concerns regarding accountability and clarity of responsibility for complaints management. The responsibility sits with corporate communications and Board secretariat which has responsibility for the feedback service, whilst the responsibility for investigation and drafting of responses sits in each clinical service. Each area of responsibility has different lines of accountability. Members of staff, including those at a senior level, were generally uncertain about who was providing leadership on complaints.

7.22 When responsibility for responding to complaints shifted from the central team to each clinical service, a number of training needs were identified such as investigation skills and letter writing. However, this training was not provided to support the change, despite the identification of a part-time training post, as the post-holder did not have capacity to deliver the training due to other demands. This may have led to some of the variation across the services that we identified in terms of levels of confidence and knowledge about complaints. NHS Grampian has advised us that steps are now being taken to roll out an e-learning training module on complaints 46

from the end of September 2014. We were informed that the roll-out had been delayed due to compatibility issues with NHS Grampian’s systems, and the need to supplement the training with support from staff in the feedback service.

7.23 We noted that the NHS Grampian ‘Handling and Learning from Feedback Annual Report 2013/14’ and the ‘NHS Grampian Stakeholder Engagement Framework’ refer to the training role “introduced within the feedback team in 2013” and to e-learning modules without mention of capacity issues and delays that have been experienced in delivering training and e-learning, and which were shared with us. The reports produced by NHS Grampian, therefore, suggest a more favourable position than would appear to be justified in reality.

7.24 We heard that complaints are viewed as “an irritation” in some parts of the acute services, rather than being welcomed as valuable sources of intelligence for improvement. We heard that there has been a significant backlog of overdue complaints leading in some cases to a focus on “chasing people” to allow responses to be issued.

7.25 Our review of complaints also found that some responses appeared to be extracts from statements provided by staff, rather than a high quality response. Therefore, when responses are completed, it appears there is a culture of ‘cut and paste’ from the statements provided by staff rather than a focus on ensuring a high quality, coherent and meaningful response.

7.26 We were informed that NHS Grampian has a robust process for quality assuring complaints and that these are all signed off by the chief executive or another executive team member in the absence of the chief executive. Through discussion, it became evident that this quality assurance process relates to checking the spelling, grammar and tone of responses. There is an absence of a clear and consistent system for quality assuring the clinical aspects of the responses. There is no one with clinical knowledge who has oversight of all complaints responses for clinical issues. We had significant concerns that there was no evidence of any independent, objective and robust system for the review of the clinical aspects of draft complaints responses. b) Process and procedure 7.27 The PwC report identifies a need to consolidate complaints handling procedures into one document. We saw at least 16 different documents, each picking up separate aspects of the complaints process or procedures. These processes and procedures were being revised at the time of our review to address this issue.

7.28 The PwC report highlighted that the severity rating for complaints is assigned by the feedback service and that a number of complaints leads were unaware of their responsibility to check this and to change the rating if it was incorrect. Our review identified several complaints where it appeared to us that the rationale for the severity rating was unclear and that the rating had been underestimated. For example, one complaint from a bereaved relative about end of life care was categorised as ‘minor’.

7.29 The PwC report referred to inconsistencies in practice around removing the closed date in re-opened cases. Our review identified a number of cases where a complaint appeared to have been closed on the system when a response letter was sent, and the dates were not subsequently changed when the complainant came back with 47

further issues, which sometimes took months to resolve. Complaints would then not show as ‘live’ on the system and the actual time taken to resolve the complaint would be inaccurately recorded and not reflect the true length of the process. The clinical governance committee16 has been advised that the number of re-opened cases has been going down. However, given the inconsistencies in recording practice that both PwC and this review have identified, it appears that the data supporting this conclusion may be flawed.

7.30 We also heard that the organisational change process for complaints management resulted in ‘confusion’ and ‘chaos’ in the service around the process and requirements. We were advised that this has been compounded by subsequent changes to sign-off procedures which have been poorly communicated to staff.

7.31 There is an inconsistent approach to recording whether a complaint is ‘fully upheld’, ‘partially upheld’ or ‘not upheld’. Sometimes the complaints leads record this and sometimes the feedback service. There is no independent quality check on this and at times the rationale for how it was recorded was unclear to us. Figures are reported to the clinical governance committee and our review would suggest that more needs to be done to ensure the robustness and reliability of the data. This was not identified in the PwC report.

7.32 We were informed that there is a separate procedure for handling complaints received through MPs and MSPs whereby these are dealt with by the chief executive’s office to ensure they are prioritised and timescales met. This raises issues of equity and risks creating a perception that complaints made through elected representatives are given greater priority than complaints received directly from patients and their carers. c) Accessibility 7.33 Information about the complaints process is available on NHS Grampian’s website.

7.34 Feedback cards are available across acute services so that people to give feedback and tick a box to indicate whether it is a complaint. Many of the complaints we saw were received through this route, but we were told that the cards are not consistently available across all services.

7.35 People can complain by telephone, although they are encouraged to put their complaints in writing or to get support from the Patient Advice and Support Service (PASS) first. PASS is an independent service delivered by the Scottish Citizens Advice Bureau Service. It provides free, confidential information, advice and support to anyone who uses the NHS in Scotland.

7.36 NHS Grampian also receives feedback and complaints through other routes, such as social media, email and the independent Patient Opinion website. d) Quality of handling responses 7.37 We considered 32 complaints records. Whilst some of the responses we saw were in line with good practice, some were not. Some of the responses were defensive and did not demonstrate an apology or a willingness to learn. There was also a lack of evidence of meaningful action taking place in response to complaints.

16 Clinical Governance Committee: Joint Incident, Feedback and Claims Report February 2014 48

7.38 It would be good practice, particularly in sensitive or complex complaints, to make personal contact with the complainant either through a phone call or meeting. This would help to understand the issues and to identify what the patient would want as an outcome from the complaint. Whilst there were some examples of this happening, there was no systematic and reliable approach to this. We saw examples of complaints where early contact with the complainant could have prevented their subsequent dissatisfaction. For example, the complainant being dissatisfied that the response did not address the main points. We have been advised that NHS Grampian is now moving to a more direct personal contact with complainants at the start of the process to try to address these issues.

7.39 Some of the responses we saw had extensive use of clinical jargon and acronyms, and some appeared to include unnecessary or irrelevant detail. These responses were not clear and easy to understand, as required by the guidance.

7.40 Guidance requires that responses to complainants should “indicate that, if they are not satisfied with the outcome, they may seek a review by the SPSO – with details of how to contact SPSO included.” We saw a standard practice of advising complainants about the SPSO in the initial acknowledgement letter and not in the actual response letter. This is not in line with guidance. There would appear to be little value in advising people about going to the SPSO if they are dissatisfied with the response, before they have actually received a response. This could also lead to premature complaints being sent to the SPSO. We noted that where a complaint had been re- opened and a further response sent to the complainant, the SPSO details were included at that stage.

7.41 Staff in the feedback service send reminders to senior managers and clinicians in the service to ensure timely responses to complaints. However, this system does not always appear to have been effective. One positive development has been the involvement of a unit operational manager since March 2014 who has been tasked with addressing the outstanding complaints in acute services. This individual is in a more senior position to staff in the feedback service and has knowledge of the service staff. This has been helpful in ensuring appropriate priority is given to responding to complaints in a more person-centred and timely manner. This has made a significant impact in a relatively short space of time and examples were given of improvements that have been made to services as a result. However, it was unclear whether funding for this post would continue. e) Learning from complaints 7.42 Datix is an information system for capturing and monitoring risks and it enables a connection to be made between the recording of a complaint and a related adverse incident. It is essential that the system for connecting these is consistent and reliable so that all relevant intelligence is shared. Healthcare Improvement Scotland noted in its review of the management of adverse events across NHS Grampian in March 201317, the innovative use and plans for an integrated Datix system for complaints, incidents and risks and highlighted then the need to ensure that this information is consistently stored in Datix across the organisation.

17http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/adverse_events_rev iews/nhs_grampian_mar_2013.aspx

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7.43 The PwC report states: “NHS Grampian cannot consistently evidence that lessons are being learned from complaints, or other forms of feedback. Datix has functionality to record lessons learned and assign actions to allow accountability and monitoring of the progress in addressing these. This functionality is not routinely used.” This was confirmed by our review of complaints and the assessment of adverse events as part of this short-life review. This is a significant concern and presents a challenge for NHS Grampian in demonstrating that it is compliant with the legislation and guidance. It also represents missed opportunities for the service to improve quality, safety and to provide a genuinely person-centred response.

7.44 We were advised that staff have been struggling with capacity to respond to complaints within the timescales and this has been made worse by the backlog. This has led to little time and priority for ensuring lessons are identified and appropriately shared.

7.45 Key themes are reported at a high level, but it is not clear what is being done to tackle all of these issues across acute services. Whilst there are some examples of improvements being made in response to complaints provided in the ‘Handling and Learning from Feedback Annual Report 2013/14’, we heard that there is no clear system for ensuring that this happens reliably and consistently across acute services.

7.46 We were informed that operational managers have not been provided with the service-specific data they need to make improvements. f) Complaints handling performance 7.47 Compliance with response times in NHS Grampian, and in acute services in particular, is poor. Only 31% of complaints within the acute sector were responded to within the 20 working day target between January and December 2013. Fields in Datix which can capture reasons for response times being greater than 20 working days or 40 working days were not completed.

7.48 It is difficult to ascertain a true picture of average response times given that the figures for re-opened complaints may not be reliable.

7.49 Whilst reports are regularly provided to governance committees, managers in the service have not routinely received reports that would support them to understand themes and issues in their own areas of responsibility.

7.50 Whilst NHS Grampian does not proactively seek customer feedback on how complaints have been handled, the number of complaints which are re-opened due to complainant dissatisfaction with responses received may provide some indication of this. However, we have identified that the data for re-opened cases may not be reliable. We noted that the number of complaints to the SPSO that included concerns about complaints handling was slightly above sector average for NHS Grampian18.

7.51 We saw little evidence of improvements routinely being made in response to how complaints were handled, following monitoring. However, additional resources provided to the feedback team more recently should support addressing some of the key issues which were highlighted in the PwC audit report.

18 Annual letter 2012–13 from the Scottish Public Services Ombudsman to NHS Grampian http://www.spso.org.uk/sites/spso/files/communications_material/statistics/2012-13/Grampian.pdf 50

Complaints management conclusions 7.52 We concluded that NHS Grampian is clear in its stated commitment to feedback and ensuring that information and learning gathered from complaints is used for continuous improvement. However, we identified substantial weaknesses in the leadership and management of systems and processes for the handling of complaints.

7.53 The ‘Listening and Learning: how feedback, comments, concerns and complaints can improve NHS services in Scotland’ report published by the Scottish Health Council in April 2014 sets out a range of recommendations for all NHS boards in Scotland to improve their practices around complaints and feedback. NHS Grampian should take full account of these in improving its own systems and practices, and seek to learn from approaches taken by other NHS boards where appropriate.

7.54 We expect NHS Grampian to develop an action plan to address the following recommendation.

Complaints management recommendation

5 NHS Grampian should improve the way it investigates, responds to and learns from complaints.

These improvements should include:

● clear, unambiguous and effective leadership on complaints at senior/executive level and ensure that appropriate priority is given to continuously improving the approach of listening to and learning from complaints consistently across NHS Grampian’s acute services

● clarity and consistency in decision-making about whether a complaint has been upheld or not

● a more robust approach to the quality assurance of complaints management

● more face to face meetings between staff, patients and relatives to resolve complex complaints

● confirmation that clinical aspects of responses address the questions posed and that responses are clear and empathetic, and

● a way in which to build on the positive impact of a nominated post in acute services who can liaise with the feedback service and managers or clinicians to support good practice in the handling of complaints and learning from these.

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8 Leadership and culture

8.1 The terms of reference for this review emphasised the importance of understanding the leadership and culture in Aberdeen Royal Infirmary. Our findings are contained below under the following headings:

• engagement between clinicians and senior management • inappropriate behaviours and leadership, and • relationships between operational services, clinicians and strategic planning.

Engagement between clinicians and senior management 8.2 A major concern identified in the initial validation visit was the fracture between the senior leadership and a strong and influential community in NHS Grampian’s acute services at Aberdeen Royal Infirmary. The evidence gathered in the validation visit pointed to a serious breakdown in relationships between senior management and clinicians in Aberdeen Royal Infirmary.

8.3 We concentrated our immediate efforts on establishing the overall culture of clinical engagement, particularly between medical staff and management on the Aberdeen Royal Infirmary site. We used the Medical Engagement Scale survey as one tool to help determine the level of clinical engagement.

8.4 The Medical Engagement Scale survey has nine domains. Taken as a whole, Aberdeen Royal Infirmary was in the lowest 20% of hospitals for three of these and the lowest 40% for the other six.

8.5 The survey results when compared with the other 70 NHS trusts and NHS boards in the database indicated that:

• although there were pockets of better (middle range) engagement at a divisional level, the results were more polarised at specialty level with some specialties being entirely in the lowest range and others in the highest • trainees accounted for 29% of responses and consultants for 60%. It would appear that grade is not the defining factor, although consultants exhibit lower levels of relative medical engagement than others, and • analysis of results by length of service shows a low level of relative medical engagement regardless of length of service, although engagement is high in the first year of service and high again between 10 and 15 years of service. It is likely that medical staff with longer service could be significant ‘influencers’ (whether formal or informal) within the organisation.

8.6 Figure 11 highlights Aberdeen Royal Infirmary’s overall results across the nine domains compared to other NHS organisations.

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Figure 11: Overall Medical Engagement Scale results compared to other NHS organisations. In the lowest 20% of organisations In the second lowest range of organisations • Having a purpose and direction • Working in a collaborative culture • Participation in decision-making • Climate for positive learning and change • Appraisal and rewards effectively • Good inter-personal relationships aligned • Being valued or empowered • Development orientation • Work satisfaction

8.7 Figure 12 below shows the Aberdeen Royal Infirmary specialties that were in the highest and lowest ranges of medical engagement.

Figure 12: Specialties within the highest and lowest ranges of medical engagement. In the lowest 20% of organisations for In the highest 20% of organisations for all scales all scales • Cardiology • Acute Geriatric • Emergency Medicine • Neurosurgery and Neurosciences • General Internal Medicine • Gastroenterology • General Surgery • Gynaecology • Plastics • Trauma and Orthopaedics

8.8 In summary, the survey indicates that Aberdeen Royal Infirmary “has a low proportion of highly engaged medical staff and a high proportion of very poorly engaged medical staff. Such a result gives cause for concern and suggests that any interventions to address the situation need to be fundamental (structural and cultural) rather than examining particular processes or functions.”19

8.9 More broadly, we found there was a climate of mistrust between clinicians and higher levels of management in several specialties. This mistrust was particularly apparent in general surgery and in emergency medicine. Consultants with designated management roles reported better engagement than those without such roles. However, it was clear that many consultants were distrustful of, and un-cooperative with, senior management.

8.10 We heard repeated instances of a lack of engagement of clinicians in management decisions. In some cases, clinicians said that they had not been consulted or even informed, in others they reported that their concerns had been ignored, and in other cases they had declined to co-operate.

8.11 We were conscious that, given changes in healthcare, there is an increasing emphasis on multidisciplinary working within teams. Therefore, we did not restrict ourselves to reviewing medical and managerial relationships. Box 1 below lists example comments made by a number of staff we spoke with, concerning leadership and engagement with staff.

19 Medical Engagement Scale survey report (August 2014) 53

Box 1 In the emergency department, senior medical management were aware that some consultants were disrespectful to colleagues and spent time in their offices rather than leading the team, but failed to take effective action. Clinicians have a high level of mistrust in the management hierarchy, including the medical management. In this department, we could find no demonstrable support for clinical leaders at lower levels from more senior managers, and the absence of a leadership strategy or organisational values that bound the organisation together.

We noted in various minutes of advisory committee meetings there was extensive reference to difficult issues and poor working relationships, which sometimes resulted in matters being escalated within and beyond NHS Grampian. For instance, the 12 December 2013 minutes of the Consultants Sub-Committee of the Area Medical Committee stated: “Opened the discussion by summarising the position from the perspective of general and vascular surgeons that the proposed plans to relocate general surgery would be the equivalent to a 40% reduction in bed space provision….the general surgeons sub-committee has written to the area medical committee, the chairman of the board and the Cabinet Secretary.”20 The escalation to the Cabinet Secretary appears to indicate a lack of confidence, whether justified or not, in the management arrangements.

Staff in general surgery told us they felt disengaged from both clinical and non- clinical senior leaders (those above middle management) within the organisation. They felt senior leaders had little knowledge of what was going on in their clinical areas and were not engaged with staff generally. Staff told us they felt valued by their colleagues and immediate managers, but not by senior managers. A number of senior consultants told us of their poor relationship with managers and what they felt was unwillingness by managers to accept medical advisory input.

Staff in general surgery provided an example where clinical areas were being refurbished, but staff working in these areas had not been consulted or involved in the process. They were, therefore, unclear how the finished area would look and if it was practical for patients. Some staff felt there was a lack of information and communication from managers about what was going on generally within the hospital and NHS board. However, we did speak to some staff who were positive about their relationship with their managers up to middle manager level. The majority of staff we spoke with felt that after this level, the engagement was lost. For example, staff in care of the elderly were mostly positive about immediate line managers and felt supported by them, but felt that communication fell down beyond that.

We spoke with a senior charge nurse whose nurse manager was on sick leave. We were told senior charge nurses were taking turns in taking the bleep and covering the shift. The senior charge nurse felt disconnected due to poor communication from senior management. They did not feel as supported or as informed as they should be as information was not filtered through due to the nurse manager being on sick leave. As a result, the senior charge nurse felt out of the loop.

As with other specialties, discussions with staff in obstetrics and gynaecology gave a picture of disconnect between frontline staff and senior management. Staff

20 Minutes of the Consultants Sub-Committee meeting of the Area Medical Committee 12 December 2013 54

reported that they felt supported by their immediate manager. One consultant felt there was no feeling of leadership or vision within the division and there is a general disengagement with senior management.

Staff in obstetrics and gynaecology wards told us that senior management assume staff will just cope and get the job done. We were given many examples of staff coming together and helping each other out, for example coming in on days off to cover a shift where someone was off sick. Staff felt that they were continually “fighting fires” and never got the chance to give the quality of care they felt their patients deserve. Some days they were only able to deal with emergency situations.

Staff, particularly doctors, told us about their relationship with hospital management. We were told that management support was very mixed and that there was a high turnover of managers and, therefore, there was little managerial continuity. Staff also acknowledged that some groups of staff monopolised managers’ time. We were also told that the “relationship between clinicians and managers had gone badly awry” and that, while this had not affected patient care, it had the potential to do so.

One clinical director told us they felt there was not a lot of interaction with executive management. They assume everyone has the knowledge to do their job. The clinical director told us there was no development or support for their role. Clinical director group meetings had felt very one sided and more like a team brief led by the medical director.

A clinical director and a clinical nurse manager told us they felt there was a reliance on staff at their level just to get on and do the right thing without being guided or led. The clinical director said they had been given no idea from higher management of how they were performing. The clinical nurse manager told us that they felt out of their depth and swamped at times. They had little or no support from their line manager and no formal one to ones and said this was not because the line manager was disinterested, but because they were too busy and stressed in their role.

Both clinical and managerial staff complained of frequent restructuring and movement of junior managers as soon as they became familiar with an area.

A large number of staff reported that they would welcome more leadership walkrounds in their area, as this was currently not common practice. One senior charge nurse in a ward told us that on the rare occasion that there had been a leadership walkround, they had been told by senior management to bring extra staff in to ensure that the chief executive saw there was enough staff on the ward.

8.12 We noted that feedback from allied health professionals and pharmacy staff was generally positive in terms of relationships within their own internal management structure. Most of these staff felt engaged with their line managers, but, consistent with the wider picture, they did not feel engaged with levels of management above their line manager.

8.13 We did hear positive views about the value and potential of the clinical lead role. There are around 25 clinical lead roles in Aberdeen Royal Infirmary, covering a range of specialties and services. However, we recognised that the role needed to be clarified and strengthened. In December 2013, the Area Medical Committee 55

undertook a survey of clinical leads. The survey report noted that the role of lead clinician had diminished since it replaced the head of service role. Twenty five clinical leads from Aberdeen Royal Infirmary were interviewed in the survey. Nine out of 25 believed they did not have sufficient time to do the job and eight of the 25 reported they did not feel involved in strategic decision-making. Only eight out of 25 had received a job description.

8.14 NHS Grampian had initiated work since the validation visit to try to improve relations and interaction between the Board and the advisory structures. For example, it held an event on 10 June 2014 to “bring the whole advisory structure together to review the position and identify how its contribution and influence can be enhanced.”21 However, we acknowledge the continued difficult relationships and more recent organisational upheaval in NHS Grampian.

8.15 Based on the Medical Engagement Scale survey results, review team visits and evidence provided, we concluded that the ‘fracture’ between management and clinicians is very significant. There is a deep seated mistrust and poor communication between senior management and some senior staff in particular.

8.16 The underlying causes for this are complex and varied, but it was evident that there were exceptionally poor levels of clinical (especially medical) and managerial engagement on the Aberdeen Royal Infirmary site that ultimately impede the effective and efficient management of operational and clinical services.

8.17 In summary, there was:

• in general, a substantial disengagement between medical staff and management in Aberdeen Royal Infirmary • poor working relationships between management and medical staff in several major clinical services over a significant period of time • evidence of some positive working relationships, but generally fragile working relationships between clinical staff and senior management in Aberdeen Royal Infirmary • poor communication between layers of management and clinicians and with more senior management, with evidence of better working relationships at lower levels, and • insufficient clarity on the role of the clinical leads and inconsistent understanding about their leadership contribution.

Inappropriate behaviours and leadership 8.18 We were told of examples of extremely poor behaviours and practices by a minority of medical staff that had been left unresolved. These included:

• undermining colleagues • bullying and threatening colleagues • airing conflicts in front of patients • not spending adequate time in ward areas, and

21 Letter of 2 April 2014 from Chief Executive of NHS Grampian 56

• excluding colleagues from meetings.

8.19 The evidence pointed to the management in Aberdeen Royal Infirmary and NHS Grampian being unable to consistently, visibly and robustly resolve such behaviours. This has had a demoralising effect and has allowed issues to grow.

8.20 There were also intra-departmental tensions, adversarial relationships and poor team working in several specialties that staff reported had a consequentially, negative impact on the effectiveness of the service, such as obstetrics and gynaecology, the emergency department, and general surgery.

8.21 The poor behaviour displayed by a small number of consultants has had a disproportionate impact on colleagues and on the working environment. We noted the absence of meaningful action by those in leadership positions to address such behaviours and were therefore complicit in allowing the behaviours to continue.

8.22 We heard there has been a culture within general surgery where clinical and managerial colleagues are often discussed behind their backs, which can lead to significant misunderstanding. The Royal College of Surgeons (England) (RCS), at the invitation of NHS Grampian, also carried out a review of the general surgical service in September 2014. The RCS review confirmed the poor team working and inappropriate behaviours. “Significant number of the surgeons working within general surgery had exhibited unprofessional, offensive and unacceptable behaviour. This included examples of conflicts between surgeons in the presence of trainees and on some occasions even in front of patients. These disruptive behaviours and the breakdown in team working were said to have affected the quality of the delivery of patient care.”22

8.23 During the course of the review, some consultants from general surgery made serious allegations about the behaviour, competence and probity of colleagues. These are very serious allegations and we have referred these to NHS Grampian for further urgent investigation.

8.24 We heard evidence from individuals in clinical leadership roles about a lack of practical and timely support or intervention from more senior leaders in NHS Grampian in resolving such behaviours. These behaviours manifested themselves in examples such as refusal to engage in the consultant job planning exercise and in the allocation of on-call rotas.

8.25 Box 2 below lists examples that a number of staff told us about concerning the behaviour of other staff.

Box 2 We heard of highly inconsistent consultant approaches to ward rounds and ward care in general surgery. Some consultants would not see patients who did not have a condition within their specialty interest. A few consultants were sometimes openly critical of each other’s management of patients. Consent for major surgery was sometimes obtained inappropriately by junior staff so that patients did not understand what was proposed. Such consent cannot be regarded as fully informed

22 Royal College of Surgeons (England) summary feedback letter to NHS Grampian Medical Director dated 9 September 2014 57

and in line with GMC guidance23 even if the plan is clinically sound.

We heard evidence that some consultant surgeons did not always attend the safety brief before surgery, with often the anaesthetist leading the safety brief and nursing staff leading the safety pause. Consequently, consultants then ask for different or additional equipment during surgery, which means that theatre staff have to then leave the theatre mid-surgery to find the equipment. Had the consultant taken part in the safety brief, this would have been discussed at that point in time. We had serious concerns about non-attendance at safety briefs before surgery. In many NHS boards, non-attendance by the consultant would mean the consultant would be prevented from operating. Staff told us that they had reported this to senior colleagues or through Datix, but nothing had been done, so they had stopped reporting these concerns.

Behaviours of consultants in some general surgery mortality and morbidity meetings were reported to be particularly unprofessional and aggressive on occasions. Some staff had reported that they had left the meetings or others had been asked to leave due to the aggressive nature of the behaviours. Some staff also told us that they did not believe these meetings were multidisciplinary or inclusive. As a consequence, not all appropriate staff attended these meetings.

Staff from general surgery cited examples of inappropriate behaviour, including questioning of clinical decisions and rudeness being displayed in front of staff, including trainees and patients in some instances. Patients had on occasion then complained to ward staff about the behaviour of some consultants.

Some consultants pressurised their colleagues not to apply for management posts. They have then refused to recognise the legitimacy of individuals they did not approve of in these roles.

We were told by several interviewees, in general surgery and the emergency department that a small group of senior consultants dominated their departments and that relatively minor issues were handled by conflict rather than support. On the other hand, serious issues were allowed to fester and were not addressed. Many consultants simply kept their heads down. The 29 November 2013 minutes of the acute sector management team stated that the deputy medical director “...felt that there was little benefit to communicating the dress code policy to medical staff again in a global fashion as in the past it had little effect. That said, he advised if someone is posing an actual ‘risk’ to the patient in terms of their attire, then it was entirely acceptable to address it with them directly.”24 A consultant told us that they had written saying that they did not agree with the dress code. The failure of management to take action contributed to a feeling amongst other staff that consultants can simply ignore the rules.

A large number of staff told us there is a perception that there are no consequences for consultants who behave inappropriately; therefore, they continue to do this, seeing it as acceptable behaviour.

Several managers told us that some consultants see themselves as ‘untouchable’. These consultants told managers that clinicians would tell managers what to do and

23 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf 24 Acute Sector Management Board meeting 25 November 2013 58

threatened escalation to Scottish Government. We heard remarks by some consultants that confirmed this.

Some staff in obstetrics and gynaecology reported they are made to feel undermined and isolated by a small group of senior staff. We heard examples where staff members are advised to keep their “head down”. Staff reported that there were a “small group of consultants that controlled everything” and that there was certain equipment that was only available to certain members of staff.

Various staff from the labour ward reported that there was undermining of junior staff that could be considered to be bullying or harassment. Most staff reported a strong working relationship with their colleagues, but there were one or two individuals who were more abrasive than others. Other staff members felt that everyone was stressed due to the low staffing cover and tempers could sometimes fray or that some people could not handle reflective criticism.

We heard examples within care of the elderly of an engaged service where consultants retained responsibility for patients ensuring good continuity of care. The service had excellent multidisciplinary relationship across a number of teams including respiratory medicine.

8.26 We can summarise that there was:

• evidence of poor behaviours and inability of senior management to resolve issues regarding inappropriate behaviour, and • an acceptance by staff that inappropriate behaviours will inevitably occur, thereby allowing issues to persist rather than seeking appropriate avenues to address them.

Relationships between operational services, clinicians and strategic planning 8.27 We identified a lack of engagement of clinicians in some service development initiatives.

8.28 In some areas, such as geriatric medicine and respiratory medicine, there were good examples of initiatives to transform the service. However, in other services there was a serious disconnect between the views of clinicians and the NHS Grampian perspective for the development of the service. This was especially the case in the emergency department.

8.29 In April 2010, the Board approved an emergency care centre following approval of an earlier outline business case in 2008. This was a major development intended to change clinical pathways and, therefore, impacted on the way many staff work. The centre is much more than the emergency department. It has over 300 beds including most of acute medical, geriatric and medical specialty beds. The emergency care centre was opened in December 2012. The unscheduled care plan was approved by the Board on 4 June 2013, and a further update was provided to the Board in December 2013.

8.30 At the validation visit, and subsequently in the course of the short-life review, there was repeated mention that concerns had been raised about the practical delivery of 59

the model of unscheduled care as expressed in the unscheduled care plan approved by the Board. A key element of the model was the proposal to establish a multidisciplinary team of unscheduled care advanced clinical practitioners, to contribute to managing the demands on the ‘front door’ of Aberdeen Royal Infirmary. The briefing for staff contained within the December 2013 Board paper refers to:

“A flexible advanced clinical practitioner workforce including advanced/emergency nurse practitioners, physician assistants and paramedic practitioners will also be developed in collaboration with primary care practices. This will significantly increase the number of trained staff available.”25

8.31 In our view, it was clear that the vision outlined to the Board did not command the confidence of many important clinical staff, who were fundamental to the successful implementation of the redesigned service. Attempts to persuade them or a revision of the plans had not achieved success.

8.32 A large number of staff referred to the model of a multidisciplinary team being unsafe and unworkable without equal attention being given to the need to secure round- the-clock senior medical expertise in the management of the most severely ill and trauma patients.

8.33 Before the papers were submitted to the Board in 2013, concerns were expressed by staff about the sustainability of the service. An emergency medicine workshop was held on 25 January 2013 to explore the future design of the service. It concluded that an expansion in the consultant workforce was required to sustain a safe and comprehensive service.

8.34 On 15 February 2013, all 10 emergency medicine consultants wrote to the unit operational manager expressing concerns about the “perceived risks to the continued provision of emergency care in Grampian…we are concerned that there will be a collapse in the ‘middle grade rota.”26 There was no response to this letter. On 1 May 2013, the consultants escalated a further letter to the chief executive of NHS Grampian. The response received from the then acute sector general manager, responding on behalf of the chief executive, acknowledged that they recognised the “emergent middle grade staffing issues cannot be attributed to any single event, it is unfortunate that these were not fully addressed by the sector. I note these had been highlighted to the unit operational management level, but with only marginal progress being made in resolving or indeed escalating such challenges further.”27

8.35 The clinical lead wrote again on 24 September 2013 to senior management in NHS Grampian stating that: “It should come as no surprise that NHS Grampian’s performance against the 4-hour standard has deteriorated since August. This was predicted by the emergency medicine consultants many months ago due to the reduction in trainees in the department….In the next few months the emergency department will face a crisis in middle-grade staffing. For us to avoid a catastrophic reduction in both performance and safety in the emergency department we have a very short time to have a clear plan of how this will be managed.”28

25 Report to NHS Grampian Board meeting 3 December 2013 26 Letter from emergency department consultants to Unit Operational Manager 15 February 2013 27 Letter from Acute Sector General Manager to Clinical Lead for Emergency Department 2 May 2013 28 Email from Clinical Lead to Senior Management in NHS Grampian 24 September 2013 60

8.36 In late January 2014, a paper was produced by the sector general manager on emergency department pressures29. It highlighted the significant implications of changes in middle grade staffing with effect from August 2014. We were informed by senior management that the paper was deemed to be unaffordable and unviable, at that time, with regard to the proposals for an expansion of the consultant establishment.

8.37 An email in March 2014 from one emergency medicine consultant to the chief executive of NHS Grampian drew attention to “beyond the consultant resignations….our medical staffing will undergo a startling reduction between now and August primarily because of a precipitous fall in trainee numbers. This will further compound the difficulties that we have in delivering a safe, efficient and sustainable emergency department.”

8.38 The most recent report30 as of September 2014 produced by the then medical director identifies serious difficulties in delivering the proposed model of care approved by the Board, especially regarding the multidisciplinary team. The report acknowledges that the redesign of emergency services “has not produced the desired outcomes to date.” The report also points to the fact that the “multidisciplinary team of specialists at the front door never materialised.” The report states:

“Without the multidisciplinary capacity on the clinical floor and with the acceptance of admissions determined by concerns around bed availability, the emergency department’s clinicians are unable to focus on their main responsibilities relating to major illness, resuscitation and trauma. They are forced to provide clinical capacity to manage the high volume of a wide range of clinical and non-clinical presentations to the department. As a result, out of an existing number of 16 emergency department clinicians, some nine are required during any one episode of 24 hours to maintain the service safely. This is unsustainable even if and when the clinical capacity in emergency medicine was restored to its full establishment. This has given rise to representation by these clinicians to the NHS Grampian Board and the Scottish Government to express their concerns on two consecutive occasions three months apart.”

8.39 The position set out in the September 2014 report reflects the outcome that many of those raising concerns, over many months, both feared and predicted. Therefore, we are extremely concerned that the serious warnings raised by staff were not heard or effectively responded to by the senior management in NHS Grampian. This represents a serious failure by NHS Grampian.

8.40 More generally, we heard concern expressed about a perceived disconnect between strategic planning and the operational and clinical services on the Aberdeen Royal Infirmary site. We heard about a range of initiatives being progressed spanning service improvement, organisational development and service planning. A large number of individuals (some at a senior level) who spoke with us appeared to be unaware of how the strategic planning process was aligned to support the operational and clinical improvement activities at Aberdeen Royal Infirmary.

8.41 We consider that NHS Grampian has tended to adopt a ‘top down’ approach to the

29 Paper by Acute Sector General Manager ‘Aberdeen Royal Infirmary (ARI) Emergency Department’ January 2014 30 Situation, Background, Assessment and Recommendations report by Medical Director September 2014 61

strategic planning and redesign of services. We are concerned that there is serious disconnect between the strategic planning processes and clinical and operational services. As a consequence, there is a mismatch in priorities and understanding regarding the practical delivery of clinical services and the development of strategic plans.

8.42 The box below lists further examples about the nature of relationships.

Box 3 We heard from staff working in general surgery that they felt like they were working in silos across the hospital and the NHS board. They reported that they did not know what was going on in other services or departments. This made it difficult to provide a seamless service for patients and also to share good practice or learn from any mistakes.

Staff working in the intensive care unit told us they felt they had little or no connection with the high dependency units. Following a serious incident in the neurology high dependency unit, which saw the unit close temporarily and transfer to the intensive care unit, staff felt they worked well together. However, they were critical of how management communicated about the situation and felt it could have been handled in a much better way.

While staff in care of the elderly felt that relationships with other parts of the hospital had improved since the move from Woodend Hospital to the Foresterhill site, they acknowledged they could still be improved. In orthopaedics, we were told that, while consultant geriatricians visited patients on the ward, there was little communication. Consultants did not provide feedback when leaving the ward and nurses on the ward did not have the time to join them on ward rounds. As a result, the majority of communication was through patients’ medical records. Staff in care of the elderly and other associated services also reported that they felt like they were working in silos across the hospital.

Staff in surgical wards informed us about the boarding of medical patients. Instances were reported of patients not being reviewed properly and/or having to be returned to their original wards to be properly reviewed. We also heard that some consultant surgeons would not allow their foundation doctors to provide basic care to these patients, which again is not in line with GMC guidance31 and potentially placed patients at risk. Staff reported that some patients had multiple moves between wards during their stay. This was demonstrated during the unannounced inspection of the care for older people in acute hospitals. Staff in orthopaedic wards reported that they sometimes have problems moving orthopaedic patients from their ward to rehabilitation wards or units within NHS Grampian. This results in beds in their wards being blocked and unavailable for acute patients.

In care of the elderly, staff also told us that patients were sometimes boarded in other specialty wards. Staff told us that patients were sometimes moved between wards overnight. Again, this was demonstrated in the unannounced inspection of the care for older people in acute hospitals. Staff told us that local policy restricts patients with an abbreviated mental test (AMT) score of 8 or lower being boarded, but that it was not clear how strictly this is applied. Staff stated that consultants are

31 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf 62

generally good at identifying patients who should not be moved. We were also told that, as patients still required care of the elderly input, the distance to patients who had been moved to other areas of the hospital, or to Woodend Hospital, could pose a problem.

Staff in the emergency department told us that there were often difficulties moving patients from the emergency department to wards, especially in care of the elderly, as ward staff were selective in the patients they took. Staff in care of the elderly stated that they often felt put upon and blamed for patient flow problems and resented the historical view that they did not do enough to help patient flow.

Leadership and culture conclusions 8.43 We concluded that there has been a lack of leadership and effective management by the Board, the executive team and the hospital management team. In addition, a small number of consultants have acted to undermine management and have exhibited poor behaviour. It is unlikely that optimum care for patients can be provided in the settings where this behaviour was most evident.

8.44 We found dedicated and hard working individuals at all levels, particularly those in frontline roles, who are committed to delivering the highest standard of healthcare to the population of Grampian. However we are concerned that many aspects of the current working arrangements, particularly those dependent upon goodwill, will be unable to meet future demands on the system.

8.45 We found that the failings of leadership had manifested itself in a number of ways and has contributed to a culture in which communication, engagement and support to develop, plan and implement change has become difficult to manage across a number of key specialties. Examples include:

• a perception of poor leadership and management visibility, communication and engagement with medical staff • failure of leadership to effectively engage with key service staff, for example the emergency care centre and issues of patient flow resulting from this major service development • a lack of clarity of management and leadership have made consultants reluctant to take on formal management roles • poor behaviour, including bullying which has not been resolved over a considerable length of time • poor supervision and education for doctors in training • a breakdown in professional relationships within and across some specialties, resulting in an inability for key staff to effectively collaborate, develop and manage • low morale, disengagement from management, a forceful style of management • only 60% of consultants had completed job plans at 15 July 2014 and this is a recurrent problem. We heard that senior consultants in general surgery had actively urged colleagues not to sign job plans, and

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• one of the surgical units is seriously dysfunctional and there are serious allegations about individual consultants which have not, to date, been resolved.

8.46 We expect NHS Grampian to develop an action plan to address the following recommendations.

Leadership and culture recommendations 6 NHS Grampian should carry out a fundamental review of the acute sector leadership with the emphasis on ensuring clear accountability and a delivery focus in respect of acute services and Aberdeen Royal Infirmary in particular.

These arrangements should include:

● an appropriate balance between structural redesign and establishment of effective leadership, whilst securing a strong focus on delivery of key objectives

● reporting lines, remits and performance of committees and individuals that are clear, unambiguous and regularly measured

● executive level professional leadership for escalation and governance of concerns regarding the currently disjointed and unclear workforce data

● opportunities for leaders and managers at all levels of the organisation to be supported through training, their peers and the managerial hierarchy to fulfil their respective roles

● a review and revision of the medical management structure (medical director, divisional clinical directors, clinical directors and clinical leads) to ensure there is clarity and consistency of job role and purpose and include job descriptions, contracts objectives and resource, and

● a review and revision of the medical advisory structure to ensure appropriate, representative, valued and effective engagement and contribution. The final structure should integral to the overall multidisciplinary professional advisory structure, and should not appear to operate outwith that professional advisory structure.

7 NHS Grampian should take urgent action to engage fully with all clinical and non- clinical staff.

The plan should:

● build on recent work to address engagement of clinicians

● acknowledge the large positive contribution made by the majority of staff, whilst addressing behaviours that undermine the organisation and where applicable adhere to GMC mandatory regulatory standards32

● specifically include work to address the issues identified in the Medical Engagement Survey, and

● include a consistent, fair and comprehensive approach to dealing with adverse staff behaviour in all groups of staff.

32 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf (standard 6.18)

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9 Governance and accountability

9.1 We assessed the governance and accountability arrangements to inform our review. Our findings are contained below under the following headings:

• advisory committee relations • clinical, operational and managerial control • clinical governance of services • Datix system, and • use of data to raise performance and the quality of care.

Advisory committee relations 9.2 The review team noted a particularly difficult, and often extremely adversarial, relationship between the Board and the executive team, and two particular professional advisory committees - the area medical committee and the consultants sub-committee. The consultants sub-committee is not a formal advisory committee but a sub-Committee of the area medical committee.

9.3 The review team heard strong views from both the senior management of NHS Grampian and the members of the area medical committee and the consultants sub-committee about their roles and responsibilities, in shaping the future priorities and direction for acute services. It was evident that there was a significant difference in views regarding roles and responsibilities and ultimately this impinged on perceptions about how and where decisions should be made in NHS Grampian.

9.4 The relationship between professional advisory committees and senior management is a crucial one, dependent upon trust and open channels of communication. Each has a different role, but equally each needs to give appropriate respect to the other's position and their contributions.

9.5 Scottish Government guidance (CEL 16 (2010)) states that NHS boards should:

“ensure effective arrangements are in place to promote and encourage the active involvement of all clinicians from across the local NHS system...to inform NHS Board decision making processes”.

9.6 This guidance emphasises the central role of the local Area Clinical Forum (which includes representation from the professional advisory committees) in acting as a conduit of clinical advice to the NHS board. It has a pivotal role in contributing to the effective engagement of clinical staff in the design and delivery of healthcare. The chair of the area clinical forum is, like other NHS boards, a non-executive member of the board of NHS Grampian.

9.7 The review team acknowledged the difficult relations evidenced between the NHS board and the executive team with the two professional advisory committees, but also noted the apparent absence of the Area Clinical Forum in resolving these differences.

9.8 The review team believes that there is a fundamental need to establish a new basis for the relationship between the Board of NHS Grampian and the area medical 65

committee and the consultants sub-committee. This should reflect - more broadly - the role of the professional advisory committees in playing a visible, active and meaningful role in providing professional clinical advice to the Board. NHS Grampian should acknowledge the contribution of such expertise in its decision-making processes. Similarly, the professional advisory committees must respect the role of the Board, the executive team and the acute sector management team in providing the strategic leadership and in the operational management of services. The Area Clinical Forum should play an active part in the establishment of a new and more productive set of relationships.

Clinical, operational and managerial control 9.9 The acute sector on the Foresterhill site33 consists of five divisions. The review was initially confined to Aberdeen Royal Infirmary, but subsequently extended to the Aberdeen Maternity Hospital to include a review of the obstetric service.

9.10 The acute sector has been through a series of organisational changes in recent years, with the creation of new divisions and the more recent re-allocation of services between divisions. One senior manager pointed out that they had three different line managers in the space of two years and another individual commented that they had three changes in 18 months and the reasons for the changes were unclear.

9.11 The minutes of the 2 September 2013 Area Medical Committee noted the rationale for the changes as expressed by the then general manager for the acute sector:

“Historically the acute sector had five divisions and there had been inequity across the platform regarding targets and hence it was felt that a more robust structure with six divisions was required…and the revised structure was implemented on 1 July 2013 to provide a better balance of a range of services and financial aspects with agreement to review after 3 months.”34

9.12 The acute sector management team is intended to be the focal point for the operational leadership of acute services in NHS Grampian, which includes Aberdeen Royal Infirmary. It is chaired by the general manager for the acute sector.

9.13 Despite its significant role, we heard evidence that the acute sector management team lacked sufficient focus, authority and presence.

9.14 We found that there was a lack of clarity about the organisational structure, lines of accountability and leadership in Aberdeen Royal Infirmary. The vast majority of staff we spoke with said that they were unable to understand how decisions were made and were also unable to consistently describe to us the lines of accountability. There was a strong and consistent reference to a dysfunctional management structure and a ‘reactive culture’. This perception was shared by those who themselves are in senior roles. In the words of one divisional clinical director: “There is confusion, uncertainty about how things are done….a complex structure, ripe for confusion.”

9.15 We heard a strong and consistent message that there was not a cohesive, visible and effective senior management team for the acute sector. One senior manager reported that their primary focus was on managing the “fortress” of their particular

33 Foresterhill site encompasses Aberdeen Royal Infirmary, the Aberdeen Maternity Hospital and the Royal Aberdeen Children’s Hospital 34 Area Medical Committee minutes 2 September 2013 66

division, rather than contributing to the collective leadership of the acute sector.

9.16 We expressed serious concern during the review visit that there was no operational or work plan for the acute sector and Aberdeen Royal Infirmary in particular. There was reference to work under way to develop an operational plan, but it was confirmed that such a plan did not formally exist, beyond the drafting stage, nor had it existed in recent years. This shortcoming impacted on the focus and clarity concerning the delivery of objectives and resultant performance management.

9.17 We considered the minutes of the acute sector management team and the previous acute sector Board. We noted a particular absence of expected performance management data and operational issues in the minutes, and an inconsistent approach to recording proceedings. There was no clarity about decisions made or actions to be taken. The level of attendance at the meetings was highly variable. There were no formal meetings of the acute sector management team from the start of December 2013 to the end of March 2014 due to cancellation of meetings or the decision to hold informal meetings.

9.18 As at August 2014, we noted that (at month five) personal objectives for the current year had not been finalised and agreed with the divisional general managers or the divisional lead nurses.

9.19 In the absence of clear and decisive leadership and well-understood governance arrangements, we noted examples of staff operating outside normal lines of accountability to achieve their required objective. For example, by going direct to the chief executive of NHS Grampian to seek resolution.

9.20 We were informed that a new set of management arrangements were being introduced. We heard different interpretations of how the model would work in practice and differing perspectives about the relationship between quality management and the governance of operational services. However, it was noted that there was currently no consistent approach to bring together the divisional general managers, lead nurses and clinical directors as a single, effective and cohesive leadership unit for the acute sector. We were told that the medical director attends a clinical directors forum.

9.21 The new divisions, established in 2013, have wide areas of responsibility. The span of control of managers in the divisions is considerable. We also noted the change in the responsibilities of divisional nurse managers who had moved into divisional lead nurse roles in 2013. In being appointed to the position of divisional lead nurse, they initially had no line management responsibility. However, the post now holds line management responsibility for nursing staff.

9.22 The unit operational management expressed concern about their span of control, remit and heavy workloads. There was consistent concern expressed about the lack of involvement in the design of the new management structures and the turnover in senior management in recent years. The absence of a forum for bringing key managers together was highlighted as a significant deficiency, which prevented resolution of operational issues and mitigated against a concentrated effort in addressing hospital-wide performance issues.

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9.23 The box below lists examples of issues staff told us about clinical, operational and managerial control.

Box 4 The emergency care centre was cited as an example where there was a lack of clarity about the accountability for ensuring strong, visible and cohesive operational leadership and management. Difficulties in resolving the issue of boarding patients into general surgical care beds and ensuring continuity of care was one example of a failure to define where responsibility lay.

We heard multiple accounts of a lack of clarity around the decision-making processes in Aberdeen Royal Infirmary. We heard from clinicians and managers that there was a failure to make decisions when issues were escalated. Equally, a large cohort of managers (both senior and middle) expressed concern and frustration that they were unable, or prevented from making decisions that matched the authority vested in their roles. One divisional clinical director informed us that processes around decision-making and decisions around priorities were obscure.

We heard of frustration from those in less senior managerial positions and in clinical roles. Staff in these roles informed us of a lack of performance management information, lack of clarity as to how or why decisions are made by those above them and insufficient clinical input into decision-making. They also informed us of disengagement between high level and the front line, competing challenges and inconsistent responses.

9.24 We noted a lot of activity at ward level, but disengagement from above, a lack of joined-up thinking and a sense of learnt helplessness pervaded the evidence presented. Fundamentally, there was a lack of clarity about the executive leadership for acute services, and for quality and safety of care in Aberdeen Royal Infirmary. We noted a significant disconnect between the senior leadership team and the clinical and operational services at Aberdeen Royal Infirmary. One charge nurse commented that: “Senior management are very detached from day to day frontline work and don't understand how serious things are.” There was a consistent message of issues being escalated up the chain of command, but not being satisfactorily addressed or being met with silence. Junior and middle managers reported feeling that they were not well supported by senior managers.

9.25 We noted the absence of a strong and well-understood governance structure, such as the lack of an operational plan, unclear management arrangements and clarity of decision-making processes. We, therefore, concluded that there were serious weaknesses in the underlying system of clinical, operational and managerial control in Aberdeen Royal Infirmary. These deficiencies manifested themselves in a lack of transparency in decision-making and prioritisation, and reactive and ineffectual management.

Clinical governance of services 9.26 NHS boards have had clinical governance arrangements in place since 1999. Clinical governance is defined as the “system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care

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will flourish.”35

9.27 We considered the work of NHS Grampian’s acute sector clinical governance group which reports to the Board clinical governance committee. The team noted that the primary aim of this group is “to question whether the NHS Grampian acute sector is appropriately managing clinical issues related to the delivery of person centred, safe and effective care.”36

9.28 We noted the consistent absence of senior management and senior clinicians from the acute sector clinical governance group meetings over the course of 2013 and 2014. NHS Grampian acknowledges in various minutes and the 2013 acute sector clinical governance group review that attendance is generally low. Given that the meeting’s purpose is to assess whether NHS Grampian’s acute sector is appropriately managing clinical issues related to the delivery of person-centred, safe and effective care, the low senior leadership attendance at the meeting was of serious concern.

9.29 We noted ambiguity for the clinical governance arrangements that were in place and how they came together to form a coherent and robust system of assurance. The minutes of 8 April 2014 meeting highlighted that:

“The way that issues/reports brought to this acute sector clinical governance group needs to be more robust than it currently is…[and] that it is not always clear to others that acute sector clinical governance group is actually an assurance group, as it can sometimes be thought of as a “solving” group. It was clarified that issues should only be brought to the acute sector clinical governance group if there is a plan already in place to deal with the issue being tabled. [It was] suggested having a divisional slot at each meeting/on the agenda and confirmed that the divisions did not have to follow the same governance “system” but a confirmation each division was using a system was required.”36

9.30 It was noted that an acute sector quality steering group was also established to support the delivery of the quality strategy. The steering group is described as being “responsible for leading and delivering the quality agenda in the acute sector.”36 The group had five sub-groups to lead work covering: education and training; clinical operations; medication and devices; incidents, complaints and feedback; and the communications group. One of the papers for the July 2014 meeting said there were now four strands of work, and it appeared that the ‘incidents, complaints and feedback’ strand had been deleted.37

9.31 At the 8 April 2014 meeting of the acute sector clinical governance group: “It was noted that the quality and safety steering group had not met in some time. The 5 sub- groups were continuing to meet and it was suggested that it can be difficult to motivate members of these group to carry out the work discussed at the sub-groups when there is no reporting forum for them…the main reason for the lack of recent quality and safety steering group meetings was due to lack of attendance by members…there is always the intention to have the meeting but often too many apologies are received in advance to make the meeting worthwhile.”38

35 British Medical Journal, Scally and Donaldson, (4 July 1998) 36 NHS Grampian Acute Sector Quality Steering Group report (April 2013) presented to ASCCG 37 Acute Sector Clinical Quality Strategy Update by Deputy Medical Director (July 2014) 38 Acute Sector Clinical Governance Group meeting minutes 8 April 2014 69

9.32 We considered that there were weaknesses in the established system of clinical governance. There was a lack of focus, structure, follow-up and meaningful executive and clinical engagement in the work of the acute sector clinical governance group. This was partly acknowledged in the paper produced by the deputy medical director.39 In our view, the current arrangements did not comply with the NHS Grampian clinical governance statement of intent to “ensure that the necessary structures and processes [to] create a culture that promotes responsibility and accountability for clinical governance at all levels within the organisation.”

Datix system 9.33 Datix is an information system for capturing and monitoring risks. We heard repeated concerns about the management of risks in the Datix system. There was particular concern expressed about the escalation of issues into the Datix system and the feedback on the management of risks.

9.34 It was reported to us that three out of four surgical groups regularly meet to discuss performance and issues are entered into Datix. However, concerns were raised with us that not all issues, including deaths, have been recorded on Datix and those that have are often recorded months after the death.

9.35 In March 201340, Healthcare Improvement Scotland published a report on the findings from its review of the management of adverse events across NHS Grampian. The report identified some areas of good practice, including the use of information management systems (Datix) and the general engagement and positive culture of reporting. Areas for improvement included the consistent management of adverse events across the organisation, engagement with patients and families, open and transparent decision-making and system-wide learning following investigation or review. During the visits to Aberdeen Royal Infirmary in August and September 2014, we heard from staff (predominantly nursing) that while, in general, they recorded adverse events onto the Datix system they did not always get feedback or see evidence of change or action resulting from their reporting. We asked NHS Grampian to provide us with the details of all the Datix risks and incidents reported during a 12-month period, so that we could see what action had been taken. The key points of that assessment are provided below.

• The majority of adverse events recorded on the Datix system have identified actions. However, it is not clear how these actions are reviewed and monitored through the organisations governance structures. • There is no recorded rationale on Datix for deciding on the level of investigation. • There is variation in the way investigations are reported, including different formats and level of detail. • There is no detailed evidence of feedback provided to staff who report adverse events on Datix. 9.36 Staff informed us of a lack of information or feedback following the recording of adverse events on Datix. Staff within general surgery told us repeatedly that the feedback or action for reporting through Datix is so poor or non-existent that many of

39 Acute Sector Clinical Quality Strategy Update by Deputy Medical Director (July 2014) 40http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/adverse_events_rev iews/nhs_grampian_mar_2013.aspx 70

them no longer use it to record risks or incidents. Concerns were highlighted that, in terms of clinical incidents, there is often little or no feedback to staff and, therefore, there is little or no learning to be taken from the incident.

9.37 One clinical director told us they get all Datix entries. However, they and their unit manager are so busy, they rarely have time to do anything about them.

9.38 Some nurses we spoke with said they had been told by senior charge nurses and clinical nurse managers not to complete Datix entries about staffing. Consultants also reported being told not to complete Datix entries about staffing.

9.39 Only one member of staff in obstetrics and gynaecology could tell us what happened to data collated from Datix. We were informed of ‘communication board’ or ‘safety board’ that is produced from these data, but we did not hear about this from any other members of staff.

9.40 We are concerned that restrictions are being placed on the recording of incidents within the Datix system. It is crucial that NHS Grampian fosters a system that encourages reporting of incidents and concerns and appropriately embeds a culture of learning and improvement across its services.

Use of data to raise performance and the quality of care 9.41 We could find no evidence of a robust and consistent performance management system in the delivery of services in Aberdeen Royal Infirmary.

9.42 We noted that there was material absence of a robust, consistent and comprehensive suite of performance data to inform operational management and decision-making. Senior managers informed us that they had to rely on basic, bespoke and ad hoc systems, such as Excel spreadsheets, to capture performance data. Each division adopted a different approach to meet their needs. We could find no evidence of robust data to inform the management of services in the acute sector, nor a system that used data to challenge and scrutinise the delivery of services. As noted earlier, there was no evidence that the acute sector management team considers data systematically and comprehensively.

9.43 There was general and universal concern expressed about the apparent absence of an effective and obvious system of performance management. An operational manager commented that: “There is no performance management here. I'm not performance managed. There is no performance management infrastructure or expectation." The deputy medical director reported that a system of performance reviews was in its “infancy”.

9.44 There was very little awareness among staff we spoke with at divisional level and below, of the ‘cross system performance reviews’ that are held between the executive team and service general managers, such as the direct reports to the deputy chief executive. These meetings are held every second month and cover NHS Grampian wide service provision.

9.45 The quality of data is crucially important in the management of healthcare. Nurse managers reported that ward-level data could be extracted from the Lanarkshire Quality Improvement Portal (LanQIP), an electronic performance management recording system. However, the data were not extracted proactively or used

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systematically. It was also extremely difficult to share and compare data beyond the confines of the division.

9.46 The Scottish Government noted that there was no confirmed bed complement data for hospitals in NHS Grampian and that NHS Grampian had not updated ISD records for over two years. In failing to ensure completeness of local and national statistics, NHS Grampian has compromised the planning of services.

9.47 A separate waiting time management review by the Scottish Government indicated that: “There are currently no prioritised action plans in place for each specialty to deliver improved performance. Minutes of meetings have only very recently been introduced to evidence decisions taken and actions agreed that are then subject to monitoring and review. Dialogue with Business Intelligence and the Waiting List centralised function is limited with little evidence of a coordinated approach to improve and refine access to information to inform future management of waiting times.”41

9.48 We noted that NHS Grampian recently introduced an Exemplar Ward Programme as an ambitious programme to improve the quality of care and the patient environment. The overall objective was to deliver ‘excellence in quality care 24-7, for every person, every time’. The Board minutes of 5 November 2013 stated that: “[the general manager] explained work to be done to achieve exemplar status and the aim of having the first exemplar ward by early 2015 then rolling the programme out across Grampian.” We heard that the Exemplar Ward Programme team was dissolved a few months later on 31 March 2014. However, it was reported that the exemplar ward project board continues to meet every two to three months. There was confusion among staff as to whether the initiative was being rolled out and, if so, the resources that would be committed to its successful delivery. There was very variable understanding, awareness or recognition of the Exemplar Ward Programme, back to the floor exercise and the SPSP walkround initiatives amongst individuals we spoke with. NHS Grampian reported that there is continuing commitment to the Exemplar Ward Programme while it is being delivered in a different way to encourage appropriate ownership at division, service and ward level.

9.49 In summary, there was:

• very limited evidence of a co-ordinated and robust arrangement for performance management beyond the cross-system performance review arrangements • an inconsistent and fragmented approach to the use of performance information across the divisions, and • a lack of systematic and open challenge of performance in Aberdeen Royal Infirmary.

Governance and accountability conclusions 9.50 We concluded that systems of accountability, governance and performance management are absent or weak and need to be substantially improved. We noted a difficult and often adversarial relationship between on one side the Board and executive team and on the other the Area Medical Committee and consultants subcommittee. It was evident that there was a significant difference in views

41 Scottish Government review of waiting time management (June 2014) 72

regarding roles and responsibilities which has impinged on how and where decisions should be made.

9.51 There is a lack of clarity in the management structure which is compounded by a lack of leadership at executive and hospital management level. The executives gave the impression that they believe that the problems that Aberdeen Royal Infirmary faces are in large part due to external factors and cannot be resolved by them. We acknowledge the general challenges that face the NHS, and some particular challenges affecting NHS Grampian, but consider that the executive team should be leading work to mitigate these.

9.52 There has been little stability in management due to both restructuring and rapid turnover. Individual managers at junior level are seldom in a post long enough to understand the department and its issues. Junior managers, and most clinical managers, have little or no decision-making authority. There is a general belief that when decisions are escalated to hospital or Board level management, decisions are either not made or not communicated. We heard multiple comments about emails and letters to managers raising important concerns going unanswered and unaddressed. It was a frequently expressed view that actions were not taken until a crisis was imminent, and then senior managers were drawn in to “fire-fight”.

9.53 The executive team is seen as remote, except by some individuals who rely on personal contacts. The Aberdeen Royal Infirmary management team is also seen as remote by frontline staff. Several months passed before the Aberdeen Royal Infirmary management team met formally. The minutes of the meetings which did take place suggested that they did not consider data or make meaningful decisions. There is little evidence of an effective performance management framework. All of this is of significant concern given the known issues with scheduled surgery, cancer waiting times, nurse staffing, and the emergency department.

9.54 We heard concerns about the lack of learning from reviews of complaints and adverse events. We felt there was inadequate evidence that the clinical governance structures resulted in learning from these sources being spread across the organisation. We also heard about some mortality and morbidity meetings within general surgery being settings for clinicians to aggressively criticise others rather than forums to share learning. Individual behaviours of some consultants in these settings need to be addressed promptly.

9.55 We expect NHS Grampian to develop an action plan to address the following recommendation.

Governance and accountability recommendation 8 NHS Grampian should introduce strong and effective governance mechanisms for the clinical, operational and managerial control of services at Aberdeen Royal Infirmary.

These mechanisms should include the following:

● a thorough examination of the effectiveness of the clinical governance function ensuring that it meets the expected objectives of NHS Grampian’s clinical governance strategy

● defined and clear roles and responsibilities of the management and advisory structure (see recommendation 6) to ensure appropriate involvement in the clinical 73

governance function

● sufficient capacity, for the NHS Grampian Board members, to constructively challenge and to assert their position as a body focused on securing improved health outcomes for the population of NHS Grampian

● defined and clear strategic organisational objectives which link to the objectives of leaders and management of the organisation

● a clear and prioritised operational plan for the delivery of strategic objectives across the acute sector, with accountability for delivery expressed

● a robust performance management framework to monitor delivery of the operational plan. The performance management framework should be based on data which should be routinely collected, distributed and used. Data will come from a variety of sources and should allow managers to share and learn from emerging themes and improve services. For example, adverse incidents, patient experience data and complaints

● arrangements for the acute management team to have regular meetings focusing on delivery, accompanied by minutes and action tracking of progress, and

● arrangements for the medical director to have regular meetings with the associate medical directors and divisional clinical directors accompanied by minutes and action tracking of progress.

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10 Staff governance

Nursing workforce 10.1 Like many NHS boards, NHS Grampian faces challenges in a number of areas relating to nursing workforce, including:

• general recruitment and retention of nursing staff • configuration of substantive nursing and midwifery establishments, including the use of national workforce tools • the use of temporary or additional staffing • governance and escalation arrangements when clinical staff are concerned that staffing is so inadequate that it may be jeopardising patient quality of care and safety • senior nursing structure and visibility, and • ward staffing.

General recruitment and retention of nursing staff 10.2 We heard concerns from some staff who felt it took too long to recruit staff, although senior charge nurses and clinical nurse managers were, by and large, content with the time period between vacancy approval and the commencement of the staff member in-post. However, they felt they had little or no control in the recruitment process.

10.3 Data provided by NHS Grampian described the actual and budgeted nursing workforce in NHS Grampian between 2009–2010 and 2012–2013. These data indicate a reduction of actual whole time equivalent (WTE) nursing staff from 5,657 to 5,192 across NHS Grampian between 2009–2010 and 2012–2013. There was also a reduction in the budgeted WTE nursing staff across the same period from 5,416 to 5,196.

Figure 13: Whole-time equivalent nursing staff and costs 2009–2010 to 2012–2013. Actual Budget Budget Difference Difference Year Actual £m WTE £m WTE £m WTE 2009–2010 £189.1m 5,657 £181.9m 5,416 (£7.2m) (241) 2010–2011 £189.4m 5,269 £179.7m 5,105 (£9.7m) (164) 2011–2012 £187.7m 5,120 £180.9m 5,122 (£6.8m) 2 2012–2013 £190.1m 5,192 £186.0m 5,196 (£4.1m) 4

Data source: Nursing Allocation Resource paper, 2013

10.4 Figure 14 shows the ratio of hospital nursing staff in post compared to the average available staffed beds for all acute specialties, presented for all NHS boards in Scotland. Nursing numbers do not include paediatric, mental health or neonatal. This shows NHS Grampian (the solid point on the chart) as having a relatively low number of hospital nursing staff to staffed beds, being between 2 and 3 standard deviations below the Scottish average.

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Figure 14: Ratio of hospital nursing staff in post (Agenda for Change bands 1-9) to average available staffed beds for all acute specialties. Data for NHS boards, with NHS Grampian highlighted as the solid point.

3

2 Ratio

1

0 - 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 Staffed beds

Data source: Information Services Division, Scottish Workforce Information Standard System (SWISS)

10.5 We did not receive evidence from NHS Grampian on the average time taken to recruit staff. Minutes of the 4 March 2014 NHS Grampian short-life working group on nursing resources implementation group meeting state: “some wards were working under because of difficulties in recruitment and retention.” There is no action arising from this statement, nor any data in the paper describing the size of the issue or risk profile.

Configuration of substantive nursing and midwifery establishments 10.6 Figure 15 shows the staff establishment submitted as part of a report to the short-life working group on nursing resources on 26 March 2014. The table indicates a shortfall between funded and assessed establishment of 244 WTE and a shortfall between actual staff in post and assessed establishment of 350 WTE across NHS Grampian acute services.

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Figure 15: Nursing whole-time equivalents for funded establishment, actual staff in post and assessed establishment. Sector Funded Actual Assessed Difference Difference Establishment Staff Establishment Between Between Actual (WTE) in Post (WTE) Funded & Staff in Post & (WTE) Assessed Assessed Establishment Establishment (WTE) (WTE) Acute Div 1 – 1009 971 1034 25 (2.4%) 63 (6.1%) Acute Medicine Acute Div 2 – 356 330 398 42 (10.5%) 68 (17.1%) Digestive Diseases & Surgery Acute Div 3 – 655 639 786 131 (16.7%) 147 (18.7%) Children, Women & Support Profs Acute Div 4 – 267 261 283 16 (5.7%) 22 (7.8%) Complex Care Acute Div 5 – 184 164 214 30 (14.0%) 50 (23.4%) MSK & Neurosciences TOTAL 2471 2365 2715 244 (8.9%) 350 (12.9%)

Data source: NHS Grampian, Short-life working group report on nursing resources, 26 March 2014

10.7 The report produced by NHS Grampian provides some narrative on specific areas of concern and concludes that:

• the assessed establishment would not be affordable for NHS Grampian • even if funding were available, it is not clear whether there would be a supply of nurses to fill posts • other options are likely to be required, for example altering the number of beds, and • the short-life working group is invited to discuss how the exercise to review nursing establishments should be progressed.

10.8 The Board is aware that the calibration, recruitment and deployment of the nursing and midwifery resource is a significant issue. A paper at the open Board session on 1 August 2014 describes that an internal short-life working group “made 20 recommendations to improve the utilisation of nursing and midwifery staff across the Board and improve the quality of care provided in NHS Grampian.” The paper states that the executive team agreed that the implementation of these recommendations is extremely important and that an implementation group would be established following the private Board session in August 2014.

10.9 The nursing resources implementation group describes the following key actions, taken from the paper at the open Board session on 1 August 2014:

• agreement of a baseline establishment 77

• identification of the estimated difference between historical establishments and current requirements • presentation of findings at a review-and-challenge peer-review workshop • consideration of ‘policy deficits’, particularly in relation to allocation of leave, utilisation of bank staff and rostering practice • consideration of 12-hour shift patterns and a tool to monitor staff attitude • an outline business case for e-rostering • working with Robert Gordon University to improve the conversion of students into NHS Grampian nurses, and • a ‘strategic review’ of recruitment.

10.10 NHS Grampian documentation shows an awareness and consideration of issues relating to workforce including:

• the variation in tools used for workforce planning • long-standing vacancies • an aim to reduce the use of bank and agency staff, and • increased investment in some areas to facilitate the recruitment of nursing staff.

10.11 Minutes of the NHS Grampian short-life working group on nursing resources (Implementation Group meeting on 4 March 2014) state that: “[the Director of Workforce] advised that the current projection discussed under nursing establishments were unlikely to reduce much and this was not affordable.”

10.12 The minutes further state that: “There were differences of interpretation of the figures requested, ie - some areas had taken the figure derived by triangulating the outputs from different workload tools and local knowledge, whilst other areas had taken it to be the current staff in-post. A range of tools had been used to arrive at the figures.”

10.13 In its general adult inpatient wards, Aberdeen Royal Infirmary has a funded nursing establishment of 904 WTE. Of these, 611 WTE (68%) are registered staff. It should be noted that these data exclude:

• emergency department • children’s services • maternity services • high dependency areas, either as substantive units or wards with mixed ‘standard’ and enhanced/HDU activity • level 3 critical care • day case areas • outpatient areas • specialist, advanced practice and consultant nurses • nurse leadership, and

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• operational support roles filled by registered staff.

10.14 Data we received for Aberdeen Royal Infirmary general inpatient wards showed that:

• there are 785 WTE staff in-post versus a funded establishment of 904 WTE, and thus an apparent vacancy rate of 119 WTE (13%) • the establishment assessed as being required is 981 WTE, versus a funded establishment of 904 WTE, a gap of 77 WTE (8%) • the establishment assessed as being required is 981 WTE, versus an in-post establishment of 785 WTE, a gap of 196 WTE (20%) • the average skill-mix in Aberdeen Royal Infirmary inpatient wards is 68% registered nursing to 32% unregistered • 11 out of 29 wards (38%) have a registered nurse to non-registered nurse skill-mix ratio of less than 65%:35% • the average number of patients per registered nurse per shift in the Aberdeen Royal Infirmary inpatient wards is 6.5, and • 11 out of 29 wards (38%) have a ratio of more than seven patients per registered nurse per shift.

The use of temporary and additional staffing 10.15 During the site visits, there was a frequent and unanimous theme of concern around the use of temporary staffing. NHS Grampian has separate stand-alone nurse banks across its delivery units. The organisation is working towards these stand-alone units adopting a consistent response.

10.16 NHS Grampian data describe the current (June, July and August 2014) fill-rate for the bank nursing (registered and unregistered) shifts in its general wards as being 56% (the fill rate is the actual number of bank nurses on the wards in response to requests made by staff for bank nurses). In discussion with nine senior charge nurses, they stated that they were dissatisfied with the bank staff arrangements.

10.17 The deployment of bank staff appears to mitigate the gap described in paragraph 10.15 between funded establishment and staff in-post. There are 899 WTE staff deployed versus a funded establishment of 904 WTE, and, therefore, an apparent gap of 5 WTE (<1%).

10.18 Figure 16 shows the hospital nurse vacancies as a percentage of the staff establishment using data from January to March 2014. This shows the percentage of hospital nurse vacancies at NHS Grampian to be more than 3 deviations higher than the Scottish average.

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Figure 16: Hospital nurse vacancies (all bands) as a percentage of establishment. Data for NHS boards, with NHS Grampian highlighted as solid point. Data for January–March 2014.

10%

9%

8%

7%

6%

5%

Nurse vacancies 4%

3%

2%

1%

0% - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 Nurse establishment Data source: Information Services Division, Scottish Workforce Information Standard System (SWISS)

Governance and escalation arrangements 10.19 It was difficult during the course of the review to elicit a consistent description of the governance and escalation processes around nursing workforce. Clinical and non- clinical staff, up to and including lead nurses, clinical directors and unit operational managers, consistently described the escalation of concerns with nursing numbers. They go on to describe what they perceive to be an absence of meaningful action or decision-making.

10.20 In June, July and August 2014, there were between 14 and 46 incidents relating to staffing submitted to Datix. This accounted for between 2–6% of the total incidents reported to Datix each month. However, these data should be treated with caution, given the assertion by many staff that there is no point in documenting staffing concerns on the Datix system due to an absence of feedback or action. Some staff also told us they had been told not to use Datix for staffing issues.

Senior nursing structure and visibility 10.21 Professional nursing in the acute services division, including Aberdeen Royal Infirmary, is led by an associate director of nursing. Each of the five divisions within the acute services division is led by a divisional lead nurse who reports professionally to, but is not line managed by, the associate director of nursing. Each divisional lead nurse has a number of clinical nurse managers reporting to them.

10.22 Ward-based staff told us they regularly saw the clinical nurse managers in their areas, being generally very supportive. There was some mention of the divisional lead nurse being seen occasionally, but that this was on the mandatory Wednesday morning clinical sessions and was not consistent or directed towards direct patient care. The 80

review team heard from a significant number of nurses and midwives, at various grades, express concern that wards are not adequately staffed, particularly at busy times of the day. In addition, when staff escalated these concerns they told us that they frequently got no meaningful response or feedback.

Ward staffing 10.23 Staff in surgical wards told us that staff nurses and healthcare support workers are being taken away from their ward duties for long periods of the day, to escort patients to and from theatre. In busy surgical wards, up to 20 patients a day can often be going to and from theatre.

10.24 Some staff in surgical wards also told us that even if their ward was fully staffed, a staff nurse would often be removed from the ward and sent to an understaffed ward. Nurses in the intensive care unit and high dependency units also told us this happened on their units. They said they had concerns that often they do not have the correct skill-mix for the ward they go onto and are not familiar with the equipment. Often they have no proper handover. Sometimes they are in charge of the ward they are sent to with no knowledge of the ward or the patients. Senior charge nurses reported that they often feel under considerable pressure to release their staff and they feel it is difficult for them to refuse to release staff.

10.25 Staff in care of the elderly also told us that there never seemed to be enough staff, particularly when it came to nursing patients with delirium who may require more attention than other patients. This was demonstrated during the unannounced inspection of the care for older people in acute hospitals. In areas where they had the full establishment of staff, there were often issues regarding backfilling sickness leave. While bank staff are used, we were told that ward staff would do extra shifts to provide cover. In the majority of instances, shifts that were short staffed were escalated through Datix. However, some senior charge nurses told us that this was not always possible as staff were inevitably busier when short staffed.

10.26 Some senior charge nurses told us of their concerns about being the nurse in charge for the hospital at night. All Band 7 nurses are on a rota for this. Staff said they often felt “out of their depth” doing this. One Band 7 senior charge nurse is now taking a Band 6 post so that they will not have to take the responsibility of being the nurse in charge for the hospital at night.

10.27 In the intensive care unit, staff on maternity leave are not back filled. The department is currently overspent each month on its salary budget, as they have 15 Band 6 nurses, but are only funded for 8, due to a legacy issue with Agenda for Change. As these Band 6 nurses leave due to natural wastage, they are replaced by Band 5 nurses. However, over time there then becomes an issue with staff turnover, as there is nowhere in the career structure for the Band 5 staff within the unit, so these staff then leave and find work elsewhere.

10.28 We heard of an example where the human resources department advised a nurse manager that they would perhaps prefer not to undertake exit interviews, as the interviews would give the person a lot of issues that they could not resolve. Given the issues that NHS Grampian has in recruiting staff, this is not helpful advice to give to managers.

10.29 There were also instances in which senior charge nurses were unable to dedicate 81

time to their non-clinical work as they were needed on the ward to cover staff absences. Instances were also given of nursing staff having to attend training or do their objectives and personal development plan in their own time.

10.30 Staff informed us during our visit in October 2014, that NHS Grampian had started doing mass monthly recruitment over the weekends to try and address the issues with staffing. However, vacancies were still high.

10.31 It has been difficult throughout the review process to gain a clear understanding of how the nursing workforce in Aberdeen Royal Infirmary is assessed, signed off and areas of concern escalated and managed. This difficulty, in addition to the challenges in securing consistent and reliable workforce information, is likely to contribute to problems in NHS Grampian with the deployment of, and communications concerning nursing workforce.

10.32 The number of nursing staff to staffed beds (January to March 2014) for NHS Grampian is low compared to the Scottish average. The funded establishment appears to be 77 WTE (8%) short of the establishment assessed as being required to provide a safe service. However, neither of these figures reflect the level of real multi- professional anxiety in Aberdeen Royal Infirmary with nursing workforce numbers, particularly given the favourable position of an average skill mix of 68% registered staff and a ratio of 1:6.5 for registered nurses per patient per shift.

10.33 Staff may continue to feel as though the hospital is short staffed due to the fact that the funded establishment is some 119 WTE (13%) short of being filled by staff in-post. There is little doubt that this, combined with a sense of being the ‘victims’ of recruitment issues in NHS Grampian, and a lack of faith in the bank staff arrangements, is at the core of these anxieties. This is the case even though the use of bank staff seems to fill 114 WTE posts of the 119 WTE posts currently vacant. Using bank staff to backfill on a regular basis creates pressure for staff compared with filling vacant posts substantively (which provides better support and continuity of care). Continually briefing and orientating bank staff puts pressure on core busy staff teams and has significant impact on patient, families and other members of the multidisciplinary team.

10.34 NHS Grampian is unable to demonstrate satisfactory governance and escalation arrangements around a number of issues, including staffing. Ward-based clinical staff were consistently very clear in their view that the organisation failed to support them in dealing with their concerns. Senior staff were also unable to convincingly describe a satisfactory approach to dealing with issues. Medical workforce 10.35 We looked at the following in relation to medical staffing in NHS Grampian:

• the total number of medical staff • the use of locum staff • appraisal and revalidation • consultant and specialty doctors job planning • consultant appointments • trainee rota monitoring, and 82

• support for trainees.

Total number of medical staff 10.36 NHS Grampian had 462 medical and dental consultants in post during January to March 2014, the highest quarter figure for two years. The number of consultants per staffed bed (0.262) for the same quarter is below the average for Scotland (0.276), and for the other large NHS boards (0.288)42, but these differences are not significant.

10.37 For January to March 2014, the number of consultant vacancies in NHS Grampian as a percentage of establishment was 9.8%. Figure 17 shows that this is double the rate for the other large NHS boards (4.9%), but not statistically different to consultant vacancy rates in NHSScotland overall.

10.38 The ratio of doctors in training to consultants is 1.33:1, which is higher than the average for Scotland (1.13:1) and for the other large NHS boards (1.23:1). However, these differences are not significant in either case.

Figure 17: Number of consultant vacancies as a percentage of establishment. Data for NHS board, with NHS Grampian highlighted as solid point. January to March 2014.

30%

25%

20%

15%

Consultant vacancies 10%

5%

0% - 200 400 600 800 1,000 1,200 1,400 1,600 Consultant establishment The use of locum staff 10.39 Staff told us that in some areas, trainees and consultants are doing locum work to support their colleagues. NHS Grampian was unable to supply data for the number of locums employed. Total reported locum expenditure was £628,038 for 2013–2014 and is projected to be similar this year. The figure is probably an underestimate. We noted that there was no internal locum expenditure identified for emergency medicine consultants despite evidence that they had been doing considerable additional hours. NHS Grampian advised that this was because pay rates had not been agreed. Given that this is a regular feature, we do not consider this to be good governance.

10.40 We heard serious concerns about the impact of shortages of medical staff on the

42 NHS Greater Glasgow and Clyde, NHS Lothian, NHS Lanarkshire, and NHS Tayside. 83

cardiac surgical intensive care unit. Whilst trainees working at middle grade in cardiac surgery are recruited nationally, service provision requires additional non-training staff. This is challenging nationally and NHS Grampian has had difficulty providing cover. As a consequence NHS Grampian is using resident consultant surgeons to provide cover for the cardiac intensive care unit at locum rates. This has been going on for five to six months and sustainability is questioned with no apparent long-term strategy. These consultants can also sometimes be the consultant surgeon on-call on the same shift, meaning that if they are in theatre or elsewhere, there may not be cover in the cardiac surgical intensive care unit at nights.

10.41 We noted that there were shortages of medical staff in key specialties, including emergency medicine, radiology, anaesthetics and oncology. Difficulties exist nationally in recruitment to several of these specialties. NHS Grampian attributed their difficulties to under-funding by the Scottish Government (see 3.17-3.18), the relatively high cost of living in Aberdeen and the remoteness of Aberdeen. However, we consider that factors within NHS Grampian’s control are at least as important as relative funding. The recruitment challenges have been apparent for several years, but there is little evidence that NHS Grampian has developed, implemented and monitored plans to address these. Although the workforce plan43 states that NHS Grampian’s ambition is to be the ‘employer of choice’, this is a long way from the reality. Indeed, the unresolved issues in Aberdeen Royal Infirmary make recruitment more difficult.

10.42 In several specialties, Aberdeen has become an unpopular place to be a trainee and there has been insufficient effort to address this. A culture of mutual distrust between consultants has also developed within some specialties in some significant areas. The relations between consultant and managerial staff have also broken down. The medical director and deputy medical director have been undermined by some consultants and have been unable to respond to problems identified in areas such as general surgery, the emergency department, and obstetrics and gynaecology. All of this makes NHS Grampian a less attractive place to work and inhibits clinical and managerial staff from working together to address challenges.

10.43 The situation in the emergency department illustrates many of the issues. NHS Grampian is facing a substantial and significant challenge in sustaining an emergency department. This is a specialty in which there are shortages of senior and middle grade staff across the UK. Other NHS boards have developed and implemented effective plans to address or at least mitigate these. There is no evidence that NHS Grampian had a plan at senior decision-maker level to address this, or that Board members were made fully, and adequately, aware of the unresolved issues whilst there was still time. During the visits, senior management continued to downplay the issue to us and seemed to regard the problems as essentially beyond solution. The poor trainee experience and the failure to address issues of behaviour by some consultant staff have also contributed to a further deterioration in the situation.

10.44 The number of emergency medicine consultants is well below that required. Those who remain are working excessively, and several are considering leaving. In recent months, one has resigned and another has signalled that they will do so. NES visited the emergency department on 8 October 2014. During that visit, consultants said that they have been told to reduce their Supporting Professional Activities (SPA) time and

43 NHS Grampian Workforce Plan 2013 84

this may impact on their ability to provide educational and clinical governance activities, which have already been highlighted as an area requiring improvement.

10.45 A new rota for middle grade staff in the emergency department was implemented in August 2014. This was due to the reduced numbers of this staff group. It has significantly improved the training environment for the senior emergency medicine trainees, and this should benefit the department’s reputation and recruitment. However, it does mean that the emergency department cannot always provide a registrar level decision-maker overnight. NHS Grampian has, therefore, required trainees in medical specialties to undertake ‘twilight’ shifts to cover duties that would normally be covered by the emergency department registrar. Trainees in these specialties expressed concern about the appropriateness of this for patients and for their own training and work patterns.

10.46 We also heard from staff that there had been no consultation about these new arrangements and that they were simply imposed by a letter or email44. This is not an effective approach to engaging staff with change which is likely to be unwelcome. Whilst the greater emphasis on training for senior emergency medicine trainees will address some concerns within the trainee survey, the changes to duties for doctors in medical specialties are likely to reduce satisfaction among staff. We are concerned that the arrangements for covering the emergency department may not be safe. It does not meet the standard expected by the College of Emergency Medicine and more junior trainees reported increased stress for them and delays in patient management. These factors put patients at risk.

10.47 We are concerned that the approach of NHS Grampian management remains complacent. During the review, individual Board members seemed unaware of the gravity of the issue. We were told that it just has to be managed and that the emergency department will require a completely different model in future that is less dependent on emergency medicine doctors.

Appraisal and revalidation 10.48 In 2013–2014, 86% of eligible consultants and 76% of eligible staff grade/associate specialist/specialty doctors had a completed appraisal. These figures are similar to other NHS boards45. Of the 230 doctors (including GPs) due for revalidation in 2013–2014, 221 had a positive recommendation and nine were deferred. Of the 439 doctors due for revalidation in 2014–2015, 53 did not have an appraisal in 2013–2014 and only eight of these had a valid reason for exemption.

10.49 We concluded that compliance with the appraisal process is noticeably better than with job planning. There is potential to improve and avoid difficulties in revalidation that may arise for individual doctors, with consequences for NHS Grampian, but the situation in NHS Grampian is broadly similar to other NHS boards in Scotland.

Consultant and specialty doctors job planning 10.50 Consultant job planning is one key mechanism through which consultants and managers agree, monitor and deliver objectives over the year. It describes how the

44 Letter from the office of Chairman and Chief Executive to all consultants regarding patient flow 5 September 2014 45http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/medical_revalidatio n.aspx 85

consultant, working as part of a team, will contribute to achieving the organisation’s objectives. It should be reflective of the professionalism of being a doctor and, therefore, contributes to maintaining the professional standards set out by the GMC in Good Medical Practice. Annual job planning is a requirement of the 2004 Consultant Contract.

10.51 The documentation supplied by NHS Grampian showed that only 60% of consultants had completed job plans at 15 July 2014 and this is a recurrent problem. The figures for 2013–2014 showed that in some specialties all consultants had job plans, in others no job plans had been completed. The NHS Grampian Workforce Plan 2013 Table of Performance reported that 70% of consultants had job plans in 2012–2013.

10.52 NHS Grampian told us that where no job plan was submitted there was no referral for mediation. We heard that senior consultants in general surgery had actively urged colleagues not to sign job plans. The result was that only 3 out of 19 had job plans last year. This is unprofessional behaviour and yet has been allowed to persist. The lack of job plans in oncology was identified as a problem. A clinical director who had sought support to achieve job planning reported that they were not supported by senior management.

10.53 Another interviewee described job planning as being essentially ‘self certification’, which raises concerns as to the quality of actual job plans. We did not examine individual job plans.

10.54 We concluded that although NHS Grampian has a job planning process, it is not delivered in practice. Some consultants have simply refused to engage and no meaningful action has been taken by management.

Consultant appointments 10.55 We heard several concerns from consultants about the appointment process.

10.56 It was alleged that a consultant was appointed to undertake a sub-specialty in which they were not adequately trained. In another case, it was alleged that a job description was specifically tailored to a candidate to the exclusion of better qualified candidates. In a third case, it was alleged that a large number of consultants were added to the appointments panel at short notice to prevent an appointment.

Trainee rota monitoring 10.57 NHS Grampian provided evidence of 17 trainee rotas. These rotas should be monitored either every six months or annually to ensure that trainees are compliant with the European Working Time Regulations and the New Deal, and are being paid correctly. The process is cumbersome and resented by many trainees and consultants. We requested details of the output of this monitoring. No collated return was available, but individual rota sheets were obtained from which it appears that NHS Grampian is achieving monitoring for about 40% of rotas. The output is shown in Figure 18.

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Figure 18: Trainee rota monitoring. Period Number of Number Number signed rotas compliant as correct by a monitored trainee

February–July 2013 11 11 6

August 2013–January 2014 7 6 3

February–July 2014 27 14 0

Data source: NHS Grampian

10.58 The process requires that both the consultant in charge of the rota and a trainee working on the rota sign off the summary of the monitoring return. This is not happening in NHS Grampian. The same individual has signed in the consultant signature box for all rotas in the second period and there are almost no trainee signatures. For the third period none of the returns are signed by either a consultant or trainee. In the most recent period, 10 returns were declared invalid as too few trainees returned monitoring forms.

10.59 We understand that a consultant used to lead the monitoring process. That consultant has left the organisation and there have been gaps in the administrative team. The evidence is that NHS Grampian is not consistently monitoring trainee hours or considering the collated information. Some trainees reported pressure to produce a compliant return. This is a risk, particularly as we heard that some trainees were doing additional work when officially off duty. In the absence of recent monitoring, NHS Grampian would be vulnerable to substantial claims for retrospective re- banding. We heard that the monitoring of the middle grade rota in the emergency department was cancelled by management whilst in progress in October 2013 and was non-compliant in May 2014. Trainees reported that they have not yet received their back pay.

10.60 The information about trainee hours monitoring was not provided in a collated form and it is almost impossible to assess the actual position. What is clear is that the process is not being followed, that many rotas are not monitored because of insufficient returns, and that no assurance can be given that contractual and legislative requirements are complied with.

Support for trainees 10.61 We received information from NES including:

• the NES Scottish Trainee Survey (STS) • the GMC National Training Survey (NTS), and • data from the NES Quality Management service.

10.62 This information was also available to NHS Grampian (except the 2014 STS survey which at point of publication had not been shared with NHS Grampian). We also received the Local Education Provider report dated 23 August 2013.

10.63 During the review visit in August, Healthcare Improvement Scotland scheduled time 87

for a discussion session with trainees, but only two trainees were scheduled by NHS Grampian to attend. Whether this represented unwillingness on the part of the trainees, or a failure of management, it was of concern to us. It was noted that a deanery visit with so few trainees would normally be cancelled. We spoke with an additional four trainees during the drop-in sessions.

10.64 Four specialties specifically highlighted in the scope of the review were considered in detail: care of the elderly, emergency medicine, general surgery, and obstetrics and gynaecology.

Care of the elderly trainees 10.65 The information from the 2014 GMC, NTS and STS returns from trainees in care of the elderly was very positive. In this specialty, the North of Scotland region of Scotland Deanery is ranked second of 19 Deaneries/Local Education and Training Boards in the UK for ‘overall satisfaction’. No serious concerns with training were identified in either the Scottish or National Training Surveys.

Emergency medicine trainees 10.66 For emergency medicine, the North of Scotland region of Scotland Deanery is ranked bottom of the 19 Deaneries/Local Education and Training Boards in the UK for ‘overall satisfaction’ in the 2014 GMC National Training Survey. Aberdeen Royal Infirmary is also either a statistical outlier within the bottom quartile or lies within the bottom quartile for 9 of the 12 indicators (reflected as either ‘red’ or ‘pink’ flags in the survey, respectively) for foundation and/or core and/or specialist trainees. For 4 of these 9 indicators (overall satisfaction, clinical supervision, workload, study leave), this poor rating has been persistent for three successive years.

10.67 The 2014 Scottish Training Survey has similar findings and places Aberdeen Royal Infirmary between the bottom and eighth centile for five domains. The emergency department is an outlier for team culture with 39% of specialist trainees saying that they “work in an environment where there is a culture of undermining of staff confidence.” The prevailing view is that teaching trainees and their learning is not perceived as a key priority of the department.

10.68 We spoke with emergency medicine trainees who reported concerns about their training experience. They perceived a situation of undue exposure due to less than optimal clinical supervision by a minority of consultants. The trainees also had limited input into the clinical governance work of the department. This was perceived to impact on patient care.

10.69 During the review, NES conducted a follow-up Training Quality Management visit on 8 October 2014 to the emergency department to assess how NHS Grampian had addressed the conditions and recommendations imposed in May 2013. It was noted that responses from the director of medical education had been inadequate and the GMC has placed the department into enhanced monitoring status. The NES visit report46 states:

“The Visit Team have seen some evidence of improvement, particularly led by the training programme director. However the Visit Team still have considerable concerns

46 NES Scotland Deanery (North) Quality Management Revisit Report (8 October 2014)

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with regard to education for trainees in this department and the lack of support from NHS Grampian. Therefore, the [emergency] department in [Aberdeen Royal Infirmary] has now been escalated to enhanced monitoring by the GMC. The Visit Team would expect an update on all conditions and recommendations in January 2015 with direct evidence i.e. outcomes and outputs in relation to each of these.”

10.70 This is an unusual step which indicates serious concern on the part of the GMC.

General surgery trainees 10.71 Overall, the North of Scotland region of Scotland Deanery region ranks 16th out of 19 across the UK for ‘overall satisfaction’ for training in general surgery in the 2014 GMC National Training Survey, and the detailed analysis for general surgery training in Aberdeen Royal Infirmary specifically adds further concern.

10.72 On the 2014 GMC National Training Survey, Aberdeen Royal Infirmary is either a statistical outlier within the bottom quartile or lies within the bottom quartile for 8 of the 12 indicators (reflected as either ‘red’ or ‘pink’ flags in the survey, respectively) for foundation and/or core and/or specialist trainees. For 2 of these 8 indicators (clinical supervision, adequacy of experience), and this has been persistent for three successive years. The National Training Survey highlights undermining and cites bullying.

10.73 The 2014 Scottish Training Survey has similar findings and places Aberdeen Royal Infirmary on the 5th to 8th centile among specialty training sites in Scotland. The unit is an outlier for team culture with 32% of foundation trainees, 22% of core trainees and 40% of specialist trainees saying that they “work in an environment where there is a culture of undermining of staff confidence.” In the survey 22-30% of trainees describe the training environment as ‘not supportive’. The prevailing view is that teaching of trainees and their learning is not perceived as a key priority of the department.

10.74 During the review, feedback from trainees largely confirmed this view. Although individual consultants were identified as supportive, the overall picture was of disorganisation, a tendency to blame individuals, favouritism and pressure on trainees to cover additional shifts and to attend when off duty to assist in theatre. We did not see any monitoring returns for surgical trainees’ hours of work. Trainees reported pressure to undertake additional hours. Some had concerns about aspects of clinical care.

Obstetrics and gynaecology trainees 10.75 The North of Scotland is ranked bottom (20th out of 20) of UK Deaneries/ Local Education and Training Boards for overall satisfaction. On the National Training Survey, there are six red/pink flags for the 12 domains and three of these have been persistent across three successive years. specialist trainees in particular rated it as poor for team culture. A substantial minority, between 25–38% perceived that teaching and learning for trainees was not a key priority.

Summary findings 10.76 Overall, NHS Grampian is clearly struggling to deliver the basic management of both career grade and trainee medical staff. This can be seen by considering the information available for job planning and trainee hours of work. There has also been a failure to plan for foreseeable issues with medical staffing and respond to poor 89

feedback from trainees.

10.77 Many medical staff members mentioned increasing difficulties in recruiting consultants. It is noted that doctors who experience poor training and an unsupportive atmosphere may choose to find consultant jobs elsewhere and not recommend Aberdeen Royal Infirmary to their peers.

Actions taken by NHS Grampian 10.78 We did not see evidence of trainees’ feedback being discussed at NHS Grampian Board meetings and were told that trainee feedback was never discussed by the Board. This is contrary to GMC guidance and it is surprising considering the serious and persistent issues across a range of specialties.

10.79 The annual Local Education Provider report submitted by NHS Grampian in August 2013 (in response to the 2013 GMC National Training Survey results) summarised the following main issues.

• The training quality lead responsibilities have been realigned this year as some work-streams have come to an end. • There have been a number of clinical areas with training and education issues as identified from Deanery visits and triggered by the GMC survey of 2012. The trainee survey of 2013 reports a more positive picture across NHS Grampian. • Patient safety concerns from the GMC survey have been actioned and have further developed links between educational governance and operational hospital management. • Equality and diversity training has been provided by a ‘Dignified Workplace Training Programme’ in some clinical areas. This was in response to the suggestion of ‘undermining’ in an earlier GMC trainee survey. • Some national projects (for example Revalidation and UK Shape of Training review) have provided an opportunity for NHS Grampian to offer an NHS Grampian view on medical education and training. • The annual Local Education Provider report also included the following comments in relation to specialties examined in the review. • In relation to emergency medicine, the reports says: “Deanery visit in May 2013. Training for junior trainees is well supported. Training experience for senior trainees as concern. Although the GMC survey reports one red flag and one green flag. With the opening of the new emergency care centre patient pathway work is ongoing and progressing. Improvement action plans are in place to develop the workforce in emergency medicine.” • In relation to general surgery, it says: “Workload for foundation programme doctors has been identified as an issue. Alternative staffing model is being pursued that will create additional capacity and flexibility.” • In relation to obstetrics and gynaecology, it says: “No problems identified.”

10.80 Given the serious and persistent issues identified, this response is worryingly complacent. In particular, the comments on emergency medicine do not reflect the degree of improvement that NES indicated was required and which the recent re-visit shows has not occurred. During the review visit, individual Board members denied 90

that there was any issue.

Staff governance conclusions 10.81 We concluded that there are considerable medical and nursing staffing difficulties.

10.82 Medical staffing within the emergency department requires urgent attention to maintain safety. Emergency department staffing has been repeatedly raised by consultants in the department and to date the plans to address these have not been adequate.

10.83 Whilst we acknowledge the difficulty in recruiting at both consultant and senior trainee level in this specialty. The failure to address the local issues, particularly issues of training, set out in this section has resulted in doctors leaving Aberdeen. The present arrangements, which depend on cover by registrars from other departments, who may not be trained in emergency or trauma medicine, are not sustainable and are considered by many staff to be unsafe.

10.84 In addition, members of the Board appear to have been unaware of the developing crisis in the emergency department, and this raises serious concern about the adequacy of governance. We are unable to say whether this is because the executive team did not inform the Board or whether the executive team underestimated the problem.

10.85 There are serious issues with the nursing staff numbers. There is variation in the use of national and local workforce planning tools which hampers the ability of NHS Grampian staff to have a complete understanding of their nursing workforce plans. Whilst NHS Grampian has begun to address these issues through a prioritised investment programme, this has not yet produced the staffing levels and skills required.

10.86 We expect NHS Grampian to develop an action plan to address the following recommendations.

Staff governance recommendations 9 NHS Grampian should develop and implement a robust nursing workforce plan using mandated national workforce tools.

These plans should include the following:

● detail on how to ensure that there are sufficient numbers of nurses with the appropriate skill mix at all times in all wards

● detail on how to fill the gaps, with defined dates and hierarchical ordering of wards

● be based on assessed priority. Through this process, nursing staff should be made aware of the most recent results of the national nursing workforce and workload tool

● consideration of the current bed model in the context of a 20% gap between staff establishment in-post and establishment-assessed-as-being-required, especially in the absence of a robust plan to successfully recruit and retain nursing staff, and

● opportunities to create learning and communication sessions with senior charge nurses regarding workforce requirements. This should include positive 91

communication regarding the funded skill mix and patients-per-registered nurse- per-shift ratio.

10 NHS Grampian should develop and implement a robust medical workforce plan.

This plan should include the following.

● have a significant focus on securing full recruitment, including anticipating retirals and proactively working to prevent gaps

● ensure that the experience of trainees in their training is consistently good so that they will be attracted to work in NHS Grampian after completing training

● ensure all consultants and specialty doctors complete a job plan review annually, and have an up-to-date job plan that explicitly and fairly outlines what is expected of them, and

● have a clear and consistent consultant appointment process that includes a list of desirable professional and behavioural characteristics for candidates.

11 NHS Grampian should ensure that the training of trainee medical staff is given a sufficiently high priority, ensuring that the General Medical Council and National Training Survey results are reviewed by the Board.

This arrangement should:

● ensure that adverse trainee survey results are noted and action plans produced to address them in line with the GMC’s mandatory regulatory standards47

● monitor the progress of such action plans

● ensure that particular attention is paid to the current training experience in general surgery and emergency medicine, and

● ensure that trainee rotas are monitored and that valid returns are produced.

47 http://www.gmc-uk.org/The_Trainee_Doctor_1114.pdf_56439508.pdf (Standards 7.2 and 7.3)

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Appendix 1 – Key lines of enquiry

Focus Key line of enquiry

Culture, Leadership, Values • Are roles, responsibilities and accountabilities in relation to and Behaviours improving quality and safety of care, clear across the hospital?

• Are there effective working relationships between senior clinical staff and NHS Grampian senior leadership?

• How does the leadership take account of clinical opinion and views when making decisions?

Accountability, • Can the NHS board articulate its governance processes for Governance and assuring the quality of treatment and patient care and can Performance Management staff at all levels of the organisation describe key elements of the governance process?

• Are the risks to the delivery of safe and high quality care identified and managed?

Translating Strategy into • Is the organisation able to effectively prioritise actions Operational Delivery associated with the quality and safety of care and then implement improvement? If not why not?

Workforce • How does the organisation approach workforce planning to ensure that patient safety is managed effectively including skill-mix?

• How does the organisation ensure staff have the skills to deliver safe and effective care?

Patient and Carer • Is there a culture of proactively and positively engaging Experience with patients to obtain their views?

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Appendix 2 – Interviews and focus groups

Options for providing information on experiences of using or Number of people who working within Aberdeen Royal Infirmary services used this route • Focus groups (6) held in Aberdeenshire and the City, NHS 35 Orkney and NHS Shetland • Aberdeen Royal Infirmary concourse and maternity hospital 203 • Telephone calls 5 • Written correspondence 8 • Link to Survey Monkey 62

Telephone line (Patient Advice and Support Service) 11

Interviews and discussions with Aberdeen Royal Infirmary staff 530

Inpatient interviews 38

Total 892

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Appendix 3 – Clinical areas visited

Clinical areas visited

12–14 August 2014 – Core team visit Emergency surgery Intensive Treatment Unit (ITU) Ward 101 (acute medical assessment) Ward 107 (respiratory medicine) Ward 504 (general surgery) Ward 507 (vascular surgery)

16 September 2014 - Care of the Elderly Ward 102 (geriatric assessment unit) Ward 105 (general medicine) Ward 107 (respiratory) Ward 109 (cardiology) Ward 204 (stroke) Ward 209 (urology) Ward 213 (orthopaedics) Ward 303 (care of the elderly) Ward 304 (care of the elderly) Ward 305 (care of the elderly) Ward 306 (care of the elderly) Ward 507 (vascular)

16 September 2014 - Emergency Medicine Emergency department Ward 216 (cardiothoracic) Ward 303 (care of the elderly) Ward 501 (general surgery elective) Ward 502 (general surgery elective) Ward 208 (ophthalmology/5 Day (Monday – Friday))

16 September 2014 - Obstetrics and Gynaecology Ashgrove Ward (Aberdeen Maternity Hospital) Labour ward (Aberdeen Maternity Hospital) Neonatal unit (Aberdeen Maternity Hospital) Ward 309 (gynaecology/breast)

16 September 2014 – General Surgery, Trauma/Orthopaedics Ward 210 (ears, nose and throat) Ward 211 (short stay surgical) Ward 212 (orthopaedics) Ward 213 (orthopaedics) Ward 214 (plastics) Ward 305 (care of the elderly) Ward 402 (short stay surgical male)

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16 September 2014 – General Surgery, Trauma/Orthopaedics - continued Ward 403 (short stay surgical female ) Ward 501 (general surgery elective) Ward 503 (high dependency unit) Ward 504 (emergency surgery) Ward 505 (emergency surgery) Ward 506 (high dependency unit) Ward 507 (vascular)

Aberdeen Royal Infirmary 16 September 2014 – night visit Labour ward (Aberdeen Maternity Hospital) Neonatal unit (Aberdeen Maternity Hospital) Ward 107 (respiratory) Ward 303 (care of the elderly) Ward 308 (gynaecology/breast) Ward 309 (gynaecology/breast) Ward 501 (general surgery elective) Ward 502 (general surgery elective) Ward 504 (emergency surgery)

9 October 2014 - Critical Care Cardiac ITU General ITU Ward 106 (critical care unit ) Ward 217 (high dependency unit) Ward 503 (high dependency unit) Ward 506 (high dependency unit)

This list excludes the clinical areas visited during the Older People in Acute Hospital inspection of Aberdeen Royal Infirmary and Woodend Hospital on 6–10 October 2014.

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Appendix 4 – Review team

Name Role Organisation Dr Angus Cameron (Chair) Medical Director NHS Dumfries and Galloway Mr Ken Barker Public Partner Healthcare Improvement Scotland Ms Nicky Berry Senior Nurse/Midwife NHS Borders Dr Dave Caesar Clinical Director, Emergency NHS Lothian Medicine Dr Brian Cook Medical Director NHS Lothian Dr Malcolm Daniel Consultant in Anaesthesia & NHS Greater Glasgow and Intensive Care Clyde Dr Frances Dow Lay Member Mr Graeme Foubister Consultant Trauma & Orthopaedic NHS Tayside Surgeon Ms Amy Fox Senior Nurse NHS Fife Ms Clair Gamble Student Nurse University of Abertay Dr Claire Gordon Clinical Director, Acute Medicine NHS Lothian Mr Colin Howie Consultant Orthopaedic Surgeon NHS Lothian Ms Penny Leggat Public Partner Healthcare Improvement Scotland Ms Bette Locke Allied Health Professional Strategic NHS Forth Valley Lead and Service Manager Ms Jennifer Lynch Student Nurse University of Abertay Dr Sheena MacDonald Medical Director NHS Borders Ms Sandra McDougall Head of Policy Scottish Health Council Dr Brian McGurn Consultant Geriatrician NHS Lanarkshire Ms Celia McKiernan Clinical Nurse Manager NHS Lothian Professor Scott McLean Director of Nursing NHS Fife Professor Alistair McLellan Postgraduate Dean NHS Education for Scotland Mr Howard McNulty Public Partner Healthcare Improvement Scotland Mr Robbie Pearson Director of Scrutiny and Assurance Healthcare Improvement Scotland Ms Susan Siegal Public Partner Healthcare Improvement Scotland Mr David Stewart Associate Medical Director NHS Greater Glasgow and Clyde Mr Gordon Thomson Lead Clinical Pharmacist, Urgent NHS Tayside Care and Medicine Dr Katherine Walesby Specialist Registrar, Geriatric & NHS Tayside General Internal Medicine Professor James Walker Consultant Obstetrician and St James’s University Gynaecologist Hospital, Leeds Mr George Welch Associate Medical Director for NHS Greater Glasgow and Surgery & Anaesthetics Clyde

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Healthcare Improvement Scotland staff

Name Role Mr Mark Aggleton Senior Programme Manager Ms Tracy Birch Programme Manager Ms Claire Blackwood Inspector Ms Aileen Bradford Administrative Officer Ms Pamela Campbell Project Officer Ms Sara Jones Project Officer Ms Morag Kasmi Programme Manager Ms Jacqui Macrae Head of Quality of Care Mr Gareth Marr Inspector Dr Simon Mackenzie Clinical Lead for Business Intelligence Head of Data, Measurement & Business Mr Donald Morrison Intelligence Mr Tim Norwood Data & Measurement Advisor Ms Irene Robertson Inspector Ms Edel Sheridan Project Officer Mr Ian Smith Senior Inspector Ms Jane Walker Inspector

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Appendix 5 – Expert advisory group

Name Role Organisation Dr Brian Robson (Chair) Executive Clinical Director Healthcare Improvement Scotland Ms Sarah Ballard-Smith Nurse Director NHS Lothian Professor Derek Bell President Royal College of Physicians of Edinburgh Dr Gordon Birnie Medical Director – Acute NHS Fife Services Mr Duncan Buchanan Head of Service Public Health and Intelligence, National Services Scotland Ms Rosslyn Crocket Director of Nursing NHS Greater Glasgow and Clyde Ms Fiona Dagge-Bell Chief Nurse, Midwife & Allied Healthcare Improvement Health Professional Scotland Dr John Dean Director of Service East Lancashire Hospitals Integration/ Associate NHS Trust Medical Director Dr David Farquharson Medical Director NHS Lothian

Ms Theresa Fyffe Director Royal College of Nursing in Scotland Ms Christine Gilmour Director of Pharmacy NHS Lanarkshire Ms Ruth Glassborow Director of Safety & Healthcare Improvement Improvement Scotland Professor Stewart Irvine Medical Director NHS Education for Scotland Ms Fiona Murphy Associate Director Public Health and Intelligence, National Services Scotland Mr Richard Norris Director Scottish Health Council Professor Rowan Parks Deputy Medical Director NHS Education for Scotland Mr Tom Woodcock Health Foundation Northwest London CLAHRC Improvement Science Fellow Imperial College London

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Appendix 6 – Unannounced inspection of the care for older people in acute hospitals: Aberdeen Royal Infirmary and Woodend Hospital – areas identified for improvement

Areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board must take action when they are not meeting the recognised standard. Where improvements cannot be directly linked to the recognised standard, but where these improvements will lead to better outcomes for patients, we will state that the NHS board should take action.

Treating older people with compassion, dignity and respect NHS Grampian: 1 must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR).

This is to comply with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy – Decision Making and Communication (Scottish Government, May 2010) and SGHD/CMO(2014)17.

2 must ensure all documentation, both nursing and medical, is legible, dated, timed and signed. It should provide details of any assessments and reviews undertaken, and provide clear evidence of the arrangements that have been made for future and ongoing care. It should also include details of information given about care and treatment.

This is to comply with Nursing & Midwifery Council, Record keeping: Guidance for nurses and midwifes (2009) and the Generic Standards of Record keeping Royal College of Physicians 2009.

3 must ensure effective discharge planning begins on, or shortly after admission, and is a continual process.

This is to comply with Clinical Standards for Older People in Acute Care Standard 5c.

4 must ensure that all patients, where clinically appropriate, are treated in accordance with the standards set out in the Clinical Standards for Older People in Acute Care.

This is to comply with Clinical Standards for Older People in Acute Care Standards.

5 should ensure that senior management is aware of the need to support clinical staff, and is able to support them.

6 should ensure that staffing levels are maintained to the levels determined by its own workforce planning analysis. This should also consider the impact of skill mix and workload.

7 should ensure bedrail assessments are carried out consistently. This will make sure that no patients are at risk of falling out of bed or that bedrails are not used unnecessarily

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on patients.

8 should ensure alternative equipment is available for use where it is identified that bedrails should not be used in line with NHS Grampian protocol. This is to ensure that patients at risk of falls are managed in a way that respects their dignity and rights.

9 should ensure the management of patient flow in the hospital is fit for purpose, and maintains patient safety, care and dignity.

Dementia and cognitive impairment NHS Grampian: 10 must ensure all older people who are being treated in accident and emergency or are admitted to hospital are assessed for cognitive impairment.

This is to comply with Clinical Standards for Older People in Acute Care, Standard 2. 3.

11 must ensure guidelines on the management of delirium are available to all staff that care for acutely unwell people.

This is to comply with Standards of Care for Dementia in Scotland.

12 must ensure current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented. In order to do so, all staff who have a professional role in the implementation of the legislation must receive training appropriate to their role.

This is to comply with the Adults with Incapacity (Scotland) Act 2000 Part 5 – Medical treatment and research.

13 must ensure patients identified as having cognitive impairment have a personalised care plan in place. This should identify the specific needs of the patient and how the staff will meet them.

This is to comply with Standards of Care for Dementia in Scotland.

14 must ensure systems are in place to record key personal information about people with dementia or other cognitive impairments. This information should be used and be shared with staff involved in the care of the patient.

This is to comply with Standards of Care for Dementia in Scotland.

15 should ensure that where a welfare power of attorney is identified, the document is checked to establish what powers are held. This will ensure that the decisions being made are within a legal framework.

16 should carry out an assessment to help them identify how way finding around the wards within Aberdeen Royal Infirmary can be made clearer. In order to do this the board should involve patient groups and other interested parties.

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Nutritional care and hydration NHS Grampian: 17 must ensure all patients have their height and weight recorded, and are accurately assessed for the risk of under nutrition, within 24 hours of admission to hospital and on an ongoing basis.

This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.

18 must ensure personalised nutritional care plans are developed, implemented and evaluated for each patient, as appropriate. They should include information about any help the patient needs to eat their meals, where appropriate. The care plans must provide sufficient detail to guide staff on how to help those patients.

This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.7.

19 must ensure patients’ intake of food and fluid is accurately recorded, monitored and that necessary action is taken if a patient’s intake is inadequate.

This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 3.6.

20 should ensure mealtimes are managed in a manner that ensure that patients are prepared for meals and get assistance in a timely manner.

Preventing and managing pressure ulcers NHS Grampian: 21 must ensure patients are assessed for the risk of developing pressure ulcers within 6 hours of admission to hospital, and are regularly reassessed to take account of any developing risks.

This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, section 2.

22 must ensure care planning documentation is improved to provide a clear record of the care required and given to a patient and to show evaluation of that care. This documentation should also demonstrate person-centred and personalised care to meet the needs of individual patients dependent on each patient’s level of risk of developing a pressure ulcer.

This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, section 1.

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Appendix 7 – Glossary

CEL Chief Executive Letter. A Scottish Government letter to NHS board chief executives.

Datix Electronic risk management system. fully upheld, A classification used for the outcome of a complaint. partially upheld, not upheld

General Medical Organisation with statutory responsibility for the regulation of Council (GMC) doctors (http://www.gmc-uk.org/index.asp).

Hospital A measurement tool where mortality data are adjusted to take Standardised account of some of the factors known to affect the underlying risk of Mortality Ratio death. It is calculated as the ratio of the actual number of deaths (HSMR) within 30 days of admission to hospital to the expected number of deaths. key lines of enquiry Detailed questions that help assessors inform their review judgements.

Lanarkshire Quality An electronic performance management recording system. Improvement

Portal (LanQIP)

Medical A tool used to assess medical engagement in management and Engagement Scale leadership in NHS organisations. (MES)

NHS Education for A special health board responsible for supporting NHS services in Scotland (NES) Scotland by developing and delivering education and training for those who work in NHSScotland.

Patient Advice and A service delivered by the Scottish Citizens Advice Bureau Service. The Support Service service is independent and provides free, confidential information, (PASS) advice and support to anyone who uses the NHS in Scotland. It aims to support patients, their carers and families in their dealings with the NHS and in other matters affecting their health.

Pricewaterhouse A company providing independent audit services. Cooper (PwC) probity Being honest and trustworthy, and acting with integrity.

Royal College of A professional membership organisation and registered charity, Surgeons of representing surgeons in the UK and abroad who advance surgical England (RCS) standards and improve care for patients.

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Scottish Patient A national initiative that aims to improve the safety and reliability of Safety Programme healthcare and reduce harm, whenever care is delivered. (SPSP)

Scottish Public The ombudsman is the final stage for complaints regarding most Services organisations that provide public services in Scotland. The Ombudsman (SPSO) ombudsman service is independent, free and confidential. whole-time An estimated measurement of the staff resource available, taking into equivalent (WTE) account full and part-time working, for example a staff member working full-time would be counted as 1 WTE and someone working half the amount of contracted hours per week would be a 0.5 WTE.

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You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Officer on 0141 225 6999 or email [email protected]

www.healthcareimprovementscotland.org

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Argyll & Bute CHP Committee 17 December 2014 Item : 13c Argyll and Bute CHP Clinical Governance and Risk Management Group September 9th 2014 from 1030 hours

Boardroom, Aros, Lochgilphead and by VC

Present:

Lochgilphead: Fiona Campbell, Clinical Governance Manager Michael Roberts, Public Representative Gillian Davies, Practice Education Facilitator Mark Middleton, Health and Safety Manager Kate MacAulay, Clinical Services Manager

Helensburgh: Pat Tyrrell, Lead Nurse (Chair) Elizabeth Reilly, Assistant Dental Director Linda Skrastin, Clinical Services Manager

Oban: Veronica Kennedy, Locality Manager

Dunoon: Viv Hamilton, Locality Manager

NO AGENDA ITEM ACTION

1.0 APOLOGIES

Christina West, Michael Hall, Robin Creelman, Joyce Robinson, Mary Wilson, Donald Watt, Fiona Thomson, Paul Sheard, John Dreghorn

2.0 DRAFT OF MINUTES OF PREVIOUS MEETING

Agreed as accurate and approved.

2.2 ACTION LOG

• Preferred Place of Care Audit Report : KB will send the report to MR KB • VK will arrange for the audit report of expected deaths at LIH to be VK circulated • Follow up with Christina West re ongoing problems with mobile PT telephone signals • Robin Creelman has agreed to take on the chair of this group RC following discussion with Garry Coutts • Care and Comfort Rounds will be spread to Glassary, Campbeltown CSMs and Ward I, following the success from Cowal and Bute • Follow up with Mike Hall re assurance report for NHS Highland Clinical Governance Committee PT • Amend Terms of Reference to include Assistant Director of Dental Services PT CQPS Meeting December 9 th 2014 Item2 • Seek Social Work representation on the group PT

3.0 SCHEDULED REPORTS

3.1 Bute and Cowal

VH highlighted the following:

- recent fire service audit carried out on 18/08 was positive - 3 training sessions held in antimicrobial prescribing - Delays in implementing the SAMTEQ patient feedback booth due to IT challenges - Bute RPIW focussed on the ECCT: standardising processes, single point of access, and use of electronic diary. Already shown improvements in length of time patients wait to be seen and more speedy responses to referrals.

3.2 Helensburgh and Lomond

LS highlighted the following:

- On line focus group on stress being progressed by Julian Gascoigne and Alison McGrory - Team leaders will bring information on Skin Surveillance to locality meeting - HEI action plans have been finalised - Recent baby death in Helensburgh has been subjected to initial case reviews and has highlighted a number of issues related to both Child and Adult protection. The ICR reports are being considered by both the CPC and APC as to whether it meets the criteria for a Serious Case review, for which there are national criteria. VH and LS are VH/LS supporting staff through what is a difficult time.

3.3 Mid Argyll, Kintyre and Islay

KMacA highlighted the following:

- SPSP will be started in Glenaray in October KMACA - Daily huddle will commence in Mid Argyll week beginning September 15 th to look at best use of resources across the hospital - High falls rates in Glassary ward have been reviewed by Wendy O Ryan and Christine McArthur and actions identified - Pressures in maintaining staffing within the local Chemotherapy service are being addressed - The local CMHT won the first monthly HQA award - MR asked if we might consider using CCTV to monitor patients in in- patient facilities to identify falls risks. PT said that we could further extend use of telecare to support easier monitoring within both hospitals and care home settings.

3.4 Oban, Lorn and Isles

VK highlighted the following:

2 CQPS Meeting December 9 th 2014 Item2 - Trying to establish pool car preparation for winter months, to have VK box in each car to deal with winter weather - Decontamination facility opened in LIH yesterday. Company called back in today to deal with problems - Fire Safety audit carried out last week with positive results. Work on compartmentation continues - 3.5 CHP Committee reports

PT highlighted following:

- No SABs, 6 CDIs (5 patients, one recurrence) - Antimicrobial audit to be repeated over the next 3 months PT - Training in powered visors underway in each hospital - Further analysis of V&A incidents underway to identify further actions that are needed - Gillian Davies is pulling together the information on incidents related GD to self harming behaviour; this will be included in the next CQPS report for CHP Committee - There has been a decrease in overall number of hospital acquired pressure ulcers - Proposal on new model for obstetric scanning will go to Core Management Team in November/December PT - Unicef reassessment of Argyll and Bute’s Baby friendly status was very positive and reaccreditation was received - Mental Welfare Commission visit to Argyll and Bute Hospital and downstairs wards in Mid Argyll Hospital – report will be available for JD the next meeting of this group - Health and Safety risk assessments monitoring will be completed by JG/MM the end of September

3.6 Maternity Services

PT highlighted the following from the workplan:

- This was agreed by the NHS Maternity Services Strategy group - Development of the plan involved all the senior midwives and the A&B Maternity Services Development Group (MSDG) - Discussed how the plan can be picked up at locality level - VH suggested that it should go to each of the Locality Executive PT groups - PT said that the report will be monitored through the MSDG

5.3 Transfer of Patients for Mental Health services

This item was taken earlier as GD had to leave the meeting. She reported that following the Options Appraisal carried out in 2013 decision was made to develop the supported transfer service with additional 2 staff members on duty in A&B Hospital. In the 7 month period since its inception there have been 39 admissions to A&B, an increase of 143%. There have also been 43 incidents reported during this time period. OLI and C&B are the busiest localities, generating the most requests for transfers. Some of the incidents have related to lack of availability of ambulances. John Dreghorn and Paul JD/PS

3 CQPS Meeting December 9 th 2014 Item2 Sheard are due to meet with clinicians in both Cowal and Bute to discuss the pathway and identify actions that can improve the current service. VK raised the need for each locality to review what is happening and this could feed into the CHP group which JD will chair. GD identified that training for staff in locality hospitals can improve confidence in dealing with people presenting in mental health crisis. PT asked if the overall number of detentions had increased. It does not appear as though this is the case. KMacA suggested that GD look at the length of detention to identify if it changed on admission GD to hospital. GD will also look to work with ACUMEN to audit patient experience of transfer. It was also agreed that the report should go to Core JD Management Team.

6.2 Risk Assessment and Management in Mental Health

GD reported that training has been provided for up to 55 staff in mental health in the use of the Sainsbury Risk Assessment. Evaluations from the training sessions are extremely positive, with all staff reporting increased confidence post-training and awareness that the newer risk assessments will indeed add value and strengths to mental health care in the future.

A number of operational issues were raised during the training sessions, which include: The wish for an operational policy to support the new Sainsbury Level 1/2 documentation, an integrated approach to positive risk taking, regular training with updates/supervision and the sharing of learning from significant event reviews/lessons learned etc.

We have established a short life working group to establish some guidance and development of an operational policy in support of positive risk taking GD and assessment/management in the future.

JD will share the draft Risk Taking policy at Joint Managers’ meeting in JD September. It has also been shared with NHS Highland Mental health Operational group.

4. PERSON CENTRED

4.1 Caring Connections

PT highlighted the work that has been progressed through the Caring Connections, person centred network. Audrey Birt will commence the training for those identified to become Person centred coaches in October. The first conversation café is due to take place in Kames on September 15 th 2014. Each PC coach will be asked to support at least one conversation café on completion of their training. We will evaluate the impact of the conversation café and consider how we will spread across Argyll and Bute, based on eh outcomes of this first session. We are also keen to develop induction standards for all staff coming to work in health and social care in Argyll and Bute. We have looked at the model developed in South Central Alaska and are keen to look at a modified form of this to make sure that everyone working in A&B is clear about the values and behaviours that are expected in delivering health and social care services.

4.2 Hello, My Name Is….

4 CQPS Meeting December 9 th 2014 Item2

FC highlighted the background to this initiative, explaining how Dr Kate Granger had observed huge variation in how she was dealt with by health care professionals during the treatment phase of her own illness, having worked as doctor in the NHS herself before this. The campaign has been launched and promoted through social media. All areas have been asked to discuss this with staff and to raise awareness of the importance of good, clear introductions to patients and members of the public. FC is attending the FC next meeting of the OLI PPF to discuss. She is also looking at how we might carry out an audit within one department, possibly out-patients. LS reported FC that she has ordered badges for all staff in Helensburgh bearing the Hello My Name is logo.

4.3 NHSH Person Centred Care Conference

VH reported that she and FC attended the NHSH Conference in August. Over 60 people attended and heard a variety of patient stories and considered the actions that could be progressed. Raigmore Hospital will trial flexible visiting times. Gareth Adkins from HIS has offered his support to A&B in looking at how we measure the impact of our actions. VH will set up VH meeting with him and the CC steering group.

5. QUALITY AND SAFETY

5.1 Mid Argyll HEI Inspection

PT highlighted that the draft report has been received and comments returned to HEI on some areas of inaccuracy. The final report will be published on the HIS website on September 23 rd . KMacA reported on the actions that have been taken to address the requirements and recommendations. New mattresses and covers have been ordered for A&E. One mattress has been taken out of use in the CMU. More robust mattress inspection programme has been instituted. PPE issues addressed in the downstairs wards. Review of hand gels has been carried out and changes made accordingly. Issues related to cleaning schedules, linen and stock rotation have been addressed – in addition the SICP audits have been commenced in the CMU and reporting systems for audit results instituted. Meeting to review the role of the ICNs in supporting local hospitals will take PT place later this week.

5.2 Lorn and islands Hospital Report

VK highlighted that many of the actions of the report have been progressed. It was agreed that this report would be very usefully replicated for all other hospitals. Discussed the need for better monthly collation of quality and safety information for each hospital. PT reported that she has discussed with Heidi may but there appears to be capacity issues in being able to progress this. It was agreed that written update on the LIH report be available for the VK next meeting of this group in December.

5.3 Transfer of Patients for Mental Health services Covered earlier on agenda

5 CQPS Meeting December 9 th 2014 Item2 5.4 SPSP

There has been delay in progressing the mortality reviews due to lack of capacity. We are due to support the reviews to be carried out in Lochgilphead as well. Mary Anne Gillies was due to provide additional training but she has been off sick for sometime now. KMacA will discuss this KMACA with DW to se how it can be progressed.

5.5 Public Improvement Facilitators

PT discussed the draft proposal on how we might develop the role of Public Improvement Facilitators in Argyll and Bute. The role of the Public Improvement Facilitator will include the following:

- visits to hospital wards and departments - observation of the environment - observation of staff interactions - observation of staff and patient interactions - observation of information available - interviews with patients and carers - immediate feedback to Senior Charge Nurses/ Heads of Departments and Clinical Services Managers

PT outlined the recommendations:

1. Develop the role descriptor for the Public Improvement Facilitator 2. Develop the training programme for the role 3. Test the approach in Lorn and Islands Hospital 4. Based on findings, develop plan for introduction to all hospital in Argyll and Bute 5. Consider how the role can also support primary and community care services as well

These were supported by the group, VK happy to test the approach in LIH. PT will feedback to RC who has been in touch with Susan Brimelow to PT identify how training might be progressed.

RISK MANAGEMENT

6.1 SERs

FC identified that 4 incidents were reviewed, 2 as SERs, since June. The 2 SERs related to transfer of a patient with mental health problems from Bute and unexpected death of patient from Kintyre. The other 2 related to a helicopter transfer and an issue to do with medication in Bute. There were 5 SER meetings, each of which has generated its own action plan. FC highlighted the administrative burden created in monitoring the action plans and in ensuring completion of the actions. FC is giving further consideration FC to this and will present suggestions for improvements at next meeting.

6.2 Risk Assessment and Management in Mental Health

6 CQPS Meeting December 9 th 2014 Item2 Covered earlier on the agenda

6.3 Risk Register

FC highlighted the use of Smartsheet to test a more dynamic approach to maintaining the risk register. PT said that this had been raised at Core Management Team and it was agreed to have short development session for Core Management Team. FC will arrange with CW. FC/CW

7.0 FEEDBACK

7.1 Complaints Responses

Discussed ongoing work to improve the quality of the responses to complaints; this has resulted in long delays in getting the responses completed. Further training and coaching for managers is needed to ensure that all those responding to complaints have the skills and confidence required to provide person centred investigations and responses to the issues raised. PT said that it is also important that all staff understand the principles which underpin how we deal with complaints as they can feel let down by the organisation when we apologise for gaps in care experience. FC/PT

7.2 Health and Care Experience Survey 2013-2014

This report was shared with the group. All managers are asked to identify the LMs key issues affecting experience of care in their areas and to consider how the information can be used to address some of the recurring themes, especially those about access to GPs and being involved in decision making with regard to their care.

7.3 In Patient Survey- CCH/LIH

The latest reports on patient experience of hospital in patient services are generally positive with hospitals in Argyll and Bute having higher scores than the Scottish average. There are still some recurring themes within the reports that indicate we are still not making it clear to patients who is in charge of each shift, patients are still affected by noise in the wards during the day and night and discharge planning experience is not as informed and person centred as it could be. Each hospital is developing its action plan to address CSMs the findings.

8. 0 FOR NOTING

8.1 Complaints Policy

8.2 Internal Audit- Complaints Management

8.3 ACF Response to Francis Report

7 CQPS Meeting December 9 th 2014 Item2

9.0 ANY OTHER BUSINESS

VK reported that this will be her last meeting as she will be retiring from her post in December. Donald watt will report at the next meeting for OLI. PT thanked VK for her input to this group, recognising the strong focus that VK had on clinical governance. MR asked if there were PPF members on each of the locality groups. It appears as though this is the case in OLI and MAKI but not in H&L and C&B. VH will follow this up. VH

8.0 DATE OF NEXT MEETING

Tuesday 9 th December 2014 at 1030 in the Boardroom, Aros, Lochgilphead and by VC.

8 CQPS Meeting December 9 th 2014 Item2

CGRM ACTION LOG- SEPTEMBER 2014

NO ACTION WHO 1. Send report on Preferred Place of Care to Michael Roberts KB 2. Share audit report of expected deaths in LIH with this group VK 3. Discuss ongoing issues with mobile telephone reception with Christina West PT re inviting Louise Mills to attend Core Management team 4. Take on Chair of this group from next meeting RC 5. Spread care and comfort rounds to Glassary, Campbeltown and Ward I CSMs 6. Follow up with Mike Hall re assurance report for NHSH CG Cttee PT 7. Amend Terms of Reference for this group to include Assistant Director of PT Dental services 8. Seek SW representative for this group PT 9. Commence SPSP in Glenaray in October KMACA 10. Complete pool car preparation for winter time VK 11. Arrange antimicrobial audit to be undertaken PT 12. Complete report on self harming incidents in A&B hospital GD 13. Proposal on new model for Obstetric Scanning to go to Core Management PT Team in December 14. MWC report on A&B and Mid Argyll to come to next meeting in December JD 15. Complete H&S Risk Assessment monitoring by end of September JG/MM 16. Share Maternity Services workplan with Locality Executive Groups for PT Children’s Services 17. Meet with clinicians in Cowal and Bute re Emergency transfers of patients to JD/PS A&B 18. Review length of detentions for patients admitted to A&B hospital GD 19. Identify audit of patient experience of emergency transfer to A&B GD 20. Take report to CHP Core Management Team JD 21. Develop operational policy on risk taking GD 22. Share risk taking policy with Joint Managers group in September JD 23. Attend OLI Locality PPF to discuss Hello My Name Is…. FC 24. Identify audit of practice in relation to Hello My Name Is….. FC 25. Organise meeting with Gareth Adkins from HIS VH 26. Review the role of ICNs in supporting locality hospitals in Argyll and Bute PT 27. Complete written report on Quality and Safety review of LIH for December VK meeting 28. Agree next steps re Public Improvement Facilitators with Robin Creelman PT 29. Suggest improvements in SER processes for next meeting FC 30. Arrange development session on Risk Register for Core Management Team FC/CW 31. Identify actions to improve responses to complaints PT/FC 32. Consider findings of Health and Care Experience Survey and actions to be LMs taken locally 33. Complete action plans to address findings of recent in patient experience CSMs survey 34. Review public involvement in Locality Quality and Safety meetings VH

9 Item : 13f NHS HIGHLAND QUALITY AWARD SCHEME

OVERVIEW

NHS Highland is looking to reward and promote the spirit and values captured in the Highland Quality Approach.

We will take nominations from staff, patients, carers and the wider public for an individual or team employed by NHS Highland, or working as part of the wider NHS. The Award will reflect on an individual or team, who has demonstrated actions and behaviours which epitomise everything about the Highland Quality Approach.

Whilst all staff strive to do a great job and provide outstanding care and compassion on a daily basis, this award will reflect actions and behaviours that demonstrate quality improvement, or where individuals or teams have gone out of their way to provide quality care, in support of the Highland Quality Approach.

HIGHLAND QUALITY AWARD PROCESS

We plan to make this a monthly award and in order to select the winning individual or team each month, we will bring together a small panel. This will be made up of a member of NHS Highland Board, the Chief Executive, the Employee Director, the Quality Improvement Lead for Staff Experience, and a member of staff who has already achieved recognition through an award for Quality, as a panel to assess the nominations.

Individuals can be nominated by staff members, patients or members of the public for this award within each month timeframe. The closing date will be at midnight on the last day of the month with the panel agreeing the winning individual or team within 10 days of the closing date.

Nominations can be by written or be by electronic submission to NHS Highland on the generic email or postal address. The winning nomination will then be posted on our website with a citation from the proposer. Nominations should be made on the standard template within the limited number of words which is available on our website. If it is not possible to use the standard template then we will accept other nominations but this should be checked in advance with the Quality Improvement Lead (Staff Experience) e-mail [email protected]

The proposer and winning individual or team will be notified by email or letter at the same time and invited to attend a small and informal celebration of the achievement. There will be a small token of recognition which will be for the individual or team to keep.

HQAaward2014 Ver:02

Item : 13f

HOW THE HIGHLAND QUALITY AWARDS SCHEME WILL WORK

1. The nomination for a Highland Quality Approach is open to all staff

2. Support can be provided to nominate individuals utilising the standard template through the Board Secretariat on 01463 704868 or via the Quality Improvement Lead (Staff Experience) e-mail – [email protected]

3. Completed forms must be returned to the following address

Highland Quality Awards, NHS Highland, Assynt House, Beechwood Park, Inverness, IV2 3BW

4. Nominations cannot be made for family members

5. Nominees must be notified by their proposers in advance of the nomination being considered by the panel

6. Winning individuals or teams cannot be selected again for twelve months.

7. Nominations which are not successful within any given month will not be contacted. They will also not be held over for future months but can be updated and resubmitted for consideration for future awards.

8. The decision of the panel is final. It would be preferable if nominees would agree to have their photograph taken for both internal and external communication purposes.

9. The scheme may change overtime and we would welcome any suggestions

You can find out more about the Highland Quality Approach on NHS Highland website

HQAaward2014 Ver:02

Item : 13f

NHS HIGHLAND QUALITY AWARD SCHEME

Nomination Form

Name of nominee -

Nominated by –

Date of nomination -

Please describe why you believe the nominee should receive this months Highland Quality Award.

In describing this you should clearly state what and where they have done this. This should be work which has or is significantly improving the quality of the service or care provided and clearly in line with the Highland Quality Approach.

HQAaward2014 Ver:02

Argyyll & Bute CHP Committee 17 December 2014 Item : 13d ARGYLL AND BUTE HEALTH AND SOCIAL CARE PARTNERSHIP

Issue 2 December 2014

Welcome From the New Chief Officer I would like to welcome you to the December edition of the Health and Social Care Partnership integration newsletter. This is our second edition and we will be producing a newsletter every month for the foreseeable future to ensure you are kept informed of the latest integration developments The newsletter is only one of the methods that we are using to keep people informed of the progress with integration. We have also had articles in the local media, information events, the integration website as well as information on the NHS/Council websites as well. We would also like to develop future editions of the newsletter with you so if there are any aspects of health and social care that you would like more information on please let us know so that we can include relevant articles in future editions. As usual, if you would like to contact us about integration or if you have any questions then email us at: [email protected]. Christina West - Chief Officer

Draft Integration Scheme Consultation Our Vision - By April 2015 we will have a Health and Social Care Partnership in place to support us to achieve the vision. We will work together to help people in Argyll and Bute live longer, healthier, independent lives. We would like to achieve this vision - with you. Please Give us Your Views - We need your views to ensure future health and social care services meet your needs. Your voice can make a difference. We would be grateful if you could take a couple of minutes to answer a short anonymous survey on the draft integration scheme. A copy of the scheme is available at www.tinyurl.com/lyskq6x and you can fill out the survey online using SurveyMonkey at www.tinyurl.com/p4dapqv or you can use the copy attached to this newsletter and post it back using the Freepost address. What is in the Integration Scheme - The Integration Scheme sets out how we will work together to deliver effective integrated services. It is the legal document that must be approved by the Scottish Ministers, giving us the legal authority to set up a Health and Social Care Partnership. It is written in the format that the Scottish Government requires all partnerships to use. The detail in the scheme is deliberately broad, to allow for flexibility where it would benefit the delivery of services. More specific details such as workforce plans, operational plans and management structures will be set out in the three year Strategic Plan that will be developed. Please let us know what you think about the integration scheme by 23rd December. If you have any questions or further comment, you are welcome to get in touch with us at [email protected]

WORKING TOGETHER WITH YOU www.healthytogetherargyllandbute.org

Page 2 ARGYLL AND BUTE HEALTH AND SOCIAL CARE PARTNERSHIP

Integration Information Drop in Events A series of information drop in events, which were publicised in our previous newsletter, are being held across Argyll and Bute during the month of December. These events form one part in our overall engagement strategy with the public and staff. Senior managers from both the NHS and the Council have been present at these events to answer any questions and discuss any issues with people who turned up on the day. The events have so far been well received and have been attended by a wide variety of individuals from across the communities in Argyll and Bute. These events were targeted mainly at the public although staff were welcome to attend as well. There will also be a future round of information events from Mid January onwards targeting staff across both organisations. Details of these will be widely publicised nearer the time.

Did You Know? News in Brief An integration website has now been launched 23% of people in Argyll and Bute (details below) and it will be continually (approximately 23,000 people) are aged 65 developed and updated on a regular basis as or over. the integration project develops. The latest population projections for Argyll If you would like to find out the latest news and Bute show that the proportion of about the project then please take a few people aged 75+ will increase significantly, minutes now and then to check out the latest whilst the proportion of younger and updates at: working aged people decline. www.healthytogetherargyllandbute.org

Next Edition In the next edition of the integration newsletter we will be feeding back some of the suggestions that have been sent in which you would like us to discuss. The integration of Health and Social Care is also all about people; the people who deliver services and the people who use our services. It is therefore important that we give you some real examples of the difference that integrated services will make so watch out for this in the next edition.

If you would like to receive this newsletter New Integration Website directly by post, email or in an alternative format/language please contact us at: www.healthytogetherargyllandbute.org [email protected]

WORKING TOGETHER WITH YOU www.healthytogetherargyllandbute.org Argyll & Bute Health & Social Care Partnership

YOUR VIEWS!

We want to hear your views on the forthcoming Integration of Health & Social Care in Argyll & Bute

Why?

We need your views to ensure that future health and social care services in Argyll & Bute meet your needs. This is where your views are important and of great value. Your voice can make a difference!

How can you do this? Complete this feedback form and return it to the FREEPOST address on page 2

complete the feedback form online at https://www.surveymonkey.com/r/IntegrationArgyllButeFeedback  email us your story / views to [email protected]

Your feedback will be confidential. By that we mean :

we will not name you in the document we will create of the views we receive if you share your views but you do not want these to be part of the public record of the feedback we receive, we will respect that and your views will not be included

Q1 Having looked at the Argyll & Bute Health & Social Care Partnership Aims, Vision and Values, do you … Agree with these Disagree with these Don’t know

Is there anything missing?

Please turn over Q2 What do you think about health and social care coming together as one organisation?

Do you see any benefits? Disadvantages? Please turn over

Q3 As we work on our Three Year Strategy (the plan that will outline how we will work in partnership and deliver services based on our aims, visions and values), we want to develop services with you at the heart of this. Do you have any comments, concerns or suggestions which will help us deliver services for you, with you?

Q4 Do you have any other comments, ideas, concerns or questions? (Please continue on a separate sheet if necessary)

We welcome your more detailed comments, ideas, concerns or questions. Please attach them to this sheet

Please return this feedback form no later than Tuesday 23rd December 2014 to :

Caroline Cecil Planning & Public Involvement Manager FREEPOST RRYT-TKEE-RHBZ NHS Highland (Argyll and Bute CHP) Blarbuie Road, LOCHGILPHEAD, Argyll, PA31 8LD

If you need help completing this form or to receive a copy in a different language / format (e.g. large print) contact Caroline  01546 605635 or [email protected]

Thank you