Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Date of Issue: Typetalk: Tel 0800 959598 23 November 2012 www.nhshighland.scot.nhs.uk HIGHLAND NHS BOARD

MEETING OF BOARD

Tuesday 4 December 2012 at 8.30 am Board Room, Assynt House, Beechwood Park, Inverness

AGENDA

1 Apologies

1.1 Declarations of Interest – Members are asked to consider whether they have an interest to declare in relation to any item on the agenda for this meeting. Any Member making a declaration of interest should indicate whether it is a financial or non-financial interest and include some information on the nature of the interest. Advice may be sought from the Board Secretary’s Office prior to the meeting taking place.

2 Minutes of Meetings of 2 October and 6 November 2012 and Action Plan (attached) (PP 1 – 24) The Board is asked to approve the Minute.

2.1 Matters Arising

3 PART 1 – REPORTS BY GOVERNANCE COMMITTEES

3.1 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 31 October 2012 (attached) (PP 25 – 40) 3.2 Highland Health & Social Care Governance Committee Assurance Report of 1 November 2012 (attached) (PP 41 – 54) 3.3 Highland Health & Social Care Governance Committee – Terms of Reference for approval by the Board (attached) (PP 55 – 58) 3.4 Clinical Governance Committee – Draft Minute of Meeting of 13 November 2012 (attached) (PP 59 – 68) 3.5 Improvement Committee Assurance Report of 5 November 2012 and Balanced Scorecard (attached) (PP 69 – 80) 3.6 Area Clinical Forum – Draft Minute of Meeting held on 27 September 2012 (attached) (PP 81 – 88) 3.7 Asset Management Group – Draft Minutes of Meetings of 18 September and 23 October 2012 (attached) (PP 89 – 96) 3.8 Pharmacy Practices Committee (a) Minute of Meeting of 12 September 2012 – Gaelpharm Limited (attached) (PP 97 – 118) (b) Minute of Meeting of 30 October 2012 – Mitchells Chemist Limited (attached) (PP 119 – 134) The Board is asked to: (a)  Note the Minutes. (b)  Note the Assurance Reports and agreed actions from the Highland Health & Social Care Governance Committee and the Improvement Committee. (c)  Approve the Terms of Reference for the Highland Health & Social Care Governance Committee.

Council/Highland NHS Board Joint Committees

3.9 Argyll & Bute Health & Care Strategic Partnership – Minute of Meeting of 3 October 2012 (attached) (PP 135 – 142) 3.10 Highland Council Partnership – Adult & Children’s Services Committee – Minute of Meeting of 26 September 2012 (attached) (PP 143 – 164) The Board is asked to:

 Note the Minutes.

4 PART 2 – THE HIGHLAND QUALITY APPROACH

4.1 The Highland Quality Approach (a) The Highland Quality Improvement System Presentation by Anne Gent, Director of Human Resources, Gill McVicar, Director of Operations, North & West and Linda Kirkland, Head of Business Transformation

Presentation on the Highland Quality Improvement System and how NHS Highland plans to build both capacity and capability to deliver the Highland Quality Approach.

(b) Feedback from visit to Torbay Care Trust Presentation by Jan Baird, Director of Adult Care

Feedback from recent visit by Senior Managers to Torbay and Southern Devon Health and Care NHS Trust.

The Board is asked to:

 Note the Presentations

2 4.2 Developing a Framework for use of Social Media in NHS Highland Report by Maimie Thompson, Head of Public Relations and Engagement on behalf of Elaine Mead, Chief Executive (attached)

The rise of social media has the potential to significantly change the way NHS conducts elements of its communications. Millions of people use social media every day and it is becoming an increasingly important communication tool. (PP 165 – 172) The Board is asked to:

 Note the context and background for the use of social media by NHS Highland as part of wider communications and engagement strategy.  Be aware of the benefits, risks and considerations.  Endorse the recommendation to explore the principle of opening up social media in the work place, initially through controlled access.

5 PART 3 – CORPORATE GOVERNANCE / ASSURANCE

5.1 Register of Interests of Members of Highland NHS Board

The Highland NHS Board Code of Conduct was formally adopted by the Scottish Ministers from 1 May 2003. Under its terms, Board Members are required to Register their interests in the Highland NHS Board Register. An exercise to update the register has now been undertaken and the formal Highland NHS Board Register will be tabled for information. The Register is kept available at the Board’s offices for public inspection.

The Board is asked to Note the position.

5.2 NHS Highland Financial Position as at 31 October 2012 Report by Nick Kenton, Director of Finance (attached) (PP 173 – 184) The Board is asked to:

 Note the current forecast remains break-even by the end of the financial year.  Note an improvement in the forecast operational position of £5.1m from the August position, reported to the Board in October.  Note the need for further improvements within the financial position of £6.9m by the end of the year, split between; - NHS Care £4.9m - Adult Social Care £2.0m

5.3 NHS Highland Annual Accounts 2011/12 Report by Nick Kenton, Director of Finance (attached)

The 2011/12 Annual Accounts were considered by the Audit Committee on 18 June 2012 and subsequently approved by a special In Committee meeting of the Board on that day. Following this process, the Accounts were submitted to the Scottish Government, for onward submission to the Scottish Parliament, where the NHS Highland Annual Accounts have now been approved. (PP 185 – 186)

3 The Board is asked to:

 Note the 2011/12 year end position for NHS Highland.  Note the completion of the audit work, the approval of the Accounts by the Board In Committee on 18 June 2012, and the subsequent Parliamentary process.

5.4 Update on Scottish Budget Report by Nick Kenton, Director of Finance (attached)

This report is to inform the Board of any potential implications that the draft Scottish Government budget for 2013-15 has for Highland NHS Board’s financial revenue plans as set out in the Local Delivery Plan. (PP 187 – 188) The Board is asked to:

 Note the draft Scottish Government Budget 2013-15 and its impact on the Board’s Local Delivery Plan.

5.5 Dingwall Health Centre Business Case Report by Michael Waters, Capital Support & Project Manager on behalf of Nick Kenton, Director of Finance (attached)

This Standard Business Case covers a revised Phase 3 to complete the redevelopment of Dingwall Health Centre, which had previously been approved from within the Board’s Capital allocation with a start date in 2010. Phases 1 and 2 have been completed but, due to the restricted availability of capital, Phase 3 could no longer be funded from within the Board’s formula Capital allocation. A revised Phase 3 solution has been agreed with the users within the £1.5m allocation agreed by the Scottish Government.

Please note that due to the size of the Business Case this has not been circulated. A link to the full document will be e-mailed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP 189 – 190) The Board is asked to:

 Approve the attached Standard Business Case for the final phase of development of Dingwall Health Centre.  Agree that the Standard Business Case can now be submitted to the Scottish Government Capital Investment Group for their approval.

5.6 NHS Highland – Proposed Implementation of the National Patient Management System (PMS) Report by Bill Reid, Head of eHealth on behalf of Deborah Jones, Chief Operating Officer (attached)

Implementation of the nationally procured Patient Management System across NHS Highland is a key component of the current NHS Highland eHealth Delivery Plan. It is planned that implementation will commence in the 2013/14 financial year. (PP 191 – 228

4 The Board is asked to:

 Agree the need for replacement of the current legacy Patient Administration Systems with a modern Patient Management System;  Consider the more detailed content of the attached draft Business Case;  Agree that NHS Highland commence implementation of the National Patient Management System from April 2013;  Agree the required local funding to allow the implementation to commence.

5.7 Carbon Management Plan Report by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance (attached)

The Carbon Management Plan attached sets some challenging priorities to contain and reduce our energy costs and reduce our impact on the environment.

Please note that due to the size of the Carbon Management Plan this has not been circulated. A link to the full document will be e-mailed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP 229 – 232) The Board is asked to:

 Approve the NHS Highland Carbon Management Plan.  Approve the target of a 33% Carbon reduction by 2016.  Note the progress made in improving our Carbon management arrangements.  Support the improved arrangements for local responsibility for Carbon Management.

5.8 Restorative Dentistry Report by Roseanne Urquhart on behalf of Ian Bashford, Medical Director (attached)

The Board is asked to confirm approval of the business case for restorative dentistry that was developed in collaboration with North of Scotland (NoS) colleagues. The business case has been agreed in principle by the NHS Highland Executive Group. (PP 233 – 262) The Board is asked to:

 Confirm approval of the business case for restorative dentistry that was developed in collaboration with North of Scotland colleagues.

5.9 Infection Control Report Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control (attached) (PP 263 – 284) The Board is asked to:  Note the performance position for the Board.  Note the progress to keep infection under control.

5 5.10 Chief Executive’s and Directors’ Report Emerging Issues and Updates Report by Elaine Mead, Chief Executive (attached)

This month’s report incorporates updates on:  Development of Primary Care Services in Tain – Outline Business Case Addendum  Letter from Minister on NHS Highland Annual Review  Regional Planning – West of Scotland Planning Group (PP 285 – 294) The Board is asked to:  Note the Emerging Issues and Updates Report.

6 FOR INFORMATION

6.1 Date of next meeting

The next meeting of the Board will be held on 5 February 2013 in the Board Room, Assynt House, Inverness.

6.2 Any Other Competent Business

7 Close of Meeting

6 1 Highland NHS Board 4 December 2012 Item 2(a) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD 2 October 2012 – 8 30 am Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Mr Bill Brackenridge Mr Robin Creelman Dr Michael Foxley Mr Ian Gibson Dr Iain Kennedy Mr Alasdair Lawton Cllr John McAlpine Mrs Gillian McCreath Mr Okain McLennan Mr Colin Punler Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy

Also present Mr George Ashton, School Pupil, Charleston Academy (Item 123) Ms Deborah Jones, Chief Operating Officer Mrs Linda Kirkland, Head of Business Transformation Mr Calum MacMillan, School Pupil, Millburn Academy (Item 123) Ms Ruth Mantle, Dementia Nurse Consultant (shadowing Board Nurse Director) Mr Kenny Oliver, Board Performance Manager Ms Moira Paton, Head of Community and Health Improvement Planning (Item 121) Mr David Paulin, Merkinch Partnership (Item 122) Mrs Lorraine Power, Board Services Assistant Ms Janet Spence, Programme Manager (Modernisation and Quality Assurance) (tem 128) Mrs Cathy Steer, Head of Health Improvement (Item 122) Mr Simon Steer, Head of Community Care Integration (Item 129) Ms Anne Sutherland, Merkinch Partnership (Item 122) Ms Maimie Thompson, Head of Public Relations & Engagement Dr Emma Watson, Director of Medical Education (Item 123)

Apologies – Apologies were received from Dr David Alston, Dr Ian Bashford, Mrs Jan Baird, Mr Mike Evans and Mrs Myra Duncan.

Welcome – The Chair welcomed Ruth Mantle, Dementia Nurse Consultant, to the Board meeting. Ms Mantle was currently shadowing Ms Heidi May, Board Nurse Director.

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105 Declarations of Interest

Board members declared the following interests:

 Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  Ian Kennedy – member of the British Medical Association (BMA), Riverside Medical Practice  Ray Stewart – Member of Unite and Staffside Chair

The Board a Noted the Declarations of Interest.

106 Minute of Meeting of 14 August 2012

The minute of meeting held on 14 August 2012 was approved, subject to the following amendments:

 Infection Control Annual Work Plan, Item 93, page 56 – to include that a report on items highlighted red and amber on the 2011/12 workplan and not picked up in the 2012/13 workplan would be reported back to the Board.  The Highland Quality Approach – Developing our Values and Behaviours, Item 99, page 59 – to amend the wording “Staff Governance Standard which puts more rights and responsibilities on staff” to read “Staff Governance Standard which places responsibilities as well as rights on staff”.

The Board a Approved the Minute of Meeting held on 14 August 2012, subject to the minor amendments b Noted that a report on items highlighted red and amber on the 2011/12 Infection Control workplan which were not picked up in the 2012/13 workplan would be reported back to the Board.

107 Matters Arising

There were none.

REPORTS BY GOVERNANCE COMMITTEES

108 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 29 August 2012

Mr Creelman, Chair of Argyll and Bute CHP advised that the August meeting had been held in Mull and the Committee had visited the Mull Progressive Care Unit. He updated on the meeting, including Clinical Governance and Risk Management, the management of Significant Adverse Events, the financial position and the eKSF trajectory.

109 Highland Health & Social Care Committee – Draft Minute of Meeting held on 7 September 2012

Mr Ian Gibson, Chair of the HH&SC Committee updated on the first meeting of the Committee. There had been discussion around identifying baseline figures, the form of reporting to the Committee and ensuring that any outstanding issues from the previous CHP Committees were

63 3 taken forward. The Chief Operating Office had also given a presentation on to the Committee in relation to reporting and assurance, outlining the principles of both governance and assurance. There had also been discussion on Home Care and Care Homes and the Health & Social Care Committee Risk Register. Dr Iain Kennedy highlighted the reference on the first page of the minute that nominations were still to be received from the Area Medical Committee (AMC) and Area Dental Committee. He advised that there had been recent AMC Elections and that Mr Quentin Cox and Dr Chris Williams (GP) had been nominated by the Area Medical Committee in relation to membership of the Highland Health & Social Care Committee. An Area Dental Committee representative was still to be identified. Mr Gibson advised that he hoped to receive a nomination from the voluntary sector by the next meeting. The Chair advised that NHS Highland aimed to have appropriate representation on the various governance committees and requested that the Chief Executive and Head of Public Relations and Engagement ensure there is appropriate patient / public and voluntary representation on this and other governance committees over the coming months.

110 Audit Committee – Draft Minute of Meeting held on 11 September 2012

In the absence of Mike Evans, Chair of the Audit Committee, Mr Okain McLennan updated on the meeting. Topics discussed included the Risk Register, the Service Level Agreement between Argyll & Bute CHP and NHS Greater Glasgow & Clyde and clinical governance arrangements in relation to internal audit reports. Mr McLennan referred to page 6 of the minute, item 4.6 in relation to the Laboratory Managed Service Contract Review and highlighted the need to include the word “no” prior to the word “evidence” in the third sentence of the first paragraph. The Chair advised that if the issue with Greater Glasgow & Clyde NHS was not resolved by the next meeting of the Committee that this would need to be taken up with Greater Glasgow & Clyde. Dr Foxley asked about the log of issues in relation to Integrating Care and where any concerns relating to child and adolescent services were being dealt with. The Chief Executive advised that any issues were being dealt with via normal systems. Any issues now arising would be expected to be dealt with in local operational units. The Chief Executive also highlighted that the King’s Fund had expressed an interest in sending a researcher to capture relevant information regarding Integrating Services.

111 Clinical Governance Committee – Draft Minute of Meeting held on 7 August 2012

Ms Sarah Wedgwood, Chair of the Clinical Governance Committee fed back on the issues discussed at the last meeting. This included the NHS Highland response to the Healthcare Improvement Scotland report on the management of Significant Adverse Events in NHS Ayrshire & Arran, the NHS Highland Transfusion Committee Annual Report, the Patient Rights (Scotland) Act 2011, the Quality Dashboard and an update following the Clostridium difficile outbreak at Raigmore Hospital.

112 Staff Governance Committee – Draft Minute of Meeting held on 28 August 2012

Mr Colin Punler, Chair of the Staff Governance Committee fed back on the issues discussed at the last meeting. He highlighted the comments regarding the process for appointing public representatives to the committee and the Chair confirmed that this issue would be addressed in the previous action for the Chief Executive and Head of PR & Engagement. Also discussed was the Workforce response to the findings of the Significant Event Review of the outbreak of Clostridium difficile and issues raised regarding staffing levels. The Board Nurse Director advised that while substantive staffing appointments had not been made that registered bank staff were currently filling these posts. The Chair emphasised the need for staffing levels to be restored to appropriate levels while any review / redesign of services was ongoing. It was noted that a Workforce Workshop had been arranged for members of the Staff Governance Committee on 17 October.

113 Improvement Committee – Assurance Report of 3 September 2012 and Balanced Scorecard

The Chair updated on the last meeting of the Improvement Committee and confirmed that the Committee had received assurance that the Directors of Operations had a programme of work in

64 4 place regarding financial balance which would also be monitored via the Argyll & Bute CHP Committee and the Highland Health & Social Care Committee. In relation to the Raigmore financial position, a Programme Board had been established and this work was being supported by the Chief Operating Officer and finance staff. In relation to eKSF there had been interest in hearing from managers how they could more constructively scrutinise the quality of the process. Anne Gent, Director of Human Resources highlighted the discussion at the recent Staff Governance Committee meeting on KSF which detailed some of the more qualitative aspects of eKSF. She also confirmed that there was ongoing work at national level to simplify the system. The Chair highlighted good work in relation to Anticipatory Care and Polypharmacy and highlighted the need to ensure these projects were property implemented. Dr Foxley recalled previous discussions in relation to capacity and the need to use the capacity of the whole network and suggested that the Chief Executive and Chief Operating Officer assist with this policy. It was noted that work was in progress and there had been discussions in relation to the Access Policy and a substantive report would be submitted to the Board in due course. Dr Foxley also highlighted the discussion at the Improvement Committee on Anticipatory Care and noted that the action box of the assurance report had no detail. The Chief Executive confirmed that this could be populated for further clarity. Sarah Wedgwood confirmed that Endoscopy would be discussed at the Clinical Governance Committee. The Chief Executive advised that this work was been led by Deborah Jones, Chief Operating Officer and was also a national issue. Reference was made to the target for A&E Waits to be a maximum of 4 hours. It was noted that while this target had not been met between February and July 2012 this related to Raigmore Hospital only and NHS Highland had met A&E targets overall. It was also noted that reassurance had been received in relation to the stroke target.

114 Area Clinical Forum – Draft Minute of Meeting held on 9 August 2012

Dr Iain Kennedy, Chair of the Area Clinical Forum updated on the meeting including Point of Care Testing and Developing Proposals for new HEAT targets for 2013/14. The ACF had recommended that the standards that apply to laboratory Point of Care Testing were also relevant to Cardiology, Respiratory Physiology and Audiology and that a full audit of Point of Care Testing in these disciplines should be carried out to document the current governance arrangements.

115 Health & Safety Committee – Draft Minute of Meeting held on 17 May 2012

Mr Alasdair Lawton, Chair of the Health & Safety Committee updated on the last meeting. Items considered included an update on the Lone Working Pilot, adverse weather driving and Clinical Governance and Risk Management. It had been agreed that a small sub group be set up to establish performance indicators relating to Clinical Governance and Risk Management. The Chair advised that adverse weather driver training was available for Directors.

116 Asset Management Group – Draft Minute of Meeting held on 6 August 2012

Mr Alasdair Lawton fed back on the issues discussed at the last meeting. Items discussed included Hubco and the Biomass Business Case which would now be submitted to the Scottish Government Capital Investment Group. It was noted that there were still two public members to be appointed. A question was raised in relation to the item on dental decontamination compliance and it was confirmed that this related to the private sector also. Ms Wedgwood referred to the item on integration in relation to backlog maintenance of properties. Mr Kenton confirmed that the transfer of the buildings to NHS Highland was the long term aim and a 5 year repairing and insuring lease had been agreed in the interim.

The Board a Noted the Minutes.

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b Remitted to the Chief Executive and Head of PR & Engagement to ensure appropriate patient / public and voluntary representation on the Health & Social Care Committee and other governance committees. c Agreed that the Audit Committee minute be amended as discussed. d Noted  the Staff Governance Committee met on 28 August 2012.  the Assurance Report and agreed actions resulting from the consideration of the specific items detailed.  that the next meeting of the Staff Governance Committee would be held on 20 November 2012. e Noted  that the Improvement Committee met on 3 September 2012.  the Assurance Report and agreed actions resulting from the review of the specific topics detailed and the Balanced Scorecard.  that the next meeting of the Improvement Committee would be held on 5 November 2012. e Agreed that a report be submitted to the Board in due course on the Access Policy and capacity across NHS Highland. f Recommended that the action box of the Assurance Report in relation to Anticipatory Care be populated.

117 NHS Board and Board Development Meeting Dates 2012 and NHS Highland Calendar of Meetings 2013 Report by Elaine Mead, Chief Executive

A list of dates for Board meetings and Board Development Meetings had been drafted for approval, as well as a list of dates for NHS Highland Governance and Professional Advisory Committee meetings for 2013. It was noted that the dates of the Control of Infection Committee clashed with the Highland Council Adult and Children’s Services Committee in January, May and September 2013 and it was agreed that the dates of the Control of Infection Committee should be revised in these months. Dr Ian Kennedy advised that new Chairs had recently been elected in relation to the Area Medical Committee, Dr Miles Mack and the General Practitioners (GP) Sub-Committee, Dr Jonathan Ball.

The Board a Approved the dates for meetings of the NHS Board and Board Development Sessions for 2013. b Approved the Calendar of Meetings for 2013, subject to revising the dates of meetings of the Control of Infection Committee in the months of January, May and September 2013.he Board. c Noted the recently elected Chairs of the Area Medical Committee and GP Sub- Committee.

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Council/Highland NHS Board Joint Committees

118 Argyll & Bute Health & Care Strategic Partnership – Minute of Meeting of 25 July 2012

Mr Robin Creelman updated on the last meeting of the Argyll and Bute Health & Care Strategic Partnership, which had been the first meeting of the committee he had chaired. He advised that lead councillors for adult and children’s services in Argyll & Bute Council are not yet represented on the Strategic Partnership. Issues discussed at the meeting included GP engagement and Delayed Discharges. A local target of 4 weeks had been introduced in relation to Delayed Discharges.

119 Highland Council – Adult & Children’s Services Committee – Minute of Meeting of 23 August 2012

The Chair highlighted the need to consider the style of assurance report from Highland Council as the Lead Agency in relation to Children’s Services. NHS Highland would also need to consider this as the Lead Agency in relation to Adult Health & Social Care. Mr Gibson advised that NHS representatives on the Committee did not receive a copy of the minute as this required to be submitted to the Highland Council for approval. He also advised that there was no action list prepared following the meeting and he had raised this issue separately with the Chair. Further work was required in relation to how financial information was presented to the Committee and in relation to performance reporting. A briefing was also expected on Child Healthy Weight.

The Board a Noted the minutes. b Agreed that consideration should be given to the style of assurance report required from Highland Council as the Lead Agency for Children’s Services and also the assurance report by NHS Highland as the Lead Agency in relation to Adult Health and Social Care.

THE HIGHLAND QUALITY APPROACH

120 The Highland Quality Approach – Next Steps / Implementation Report by Linda Kirkland, Head of Business Transformation and Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, Chief Executive

The Highland Quality Approach captures the spirit of how NHS Highland is working to improve care and outcomes for people in Highland. It describes our ways of working, values and behaviour. It recognises how important it is to improve the health of the population and get the experience of care right for individual people, every time.

Elaine Mead, Chief Executive advised that The Highland Quality Approach was formerly launched at NHS Highland Annual Event on 5 September at Eden Court Theatre in Inverness. Over 300 people attended the event and a further 375 participated through a live web stream. Ms Mead thanked all staff involved in organising and participating in the event as well as the patient and public participants and the facilitator for the day Pennie Taylor. The event included presentations by Garry Coutts and Elaine Mead outlining the Highland Quality Approach. The morning session culminated with key representatives signing up to the Highland Quality Approach on behalf of the staff groups they represent including Dr Iain Kennedy (Chair of Area Clinical Forum) and Ray Stewart Employee Director and co-chair of Highland Partnership Forum. Having now formalised the branding this is supporting production of wider communication and engagement materials. The supporting strap line is: “Putting Quality first to deliver better health, better care and better value”

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The Strategic Framework is a key element of the Highland Quality Approach and an updated summary was attached at Appendix 1 to the report. Ms Mead updated on the Project Management Methodology and confirmed that Board members would have an opportunity to see this in a working demonstration over lunch-time. The Project was overseen on a weekly basis and had Executive support. It was noted that some clinical colleagues were visiting Virginia Mason in Seattle this week and would update on their experience.

Dr Margaret Somerville, Director of Public Health and Health Policy updated on the Care Pathways and Anne Gent, Director of Human Resources updated on the Organisational Workstreams. Maimie Thompson, Head of PR & Engagement updated on Communication and Engagement and advised that there was more engagement with community councils and a demonstration would be available for Board members at lunch-time in relation to communication including social media and the NHS Highland website.

The Board a Noted the formal launch of the Highland Quality Approach on 5 September at Eden Court Theatre, Inverness. b Noted various updates on the workstreams to implement the Highland Quality Approach. c Noted the demonstrations available for Board members during the lunch break on the Project Management Methodology and Communications.

121 Patient Rights (Scotland) Act 2011 Report by Moira Paton, Mirian Morrison, Margaret Brown and Maimie Thompson on behalf of Heidi May, Board Nurse Director

The Patient Rights (Scotland) Act 2011 aims to improve patients’ experiences of using health services and to support people to become more involved in their health and health care. This paper summarised the content of and duties inherent in the Act, and provided an assessment of the progress of implementation of the different elements of the Act. Moira Paton, Head of Community and Health Improvement Planning, updated on the Act which had three main elements: Patient Rights and Responsibilities, Schedule of Healthcare Principles and the Treatment Time Guarantee (TTG). The Act was in line with the Highland Quality Approach and the strategic direction of the Board and reflected the responsibility of patients to engage in looking after their own health. Guidance in relation to the TTG suggested a different way of engaging with patients and suggested that we encourage more feedback from patients, particularly in relation to primary care.

During discussion Robin Creelman referred to a presentation on this subject by NHS Education Scotland (NES) which is to be given at Argyll & Bute CHP Committee and which might be worthwhile for the Board. Sarah Wedgwood suggested that the legislation could increase the number of complaints received by the NHS. In relation to GP complaints it was noted that while a complainant could complain direct to the Board that it was more usual to deal with this via the practice. It was noted that one of the most significant areas of work was in relation to administration and the task of developing new letters to comply with the Act. Deborah Jones, Chief Operating Officer updated on work in progress in relation to waiting times and highlighted the work of the eHealth team and the Planning team in developing the relevant dashboards.

The Chair welcomed the legislation, which highlighted the need to provide care as promptly as possible. He recognised the work NHS Highland had undertaken over recent years to reduce waiting times for patients and welcomed the opportunity for NHS Highland to reduce waits even further.

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The Board a Noted the elements of the Patient Rights (Scotland) Act 2011. b Noted the progress made regarding the implementation of each of these elements.

122 Inequalities Action Plan (a) Update on Inequalities Action Plan Report by Margaret Somerville, Director of Public Health & Health Policy (b) Update on Action to Reduce Inequality taken since the publication of the 2011 Annual Report by the Director of Public Health Report by Tara Shivaji, StR Public Health on behalf of Margaret Somerville, Director of Public Health and Health Policy

The first paper summarised the work taking place across NHS Highland in response to national and local initiatives and outlined an approach to reducing inequalities for the Board to discuss and approve. The second paper updated on action to reduce inequality taken since the publication of the 2011 Annual Report by the Director of Public Health. Dr Margaret Somerville gave a short presentation to support the reports. The presentation recapped on the recommendations of the 2011 Annual Report, current work in relation to embedding inequalities in mainstream services, targeting geographical communities and targeting communities of interest, the Keep Well programme, the Merkinch project and ongoing actions. Dr Somerville then introduced Anne Sutherland and David Paulin from the Merkinch Partnership to highlight some of the work in the Merkinch area of Inverness. The Chair asked that in relation to any geographic based initiatives relating to community deprivation that support should be provided over a period of time rather than simply for the duration of a project. Dr Somerville advised that key to this was the engagement with the community to help them to sustain the work.

David Paulin advised that the Merkinch Partnership now had a 5-year plan and there was more stability with a variety of funding. Mr Paulin was the Active Merkinch Co-ordinator and delivered sports initiatives to children and adults via a team of volunteers and sessional workers. Anne Sutherland was the Project Officer and much of her work involved inequalities, she ran a work club with the aim of getting people off benefits and into employment. Dr Somerville advised that often those things that influenced health were outwith the health service, e.g. employment, education and early year’s development. The Chair referred to a recent discussion at the Community Planning Partnership, which had been enthusiastic about this type of approach and recognised the need to change the way we think and to align to these objectives. He also confirmed that the Board would look forward to receiving update reports on this work in the future.

The Board a Noted progress on existing programmes designed to reduce health inequalities across NHS Highland and partners. b Endorsed the proposed approach to tackling inequalities in NHS Highland. c Noted the engagement and commitment of the voluntary sector in addressing the issue of inequality in Merkinch. d Noted the findings and recommendations resulting from this community consultation process. e Noted the contribution to corporate objectives of action by partners committed to a wider health improvement agenda in Merkinch.

69 9 f Agreed that regular updates on progress should be submitted to the Board.

The Board adjourned at 10.30 am and resumed at 10.45 am.

123 Presentation – NHS Highland Engagement with School Pupils

The Chair welcomed Emma Watson, Director of Medical Education and school pupils Calum MacMillan and George Ashton to the Board meeting. Dr Watson advised that Calum and George were just two of the 23 school pupils who had attended the programme intended for people who wished to pursue a medical career. She welcomed the opportunity to update the Board on the work of the Medical Education Department. Dr Watson advised that both Calum and George had applied for the Doctors at Work programme, which was a competitive application process, and had been successful and given the opportunity to undertake the programme at Raigmore Hospital. The school pupils explained why they wished to progress a career in medicine, and told the Board about some of what they had experienced across the various specialties including time in theatres observing surgery. They highlighted the team work involved across the health service staff, the need for staff to help patients feel safe and to communicate various information to patients. All pupils involved had had homework to complete for the next day. The pupils confirmed that the experience had reinforced their desire to become involved in medicine and they felt that it would also strengthen any applications to universities. Dr Watson confirmed that it was planned to run this session again in June / September next year.

During discussion Dr Foxley referred to the application process for medical school and highlighted the need to address the propensity for medical schools to choose applicants from a private school education. Dr Watson advised that the UCAT test was standard in relation to all medical school applications and there were often approximately 2000 places for some 10000 applicants. The Medical Education Department was aiming to get messages to schools and pupils from the first year of secondary education onwards and would also aim to ensure that Highland pupils were as competitive and as prepared as they could be for the process. Dr Somerville highlighted the need for not only academic ability, but also the appropriate attitude and approach. Dr Watson confirmed that at present the numbers of pupils being accepted to medical schools from Highland were small and it was hoped that this initiative would help those school pupils in Highland wishing to pursue a medical career.

The Board a Welcomed the presentation on NHS Highland Engagement with School Pupils. b Supported the initiative.

124 Director of Public Health Annual Report 2012 Presentation and Report by Margaret Somerville, Director of Public Health and Health Policy

The theme of this year’s annual report is the health and well-being of older people. The paper contained the report summary and recommendations and the full report had been circulated to Board members prior to the Board meeting.

Dr Margaret Somerville, Director of Public Health and Health Policy gave a detailed presentation to the Board on her 2012 Annual Report. This covered aging and health, specific conditions such as falls and lung disease, hospital care in relation to admissions and dementia. The conclusions were:

 Services for older people are much of the work of health and social care services;

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 With service integration in the Highland Council area, and good joint working in Argyll and Bute, there is great scope for well-integrated care;  All our work with older people needs to involve older people, and to take account of their views;  Work on falls prevention and early intervention on COPD are examples of NHS activities that can reduce suffering;  Voluntary organisations and community groups have a key role in promoting well-being, and in recognising the vital contribution of older people;  Good staff training across all organisations is essential, including in the recognition and management of dementia.

The Chair advised that the theme for the report was very relevant in relation to the recent work on Integrating Care in the Highlands and end of life care. Much of the work could impact on providing better care and releasing hospital resources. Dr Foxley referred to the links between Chronic Obstructive Pulmonary Disease (COPD) and smoking, which was the single biggest cause with over half of those people who smoke developing COPD. He emphasised the need to stop people smoking at a younger age and asked whether work was ongoing in high schools. Dr Somerville confirmed that the Smoking Prevention Officer visited all secondary schools and some primary schools and also promoted the smoke free homes and smoke free cars initiatives. It was also felt that NHS Highland could do more as an employer to promote smoking cessation to staff. Dr Somerville confirmed that she would present her report to both local authority partners, the Highland Council and Argyll & Bute Council.

The Board a Noted the content and recommendations of the report. b Remitted to the Director of Public Health to present the Annual Report to local authority partners.

CORPORATE GOVERNANCE / ASSURANCE

125 NHS Highland Standing Orders & Scheme of Delegation Report by Kenny Oliver, Board Secretary, on behalf of Elaine Mead, Chief Executive and Nick Kenton, Director of Finance

The Chair asked that this item be deferred to the next meeting of the Board to allow clarification on a number of issues.

The Board a Deferred consideration of this item to the next meeting of the Board in December 2012.

126 NHS Highland Financial Position as at 31 August 2012 Report by Nick Kenton, Director of Finance

Mr Nick Kenton, Director of Finance updated on the financial position to 31 August 2012 which highlighted a current forecast of break even for the financial year. However, the underlying operational forecast, which now included adult social care, remained high with a forecast overspend of £12m and a significant focus was required to ensure that the benefits from the Highland Quality Initiatives are realised, along with traditional efficiency measures, to ensure that the Board’s statutory financial targets are met.

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Detailed financial positions for each Operational Units were detailed in section 3 of the report. South & Mid Operational Unit was now forecasting a break even position, an improvement of £0.5m on the previous forecast. The Raigmore position had deteriorated primarily due to a revision to their expected savings in respect of schemes which were now unlikely to materialise this financial year. The unit was currently reporting around £2.1m of pressures in addition to £1.8m of savings yet to be delivered / identified. The Tertiary budget was forecasting an over spend of £1.2m. The vast majority of the current estimated overspend related to an increasing number of expensive forensic psychiatry placements. In relation to the Highland Quality Approach / System Wide Initiatives, the financial plan for 2012/13 includes a northern Highland-wide target totalling £4.5m (full year effect £9m). As requested and agreed by the Directors of Operations, the work of the financial benefits realisation will now be included in a meeting chaired by the Chief Operating Officer – this recognises the need to connect this work with operational matters and to rationalise the number of meetings.

Actions being taken included:

 In relation to the Adult Social Care budget discussions were ongoing with the Highland Council.  It had been agreed that a Programme Board would be set up by Raigmore, (chaired by the Director of Operations) to oversee and assure the delivery of the Raigmore quality plan which will include in-year financial recovery as a core component. The Programme Board will assure delivery and hold the project teams to account for this.  In relation to Tertiary and Out of Area Referrals, a review would be undertaken of all long- term placements. A short-life working group was being set up by the Director of Public Health and Health Policy which would report to the Clinical Advisory Group.  It was possible there might be some non-recurring slippage.  There were potential improvements in relation to prescribing.

The Chair highlighted that in relation to the Adult Social Care budget that discussions were ongoing and there were mechanisms in place to escalate to Chief Executive level if there were any concerns regarding a resolution. Sarah Wedgwood asked about the significant ongoing projects and the level of confidence in achieving a return from these. The Chief Executive advised that there were still benefits from the Change Fund which had not yet been accounted for and there would be some financial benefits from reablement. The Chair confirmed that any concerns would be reported to the Board. Deborah Jones, Chief Operating Officer updated on the Programme Board for Raigmore which had held its first meeting two weeks ago. She confirmed that a small group was working to interrogate the systems and processes within Raigmore. It was recognised that not all of the Highland Quality initiatives would come to fruition this year. Ray Stewart sought an update on the plans for the following year and it was confirmed that some of this would be reported to the next Board meeting. Ms Jones advised that the delivery of the Local Delivery Plan for 2013/14 would be aligned to Operational Development Plans and the aim was to get into a cycle of prospective planning. Dr Foxley referred to section 3.2 on page 2 of the report regarding North & West Operational Unit and the cost of supporting vacant GP practices and asked where the discussion regarding this issue had taken place. It was confirmed that this would happen at local operational management meetings.

The Chair confirmed that the Board was aware that this year would be challenging for NHS Highland. He highlighted the ongoing work relating to the Highland Quality Approach, the setting up of the Programme Board for Raigmore and advised that there would be further scrutiny of the operational units by the Senior Management Team and the Board. The Chair also referred to recent comments by the Scottish Patients Association suggesting that operations had been cancelled and waiting times for patients had increased. He had not indication that this was in fact the case and confirmed that he would write to the Association and, if there was a local branch, engage with them also. The Chief Executive remained confident that NHS Highland would achieve financial breakeven and those who needed care and treatment would receive it.

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The Board a Noted the current forecast remains breakeven by the end of the financial year. b Noted the underlying operational forecast of £12m split between; - Adult Social Care £2m - NHS Care £10m c Noted the further deterioration in the Raigmore financial position. d Requested that the Finance report to the next meeting of the Board update on work in progress with Raigmore and the Project Board and a more detailed update on the Highland Quality Initiatives. e Remitted to the Board Chair to write / engage with the Scottish Patients Association.

127 Infection Control Report Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

Ms Heidi May, Board Nurse Director updated on the Infection Control Report. The Executive Summary of the main Infection Control Report, which summarised the key information in the report, is detailed below:

Staphylococcus aureus HEAT Target 26 per 100,000 bed days, (0.26 per 1,000 bacteraemia (SAB) bed days).

NHS Highland rate April – August 2012 is 20.0 per 100,000 bed days, (0.20 per 1,000 bed days).

Clostridium difficile HEAT Target 39 per 100,000 bed days, (0.39 per 1,000 OBDs) which is based on the protocol which tests for Clostridium difficile toxin production.

NHS Highland rate April – August 2012 is 21.7 per 100,000 total occupied bed days, (0.217 per 1,000 OBDs) (20 cases) in patients age 65 and over using the Clostridium difficile toxin test. Hand Hygiene National Compliance 95%.

NHS Highland Compliance with hand hygiene 98% in July and August 2012.

Cleaning and the Healthcare National Compliance 90% and above. Environment NHS Highland Cleaning Compliance 96% in July and August 2012.

NHS Highland Estates Monitoring Compliance 97% in July and August 2012.

HEI Inspections Raigmore Hospital – 9 requirements and 2 recommendations.

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An unannounced visit was undertaken in Caithness General Hospital on 3rd & 4th September 2012. The report is awaited.

Significant HAI incidents / No outbreaks during July and August 2012 outbreaks, emerging threats

Antimicrobial Prescribing Hospital based empirical prescribing - non compliant. National Indicators Surgical prophylaxis – compliant.

Primary care empirical prescribing – compliant.

Surgical site infections (SSIs) Caesarean surgical site infection rate remains unchanged.

Orthopaedic surgical site infection rates remain low, and within anticipated levels.

Since surveillance commenced in June 2011, the rate of colorectal surgical site infections has not changed.

Decontamination Capital money has been allocated to support the purchase of replacement washer disinfectors. The planned preventative maintenance programme continues for the existing washer disinfectors.

The programme of audit of all General Dental Practitioner contractor decontamination units will be complete by the end of September 2012.

Ms May confirmed that in relation to the Health & Safety Executive (HSE) all care homes were now undertaking the NHS Highland Environmental Audit and Control of Infection training. There had been an unannounced visit by the Healthcare Environment Inspectorate (HEI) at Caithness General Hospital on 3 and 4 September. Although the final report was awaited feedback had been positive. Ward 4c at Raigmore Hospital had become an exemplar ward in relation to cleaning and hydrogen peroxide fogging. The impact of all initiatives would continue to be monitored.

The Chair commented that despite the fact there had been an outbreak earlier in the year that overall infection rates were still low and he welcomed the introduction of the system to indentify more people with Clostridium difficile and reduce the risk of infection. Mr Creelman referred to non-compliance in relation to hospital based empirical prescribing in relation to what area of policy was non-compliant and whether this was causing risk. The Chair suggested that an update on this could be included in the next report to the Board. It was noted that the Unannounced HEI Inspection Report for Raigmore Hospital on 26 and 27 June had been circulated as Appendix 2A to the report and the Action Plan as Appendix 2B. Robin Creelman asked if requirements 2 to 7 had now been completed. Ms May confirmed that this was the case. There was some discussion around the Health & Safety Committee and improvement notices and the Chair confirmed that the route for such notices would be via the Health & Safety Committee, the Staff Governance Committee and then the Board. Mention was made of the phrase zero tolerance in relation to hand hygiene and whether action had been taken in this respect. Ms May confirmed that action had been taken, but not to dismiss staff. However if a member of staff was not prepared to comply with hand hygiene requirements then zero tolerance could apply. Dr Foxley referred to media attention in relation to infection control and suggested that there should often be more context given around such issues. The Chair shared this concern and confirmed that he would endeavour to include relevant context where possible.

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The Board a Noted the contents of the Infection Control Report.

128 Adult Support and Protection – National Reviews Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive

The Adult Support and Protection Committee (ASPC) of the Highland Partnership received a report from the Quality Assurance sub-group highlighting a number of current National Reports relating to incidents of Adult abuse or neglect. The Quality Assurance Group had reviewed these reports and was asked to provide assurance to the committee that all recommendations had been considered across partners in Highland and any outstanding actions were being progressed. Janet Spence, Programme Manager (Modernisation and Quality Assurance) spoke to the report. She referred to the two cases relating to Highland and confirmed that urgent steps had been taken in relation to learning and the recommendations. A detailed action plan had been prepared to address any gaps and areas of potential weakness and this had been formally signed up to by all partners. Ms Spence confirmed that further assurance reports would be submitted to the Board in due course. It was noted that Pam Courcha, who had previously been a Non-Executive member of the Board had been appointed as the new Chair of the Adult Protection Committee for Highland Council area.

The Board a Noted the actions and process being followed. b Noted the role of the Adult Support and Protection Committee. c Noted the proposal for further assurance reports. d Requested a follow up report on lessons learned.

129 Highland Strategic Commissioning Group Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive

During the development of the Lead Agency model for adult and children services, it was recognised that there would be a requirement for a strategic Group to oversee the Partnership Agreement and specifically the Commission. Appendix 1 to the report detailed the proposed role and remit of the Highland Strategic Commissioning Group. The group would have a specific role in overseeing the Partnership Agreement as well as ensuring the development of strategic commissioning – as described in the Partnership Agreement, is developed across Highland. The proposed membership had already been discussed within the Council and Health Board to ensure appropriate links to the performance management framework previously agreed. The schematic included in the appendix highlighted the relationships with the developing governance frameworks. Some of these structures were still evolving but it was anticipated that such changes would not impact on the overall role of the Strategic Commissioning Group, which would report to the HH&SC Committee and the Highland Council Adult and Children’s Committee.

The Board a Agreed the role and remit of the Strategic Commissioning Group. b Agreed that this role and remit will be reviewed for effectiveness twelve months after the first meeting. c Noted further developments around commissioning in Children’s services.

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130 Chief Executive’s and Directors’ Report – Emerging Issues and Updates Report by Elaine Mead, Chief Executive

This month’s report covered the following:

 District Partnerships  NHS Highland Annual Event and Annual Review – 5 September 2012  Regional Planning – North of Scotland Planning Group and West of Scotland Planning Group  NHS Highland Engagement with School Pupils

Ms Elaine Mead confirmed that the Board had already had reports earlier in the meeting regarding the Annual Event and engagement with school pupils. Mr Creelman referred to the briefing on the West of Scotland Planning Group in relation to the language used regarding patient and public engagement and confirmed that he would follow this up direct.

The Board a Noted the emerging issues and updates report. b Remitted to Robin Creelman to follow up the issue regarding patient and public engagement within the West of Scotland Planning Group.

131 Any Other Competent Business

Lunch Time Demonstrations – The Chair reminded Board Members of the demonstrations in relation to Project Management Methodology and Communications, which would take place over the lunch, break.

132 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 4 December 2012 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 12.20 pm.

76 16 17 Highland NHS Board 4 December 2012 Item 2(b) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD 6 November 2012 – 9 00 am Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Dr David Alston Mr Bill Brackenridge Mr Robin Creelman Mrs Myra Duncan Mr Mike Evans Dr Michael Foxley Mr Ian Gibson Dr Iain Kennedy Cllr John McAlpine Mrs Gillian McCreath Mr Okain McLennan Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy

Also present Mr John Bogle Acting Head of Capital and Property Planning Ms Deborah Jones, Chief Operating Officer Mr Kenny Oliver, Board Performance Manager Mrs Lorraine Power, Board Services Assistant Mr Nigel Small, Director of Operations, South & Mid Operational Unit Ms Maimie Thompson, Head of Public Relations & Engagement

Apologies – Apologies were received from Mr Alasdair Lawton and Mr Colin Punler.

133 Declarations of Interest

Board members declared the following interests:

 Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  Iain Kennedy – member of the British Medical Association (BMA), Riverside Medical Practice.  Ray Stewart – Member of Unite and Staffside Chair.

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The Board a Noted the Declarations of Interest.

CORPORATE GOVERNANCE / ASSURANCE

134 The Development of Primary Care Services in Tain – Outline Business Case Addendum Report by John Bogle, Acting Head of Capital & Property Planning on behalf of Nick Kenton, Director of Finance

The Board approved an Outline Business Case (OBC) for the Development of Primary Care Services in Tain in December 2012. The OBC was subsequently approved by the Scottish Government Capital Investment Group (SGCIG). NHS Boards are required to engage with the Scottish Futures Trust (SFT) hub programme for the provision of community facilities. Hub North Scotland Ltd (Hubco) had now produced proposals for Tain and these costs were included in this addendum. Nick Kenton, Director of Finance referred to a recent Hubco presentation which some Board members had attended. The Addendum now submitted to the Board reflected changes since the introduction of the Hubco model. In the OBC the Unitary Charge was estimated at £557,560 per annum, the proposals from Hubco showed a reduction to £544,570 per annum. In addition, at the time the OBC was written it was not known that the Scottish Government would offer revenue support for the project which could be up to 90.25% of the Unitary Charge. There would be additional running costs associated with a much larger building and the Operational Unit had agreed to fund the estimated £157,000 from savings in the provision of local services. Mr Kenton advised that the figures quoted could be subject to change dependant on financial markets. He confirmed that if the Addendum was approved today and support given to proceed to develop a Full Business Case (FBC) that the Board would have a further opportunity to review the business case when the FBC was finalised around May 2013.

Mr Bogle gave reassurance to the Board in relation to the governance structure. He advised that there was a Joint Project Board which was co-Chaired by the Directors of Finance for NHS Highland and NHS Grampian, the local Project Team was chaired by the Director of Operations for South & Mid Operational Unit and comprised of a variety of representatives, including representatives of both Tain medical practices, community and dental staff and a patient representative.

The Board discussed the Addendum to the OBC including issues around planning gain conditions and the possibility of not obtaining General Practice sign-up to commit to the accommodation being provided. Mr Small advised that there was little risk of the GP practices not signing up and they were committed to the additional running costs. The Chief Executive asked about the link with other facilities and Mr Small confirmed that as well as the two GP practices that accommodation would be provided for an integrated team and dental services, providing a hub and spoke service for the surrounding villages. Dr Alston asked whether local authorities would be given the opportunity to invest in the project. Mr Kenton advised that according to the financial model, the total sub debt investment required from participating authorities for the Bundle is in the region of £0.689 million, with NHS Grampian asked to plan for contributing in the region of £0.484 million in respect of the Forres and Woodside share of the investment and NHS Highland asked to plan for £0.205 million approx for the Tain share. He confirmed that NHS Highland had made provision for this amount. However, these amounts assume that none of the other Territory Partnering Board participants choose to invest in the projects. All participants will be given the opportunity to contribute and therefore the Highland Council could chose to invest. Mr Kenton also added that the Scottish Government had asked NHS Grampian and NHS Highland to consider a revised timetable that would achieve financial close by 31 March 2013.

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This would require some of the approval processes to be run in parallel, but the Scottish Government and the Scottish Futures Trust were comfortable with this. The Scottish Government had indicated that it would be willing to contribute both Boards’ share of the sub debt if financial close can be reached by 31 March 2013. Ms Mead noted that the project had previously been tied to the Grampian Health Village project and asked if this was still the case and whether this could cause any delay. Mr Bogle advised that this was no longer the case and should not cause any delay.

In summary, the Chair confirmed that the Board was committed to replacing the services in Tain and welcomed the opportunity to work with the care home and work in an integrated model.

The Board a Approved the Outline Business Case Addendum for the Development of Primary Care Services in Tain. b Agreed that the Project Team should proceed to develop a Full Business Case for future consideration by the Board.

135 Any Other Competent Business

There was none.

136 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 4 December 2012 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 9.15 am.

79 20 FOLLOW UP FROM BOARD ACTION PLANS – JUNE 2011 ONWARDS 21 Highland NHS Board Those items shaded grey are due to be removed from the Action Plan as they have been completed, or will be considered at 4 December 2012 the next Board. Item 2(c)

Meeting Item Action / Progress Outcome

Board 07/06/11 Audit Committee Hospital and Community Health payments to GPs in Argyll and Future Board – letter received from SG Bute – to seek clarification on this issue and report back to the 21/10/11 – being progressed Board in due course. Being reviewed by national Primary Care Leads with a view to providing additional guidance. Board Dev. Archie Foundation Update The Chair advised that he felt it was necessary for a protocol to Chair / Chief Executive to progress. 08/08/11 be in place regarding similar style projects to ensure that these were brought to the attention of the Board in a timely fashion. Board 04/10/11 Matters Arising Patient / Public Representatives on Committees – an action Work in progress should be added to the Board Rolling Action Plan in relation to appointing patient and public representatives to governance committees. Pharmacy Practices Committee Report to be prepared for Board members on the support Work in progress available to applicants, as the new way of working was very complex. Patient Experience at Governance To consider whether patient experiences should also be Chair to consider Committees considered at the Board as well as governance committees. Board 06/12/11 Internal Evaluation of NHS To bring forward proposals to the Board early in 2012 on the 2nd Edition of Newspaper to be Highland Newspaper production of two editions of the newspaper in the spring and issued. Copy now being pulled autumn. together. Board 07/02/12 Highland Health & Social Care To review the governance arrangements once the structure had Board June 2013 Partnership – Proposed been operational for one year. Governance Arrangements Senior Operational Management A more detailed diagram of the structure to be circulated to Work in progress – being finalised. and Professional Leadership Board members for information. Arrangements NM&AHPs Board 03/04/12 Chair and Chief Executive to consider suggestion for a future Future Board / Brd Dev. Session discussion on the key priorities for the Board in relation to risk management and the governance of risks. Board 05/06/12 Infection Control Report Clinical Director at Raigmore to circulate the Terms of Board Members Reference to all Board members for information. CG Committee – 07/08/12 & 13/11/12 The various issues would be progressed via the Clinical SG Committee – 28/08/12 & 20/11/12 Governance Committee and the Staff Governance Committee 22 Meeting Item Action / Progress Outcome

Board 05/06/12 CHP Committees To issue a structure diagram of the revised tiers of management Work in progress – being finalised. to Board members once available.

Governance Committees – Review To review the mechanisms for governance committees to report Work in Progress of Assurance to Board to the Board.

Board 14/08/12 South East Highland CHP A report be brought back to a future Board on the involvement of Discussions have taken place between Committee Scottish Ambulance Service in critical incident reviews. NHS Highland and the Northern SAS. There are now routine meetings between the Medical Director and the SAS Northern Clinical Governance Lead (Jill Fletcher) where all aspects of Clinical Governance and the involvement of both parties discussed. There has been an agreement that the SAS will be informed of any Critical Incident Reviews at the appropriate time and will attempt to field the appropriate personnel. This has just been implemented and will be audited over the next 6 months. No report to the Board at this stage. Issue to be reviewed in June 2013. Area Clinical Forum The Board Medical Director, Chief Executive and Chair of Area No change to ACF structure of Clinical Forum to review structure of clinical involvement in the clinical involvement. Area Clinical Forum.

Argyll & Bute Health and Care Requirement to review the constitution of the Argyll & Bute Robin Creelman and Derek Leslie to Strategic Partnership Health and Care Strategic Partnership and ensure that the Chair action. and Chief Executive are involved to ensure consistency between local authority areas.

Integrating Care in the Highlands – Small group to be established to agree a work plan to take Improvement delivery plan drafted Forward Plan forward issues on the forward plan and other items on the based on outcomes and themes agreed agenda in order that the Board can be informed of progress during P4I. Operational Units working on local plans and identifying gaps and Highland wide work.

2 23 Meeting Item Action / Progress Outcome

Board 14/08/12 Quality Approach to Improvement Progress against plans to be linked into Integrating Care in the As above – plans set in context of Reports by Directors of Operations Highlands work plan. Highland quality approach. High level project charter completed. Operational unit delivery plans will inform workstreams and further charter work. Supporting Highland’s Carers Revised Carers’ Strategy to be presented to the December Board 04/12/12 – Deferred 2012-2015 meeting of the Board. Board 05/02/13

NHS Highland Maternity Services Approved the Maternity Services Strategy and Strategy Helen Bryers to action. Strategy Workplan, subject to this being refreshed during the next year as discussed.

Board 02/10/12 Board Minute of 14 August 2012 To make amendments as discussed. Completed

Infection Control Workplan 2011/12 – Report on items Board 04/12/12 highlighted red and amber on the 2011/12 workplan and not picked up in the 2012/13 workplan to be reported back to the Board. Board 02/10/12 Highland Health & Social Care To note the nominations of Quentin Cox by the Area Medical Completed Committee Committee and Chris Williams by the GP Sub-Committee in relation to membership of the Committee. To ensure appropriate patient / public and voluntary Elaine Mead / Maimie Thompson to representation on this and other governance committees. action. Work in progress Audit Committee To amend the minute to read “no evidence” in relation to Completed item 4.6, Laboratory Managed Service Contract Review, on page 6 Improvement Committee Report to be submitted to Board in due course on Access Policy Future Board and capacity across NHS Highland. To populate the action box of the Assurance Report in relation to Completed Anticipatory Care.

3 24 Meeting Item Action / Progress Outcome

Calendar of Committee Meetings To revise dates of meetings of the Control of Infection Completed – A3 Calendar of meetings for 2013 Committee which clash with the Highland Council Adult & circulated to Board members with Children’s Services Committee in January, May and September December Board papers. 2013.

To note the recently elected Chairs of the Area Medical Committee and GP Sub-Committee.

Highland Council – Adult & Consideration to be given to the style of assurance report Assurance style report for HH&SCC Children’s Services Committee required from Highland Council as the Lead Agency for (submitted to 04/12/12 Board) Children’s Services and also the assurance report by NHS Work in progress / ongoing discussions Highland as the Lead Agency in relation to Adult health and with Highland Council. social care.

Inequalities Action Plan To submit regular updates on progress to the Board. Future Boards

Director of Public Health Annual To present Annual Report to local authority partners. Dates set: Report 2012 Highland Council – 13/12/12 A&B Council – 24/01/12 NHS Highland Standing Orders Standing Orders deferred to December Board Meeting. Board 04/12/12 – Deferred Board 05/02/13 Board 02/10/12 Area Finance Report Assurance report to be submitted to next meeting of the Board Board 04/12/12 in relation to work in progress with Raigmore and the Project Board. Report to December Board also to include more detailed Board Dev. 03/12/12 update on the Highland Quality Initiatives. In relation to recent comments by the Scottish Patients Completed Association, Board Chair to write to the Association and if there is a local branch, engage with them also. Adult Support & Protection Follow up report on lessons learned requested by Board Chair. Benchmarking exercise completed with subsequent actions for discussion at ASPC delivery group. Further report to ASPC scheduled. Further update to February Board. Board 05/02/13

4 25 Highland NHS Board 4 December 2012 Item 3.1

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

Mid Argyll Community Hospital & Integrated Care Centre 31 October 2012 Lochgilphead

Present Mr Robin Creelman, Chairman, Argyll & Bute CHP Mr Derek Leslie, Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Mr David Ritchie, Communications Manager, Argyll & Bute CHP Ms Tricia Morrison, CVO Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Mr Duncan Martin, Chairman, Public Partnership Forum Mr Michael Roberts, Vice Chair, Public Partnership Forum Ms Glenn Heritage, CVO Representative Ms Liz McMillan, Staffside Representative Councillor Elaine Robertson, Argyll & Bute Council Representative (by VC)

In Attendance Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr David Logue, Head of HR, Argyll & Bute CHP Mr Stephen Whiston, Head of Planning Contracting & Performance, Argyll & Bute CHP Ms Sara Wedgwood, Chair of Clinical Governance Committee & Spiritual Care Committee, NHS Highland Mr John Dreghorn, Project Director, Mental Health Modernisation - (agenda item 14.1) Mrs Sheena Clark, PA to Director of Operations - Minute Secretary

Apologies Councillor George Freeman, Argyll & Bute Council Representative Mr Cleland Sneddon, Argyll & Bute Council Representative Ms Dawn Gillies, Staffside Representative Mr Donald Barr, Area Optical Committee Representative Mr Neil Robinson, Area Pharmaceutical Committee Representative Ms Ann Gent, Director of HR, NHS Highland

1. CHAIRMAN’S WELCOME

The Chairman opened the meeting by welcoming everyone to the Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead.

2. APOLOGIES

Apologies for absence were noted as above. 26

3. CONFLICTS OF INTEREST

No conflicts of interest were declared.

4. MINUTE FROM PREVIOUS MEETING

4.1 Minute of Meeting held on 29 August 2012

Mr Michael Roberts asked that his apologies be recorded.

With the above amendment the Minute of the meeting on 29 August 2012 was accepted as a complete and accurate record of the meeting.

The Committee:

 Approved the content of the Minute of the meeting on 29 August 2012.

4.2 Minute of Public Session – 29 August 2012

The Minute of the public session on 29 August 2012 was accepted as a complete and accurate record of the meeting.

The Committee:

 Approved the content of the Minute of the public session on 29 August 2012.

5. MATTERS ARISING FROM PREVIOUS MEETING HELD ON 29 August 2012

Page 4 – Helensburgh & Lomond Planning Group

Ms Wedgwood requested clarification on the position regarding public engagement with Helensburgh & Lomond patients. Mr Leslie reaffirmed that the public should engage with the CHP through local Public Partnership Fora. There continued to be some challenges in establishing such a forum to cover the Helensburgh and Lomond locality however.

Page 4 – Pressure Ulcer Prevention

Ms Wedgwood commented on the reference to photographic data. Ms Tyrrell provided assurance that a clear policy is followed when obtaining this photographic evidence, which, Mr Creelman advised, verifies the grading of the ulcer and enables monitoring of healing.

Mull PCC

Mr Leslie reported on the public meeting in Mull on 16 October, attended by representatives of the CHP, Argyll & Bute Council and West Highland Housing, with an attendance of approximately 100 members of the public.

The meeting addressed a number of predetermined questions relating to various areas of public concern, including outreach clinics, physiotherapy, transport, kitchen facilities.

The Mull PCC Frequently Asked Questions information sheet will be updated to capture the detail of the questions and responses.

2 27

Open Days within the new unit have been arranged for 6 and 7 November 2012.

A further public session has been arranged on Mull for 4 December 2012, when the model of care for older peoples’ services will be presented again and discussed and the public given the opportunity to seek clarity around all aspects of service provision.

Ms Heritage advised that a meeting of the Transport Network Partnership Initiative is scheduled to take place on Saturday 3 November 2012 at the Loch Fyne Hotel, Inveraray, attended by the representatives of the Scottish Ambulance Service, the Red Cross and the Voluntary Sector. Ms Heritage suggested that representatives from the Mull Community Council may wish to link in to this meeting which would provide an opportunity to discuss transport concerns on Mull.

Ms Tyrrell stated that she would contact Councillor Mary-Jean Devon to ensure that she was aware of the above event.

6. NHS Highland Organisational Issues

6.1 Meeting of Highland NHS Board Meeting – 2 October 2012

The draft Minute was circulated for information.

Mr Creelman highlighted details in the Minute particularly relevant to the CHP.

110 Audit Committee – Mr Creelman requested an update regarding the Service Level Agreement with NHS Greater Glasgow & Clyde.

121 Patients Rights (Scotland) Act 2011 – Mr Creelman advised that the presentation referred to in the Minute was still to be given to the CHP. Jane Davies from NES will be attending the CHP Committee Development Session in December to discuss the work currently being undertaken from the perspective of preparing the NHS Scotland workforce for the Patient Rights Act and the forthcoming Charter of Patient Rights and Responsibilities.

122 Inequalities Action Plan - Ms Wedgwood reported on the initiatives and targeted work to reduce inequalities in poverty areas. The importance of early interventions is recognised throughout the Board area, i.e. Healthy Living Initiatives. Ms Garman reported that the Director of Public Health's Annual Report details the extensive work of the Keep Well project and on health inequalities within remote and rural settings. The report will be taken to the CHP Committee meeting in December.

123 NHS Highland Engagement with School Pupils - Mr Creelman reinforced the need for NHS Highland to continue the programme of engagement with school children and young people who are considering a career within the NHS. He acknowledged the quality of the pupils who had recently participated in the NHS Highland engagement process and the need to maximise this engagement. Ms Garman advised that within the CHP the engagement process is conducted through Curriculum for Excellence, in conjunction with Argyll & Bute Council. This approach will be refreshed, with the focus to ensure re- engagement by young people. It was suggested that pupil representation may be appropriate within the local network, i.e. Public Partnership Forum (PPF) and the Community Planning Partnership (CPP). Mr Leslie will discuss this further at the next meeting of the CPP and with the Chair of the PPF.

Ms Tyrrell highlighted the Child Protection poster on display at today's meeting and advised that the details and drawings were produced with the involvement of children and young people.

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130 Chief Executive's and Directors' Report – Mr Creelman asked for clarity around the public and patient engagement process by NHS Greater Glasgow & Clyde during their current clinical review. Mr Whiston advised that the recent paper produced for the West of Scotland Planning Group is a summary of activity and confirmed the engagement process is ongoing, with Scottish Health Council involvement and continuing discussions with the NHS GG&C Lead Planner in relation to impact of the review on CHP patients.

Mr Roberts advised that he is aware of information regarding the NHS GG&C clinical review and process being presented at 3 Public Partnership Forum meetings but not currently presented to the wider public.

The Committee:

 Noted the Minute of the meeting on 2 October 2012

6.2 Director of Operations Report

Mr Leslie stated that the circulated report resulted from recommendations of the recent Internal Audit report on CHP governance and management arrangements, and featured highlights of the business of the CHP Core Team and CHP Management Team. Mr Leslie requested members of the Committee forward to him any comments/suggestions on this initial report.

Mr Creelman thanked Mr Leslie for his report and recorded his support of Mr Leslie in the ongoing discussions between the CHP, Islay GPs and representatives of the community to ensure the continuation of a safe and sustainable health service on the island.

Ms Wedgwood acknowledged the conciseness, brevity and succinctness of the report, together with the operational content but advised the need for a corporate view from the NHS Highland Board to clarify issues/topics which are for governance decision and those which require operational consideration and input.

Mr Leslie advised that he and Mr Creelman will further consider the content of future reports and will await a corporate view from the Board.

6.3 NHS Highland Internal Audit Report – A&B CHP Governance and Management Arrangements

Mr Leslie provided a brief summary of the outcome of internal audit carried out by Scott- Moncrieff, to review the governance and management arrangements in place within Argyll & Bute CHP, and to consider the interaction with the Board of NHS Highland and its standing committees, as well as plans to integrate services with Argyll & Bute Council.

The outcome of the report was generally positive, with management action points identified being considered and actioned by the Chairman and Director of Operations.

Ms Robertson enquired about the timescale for the proposed integration of services. Mr Leslie replied that the timescale is set by the outcome of the national consultation. Broader discussions are due to take place between NHS Highland and Argyll & Bute Council and further information will be given at the next Committee meeting.

Ms Wedgwood congratulated the CHP on a positive audit report.

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7. Hospital Dialysis Service

Mr Whiston referred to the conclusion of the previous report in May 2012, as detailed, and advised that the purpose of this report is to update the Committee on additional actions agreed with regard to planning for the future provision of hospital renal dialysis services for a proportion of the CHP’s population in the Oban, Lorn & Isles catchment area.

On 1 October 2012 CHP management representatives attended a community council meeting in Taynuilt, which was hosted to enable the public and local councillors, including the MP Alan Reid, to explore the CHP’s conclusion and to request the CHP to reconsider the possibility of an enhanced local access to renal dialysis.

Particular points made at the meeting included:

. the current very high cost of transporting patients to the Belford, . the significant impact the current travel arrangements using taxis has on patients travelling to the Belford for hospital dialysis . option of the qualified renal nursing staff from Belford (who run the unit - Mon, Wed & Fri) coming down to provide the service at LIH unit Tues, Thurs, Sat. . indication that the community would look to fund raise to pay for the facility and buy the equipment etc for a local unit, . the opportunity to gain income from holiday dialysis.

The CHP agreed to undertake a high level piece of work to assess whether there is a case for establishing a viable Hospital dialysis service at LIH. Mr Whiston advised that a high level macro analysis, based on current available information, supplemented by user and stakeholder feedback on current service provision, will be carried out to assess the viability of a local service.

Ms Garman advised that equality and diversity regarding the number of population, the area covered and transport concerns required to be considered in relation to any proposed service. Mr Leslie commented that current discussions had attracted significant political and public interest and the review will be undertaken set against the facts and public health predictions to consider and address the concerns of those involved.

Mr Roberts enquired regarding the viability of anticipating the number of renal patients and the subsequent provision of a renal nurse specialist, in comparison to the chemotherapy provision at Mid Argyll Hospital.

Mr Morrison replied that a renal dialysis service requires a more complex infrastructure and therefore enhanced capital investment.

Ms Garman stated that projected figures for the future development of a dialysis service should be modelling dependent, not predicted. It is not intended to present an outline business case but a written report outlining the findings and criteria to establish a viable unit will be taken to the CHP Management Team and CHP Committee in December 2012.

The Committee:

 Noted the findings in regarding the currently and future profile of service delivery.  Considered the criteria identified to inform the assessment of what would make a viable “local” hospital dialysis service in Lorn & Isle Hospital.  Approved the approach outlined and the level of detail to be presented in the report.

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Mr Creelman agreed to take Mental Health Services Modernisation Project as the next agenda item.

14. MENTAL HEALTH SERVICES MODERNISATION PROJECT

14.1 Update Report

Mr Dreghorn spoke to the previously circulated report.

Project governance arrangements have been reviewed for the capital element of the project, resulting in the establishment of a new Capital Project Board. The first meeting of this group took place on 19 October 2012 and will meet monthly to oversee the new inpatient services mental health hospital capital project.

Capital Project – the hub stage 1 submission was received on 5 October 2012 and was presented to the Project Board on 19 October.

Key points within the report included:

 Estimated capital cost is within the £9.45 million cap set at the start of the project.  The Facility Management (FM) and Life Cycle Costs (LCC) are currently projected to be above the £43 per m2 set at the start of the project. These costs are currently being reviewed by external advisors (Technical, Financial & Legal) and a final report is awaited, which will to a large extent dictate whether the stage 1 submission is accepted. This process should be completed by 4 December 2012  The design development work is progressing well with a full set of drawings likely to be available by the end of November.

Ms Wedgwood enquired about the remit of the external advisors. Mr Dreghorn assured the Committee regarding their financial and legal expertise in relation to Hub projects.

The development of the Outline Business Case continues to progress, with the approvals timetable revised to : CHP Committee on 19 December 2012; NHS Board on 5 February 2013; Asset Management Group on 15 February 2013; and the Scottish Government - Capital Investment Group on 26 February 2013.

Mr Dreghorn summarised the detail of the report relating to:  Inpatient services  Staff redeployment  New posts  Budget  Projected Operational Funding Gap  Resettlement Group  New hospital  Community Mental Health Service (CMHS)  Community Mental Health Service Team Base  Crisis Response

Mr Dreghorn advised that the lead Architect has met with staff and service users to discuss the design of the new hospital building and the plans have subsequently been amended following those discussions.

Identifying suitable premises as a base for the CMHS teams in Campbeltown and Dunoon continue to be problematic. The benefits of having all members of a CMHS team in one location has been acknowledged, therefore in both areas it is planned to develop underutilised areas of the hospital as a CMHS base, incorporating NHS and council staff. Discussions are ongoing regarding the financial implications of this proposal. 6 31

Mr Creelman raised the issue of crisis response in Dunoon.

Mr Dreghorn acknowledged the concerns and advised discussions have taken place regarding the sufficiency of the designated place of safety in the hospital. Community mental health teams are very responsive but concerns around provision during out of hours are being addressed.

Mr Dreghorn reported that he is currently visiting all places of safety within the CHP and meeting with staff, management and service users and the discussions and any recommendations will be reviewed.

The Committee:

 Noted content of the Modernisation of Mental Health Services Update Report

8. Workforce Planning

Mr Logue referred to the circulated paper summarising the detail of the monthly NHS Highland Workforce Information report. This provides a range of information on staff throughout NHS Highland and a comparison can be made on some items between Argyll & Bute CHP and other areas in NHS Highland. The paper provides a snapshot of the situation at August 2012, with some charts providing trends and historical data over the previous 12 months.

Points highlighted:

 Replacement Whole Time Equivalent – use of Bank staff is reducing.

 Job Families – comparable figures – NHS Highland 64.44% staff in immediate front line patient care, 34.81% - support and administrative services staff. CHP 64.26% of staff in immediate front line patient care, 35.07% - support and administrative services staff. Senior managers – 0.74% in Highland, 0.68% in the CHP.

 Turnover and Stability – figure is currently falling, indicating a trend towards higher turnover and possibly a more active employment market, which is also indicated by an increase in vacancies over the last 12 months.

 Occupational Health (OH) Service KPIs - KPI 2 shows the average referral to treatment time (RTT) for seeing an OH nurse. Although improving recently this remains low. It should be noted that the target RTT for Inverness is lower than other areas. The OH is working to overcome the challenges presented by the wide geographic area and have recently appointed to a vacancy covering Argyll and Bute. Also, increased use of telephone appointments has been introduced providing a more flexible and quicker response to staff out with Inverness.

 Sickness Trends - the Argyll and Bute figure remains above that of NHS Highland overall. There is continuing work between HR, managers and OH to address frequent or long term absences. The annual trend for Argyll and Bute follows the NHS Highland trend line for reduction and the gap has closed over the year from 0.6% to 0.2%.

 Employee relations - charts provide information on the numbers and lengths of the various procedures being undertaken under NHS Highland Employee Relations Policies (PIN Policies). A summary for the CHP is taken to the Core Management team for discussion. Managers and HR, in partnership with the Staffside, are 7 32

committed to reducing the time taken to complete these procedures, with regular case reviews undertaken to improve the timeline. Mr Logue advised that the CHP % of cases and lengths of completion times are similar to NHS Highland.

 NHS Highland Re-deployment Register - there are considerably more staff on this register in the CHP than in other areas of Highland and this is indicative of the scale of service changes being enacted. The large majority of staff are on the register due to their posts being subject to change. They remain at work and undertaking their normal duties but are given priority status for any vacancies which arise. This greatly assists in the process of revising service establishments and supporting staff to move into suitable alternative posts.

 Employee Friendly Leave – the range of leave available to staff to assist them at times of emergency, family crisis or similar events provide them with the opportunity to overcome or deal with the difficulty. NHS Highland initiatives are valued by staff and are a small aspect of staff attendance. In August 2012 total leave of this type in NHS Highland was 30.96 wte equating to 0.46% of the workforce.

Ms Wedgwood asked for clarification of the figure of 161 fixed term contracts. Mr Logue replied that this is possibly due to cultural issues around recruitment but will ensure a specific examination of this figure.

Ms Tyrrell highlighted the age profile of staff and the challenges for the CHP in forthcoming years to address any resulting issues. Ms Tyrrell asked about the appropriateness of discussing retirement plans with individual staff. Mr Logue advised that this would be appropriate in the circumstances of addressing any capability issues but the preparation for such discussions was critical to the need of the individual in relation to discussions with Managers and could also be incorporated within the individual’s eKSF/PDP procedure.

9. Clinical Governance

9.1 Clinical Governance & Risk Management Report

Ms Tyrrell spoke to the previously circulated paper and highlighted a number of areas from the report.

Risk Management

Incidents

A total of 442 incidents were reported during quarter 2 of 2012/13 which is a reduction on the previous reporting period. Slips, trips and falls remain the highest reported category of incidents in Cowal & Bute, Mid Argyll & Kintyre and Lorn & Isles. Medication and sharp incidents were the highest reported category in Helensburgh & Lomond.

During the reported period the reported incidents were reported as low -242 (54.74%) and medium – 165 (37.33%), with the remaining 35 incidents still to be graded.

Pressure Ulcer Prevention

The CHP is continuing to implement the NHS Highland zero tolerance approach to preventable pressure ulcers. There is heightened awareness of early identification and increased reporting and a range of measures to improve the identification and management of those patients at risk of developing pressure ulcers in all hospital and community settings.

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Ms Tyrrell advised that Argyll & Bute CHP is at the lower end of reported cases but actions continue to drive down any incidences. Details are recorded on Datix and learning is shared through the Tissue Viability Leadership Group and also reported to the Board Clinical Governance Group.

Ms Garman enquired about the level of CQI training for staff. Ms Tyrrell advised that actions are being taken to address identified gaps and needs in staff training and skills. Senior Charge Nurses have identified the need for ownership by teams.

Ms Wedgwood asked about the plan for the care of tissue viability patients on discharge from hospital to the community. Ms Tyrrell advised that details are recorded in the patient discharge plan, with the transfer of care managed by the Community Nursing Team. Discussions have been held with and assurance given by NHS Greater Glasgow & Clyde to assure that accurate details are included in the care plan for tissue viability patients on discharge from NHS GG&C back to Argyll & Bute.

Mr Roberts requested clarification on the July and August figures reported for Islay. Ms Tyrrell confirmed that the reported figures are by occupied bed day numbers and she will circulate information to provide clarification on the numbers reported.

Falls Prevention

Ms Tyrrell reported that a significant amount of work is being undertaken to reduce the risk and number of falls in healthcare settings; to improve the reporting information available and to highlight areas requiring support.

Complaints

Ms Tyrrell commented on the challenges in adhering to the 20 day response time due to the complexity of some complaints and the need to provide a concise response. Ms Wedgwood advised that this is a concern expressed in other areas and is due for discussion at the NHS Highland Clinical Governance and Risk Management meeting.

Health & Safety and Fire Safety

An Argyll & Bute Hospital Risk Assessment group has been established to carry out a review of environmental and statutory requirements to ensure safe practice and a safe environment for staff and patients. An action plan has been drawn up for review at the fortnightly meetings, chaired by Mr Leslie.

Quality

Scottish Patient Safety

Focus on Medicines Management and Medicines Reconciliation continues, to address areas requiring improvement. Further detail will be provided in the next report to the Committee.

External Reviews

Forensic Network Review

A Forensic Network Review of the Intensive Psychiatric Care Unit at Argyll & Bute hospital was carried out in September 2012 as part of a peer review to measure performance against the Low Secure Forensic Standards. A draft report has been received indicating that most standards were assessed as being at the developing stage.

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Care Inspectorate Follow Through Inspection of Services to Protect Children & Young People

Ms Tyrrell advised that a follow up inspection by the Care Inspectorate is scheduled to take place in January 2013.

Healthcare Environment Inspectorate

Notification has been received that the HEI will undertake a minimum of 30 annual, unannounced inspections of acute and community hospitals. All hospitals within the CHP are required to reassess their compliance with the standards and further walk rounds are planned to support this process by a number of senior staff.

The Committee:

 Noted the content of the Clinical Governance and Risk Management Report

9.2 Infection Control Report

Ms Tyrrell spoke to the previously circulated paper.

Staphylococcus Aureus Bacteraemia (SAB)

NHS Highland rate April–August 2012 is 20.0 per 100,000 bed days, (0.20 per 1,000 bed days). The MRSA programme has been implemented and there have been no further cases of SAB in the Lorn & Isles hospital since the last report.

Clostridium Difficile

NHS Highland rate April – August 2012 is 21.7 per 100,000 total occupied bed days, (0.217 per 1,000 occupied bed days) (20 cases) in patients age 65 and over using the Clostridium Difficile toxin test.

Hand Hygiene

NHS Highland Compliance with hand hygiene 98% in July and August 2012.

Mr Roberts challenged the reported figures, particularly with regard to clinicians. During discussion it was suggested that it may be appropriate for a public representative to participate in infection control walk rounds.

Ms Tyrrell acknowledged the need for locality ownership and external scrutiny to maintain compliance by all staff.

Mr Creelman supported the CHP process and commented that there is scope for members of the public to receive training to enable them to participate in the carrying out of audits.

Ms Tyrrell acknowledged the need for locality ownership and external scrutiny to maintain compliance by all staff, and welcomed the suggestion of a public representative.

Health & Safety Executive Visit to Care Homes in North Highland

NHS Highland is working with the Health and Safety Executive on two strands of infection control work at present; one relates to improving the arrangements for managing infection control in NHS Care Homes, the other relates to community nursing staff.

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Within Argyll and Bute CHP we will ensure that actions within the plan for training and education for staff working in community settings are complied with across all sites. In addition we will work with partners in the Argyll and Bute Council and Independent Sector to share the learning and policy changes developed through the NHS Highland Health Protection Team.

The Committee

 Noted the content of the Infection Control Report.

9.3 Health Improvement Report

Mental Health & Wellbeing Framework

Ms Garman reported that the Argyll and Bute Community Planning Partnership document Strategic Framework for Mental Health and Wellbeing in Argyll and Bute 2012–2014 was launched in March 2012. This framework arose from the mental health modernisation programme and was developed from a partnership of Argyll and Bute Council, the Third Sector and Argyll and Bute Community Health Partnership. The purpose of the framework is to ensure investment in evidence informed approaches to improving mental health.

A CHP action plan is currently being developed which will be governed by the Mental Health Modernisation Programme Board and the Community Planning Partnership Management Committee.

Young People in Alcohol

In March 2011 the Argyll & Bute Alcohol & Drug Partnership released the needs analysis report “Young People, Alcohol and Drug Misuse Across Argyll and Bute” by Barnard, Griffin and Milton which identified a number of key points in relation to young people’s alcohol use in Argyll & Bute.

The Scottish Schools Adolescent Lifestyle and Substance Use Survey 2010 (SALSUS) report for Argyll & Bute indicated that:

 Compared with 2006, there has been a decrease in the proportion of 13 year old pupils who had ever had an alcoholic drink (from 63% in 2006 to 51% in 2010) . There has been no statistically significant change in the proportion of 15 year olds who have ever had an alcoholic drink (86% in 2006 and 84% in 2010)  In both age groups, the proportion of pupils in Argyll & Bute who have ever had a proper alcoholic drink is higher than the national average (51% of 13 year olds compared with 44% nationally, and 84% of 15 year olds compared with 77% nationally)

The CHP Senior Health Promotion Specialist: Alcohol and Drugs has undertaken research work looking at the alcohol use by 5th year pupils in three schools in Argyll & Bute and the results were detailed in the circulated report. Alcohol brief intervention work was recently delivered through a series of training events to staff working with young people within the public sector and third sector organisations. The Argyll & Bute Alcohol & Drug Partnership Children & Families group are in the process of finalising an action plan, connected to five key practice areas:

 Education, information and prevention  Diversion and prevention  Identification and response to children at risk

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 Training and Development  CAPSUM (Children Affected by Parental Substance Misuse)

Mr Leslie emphasised the value and benefits of health improvement work. There is a need to address the stigma in mental health and to advocate the importance of mental health wellbeing.

It was acknowledged that the work being carried out to address concerns regarding young people and alcohol requires the sign-up of the young people and a cultural change to achieve self management.

The Committee:

 Noted the content of the Health Improvement Report.

10. FINANCIAL GOVERNANCE

10.1 Finance Report

Financial Position

At end September 2012 Argyll & Bute CHP recorded an overspend of £57,000, a significant improvement on the previous month as it represents a decrease of £128,000 on the overspend of £185,000 recorded at the end of August.

Mr Morrison summarised the budgetary performance across Argyll & Bute CHP to end September 2012 and advised on the overspending budgets caused by either unachieved savings or cost pressures.

The main cost pressures being experienced are;

 Medical locum cover for vacancies and a suspension in Cowal.  An overspend on commissioned services relating mainly to increased patient referrals to Raigmore & Belford Hospitals which are internally cross-charged on a cost per case basis.  Locum cover for GP vacancies in Bowmore, Jura and Inveraray.  An overspend on hospital and community nursing pay costs on Bute.

In addition to the cost pressures noted above, there is also the ongoing risk relating to settlement of the patients services SLA with NHS Greater Glasgow & Clyde. No value has been agreed for this financial year and GG&C are continuing to claim that a substantial increase to the SLA value is required to reflect increased activity and case complexity.

Specific attention is drawn to the entry of “Planned Management Action”. This entry is necessary to support a forecast year-end break-even position for the CHP. However it indicates that without action to address savings target shortfalls, it is likely that the CHP will overspend by £300k.

Cost Improvement Programme 2012/13

The CHP approved budget for 2012/13 contained a requirement to achieve savings of £5m. Several of these savings will arise naturally e.g. prescribing drugs coming off-patent, restricted uplift to SLA values, etc.

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Initially a balance of £2.24m required to be delivered through management action, however this has recently been reduced to £1.56m, mainly as a result of increased savings being achieved from off-patent prescribed drugs. This has enabled locality savings targets to be reduced from 3% to 2%.

Recurring targets by budget manager, sums declared achieved to date, forecast achievements based on current information, and likely shortfalls are as detailed in the report. Based on current information, there is likely to be a shortfall of £0.5m against savings targets.

Mr Morrison emphasised the need for managers to take action to deliver on savings targets where a shortfall is currently predicted.

Forecast Outturn for 2012/13

Overall, notwithstanding the risk relating to the GG&C SLA, Argyll & Bute CHP is forecasting a year-end break-even position. This is, of course, dependent on managers delivering on their savings targets and continuing to exercise control over emerging cost pressures.

The Committee:

 Noted the contents of the Finance Report

10.2 Service Level Agreement (SLA) Update Report

Mr Whiston advised that the detail of the paper sets out the governance arrangements and provides a broad scope of contracts for services provided to the Argyll and Bute population for 2012/13.

NHS Greater Glasgow & Clyde – Main Patient SLA

The CHP participates in regular liaison meetings with senior management of NHS GG&C with regard to its’ SLA to consider and address operational and financial issues pertaining to the services it commissions. There are 2 sets of meetings, financial and operational:

The SLA Finance Group oversees overall financial arrangements, including agreeing costs, variations and exclusions, managing financial risks between both organisations, taking account of West of Scotland Regional Planning arrangements as well as monitoring financial and activity performance.

The SLA Operational Review Group reviews and monitors the operational delivery of services against the SLA as well as issues and progress against action achieved. There is also an emphasis on ensuring equitable access for Argyll and Bute patients to NHS GG&C services by having these formal arrangements. Service redesign are managed and lead through the CHP planning managers with consultant outreach services (specialist clinics delivered in Argyll and Bute) being the most frequent issue.

Discussions are taking place with NHS Highland regarding the implementation of the Patient Management System (PMS) and the specific issues for the CHP in relation to patient flows predominantly being to NHS Greater Glasgow & Clyde.

There are ongoing discussions to clarify laboratory governance following changes to the NHS GG&C laboratory management structures.

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11. STAFF GOVERNANCE

11.1 Argyll & Bute CHP Partnership Forum Draft Minute - 23 August 2012

The draft minute was previously circulated for information.

The Committee:

 Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of 23 August 2012

11.2 PDP/R and eKSF Implementation

Mr Logue reported that at end September 2012 the CHP recorded 10.86% of reviews completed for all AfC staff (14.82% excluding Bank staff). Concerted efforts are being made in all areas to achieve the target of an 80% completion rate by end March 2013.

Derek advised that he has received assurances from Managers that review dates for staff have been set which will result in an improved completion rate to ensure the target is met.

The Committee: 12. PARTNERSHIP WORKING Noted the content of the PDP/R and eKSF Implementation 2012/13 Report

12.1 Argyll & Bute CHP Public Partnership Forum Draft Notes – 28 August 2012

The draft note was previously circulated for information.

The Committee:

 Noted the contents of the Argyll & Bute CHP Public Partnership Forum Draft Notes of 28 August 2012

13. PERFORMANCE MANAGEMENT

13.1 Delayed Discharge/Joint Performance Report

Mr Leslie reported on the monthly census which indicated 1 case >6 weeks, with an exemption code due to the complexity of the case. Delayed discharge performance is a key priority in partnership working which is positively reflected in the reporting of only 2 delayed discharges breaching targets over a considerable number of months.

It was agreed that the Joint Performance Report will be included in future Committee papers.

The Committee:

 Noted the contents of the Delayed Discharge Report.

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15. Papers for Noting

15.1 CEL 27 (2012) - AHPs as Agents of Change in Health & Social Care – The National Delivery Plan for the Allied Health Professions in Scotland, 2012–2015

15.2 Proposed CHP Committee Dates 2013

The Committee:

 Noted content of the above papers.

16 AOCB

There was no other competent business highlighted.

17 DATE, TIME & VENUE FOR NEXT MEETING:

Wednesday 19 December 2012 at 10.30am in Queens Hall, Dunoon

15 40 41 Highland NHS Board 4 December 2012 Item 3.2

HIGHLAND HEALTH & SOCIAL CARE GOVERANCE COMMITTEE

Report by Deborah Jones, Chief Operating Officer

The Board is asked to:

 Note that the Highland Health & Social Care Governance Committee met on Thursday 1 November 2012 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present: Mr Ian Gibson, Board Non Executive Director (Chair) Helen Bryers, Head of Midwifery Myra Duncan, Board Non Executive David Flear, Patient/Public Representative David Garden, Head of Financial Planning Gavin Hogg, Patient/Public Representative Deborah Jones, Chief Operating Officer Chris Lyons, Director of Operations – Raigmore Hospital Fiona MacFarlane, Pharmacist Representative Margaret MacRae, Staffside Representative Gillian McCreath, Board Non Executive Gill McVicar, Director of Operations – North & Mid Brian Robertson, Head of Adult Social Care Nigel Small, Director of Operations – South & Mid Kate Stephen, Elected Member, Highland Council Bren Gormley, Elected Member, Highland Council Mr Quentin Cox, Area Medical Committee Representative – Consultant Dr Chris Williams, Area Medical Committee Representative – GP Mhairi Wylie – Voluntary Sector Representative Katherine Sutton, Associate Director, AHPs

In Attendance: Jan Baird, Director of Adult Care Bob Summers, Head of Health & Safety Sarah Wedgwood, Board Non Executive Okain McLennan, Board Non Executive Leah Morrison, PA to Chief Operating Officer Mr Kenny Oliver, Board Secretary Margaret Dakers-Thompson – Member of Public

Apologies: Helen Morrison – Lead Nurse Representative Philip Walker, Head of Personnel Alisa McInnes, Optometrist Representative Linda Munro, Elected Member, Highland Council Adam Palmer, Staff Side Representative 42

AGENDA ITEMS

 Chief Operating Officer Report

 Operational Unit Reports

 Scottish Patient Safety Programme – North & West, South & Mid

 Highland Health and Social Care – Financial Position at 31 August 2012

 Highland Health and Social Care – Health & Safety Report

 Performance in Adult Services

 Care at Home/Care Homes – Care Inspectorate Reports and Action Planning

 Contract Monitoring

DATE OF NEXT MEETING

The next meeting will be held on Thursday 10 January 2013 in the Board Room, Assynt House, Inverness at 9.30 am.

2 43 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

3.1 TOPIC: Public Engagement – Verbal Update – Maimie Thomson, Head of Public Relations and Communication Issues/Risks Assurance Actions

Public members seeking to establish Head of Public Relations and links to other Public and Patient Communications and team are continuing forums to support Directors Of Operations in the development of networks in local areas and to facilitate appropriate links with the Public/Patient members

Website is currently being updated and the Website/social media could be Board is already starting to use twitter and better utilised facebook

Agreed that Operational Unit public Action: Format and structure of future engagement issues would be picked up reports to the HHSC Governance through the Operational Unit Reports and  Directors of Operations and Chief Operating Officer to Committee regarding Public any Highland wide issues would be picked include update on public engagement within their regular Engagement. up through the Chief Operating Officers reports to the HHSC Governance Committee Report.  Board Secretary to pursue web casting of committee meetings

3.2 TOPIC: Professional Executive Committee – Verbal Update – Deborah Jones, Chief Operating Officer Issues/Risks Assurance Actions

Concern that the establishment of a Chief Operating Officer to meet with Action: Professional Executive Committee Medical Director and others to review would overlap with other already existing structures and ensure that the role  An update on the establishment of a Professional Executive established Committees – Area required of a Professional Advisory Committee to the January meeting of the HHSC Governance Clinical Forum, and other Committee is clear and complementary. Committee – Chief Operating Officer Professional Committees, but recognising that Social Work needs to be represented.

3 44 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

3.2 TOPIC: Risk Registers – Verbal Update - Directors of Operations Issues/Risks Assurance Actions

How should the Corporate and Chief Operating Officer currently working Actions: Operational Unit Risk Registers be with others to update the Risk Registers  Corporate Risk Register to Clinical Governance Committees reviewed by the HHSC Governance and ensure that they reflect the new on a quarterly basis – Chief Operating Officer Committee integrated organisation  Audit Committee to review Risk Register on a 6 mthly basis. Operational Unit Risk Registers to be reviewed quarterly by HHSC Governance Committee – first reports for the March Meeting – Chief Operating Officer  Any specific issues in the meantime to be included in the Operational Unit/COO Reports – Director of Operations/Chief Operating Officer

4.1 TOPIC: Chief Operating Officer Report – Deborah Jones, Chief Operating Officer Issues/Risks Assurance Actions Older Adult Mental Health Redesign Update outlines key issues and progress, a more detailed report will be presented to a future meeting

Healthcare Environment Raigmore will be subject to an announced Inspectorate Visits/Control of visit during this year. All other Hospital Infection sites are prepared for an unannounced visit. Actions from previous visits in Raigmore and Caithness General are continuing to be progressed including the introduction of new cleaning methods. Both the Chief Operating Officer and the Chair of the Control of Infection Committee are assured by the level of Scrutiny the Raigmore Management Team have in relation to Infection Control

4 45 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

Delayed Discharges – highlighted as Each Operational Unit has an action plan a performance issue as NHS to tackle delayed discharges including the Action: Highland is currently behind use of Change Fund monies to redesign  An update on progress with reducing delayed discharges will Trajectory existing services. Includes working with presented to the next meeting of HHSC Governance Care Homes to develop models of care Committee – Chief Operating Officer which include the use of their facilities.  Board paper on Change Plan/Fund to be distributed to Each Operational Unit meet on a regular members of HHSC Governance Committee – Board basis to review delayed discharges on a Secretary patient by patient basis

Older People in Acute Hospitals – An extensive piece of work is ongoing to need to ensure that the impact of ensure NHS Highland is ready for future nutritional and fluid advice and HEI inspections including the links with the support is key for older people in Leading Better Care project which has hospital. specific clinical quality indicators around nutrition and fluid.

Integration – requirement to link 4 Progress is being made, however with the key patient/client administration pending introduction of the new Patient Action: systems to allow appropriate sharing Management System sometime in  Report on progress with the integration of patient/client of information to clinicians when 2013/14 – all other systems will need to be systems to be presented to a future meeting of HHSC required compatible with it. Governance Committee –Chief Operating Officer

Cancer Waiting Times – issues with There is an action plan in place to address radiotherapy and oncology capacity the issues including a comprehensive Action: which are impacting on the waiting international recruitment process and  Report to Improvement Committee in January – Director of time to commence treatment using services from Newcastle and Operations – Raigmore Hospital Dundee.

5 46 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

4.2 TOPIC: Operational Unit Reports – Directors of Operations Issues/Risks Assurance Actions

North and West Operational Unit Expect a 6 month programme of Action: Report community engagement starting in early  Time line for Caithness Care of the Elderly Review to be Caithness Care of the Elderly December, proposals will be taken to a included in the Director of Operations report – Director of Review – process underway – future HHSC Governance Committee Operations - North & West looking a key services rather than meeting prior to submission to NHS facilities. Highland Board.

Skye Hospitals – early discussion Plans to start a wider community with clinical colleagues regarding engagement exercise. Will need to focus the hospital facilities on Skye. on rural resilience as it will be key to future of a lot of the remote and rural services. Any review will also include social care services.

Health & Safety Improvement Notice A very robust action plan with the care – Care Home – Lochaber home has been put in place and is being progressed according to the agreed timescales.

South & Mid Operational Unit Reports

Integrated Team Leader Spent some time to ensure that the role Action: appointments – a key building block and remit is right and meets the needs of  Update on progress with integration to be included in of integration. the organisation. Role has now been Director of Operations reports for January meeting of HHSC banded and will be advertised shortly. Governance Committee – Directors of Operations – North & West, and South & Mid.

6 47 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

Raigmore Operational Unit Report This is the biggest redevelopment of Action: Reconfiguration of Tower Block – Raigmore Hospital since it opened and  Update on progress with reconfiguration to be presented to a the first elements of the includes an urgently needed upgrade of future meeting of HHSC Governance Committee – Director reconfiguration are underway the fire prevention facilities. of Operations, Raigmore Hospital

The Archie Appeal has recently achieved Update on Archie Proposals its original target of £1m for an upgrade to the Children’s Ward. The current plan is to move the Children’s Ward to Ward 11 as part of the reconfiguration work; however this will need capital investment which will require Scottish Government approval.

Reliance on the use of expensive Raigmore Hospital is having to be more Locum’s in a number of key creative in its recruitment drives to try and specialties. attract, particularly medical staff, to the Highlands. They have been targeting specific countries particularly Greece and have had some success.

Older People in Acute Care – is Raigmore has done a lot of recent work to Raigmore Hospital ready for HEI ensure that all the necessary standards inspections are being met. Mock inspections have been undertaken. One risk identified is the departure of the Lead Nurse from Raigmore – this will leave a significant gap as they were the lead for the OPAC agenda. Work is underway to fill this gap.

7 48 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

4.3 TOPIC: Scottish Patient Safety Programme Reports – Directors of Operations – N&W & S&M Issues/Risks Assurance Actions

Assurance required that the learning Report required for future meeting of Action: is taken forward from national HHSC Governance Committee to assure  Report required for HHSC Governance Committee to the reviews such as Winterbourne View. committee that the recommendations March Meeting, on the implementation of national reviews in brought forward in these national reports social care settings – Head of Adult Social Care have been addressed where appropriately in the Care Services we are responsible for.

5 TOPIC: Financial Position as at 31 August 2012 – Head of Financial Planning Issues/Risks Assurance Actions

Underlying Operational forecast Ongoing budget negotiations with Action: overspend £8.5m – split £2.5m Adult Highland Council regarding the £2.5m  An update on progress towards achievement of Financial Social Care and £6m NHS Care. overspend in Adult Social Care and Balance in 2012/13 and some idea of the longer term regular meetings with area teams. Work is strategies being looked in January report – Head of underway to develop a 5 year plan for Financial Planning Adult Social Care to build on the  5 Year Plan to be presented to a future meeting of HHSC Partnership Agreement. Governance Committee – Director of Adult Care

There are expected improvements in the prescribing budget and NHS Highlands contribution to the CNORIS allocation through a national reduction of the premium. Raigmore Hospital has already achieved £0.5m savings and plan to achieve another £0.5m savings by the end of December. Still a reliance on non – recurring savings.

8 49 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

There remains a significant risk to achieving Financial Balance in 2012/13

Tertiary Budget showing a Discussions already underway looking at considerable overspend. some short term measures to help in 2012/13 and the longer term measures for 2013 and beyond.

No specific budget for tertiary care – reason for overspend relates to a number of very expensive placements out of area in Secure Units. The development of the North of Scotland Medium Secure Unit should help provide a more local service and also provide a risk sharing mechanism for some of these packages.

6 TOPIC: Health and Safety Report – Bob Summers, Head of Health and Safety Issues/Risks Assurance Actions

Updates to Health & Safety Policies Following the restructuring of NHS and Strategies required Highland and integration there are some amendments to the existing Policies and Strategies which will be considered shortly by the Health and Safety Committee

The H&S strategy updates have be delayed due to the significant workload arising from the increase in HSE inspections

9 50 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

HSE Activity Over 90% of staff have now been trained. Action: Infection Control work in Care  Update on progress on the inclusion of Control of Infection Homes specifications in Care Home contracts to be included in Some early discussion underway to paper on Contract Monitoring for the January meeting of include specifications in our contracts with HHSC Governance Committee – Director of Adult Care Private Care Homes for Infection Control.

Improvement Notice in Care Home, Plans are in place with some tight Lochaber deadlines. The majority of actions have already been met and a draft response to the HSE is being prepared. The one outstanding area will be moving and handling training for staff and NHS Highland is seeking an extension to this deadline. Action:  Concerns regarding the response time from the HSE to be Concern at the lack of responses from raised with Chief Executive and Chairman – Head of Health HSE to queries raised and Safety

7 TOPIC: Performance in Adult Services – Jan Baird, Director of Adult Care Issues/Risks Assurance Actions

61 measures in Partnership The 61 measures in the partnership Action: Agreement plus the development of agreement will continue to monitored.  A further update on progress with the development of 14 key measures – all interlinked. Work is underway to develop a dashboard measures for adult services to be brought to the January for HHSC Governance Committee meeting of HHSC Governance Committee. Director of covering the 14 additional measures which Adult Care will provide a proxy measure for improvement. These measures will  Progress against Performance Measures and any provide the basis for the 5 year plan for associated exception reports to be presented to future HHSC Adult Social Care. They also provide a Governance Committee meetings – Chief Operating Officer good measure of improvement related to the Change Fund monies.

10 51 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

A number of qualitative measures have also been developed which can sit alongside the quantitative measures previously referred to. A baseline measure has already been taken and will be revisited in due course. Action: Further refinement required of the Discussions are ongoing with Highland  Report on the revised assurance framework to be brought to assurance framework for Adult Council with regard to ensuring that there the January meeting of HHSC Governance Committee – Social Care is the appropriate level of assurance Director of Adult Social Care required by each organisation. Duplication of assurance is to be avoided and it should be more than just the sharing of minutes. Action: Meeting HEAT targets for 2012/13 Improvement Committee is well sighted on  Responsibility for the monitoring of HEAT targets to move to onwards the issues regarding delivery of HEAT HHSC Governance Committee with effect from April 2013 Targets – in particular CAMHS and onwards – Chief Operating Officer, Committee Chair Psychological Therapies, and will continue to monitor them as before.

8 TOPIC: Care at Home/Care Home, Care Inspectorate Reports & Action Planning – Jan Baird, Director of Adult Care Issues/Risks Assurance Actions Review required of quality Regulated services will continue to Actions: assurance arrangements to set a undertake self assessments.  Details of the process for managing action plans and how revised regime able to provide Database of all registered care services this fits within NHS Highland’s existing Governance assurances that regulatory activity is will be maintained which will record all Structures to be brought back to future HHSC Governance effective and appropriate remedial inspections and outcomes and that action Committee meeting – Director of Adult Care action is being taken as required. plans have been submitted and are being  A Development session to be set up with the Care progressed within timescales. Inspectorate to better understand their role and how we can Contract Team will liaise with operational work collaboratively with them. – Director of Adult Care managers to ensure contracts are  Paper on Contract Monitoring required for January Meeting appropriately monitored including the of HHSC Governance Committee – Director of Adult Care scrutiny of the outcomes of individual care packages.

11 52 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

Regular meetings will take place with local Care Inspectorate Managers Reports will be regularly submitted to HHSC Governance Committee

9 TOPIC: Other Matters for Information Issues/Risks Assurance Actions

9.1 – Out of Hours HUB Will proposed changes impact on Additional staffing already in place and the current services delivery further improvements are planned. The service is already set up in this way Should limit the centralisation of and exploring the use of technology to services, more community based facilitate far more community based services working to a shared system services. of working No Issues 9.2 – Proposals for an Integrated Strategic Commissioning Group

9.3 – Psychological Therapies A challenging target but the service is Action: Waiting Times moving in the right direction and waiting  Update on progress with this target to be presented to March times are reducing. 13 meeting of HHSC Governance Committee – Director of Operations, South and Mid

9.4 – Anticipatory Care & A good demonstration of how a Polypharmacy contractual mechanism with GP’s has helped to shift work from a hospital based service to a community based service

12 53 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

9.5 – Review of Assurance from Reports/Discussion

Need clarity around the content of This will be an ongoing process of review COO/DOO Reports. and each after each HHSC Governance Action: Committee we will review the assurance HHSC Governance Committee need  To review the discussion regarding assurance as part of the received. assurance that services and preparation of the agenda and papers for the next meeting of changes can be delivered. HHSC Governance Committee – Chief Operating Officer and Chair of HHSC Governance Committee May need sub committees of HHSC Issues will be taken forward through the Governance Committee to assist agenda and papers of future meetings. getting through the issues. Need to avoid duplication with existing structures How do we get public/patient feedback Should avoid just discussing things we can measure Should be challenging the assumptions and looking at alternatives. Need to have clear lines of communication – know who to ask what? The right services need to be discussed at the right committee. Need to get the balance between looking at the detail and covering the breadth of issues.

13 54 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 1 November 2012

FUTURE AGENDA ITEMS Meeting on 10 January 2013:  Reablement Strategy – Brian Robertson  Carers Update – Jan Baird  Telehealth and DALLAS – Jan Baird/Gill McVicar  Flexibility of Respite Care Facilities – Brian Robertson  Charging for Care – Brian Robertson  Anticipatory Care Plans – Progress to Date – Linda Kirkland  CHP Assurance Close Down Reports – DOO’s  Care at Home Services – targets, trajectories & actions being taken to Improve Care Commission grading.  Adult Support & Protection Committee minutes to be presented to future meetings  Staffing Report – to be included in Director of Operations reports Items for 10 January 2013 – from Assurance Report  Update on establishment of Professional Executive Committee – Deborah Jones  Update on progress to tackle Delayed Discharges – Deborah Jones  Timeline for Caithness Care of Elderly Review – Gill McVicar  Adult Social Care Performance Measures – Update on Progress – Jan Baird  Update regarding Adult Social Care Assurance framework – Jan Baird  Contract Monitoring Report – Jan Baird Future Meetings:  Quarterly – Risk Registers – due 7 March 2013 – Directors of Operations in Operational Unit Reports  Update on implementation of recommendations from National Reviews in local Care Homes – due 7 March 2013 – Brian Robertson  Progress on integration of Patient/Client information systems  Update on progress with reconfiguration of Raigmore Hospital Tower Block  Process for managing Care Inspectorate Action Plans  Transitions – update on progress with Strategy – Chief Executive  Self Directed Support for Adults including issues in relation to older adults

DATE OF NEXT MEETING

The next meeting of the Committee will take place on Thursday 10 January 2013 in the Board Room, Assynt House, Inverness at 9.30 am

14 55 Highland NHS Board 4 December 2012 Item 3.3

HIGHLANDHEALTH&SOCIALCAREGOVERNANCECOMMITTEE TERMSOFREFERENCE

1. Committee Remit

The remit identified by the Committee is:

Overall Remit

 To co-ordinate for the Highland Health and Social Care area the planning, development and provision of services which it is the function of NHS Highland to provide with a view to improving these services.  To provide quality, safe and effective care as close to home as possible and to ensure frontline staff have the opportunity and resources to achieve that objective.  To be closely involved in community planning with emphasis on Health & Quality Improvement.  To play a key role in the modernisation of healthcare services along with a vital participation in partnerships, integration and re-design.

Specific Responsibilities

Improving Services  Planning, provision and improvement of a full range of (General/Family) Medical, Community Services and Social Care Services also covering Practice Governance (Clinical and Social Care Governance) issues and Risk management.  Control of Infection  Promotion of/participation in joint working arrangements including adherence to Staff Governance Standards  Achievement of specific outcomes, targets.  Delivery of the NHS Highland Quality ambitions – Better Health, Better Care, Better Value Improving Health  Maximising Health Improvement/Promotion activities in conjunction with Public Health colleagues and other partners.  Collaboration with partners in Community Planning.  Addressing health inequalities Staffing  Staff Governance and observance of the Staff Governance Standards.  Staff Partnership arrangements  Professional leadership  Establishment of leadership structures including Nurses, AHPs and Social Care Staff. District Partnership Forums  Development of District Partnership Forums and ensure any relevant issues are brought to the Committee’s attention through the Directors of Operations Operational Unit Reports. Partnerships  Development of working relationships with other health professionals, Local Authority, Voluntary Sector, Wellbeing Alliance Partners etc. Finance  Management of devolved Budgets  Financial Planning incorporating continuous review of activity/cost 56

Local Delivery Plan Responsibilities

 Health Improvement – improving life expectancy and healthy life expectancy  Efficiency and Governance Improvements – continually improve the efficiency and effectiveness of the NHS.  Access to Services – recognising patients need for quicker and easier use of NHS services  Treatment appropriate to individuals – ensuring patients receive high quality services that meet their needs.

Agenda

 Declaration of Interests

 Minutes o Last Meeting o Formal Sub Committees o Formal Working Groups o Last meeting of Highland NHS Board

 Quality – Service Redesign

 Practice Governance (Clinical and Social Care Governance)

 Financial Governance

 Performance Management

 Staff Governance

 Stakeholder Satisfaction

 Health & Safety

 Chief Operating Officer Report / Operational Unit Reports

Boundaries and Accountabilities

The Highland Health and Social Care Governance Committee is a Governance Committee of NHS Highland and is accountable directly to the Board.

The Committee will report to the Board through the issue of Minutes/Assurance Reports and an assessment of the performance of the Committee will be undertaken annually and presented by way of an Annual Report to the Audit Committee, then the Board.

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Committee Membership

The membership of the Committee is agreed by the full NHS Board and has a Non Executive Chair.

Chair – Non-Executive Director of NHS Highland Board Chief Operating Officer Head of Social Care Chair of Professional Executive Committee NHS Board Non-Executive Directors X 2 Elected Member X 3 Staff Side Representative X 2 Public/Patient Member Representative X 3 Lead Doctor (GP) Medical Practitioner (not a GP) Director of Operations – North & West Director of Operations – Mid & South Director of Operations – Raigmore Pharmacist Dentist Optometrist Lead AHP Lead Nurse Lead Midwife Head of Financial Planning

In Attendance Head of Personnel Head of Health & Safety

The Committee Chair is appointed by the full Board and a quorum for Committee meetings will be at least one Non-Executive Director being present, plus one third of Committee members OR by simple majority provided that at least 12 Committee Members are present in addition to the Non Executive Director.

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Administrative Arrangements

The Committee will meet at least five times per year. The Chair at the request of any three Members of the Committee may convene ad hoc meetings to consider business requiring urgent attention.

The Board Chair is not a Member but has the right to attend meetings.

The Committee will be serviced within the NHS Highland Committee Administration Team and minutes will be included within the formal agenda of the NHS Board.

Any amendments to the Terms of Reference of Highland Health and Social Care Governance Committee will be submitted to NHS Highland Board for approval following discussion within the Governance Committee.

4 59 Highland NHS Board 4 December 2012 Item 3.4 Assynt House Beechwood Park Inverness IV2 3BW HIGHLAND NHS BOARD Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/

DRAFT MINUTE of MEETING of the Clinical Governance Committee 13 November 2012 - 9.15 am Board Room, Assynt House

Present: Ms Sarah Wedgwood, Chair Dr Ian Bashford, Medical Director Mr Bill Brackenridge, Non-Executive Director Dr Paul Davidson, Clinical Director, North & West Highland Operational Unit Dr Michael Foxley, Non-Executive Director Dr Michael Hall, Clinical Director, Argyll & Bute CHP (videoconference) Dr Roderick Harvey, Clinical Director, Raigmore Hospital Mrs Liz McClurg, Infection Control Manager Ms Heidi May, Nurse Director Dr Iain Kennedy, Chair, Area Clinical Forum Mr Alan Simmons, Public Member Dr Margaret Somerville, Director of Public Health Ms Katherine Sutton, Associate Director, AHPs

Also Present: Mr Garry Coutts, Chair, NHS Highland Ms Elaine Mead, Chief Executive

In Attendance: Dr Rob Henderson, Consultant in Public Health Medicine (item 5.1.1) Mr John MacKintosh, Clinical Governance Facilitator (item 6.1.2) Mrs Mary Vance, Local Supervising Authority Midwifery Officer (item 6.5) Mr Bill Alexander, Director of Health and Social Care (item 7) Mr Brian Robertson, Head of Adult Social Care (item 7) Mrs Linda Kirkland, Head of Business Transformation Ms Ruth Mantle, Alzheimer’s Scotland Dementia Nurse Consultant Mrs Mirian Morrison, Clinical Governance Development Manager Miss Irene Robertson, Board Committee Administrator

Apologies – apologies were received from Ms Caron Cruickshank, Mr Bill Reid, Mr Michael Roberts and Dr Ian Scott.

Welcome – welcoming everyone to the meeting the Chair introduced Ruth Mantle, Alzheimer’s Scotland Dementia Nurse Consultant who was shadowing Heidi May, Board Nurse Director.

1 Declarations of Interest

There were no declarations of interest made. 60

2 PERSON CENTRED

2.1 Case Study

The Committee discussed the circulated case study relating to a resident in Argyll & Bute which identified instances of poor communication with the patient and gaps in his care. A copy of the response which had also been circulated provided assurance that the issues had been acknowledged and were being addressed. The Committee felt the case highlighted the need for a joined up approach to healthcare to assure quality in terms of patient care/patient experience. Dr Michael Hall, clinical Director, Argyll & Bute CHP reported on the work being done to address the concerns raised, in particular around communication with patients. In addition to written letters other options such as telephone and text messaging were now available to ensure patients received appointment offers and other relevant information. It was also important to ensure that patients were informed of potential complications or reactions to a particular procedure where these were common and could be anticipated. It was noted that departments in Raigmore Hospital produced information booklets explaining the risks of various procedures which were given to patients six weeks in advance of their treatment. Dr Hall would also follow up on the matter of feedback to healthcare providers treating Highland patients under SLA arrangements if there were any issues relating to quality of treatment or care.

The Committee Noted the issues identified and the actions taken to address them.

2.2 Questions from Lay Members of the Committee

There were no questions raised. The issue of living wills which had been raised at a previous meeting would be considered at the next meeting of the Committee.

2.3 Emerging Issues

2.3.1 Cardiology Services – Audit Scotland Report

The Chair referred to the Audit Scotland report on cardiology services. The key message was that while care and outcomes for heart patients had improved NHS Boards could do more to ensure that all patients received the services they needed. The report contained a number of recommendations which would be considered at, and progressed through, the Cardiac Managed Clinical Network (MCN). It was agreed to ask the MCN for its response to the report and an update on implementation of the recommendations. Any issues identified could be discussed by the Committee as appropriate.

The Committee:

 Noted the publication of the Audit Scotland Report.  Agreed to ask the Cardiac MCN for an update on activity in response to the report’s recommendations.

2.3.2 Better Together: Patient Experience Survey

Mirian Morrison, Clinical Governance Development Manager spoke to her tabled report on the Better Together Inpatient Patient Experience Survey 2012 which provided a Highland wide analysis of the findings. She advised that a detailed analysis of the results by hospital had also been undertaken and the reports distributed to the Operational Units for discussion and action where appropriate. A recurring issue raised by patients related to noise at night.

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The Committee noted that this issue had been discussed by the Nursing, Midwifery and AHP Leadership Group when a number of actions had been agreed. The position would be reviewed in due course to identify the impact of the actions.

The Committee:

 Noted the results of the survey and the actions being taken to address the issues identified.  Agreed to seek an assurance that the issues identified had been addressed. A report on the impact of actions taken to be submitted to the meeting in May 2013.

3 Minute of meeting held on 7 August 2012

The Minute of meeting held on 7 August 2012 was Approved.

The rolling action plan, updated following the August 2012 meeting, was circulated and noted. The Chair identified a number of items due to be considered at today’s meeting which she proposed to defer to the next meeting.

The Committee Agreed to defer a number of items on the rolling action plan to the next meeting.

4 Matters Arising

4.1 Food, Fluid and Nutritional Care

It was agreed that this topic which was due to be discussed at today’s meeting would be considered at the next meeting as part of the update on Older People’s Acute Care.

4.2 Patient Rights (Scotland) Act 2011

At the last meeting it had been agreed that responsibility for governance would lie with the Clinical Governance Committee. The Chair advised that she would discuss the development of a formal process for reporting and monitoring achievement of compliance with the provisions of the Act with Mirian Morrison, Clinical Governance Development Manager and Moira Paton, Head of Community and Health Improvement Planning and would bring a proposal to the next meeting for the Committee’s consideration.

4.3 NHS Highland Internal Audit Report on Clinical Governance August 2012

The Chair summarised the findings of the review of clinical governance undertaken by the Internal Auditors. The report concluded that overall the clinical governance arrangements within NHS Highland were adequate and effective. It also highlighted some opportunities for further development, work on which was already underway. A key action was the development of a revised Quality and Patient Safety Governance Strategy which was due to be submitted to the Committee for approval at today’s meeting. The Chair advised that work was being done in this regard, however it was necessary to ensure that the strategy reflected the principles of the Highland Quality Approach and as such she proposed to discuss the further development of the document with Linda Kirkland, Head of Business Transformation.

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The Committee:

 Noted the findings of the Internal Audit Report.  Noted that the Chair would progress the development of the revised Quality and Patient Safety Governance Strategy with Linda Kirkland, Head of Business Transformation.

5 EFFECTIVE

5.1 Screening Programmes Annual Report

5.1.1 Abdominal Aortic Aneurysm (AAA), Breast, Bowel and Cervical Screening Programmes

The Chair welcomed Dr Rob Henderson, Consultant in Public Health Medicine who spoke to his circulated report which set out the main issues relating to the delivery of the screening programmes. In the ensuing discussion a number of points were raised.

Information describing how the screening programmes were functioning was essential to assess and monitor their performance. For cervical screening, a variety of reports required to be sourced from colleagues in several locations to obtain information describing the programme’s performance. With regard to bowel screening data NHS Scotland’s Information Services Division published annual data relating to North Highland. For North Highland data there was a dissonance between the Health Improvement Scotland standards and how time from referral to colonoscopy was presented in the ISD data. Pressures on endoscopy services meant that some patients were experiencing delays in undergoing colonoscopy. There was significant work ongoing to address this issue. The aim was to increase uptake of screening, it was anticipated that the Detecting Cancer Early programme would encourage people to take part in the programme. Data relating to Argyll & Bute was included under NHS Greater Glasgow & Clyde. The issue of separating out Argyll & Bute data was being pursued.

The Committee then considered the role and remit of the NHS Highland Bowel Screening Steering and Core Groups which Dr Henderson had circulated with his report. He explained that the Board’s Internal Auditors had reviewed the bowel screening programme, together with pregnancy screening, and concluded that NHS Highland had appropriate governance structures in place to oversee these screening programmes. The review had recommended that the steering groups should finalise the roles and remits for their operation and that these should be agreed and signed off by the Clinical Governance Committee. After discussion the Committee approved the role and remit of the bowel screening groups.

The Committee:

 Noted the content of the report.  Approved the role and remit for the NHS Highland Bowel Screening Steering and Core Groups.

5.1.2 Pregnancy, Newborn and Pre-school Vision Screening within NHS Highland

Dr Margaret Somerville, Director of Public Health spoke to the circulated report which provided an overview of the pregnancy (Down’s syndrome and foetal anomaly, haemoglobinopathy, communicable disease) and newborn (newborn hearing and blood spot) and pre-school vision screening programmes in the Highland Partnership in 2011 – 2012.

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Screening Reference Groups provided oversight of the delivery and quality of screening programmes. In addition the Board’s Internal Auditors had carried out a review of the Down’s syndrome screening programmes, overall the findings were positive and no significant risks were identified. There was scope for improvement in some areas and work was ongoing in this regard. It was noted that a Pregnancy Screening Reference Group had been established for the screening programme for communicable disease in pregnancy. With regard to pre-school vision screening, a number of pre-school centres had not been visited during 2011-2012; there were some transitional issues to address in working towards integrated services.

The Committee Noted the content of the report.

6 STRUCTURES AND PROCESSES

6.1 Clinical Governance and Risk Management

6.1.1 Feedback from Operational Units

Dr Paul Davidson, Clinical Director, North & West Highland Operational Unit gave a presentation on the visit which he and a number of NHS Highland colleagues had made to the Virginia Mason Institute in Seattle to learn about the systematic approach to healthcare which it had adopted and the impact on patient care. The key message was about developing a standard way of working, paying rigorous attention to detail, to ensure the delivery of safer and more efficient patient focused care. Implementation of the system had been an evolving process, taking a number of years to effect the cultural and behavioural changes necessary to get all staff on board and standard working embedded in their practice. The learning from the Virginia Mason experience was being applied in Highland to consider how things might be done more efficiently and effectively, ensuring the patient comes first.

6.1.2 Clinical Governance Scorecard

The Chair welcomed John MacKintosh, Clinical Governance Facilitator who gave a presentation on the clinical governance scorecard in which he explained the format, the range of information contained within it, and noted its ability to demonstrate trends over a period of time. The purpose of the scorecard would be to enable the roll out of quality data for scrutiny by the Operational Units’ Clinical Governance and Risk Management Groups focusing on various core aspects of quality. The scorecard had been circulated to the Operational Units for comment as to its usefulness and effectiveness.

Noting that Raigmore Hospital had developed a scorecard, and bearing in mind national work streams underway (the Scottish Patient Safety Programme and Clinical Quality Indicators), the Committee acknowledged the need for a single entry, multi-user system which was easily accessible and which would meet the requirements of all the various different sites. There was a need to identify relevant indicators and ensure the scorecard was populated with the necessary information to provide assurance of performance. Consideration required to be given to the dissemination of the scorecard, there was also a need to ensure that those receiving the scorecard understood its purpose and how to use it. Dr Roderick Harvey, Associate Medical Director, Raigmore Hospital felt that information was required on the outcomes of serious adverse events. He also highlighted the need for clarity of terminology, noting that the scorecard referred to ‘adverse events’.

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Bill Brackenridge, Non-Executive Director referred to the “Pyramid” system which the Argyll & Bute Health and Care Strategic Partnership used as a monitoring tool in respect of success measures and actions relating to integrated and partnership service delivery to older people and from which there may be some learning that could be applied to the development of the scorecard.

Dr Davidson left the meeting

The Committee would need to identify the information it required to give it assurance that the data was being scrutinised at operational level and that appropriate action was taken as required and the loop closed.

The Chair thanked Mr MacKintosh and his colleagues in the Clinical Governance Support Team for their work in developing the clinical governance scorecard. It was suggested that the Quality Hub be asked to consider the scorecard and the issues identified in more detail and report back to the Committee in due course on their conclusions.

The Committee Agreed to refer the clinical governance scorecard to the Quality Hub for consideration as to its further development, a report to be submitted to the Committee in due course on the implementation of the scorecard and its impact.

6.1.3 Complaints – Performance against the 20 day response target and revised performance indicators

There was circulated report by Mirian Morrison, Clinical Governance Development Manager which gave details of complaints received during the period July – September 2012 and provided a breakdown by operational unit of performance against the 20 day response target. It was noted that the number of complaints received over this quarter had increased, and performance against the target required to be improved. The Improvement Committee which had been monitoring performance had remitted to the Clinical Governance Committee to review the performance indicators. A proposal for a new set of indicators would be presented to the Committee at its next meeting for ratification.

The Committee:

 Noted the position regarding performance against the 20 day response target.  Noted that a new set of indicators would be presented at the next meeting for ratification.

6.1.4 Incident Management

There was circulated report by Mirian Morrison, Clinical Governance Development Manager which gave details of incidents reported in Quarter 2 of 2012 – 2013 (July – September) and noted the actions taken by the Operational Units in response to incidents graded with a consequence of major and extreme. The report also noted progress with implementation of the actions arising from the review of the incident management system conducted by the Internal Auditors in 2010 and gave details of areas identified for improvement arising from the recent organisational changes.

The Committee Noted the content of the report.

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6.2 Strategic Clinical Risk Register

The Chair advised that the Risk Management Steering Group would be meeting shortly to discuss the Strategic Clinical Risk Register and a report would be brought to the next meeting of the Clinical Governance Committee on progress with the development of this document.

The Committee Noted that a report on the development of the Strategic Clinical Risk Register would be submitted to the next meeting in February 2013.

6.3 Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions

A revised draft policy was currently out for consultation. The Chair requested that members send comments on the document to Mirian Morrison, Clinical Governance Development Manager by 30 November 2012.

The Committee Remitted to its members to submit comments on the draft policy to Mirian Morrison, Clinical Governance Development Manager by 30 November 2012.

6.4 Infection Prevention and Control

6.4.1 Control of Infection Committee

There was circulated minute of meeting of the Control of Infection Committee held on 25 July 2012. It was noted that the committee had discussed a number of matters relating to Clostridium difficile, in particular implementation of the action plan arising from the significant event review of the outbreak of Clostridium difficile infection (CDI) at Raigmore earlier in the year and the introduction of a new Clostridium difficile testing regime.

6.4.2 Infection Control and Prevention Control Work Plan 2012 – 13

Dr Roderick Harvey, Associate Medical Director, Raigmore Hospital updated the Committee on progress against the action plan developed in response to the Raigmore CDI outbreak noting that four of the recommendations had not yet been completed.

Standards of cleanliness Work was underway to produce a short policy describing lines of responsibility for cleanliness. In addition to producing a written policy signage was also being put up throughout the hospital to reinforce the message that every member of staff had a responsibility to highlight sub-standard cleanliness.

Nurse staffing levels Action had been taken to rectify the issue identified, new members of staff having been appointed to ensure adequate levels of staffing in relation to patient acuity/activity.

Review of single room usage An audit had been undertaken of current patterns of usage and demand, and consequent implications for the control of infection. Work was now underway to develop a bed policy for the effective utilisation of all beds.

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Use of proton pump inhibitors (PPI) The Formulary Sub Group of the Area Drug and Therapeutics Committee had convened a short life working group to develop a protocol for the appropriate use of PPI drugs in hospital and pre-admission. A timescale for completion of this piece of work had not yet been identified.

Dr Harvey advised that the recommendation in relation to patients with ongoing symptomatic diarrhoea without a confirmed cause remaining in isolation irrespective of a negative stool result would not be progressed. He explained that there was a fixed number of isolation facilities in the hospital and these would be kept available for patients with a confirmed infection. The new regimen of stool testing for CDI which could deliver results within a short period thereby increasing the rates of early detection of infection would assist the management of patients with suspected CDI.

The Committee:

 Noted the minute of meeting of the Control of Infection Committee held on 25 July 2012.  Noted progress with implementation of the action plan arising from the significant event review of the Clostridium difficile infection outbreak at Raigmore.

6.5 Annual Local Supervising Authority Report to the Nursing and Midwifery Council 2011 – 2012

The Chair welcomed Mary Vance, Local Supervising Authority Midwifery Officer who spoke to the circulated Annual Report of the Local Supervising Authority (LSA) to the Nursing and Midwifery Council (NMC) for 2011 - 2012. She explained that the report had been informed by the Annual LSA Audits for 2012 – 2012 and the Supervisors of Midwives Annual Report to the LSA 2011 – 2012, copies of which had been circulated for the Committee’s information. The North of Scotland Consortium, of which Highland was part, had been reviewed last year by the NMC and had met 53 out of the 54 standards for statutory supervision with one standard relating to reporting of serious untoward incidents partially met.

Mrs McClurg left the meeting

Mrs Vance highlighted areas of good practice and the key areas for improvement for Highland. Recruitment to the role of supervisor of midwives remained challenging; there were capacity and training issues to address. The introduction of a training programme for supervision of midwives at Robert Gordon University in Aberdeen had facilitated access to training for Highland staff. The overall ratio of supervisors to supervisees in Highland was 1:13, which was within the NMC ratio of 1:15; however there were a number of supervisors who had a higher ratio. There was a need to increase the number of midwives in training to be supervisors to ensure the sustainability of the supervisory framework. A concern had been expressed in relation to midwives being able to access their supervisor; the position was variable across the area. A robust mechanism in addition to audit and feedback from midwives required to be put in place to assist in measuring quality of supervision. On the point raised in relation to babies born before arrival of a midwife Mrs Vance advised that this was not an area of concern in Highland where the numbers were very small. The Committee acknowledged the work being done in relation to public involvement in the development and improvement of midwifery and maternity services and obtaining feedback from service users.

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The Committee:

 Noted the LSAMO Report 2011 – 2012 to the Nursing and Midwifery Council.  Supported the recommendations for further action to address the issues identified.

6.6 Maternity Services Strategy Coordination Group Annual Report 2011 – 2012

Heidi May, Board Nurse Director spoke to the circulated report which detailed activity of the Maternity Services Strategy Coordination Group (MSSCG) during 2011 – 2012. She highlighted two key work streams:-

(i) The completion of the new Maternity Services Strategy and the development of implementation plans. The Operational Units had developed individual work plans which were being monitored through the MSSCG.

(ii) The development of a Highland wide web-based maternity dashboard. Some work required to be done in relation to the community dashboard.

The report outlined key priorities for the coming year, one of which was implementation of the new HEAT target in relation to pregnant women having early access to antenatal care. The target of 80% was currently being achieved in Highland. It was noted that NHS Highland had recently achieved full Baby Friendly accreditation in all its operational units, only the second Board in Scotland to do so.

Mrs Kirkland left the meeting

The MSSCG held annual meetings to consider learning from Significant Event Reviews. The importance of ensuring that lessons learned from such events were disseminated and applied across the organisation was emphasised. In response to a query regarding Surgical Site Infections Ms May indicated most were minor wound infections occurring post-discharge and midwives in the community had been trained in the standard approach to diagnosis and treatment. On the point raised by Dr Iain Kennedy, Chair, Area Clinical Forum in relation to vaccination of pregnant women Ms May undertook to confirm the position in respect of influenza and pertussis vaccination.

The Committee Noted the annual report of the Maternity Services Strategy Coordination Group for 2011 - 2012 and its ongoing activity.

Mr Brackenridge left the meeting

7 LEARNING AND DEVELOPMENT SESSION

7.1 The Implications of Integration for Clinical Governance

The Chair welcomed Bill Alexander, Director of Health and Social Care and Brian Robertson, Head of Adult Social Care who gave a presentation describing professional practice for the social care workforce and the infrastructure supporting the governance and support of individuals, including Mr Alexander’s role as Chief Social Worker for Highland, and the various regulatory and inspection regimes pertaining to social care services. There was also an issue around the regulation and inspection of external service providers. Mr Alexander described the systems and processes being put in place to support the workforce at operational level to assure clinical governance eg quality frameworks, audit of professional practice, organisational learning, complaints and incidents, as well as providing a picture of

9 68 the range of services for which NHS Highland was responsible for delivering. He referred to the move to integrated teams and the challenges during this transitional period in developing appropriate structures in terms of managerial and professional accountability. Discussions were ongoing between The Highland Council and NHS Highland in relation to the development of appropriate structures and systems to further integrate work teams in order to assure governance of practice and service delivery.

The Chair thanked Mr Alexander and Mr Robertson for their comprehensive overview.

8 FOR INFORMATION

8.1 Reports from Operational Units

The following minutes were received and noted:-

 North & West Highland Operational Unit: (i) North Clinical Governance & Risk Management Group – draft minute of meeting held on 3 September 2012

 Raigmore Hospital Quality and Patient Safety Management Team minutes of meetings held on 12 July, 9 August and 13 September 2012

9 Any Other Business

9.1 Schedule of Clinical Governance Committee Meetings in 2013

The additional meeting of the Committee in 2013 was planned for 10 December, however as the Audit Committee was due to meet the same day an alternative date for the Clinical Governance Committee would be arranged.

10 Health Improvement Scotland

Due to time constraints the following items were not considered:-

 Health Improvement Scotland Review of Adverse Event Management

 The Management of Significant Adverse Events in NHS Ayrshire & Arran: Health Improvement Scotland Report June 2012 – Implications for NHS Highland

These items would be included on the next agenda.

11 Date of Next Meeting

The next meeting will be held on Tuesday 12 February 2013 at 9.15am in the Board Room, Assynt House, Inverness.

The meeting concluded at 1.00 pm

10 69 Highland NHS Board 4 December 2012 Item 3.5

IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive

The Board is asked to:

 Note that the Improvement Committee met on Monday 5 November 2012 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached).

Panel: Mr Garry Coutts, Chair Dr Ian Bashford, Medical Director Cllr Alasdair Christie, The Highland Council Dr Iain Kennedy, Non-Executive Director Ms Elaine Mead, Chief Executive Ms Sarah Wedgwood, Non-Executive Director

In Attendance: Mr Bill Alexander, Director of Health and Social Care Mr Kenny Oliver, Board Performance Manager Miss Irene Robertson, Board Committee Administrator

Apologies: Ms Margaret Brown and Mrs Linda Kirkland

Respondents: Mr Robin Creelman, Chair, Argyll & Bute CHP Mr Ian Gibson, Chair, Highland Health & Social Care Governance Committee Ms Deborah Jones, Chief Operating Officer Dr Roderick Harvey, Clinical Director, Raigmore Hospital Mr Derek Leslie, Director of Operations, Argyll & Bute CHP (videoconference) Mr Chris Lyons, Director of Operations, Raigmore Hospital Mrs Gill McVicar, Director of Operations, North & West Highland Operational Unit Mr Brian Robertson, Head of Adult Social Care Mr Nigel Small, Director of Operations, South & Mid Highland Operational Unit Mrs Jan Baird, Director of Adult Social Care (item 1) Mr Nick Kenton, Director of Finance (item 2a ) Mr David Garden, Head of Financial Planning (item 2a)

TOPICS DISCUSSED

1. Integration – Quality and Improvement a. Scorecard for Adult Social Care b. Scorecard for Children’s Services

2. Review of Board Assurance Report Actions a. Financial Position – Highland and Operational Units b. Urology Services 70

3. Balanced Scorecard

3.1 Heat Targets a. Child and Adolescent Mental Health Services (CAMHS)

3.2 Standards

a. 12 Weeks Time to Treatment Guarantee b. A&E – waits to be a maximum of 4 hours c. Cancer Waiting Times, Raigmore

4. HEAT Target 2012 – 13 Risk Matrix - NHS Highland position October 2012

DATE OF NEXT MEETING

The next meeting will be held on Monday 7 January 2013 in the Board Room, Assynt House, Inverness at 1.30pm.

2 71 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 5 November 2012

The Committee’s role and remit is to scrutinise NHS Highland’s performance and ensure remedial action is taken, as required. NOTE: To ensure the quality of reporting to the Committee those papers being submitted are required to contain more associated commentary and follow the prescribed template as agreed.

1 INTEGRATION – QUALITY AND IMPROVEMENT Issues/Risks Assurance Actions Scorecard for Adult Social Care Meetings are planned to discuss A detailed report describing processes and systems that will position as at end of first systems and processes that need to provide assurance to both organisations of governance and quarter: be put in place in terms of scrutiny appropriate structures in place to be prepared for the next Need to develop appropriate and monitoring of performance and meeting of the Improvement Committee on 7 January 2013. structure and supporting delivery of the desired outcomes, Action: J Baird infrastructures to enable the clarifying the roles of the various Highland Council and NHS committees and sub committees and Report on SDS to be prepared for the next meeting setting out the Highland to deliver the necessary ensuring all relevant issues are issues and steps being taken to facilitate the process and improve assurances to each other of captured while avoiding duplication of the position. performance and achievement of work. Action: B Robertson targets in relation to both adult and children’s services.

Need also to consider the role of District Partnerships, where they sit and how they feed in to the structure in terms of providing assurance.

A number of indicators and Indicators carried forward on the BSC performance measures are still prior to 1 April 2012 are being under development. There are a revisited with a view to establishing number of other indicators which trajectories where appropriate. have not yet been progressed due a lack of understanding of the Work is ongoing around the purpose of the measures and development of a number of agreement of the definition of the indicators and methodology to be various indicators. used. It is proposed to set up a short life working group with 72

The self care indicator (how many representatives from health and social people following reablement have care to progress the outstanding reduced dependency) showed indicators. data only for the Inverness, Nairn, Badenoch & Strathspey area. With regard to the self care indicator it Also the number of people whose was clarified that this related to a needs had reduced following small cycle of change piece of work reablement was lower than would begun in Inverness and therefore the have been anticipated. Need to sample size was limited. The capture data in relation to programme will be rolled out as it numbers of people going through demonstrates its effectiveness. It was the reablement programme and agreed that this indicator should be its benefits. included within the other indicators currently under development. Numbers of people aged 65+ in receipt of a Self Directed Support (SDS) package – performance has remained at amber since June 2012. Issue around the bureaucratic process involved.

Delayed Discharges: Report submitted to Highland Health Copy of report and action plan prepared for the Senior Some specific issues to be & Social Care Committee, an action Management Team to be circulated to Improvement Committee addressed, particular challenges plan has been developed to address members for information. in the North. the issues identified. Action: J Baird/I Robertson

Scorecard for Children’s Work is ongoing around the further Updated scorecard to be submitted to the next meeting of the Services: development and refinement of the Improvement Committee on 7 January 2012. scorecard. Action: B Robertson

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2 REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Financial Update: Work is ongoing with The Highland A detailed report to be prepared for the next meeting of the Underlying forecast operational Council to ensure a consistent Improvement Committee on 7 January 2013 in relation to the work overspend. Key areas:- approach is taken to financial of the Raigmore Programme Board, the projects underway and Raigmore position, tertiary reporting for the year to date position. the level of confidence in completing these projects and achieving expenditure, adult social care. Break even continues to be predicted their objectives. for the end of the financial year, Action: C Lyons Shifting the balance of care with however this is dependent on appropriate transfer of resources management actions to achieve the The financial report to the December Board to include an update to achieve sustainable solutions necessary savings. on the activity of the Raigmore Programme Board. for the delivery of health and Action: N Kenton social care. Raigmore: There has been an improvement in Risk around creeping the position. A quality approach has developments. Need to ensure been adopted and more rigour has appropriate controls and been introduced into plans for processes are in place to manage achieving savings. The Programme service development bids. Board is a key element. Thirty Potential impact of constraints on projects are underway, detailed work introduction of new technologies is in progress with the emphasis on on recruitment and quality. ways of doing things differently and more efficiently rather than from a purely cost savings perspective.

North & West Operational Unit: North & West: Currently reporting an overspend. Each team is being set a number of Risk around laboratories and small targets which will contribute to OOH in particular. Significant the overall position. Training is also locum cost pressures - providing being provided to identify short term cover for consultant staff in rural schemes that can be put in place. general hospitals and also for The position in relation to prescribing several general practices. savings has improved.

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Pressures on social care budget Options are being considered, e.g. in relation to care home packages developing rural physician posts, to and OOH care. reduce the need for locums, there is also a national workstream around OOH underway, however break even cannot be guaranteed at this stage. South & Mid Operational Unit: Social Care budget will overspend South & Mid: With regard to the health element of the budget the Unit is fairly confident of break even, the CRES savings have been achieved and work is ongoing to convert the non-recurrent element to recurring savings. Action is being taken to reduce the predicted overspend on the social care budget, mainly due to non- achieved savings from the savings plan brought across at the time of integration, however not confident of break even at the end of the financial year.

Argyll & Bute CHP: Argyll & Bute: End of year deficit forecast. Confident of addressing deficit and Generic drug issues. achieving break even as a result of Risk around an increased SLA management actions being taken. payment to NHS Greater Ongoing discussions with NHS Glasgow & Clyde. Greater Glasgow & Clyde regarding SLA payment. There may be some slippage in the Change Fund that could be used to contribute to the break even position.

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Urology Services Update: Work is ongoing to recruit to the The position to continue to be monitored. Sustainability of service. consultant urologist post. In the Action: D Jones/C Lyons Clinical and financial implications interim assistance is being provided of using short term locums to by the Belford Hospital and NHS cover backfill. Greater Glasgow & Clyde is Difficulties being experienced in continuing to accept a slightly higher recruiting locums. number of referrals.

3.1 BALANCED SCORECARD 2012 – 13 - HEAT TARGETS Issues/Risks Assurance Actions CAMHS: The position is improving, 85% of A position report to be submitted to the next meeting of the Recruitment to vacant posts patients are now waiting less than 26 Improvement Committee on 7 January 2013 including an update remains challenging. weeks. Interviews are being held on recruitment to the vacant posts. Staffing constraints. later this month for the psychologist Action: S Amor Risk associated with the post, two consultant psychiatrist posts retirement of a consultant have been advertised. psychiatrist. Work is ongoing in preparation for the Mental Health Services Review.

3.2 BALANCED SCORECARD 2012 – 2013 – STANDARDS Issues/Risks Assurance Actions

12 Weeks Time to Treatment Actions have been taken to achieve The position to continue to be monitored. Guarantee: the target, the position is being Action: D Jones Risk around use of locums to closely monitored, robust systems are cover consultants’ sick leave. in place to enable patients to be tracked on a daily basis. Fairly confident of being able to sustain the position.

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A&E Raigmore – maximum 4 Monthly breach meetings are taking Recommended that daily breach meetings be reinstated. hours wait: place and an escalation policy has It was suggested that a project be developed under the auspices The target of 98% of patients been agreed which will come into of the Raigmore Programme Board to develop a quality approach being admitted or discharged operation after three hours if a patient to ensure effective systems are in place to resolve the issues within 4 hours has not been met has not been reviewed by a specialist identified. A report on the position to be submitted to the next since January 2012. The figure or if there is no bed available. In meeting of the Improvement Committee on 7 January 2013. achieved in September was addition Emergency Department Action: C Lyons/D Jones 96.7%, and the latest figures representatives now attend daily bed indicate that the target failed to be meetings, and weekly meetings take met in October. place with orthopaedic consultants. Key issues impacting on the position are pressure on beds within individual hospital areas and numbers of orthopaedic expects particularly at weekends and out of hours.

Cancer Waiting Times, An action plan with timelines has A position report to be prepared for the next meeting of the Raigmore: been developed to address the Improvement Committee on 7 January 2013 detailing the impact 31 day target for Quarter 3 to end capacity and recruitment issues to of the actions taken, the report to consider how the roles of the September was not met, and it is enable a sustainable service to be put service and clinical leads for cancer services can be maximised. anticipated that the target will not in place. In the short term locums are Action: C Lyons be achieved in the next quarter. being sought in both radiotherapy The breaches are due largely to planning and clinical oncology to Consideration to be given to a proposal for an external review of delays in radiotherapy planning ensure service continuity and delivery cancer services looking at clinical processes and how things might and clinical oncology capacity within the target times. be done differently to improve effectiveness and efficiency. shortfall. Action: D Jones

National recruitment problems with regard to radiotherapy physics. In Highland the banding of the radiotherapy planning posts has contributed to the challenges in recruiting to vacant posts.

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Concern that the current difficulties could undermine Raigmore’s status as a cancer centre with potential impact on funding for a number of charitable organisations.

4 TOPIC: HEAT TARGET 2012 – 2013 RISK MATRIX Issues/Risks Assurance Actions The risk matrix for October 2012 Fairly confident of delivering on most The position in relation to performance on Stroke to be clarified. highlighted a number of areas not of the targets. A range of actions is Action: I Bashford on trajectory. underway to improve waiting times for CAMHS - 26 weeks referral to psychological therapies. The position A report on A&E Attendances to be prepared for the Improvement treatment showing red – behind will be reported to the forthcoming Committee meeting to be held on 4 March 2013. trajectory and recovery actions Mental Health Service Review visit. Action: C Lyons still to be agreed and/or unlikely Some of the issues relate to CAMHS. target will be delivered.

Child Fluoride Varnishing, Psychological Therapies Waiting Times, A&E Attendances and Stroke all showing amber – behind trajectory but recovery actions agreed and being implemented. Some surprise was expressed that Stroke was not showing green.

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5 FUTURE AGENDA ITEMS

Meeting on 7 January 2013:  A&E Raigmore – maximum 4 hour wait  Cancer Waiting Times, Raigmore  Pyramid System - presentation

Future Meetings:  A&E Attendance Rates and ‘3 Day Guidance’ Pilot Evaluation Report (March 2013 meeting)  Quality Outcomes Framework  Detect Cancer Early Programme

6 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 2013

The Improvement Committee will meet on the following dates in 2013:-

(Mondays, 13:30)  7 January  4 March  29 April  1 July  2 September  4 November

7 DATE OF NEXT MEETING

The next meeting of the Improvement Committee will take place on Monday 7 January 2013 in the Board Room, Assynt House, Inverness at 13:30.

10 NHS Highland - "At A Glance" HEAT Targets 79 Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 5th November 2012 Targets with a delivery date by the end of March 2013 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D

FinancialPerformance Aug-12 Mar-13 CashEfficencies Aug-12 Mar-13

Drug&AlcoholTreatment:ReferraltoTreatment Jun-12 N/A N/A N/A N/A Mar-13 FasterAccesstoSpecialistCAMHS Aug-12 Mar-13

90%ofpatientsdiagnosedwithstrokeadmittedtoastrokeunit Aug-12Currently reported at Board Level Only Mar-13 DelayedDischarges-28days Sep-12 Mar-13 MRSA/MSSA Bacterium: 30% reduction Jun-12Currently reported at Board Level only Mar-13 C.DiffInfections:30%reduction Jun-12Currently reported at Board Level only Mar-13 ReductioninEmergencybeddaysforpatientsaged75+ Aug-12 N/A Mar-13 Targets with a delivery date beyond March 2013 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D No Trajectory EarlyAccesstoAntenatalServicesData sources being developed Mar-15 No Trajectory DetectCancerEarly Data sources being developed Apr-15 ChildHealthyWeightInterventions Sep-12 N/A N/A N/A Mar-14 SmokingCessation-2mostdepriveddatazones Jun-12 N/ACurrently reported at Board Level Only Mar-14 SmokingCessation-generalsmokingpopulation Sep-12 N/A N/A N/A Mar-14 ChildFluorideVarnishApplications Jun-12 N/ACurrently reported at Board Level Only Mar-14

ReduceCarbonemmissions Jun-12Currently reported at Board Level Only Mar-15 ReduceEnergyConsumption Jun-12Currently reported at Board Level Only Mar-15

No Trajectory FasterAccesstoPsychologicalTherapiesTrajectory in development Dec-14

RateofattendancesatA&E Sep-12 N/A Mar-14 NHS Highland - "At A Glance" Standards e d e t on t ut t i s s t B i e a por E e W os e nd r P & a or & l h d l h h r t gm i gy ont oa a or r out

B Target M R N S A Alcohol\BriefInterventions Aug-12 N/A InequalitiesTargetedCardiovascularHealthchecks Jun-12 N/A N/A Breastfeedingat6-8week-Target36% Mar-12 N/A N/A N/A N/A MMRuptakerates-target95%at5yearsold Jun-12 N/A N/A N/A

SicknessAbsence-4%target Jul-12 N/S SMRreturnrate-90%ofSMR1returnsreceivedwithin6weeks Jul-12 Complaints-80%ofcomplaintscompletedwithin4weeks Aug-12 Complaints-No.over40workingdays-Target0 Aug-12 Complaints-No.ofcomplaintsreceivedTargetlessthan33 Aug-12 Complaints-No.categorisedasHighRisk-Targetlessthan7 Aug-12 Daycaserates-Target78.9% Aug-12 N/A Outpatients-DNArate-Target6.9% Aug-12 ReducePreOperativestay-Target0.65days Aug-12 N/A NewtoReturnOutpatientattendanceRatio-Target2.02 Aug-12 eKSF&PDP's-Target80% Aug-12

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Apr-12 Reported at Board Level only Dec-11 AllCancerTreatment(31days)(DueforDeliveryDec2010) Apr-12 Reported at Board Level only Dec-11 18weeksReferraltoTreatment(DueforDeliveryDec2010) Sep-12 Currently reported at Board Level only Dec-11 NewOutpatientWaitingtimes-12weeks(allreferralsources) Sep-12 N/S Inpatient/DayCasesWaitingtimes-9weeks Sep-12 N/A N/S CataractWaitingTimes-assessment-9weeks Sep-12 N/A Hipsurgery-98%ofpatientstreatedwithin24safeoperatinghrs Sep-12 N/A N/A Angiography-4weekwaitingtime Sep-12 N/A N/A N/A Daignostictestswaitingtimes-4weeksfor8keytests Aug-12 N/A A&E Waiting times - 4 hours Sep-12 N/S Annual AdvanceBooking-GP's N/S

CervicalScreening-80%uptakeof20-60yroldwomenscreened Jun-12 N/A ReduceOccupiedBeddaysforlongtermconditions May-12 N/A Dementia (Unvalidated -validatedpositionavailableannually) Aug-12 N/A N/S

N/S : National Standard 80 NHS Highland - Review of Timeliness of Data for Balanced Scorecard

Targets with a delivery date by the end of March 2012 MAY BSC Data NHSH Reported Target Period Time Lag Updated to SGHD Data Source Alcohol Brief Interventions Feb-11 6 weeks Monthly Quarterly Local data used Inequalities Targeted Cardiovascular Health checks Mar-11 2 weeks Monthly Quarterly Local data used

Financial Performance Mar-11 2 weeks Monthly Monthly Local data used Cash Efficencies Mar-11 2 weeks Monthly Monthly Local data used

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Dec-10 3 months Quarterly Quarterly Scottish Cancer Waiting Times System All Cancer Treatment (31days) (Due for Delivery Dec 2010) Dec-10 3 months Quarterly Quarterly Scottish Cancer Waiting Times System 18 weeks Referral to Treatment (Due for Delivery Dec 2010) Feb-11 3 weeks Monthly Monthly Local Data used

Reduction in Emergency bed days for patients aged 75+ Dec-10 3 months Monthly Monthly ISD data used Targets with a delivery date beyond March 2012 MAY BSC Data NHSH Reported Target Period Time Lag Updated to SGHD Data Source Child Healthy Weight Interventions Feb-11 6 weeks Monthly Quarterly Local data used Smoking Cessation - 2 most deprived data zones N/A 6 weeks Monthly Quarterly Local data used Smoking Cessation - general smoking population Feb-11 6 weeks Monthly Quarterly Local data used Child Fluoride Varnish Applications Sep-10 6 months Quarterly Quarterly ISD data used

Reduce Carbon emmissions Dec-10 3 months Quarterly Quarterly Environment Monitoring & Reporting Tool (eMart) Reduce Energy Consumption Dec-10 3 months Quarterly Quarterly Environment Monitoring & Reporting Tool (eMart)

Drug & Alcohol Treatment: Referral to Treatment Dec-10 3 months Quarterly Quarterly Drug & Alcohol Treatment Waiting Times Database Faster Access to Specialist CAMHS Feb-11 3 weeks Monthly Monthly Local data used Faster Access to Psychological Therapies N/A 3 weeks Monthly Monthly Local data used

90% of patients diagnosed with stroke admitted to a stroke unit N/A 2 months Monthly Quarterly Scottish Stroke Care Audit MRSA/MSSA Bacterium: 30% reduction Dec-10 3 months Quarterly Quarterly Health Protection Scotland C. Diff Infections: 30% reduction Dec-10 3 months Quarterly Quarterly Health Protection Scotland Rate of attendances at A&E Feb-11 3 weeks Monthly Quarterly Local data used

NHS Highland - "At A Glance" Standards

MAY BSC Data NHSH Target Period Time Lag Updated Data Source Breastfeeding at 6-8 week- Target 36% Sep-10 6 months Quarterly ISD data used MMR uptake rates - target 95% at 5 years old Dec-10 3 months Quarterly Health Protection Scotland

Sickness Absence - 4% target Jan-11 6 weeks Monthly Local data used SMR return rate - 90% of SMR1 returns received within 6 weeks Feb-11 6 weeks Monthly ISD data used Complaints - 80% of complaints completed within 4 weeks Feb-11 6 weeks Monthly Local data used Complaints - No. over 40 working days - Target 0 Feb-11 6 weeks Monthly Local data used Complaints - No. of complaints received Target less than 15 Feb-11 6 weeks Monthly Local data used Complaints - No. categorised as High Risk - Target less than 20% Feb-11 6 weeks Monthly Local data used Day case rates - Target 78.9% Jan-11 2 months Monthly Local data used Outpatients - DNA rate - Target 6.9% Feb-11 6 weeks Monthly Local data used Reduce Pre Operative stay - Target 0.65 days Feb-11 6 weeks Monthly Local data used New to Return Outpatient attendance Ratio - Target 2.02 Feb-11 6 weeks Monthly Local data used eKSF & PDP's - Target 80% Mar-11 2 weels Monthly Local data used

New Outpatient Waiting times - 12 weeks (all referral sources) Mar-11 3 weeks Monthly Local data used Inpatient/Day Cases Waiting times - 9 weeks Mar-11 3 weeks Monthly Local data used Cataract Waiting Times - assessment - 9 weeks Mar-11 3 weeks Monthly Local data used Hip surgery - 98% of patients treated within 24 safe operating hrs Mar-11 3 weeks Monthly Local data used Angiography - 4 week waiting time Mar-11 3 weeks Monthly Local data used Daignostic tests waiting times - 4 weeks for 8 key tests Mar-11 3 weeks Monthly Local data used A&E Waiting times - 4 hours Mar-11 3 weeks Monthly Local data used Advance Booking - GP's Mar-10 3 months Annually National Audit data used

Cervical Screening - 80% uptake of 20-60 yr old women screened Dec-10 3 months Quarterly Health Protection Scotland Reduce Occupied Bed days for long term conditions Dec-10 3 months Monthly ISD data used Balance of care for Older People with complex care need Sep-10 3 months Quarterly Local data + Local Authority data Delayed Discharges - no clients waiting over 6 weeks Mar-11 3 weeks Monthly Local data used Dementia (Unvalidated - validated position available annually) Feb-11 6 weeks Monthly Local unvalidated data used 81 Highland NHS Board 4 December 2012 Item 3.6

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DRAFT MINUTE of MEETING of the AREA CLINICAL FORUM 27 September 2012 – 1.30 pm Board Room, Assynt House, Inverness

Present Dr Iain Kennedy, Chair Mr Derek Brown, NMAHP Mrs Mary Burnside, Area Nursing, Midwifery and AHP Advisory Committee Mr Ryan Cooper, Area Healthcare Science Forum Mr Quentin Cox, Area Medical Committee Mr Colin Crawford, Area Dental Committee Dr Douglas Hutchison, Psychology Advisory Committee Mr Duncan Martin, Patient Representative Ms Mary Morton, Area Pharmaceutical Committee representing Mr Ian Rudd Dr Rob Peel, Raigmore Hospital Dr Boyd Peters, South and Mid Operational Unit Dr Anne Pollock, Area Healthcare Science Forum Mr Duncan Railton, Area Dental Committee Mrs Margaret Steventon, Area Optometric Committee representing Hugh Campbell and Donald Goskirk Mr Ray Stewart, Employee Director Mrs Pat Wells, Patient Representative

In Attendance Dr Ian Bashford, Board Medical Director until 3.05pm Mr Ken Proctor, Associate Medical Director (Primary Care) Mrs Margaret Somerville, Director of Public Health (until 2.30pm) Mrs Christine Thomson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Dr Kennedy welcomed those present to the meeting, in particular Derek Brown who was attending his first meeting of the Committee. Apologies were received from Elaine Mead, Margaret Moss, Rhiannon Pitt, Sheelagh Rodgers and Ian Rudd,

1.1 DECLARATIONS OF INTEREST

Iain Kennedy declared an interest as Executive Partner at Riverside Medical Practice which had already signed up to the new Service Level Agreement on diabetes. 82

2 MINUTE OF MEETING HELD ON 9 AUGUST 2012

The minute of the meeting held on 9 August 2012 was agreed subject to the following amendments:  It was noted that Douglas Hutchison and Rachel Atherton should both be titled Dr  It was noted that Dr Anne Pollock had been in attendance at the meeting

After discussion and noting the above, the minute was proposed by Ray Stewart and seconded by Rob Peel and accepted as a true record.

3 MATTERS ARISING

3.1 Diabetes Service Redesign – Services for Adults with Diabetes in North Highland Highland Quality Approach to Diabetes

Dr Kennedy reported that he had taken the Forum’s advice to the meeting of the Board held on 14 August 2012 and spoke to the circulated letter which had been sent to Garry Coutts, Board Chair. He advised that a response had been received which endorsed the ACF’s clinical advice. Dr Kennedy had also established from Nigel Small, Director of Operations for South and Mid Highland, that there had been no cut in overall financial resource to diabetes with £846,000 being allocated in the last financial year. There had however been a reallocation and £150,000 had been re prioritised to cover 3 new diabetic specialist nurses. Dr Kennedy advised that the deadline for signing up to the Service Level Agreement was 28 September 2012.

On a point of process Dr Bashford stressed the importance of future presentations to the Forum being balanced in order to assist the Forum in making a considered decision. Dr Kennedy and Mr Cox confirmed that a balanced Primary Care / Secondary Care approach was indeed sought by Dr Kennedy through the Area Medical Committee. Dr Kennedy also stated that he was always very open to any managerial approaches. The difficulty in always achieving a balanced presentation was duly noted.

3.2 Developing Proposals for New HEAT Targets for 2013/14

Dr Kennedy spoke to the circulated response from NHS Highland to the Scottish Government’s Director of Workforce and Performance, this work having been undertaken by the ACF on behalf of the Board. He expressed his thanks to all members who had contributed to the response, highlighting the quality of the feedback to Government.

3.3 NHS Highland Annual Review – 5 September 2012

Dr Kennedy reported on the Annual review and highlighted the brief summary of the event which was included in the Chief Executive’s report at item 7.5. He reported that he had signed up to the Highland Quality Approach on behalf of all members of the ACF.

3.4 ACF Development Workshop

Dr Kennedy reported that the workshop planned for November would now take place in Spring 2013. As no suggestions had been received for possible facilitators he had been in discussion with Elaine Mead regarding the possibility of an external facilitator, and Dr Kennedy intended to seek support at national level from the ACF Chairs’ Group. The possibility of holding this workshop on a Tuesday (or a Thursday) was explored and no Member had any problem with Tuesdays, provided sufficient notice was given and subject to accommodation being available.

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4 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES

4.1 Area Nursing, Midwifery and AHP Advisory Committee

Derek Brown advised that the last meeting had taken place on 7 August 2012 when the main topic of discussion was recruitment and in particular the dilemma of internal versus external recruitment.

4.2 Area Dental Committee

Colin Crawford advised that in addition to the circulated minute of 13 June 2012, a further meeting had been held on 29 August 2012 where details of Service Level Agreements were provided to members and it had been agreed that guidance would be sought on referral for treatment within the area of registration for patients who reside away from home such as students.

He advised that nominations were still sought for membership of the Highland Health & Social Care Governance Committee (HHSCC) and it was noted that although a GDP would be ideal it was felt that the level of commitment required could be a barrier to such an appointment.

As regards decontamination, an outcome report would be considered by the Dental Clinical Governance and Risk Management Group at their meeting to be held on 3 October.

He further advised that agreement had been reached for the appointment of two North of Scotland restorative dentistry posts one for Highland and one for Grampian and it was noted that the development of a Network approach was expected to assist in attracting high levels of candidates.

Mr Crawford also stated that quarterly complaint reports would now be submitted to the Area Dental Committee.

4.3 Area Medical Committee

Mr Cox reported that the draft minute circulated had been confirmed at the meeting of the AMC held on 25 September 2012. At this meeting Miles Mack was appointed as the new Chair and it was confirmed that the representatives on the ACF would in the meantime remain Iain Kennedy and Quentin Cox.

Mr Cox advised that different arrangements for diabetes were in place in Argyll & Bute as there is no locally enhanced service.

On a query from Boyd Peters it was noted that the situation regarding endoscopy at the Belford would be considered under a presentation later in the meeting.

Mr Cox advised that there were several pieces of work ongoing some of which may be more sensible to be completed in primary rather than secondary care. Such work included colonoscopy, renal function check and monitoring of drugs in psychiatry and it was felt that a sub group should be established to investigate where procedures should take place and the resource implications of this. In addition the funding of the labs would be considered at this sub group as there had been a 27% increase in testing. This was actively being taken forward and Anne Pollock suggested it would be beneficial to have some lab input to the Group and Mary Morton considered that pharmacy could also become involved.

Pat Wells expressed the opinion that 10 days was an extremely short timescale for patients to respond to an offer of appointment under the current patient focussed booking system.

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Colin Crawford advised of a system in operation in the dental service whereby patients are first phoned to confirm whether a date is suitable. Mr Cox advised that patients were at present sent two letters and then telephoned or texted. Colin Crawford further advised that a new template had been sent out in Highland which had led to great successes.

At this stage it was agreed to consider the presentation on the Endoscopy Service and Pathway.

5 HIGHLAND QUALITY APPROACH (QUALITY AND EFFICIENCY) – PROFESSIONAL ADVISOR GROUPS/OPERATIONAL UNITS

5.1 Endoscopy Service and Pathway

Lindsay Potts, Consultant Gastroenterologist and Donna Janssens, Endoscopy and General Surgery General Manager, spoke to their presentation on the Colonoscopy Service and pathway.

They advised that the majority of endoscopy services were currently carried out at Raigmore Hospital, other sites offering the procedure being Belford Hospital, Fort William, Caithness General Hospital, MacKinnon Skye, and Oban.

It was noted that the aim was to maximise the capacity across Highland and that whilst Raigmore had no capacity, the Belford had both capacity and endoscopists available.

Some discussion took place over the advantages and disadvantages of referring patients to the Belford. The necessity of using all available NHS capacity was noted but it was also recognised that some patients may be reluctant to travel to Fort William when a facility existed closer to their home especially bearing in mind the need for an escort to accompany the patient.

It was noted that a patient could be removed from the waiting list if they were offered and refused 2 reasonable offers of appointment but that they would not be removed from the list for refusing to travel to the Belford.

It was generally considered that if patients were aware of a timing advantage then they may be willing to travel but that information must be available for the patient and similarly there should be regular up to date information on waiting lists available to GPs.

It was noted that the ACF could not recommend to the Board that patients be allocated to the Belford unless it was their choice but agreed that the Forum would advise the Board to make patients aware that they do have the choice in order to utilise the spare capacity.

The Forum Agreed that NHS Highland could set up a working group to look into the matter of patients travelling outwith their area to obtain quicker treatment, and that public consultation should take place.

5.2 Scottish Patient Safety Programme – Hospital Standardised Mortality Ratio (HSMR)

Stewart Lambie, Clinical Director, Medical and Diagnostics Unit at Raigmore Hospital and Maryanne Gillies, Patient Safety Manager spoke to their presentation on the Scottish Patient Safety Programme and in particular how the Standardised Mortality Ratios had decreased over the past few years.

4 85

They highlighted achievements against objectives citing as examples a 15% reduction in mortality, a 30% reduction in adverse events, improvements in occurrences of ventilator associated pneumonia and central line bloodstream infection. It was also noted that a Medical Emergency Team (MET) had been introduced to Raigmore Hospital with data demonstrating that 80% of calls had been responded to within 15 minutes, that the crash call rate had shown sustained improvement and that the in-patient mortality demonstrated a positive shift downward. Examples of further SPSP achievements were noted as first rate data collection tools and recording systems, safety briefs taking place across all wards and across all four sites, sustained improvement in medicines reconciliation, leadership walk rounds taking place across all four hospital sites and surgical pause occurring in theatre for every patient every time. The Forum congratulated all who had contributed to this success story and agreed that the ACF had to support this sustained change across the Highlands

The Forum Noted the very positive contents of the presentation.

6 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES

6.1 Highland Area Optometric Committee

Mrs Steventon advised that there was no further report.

6.2 Area Pharmaceutical Committee

Mary Morton reported that a meeting of the Committee had taken place on 20 August 2012 where an update on the Chronic Medication Service had been discussed. She suggested that a report on CMS Implementation could be provided to the ACF if they wish. She advised that Andrew Green, Area Regulations, Contracts & CD Governance Pharmacist had provided information on the workings of the Pharmacy Practices Committee.

She advised that the constitution had been reviewed and that discussion had taken place on developing roles and changing ways of working. It was noted that 2 nominations had been received for the position of Chair and both nominees were considering their position. In addition the position of Professional Secretary had been filled and a representative for the HHSCC had been appointed. She reported that discussion had also taken place on managed repeat prescription schemes and an update on the difficulties in changes to Gemscript had been reported. It had also been agreed to set up a short life working group to consider monitored dosage systems in hospital and primary care.

6.3 Psychology Advisory Committee

Dr Doug Hutchison reported that a review of the membership of the Committee was taking place with the aim of achieving representation across all areas of psychology, including guided self-help. He advised that work was progressing towards a 26 week referral with interim treatment targets. He further advised that an activity audit was currently taking place to inform attempts to eliminate waste. In addition the policy on missed appointments was under review. The potential for piloting an alternative method of psychological therapy whereby the patient was seen early with 2 or 3 treatment sessions in an attempt to prevent the problem escalating during the waiting period was also being considered. It was generally agreed that early intervention was an appropriate route to take. Finally it was noted that a more robust data collection system was being investigated.

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6.4 Healthcare Scientists Forum

Ryan Cooper advised that a further meeting of the Board Healthcare Science Leads had taken place in October and advised that Dr Pollock would be giving a presentation on Point of Care Testing at the next meeting of Board Healthcare Science Leads in Edinburgh in October. Mr Cooper advised that data on examples of waste of time, effort and resources would be discussed at the next meeting of the Health Care Science Forum in an effort to improve efficient use of resource.

The Forum noted the updates from the Professional Advisory Committees.

7 AREA CLINICAL FORUM CHAIRS’ GROUP MEETING – 30 August 2012

Dr Kennedy advised that the last meeting of the Chairs’ Group had taken place in August and that Professor George Crooks had joined the Group representing NHS 24. He reported that Jason Leitch, Clinical Director from the Scottish Government had spoken on the Scottish Patient Safety Programme and that the aim was to have “harm free care” across 95% of patient journeys. It was noted that SPSP in acute hospitals had been due to end in 2012 but that this programme had been extended to 2015 with a target of reducing inpatient mortality by 20%. A Patient Safety programme had been launched in paediatrics and would be launched for Primary Care in 2013. In addition the maternity and mental health programmes were also about to commence.

Dr Kennedy reported that ongoing discussion had taken place regarding the capacity of Area Clinical Fora to deliver their functions and that Janet Mackay, the Chair of the National Chairs Group would be following this up with the Cabinet Secretary. He advised that there were concerns about the variation in time and resource provided to ACFs across Scotland and that Highland appeared to have less time allocated to clinicians, especially the Chair, than some other fora.

He further reported that updates had been received from the Quality Alliance Board and that papers entitled “Achieving the 20:20 Vision” and “Progress by Delivery Groups” had been circulated to members for information to update members on the national picture.

Finally he reported on NHS Highland’s response to the proposed HEAT Targets.

8 NHS HIGHLAND BOARD MEETING – 14 AUGUST 2012

8.1 The Highland Quality Approach – Update

There had been circulated a report by Maimie Thompson, Head of Public Relations and Engagement, on behalf of Elaine Mead, Chief Executive

It was agreed that it was necessary to engage staff at the frontline in the Highland Quality Approach and that every member of staff had a responsibility to be corporate. Ray Stewart advised that the Highland Partnership Forum had made similar comments as regards the staff on the ground being able to buy into the concept and there was agreement that it was unknown whether the approach would deliver the savings required.

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8.2 Infection Control Report

There had been circulated a report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

On a query regarding hospital based prescribing it was noted that it was difficult to monitor as there was no electronic system in place.

8.3 Adult Support and Protection – National Reviews

There had been circulated a report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive.

8.4 The Highland Strategic Commissioning Group

There had been circulated a report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive.

8.5 Chief Executive’s and Directors’ Report Emerging Issues and Updates

There had been circulated a report by Elaine Mead, Chief Executive

The Forum Noted the circulated internal communications whilst stressing the comments highlighted.

9 SCHEDULE OF MEETING DATES FOR 2013

The Forum Agreed the proposed schedule of meetings for 2013.

10 FOR INFORMATION

10.1 Attendance Record

Members were advised the Attendance Record would be updated and circulated after the meeting.

The Forum Noted the attendance record.

11 AOCB

Ray Stewart suggested that with closures of the Kessock Bridge occurring in the near future, this could provide an opportunity for testing changes in some services.

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12 DATE OF NEXT MEETING

The next meeting will be held on Thursday 29 November 2012 at 1.30 pm in the Board Room, Assynt House, Inverness.

The meeting closed at 4.05 pm

8 89 Highland NHS Board 4 December 2012 Item 3.7(a) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the NHS Board Asset Management Group Tuesday 18 September 2012 at 1.00 pm Ante Room, Assynt House, Inverness

Present: Alasdair Lawton, Chair John Bogle, Acting Head of Capital and Property Planning Carol Marlin, Monitoring Accountant Chris Lyons, Raigmore General Manger Bill Reid, Head of eHealth Alex Javed, Service Manager – Labs and Radiology Nick Kenton, Executive Lead Malcolm Iredale, Head of Procurement Ray Stewart, Staffside Representative Eric Green, Head of Estates (by VC) Derek Leslie, Director of Operations, A&B (by VC)

In Attendance: Lynda Main, Personal Assistant (minutes)

1 WELCOME/INTRODUCTIONS

Alasdair Lawton welcomed everyone to the meeting and everyone around the table introduced themselves.

Apologies for absence were received on behalf of Bill Brackenridge, John Crossley and Michael Hall.

2 MINUTE OF THE MEETING HELD ON 21 AUGUST 2012

The minute was approved.

3 MATTERS ARISING

Radiology – Deirdre Brindle had spoken to Katherine Sutton regarding the radiology budget, she confirmed that the allocation will be spent this year.

Washer/Disinfector – A way of leasing is to be finalised, revenue finance to cover the lease has been identified. This would leave £400k in the plan for installation; however it is unlikely the equipment will be procured in time for the whole installation to take place this financial year. Confirmation of costs will not be known until the equipment being purchased is finalised. 90

Terms of Reference – Minor changes had been made to the Asset Management Group ToR and these had been circulated. Derek Leslie raised the issue of deputies at the previous meeting, the Group discussed this and concluded it would be acceptable for deputies to attend meetings, but only when necessary and on the strict understanding that they had the requisite knowledge and authority to fully represent the absent member. . A small change would be made to the ToR so that this was included.

John Bogle will forward the finalised ToR along with the Role Description for the Public/Patient Member to Maimie Thompson (Head of Public Relations) for her to take forward. It is hoped a public/patient member will be appointed by Christmas.

Hubco – John Bogle has arranged a presentation for 23 October at 11am, this will take place before the AMG and Board members will be invited to attend.

Actions:

Eric Green will give an update at the next meeting regarding the washer/disinfector.

The Terms of Reference will be altered and then the paperwork passed to Maimie Thompson so that a public/patient member can be appointed.

Board members will be invited to attend the Hubco presentation.

4 FINANCE REPORT

The total spend to date is just over £1m. Slippage of £896k for Oban dental has been brokered with SG as this is not required until 2013/14. The funding for Oban is more than was expected, Carol Marlin is in discussion with Ian Waugh regarding this, and it is thought it could be related to previous PCCPMP funding.

There could be slippage on Mull and Iona and also the replacement washers disinfectors. Carol Marlin again stressed the requirement for robust forecasts in order to maximise spend.

Derek Leslie reminded the meeting that the CHP had been faced with a particular challenge regarding the Bowmore GP Surgery which were leased premises but required considerable expenditure to make them fit for purpose. The service had been moved into the hospital at short notice and was working well. However, works totalling up to £80k were required and it would be preferred if these could be completed before a new GP starts on 1 November 2012. It was agreed to proceed, Eric Green will agree how much of the work will be capital with Deirdre Brindle and report back to the next meeting.

Approval was given in principle to proceed with work on Kyle Court at Raigmore up to a maximum of £150k, it is still to be identified if this will be revenue or capital, and it is thought there will be elements of both. Eric Green will have to discuss the work with Building Control and will be able to confirm the amount after that meeting.

Actions:

Capital forecasts required from all project managers.

Eric Green to update the Group at the next meeting on Islay and Kyle Court.

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5 ESTATES SCHEMES

Eric Green said that they are currently working through a list of estates schemes. A decision has still to be made about the location of the endoscopy department at Raigmore and this is causing delays, once a decision is made work can begin on the design. Chris Lyons added that there is the opportunity to reconfigure the Towerblock at the same time and a lot of work has been done on this recently, the key to this is do decide where endoscopy will be situated. There are 5 possible options being considered.

The internal layout of Dingwall Health Centre is still to be finalised. Discussions with the staff are ongoing and it is hoped a decision will be made in the next few weeks.

Work should start on the Towerblock in mid October, starting with ward 7A. The programme is currently two weeks behind but this is not a cause for concern.

The Government announcement on Biomass funding has been delayed; the Raigmore Business Case has been submitted to the Capital Investment Group for the October meeting. It is likely that there will be additional funding being made available for energy efficient schemes; Estates will be submitting additional bids. The Estates risk register is nearly complete and will be circulated before the next meeting.

As discussed at the previous meeting, a copy of the property database held by Helen Emery will be circulated before the next meeting.

Derek Leslie queried if the buildings coming from the Highland Council for integration have a ring-fenced sum also transferring, Eric Green informed him that the buildings are only being leased and any capital funding required will be provided by the Highland Council.

Eric Green has asked for a second opinion on the Raigmore Labs chiller, which was reported at the last meeting as having failed. He will report back to the Group.

Actions:

Eric Green to circulate estates risk register.

A copy of the property database will be circulated to Group members.

Eric Green to feed back regarding the Lab chiller.

6 ESTATES RISK REGISTER

This is still to be finalised and the final version will be circulated.

The Group noted the position.

7 ANY OTHER COMPETENT BUSINESS

Patient Management System - The Business Case for the purchase and implementation of a new Patient Management System (PMS) is being finalised and will be submitted to the Senior Management Team next week and will come back to the AMG in October.

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It has already been approved by the eHealth Strategy Group. It is thought that around £1.5m of funding will be available from the Scottish Government; this will leave NHS Highland to fund £1,292k of implementation costs over 2 years. The Capital Charge will be approximately £240k. Total revenue costs of PMS is approsimately £1,074,387, however this will be offset by the current cost of supporting i SOFT PAS and HELIX PAS - annual support for these systems is £323,442k which will leave a gap of £750,945 to be funded from the eHealth capital allocation. Bill Reid would discuss the options for Argyll and Bute with Derek Leslie. Bill Reid would also meet with John Bogle to discuss.

Medical Equipment - A paper from John Crossley was circulated detailing Capital equipment replacements required. This included two gastroscopes for Lorn and Islands Hospital, one for Caithness General and an additional two for Belford and Raigmore – the cost will be approximately £210k.

A bladder scanner at a cost of £10k and patient monitors at as cost of £90k were also required.

All of the above would be funded from the existing Medical Equipment capital allocation.

Ultrasound - Alex Javed tabled a paper for information explaining that the leases have expired on the ultrasound equipment at County Hospital, Invergordon and Lawson Memorial Hospital, Golspie and that they had not been renewed due to concerns over quality of the images produced. An option appraisal was carried out to decide on how service delivery could best be achieved. There is sufficient capital only to purchase one piece of equipment and it was recommended to place this equipment at Invergordon and to roll the Golspie service back to Caithness. This had yet to be agreed with local management, a meeting to discuss the paper being scheduled for 25 September 2012.

A&B Mental Health – It was noted that external advice regarding the project structure had been received, there is a requirement to have a formal Project Board. Nick Kenton is leading on this.

The Group noted the above.

A&B Mental Health would be added to the next agenda.

8 DATE OF NEXT MEETING

The next meeting will be held on Tuesday 23 October at 12 noon in the Boardroom, John Dewar Building, Inverness.

Please note that the presentation by Hubco will take place before the meeting at 11am.

4 93 Highland NHS Board 4 December 2012 Item 3.7(b)

Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the NHS Board Asset Management Group Tuesday 23 October 2012 at 11.00 am Ante Room, Assynt House, Inverness

Present: Alasdair Lawton, Chair John Bogle, Acting Head of Capital and Property Planning Carol Marlin, Monitoring Accountant Chris Lyons, Raigmore General Manger Bill Reid, Head of eHealth Alex Javed, Service Manager – Labs and Radiology Nick Kenton, Executive Lead John Crossley, Ray Stewart, Staffside Representative Eric Green, Head of Estates (by VC) Derek Leslie, Director of Operations, A&B (by VC)

In Attendance: Lynda Main, Personal Assistant (minutes)

1 WELCOME/INTRODUCTIONS

Alasdair Lawton welcomed everyone to the meeting and everyone around the table introduced themselves.

Apologies for absence were received on behalf of Bill Brackenridge, Malcolm Iredale and Linda Kirkland.

2 MINUTE OF THE MEETING HELD ON 18 SEPTEMBER 2012

The minute was approved.

3 MATTERS ARISING

Washer/Disinfector – This issue has now been resolved, £200k enabaling costs are required and this is reflected in the Capital Plan.

Terms of Reference – The document has been changed to reflect the minor changes previously discussed and it has bow been passed onto Maimie Thompson for her to progress the appointment of a public/patient member.

Capital Forecasts – This item will be carried forward as an action. 94

Islay – There will be a start up meeting today.

Kyle Court – This is also progressing.

Estates Risk Register – Eric Green would discuss this with Alasdair Lawton after the meeting.

Raigmore Labs Chiller – A possible method of repair has been identified, it is hoped this will be successful.

Actions:

Capital forecasts are still required from all project managers.

4 FINANCE REPORT

The total spend to month 6 is £1.465m, no funding changes have been recived from the Scottish Government.

Approval was given for Lawson Memorial upgrade, Bowmore upgrade, Kyle Court upgrade and additional funding for the Raigmore masterplan.

The £210k previously approved for hub Subdebt has been slipped to 13/14 as this is not required this year, £500k for Oban dental has also been slipped to 13/14 and £250k for SSD washer disinfectors. Spend must be brought forward from 13/14 plan in order to secure funds. This would probably be for medical equipment, eHealth and radiology – managers were asked to liasie with Carol Marlin regarding this. There would be approximately £871k to be spent before March.

Firm committements are required so that slippage can be assessed and this will be manged within NHS Highland and can’t be banked with the Scottish Government.

Actions:

Medical equipment, eHealth and radiology managers to advise which items from next year’s planned expenditure can be brought forward to this year

5 ESTATES SCHEMES

Work will start on the fire compartmentation in the Tower block at Raigmore soon, depending on when the Building Warrant is received. The Masterplan should be completed in June 2013. Government funding has now been annouonced for the Biomass project. Endoscopy is still causing delays and a decision is needed from senior management soon, Nick Kenton will take this forward. This is part of the overall Tower block reconfiguration and an options appraisal has been started and should take 4-6 weeks to complete. Chris Lyons, Nick Kenton and Eric Green will meet to discuss.

The design layout for Dingwall Health Centre has now been agreed.

Actions:

Nick Kenton to take forward Endoscopy and also meet with Chris Lyons and Eric Green to discuss.

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6 A&B MENTAL HEALTH PROJECT

Jackie Bremner from NHS Grampian has carried out a review of the Governance Structure for the A&B MH project which highlighted key actions and cction has been taken to address this.

Tain Health Centre is part of a bundle along with Forres and Woodside in NHS Grampian. A&B Mental Health Project is being taken forward by hub as a stand alone project; however hub had suggested that if the other three projects were delayed so that A&B Mental Health Project could join the bundle there would be a reduction in costs. The Scottish Government are keen for the current bundle to reach Financial Close this year and are providing enabling funding to help ensure this.

The Group agreed that the A&B project should not delay the bundle, however Nick Kenton would speak to hub to ensure the project was progressed as quickly as possible, either as a stand along project or part of another bundle. Alasdair Lawton agreed to contact Alastair Nicol at SFT about it. Nick Kenton also informed the group that a he was asked to be senior responsible officer for the A&B MH project and the group ratified this.

The Group noted the position.

Nick Kenton would speak to hub regarding A&B MH Project.

Alasdair Lawton would speak to Alastair Nicol regarding the A&B MH project.

Approved Nick Kenton as Senior Responsible officer for the A&B MHU project.

7 TAIN OUTLINE BUSINESS CASE ADDENDUM

The NHS Highland Board approved the Tain OBC in December 2010. Scottish Government later announced revenue support for schemes such as Tain. This revenue support shows a real saving to the Board. Scottish Government Capital Investment Group require an OBC Addendum and it will go to their meeting on 20 November 2012 and NHSH Board on 6 November 2012. The Group approved the Tain OBC Addendum

The Group approved the Tain OBC Addendum

8 PMS BUSINESS CASE

The Senior Management Team have accepted the Business Case in principle and the Business Case will be going to the eHealth Strategy Group next week and then to the Board meeting on 4th December 2012.

Discussions are ongoing with Argyll and Bute as to whether they will be part of the NHS Greater Glasgow and Clyde or NHS Highland implementation. Focus groups have been set up to help clinicians embrace new ways of working. The capital and revenue finance phasing is still being worked on. Deloitte are producing a report looking at the implications on cost and service and this will be available in a few weeks. The figures and Business Case still have to be refined and the Group will monitor this going forward.

The Group noted the above.

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9 REPLACEMENT OF THE LABORATORY INFORMATION SYSTEMS (LIMS)

The existing LIMS used comprises of GE Ultra Centricity Laboratory (Pathology) and LRS Medipath (Blook Sciences and Microbiology). The Pathology system is time limited as GE have announced that they will be undertaking no further development work on this product and it must be withdrawn from use by July 2013, due to NHSH signing a support contract with the company this would extend until July 2016.

The Medipath system is supported by an Australian company and user requirements have to be met by customised alterations to software and this limits functionality. There are benefits to changing both systems and the procurement could be phased.

The Group gave approval for Alex Javed to start approaching suppliers in order to get prices and look into leasing. A paper will come back to the November or December AMG meeting detailing the options and cost.

The Group noted the above.

Alex Javed to take a paper back to November or December AMG meeting.

10 DINGWALL HEALTH CENTRE

The Standard Business Case is a consequence of £1.5m of funding becoming available from Scottish Government. The Business Case must be approved by both NHSH Board and Scottish Government Capital Investment Group.

The project is phase 3 of a programme of works at the health centre and will result in reconfiguration of the ground floor which will be kept as mainly a treatment and consulting areas. The roof space will be split into a staff room, changing room, storage, open plan office, treatment and meeting rooms. All of these rooms can be locked so that the space can be utilised out of hours. The NHS Highland Estates department are liaising with planners.

The Asset Management Group granted approval for the Business Case to go to the Board meeting in December and then to the Capital Investment Group meeting in January. It is hoped a start on site will be made in April.

The Group approved the Dingwall Health Centre Standard Business Case.

11 DATE OF NEXT MEETING

The next meeting will be held on Tuesday 20 November at 2.00 pm in the Ante Room, Assynt House, Inverness.

4 97 Highland NHS Board 4 December 2012 Item 3.8(a)

PHARMACY PRACTICES COMMITTEE MEETING – WEDNESDAY, 12 SEPTEMBER, 2012 at 11.30 AM, CULDUTHEL CHRISTIAN CENTRE, CULDUTHEL AVENUE, INVERNESS, IV2 6AS

Report by Helen M MacDonald, Community Pharmacy Business Manager on behalf of Okain McLennan, Pharmacy Practices Committee Chair

The Board is asked to:

 Note the decision of the Pharmacy Practices Committee.

NHS (Pharmaceutical Services)(Scotland) Regulations 2009 Provision on Control of Entry to Pharmaceutical Lists Under these Regulations each Health Board must establish a Pharmacy Practices Committee (PPC) with membership defined as 3 pharmacists, 3 lay persons and a chair who is a member of the Board. If the application being considered is in a neighbourhood where there is a dispensing doctor then a further member is appointed by the GP Sub-Committee on behalf of the Area Medical Committee.

Under the Regulations the Board unconditionally delegates its function to assess and determine the need for additional pharmacy contracts or services to the PPC and the decision of the PPC is final. The PPC is concerned only with NHS contract services and the provision of NHS pharmaceutical services.

1 Background and Summary

The Committee was asked to consider the application submitted by Gaelpharm Limited to provide general pharmaceutical services from premises sited at Lochardil Stores, Morven Road, Inverness, IV2 4BU under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the Applicant’s proposed premises were located.

2 Decision

The Pharmacy Practices Committee (PPC) was satisfied that the provision of pharmaceutical services at the premises of the applicant was not necessary at the current point in time but that it was desirable in order to secure the adequacy of provision of pharmaceutical services into the future within the neighbourhood, as redefined by the Committee.

The Chair invited members of the Committee to vote on the application by Gaelpharm Limited to provide pharmaceutical services at Lochardil Stores, Morven Road, Inverness, IV2 4BU. The Committee unanimously agreed to grant the application.

Full notes of the hearing may be viewed on the NHS Highland website via the following link:- http://www.nhshighland.scot.nhs.uk/Meetings/PharmacyPracticesCommittee/Pages/welcome.aspx

Helen M MacDonald Community Pharmacy Business Manager Integrated Pharmacy

23 November 2012 98

PHARMACY PRACTICES COMMITTEE MEETING Wednesday, 12 September, 2012 at 11.30 am Culduthel Christian Centre, Culduthel Avenue, Inverness, IV2 6AS Application by GAELPHARM LIMITED for the provision of general pharmaceutical services at Lochardil Stores, Morven Road, Inverness, IV2 4BU

PRESENT Ian Gibson (Chair) Sandy Cumming (Lay Member) Michael Roberts (Lay member) Ron Shiels (APC Non Contractor Nominate) John McNulty (APC Contractor Nominate)

In Attendance Andrew J Green (Area Regulations, Contracts & Controlled Drugs Governance Pharmacist) Helen M MacDonald (Community Pharmacy Business Manager) James Higgins, Gaelpharm Limited, Applicant Dale Winchester, Gaelpharm Limited, Applicant Support Michael Church, Rowlands Pharmacy Gayle MacDonald, Rowlands Pharmacy Support Charles Tait, Boots UK Limited Fiona MacFarlane, Boots UK Limited Support Wendy Laing, Area Pharmaceutical Committee

Apologies Tesco Pharmacy Superdrug Pharmacy

Observers Okain Maclennan (Chair of NHS Highland PPC Member in training) Dr Susan Taylor (GP Sub Committee Nominate NHS Highland PPC Member in training) Fiona Thomson (APC Non Contractor Nominate NHS Highland PPC Member in training)

1. The Chair welcomed everyone to Inverness. He asked all members to confirm that they had all received the papers for the hearing and had read and considered them. All members affirmed these points.

2. APPLICATION FOR INCLUSION IN THE BOARD’S PHARMACEUTICAL LIST

Case No: PPC – Lochardil, Inverness Gaelpharm Limited, Lochardil Stores, Morven Road, Inverness, IV2 4BU

The Chair asked each Committee member if there were any interests to declare in relation to the application being heard from Gaelpharm Limited. No interests were declared.

3. The Committee was asked to consider the application submitted by Gaelpharm Limited to provide general pharmaceutical services from premises sited at Lochardil Stores, Morven Road, Inverness, IV2 4BU under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the Applicant’s proposed premises were located.

The Committee, having previously been circulated with all the papers regarding the application from Gaelpharm Limited, agreed that the application should be considered by oral hearing. P1 Gaelpharm Limited Lochardil _ PPC 12 September 12 NOTES.doc 99

Prior to the hearing, the Committee had, as a group, visited the vicinity surrounding the Applicant’s proposed premises, the existing pharmacies at Boots, Southside Road, Tesco, Inshes, and Rowlands, Balloan Park, all in Inverness and facilities in the immediate area and surrounding areas of Holm, Slackbuie, Lochardil, Drummond and Culduthel where social housing, two supermarkets with petrol filling stations, four primary schools, residential nursing homes, community halls and a secondary school were pointed out. They were then driven around the boundaries of the neighbourhood as defined by the Applicant, with the exception of travelling some 8 miles along the B862 to the village of Dores. The Committee had agreed in advance that since this route is sparsely populated and the patients of Dores would be most likely to access GP dispensing services in the village of Foyers there was no value in visiting this proposed boundary.The Committee then returned to the Culduthel Christian Centre, Culduthel Road, Inverness where the hearing was to be held. During the tour, the situation of GP practices, dental surgeries along Culduthel and Southside Roads were noted.

The Committee then visited the proposed premises where the Applicant and Applicant Support were on hand to guide the Committee around the premises.

The hearing was convened under paragraph 3(2) of Schedule 3 to the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 as amended (“the Regulations”). In terms of this paragraph, the Pharmacy Practices Committee “shall determine an application in such a manner as it thinks fit”. In terms of Regulation 5(10) of the Regulations, the question for the Pharmacy Practices Committee is whether “the provision of pharmaceutical services at the premises named in the application is necessary or desirable to secure adequate provision of pharmaceutical service in the neighbourhood in which the premises are located by persons whose names are included in the Pharmaceutical List.”

The Applicant, Support and Interested parties were invited into the meeting at around 11.40am

4. The Chair welcomed:-

The Applicant, Gaelpharm Limited represented by James Higgins who was supported by Dale Winchester, the Interested Parties who had submitted written representations during the consultation period and who had chosen to attend the hearing, were Michael Church, Rowlands Pharmacy and Gayle MacDonald, Rowlands Pharmacy support, Charles Tait, Boots UK Limited, Fiona MacFarlane, Boots UK Limited support and Wendy Laing of the Area Pharmaceutical Committee, (“the Interested parties”). It was noted that Superdrug and Tesco Pharmacy had submitted apologies in advance to the Health Board. The Chair then invited the Committee members to introduce themselves. Committee members introduced themselves to the Applicant and all other parties.

The Chair asked the Applicant and the Interested Parties to confirm that they were not attending the Committee in the capacity of solicitor, counsel or paid advocate. They each confirmed that they were not.

5. The Chair reminded everyone that the meeting had been convened to hear the application from Gaelpharm Limited for the provision of general pharmaceutical services at Lochardil Stores, Morven Road, Inverness, IV2 4BU. The application would be considered against the legal test contained in Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

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6. Regulation 5(10) was read out:

An application shall be granted if the Board is satisfied that the provision of the pharmaceutical services at the premises is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located.

7. The Chair then described the format of the hearing, reminding those attending that no new evidence could be introduced at the summing up.

The procedure adopted by the Committee at the hearing was that the Chair asked the Applicant to make his submission. There followed the opportunity for the Interested Parties and the Committee to ask questions. The Interested Parties would then make their submissions. There followed the opportunity for the Applicant and the Committee to ask questions of the Interested Parties in turn. The Interested parties and the Applicant were then given the opportunity to sum up.

The Chair then asked the Applicant to give his statement.

7.1. The Applicant’s Case

James Higgins, Gaelpharm Limited stated “I am very grateful to the Chair, to the Committee and to NHS Highland for affording me the opportunity to appear here today and to present the evidence in support of this application on behalf of Gaelpharm Limited.

I will endeavour to be as concise as possible – you will be glad to know – in presenting quite a large amount of relevant information.

Our application relates to the Lochardil Stores of Morven Road, Inverness. We propose to offer a full pharmaceutical service from these premises during the hours of 8.30am to 5.30pm, Monday to Friday and 9am to 5pm on Saturday with a Sunday closure.

As we have heard, this application is to be judged according to the legal test and this requires us to define the neighbourhood and to consider the provision of pharmacy services within this neighbourhood.

So, I will begin with a definition, defined by the Oxford English Dictionary as a district or community surrounding a particular place, person or object. A neighbourhood is often also defined as an area which has its own distinct identify to which its residents feel they belong and which is, to some extent, self contained and bounded by physical and geographical features both natural and man made.

To illustrate the wider area of the neighbourhood, we take our western boundary as the River Ness and our northern boundary as Drummond Burn. To the east, our boundary line is formed by Culduthel Road, Slackbuie Avenue and the western edge of Fairways Golf Course and the southern edge being in a less populous area is more difficult to define could be reasonably considered as the limits of the Village of Dores, although the population is much less.

On another map the city boundaries of the neighbourhood are more easily discerned. This gives us a resident population of 7,894 people as defined by Mr Cameron Thomas, a Research Officer at The Highland Council.

The neighbourhood is one which has seen significant growth in recent years. The Highland Council data reveals that the data zones which in whole or in part comprise the neighbourhood has increased by more than 30% since 2000.

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18% of the population is under 16 and 19% is over 65 years of age, giving us 37% of the population who require a higher than average input from community pharmacy services. Scottish neighbourhood statistics lists the Council Ward containing our neighbourhood as having 23% of residents of pensionable age (15% above the Scottish average).

There are five schools within the areas; three primary, Holm, Lochardil and Bun-Sgoil Ghaidhlig (I hope I have said this correctly), Drummond School for pupils with additional support needs and the large secondary school of Inverness Royal Academy. There are three care homes and several community halls and facilities such as this building in which we are meeting in today.

Aside from marked growth in population and housing, one of the most dramatic changes to the area has been in its retail offering. The last two years have seen the opening of both a Tesco and an Asda within the area. These bring with them additional services in terms of petrol stations, grocery and non food retail, opticians, ATMs, a café, recycling facilities, in store collection and 24 hour opening. This has, in many cases, entirely eliminated the need for residents to travel outwith the neighbourhood to access essential services with the exception of pharmacy.

Utilising figures provided by The Highland Council, illustrated on my lovely map, we can clearly define three areas of major growth within the neighbourhood, and these are illustrated firstly, with the continuing development at Slackbuie (the area in blue), is set to add a further 716 homes which are projected to increase the population by 1,360. Secondly, Ness Castle (in yellow) which has planning permission for 984 homes projected to increase the population by 1,930. The preparatory work alone will include a bridge and road widening and the first phase of these comprise 368 homes with 720 expected residents and as well as the access work and road changes being completed, the Scottish Government has contributed £1.9million to kick start the development.

In the red area, Ness Side there is an expectation that this will contribute 500-750 additional homes, although there is some uncertainty about this as it is dependant on the west link road, which is the key to these being developed and is hoped to join to the A82. The Highland Council confirm that development in this area is currently being held back until this is completed. The crossing is at an advanced stage of planning and there is The Highland Council commitment to ensure that it is built. In the longer term development it is expected to contribute a further 980 residents to the community and to include a further primary school. All this information was provided by Cameron Thomas of The Highland Council.

This large scale development, both since 2,000 and over the coming years is being progressed in line with the policy requirement that 25% of all of the homes are required to be of low cost housing.

The burden on all pharmaceutical services is also set to increase across Highland due to other demographic changes. Most notably that of an ageing population. The Highland Council figures show that the number of households headed by 65-70 year olds is projected to rise by 35% and those of households headed by persons 75 years of age or older by 106% in the years 2008-2033 across Highland. It is worth noting that locally the rate of increase of people of pensionable age has been more than twice the Scottish average (according to SNS data) and, if we add this to population growth of 33% in the last 10 years with an expected further increase of over 50% to come, the need for service infrastructure within the neighbourhood is clear.

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This is recognised in the 2006 Inverness Local Plan which states:-

…”rapid expansion of new peripheral residential areas is outstripping the resources of public agencies to provide infrastructure and key services. Stronger design principles are needed to improve the form and functioning of these neighbourhoods…” It then goes on to say:-

“…a new approach is needed to better engage landowners and developers in securing the proper layout and range of community facilities that future residents will need to enjoy reasonable self containment and a quality environment…”

More recently the NHS Highland Pharmaceutical Care Plan points out the same need, saying

“…significant growth in the general population through planned housing development will necessitate corresponding planned developments in the provision of core and additional pharmaceutical services…”

As shown this is particularly pertinent in our neighbourhood.

Having looked at our neighbourhood and its characteristics we must turn our attention to current service provision.

In accordance with current legislation we conducted a public consultation. A notice was placed in the Inverness Courier on 4 May which invited people to submit their opinions and comments and the early responses to this were submitted with our application, together with the adverts themselves.

In order to widen our consultation, a large number of community groups, elected representatives and stakeholders were also contacted to ensure that all interested parties had an opportunity to present their views.

Further notices were also distributed to all retail outlets, schools and community centres, within the neighbourhood.

In addition, all medical practices in Inverness were contacted, first by letter and then by follow up phone calls. None of the practices wished to raise any objection whilst one state that they felt that the area was not well served at present.

Lochardil and Drummond Community Council and Holm Community Council have both gone on record to say that they support our application.

A concurrent survey or households was conducted to obtain the views of residents on the questions pertinent to the legal test. We were anxious that our survey not be open to dismissal on the grounds of either leading questioning or undue influence by those gathering information. To that end we obtained advice from professionals on its construction and distributed it according to the principles of systematic random sampling. A simple survey put through the letterbox of every seventh house gave us a total of just over 600 households contacted from a total of 3,722 or 16%. A response rate of 26% was returned, giving us a return of 156 households and I have the originals of these with me today should you wish to inspect them.

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The survey was accompanied by an explanatory letter which laid out the reasons for conducting the survey and an information sheet which explained pharmacy services as defined in the new contract. The latter was included to allow people to measure their experiences against the services a modern community pharmacy might be reasonably expected to provide using information taken solely from the NHS SHOW website.

The language used in our letter was deliberately non prejudicial as can be seen and the survey consisted of a series of statements which people were invited to strongly agree, agree, neither agree nor disagree or strongly disagree with. The exception to this being questions related to neighbourhood or to expected use and awareness of contract services.

I would like to draw the attention of the Committee to some of our results.

Current Pharmaceutical Services in my neighbourhood is adequate – 19.3% feel this to be true but 62.9% did not think this was the case and either disagreed or strongly disagreed with this statement. The wording is designed to reflect the legal test and patients are responding from an informed position. To put this in context only one in five households feel that current pharmaceutical service is adequate.

I find it easy to obtain a consultation with a pharmacist whenever necessary – 24.2% agreed with the proposition whereas 37.9% report difficulty. 37.9% were undecided. This is a worrying result given that so much of modern pharmacy is dependent on the access to and availability of the pharmacist for delivery of patient centred services which in this case resulted in just under a quarter feeling at ease with.

A new pharmacy is necessary to ensure adequate provision of pharmaceutical services in my neighbourhood – 72.5% agree this is the case, 12.2% disagree and 15.4% are undecided. Interestingly, here is the actual strength of feeling 7 out of ten households feeling with the necessary of this application and more than half of these strongly agreeing whilst just one in ten disputes this. Again, I would like to point out that these households received just a single survey and the results are representative of deep conviction on this subject.

At this stage, I must say that I find myself in disagreement with the assertion made by Rowlands Pharmacy in their written submission that

“…if asked, patients will always say “yes” to a pharmacy in their neighbourhood so this should not be taken as an indications of need…”

It is neither fair nor wise to state that residents faced with a question formulated on the basis of the legal test and in possession of the relevant information are incapable of answering that question and that if they do their opinions are not valid or answered.

Having garnered this information from people resident within the neighbourhood, let’s then look at the access that these people have to pharmaceutical services to find out what is behind these results.

The neighbourhood as defined does not contain any pharmacies and has, therefore, no pharmaceutical services to speak of. Residents are obliged to travel outwith the area to access pharmaceutical services.

Residents may travel to access services via public transport, by walking or by private car. How far, then, are these people travelling and how long does that take? To calculate this we selected four points within the neighbourhood and measured the distances to the nearest three pharmacies from here. The selected points were, Morven Road, Drummond Road, Essich Gardens and Drumfield Road.

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The mean travel times for accessing a pharmacy were 81 minutes walking – for a return journey, 14 minutes driving – if parking is available and 100 minutes by bus. This does not take into account time spent waiting in a pharmacy but travel alone. The mean distance for a return journey was four miles. As pointed out by residents in responses to consultation, some residents are even making these long journeys twice for a single prescription, one to hand it in and another to collect it.

Effectively then, access to a pharmacy and the services it provides is really only available to those with private transport. Even households which do have a car may not have it available at key times due to its use for commuting. Such a scenario being very likely in an area of the city with few employers and very little industry. This is supported by comments made in our survey and by responses obtained from Lochardil and Drummond Community Council, both to our consultation and that of NHS Highland. Many of the respondents to our survey also commented on this, to quote a few of these:-

“The nearest pharmacy at present is Tesco which is too far to walk and it is not always possible by car”.

“Access at present depends on motorised transport”.

“Currently we have to use Riverside, which is five miles away”.

Councillor Alasdair Christie also spoke to the Inverness Courier or 13 July, 2012 on the subject, saying:-

“I am hoping that they take into account that large proportion of the population in Lochardil is elderly and do not have access to transport that would get them to suitable alternatives except for the town centre”.

Delivery of prescriptions is available into the area from at least one pharmacy and whilst this can be useful it is no substitute for the full pharmaceutical service including the new contract services and the potential for improved health outcomes and quality of life that these can provide. Such services as PHS, smoking cessation, MAS and CMS are not deliverable from a van.

As regards the adequacy of service provision we have firm evidence that current services are under severe strain.

To begin with, Rowlands Pharmacy at Balloan Park – this is a small pharmacy dispensing a very high number of prescriptions. With a monthly average of approximately 9000 per calendar month (according to a 2011 FOI request by another party) it struggles to maintain this whilst being accessible to the needs of patients and delivering the pharmacist contact time necessary for a modern community pharmacy.

Evidence of this is clear in the submissions by Lochardil and Drummond Community Council, which states:-

“The wait to have a prescription made up was 30 minutes and one pharmacist was on duty. How do you get a consultation with a pharmacist in such circumstances?”

Comments obtained as a result of our consultation such as “…the pharmacy we use is far too far away and it is too busy…” support this view.

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More evidence is available in the form of a critical incident which recently occurred. During our four week consultation period, Rowlands, Culloden Branch was left without a pharmacist. On 4 June, 2012, the Responsible Pharmacist at Balloan Park left the branch for two hours to cover Culloden, returning to Balloan Park after this time had elapsed. During the periods where no pharmacist was present, no prescriptions could be dispensed, no “P” medicines sold, pharmacist consultations undertaken and all new contract services were suspended at the affected branches – both affected pharmacies. Patients having made often substantial journeys found them to be wasted. Culloden Pharmacy was again without a pharmacist on 6 June, 2012.

Responsible Pharmacists, acting as the sole pharmacist at more than one branch on the same day, have also, in other instances attracted GPhC (meaning General Pharmaceutical Council) censure and according to the RPS (meaning Royal Pharmaceutical Society), this practice is not supported by their interpretation of current Responsible Pharmacist legislation.

In their written submission to NHS Highland, Rowlands have stated that they are not aware of patients having difficulty accessing services – not just in our neighbourhood, but at their closest branch is available for the asking.

The City Centre pharmacies including Superdrug and the Boots Stores at Southside Road and Eastgate Shopping Centre also present barriers to patients. The first two having virtually no parking and the latter having ample paid parking should patients have access to a vehicle. They were rarely mentioned in consultations, except to note their remoteness, difficulty in reaching them or how busy they were. Clearly, residents and householders within our neighbourhood see them as no solution to the poor access to service they face and, in this, I agree totally with them.

Another of the pharmacies to which travel times were listed, and did appear on our consultation, was Tesco pharmacy at Inshes. Again, the Freedom of Information data shows us a picture of a pharmacy at capacity. Averaging of 8000 items is indicative of a very busy dispensary but the very low levels of EHS and smoking cessation paint a picture of a pharmacy struggling to maintain all but a most basis level of a service and certainly not in a position to deliver what is required of it in the current pharmacy contract.

Again, this pharmacy has had problems during our public consultation. As well as its lack of privacy and cramped dispensing area for its workload it has struggled with chronic under re- sourcing. Unusually for any pharmacy this branch has operated with a single PC. This causes many problems for staff but never more so than when, on 2nd June this year, the computer failed totally and, incredibly, was not repaired until 6th June, 2012. During these five days, the dispensary turned away non urgent prescriptions and used handwritten labels on items where patients were unable to return. Due to the length of this service disruption, many patients returned several times expecting the situation to have been resolved.

A second equipment failure concerned the pharmacy fridge having failed. This was still not operational at the end of last week, meaning that during a period of at least 9 weeks, all fridge lines were stores in a fridge with fruit and vegetables situated some distance from the pharmacy itself. The pharmacy elected to stop holding fridge lines in stock until a prescription required them resulting in return journeys. Yet more unnecessary travel and inconvenience in the case of every patient prescribed one of these products.

The keyboard within the dispensary was also allowed to become so worn as to cause staff to be concerned about its impact on patient safety.

Pharmacists and support staff raised these issues and several agreed dates for new equipment passed without this being made available.

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It seems incredible to think that pharmacy could be badly mis-firing for want of three pieces of equipment – a PC, a keyboard and a fridge – when all three of these items are available for sale by that same retailer!

Despite all of this, Tesco state in their written submission that “…we do not see that there are any gaps in the current level of services provision…”

We disagree – and we feel strongly that the service available from at least two of the outlets our residents are forced to travel to use is demonstrably partial, unreliable and certainly not adequate to meet the needs of the population.

I would draw to the attention of those present the fact that all of these failures listed are not historic nor have they accumulated over years but rather all have occurred in the short period since our consultation began in May of this year. What is more, on 4th June, 2012, two pharmacies suffered a simultaneous failure of services, one due to an absent pharmacist and the other due to IT failures.

In summary, then, the neighbourhood has been clearly defined and not only are pharmaceutical services absent within this neighbourhood but those outwith this area have proven themselves incapable of providing an adequate level of service even to those who find themselves in the fortunate position of being able to travel to access these.

With the added pressure of a greatly increased population and with further and greater increases to come, Gaelpharm Limited respectfully submit that this application be granted in order to secure adequate provision of pharmaceutical services within this neighbourhood.

The Chair thanked Mr Higgins for his statement on behalf of Gaelpharm Limited and invited the Interested Parties and then members of the Committee to ask questions of him.

7.2 Questions from Michael Church, Rowlands Pharmacy to the Applicant

Mr Church enquired whether Mr Higgins would be the Responsible Pharmacist at the proposed pharmacy.

Mr Higgins replied that he would not. Mr Church then asked who this would be. Mr Higgins advised that he would presume they would employ a Pharmacist Manager as per the model of the other pharmacies the Company owned but that they had not looked into recruiting at this point in time as they did not wish to do so prior to any contract being awarded.

Mr Church enquired whether Gaelpharm had a qualified independent pharmacist prescriber as part of their workforce.

Mr Higgins advised that there were three in the business in total and that he himself was qualified as an independent prescriber and held 3 prescribing clinics from 2 of the pharmacies owned and therefore it was appropriate to utilise the skill mix of staff and how to share this across the company where required..

Mr Church enquired whether the premises had been secured. Mr Higgins advised that this would be firmed up formally if the application was granted.

7.3 Questions from Mr Charles Tait, Boots UK Limited to the Applicant

Mr Tait commented that he had heard Mr Higgins mention a couple of definitions of neighbourhood and asked if he could explain this applying it to his neighbourhood, some of which crossed roads and parks.

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Mr Higgins advised he would be happy to do so and explained that he had looked at a number of physical aspects, whether they be natural or man-made. To the west of his neighbourhood, there was the River Ness and to the East it followed Culduthel Road and Slackbuie Avenue and the areas of Drummond and Lochardil and Hilton and Castle Heather as far as Fairways Golf Course which was a physical barrier and could not be crossed. To the North the boundary was at Drummond Burn and the Southern edge was more different with an area of trees. He had taken the definition of this from a previous application in Highland for the Village of Newtonmore where the next settlement was as far as Dalwhinnie.

Mr Tait then enquired what made half way down Culduthel Road a definitive boundary as it did extend to Slackbuie and there was no population at Fairways Golf Course. Mr Higgins agreed there was no real population to include after the Golf Course.

Mr Tait then enquired whether his definition of the neighbourhood was based around a sense of being then and, if so, where that had come from. Mr Higgins advised that this was not entirely true.

Mr Tait enquired if he would say he lived in Drummond and Mr Higgins agreed that he possibly would.

7.4 Questions from Wendy Laing, Area Pharmaceutical Committee to the Applicant

Ms Laing had no questions for the Applicant.

7.5 Questions from the Committee to the Applicant

Mr Shiels enquired if you were to ask someone who was resident in Dores whether they were a resident in Lochardil were it not true that they would disagree with that.

Mr Higgins replied that possibly but that there was no real obvious dividing line prior to Dores that he could see, however, he would serve that community, should they so wish, by a delivery service, if the contract was awarded.

Mr Shiels then wondered of Mr Higgins what his reasons were for including Dores in his neighbourhood.

Mr Higgins advised that the purpose of the application was to serve the population which were not currently serviced by a community pharmacy and that if the residents of Dores were making their way into Inverness then, if granted, the new pharmacy may be able to service their pharmaceutical needs.

Mr Roberts had noted that the Applicant had highlighted the Oxford English Dictionary definition of a neighbourhood in his submission but that he was then saying that he included other areas such as Ness Castle, Dores and Slackbuie in his neighbourhood and was the majority of the neighbourhood not resident in Drummond and Lochardil.

Mr Higgins advised that at present, Ness Castle was essentially a building site.

But, Mr Roberts enquired – you would serve Dores?

Mr Higgins replied in the affirmative that he would be happy to and he was not surprised that he only received one piece of feedback from the Dores area regarding his consultation.

The Chair asked if The Highland Council, in providing their figures, whether they projected the population increase in the area over the next one to two years.

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Mr Higgins replied that not exactly, that the blue area on his map was fluid and ongoing development was being progressed with the expectation that Slackbuie would be completed prior to commencing the development of Ness Castle but that The Highland Council had advised that there would be a period of 18 months before the Ness Link was developed and that the first phase of Ness Castle would not start until after that and the area highlighted by him in red would take longer still.

Mr Cumming referred to the topic of public transport, enquiring how the public might access his proposed pharmacy by that means and whether an analysis of that was available for the Committee to view.

Mr Higgins replied that every one of the points he mentioned, which he had previously prepared the analysis of to travel to the existing pharmacies were all within a mile of the proposed pharmacy and one of which was the proposed premises themselves. He did not have bus times for this, however, he pointed out there was a bus stop immediately outside the proposed premises which may make it easier to travel into town and that it may be easy to get a bus to the proposed premises from Essich and perhaps from Holm but that he could not definitely say so.

Mr Roberts enquired of the whereabouts of the local GP Surgery, which he had thought were mainly near the centre of the City so could Mr Higgins explain to him why people would still use the pharmacy at the proposed premises.

Mr Higgins replied that, firstly, though the proposed premises may not be immediately obvious he would engage with the public and advertise for publicity. Secondly, regarding GP services there were none at present within the neighbourhood but that acute prescriptions did come to pharmacy and if granted, would be more aware of this. Additionally, the aim of a new contract would be it would become more necessary to position a pharmacy where there was no GP to readily access.

Mr Roberts commented that 3,700 homes with a 25% increase in social housing it was still an affluent area and did not most residents have ownership of a car.

Mr Higgins replied this was true, however, not all and the population was elderly.

Mr McNulty enquired what pressure had he received from the community to not loose their local grocery store and what, if anything, he intended to do to address this.

Mr Higgins advised that he would like to continue merchandising milk, bread, newspapers and that his company had experience of this in other stores, such as their one in Aberchirder where there was a Post Office and explained that he did not wish to remove convenience services and would prefer to acquire the additional unit next door in order to provide this.

8. The Interested Party’s Case – Mr Michael Church, Rowlands Pharmacy

Mr Church stated “thank you for allowing me to present my views on the application at Lochardil Stores on behalf of Rowlands Pharmacy today.

In terms of neighbourhood, we would accept the boundary given by the Applicant, and agree with his boundary definitions. For clarity reasons, these are:-

To the West, the River Ness; To the North, Drummond Burn; To the East, the road running south that contains Culduthel Road, Slackbuie Avenue and the B861. To the South, Dores.

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Using this neighbourhood boundary, you can see that there is currently no pharmacy service within the neighbourhood and I think it’s important to highlight that not every neighbourhood needs its own pharmacy. An adequate service can easily be supplied by pharmacies in the adjoining neighbourhoods, normally ourselves at Rowlands in Balloan Park, along with the ten other pharmacies in the Inverness area.

I think it’s worth noting at this point that the population of Inverness can be registered at any GP across the city – so people from this area may be registered with a GP on the other side of the city, and as a result, most people will quite often access a pharmacy outwith their “home neighbourhood” anyway.

If we have a look at the population in this neighbourhood I would class this as a reasonably affluent area. It has lower than average claimants of income support and job seeker’s allowance and a higher than average percentage of households with cars. Speaking generally, it is mixed, with young families living alongside the elderly population. As already alluded to, there is no GP surgery so there is no requirement for a pharmaceutical service. If we have a look in the neighbourhood, what facilities are there? A couple of schools, a couple of small convenience stores, but as far as I am aware there is an absence of banks, post offices, libraries or GP surgeries. As a result, the population will be used to travelling in their day-to-day lives to access these services, along with any pharmaceutical services they need. There are extended hours pharmacies in Inverness, so any working member of the population can easily access services at a time to suit them. As a whole, I believe the working families; young and older residents will generally have access to a car and find no problem with using existing pharmacies. Consequently, I see no problem with access to pharmacies from this neighbourhood.

All pharmacies in Inverness are providing full pharmaceutical services insofar as I am aware. I certainly don’t see the applicant bringing anything new, nor is there anything to say that current provision is poor, which is a view supported by the Area Pharmaceutical Committee. At Balloan Park, we have a pharmacy with a consultation room providing all core elements of the pharmaceutical contract. We provide a full collection service from all the GP surgeries in Inverness and a full delivery service to the surrounding area, including the defined neighbourhood. Jen Lumsden is the Pharmacy Manager there and has been since April this year. She has developed excellent links with the locals and GPs alike. The team as a whole work well, exceeding national and NHS Highland average service figures for providing smoking cessation, eMAS and CMS. Indeed, at Rowlands we do our best to go above and beyond contracted services. Gayle MacDonald, who is with me today, recently qualified as a prescriber and manages our pharmacy in Culloden and runs an asthma clinic with Dr Kelly at Southside Surgery one day per fortnight.

So, it is our opinion the applicant is bringing no new services to the area and the opening hours offer nothing in addition to what is already being provided. The population in this neighbourhood move freely around the City and access services as and when they need them. As a result I don’t believe this application is necessary or desirable.

The Chair thanked Mr Church for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of her.

8.1 Questions from the Applicant to Mr M Church, Rowlands Pharmacy

The Applicant asked if Mr Church thought services were adequate on the 4th of June, 2012. Mr Church refuted the suggestion which the Applicant was making that they were not. Mr Higgins then enquired the reason that the Rowlands Pharmacies had been unable to fulfil their contractual obligations on that date. Mr Church advised that there had been a road traffic accident on the A9 and due to that the locum had been unable to travel to Inverness from Glasgow.

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Mr Higgins then enquired then if on the 6th June, 2012 if the reason Rowlands were unable to fulfil their contractual obligations was due to a further road traffic accident.

Mr Church advised that the locum pharmacist who had been booked for the 6th June, 2012 had cancelled on the day and that as a result of that Rowlands Pharmacy have now put measures in place to increase the pool of locums available to them to call on.

Mr Higgins again enquired if Mr Church felt that services were adequate on these days

Mr Church advised that they had done their best to reduce disruption and that services were adequate at the branches in question whilst the pharmacist was on the premises. Mr Higgins referred to Mr Church’s reference that car ownership was higher than the Scottish average in the area and wondered whether he was aware that the figure for this was higher against the Scottish average in any event, due in part to its geography.

Mr Church advised that he did not know that.

8.2 Questions from Mr C Tait, Boots UK Limited to Mr M Church, Rowlands Pharmacy

Mr Tait had no questions for Mr Church.

8.3 Questions from Ms W Laing, Area Pharmaceutical Committee to Mr M Church, Rowlands Pharmacy

Ms Laing had no questions for Mr Church.

8.4 Questions from the Committee to Mr M Church, Rowlands Pharmacy

Mr Cumming asked Mr Church to tell him about their delivery service. Mr Church replied that there was a delivery driver available Monday to Friday.

Mr Roberts asked to whom Rowlands Pharmacy were delivering. Mr Church advised to patients of the pharmacy.

9. The Interested Parties’ Case – Mr Charles Tait, Boots UK Limited

Mr C Tait thanked the Chairman and spoke of a different take on the definition of neighbourhood which he felt was defined in law and the basis of the definition had come from Lord Justice Banks in 1932. Mr Tait quoted this as follows:-

“…It is impossible to lay down any general rule. In country districts people are said to be neighbours, that is to live in the same neighbourhood, who live many miles apart. The same cannot be said of dwellers in a town where a single street or a single square may constitute a neighbourhood ... Again, physical conditions may determine the boundary or boundaries of a neighbourhood, as for instance, a range of hills, a river, a railway, or a line which separates a high class residential district from a district consisting only of artisans’ or workmen’s dwellings.”

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This is still the definition of a neighbourhood in the main but to add to that Lord Nimmo Smith said:-

“Neighbourhood is not defined in the Regulations and must therefore be given the meaning which would normally be attributed to it as an ordinary word of the English language. As the word is ordinarily understood, it has connotations of vicinity or nearness ... the word “neighbourhood” in regulation 5(10) of the 1995 Regulations means an area which is relatively near to the premises in question, which need not have any residents, and which can be regarded as a neighbourhood for all purposes.”

These words of Lord Nimmo Smith expand on what was said by Lord Justice Banks and leaves a decision on natural boundaries and could be hills, roads, mountains although these would be difficult to show neighbourliness in.

Lochardil is separated from Drummond by green areas and a couple of schools. Culduthel Road forms a boundary to only Culduthel Woods, which you could not get a car down. Unfortunately, half way down Dores Road there is no way round the line of trees. These are genuine physical boundaries and that’s why the chosen neighbourhood only has a small convenience store. The area is in the top 30% least deprived in Scotland if measured against deprivation measures – that is good going. Buses and travel leaves from the site itself every half hour going into the town centre – the applicant mentioned that himself. If you left from the west a bus would not bring you to the east as they do not travel across the neighbourhood. This construes a smaller population which has high wealth and mobile but mixed in age which is slightly above the Scottish average and the young currently access all services outwith the neighbourhood.

There is a Post Office in Holm Mains but I think that is outwith the neighbourhood but you would require to drive to get there.

Is this application necessary? I don’t believe so – the bus route is very busy as well as folk exiting the area in their cars.

Is it desirable? That is hard to say but if the community are not driving a big pharmaceutical need and there are deliveries into the area – we (Boots) do too and the applicant says he would also do this.

I believe the neighbourhood to be for Lochardil. Is it necessary or desirable? Given the accessibility to all services I believe this application will fail.

The Chair thanked Mr Tait for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

9.1 Questions from the Applicant to Mr C Tait, Boots UK Limited

The Applicant asked Mr Tait to clarify if he felt that the neighbourhood should be Lochardil alone. Mr Tait replied in the affirmative.

The Applicant then asked Mr Tait if he was aware that the Drummond and Lochardil Community Council considered themselves as one Community Council covering both areas. Mr Tait felt that it was a political decision to join the two areas.

9.2 Questions from Mr M Church, Rowlands Pharmacy to Mr C Tait, Boots UK Limited

Mr Church had no questions for Mr Tait.

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9.3 Questions from Ms W Laing, Area Pharmaceutical Committee to Mr C Tait, Boots UK Limited

Ms Laing had no questions for Mr Tait.

9.4 Questions from the Committee to Mr C Tait, Boots UK Limited

Mr Cumming commented that he understood where Mr Tait was coming from, however, did he not feel that Holm was within the neighbourhood.

Mr Tait said that that could be argued, however, the neighbourhood was defined by physicality and nature and how folk moved around it.

The Chair mentioned Mr Tait’s reference to the lack of services in the neighbourhood in his submission and wondered did he not feel that services should then be created within the neighbourhood. Mr Tait felt that that would be sensible - where they could be accessed - but not only for people in the immediate vicinity but for those who will travel to a site where more than one service is available and a variety experience of shopping, banking and other services would come into play.

10. The Interested Parties’ Case – Ms Wendy Laing, Area Pharmaceutical Committee

Ms W Laing stated “I am here to represent the Area Pharmaceutical Committee and provide the opinion of the Area Pharmaceutical Committee (APC). I will therefore endeavour to answer questions at the end but will refrain unless it is an area where there has been previous discussion by APC and I therefore know the opinion of the Committee. Firstly, to bring to your attention there were a number of Committee members who declared themselves either as an interested party or an employee of an interested party and these members refrained from the discussions regarding the application.

In terms of the neighbourhood, the APC agrees with the Applicant’s proposed boundaries and definition of the neighbourhood. This opinion has been influenced by the recent supermarket developments which allow the population of this neighbourhood to access the majority of their daily amenities within the area.

In terms of adequacy of current pharmaceutical services or necessity, the APC does not believe the Applicant has demonstrated that pharmaceutical services to their proposed population are inadequate. There was some reference to the distance to pharmacies and that current pharmacies are too busy to provide the services required, however, there have been no complaints to the Board about services to patients within the Applicant’s neighbourhood or, on that note, outwith the neighbourhood. So, on this basis APC does not believe it is necessary to grant the application to secure adequacy.

However, in terms of desirability, as previously mentioned, there have been recent supermarket developments which allow the population of the proposed neighbourhood to increasingly access the majority of their everyday needs locally. This change introduces the need for a pharmacy in the neighbourhood since pharmaceutical services will be one of the few necessities of life which will not be available within the neighbourhood. On this basis the APC does believe it is desirable to grant the application to sustain pharmaceutical adequacy. In summary, in light of the recent developments within the area, the professional advice of the APC to the Pharmacy Practices Committee is that the application is not necessary but is desirable to sustain pharmaceutical adequacy.

The Chair thanked Ms Laing for her statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of her.

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10.1 Questions from the Applicant to Ms Laing, Area Pharmaceutical Committee

The Applicant enquired that when the Area Pharmaceutical Committee met and discussed necessity, were they aware of the problems at Tesco and Rowlands over the Jubilee bank holiday weekend, referred to by him earlier. Ms Laing advised that that had not been discussed, rather based on patient complaints of which there had been none.

10.2 Questions from Mr M Church, Rowlands Pharmacy to Ms W Laing, Area Pharmaceutical Committee

Mr Church had no questions for Ms Laing.

10.3 Questions from Mr C Tait, Boots UK Limited to Ms W Laing, Area Pharmaceutical Committee

Mr Tait referred to the statement from the Area Pharmaceutical Committee where it had been mentioned that there had been a major change in retail services in the neighbourhood and wondered if there was no supermarket would their opinion have been different. Ms Laing advised that she could not say but that that would have made it a totally different situation.

10.4 Questions from the Committee to Ms Laing , Area Pharmaceutical Committee

The Committee had no questions for Ms Laing.

11. Summing up

The Applicant and Interested Parties were then given the opportunity to sum up.

11.1 Ms W Laing, Area Pharmaceutical Committee stated “to summarise I would just say that the application is desirable really because patients would be able to access facilities they could not before”.

11.2 Mr C Tait, Boots UK Limited stated “the neighbourhood as I see it is unsustainable for a pharmacy and perhaps the Applicants definition is more sustainable when looking at necessity and desirability but everyone within the neighbourhood presently leaves on a day to day basis to access other services, therefore, the application is neither necessary nor desirable”.

11.3 Ms M Church, Rowlands Pharmacy stated “As previously discussed there is adequate provision of pharmaceutical services at present, therefore the application is not desirable”.

11.4 Mr James Higgins for Gaelpharm Limited, Applicant stated “In summary, we have demonstrated a clearly defined neighbourhood recognisable to any resident of it. Our application has the support of our Westminster MP, the Right Honourable Danny Alexander, MSPs, the only local councillor to have gone on record, Lochardil and Drummond Community Council, Holm Community Council, a number of private individuals and the vast majority of respondents to our survey.

The Area Pharmaceutical Committee feel that the granting of our application is desirable to secure adequate pharmaceutical service and our survey response agrees.

We have demonstrated that there is a clear inadequacy of current pharmaceutical service on three fronts. Pharmaceutical service is currently inadequate as evidenced by recent failures and inadequate in the eyes of residents as evidenced by our survey opinions of households and by submissions to public consultation.

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And, finally, current pharmaceutical service is inadequate in light of the future needs of the neighbourhood and its population.

It is necessary and desirable to grant this application and doing so will improve the quality of life and health of residents and meet the health outcomes of this large and previously overlooked area of the City”.

At the conclusion of the summing up, the Chair asked the Applicant and all of the interested parties if they considered that they had had a fair hearing. Mr Higgins, Mr Winchester, Mr Church, Mrs MacDonald, Mr Tait, Ms MacFarlane and Ms Laing replied yes, that they did consider they had had a fair hearing.

The Chair advised that a written decision would be sent out within 15 working days. A letter would be included with the decision advising of the appeal process. The Chair then thanked the parties for attending.

Mr Higgins, Mr Winchester, Mr Church, Mrs Gayle MacDonald, Mr Tait, Ms MacFarlane, Ms Laing and Mr Andrew Green, Area Regulations, Contracts & Controlled Drugs Governance Pharmacist left the meeting.

12. DECISION Having considered all the evidence presented to it, and the Committee's observations from the site visits, the Committee had firstly to decide, the question of the neighbourhood in which the premises to which the application related, were located.

The Committee took into account a number of factors in defining the neighbourhood including the natural and man-made boundaries, who resides in it, neighbourhood statistics, the location of existing shops, health services and schools, land use and topography, and the distance and the means by which residents are required to travel to existing pharmacies and other services.

In addition it anticipated future developments including plans for the further expansion of housing estates in the lower Slackbuie area, particularly those by Tulloch, Builders in the Greenfields and Culduthel Farm developments and the Duke’s View estate and surrounding area.

Special regard was made to the requirements of the Equality Act 2010:

 the need to eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act;

 advance equality of opportunity between people who share a protected characteristic and those who do not;

 foster good relations between people who share a protected characteristic and those who do not.

The Committee considered the Applicant's definition of the neighbourhood and how this compared to those put forward by the Interested Parties as well as comments received from the public consultation, and it was unanimously agreed that the neighbourhood was not as defined by the Applicant in his submission.

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12.1 Neighbourhood: The Committee considered that the neighbourhood should be defined as follows:

North: the northern boundary was agreed to end at the Crossroads of Culduthel Road and Drummond Road, but not as far as Altnaskiach Avenue, extending west to the Drummond Burn which runs under Island Bank Road and out into the River Ness just prior to Elm Park, at Bellfield as the area beyond these points became part of the City Centre and outwith the Lochardil Community Council boundary;

East: the eastern boundary was agreed as bounded by Culduthel Road and Slackbuie Avenue which marked a boundary as there was a clear definition for local people between the Hilton and Lochardil/Drummond areas in addition to the area bounded on the west by the Indoor Bowling Stadium, Business Park and Fairways Golf Course sites, after which there was no right of access, creating a physical boundary;

South: the southern boundary was agreed to be bounded by Holm Road and Culduthel Avenue, including the Tulloch Builders housing developments of Culduthel Mains Farm, Greenfields and the Duke’s View Estate and others on the southern side of Holm Road and including the ASDA Supermarket and petrol filling station, as this represents the extent of residential housing and the start of the countryside;

West: the edge of the western boundary was agreed to be as marked by the roundabout joining Dores Road to Holm Road and the road leading to the TESCO Supermarket. The neighbourhood should also include the sparse housing on the west side of Dores Road leading towards the northern boundary, whose residents would consider themselves part of the Holm neighbourhood back to Drummond Burn, along Island Bank Road. In addition, the River Ness is the physical boundary on this side of the neighbourhood.

There is an undeveloped spur road from the roundabout on the western boundary referred to above which is to be used at some point in the future to link transport to Holm Road from the A82 on the other side of the City.

In considering this area the Committee were of the opinion that the neighbourhood contained all the requirements of daily living, such as a post office, churches, a hotel, 4 primary schools (one for special needs children) and one secondary school. There was also access to optical services, two supermarkets with automated teller machines (ATMs) and two fuel filling stations.

It was agreed that the village of Dores, which lay eight miles outwith the area as defined by the Committee should be excluded from the neighbourhood as residents of that village would not consider themselves to be residents of the neighbourhood as defined.

In general, the above areas described are within the Community Council areas of Lochardil, Holm and the Lower Slackbuie portion of the Inverness South Community Council boundaries, which contain Holm and Upper and Lower Drummond within them.

It was agreed that residents from Holm access services, such as shops, bar and restaurant in the Lochardil area and that, as Holm Primary School is located off Stratherrick Road, very close to Lochardil residents. Access to Holm Primary School is challenging with a steep footpath up from "lower" Holm, and many parents will drive through Lochardil when taking children to and from Holm School and, as such, would therefore, consider themselves as part of that neighbourhood.

It was obvious from the very title of the letter received by the Health Board from the Community Council that residents of both Drummond and Lochardil considered themselves to be a single community/neighbourhood.

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12.2 Adequacy of Existing Provision of Pharmaceutical Services and Necessity or Desirability:

Having reached that decision, the Committee was then required to consider the adequacy of pharmaceutical services within that neighbourhood, and whether the granting of the application was necessary or desirable to secure adequate provision of pharmaceutical services in that neighbourhood.

The Committee noted there were no pharmaceutical services in the area but pharmaceutical services were provided by pharmacies outwith the neighbourhood.

Taken into consideration was a letter dated 12 August 2012 to the Health Board from the Lochardil & Drummond Community Council which provided a concise overview of the area, services currently accessed and the nature of the population, which was noted to have a particularly high proportion of elderly in age. The letter went on to state that much of the population did not have transport of their own and had grown old in a community, mainly of bungalow type housing, after their children had moved away. The letter further informed of the mix of newer, much younger residents moving into the area, causing issues for families with young children in accessing pharmaceutical services and the feeling by the community that they currently were inadequately served in comparison to people on the north side of the City vis a vis pharmaceutical services.

The Committee were disappointed to note that, despite the efforts to consult, no response had been received from any of the Members of Scottish Parliament, Members of Parliament or Councillors they had written to, with the exception of a late email from Mrs Caddick, Inverness South Community Councillor, on the day of the hearing in support of the application, as it was considered that as elected representatives of the people living in the neighbourhood they could reasonably be expected to have been able to support their views.

No member of the public responded to the NHS Highland public consultation, however, attention was paid to the consultation which was available for inspection at the hearing undertaken by the applicant with the public, and which demonstrated a high percentage of the community who considered themselves to be a resident of the Drummond/Lochardil areas and either agreed or strongly agreed a pharmacy was necessary to secure adequacy of pharmaceutical services in the area. There was evidence of disagreement or strong disagreement that pharmaceutical services currently in the neighbourhood were adequate.

The Committee took into consideration submissions by Rowlands Pharmacy and Boots UK Limited by their representatives and noted the letters sent by Tesco Pharmacy and Superdrug Pharmacy, although they had submitted their apologies for attending the hearing in advance.

There was evidence of long travelling times and difficulty in accessing existing pharmaceutical services in other neighbourhoods and due to this that perhaps the elderly population were unable to access such services as the Chronic Medical Service, Minor Ailments Service or Smoking Cessation Services, however, these can currently be accessed outwith the neighbourhood.

Advice from the Area Pharmaceutical Committee was also considered and that although they were not aware of any reasons that current pharmaceutical services were inadequate to the neighbourhood, did believe that with recent and current developments in the area it would be desirable to grant the application in order to sustain pharmaceutical adequacy into the future.

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The Committee had access to the Scottish Neighbourhood Statistics which were in agreement with those submitted by the Applicant through Mr Cameron Thomas of The Highland Council.

The Area Pharmaceutical Committee, when writing their response, had not been aware of any pharmaceutical inadequacies, however, there was evidence in the PPC Members information pack that those referred to by the Applicant in his submission had, in fact, been known to the Board although no complaints from members of the public had been received. Also included in the pack was information regarding engagement by existing pharmacy contractors in the pharmacy contract which did not highlight any inadequacies.

NHS Highland were aware of the problems experienced on 4th and 6th June, 2012 by both Rowlands Pharmacy and Tesco Pharmacy who had contacted the Health Board to bring the issues to their attention and who had subsequently worked and supported them in their efforts to rectify the situations as soon as practicable. Tesco have since purchased a second computer which is now operational (as evidenced in the Members information pack) and Rowlands have put measures in place to increase their locum pool and out of hours contact information, as advised by their Area Manager.

The Committee, in determining the adequacy of existing provision of pharmaceutical services in the defined neighbourhood, took account of the evidence provided by the Applicant, and the Interested Parties and made available from other sources and concluded that the level of existing pharmaceutical services was adequate at the present moment.

The Committee then considered whether it would be desirable to grant the application to maintain adequacy into the future. They concluded that predicted increased demand with the current and future developments would make it difficult for existing pharmacies adjacent to the neighbourhood to sustain adequacy and render them less likely to be able to offer residents from this neighbourhood core pharmaceutical services such as Minor Ailments Service, Chronic Medication Service, Public Health Services (including smoking cessation and emergency hormonal contraception) and for this reason they considered that the application was desirable.

The Committee did comment that they would have preferred the premises to be more centrally located within the neighbourhood but acknowledged that the proposed premises were the only site available to the applicant.

The non-voting pharmacists then left the room.

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12.3 In accordance with the statutory procedure the Pharmacist Contractor Members of the Committee, and Board Officers were excluded from the decision process:

DECIDED/-

The Pharmacy Practices Committee (PPC) was satisfied that the provision of pharmaceutical services at the premises of the Applicant was not necessary at the current point in time but that it was desirable in order to secure the adequacy of provision of pharmaceutical services into the future within the neighbourhood, as redefined by the Committee.

The Chair invited members of the Committee to vote on the application by Gaelpharm Limited to provide pharmaceutical services at Lochardil Stores, Morven Road, Inverness, IV2 4BU. The Committee unanimously agreed to grant the application.

The non-voting pharmacists were invited into the room and advised that the application had been granted.

The Hearing was then closed.

Ian Gibson as Chair of the PPC

Date: 20 September 2012

P21 Gaelpharm Limited Lochardil _ PPC 12 September 12 NOTES.doc 119 Highland NHS Board 4 December 2012 Item 3.8(b)

PHARMACY PRACTICES COMMITTEE MEETING – TUESDAY, 30 OCTOBER, 2012 AT 1.30 PM, SEMINAR ROOM, MIGDALE HOSPITAL, CHERRY GROVE, BONAR BRIDGE, IV24 3ER

Report by Helen M MacDonald, Community Pharmacy Business Manager on behalf of Okain McLennan, Pharmacy Practices Committee Chair

The Board is asked to:

 Note the decision of the Pharmacy Practices Committee.

NHS (Pharmaceutical Services)(Scotland) Regulations 2009 Provision on Control of Entry to Pharmaceutical Lists Under these Regulations each Health Board must establish a Pharmacy Practices Committee (PPC) with membership defined as 3 pharmacists, 3 lay persons and a chair who is a member of the Board. If the application being considered is in a neighbourhood where there is a dispensing doctor then a further member is appointed by the GP Sub-Committee on behalf of the Area Medical Committee.

Under the Regulations the Board unconditionally delegates its function to assess and determine the need for additional pharmacy contracts or services to the PPC and the decision of the PPC is final. The PPC is concerned only with NHS contract services and the provision of NHS pharmaceutical services. It is not the function of the PPC to consider the need for dispensing doctors.

1 Background and Summary

The Committee was asked to consider the application submitted by Mitchells Chemist Ltd to provide general pharmaceutical services from premises sited at the former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the applicant’s proposed premises were located.

2 Decision

As there were no pharmaceutical services currently within the neighbourhood it could not be said that current services were adequate and therefore the Pharmacy Practices Committee agreed that it would be necessary to grant the application in order to secure adequate provision of pharmaceutical services.

The Chair invited members of the Committee to vote on the application by Mitchells Chemist Ltd to provide pharmaceutical services at the former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB. The Committee unanimously agreed to grant the application.

Full notes of the hearing may be viewed on the NHS Highland website via the following link:- http://www.nhshighland.scot.nhs.uk/Meetings/PharmacyPracticesCommittee/Pages/welcome.aspx

Helen M MacDonald Community Pharmacy Business Manager Integrated Pharmacy

23 November 2012 120

PHARMACY PRACTICES COMMITTEE MEETING Tuesday, 30 October, 2012 at 1.30 pm Seminar Room, Migdale Hospital, Cherry Grove, Bonar Bridge, IV24 3ER

Application by Gareth Dixon of MITCHELLS CHEMIST LTD for the provision of general pharmaceutical services at The Former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB

PRESENT Okain Maclennan (Chair) Margaret Thomson (Lay Member) Michael Roberts (Lay member) Susan Taylor (GP Sub Committee Nominate) Fiona Thomson (APC Non Contractor Nominate) John McNulty (APC Contractor Nominate)

In Attendance Andrew J Green (Area Regulations, Contracts & Controlled Drugs Governance Pharmacist) Helen M MacDonald (Community Pharmacy Business Manager) Gareth Dixon, Mitchells Chemist Ltd, Applicant Donna Gillespie, Mitchells Chemist Ltd, Applicant Support Christopher Mair, GP Sub Committee Andrew Paterson, Area Pharmaceutical Committee

Observers Nicola Macdonald (APC Contractor Nominate NHS Highland PPC Member in training)

1. The Chair welcomed everyone to Bonar Bridge. He asked all members to confirm that they had all received the papers for the hearing and had read and considered them. All members affirmed these points.

2. APPLICATION FOR INCLUSION IN THE BOARD’S PHARMACEUTICAL LIST

Case No: PPC – Bonar Bridge, Sutherland. Mitchells Chemist Ltd, The former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB.

The Chair asked each Committee member if there were any interests to declare in relation to the application being heard from Mitchells Chemist Ltd. No interests were declared.

3. The Committee was asked to consider the application submitted by Mitchells Chemist Ltd to provide general pharmaceutical services from premises sited at The former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the Applicant’s proposed premises were located.

The Committee, having previously been circulated with all the papers regarding the application from Mitchells Chemist Ltd, agreed that the application should be considered by oral hearing.

P1 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc 121

Prior to the hearing, the Committee had, as a group, visited the neighbourhood as defined by the applicant surrounding the applicant’s proposed premises, which comprised three primary schools, post offices, churches, community halls, a day care centre, community hospital, hotels and holiday accommodation (including lodges and B&Bs), golf and football clubs, youth hostel, country estates, a visitor centre and shops where other daily needs and services were accessed, including fuel and the Highland Council service point.

There was no secondary school, or dental practice in the proposed neighbourhood.

After a visit of the proposed pharmacy premises, facilitated by the applicant, the Committee walked past the car park immediately behind the proposed pharmacy premises to view the site of the GP practice where parking available for patients and surgery access was noted.

The hearing was convened under paragraph 3(2) of Schedule 3 to the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 as amended (“the Regulations”). In terms of this paragraph, the Pharmacy Practices Committee “shall determine an application in such a manner as it thinks fit”. In terms of Regulation 5(10) of the Regulations, the question for the Pharmacy Practices Committee is whether “the provision of pharmaceutical services at the premises named in the application is necessary or desirable to secure adequate provision of pharmaceutical service in the neighbourhood in which the premises are located by persons whose names are included in the Pharmaceutical List.”

The Applicant, Support and Interested parties were invited into the meeting at around 1.30 pm

4. The Chair welcomed:-

The applicant, Gareth Dixon of Mitchells Chemist Ltd who was supported by Donna Gillespie, the Interested Parties who had submitted written representations during the consultation period and who had chosen to attend the hearing, were Christopher Mair, GP Sub Committee and Andrew Paterson, Area Pharmaceutical Committee (“the Interested Parties”). The Chair then invited the Committee members to introduce themselves. Committee members introduced themselves to the applicant and all other parties, and all other parties introduced themselves to the Committee.

The Chair asked the applicant and the Interested Parties to confirm that they were not attending the Committee in the capacity of solicitor, counsel or paid advocate. They each confirmed that they were not.

5. The Chair reminded everyone that the meeting had been convened to hear the application from Mitchells Chemist Ltd for the provision of general pharmaceutical services at the former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB. The application would be considered against the legal test contained in Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

6. Regulation 5(10) was read out:

An application shall be granted if the Board is satisfied that the provision of the pharmaceutical services at the premises is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located.

7. The Chair then described the format of the hearing, reminding those attending that no new evidence could be introduced at the summing up.

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The procedure adopted by the Committee at the hearing was that the Chair asked the applicant to make his submission. There followed the opportunity for the Interested Parties and the Committee to ask questions. The Interested Parties would then make their submissions. There followed the opportunity for the applicant and the Committee to ask questions of the Interested Parties in turn. The Interested Parties and the applicant would then be given the opportunity to sum up.

The Chair then asked the applicant to give his statement.

7.1. The Applicant’s Case

Gareth Dixon of Mitchells Chemist Ltd stated “Thank you very much, I shall try and be brief. Mitchells Chemist Ltd in Dornoch was taken over by wife and I in 2006 and a second pharmacy in Golspie was purchased in 2011. The company has a proven record of working in small rural Highland communities and for being active and enthusiastic regarding the provision of new and existing services. The Dornoch branch has over 50% more minor ailment service patients (MAS) registered compared to the Highland average and 58% above that for chronic medication service (CMS) patients registered above the highland average. Patients are actively encouraged to access advice and health services e.g. smoking cessation and we are very active with health promotion though our social networking sites and we support other causes such as “Wear it Pink Day” for breast cancer and “Movember”.

We also provide additional services including blood pressure, diabetes and cholesterol checks, and the provision of private flu vaccinations is also available. Since acquiring the Golspie pharmacy in November 2011, we have pushed for CMS registrations to have been increased from 3 patients to 149 patients in August 2012, bringing the number of registrations up to the Scottish average within 7 months. This demonstrates that patients in this type of rural community like to engage with these services and that the pharmacies are always trying to provide a high class pharmaceutical service. In May 2012 the Dornoch smoking cessation quit rate was 44% compared to 41% for Highland and 39% for Scotland, thereby proving a higher than average patient engagement is possible in a small rural environment. This hopefully leads to an overall health improvement in the communities in which pharmacies are situated.

Although Dornoch and Golspie have relatively small rural communities, they have both proved to be very successful at achieving positive health outcomes. I am just trying to show that we have a proven record of providing pharmaceutical services in these types of communities.

With regard to the proposed neighbourhood boundaries and as with most rural Highland communities, which I am sure you have seen this morning, this extends over a large geographical area and, although there are distinct communities within the neighbourhood, we believe that Bonar Bridge is where these communities come together to access their services

I’ve tried to describe the proposed neighbourhood by starting at Spinningdale on the A949, heading north to Bonar Bridge including the surrounding areas on this road. From Bonar Bridge it would reach as far south as Fearn along the A836 including Ardchronie and Kincardine. Then west to Croick including Ardgay and West Gruinards. To the north along the A836 to Achinduich and along the A837 as far as Oykel Bridge including Inveran and Rosehall and also east as far as Migdale including Tulloch, Ardens and Achuan.

As for the existing population, the GP practice populations in the area I have taken appear to be remaining fairly static over the last 9 years - that is the GPs in the Sutherland area which I have compared.

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Currently Lairg, Golspie and Dornoch practice populations all benefit from the access to pharmacy services but despite the fact that Creich has a greater population than Lairg it lacks the access to pharmaceutical services. The proposed neighbourhood overlaps various datazones and information which was provided by Cameron Thomas of The Highland Council.

The proposed neighbourhood has a progressively ageing population and has a greater percentage of pensionable population compared with the rest of the Highland area and Scotland. Within the population of the proposed neighbourhood 33.1% of residents are over 60 years of age. This is higher than Highland and the Scottish average. Typically it is this group that could benefit from additional services a Pharmacy could provide. Studies have shown that many hospital admissions are caused by preventable medicine related problems. Patients, especially older people and those with chronic conditions, often receive treatment with four or more medicines. These patients are more likely to develop side effects which, in turn, can result in more medication being prescribed. A regular medication review by the patient’s pharmacist, working in partnership with their GP, could reduce the incidence of these medicine related illness

With the existing services in the proposed neighbourhood, Bonar Bridge currently acts as a central hub for the surrounding area as it has a Spar shop – known as Kyle Bakery, (which, if you have been in you will see does a minor range of general sales list medicines and toiletries), police station, post office, library, bistro, café and craft shop, primary school, Highland Council Service Point, the Creich Medical Practice, The Bradbury Day Care Centre, a 22 bed GP lead Migdale Community Hospital, two hotels and other guest house accommodation; is on the main tourist route which includes the Falls of Shin Visitor Centre, Alladale Wilderness Lodge and Wildlife Reserve, Bonar Bridge Golf Club, Inveroykel Lodge, Lairg Estate, Glencalvie Estate and Carbisdale Castle as well as numerous fishing, walking and cycling activities available in the area. There is currently no pharmacy or dental practice within the Bonar Bridge neighbourhood.

With regards to public transport - MacLeod’s Coaches runs a return bus services from Tain to Lairg, via Ardgay and Bonar Bridge, up to four times a day, Monday to Saturday. A Dial-A- Bus service is available within a 6 mile radius of Ardgay Station, plus Strathcarron Road as far as Croick, also to and from Dornoch and the Lawson Memorial Hospital in Golspie up to twice daily, three times a week.

The Bradbury Day Care Centre provides a return bus service to Tain once a week and to Alness once a week.

I don’t know why I left it out of my initial submission to the Committee but, there are rail stations at Ardgay and Inveran which have a service passing through them seven times a day and I will leave information on that behind for the Committee to view should they wish to. A return rail service operates to Invershin Rail Station (approximately 3 miles north of Bonar Bridge) three times daily Monday to Saturday and twice daily on Sundays.

Due to a lack of public transport as a result of the extensive geographical area, many people rely on the use of their own vehicle or asking someone else to transport them.

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As part of the public consultation process, required for any new community pharmacy contract application, as the proposed neighbourhood covers a large geographical area which is generally covered by two local newspapers an advert inviting comments was placed in both the Northern Times and the Ross-shire Journal. GPs at Creich Medical Practice were informed of the intended application advert before it appeared in the newspapers, although this was only 24-48 hours before the applicant advert was publicised. Unfortunately a meeting could not be arranged until after the advert appeared due to time constraints. During the resulting discussion the additional services a community pharmacy could provide were outlined. Also that if a pharmacy contract was to be awarded it would necessitate a good working relationship with the practice for the patients to fully benefit.

The Creich and Ardgay Community Council Meetings were attended by myself to outline the proposed pharmaceutical services. At that point, I did not ask the councils to make comment but it was explained what pharmaceutical services are, their intended benefits to the community and that if the application were to be successful it would result in the cessation of dispensing services at Creich Medical Practice. It was also explained that if the community response to the consultation was favourable then the application would be submitted to the Highland Health Board and at that point the Community Council would be contacted for a formal response. The community response was mostly favourable and it was the responses that were received that contributed towards the proposed pharmacy neighbourhood.

Sorry, but the next piece I am going to read comes directly from “The Right Medicine” (meaning the Scottish Executive publication – The Right Medicine: A Strategy for Pharmaceutical Care in Scotland. Edinburgh: Scottish Executive; 2005), as they say it better than me:-

Community pharmacists are a cornerstone of primary care and make a vital contribution to patient care and health improvement, both as individual professionals and as part of the wider National Health Service. Pharmaceutical care reflects a systematic approach that makes sure that the patient gets the right medicines, in the right dose, at the right time and for the right reasons. It is about a patient-centred partnership approach with the team accepting responsibility for ensuring that the patient’s medicines are as effective as possible and as safe as possible. This is done by identifying, resolving and preventing medicine- related problems so the patient understands and gets the desired therapeutic goal for each medical condition being treated. Pharmacists can and do make a unique contribution to improving patient care. Medicines are the most common of all the steps taken by clinicians to help treat patients; and of all the healthcare professions, pharmacists have the widest knowledge in the science and use of medicines. Pharmacy focuses on empowering and protecting patients. Pharmacists have a key role to play in ensuring health gain wherever medicines are used.

Pharmacists provide care not just to patients but to the wider general public. The ’pharmaceutical health’ of the nation depends on good access to medicines, advice and to tailoring therapy to the needs of individuals. Community pharmacists are often patients’ first point of contact, and for some their only contact, with a healthcare professional. This creates a unique opportunity to improve the gateways for signposting, accessing and providing services and information on health and health issues to a broad spectrum of the population. This includes the most vulnerable in our communities; older people, people with mental health problems, homeless people, travellers and drug mis-users. All of these are people who might have difficulty, for lifestyle reasons, in accessing healthcare. Pharmacists have always worked to promote, maintain and improve health. Pharmacists offer non-judgmental help with a range of products and advice. Pharmacists provide a valuable link between the NHS and the public.

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The pharmacy presents a familiar unthreatening environment where advice and expertise on medicines and major health messages can be delivered to the public at large. Pharmacists work to minimise problems with medicines by providing advice on their safe storage, use and disposal. This helps to ensure patients and the public get maximum benefit and minimal risk from medicines. Currently, however, there are difficulties in accessing pharmaceutical services in some of Scotland’s most remote and rural areas as well as in deprived communities. Community pharmacy has already been recognised as one of the key partners within NHS24. Where appropriate, the public would be directed to community pharmacies for advice and support in managing minor ailments, for answers to questions about their medicines and, if necessary, to access medicines.

In general, the view has been taken that it is preferable for doctors to prescribe and for pharmacists to dispense. In that way, the pharmacist brings his/her separate expertise to bear upon the questions of whether the drug has been appropriately prescribed and whether the dosage is within normal limits.

Pharmacy services differ considerably from a GP dispensing service. Apart from providing a dispensing service, over the counter medicines sales and advice a community pharmacy provides the core pharmacy contract services:

The Minor Ailment Service (MAS) allows eligible individuals to register with and use a community pharmacy as the first port of call for the treatment of common illnesses on the NHS. A patient registers with the community pharmacy of their choice in order to use MAS. Once registered they can present at any point with symptoms and the pharmacist, having ascertained whether the patient is still eligible to use the service, will treat, advise or refer them to another health care practitioner where appropriate.

Also the Acute Medication Service (AMS) – which introduced the Electronic Transfer of Prescriptions (ETP) and supports the provision of pharmaceutical care services for acute episodes of care and any associated counselling and advice; and the latest one, which we are all currently very active in providing:- Chronic Medication Service (CMS) – which allows patients with long-term conditions to register with a community pharmacy of their choice for the provision of pharmaceutical care and, as part of a shared agreement between the patient, community pharmacist and the General Practitioner (GP), it introduces a more systematic way of working and formalises the role of community pharmacists in the management of individual patients with long term conditions in order to assist in improving the patient’s understanding of their medicines and optimising the clinical benefits from their therapy.

The Public Health Service (PHS) , which incorporates the display of posters, provision of smoking cessation services and emergency hormonal contraception and allows the contribution of pharmacists to health protection, health improvement and medicine safety aims to encourage the pro-active involvement of community pharmacists and their staff in supporting self care, offering suitable interventions to promote healthy lifestyles and establishing a health promoting environment across the network of community pharmacies by participating in national and local campaigns. In independently owned pharmacies we can also provide information from NHS Scotland and our own campaigns reflecting the same issues at the same time.

Unscheduled Care - enables community pharmacists to provide patients with up to one prescribing cycle of their repeat medicines and appliances when the patient’s prescriber is unavailable; the surgery is closed or the out-of-hours system is in operation. Community pharmacies also provide a valuable support service to both NHS24 and the Out of Hours (OOH) service. Sometimes when patients are reviewed by a pharmacist, it is the pharmacist’s opinion that they require Direct Referral to OOH services which happens a lot in pharmacy.

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We have a direct to professional number for the Highland Hub, stopping the patient having to go through the whole process themselves again with NHS 24. In Dornoch, the service is used for holiday makers, reducing the workload for GPs by referring them to the pharmacy. With regard to pharmaceutical need within the proposed neighbourhood, the proposed neighbourhood does not contain any pharmaceutical services other than the dispensing service provided by the Creich Medical Practice. All residents have to travel a significant distance, even by rural standards, to access these services. The nearest pharmaceutical services currently available are provided by the Co-op Pharmacy in Lairg (11 miles to the north), Mitchells Chemist in Dornoch (14 miles to the east) and the two Co-op pharmacies in Tain (16 miles to the south east). There is no history of there ever being a pharmacy in Bonar Bridge although there was a shop many years ago which was known as “The Chemist Stores” which stocked toiletries and some general medicines.

As part of the business model, research was conducted to establish the viability of a community pharmacy within the proposed neighbourhood. As part of this research the dispensing figures for the nearest pharmacies and some newly granted contracts were requested and are included in my pack.

The proposed premises, as you know as you visited these this morning, is closely situated to the Creich Medical Practice on Dornoch Road and is currently in a dilapidated state. This is due to the water tank having exploded and not being occupied for the last 3-4 years, effectively leaving the premises to have been locked and left to rot.

The proposed premises were purchased by Mitchells Chemist Ltd in May, 2012 and were originally built in 1901 with various additions made over the years. On the ground floor the property comprises a spacious shop unit, a large store to the rear with toilet facilities and an office. From an inner hall, stairs lead to the upper floor which is presently laid out as a flat. If the application were to be successful, extensive renovation is intended. The flat above would be given it’s own entrance to provide a secure entrance separate from the pharmacy. Pending planning approval, the pavement outside the premises would be elevated or a ramp installed to allow for disabled access to street level and, on talking to planners would be more aesthetically pleasing if raised.

Mark Forbes from Retail Design Consultants Ltd, has over 20 years of experience exclusively designing and fitting pharmacies, was contacted and provided some preliminary drawings for the planned layout of the premises. I intend to take out the stairs and have a flat above the ground floor premises with completely separate access. I have already worked with Mark, who is very professional and switched on regarding pharmacy requirements and the accessibility needs for disabled.

The Chair thanked Mr Dixon for his statement on behalf of Mitchells Chemist Ltd and invited the Interested Parties and then members of the Committee to ask questions of him.

7.2 Questions from Mr Andrew Paterson, Area Pharmaceutical Committee to the Applicant

Mr Paterson had no questions for the Applicant.

7.3 Questions from Dr Christopher Mair, GP Sub Committee to the Applicant

Dr Mair had no questions for the Applicant.

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7.4 Questions from the Committee to the Applicant

Mr Roberts asked how the applicant had arrived at the description of the proposed neighbourhood. Mr Dixon replied that this had mainly been done by speaking to the local population, asking where the existing GP patient population travelled to and from in conjunction with the knowledge that, from his pharmacy in Dornoch, he had dispensed for patients from as far away as Spinningdale.

Mr Roberts then asked if he dispensed for patients in the nearby vicinity from the Golspie pharmacy which he owned. Mr Dixon replied that the Golspie pharmacy tended only to service the population as far as Rogart.

Dr Taylor referred to Mr Dixon’s mention of contact with GP practices and wondered how he envisaged that would work in this community. Mr Dixon replied he felt this would be positive from his initial discussions with the practice.

Dr Taylor then went on to enquire, in relation to unscheduled care and access to NHS 24 services out of hours if there was a mechanism by which he could be contacted out of hours by the NHS if required.

Mr Dixon replied in the affirmative, adding that he had in the past been contacted by NHS 24 to dispense urgent prescriptions.

Mrs Margaret Thomson advised she had not heard much in the Applicant’s presentation about people with disabilities, and not solely those in the elderly population, and wondered if he agreed that there may be people in that category within the community and how would he envisage a pharmacy benefiting that patient group. Mr Dixon replied that there certainly were a number of disabled patients in the area which he had heard about from discussion with the district nurses and imagined they would certainly benefit from engaging with the services provided through a community pharmacy.

Mrs Margaret Thomson then wondered how the applicant would service that community and enquired whether he would visit them or expect them to visit him at the pharmacy. Mr Dixon advised that, being an independent contractor, he has the ability to visit patients and does actually make the effort himself, particularly if there is a new medicine but that he could not say that that was usual practice or provide assurance that this would happen for every disabled patient.

Mr Roberts enquired, with regard to public transport, whether there was transport available for patients from the Main Road to the Hospital. Mr Dixon advised that he was not aware of any scheduled services, however, it may be that the Dial-A-Bus Service would offer some Service.

Mr McNulty advised that he had noticed that the applicant had said he would be the Responsible Pharmacist on the application form and wondered who would be the pharmacist at the new premises if the application was granted. Mr Dixon replied that he had been in talks with those pharmacists that he had already worked with who had left the area to pursue pharmacy work/attend college and that he would be encouraging them to come back. He further stated he acknowledged what Mr McNulty was saying that in a remote and rural area there may be difficulties in securing the services of relatively qualified staff.

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8. The Interested Party’s Case – Mr Andrew Paterson, Area Pharmaceutical Committee

Mr Paterson stated “I am here to represent the Area Pharmaceutical Committee (APC) and to provide the opinion of the APC. I will endeavour, therefore, to answer questions at the end but will refrain unless it is an area where there have been previous discussions by the APC and I therefore know the opinion of the Committee. The APC agreed with the applicant’s proposed boundaries and definition of the neighbourhood as these appeared to be reasonable.

It is the APC’s view that current pharmaceutical services in the proposed neighbourhood are inadequate. Although dispensing services are currently provided by a local GP surgery, patients in this neighbourhood have no access to the additional pharmaceutical services offered by a community pharmacy without the need to travel considerable distances to access them. This lack of access to pharmaceutical services in the opinion of the APC makes the current service inadequate.

The APC believe that although the letters of support have not demonstrated an inadequacy with the current dispensing service offered by the GP practice they have highlighted a desire from within the local community for other pharmaceutical services not offered by the GP surgery.

The APC agreed that the application would secure adequacy because it will provide the additional pharmaceutical services within the neighbourhood that are not currently available

After reviewing and discussing the application and supporting documentation the professional advice from the APC to the Pharmacy Practices Committee is to recommend the application is granted. Thank you”.

The Chair thanked Mr Paterson for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

8.1 Questions from the Applicant to Mr A Paterson, Area Pharmaceutical Committee

The applicant had no questions for Mr Paterson.

8.2 Questions from Dr C Mair to Mr A Paterson, Area Pharmaceutical Committee

Dr Mair had no questions for Mr Paterson.

8.3 Questions from the Committee to Mr A Paterson, Area Pharmaceutical Committee

Members of the Committee had no questions for Mr Paterson.

9. The Interested Parties’ Case – Dr Christopher Mair for the GP Sub Committee

Dr Mair stated “I am the GP here today, representing the view of the Area Medical Committee and would refer the Committee to the letter sent to represent those views from the GP Sub Committee.

Financial viability for a pharmacy is seen to be achieved with a dispensing turnover of at least £400,000. The dispensing turnover for the Bonar Bridge/Ardgay practice is £270,000 which is only two thirds of that which would be required and as such, cannot be regarded as a sustainable model.

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The pharmaceutical arrangements for the patients are fully met by the current dispensing arrangements and I would argue in a manner of luxury as access to these are extremely available and prompt, in that people do get their medicines dispensed more rapidly than in a pharmacy, which can be delayed due to the distance between prescriber and pharmacist and any delay would probably be intimated as an issue for patients in having their needs met.

The surgery is actually open for longer hours than those indicated would be offered by the applicant and the dispensing of acute scripts is done at the time of consultation. In terms of non dispensing services that the pharmacy would offer, be it the highlighted smoking cessation service, minor ailments or emergency hormonal contraception, these are all currently met by the practice in a timely matter and same day appointments are available due to staffing levels.

The area covered by the practice extends beyond that proposed to be serviced by the pharmacy application, with a patient population from as far as Ledmore Junction and Edderton.

In terms of the chronic medication prescribing aspect of the community pharmacy, we receive regular presentations and analysis of our prescribing and this comes out more favourably and less than per practice, on a demographic practice on target areas of non steroidal anti-inflammatory drugs, asthma clinics, and benzodiazepines. We perform above standard practice behaviour because of the integrated nature of the practice and patients are always seen by a doctor as we do not have a practice nurse, resulting in the provision of a high level of medical care.

Regarding disability access, the GP premises provides for parking at the site, directly in front of the premises which you will see on your way out. The proposed pharmacy premises on the corner is a bit of a black spot and would make it difficult for disabled patients to access when they currently have disabled access at the surgery.

The Chair thanked Dr Mair for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

9.1 Questions from the Applicant to Dr C Mair, GP Sub Committee

The applicant had no questions for Dr Mair.

9.2 Questions from Mr A Paterson, Area Pharmaceutical Committee to Dr C Mair, GP Sub Committee

Mr Paterson had no questions for Dr Mair.

9.3 Questions from the Committee to Dr C Mair, GP Sub Committee

Mr McNulty enquired about the staffing level maintained currently by Dr Mair at the dispensing practice. Dr Mair replied that “the pharmacy” (meaning the dispensary in the GP practice) had been run by the Dispensing GPs since 1991, prescriptions were monitored by GPs and all repeat prescribing was done by through the GP for those patients receiving medicines for chronic medication. He advised that the identification and packaging of medicines was carried out by staff trained by the doctors and the senior dispenser of this had done some pharmaceutical training, albeit this was some time ago, in the making up of prescriptions.

Mr McNulty enquired if the staff were trained to NVQ level. Dr Mair replied they were not.

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Mr McNulty asked, that aside, was each prescription looked at by the GP. Dr Mair replied in the affirmative, that the GP makes the final checks and that for the first 10-15 years of dispensing history they used to drag through the notes in order to do so but this is no longer required.

Mr McNulty asked if the same process was followed for prescriptions for CDs (meaning controlled drugs) to which Dr Mair confirmed it was.

Mr McNulty enquired if there were any methadone patients registered at the surgery. Dr Mair advised the Committee they did not and that there was not a demand for that service at the practice and never has been at any stage.

Mr Roberts referred to Dr Mair’s comment that the practice neighbourhood extended further than that proposed by Mr Dixon in his application. Dr Mair replied that yes, this extended to Ledmore Junction, farther on the west beyond Oykel Bridge and to Edderton to the south with the odd patient beyond these boundaries and across the Struie (Struie Hill) where there were wind farms and used to be a pub and now a number of dwellings.

Dr Taylor referred to Dr Mair’s mention of availability of appointments at the Practice and enquired whether these were all by consultation or via drop-in surgeries.

Dr Mair advised that all consultations were carried out by appointment, but had previously been drop in. He explained that with the change in the GP contract they had moved to an appointment only system, however, they do open until 7pm sometimes and that realistically, patients would be seen the same day but that they made extra exceptions on occasions, particularly for those working remotely from their home i.e. offshore.

Dr Taylor enquired if it would, and if so how Dr Mair felt it would impact on practice and dispensary staff, if there was a change in the dispensing service provided by the Practice.

Dr Mair replied that it would certainly have a big impact, particularly in terms of continuity and level of service provided by medical staff from within the area; with 3 GPs currently working which would possibly change and be an ongoing issue, although he recognised that that was not necessarily a question for this Committee to entertain.

Mr Roberts enquired whether there was any provision of delivery of prescriptions to patients by the Practice. Dr Mair advised that this was provided, where appropriate, and that they did post out medicines to patients and that district nurses would take these to patients and, sometimes themselves. He also advised that when carrying out home visits, the GPs had the ability to provide a full prescription cycle to patients rather than a starting pack but would lose the ability to do so if dispensing services were lost and this would result in quite a material change which could be quite an important issue for the community. Dr Mair added that the neighbourhood was in a geographical territory where a large element of the community had access to personal transport but that the public transport available, should it be required, was derisory.

Mrs Margaret Thomson enquired, in relation to the dispensing aspect, whether the three GPs referred to by Dr Mair were all employed full time. Dr Mair replied that they worked ¾ time.

Mrs Margaret Thomson then asked how many people staff the dispensary at any one time. Dr Mair advised that there were five staff and two or three were present in the dispensary at any one time.

Mrs Margaret Thomson enquired if those involved in the making up of prescriptions were all trained as dispensers. Dr Mair replied that they were not.

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Mrs Margaret Thomson then asked if it was the GPs that were issuing the prescriptions and the dispensing staff that were making these up, then who was it who provided the final check. Dr Mair advised that prescriptions were dispensed by a member of the dispensary staff and were checked by another dispenser. To clarify, Mrs Margaret Thomson said, so the GPs prescribe, the dispensing staff make up the prescription, and then could Dr Mair inform her whom it was who carried out the final prescription check. Dr Mair replied that a doctor carries out the final check. Mrs Margaret Thomson enquired if the dispensers undertook training to do this. Dr Mair replied they did not.

10. Summing up

The Applicant and Interested Parties were then given the opportunity to sum up.

10.1 Dr C Mair, GP Sub Committee stated “A new pharmacy would be a major change to the area and needed to demonstrate that it would add and would not take away from the current provision of services. I am of the view that in fact the type of vision required for the area is different than that in an urban area and in order to do so may not be as comprehensive but all additional pharmaceutical services are currently met within a high staff level within the practice”.

10.2 Mr A Paterson, Area Pharmaceutical Committee stated “ I would refer the Committee to the statement presented by the Area Pharmaceutical Committee which recommends that the application is granted”.

10.3 Gareth Dixon for Mitchells Chemist Ltd, Applicant stated “within the proposed neighbourhood there are currently no pharmaceutical services. Therefore, it is both necessary and desirable to grant this contract. As discussed, the nearest pharmaceutical services are provided by the Co-op Pharmacy in Lairg at a distance of eleven miles. The proposed neighbourhood has a progressively ageing population and has a greater percentage of pensionable population compared with the rest of the Highland area and Scotland and this group tend to derive the most benefit from pharmaceutical services.

As a company I would like to thank all the residents of the proposed neighbourhood, Members of the Scottish Parliament, Members of Parliament and Community Councillors who all took time to make comment, especially NHS Highland Pharmaceutical Services for all their time and patience and finally the Pharmacy Practices Committee for giving up time for consideration of this application. We understand that with the allocation of NHS resources that difficult choices require to be made and we will respect whatever decision the Committee makes.

At the conclusion of the summing up, the Chair asked the applicant and all of the interested parties if they considered that they had had a fair hearing. Mr Dixon, Ms Gillespie, Dr Mair and Mr Paterson replied “yes”.

The Chair advised that a written decision would be sent out within 15 working days. A letter would be included with the decision advising of the appeal process. The Chair then thanked the parties for attending.

Mr Dixon, Ms Gillespie, Dr Mair, Mr Paterson and Mr Andrew Green, Area Regulations, Contracts & Controlled Drugs Governance Pharmacist left the meeting.

11. DECISION Having considered all the evidence presented to it, and the Committee's observations from the site visits, the Committee had firstly to decide, the question of the neighbourhood in which the premises to which the application related, were located.

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The Committee took into account a number of factors in defining the neighbourhood including the natural and man-made boundaries, who resides in it, neighbourhood statistics, the location of existing shops, health services and schools, land use and topography, and the distance and the means by which residents are required to travel to existing pharmacies, if they chose to do so, all of which were located outwith the proposed neighbourhood and other services.

Special regard was made to the requirements of the Equality Act 2010:

• the need to eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act;

• advance equality of opportunity between people who share a protected characteristic and those who do not;

• foster good relations between people who share a protected characteristic and those who do not.

The Committee considered the applicant's definition of the neighbourhood and how this compared to those put forward by the Interested Parties as well as comments received from the public consultation, and it was unanimously agreed that the neighbourhood was as defined by the applicant in his submission.

11.1 Neighbourhood: After considerable discussion, the Committee agreed that the neighbourhood had been as clearly defined by the applicant as was possible, and had been difficult to define due to the nature of the spread of the population and rural geography. Taking all this into account, the Committee supported the applicant’s definition of the neighbourhood and considered the detail of that neighbourhood and where the boundaries would lie as follows:-

North: the northern boundary was agreed, as proposed by the applicant to be Achinduich on the A836, taking in the surrounding areas. It was not considered that residents beyond this point would access pharmaceutical services from Bonar Bridge as there was adequate service provision in the village of Lairg which would be closer and seemed to be more probable that residents beyond Achinduich would more likely consider themselves to be neighbours of the village of Lairg and more likely, though not completely, be registered with the GP Practice in Lairg.

East: bounded on the north east by the community known as Spinningdale, but no further north east from that point, as by the applicant’s own information he dispenses to some patients in Spinningdale, therefore, it would appear that those beyond that point would access services in Dornoch. To the north east of Bonar Bridge, the communities known as Tulloch, Migdale, Ardens and Achuan.

South: the south eastern boundary was agreed as proposed by the applicant as Wester Fearn on the A836, although the GP had advised the Committee that a small patient population was registered at the Creich Surgery who were resident in Edderton. The reason for this was that residents beyond this point would naturally follow the A9 south to Tain to access pharmaceutical services at either of the two pharmacies sited there and who offered all the core elements of the pharmacy contract. It was agreed that the village of Ardgay, including the communities along the Croick Road, including Wester Gruinards be included in the neighbourhood as it was necessary for those resident along the Croick Road to return back along it to Ardgay and, therefore, would access services in either Ardgay or Bonar Bridge as a matter of course.

P13 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc 133

West: the western boundary was agreed, as proposed by the applicant, to be as far – but no further than Oykel Bridge on the A837. The Committee felt that, although it had been advised by the GP that there was some patients resident between Oykel Bridge and Ledmore Junction that, and in particular as this area was vast and sparsely populated, any residents therein would not consider themselves to be a neighbour of Bonar Bridge for the purpose of accessing daily needs or pharmaceutical services and, as a result would be more likely to consider accessing such services in Ullapool, where there was current adequate pharmaceutical provision in place.

11.2 Adequacy of Existing Provision of Pharmaceutical Services and Necessity and/or Desirability:

Having reached that decision, the Committee was then required to consider the adequacy of pharmaceutical services within that neighbourhood, and whether the granting of the application was necessary or desirable to secure adequate provision of pharmaceutical services in that neighbourhood.

The Committee noted there were no pharmaceutical services in the area but pharmaceutical services may be provided by pharmacies outwith the neighbourhood. That said, a prescribing data report run by the Health Board demonstrated only 0.5% of items prescribed from the Creich Surgery over the previous year had been dispensed at the closest pharmacy in Lairg and far less - in fact negligible amounts - from the other Sutherland pharmacies. After that analysis, it was the decision of the Health Board that no pharmacy could be construed to be an interested party, as there was no evidence that any were significantly affected by the application.

Having identified that there was negligible pharmaceutical input into the neighbourhood from outwith the neighbourhood, the Committee then considered what pharmaceutical services were available from within the neighbourhood. There were no pharmaceutical services currently provided from within the neighbourhood, although it was acknowledged that a highly quality dispensing service had been provided to patients in the neighbourhood by the Creich Surgery, which the Health Board had been most grateful to them for providing.

In addition, the Health Board acknowledged and appreciated that the surgery had done all that it could, within its restraints to emulate elements of the pharmacy contract such as minor ailments and chronic medication services, however, this could not be deemed as a pharmaceutical service.

Taking all the above into account, the Committee agreed and concluded there were no pharmaceutical services currently being offered within the neighbourhood and as a result the current provision of pharmaceutical services could not be deemed to be adequate, for the purpose of this application.

The Committee considered the letter from the GP Sub Committee. However, much of the points raised were around the financial implications to the GP Practice if the application were successful, which the Pharmacy Practices Committee, were unable to consider in their deliberations.

The Committee also took into consideration the letter from the Area Pharmaceutical Committee which agreed with the proposed neighbourhood and recognised that the provision of current pharmaceutical services were inadequate and therefore recommended the application was necessary and desirable in order to secure adequate pharmaceutical provision.

P14 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc 134 135 Highland NHS Board 4 December 2012 Item 3.9

Argyll & Bute Health and Social Care Strategic Partnership

Minute of Meeting held on Wednesday, 3 October 2012 Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead @ 10.00 am

Present

Robin Creelman (Chair) Chair – Argyll & Bute CHP Derek Leslie Director of Operations (Argyll and Bute CHP) Jim Robb Head of Adult Care (A & B Council) Councillor Roddy McCuish Leader – Argyll & Bute Council Councillor Dougie Philand Argyll & Bute Council Councillor Elaine Robertson Argyll & Bute Council Pat Tyrrell Lead Nurse (Argyll & Bute CHP) Louise Long Head of Children & Families (A & B Council) Tricia Morrison Carers Development Officer (A & B Council) Dr Michael Hall Clinical Director (Argyll & Bute CHP) PatTrehan JointPerformance&PlanningOfficer(A&BCouncil) Lorna McCallum (minutes) Admin Officer – Learning Disability (A & B Council)

In attendance

Apologies

Sally Loudon Chief Executive – Argyll & Bute Council Cleland Sneddon Executive Director – Community Services (A & B C) Councillor John McAlpine Non-Executive Director – NHS Highland

Item: Action 1. Introductions

Robin Creelman welcomed everyone to the meeting and introductions were made. .

2. Minute of Previous Meeting

Minute of previous meeting held on 25 July 2012 was agreed as a For noting correct record.

3. Matters Arising

Review of Partnership Agreement & Standing Orders – Derek Leslie expressed his concern that the portfolio holders within the Council were not represented at the Strategic Partnership Committee. Jim Robb stated that his understanding was that Councillor Dougie Philand and Councillor Robert MacIntyre were the nominated representatives from Argyll and Bute Council and this decision had been taken by the Council Administration. 136

Item: Action Councillor McCuish confirmed as Leader of the Council, he is a member of the Partnership and added further that he reports back to the portfolio holders and they are able to feed into the Partnership via himself. However, Councillor McCuish acknowledged the Cllr concerns raised and will discuss further with the Administration. McCuish

It was noted that the original Partnership Agreement had a balance of members from both the Local Authority and Health for voting purposes. However, it was noted that a core membership could be agreed and other individuals could attend the meetings if they wished.

It was therefore agreed that Jim Robb, Pat Tyrrell and Louise Long J Robb/ will redraft the partnership Agreement and circulate to the L Long Committee prior to the next meeting for comment. /P Tyrrell

NHS MiDIS Evaluation – update report prepared by James Brass L McCallum will be circulated with the minute. Derek Leslie reported the Project Board has now been established and a nomination from Argyll and Bute Council was requested. It was agreed this would be Dougie Hunter, Team Leader – Service Development Team. Roll-out will be on a locality basis commencing with Cowal. The “Implementation Champion of Community” post will be seconded to. The use of digital pens is also being investigated.

The Highland Partnership is looking at access shared access to CareFirst in relation to Child Care. As staff are now employed by one organisation, this addresses governance issues. Derek Leslie will seek clarification on the interaction between MiDIS and CareFirst. D Leslie

Joint Equipment Store – Pat Tyrrell has spoken with Malcolm MacFadyen and asked that the surveyor contact David Ross to P Tyrrell discuss the availability of premises in Helensburgh. If this proves unsuccessful, Pat will advise Jim Robb who will pursue further. Funding for the new joint store is available via the Change Fund.

Carers Strategy – Tricia Morrison, Pat Trehan and Dougie Hunter are updating the Carers Strategy and the revised document will be T Morrison/ presented to the next meeting. P Trehan

Occupational Therapy – James Brass has advised that NHS Highland are working on reporting from AWT system. Mary Wilson has advised that she will be able to pull basic information from the system and Pat Trehan will meet with Mary to discuss further. P Trehan Children & Families Teams – NHS Highland are looking at the way children’s teams are currently managed. The proposal is to align teams with Local Authority, with four locality teams with Team Leaders. Consultation will be held with staff initially prior to wider consultation.

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Item: Action 4. Child Protection Improvement Plan

Copies of the Child Protection Committee (CPC) Improvement Plan 2012/13 were circulated.

Louise Long reported the CPC Improvement Plan is a working document, written for staff and which is updated and presented to each Child Protection Committee meeting. The Improvement Plan addresses the significant issues raised at the multi-agency inspection undertaken in 2011. The main priorities are Identification, Assessment and Planning. A further follow through inspection will take place in January 2013.

Louise advised that actions have been completed with practice changing in each area. However, the impact of pathways is not evident at this stage. However, the Scorecard on Pyramid will measure outcomes and Louise agreed to bring the scorecard to the L Long Partnership meeting for noting.

5 (a) Update on Redesign of Older Peoples Services

Care at Home - Jim Robb advised that the Project Board decided that Care at Home Services would be commissioned from three preferred providers in the following localities: Lorn, Bute, Cowal and Helensburgh & Lomond. Implementation will commence approx third week in January 2013. Care at Home Services in Mid Argyll, Kintyre, Islay & Jura, Mull & Iona and Tiree will remain in-house.

Home Care Organiser posts will be converted to Quality Assurance roles which will ensure that all clients are visited to see how their service, whether internal or external, is being received. It is anticipated that this quality assurance model will be replicated across all Adult Care services as funding and redesign of services progresses.

Proposed implementation of Self Directed Support (SDS) – phase 1 is due for implementation in April 2013, with full implementation in place 2014/15. This will allow individuals to purchase services from other providers with any new business going to the preferred providers. A briefing paper on the implementation of SDS will be presented to both the Strategic Partnership and Council J Robb in due course.

Intensive Home Care Staff (formerly ICT) – Originally, ICT staff were due to be included in the tender process, however, a decision was then taken to exclude this staff group from the process and staff would be placed within community teams. This model of care was approved as anticipatory care is everyone’s business. Some staff (approx 6-7) had requested voluntary redundancy (VR) when initially thought they would be included in the process.

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Item: Action After discussion, it was proposed that as these posts are funded through resource release, where staff wish to take (VR) they can do so or remain they can remain in post if they wish. Usually if staff are granted VR then both the posts and the funding are removed. However, the Council have agreed that Home Care posts can be retained if efficiencies have been made. Jim Robb also suggested that the above VR option does not apply to Mid Argyll staff as this service is remaining in-house.

The group agreed that Jim Robb be delegated to prepare a report J Robb for the Leader, Chief executive and Executive Director outlining the above proposal on behalf of the Strategic Partnership.

Day Services – The Project Board agreed to retain day services for both Older people and Learning Disability in-house. These services will be redesigned and negotiations are ongoing with Trade Unions regarding staff terms and conditions in order to provide a flexible outreach service.

Care Homes – a full assessment of all Council Care Homes will be undertaken and findings presented to the Project Board. Potential joint commissioning with Health will be explored.

Mull Progressive Care Centre – facility is due to open within next two months will result in the closure of Dunaros.

5 (b) Update on Mental Health Redesign

Update report prepared by John Dreghorn was circulated and For noting noted.

Derek Leslie reported that a Project Board has been established to meet the governance arrangements for the capital funding for the new build. Proposals for the hub stage 1 will be submitted to the Capital Investment Group in January 2013. The bed compliment is now 38 beds. Bridging finance of £500,000 is still required. Tigh- na- Linne is expected to close in November with patients be relocated to either a group house in Lochgilphead or in Firgrove.

A large amount of consultation has taken place regarding site selection with the Tign-na-Linne site being deemed the most appropriate. Some issues remain regarding co-location of CMHS Teams in Dunoon and Campbeltown but work is ongoing to resolve these. The proposed date for the opening of the new hospital remains 2014.

It was noted that health need to engage with the Council in regard to the local Development Plan. John Dreghorn will be asked to contact Fergus Murray regarding this.

Dr Hall left the meeting at 12:05 p.m.

4 139

Item: Action 5 (c) Partnership Working – Integrated Services Consultation

Copies of the Argyll and Bute Council response to the Integration of For noting Adult Health and Social Work Care in Scotland consultation were circulated. Argyll and Bute CHPs response has been incorporated into NHS Highland’s response.

Discussions have been ongoing between the Leader and Chief Executives for both Argyll and Bute Council and NHS Highland.

It was noted that is essential that a model should be devised which works best for Argyll and Bute. The Partnership can evidence the significant progress made on a number of issues to date.

5 (d) Change Fund Bid/IRF Scoping Report

Copies of the mid-year progress report prepared by Pat Tyrrell were For noting circulated and content noted.

The report highlights five key achievements made to date:

 Partnership Model of Planning, Prioritising and Decision Making  Model for Workforce Development  Carers  Provision of Joint Equipment Store  End of Life Care

The Joint Commissioning Strategy will be submitted in February 2013. The Performance Framework will be reported on Pyramid.

The Argyll & Bute Dementia Partnership won the “Most Innovative Partnership” at the Scottish Dementia Awards.

The Change Fund Plan builds on the work previously established over the last five years.

6. ADP Delivery Plan 2012-15 & Annual Report For noting Item deferred to next meeting. New Co-ordinator and Information Officer are now in post.

7. Joint Performance Update

Report prepared by Pat Trehan, Joint Performance and Planning Officer, dated August 2012 was circulated and its contents noted.

Pat Trehan highlighted a number of points contained within the report as follows:

Hospital Admissions/Readmissions – overall, admissions are reducing, however, they are not yet on target. A further audit of the

5 140

Item: Action Admissions, Discharge and Transfer policy will be undertaken in November. Pat Tyrrell reported that hospitals have been asked to make the reason for admission absolutely clear. There is a variation in practice amongst GPs, therefore, there needs to be confidence that any admissions to hospital are in the best interest of the patient. The experiences of individuals should be explored and the quality approach examined.

It was noted that readmissions were high on Islay. As such, it was agreed that Pat Trehan will undertake an audit of these cases to P Trehan identify for the reasons for this.

Admissions from North Argyll House Care Home were also high. P Trehan/ Pat Trehan and Pat Tyrrell will again investigate the reasons for this. P Tyrrell

Social Care Bed Vacancies – currently there are 71 vacancies across Argyll and Bute.

Delayed Discharges – the 4 week target has been introduced ahead of national implementation. This will further be reduced to 2 weeks from April 2013.

Overall Balance of Care – currently 68% with target of 70%.

In-Year Balance of Care – showing a downward trend, however, still above target.

OT – AWT database is still unable to provide management reports, therefore data continues to be collated manually. Work is ongoing to identify the delay in resolving this issue.

Overnight Care Teams – usage of the overnight teams varies on a month to month basis as this is a response service. Travel time is now included in the monthly reporting.

Learning Disability –Data verification exercise is ongoing.

Gary Coutts from Highland Partnership has advised they would like a Pyramid demonstration to be given to the Board. Confirmation of when this will take place is awaited.

8. Children’s Services Update

Louise Long reported the Care Inspectorate released the Fatal For noting Accident Inquiry (FAI) report in August.

A single agency review is ongoing where 14 – 16 year olds who meet the same criteria of self harm/attempted suicide are being interviewed. Many of the issues identified during the FAI remain the same. The findings of this audit will be reported to a future meeting.

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Item: Action An Abuse and Trauma Service has been introduced. There are also Primary Mental health workers in schools with increased capacity in CAMHS teams. However, it must be ensured that these services deliver what is required. 9. A.O.C.B.

Dates for 2013 – Derek Leslie will ask Sheena Clark to liaise with D Leslie Mary-Theresa Bulloch to arrange next year’s meeting dates.

Agenda Item – Mary-Theresa Bulloch to be asked to add AOCB as M-T Bulloch standard item to each agenda.

Papers for Meetings – Robin Creelman asked that both electronic M-T Bulloch and paper copies of reports circulated for meetings are the same version and that the minute is circulated in advance of the meeting.

9. Date of Next Meeting

The next meeting will be held on Wednesday, 28 November 2012@ 10.00 am in the Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead.

7 142 143 Highland NHS Board 4 December 2012 Item 3.10 The Highland Council

Minutes of Meeting of the Adult and Children’s Services Committee held in the Council Chamber, Council Headquarters, Glenurquhart Road, Inverness on Wednesday26 September 2012 at 10.00 am.

Present:

Highland Council:

Dr D Alston Mrs D Mackay Mrs I Campbell Mr W Mackay Mr A Christie (Chair) Mr G MacKenzie Mrs M Davidson Mr T MacLennan Ms J Douglas Ms L Munro Mr B Fernie Mr M Rattray Mr K Gowans Mrs F Robertson Mr M Green (Substitute) Ms G Ross Mr D Hendry Mr G Ross Mr E Hunter Ms M Smith (Substitute) Mrs L MacDonald (Vice Chair) Ms K Stephen

NHS Highland:

Mr I Gibson Mrs G McCreath Dr M Somerville

Religious Representatives:

Rev C Mayo Ms M McCulloch Mr G Smith

Youth Convener:

Mr J Erskine

Non-Members also present:

Mr B Clark Mr N MacDonald Mr A Duffy Mr A MacLeod Mr D Fallows Mr G Rimell Mr R Laird

In attendance:

Mr H Fraser, Director of Education, Culture and Sport Mr B Alexander, Director of Health and Social Care Mr R MacKenzie, Head of Support Services, Education, Culture and Sport Service Mr C MacSween, Head of Education, Education, Culture and Sport Service Mrs B Cairns, Principal Officer Early Education, Education, Culture and Sport Service Ms S Belford, Quality Improvement Officer (North Area),Education, Culture and Sport Service Ms B Dunthorne, Finance Manager, Finance Service Mr C Munro, Highland Children’s Forum } 144

Ms A Darlington, Action for Children } Third Sector Ms A Brady, Care and Learning Alliance } Miss J Maclennan, Principal Administrator, Chief Executive’s Office Miss M Murray, Committee Administrator, Chief Executive’s Office Mrs R Daly, Committee Administrator, Chief Executive’s Office

Also in attendance:

Mr A Brown, Education Scotland Mrs T Morrow, Connecting Carers Mrs M MacMillan, Connecting Carers Ms K Cormack, Head Teacher, Dingwall Academy Ms T Mackie, Cluster Head Teacher, Park and South Lodge Primary Schools, Invergordon 3 pupils from Park Primary School, Invergordon

An asterisk in the margin denotes a recommendation to the Council. All decisions with no marking in the margin are delegated to the Committee.

Mr A Christie in the Chair

Business

Preliminaries

Rev C Mayo opened the meeting with a prayer.

1. Apologies for Absence Leisgeulan

Apologies for absence were intimated on behalf of Mr B Gormley, Mrs B McAllister, Mrs M Paterson and Ms J Slater.

2. Declarations of Interest Foillseachaidhean Com-pàirt

The Committee NOTED the following declarations of interest:-

Item 4 – Mrs G McCreath (financial) Item 5 – Ms J Douglas, Mr K Gowans, Mr M Rattray, Ms M Smith (non-financial) Item 7 – Mrs G McCreath (financial) Item 13 – Mrs G Ross and Ms J Douglas (non-financial) Item 15 – Mrs G McCreath (financial)

3. Presentations Taisbeanaidhean

i. New School Inspection Model ModailÙrSgrùdadhSgoile Mr A Brown, Area Lead Officer for Highland, Education Scotland, undertook a presentation on the new School Inspection model which detailed the purpose and aims of the inspection process in evaluating the quality of learning and teaching in Scottish schools and education services. In providing a flavour of

2 145 what school inspections currently entailed, he outlined the focus of all inspections:-

 How well do children or young people learn and achieve?  How well does the school support children or young people to develop and learn?  How well does the school improve the quality of its work?

Education Scotland aimed to help head teachers prepare for the inspection which would involve Inspectors spending up to a week in a school, observing lessons and learning and consulting parents, staff and pupils. He detailed the key quality indicators of each inspection: improvements in performance; the learners’ experiences; the curriculum; meeting learning needs and improvement through self-evaluation. An assessment of these indicators enabled strengths and areas for improvement to be identified and formed the basis for advice and support, together with the Inspection Report findings. Mr Brown was keen to stress that Education Scotland did not aim to look for faults, neither did it only consider examination results, evaluate individual lessons or teachers and neither would it walk away from any school with serious weaknesses.

Responding to questions, it was confirmed that, while prioritising assessment of pupils’ learning experiences, account was taken of probationer teachersand Inspectors always made a point of meeting them to establish their views. Probationer teachers were generally comfortable with the presence of Inspectors as they were used to being observed as part of their probationary period. Education Scotland was confident that Local Members would already be involved in providing support to schools and would take a constructive interest in Standards and Quality Reports produced by the school.

Education Scotland was now beginning to pilot integrated inspections which assessed wider issues and aimed to address the new integrated service. A member of the inspection team was tasked specifically with assessing how school and community partners were contributing to non-mainstream provisions and the Health and Wellbeing agenda. A similar assessment process also applied to early years education centres. Responding to queries regarding arrangements to notify Local Members of when inspections were planned, the Chairman undertook to liaise with the Director to ensure that Local Members were given early notification.

Education Scotland had responded to feedback from stakeholder groups in moving away from long detailed assessment reports. In addition, letters to parents provided a shorter summary but directed them to where more detailed information was available, if required. The aim was to encourage parents and stakeholders to read the overall school assessment and gain a broad picture of progress. Feedback on this change had generally been very positive.

Thereafter, having thanked Mr Brown, the Committee NOTED the presentation and that the Chairman would liaise with the Director regarding a request for Local Members to be notified of when inspections were going to take place.

3 146

ii. Health and Wellbeing SlàinteagusMathais

Ms K Cormack, Head Teacher of Dingwall Academy, delivered a presentation on Health and Wellbeing which was a key entitlement of Curriculum for Excellence and the delivery of which was the responsibility of all teachers and everyone that worked with children in schools. The Health and Wellbeing Strategy embraced a wide spectrum of factors going beyond physical activity and healthy food. Health and wellbeing also included attention to digital literacy, recognising emotional literacy and encouraging pupils to articulate concerns so as to nurture and support the learning experience.

Ms T Mackie, Head Teacher of Park and South Lodge Primary Schools, Invergordon, together with pupils from Park Primary School, provided a presentation of what Health and Wellbeing meant to pupils, staff, parents and community. Park Primary School had created a sustainable vegetable garden and terraces, held a Health Day and Citizen Fridays where children from Park and South Lodge Primaries joined together. In addition, pupils had become involved in the Junior Award Scheme Scotland, a range of other enterprise projects and first aid courses.

Responding to questions, pupils confirmed the involvement and commitment of their parents in the Health and Wellbeing agenda, including attendance at open days. They also confirmed the extent to which pupils enjoyed and benefited from Citizen Fridays meeting with new friends from the neighbouring school which would prepare them for their progression to Invergordon Academy.

Thereafter, having expressed their thanks, the Committee NOTED the presentation.

11. Update on Carers Services – Presentation by “Connecting Carers” Cunntas as Ùr mu SheirbheiseanLuchd-cùraim – Taisbeanadh le “Connecting Carers”

In terms of Standing Oder 18, the Committee AGREED that this itembe taken at this point in the proceedings.

There had been circulated Report No ACS/35/12 dated 17 September 2012 by the Director of Health and Social Care which introduced a presentation by “Connecting Carers”,part of Highland Community Care Forum, about the services they operated to support unpaid carers and young carers.

The Chairman introduced Ms Tina Morrow, Service Development Manager, Connecting Carers, who delivered a presentation to the Committee and explained that in Highland there were approximately 24,000 unpaid adult carers and 6,000 young carers, all of whom played an incredibly valuable role.

Connecting Carers worked with carers to develop an awareness of their caring role, recognise and identify their own health and social needs, be informed and involved in decision making processes, enable carers to come together to share experiences and to continue to care for as long as they were able and/or willing. The organisation worked with professionals, other voluntary organisations and the public to promote 4 147

an understanding of the role of unpaid carers, promote carers as equal partners, ensure carers’ collective voices were heard, offer specific carer awareness training and act as a referral point and source of information.

Responding to questions, it was confirmed that in relation to young carers, there were awareness raising mechanisms available in schools and referrals sometimes came from schools. It was also confirmed that becoming a carer created a fundamental change in relationships, that 80% of carers undertook their caring role at home and that there was a need to raise public awareness in addressing the potential negative health impacts for carers themselves.

Members recognised the importance of involving carers in the overall patient care, the need for respite and difficulties encountered in creating time for respite opportunities. The East Sutherland organisation TYKES, aimed at supporting young carers, had recognised the benefit of early identification of young carers and provision of practical support. It was confirmed that Connecting Carers were considering a range of alternative funding opportunities to develop and introduce peer support and mentoring opportunities for young carers.

During further discussion, Members requested information on how much spending the Council directed to this valuable area of work. It was confirmed that Connecting Carers’ was funded by a range of different funding streams including the Highland Council and NHS Highland, the details of which would be provided.

Thereafter, having expressed their thanks, the CommitteeNOTED the presentation, andAGREED:-

i.to acknowledge the significant contribution that carers made to those for whom they cared, their communities and the local economy; ii. to endorse the work of the Council, NHS Highland and the Highland Community Care Forum in supporting carers; and iii. that information on the level of funding the Council was presently providing to carers’ services be made available to Mr T MacLennan.

Addendum

At this point, the Committee NOTED and welcomed confirmation that Inverness Royal Academy had been listed as one of the 30 Scottish schools to receive additional Scottish Government funding under the Scotland’s Schools for the Future Phase 3 programme which would permit a £37.5m replacement building.

4. Revenue Budget 2012/13 – Monitoring BuidseatTeachd-a-steach 2011/12 – Sgrùdadh

Declaration of Interest:

Mrs G McCreath declared a financial interest in this item as a foster parent and advised that if there was any specific discussion in relation to fostering she would leave the room.

i. Education, Culture and Sport Foghlam, CultaragusSpòrs 5 148

There had been circulated Report No ACS/26/12 dated 17 September 2012 by the Director of Education, Culture and Sport setting out the revenue budget monitoring position for the four months to July 2012.

The current year-end estimated position was a projected under-spend totalling £0.023M. Projected variances had arisen as a result of the periodic review of the insurance premium payable under the terms of the PPP contract and a reduction in the number of school meals being sold year-on-year for the summer term. The report also provided commentary on the main areas of risk that might impact on the year-end outturn position and sought approval for a change in playground supervision arrangements emerging as a consequence of the on-going rollout of the Facilities Management model.

During discussion, clarification was sought on a number of specific points. In particular, it was explained that:-

 additional funding had been allocated to Additional Support Needs and this had been flagged up as a potential budget pressure which the Administration was monitoring closely; together with the allocation model, which was the subject of a separate item on the agenda (item 9 refers), there would be future monitoring reports to Committee;  an update on facilities management would be submitted to the January 2013 meeting of the Committee. This timeframe would permit inclusion of an update on rolling out the project over the winter period so as to consider any problems encountered, lessons learned and how it could be further improved; and  free school meals would be the subject of a report to the next meeting of the Committee and at subsequent meetings.

Thereafter, the Committee:-

i. AGREEDthe on-going management actions being taken to achieve a balanced budget at the end of the financial year; ii. AGREEDthat as the Facilities Management (FM) model was rolled out across Highland, any schools which previously were entitled to dedicated janitorial provision and which would lose this dedicated provision as a result of the transition to the FM model would receive funding for a playground supervisor; and iii. NOTED that reports would be submitted to future Committee meetings in relation to Facilities Management and uptake of free school meals. ii. Health and Social Care SlàinteagusCùramSòisealta

There had been circulated Report No ACS/27/12 dated 13 September 2012 by the Director of Health and Social Care setting out the revenue monitoring statement for the Health and Social Care Service budget for the four months to 31 July 2012.

Members were informed that work was continuing on the final detail of the budget for Health and Social Care in 2012/13. The transfer of funding for adult social 6 149 care services would be reported to the Adult Services Development and Scrutiny Sub Committee meeting on 27 September. The projected outturn for the Service at the year-end was £131.356m which represented a projected overspend of £1.463m. It was confirmed that the budget was experiencing pressure in relation to external placements for looked after children regarding (a) purchased care placements within Highland, and outwith the authority, in residential care (projected overspend of £1.692m); and (b) placements with independent fostering agencies (projected overspend of £0.213m).

Close monitoring and Service Management scrutiny would continue during the financial year to minimise the financial demands on the service while still providing the necessary level of services to children and families.

During discussion, Members raised a range of issues, including:-

 there was a significant underspend on Educational Psychologists and this merited a full explanation;  it was suspected that underspend on disability teams and services had resulted from vacant posts not having been filled and it was hoped that these posts would not be kept vacant;  it would be important to address risks, particularly those created by not filling vacancies;  there was a need to identify savings that would have an impact on the current financial year’s budget and it would be important to consider what measures could to be taken to bridge the budget gap; and  it would be essential for a plan of action to be established to address the projected overspend but, so far,this appeared to be absent.

In response to questions, it was recognised that the budget was under immense pressure and it was planned to address this partly through preventative spend.

With reference to Educational Psychologist posts anddisability teams and services, it was confirmed that some vacancies had not yet been filled. This has resulted from a national shortage of Educational Psychologists which had created difficulties in filling posts. It had not been the Service’s intention to hold posts vacant, rather it was their priority to ensure that specialist resources were available to meet children’s needs. It was confirmed that a report would be presented to a future meeting of the Committee on recruitment to certain vacant posts, highlighting reasons why it had been hard to recruit to these posts and what measures could be taken to enable the Council to continue to provide the necessary services.

The Chairman confirmed that the Administration was committed to providing the necessary care and support to children that needed it. While it was the aim that this would be done within budget, it had to be recognised that at times these two aims could conflict. In terms of closing the budget gap, alternative methods would be considered, but it was stressed that at no time would any child’s care be put at risk.

Thereafter, the CommitteeNOTED:- i. the projected overspend of £1.463m monitoring position; 7 150

ii. that there was a further report on the Committee agenda about external placements, including actions being taken; and iii. that a report would be presented to a future meeting in relation to recruitment of certain vacant posts, highlighting reasons why it had been hard to recruit to these posts and what measures could be taken to enable the Council to provide the service it needed.

5. Capital Expenditure 2012/13 – Monitoring CaiteachasCalpa 2012/13 - Sgrùdadh

Declarations of Interest:

Ms J Douglas and Mr K Gowans declared non financial interests in this item as Directors of High Life Highland and advised that if there was any specific discussion in relation to the funding of High Life Highland they would leave the room.

Mr M Rattray and Ms M Smith declared non financial interests in this item as Directors of Averon Leisure Centre but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that their interests did not preclude their involvement in the discussion.

i. Education, Culture and Sport Foghlam, CultaragusSpòrs

There had been circulated Report No ACS/28/12 dated 17 September 2012 by the Director of Education, Culture and Sport which set out the net Capital expenditure position for the four months to 31 July 2012, the related year-end projections and progress on the major projects that would be completed within the next three financial years. The report also sought approval for specific projects and provided an update on progress with the Sustainable School Estate Review.

During discussion, clarification was sought on a number of specific points. In particular, it was explained that:-

 problems had been encountered in relation to the tendering exercise for work at the Highland Folk Museum store which had led to a delay of 3 months. However officers were confident that the project would be delivered on time;  the feasibility study assessing the condition of four schools, including St Duthus Special school, would be completed by 26 October and recommendations would be submitted to the next meeting of the Committee. In parallel with this, the demountable accommodation at St Duthus Special school would be considered, including an assessment of interim measures needed to be put in place over the coming months;and  with regard to buildings soon to become surplus to requirements as a result of new builds, it was confirmed that the Director of Housing and Property had undertaken a major exercise to identify assets due to come onto the market and that this situation was being actively managed.

During further discussion, the following issues were raised:-

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 while it was pleasing to see some progress made in Inverness High School, some problems with the fabric of the building were still evident and had been there for many years. The recommendation to invest in the school building was welcomed but this would be all the more challenging on account of it being a Listed Building;  Members welcomed progress on capital investments in projects in Plockton, Milton of Leys Primary School, Aldourie Primary School and the Highland Folk Museum. In particular, appreciation was expressed for the level of investment in projects in the Fort William area;  concerns were expressed regarding the condition of buildings at the Black Isle Education Centre and it was disappointing that this was still only at the feasibility stage – not progressing this as a matter of priority compounded problems for vulnerable children;  concern was expressed that Balnain Primary School had needed a replacement demountable unit for some considerable time and, given that there was predicted £4.262M underspend in Capital expenditure, it was hoped that this could be addressed in early course; and  in terms of transparency it might be helpful if the list of capital projects could include and indicate projects where it was known that work was needed but which could not be pursued at the present time.

The Chairman undertook to look into the matter of a replacement demountable unit for Balnain Primary School and confirmed that an update on progressing the necessary work at the Black Isle Education Centre would be reported to the next meeting of the Committee.

Regarding how projects were included in the list, Members were reminded that the Council had agreed the Capital Programme unanimously. However, this was a living document and would be revisited later in the year. It was the responsibility of the Committee to ensure delivery of agreed projects and a degree of over-programming had been included in the Capital Programme so as to create a larger margin for unexpected events.

Thereafter, the Committee:- i. AGREED that an independent post-project review of the Lochardil Primary School extension/refurbishment project be progressed and that the recommendations contained in that report be presented to a future Committee; ii. AGREED that £0.137M be drawn down from the Life Cycle Investment budget to fund the infrastructure and new server configuration required to progress the upgrade of the People’s Network; iii. AGREED that £0.100M be drawn down from the generic Life Cycle Investment budget to fund various works at Inverness High School; iv. AGREED that up to £0.050M be drawn down from the Life Cycle Investment budget to fund a replacement vehicle in the Sutherland School Transport fleet; v. AGREED that £0.020M be drawn down from the Life Cycle Investment budget to fund the creation of additional play space at MacDiarmid Primary School required as a result of the loss of existing play space to house modular classroom accommodation;

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vi. AGREED that £0.050M be allocated from the Community and Leisure Facilities budget for the formation of a fitness suite at the Leven Centre in Kinlochleven; vii. AGREED that £0.017M be drawn down from the Life Cycle Investment budget to fund the replacement of the grass cutting machinery at Inverness Royal Academy; viii. AGREED that Maryburgh Primary School be declared surplus in accordance with the procedures outlined in paragraph 3.8 of the report; ix. NOTED that the post-occupancy evaluation report on the building operating efficiency of Acharacle and Milton of Leys Primary Schools would be presented to the Committee in November 2012; x. AGREED that the project to provide a synthetic surface play area at Roy Bridge be overseen and managed by the Council on the basis that all related costs would be met from the sum raised by the local community; xi. AGREED that a feasibility study be carried out in relation to the boiler system at the Averon Centre, Alness and that the findings be reported to Committee in November 2012 for further consideration; xii. AGREED that the second phase of the building condition survey programme to inform the Sustainable School Estate Review be undertaken at a cost of £0.300M and that this funding be drawn down from the SSER budget heading; xiii. NOTED that the Chairman would look into the issue of a replacement demountable unit for Balnain Primary School; and xiv. AGREED an update would be presented to the next meeting of the Committee regarding the condition of the Black Isle Education Centre building and considering ways in which this issue could be addressed. ii. Health and Social Care SlàinteagusCùramSòisealta

There had been circulated Report No ACS/29/12 dated 17 September 2012 by the Director of Health and Social Care which provided an update on progress to date with the Health and Social Care Capital Programme and included a monitoring report on expenditure in 2012/13; details of a proposal to provide financial assistance to a foster carer to create an additional bedroom; and an update on work being undertaken in relation to a number of fire safety and other health and safety capital works.

The budget for 2012/13 amounted to £3.430M and expenditure to date amounted to £0.384M (11%). At this stage in the financial year, it was projected that the programme would be overspent by £0.081M. An update on a range of projects was presented, including refurbishment work at Duthac House, Grant House, Invernevis House, Ach an Eas and the new Children’s unit in Caithness.

During discussion, clarification was sought on a number of specific points. In particular, it was explained that:-

 while the Council was continuing with its Capital Expenditure commitments for the current year, the property teams of both the Council and NHS Highland were considering future working arrangements and it was envisaged that proposals for post April 2013 would be presented to Members within the year; 10 153

 the Welfare Reform Working Group, established by the Finance, Housing and Resources Committee, would consider the impact of a range of issues. Amongst these would be Housing Benefit reforms, such as the proposed “bedroom tax” which would reduce the amount of housing benefit support to tenants in the social rented sector and, in particular, how this might impact on foster carers; and  it was confirmed that a full refurbishment of the Ach an Eas facility was planned and that full details of this, as had been detailed in previous reports to Committee, could be provided as appropriate.

Thereafter, the Committee:-

i. AGREED to support the request to the full Council for an allocation of £0.007m to provide increased foster provision by a current foster carer; ii. APPROVED the report and the budgetary position; iii. NOTED that details of the full refurbishment work being undertaken at Ach anEas would be made available to Ms Gillian McCreath; and iv. NOTED comments made regarding the need to improve communications between the Council and NHS Highland to make progress with projects in the Capital Programme which had been held in abeyance over the last year.

6. Preventative Spend: Early Years and Families, Older People and Deprivation CosgaisChasgach: Tràth-bhliadhnaicheanagusTeaghlaichean, SeannDaoineagusBochdainn

There had circulated Report No ACS/30/12 dated 17 September 2012 by the Director of Health and Social Care which made proposals to direct expenditure into activities associated with preventative interventions, promote the well-being of individuals and communities, achieve the better use of resources and avoid unnecessary public spending.

During a summary of the report, it was confirmed that the Programme for the Highland Council included commitments to secure £3m of the Council’s budget to preventative spend to improve the quality of life for young people, older adults and those struggling with deprivation. The report set out proposals in these areas for Members’ consideration prior to decisions being taken about the implementation of preventative measures. It was intended that the proposals for older people services be considered at the Adult Services Development and Scrutiny SubCommittee and thereafter at the Highland Council on 25 October and that proposals in relation to early years and deprivation be considered further at the next meeting of the Committee in November with a view to recommendations being made to the Council in December.

It was considered that the report represented a milestone in making a far reaching move towards the implementation of preventative spend. Preventative spend was far more than a 'spend to save' exercise, rather, it represented public spending that aimed to prevent, rather than respond, to negative social outcomes.

Responding to comments, it was confirmed that risks associated with savings not being made, on account of responsibility being with other areas of Council services or outwith Council budgets, should be mitigated by being a corporately agreed responsibility which would be reviewed across services. The report represented early delivery of one of the commitments included in the Programme for the Highlands. 11 154

It was explained that while care and education services could be brought under one roof in some areas, this did not suit the wider Highland geography. Therefore, the “virtual family centre” described a more outreach-focus way of targeting care and education services so as to overcome the difficulties of the expansive Highland geography.

It was confirmed that a report would be submitted to the next meeting of the Committee on transitional years and work had been on-going in relation to investigating temporary emergency accommodation for children. The report represented a very welcome progression and had resulted from effective joined up thinking with the NHS and the Scottish Government. While the Council had spent preventatively in the past, this approach represented a Council priority to change spending profiles in accordance with preventative spending motives and represented a statement regarding the overarching priorities of the Council and matching this in the structure of the budget.

It was also confirmed that the Council’s Carers’ Champion would take on board comments raised during debate.

During discussion, a range of other comments were made, including:-

Early Years

 it would be useful if Members had a presentation informing them about early years brain development so that they could be aware of the importance of early intervention and see the benefits of preventative spending in this area;  while welcoming the emphasis of preventative spend in relation to early years, it was acknowledged that the benefits of such a strategy would take many years to become evident and there was, therefore, a need to consider services for transitional years in parallel;  suggestions for virtual family centres were welcomed as this would work well with the Highland geography;  childcare benefits in Scandinavia were detailed and this supported the proposal to spend in this worthwhile area;  if the Council was serious about investing in early years, it should consider ways to lobby the Scottish and UK Governments to address the cost of childcare and to advocate the use of taxation to provide investment for early years; and  the Health Service was very supportive of preventative spend in early years recognising that this was where the most benefits could be derived.

Deprivation

 it was important to recognise that, in addition to those areas listed in the report, there were other pockets of deprivation in the Highlands and many hidden areas of deprivation in rural areas. It was hoped that some flexibility could be applied to the working arrangements of the proposed three Community Development Officer posts to take this into account;  evidence had confirmed that the most benefit would be derived from focussing attention on concentrated areas of deprivation and targeting these areas with

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coherent and joined-up initiatives. As a result, a more targeted approach would have the most impact on deprivation;  the proposals to direct spending towards drug and alcohol education with young people and preventing violence against women and supporting their families were particularly welcomed;  reference was made to the success of the Lochaber Pub Watch which had a significant impact on school children as it involved trade representatives. In a similar approach, it might be helpful to include medical professional advice regarding the message they wished to convey to young people on drug and alcohol education;  the proposal to spend £0.175M on enhanced support for carers and young carers was welcomed. However, on the basis that there were 24,000 adult carers and 6,000 young carers in Highland, this would equate only to £5.83 per carer and it was hoped that further work could be done to reinforce the message that these carers played a valuable role; and  it was noted that Highlands and Islands Enterprise and Albyn Housing Association were looking forward to bidding into the Council’s Community Challenge Fund to establish and support social enterprises. In addition, to encouraging communities to help themselves, it might be beneficial if this could be complemented by the Council providing a support role.

Older People

 with regard to the proposal to create integrated early intervention posts in fieldwork teams, it was not clear whether these staff would have the ability to carry out social work assessments; and  there might be benefit in enhancing Community Development Officer roles and consider locating these posts in community groups that were driving care for older people in communities and consider more radical changes to management structures.

Thereafter, the Committee AGREED that the points raised during discussion be used to inform the report and recommendations for future meetings of the Committee and the full Council.

The Committee also:-

i.AGREED that a presentation or seminar be held to inform Members on early years brain development; ii. NOTED that reference in the report to risks associated with savings not being made, on account of responsibility being with other areas of Council services or outwith Council budgets, would be mitigated by being a corporately agreed responsibility involving Community Planning partners and was covered by the provisions of the Programme for the Highlands; iii. NOTED that a report would be submitted to the next meeting of the Committee addressing transition and transition years; and iv. AGREED to consider ways to lobby the Scottish and UK Governments to address the cost of childcare and to advocate the use of taxation to provide investment for early years.

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7. External Placements of Looked After Children Suidheachaidhean air an Taobh a-muigh do Chloinn a tha air an Coimheadàs an Dèidh

Declaration of Interest:

Mrs G McCreath declared a financial interest in this item as a foster parent and left the room during the specific discussion in relation to supporting and recognising foster carers.

There had been circulated Report No ACS/31/12 dated 17 September 2012 by the Director of Health and Social Care which provided information on placements of Looked After Children in external care, residential school and fostering placements.

During a summary of the report, it was confirmed that there was a projected overspend of £1.905m on these placements which involved £1.692m on residential placements and £0.213m on foster care placements. There had been continuing pressures during July and August 2012 on these budgets, including admissions to residential schools that would cost around £0.75m in a full year. While it was acknowledged that these admissions would be mitigated by other children moving on from their placements and returning to live in Highland, updated figures would be available for the next meeting of the Committee and there was a very real risk that the projection would increase.

There had been increasing numbers of placements outwith the Highland area of children with very significant disabilities and/or communication disorders: young children with attachment disorders and children with disabilities, both of which had challenging behaviours. The percentage of looked after children funded via the integrated out of authority placements budget had increased steadily, however, the cost of those placements had increased exponentially. Officers were endeavouring to work within budget allocations although it had to be recognised that one single placement would create a significant impact on the budget.

During discussion, clarification was sought on a number of specific points. In particular, it was explained that:-

 the Council would continue to hear updates on health outcomes for Looked After Children, including those placed out of authority. It was a priority to ensure that children’s health needs were met and the Council would continue to raise this with other authorities and the Scottish Government;  the Council took active steps to meet the health needs of children placed in Highland from elsewhere but could only do so if it had notification of these placements from either the fostering agency involved or the placing authority. Such notification was a legal requirement and the Council would continue to stress its importance to other authorities;  while attachment disorders could result from parental drug and alcohol misuse, there could also be a range of other causes - the proposals regarding parenting in the preventative spend approach aimed to address this situation, in parallel with the Government’s National Parenting Strategy; and  advertisements had been placed recently seeking to recruit foster carers and work was on-going in this regard. Furthermore, holding an event to thank and celebrate foster carers and to assist recruitment would be appropriate. 14 157

During further discussion, a range of other issues were raised, including:-

 while recognising the huge budgetary pressure facing the Council on this area, Members acknowledged the work of the previous Council and made a commitment to continue this good work and consider preventative and capital spend in this area;  irrespective of the financial situation, the Council should be proud of and acknowledge the success of its practice model;  it was recognised that consideration would be given to developing the initiative to establish a dedicated throughcare resource for children with disabilitiesby utilising hostel and school capacity in a number of locations. Consideration would also be given to whether this approach could be extended to include any other groups of children;  it was a concern to see that three children were presently in secure care in Highland; and  it was hoped that budget pressures would not be addressed through the holding of vacancies as the outcome of this was unpredictable. It was hoped that consideration could be given to forecasting demand over the next 3-5 years so a longer term approach could be adopted rather than depending on yearly bids.

Responding to these and other comments, it was confirmed that the Council’s position regarding looked after children had been referenced at CoSLA, both in terms of the integration work with the NHS and in terms of Community Partnership at the Leadership Board and CoSLA Leaders meetings.

The Administration recognised the recurring overspend in the budget and was committed to addressing it. The new integrated service would put Highland in an informed position to forecast needs at an early stage and identify the necessary resources.

Following discussion, the Committee AGREED the actions being taken to address the projected overspend.

The Committee also NOTED that advertisements had been placed recently seeking to recruit foster carers and that work was on-going in this regard and AGREED to hold an event to thank and celebrate foster carers and to assist recruitment.

8. Integration of Health and Social Care - Update AmalachasSlàinteagusCùraimShòisealta – Cunntas as Ùr

There had been circulated Report No ACS/32/12 dated 18 September 2012 by the Director of Health and Social Care which provided an update on progress towards integrated services for children and adults in Highland.

With regard to the schedule of District Partnership meetings which formed part of the report, the Chairman highlighted that the Sutherland Pre-Meeting had been rescheduled to 17 September 2012 and the Skye, Lochalsh, Wester Ross and Assynt Pre-Meeting would now take place on 2 October 2012. In relation to the Sutherland Inaugural Meeting on 5 October 2012, this would commence at 3.00 pm as it was the same date as the District Partnership Seminar.

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In response to questions, it was explained that:-

 the Community Development and Volunteering Strategies were currently out for consultation with the Third Sector and would be reported to a future meeting of the Committee;  in relation to Council Members accessing NHS Highland Committee papers and vice versa, the Chief Executives of both organisations had been asked to explore the best way to facilitate this and an update would be provided to Members in early course;  with regard to the membership of the Strategic Commissioning Group, it was an Administration function to ensure that services were delivered in accordance with the Council’s Programme. However, access to information and briefings would be available to Opposition Members;  discussions were ongoing between Third Sector groups and the Third Sector Interface as to who the four representatives on the Strategic Commissioning Group would be and how to ensure that information was shared between all Third Sector organisations;  the post of Programme Manager had been re-advertised following a poor response to the initial advertisement;  on the basis of the pilot District Partnerships in Lochaber and Caithness, the guidance had been redrafted to incorporate open public submissions rather than a single patient/public representative. However, District Partnerships were still evolving and this could be discussed further at the seminar on 5 October 2012;  District Partnerships were a forum for detailed discussions on issues in local communities and it was anticipated that there would only be a small number of items on each agenda. Some issues would be progressed through different routes and that was a matter for the Assessment Panel, the membership of which was set out in the guidance. Highland was the first local authority in Scotland to implement District Partnerships and a review would be carried out at an early stage; and  in relation to how issues raised at District Partnerships would be picked up at a strategic level, the Area Children's and Adult Services Managers were key and would inform the appropriate Improvement Group. It was emphasised that there was a lead Adult and Children's Services Committee Member and NHS Board Member on each District Partnership. In addition, if it was considered that a particular issue was not being addressed, it could be raised directly with the appropriate Chief Executive. It was important to have a strategic planning structure that was responsive but not excessive.

At this stage, concern was expressed that Opposition Members were being disenfranchised from the Strategic Commissioning Group and procedural advice was sought in relation to the Council's Standing Orders. Following further discussion, it was explained that the Leader of the Council would be having a series of meetings with the Leader of the Opposition and the issue of Opposition Member involvement in the Strategic Commissioning Group would be discussed.

Thereafter, the CommitteeAGREED:- i. the terms of reference for the Strategic Commissioning Group and the updated guidance for the Health and Social Care District Partnerships as set out in Appendices 1 and 2 of the report; and

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ii. that discussions take place between the Leader of the Council and the Leader of the Opposition regarding Opposition Member involvement in the Strategic Commissioning Group.

9. Additional Support Needs – Allocation Model FeumalachdanTaic a Bharrachd – ModailRiarachaidh

There had been circulated Report No ACS/33/12 dated 18 September 2012 by the Director of Education, Culture and Sport which proposed an allocation model for additional support needs (ASN) funding.

During discussion, the following comments were made:-

 whilst welcoming the model, concern was expressed that the majority of resources would be allocated to areas with the greatest population, to the detriment of remote rural areas;  the transparent, evidence-based model would provide equity for all children in Highland and identify the scale and scope of need so that services could be properly financed;  concern was expressed that the existing budget was based on the minimum level of support. For the model to work effectively, there had to be sufficient resources to cover the enhanced support which might be required in individual circumstances; and  the efforts of the cross-party working group which had overseen the review of classroom support needs were acknowledged.

In response to questions, it was explained that:-

 it was recognised that some schools would have less entitlement than they had previously and an assurance was given that the new model would be phased in over two to three school sessions;  an additional £957k was allocated to the ASN budget during the budget setting process for 2012/13. The new model was an expansion of the previous service and provided a more holistic way of addressing the needs of children. Whilst needs driven, it also took account of other issues such as deprivation and support for small rural schools;  the ASN budget had been flagged in the revenue report as a potential budget pressure and trends would be closely monitored to ensure corrective action could be taken at an early stage, if necessary; and  in relation to the Caithness Early Years and Autism Centre (CEYAC), it had become a more focused early years centre with Support for Learning Teachers and Pupil Support Assistants providing outreach and additional support for children with autism in their Associated School Groups or smaller clusters of primary schools. In addition, the central Autism Outreach Service had been enhanced. Discussions had taken place with practitioners to assure them it was not a reduction in service but rather a change in the way the service was delivered.

During further discussion in relation to CEYAC, it was highlighted that issues were being addressed by officers and positive feedback had been received from the families affected. The Chairman suggested that it would be helpful to explore the

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matter further to ensure that everyone was receiving the same information and that a meeting take place between himself, Local Members and the Head of Education.

Thereafter, the Committee:-

i. NOTED the significant progress made thus far to modernise support within the classroom; ii. AGREED the implementation of the proposed budget allocation model as a transparent means of equitably allocating the ASN budget across the four Council areas and providing a guide to the level of support required to meet identified need at varying levels across schools in Highland; and iii.AGREED that a meeting be arranged between the Chair of the Adult and Children’s Services Committee, Local Members and the Head of Education to discuss the issues surrounding the Caithness Early Years and Autism Centre.

10. Update on Highland Alcohol and Drugs Partnership Cunntas as Ùr mu Chom-pàirteachasDeoch-làidir is DhrogaicheannaGàidhealtachd

There had been circulated Report No ACS/34/12 dated 18 September 2012 by the Director of Health and Social Care which presented the Highland Alcohol and Drugs Partnership Annual Report and informed Members about progress towards a single substance misuse service for adults.

During discussion, Members welcomed the report, particularly the emphasis on working in partnership with other organisations.

In response to a question, it was explained that the next meeting of the Safer Highland Leadership Group would be considering political representation. In addition, a Seminar on For Highland's Children 4 would take place later in the year at which Members would have access to various strategic planning groups, including in relation to alcohol and drugs issues.

Thereafter, the Committee:-

i. NOTED the work of the Highland Alcohol and Drugs Partnership; and ii. AGREED to endorse the work towards a single substance misuse service for adults.

12. Curriculum for Excellence – 3 Year Strategic Plan CurraicealamairsonSàr-mhathais – Plana Ro-innleachdail 3 Bliadhna

There had been circulated Report No ACS/36/12 dated 17 September 2012 by the Director of Education, Culture and Sport which provided an update on progress in implementing a Highland Curriculum for Excellence Strategic Plan.

During discussion, Members welcomed the report, particularly the new arrangements in relation to School Improvement Plans and the emphasis on self-evaluation. With regard to bringing together Curriculum for Excellence and the new school inspection model, reference was made to the parallel inspection which took place in the local community when a secondary school was inspected and it was suggested that

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consideration be given to how to bridge the gap between schools and other local organisations.

In response to questions, it was explained that:-

 the Health and Wellbeing Strategy framework would include links with HEAT (Health Improvement, Efficiency, Access and Treatment) performance targets; and  in relation to guidance on self-evaluation, seminars had taken place recently which emphasised the links between Education Scotland and local authorities and Mr A Brown, Area Lead Officer had provided information for Head Teachers on self- evaluation. Self-evaluation was one of the key priorities in the new Service Plan and was linked to the Council's Programme in terms of ensuring that Head Teachers and staff were fully equipped to deliver the new curriculum.

Thereafter, the Committee:-

i. NOTED the progress made in developing a Highland Curriculum for Excellence Strategic Plan and associated strategic advice papers; and ii. AGREED to endorse the approach of providing strategic direction coupled with advice papers built on existing good practice in Highland.

13. The Highland Council PE Plan 2012-2014 Plana EòlaisChorporraChomhairlenaGàidhealtachd 2012-14

Declarations of Interest:

Ms G Ross declared a non-financial interest in this item as her husband was a PE Teacher but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that her interest did not preclude her involvement in the discussion.

Ms J Douglas declared a non-financial interest in this item as her husband was a junior shinty coach but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that her interest did not preclude her involvement in the discussion.

There had been circulated Report No ACS/37/12 dated 14 September 2012 by the Director of Education, Culture and Sport which provided an update on progress in developing a plan for delivering two hours of PE per week in both primary and secondary schools.

During discussion, the following comments were made:-

 physical activity was not confined to participation in team sports and included things such as walking and dancing;  private schools recognised the importance of PE and local authorities should aspire to provide the same level of activities;  it was important to capture the enthusiasm generated by the London 2012 Olympics to promote physical activity;  there were significant economic development opportunities around sports, particularly traditional sports and Highland Games; 19 162

 the importance of physical activity to the health and wellbeing of young people with additional support needs was emphasised; and  one person who was enthusiastic and focused on a particular sport could inspire a whole school.

In response to questions, it was explained that:-

 in relation to targeting hard to reach groups such as teenage girls, part of the PE Plan was to examine all types of PE provision including, for example, dance. However, participation had to be by choice as making activities compulsory could have a negative effect;  anecdotal evidence was that whilst some children enjoyed taking part in PE at school they did not necessarily have the confidence to join a sports club after they left school. It was therefore essential to establish strong links between schools and local clubs so that there was a natural progression;  the views of young people would be sought through, for example, consultation with Highland Children's Forum, Highland Youth Voice and pupil councils;  with regard to the range of sports being provided in Highland schools and how specialisms could be shared, there was an informal network of PE teachers whereby, if an activity was particularly successful, it could be rolled out in other schools. Part of the PE Plan was to research what was effective in terms of physical activity and PE provision for 3 to 18 year olds and consideration was being given to how the model developed by Portree Primary School, which had won a national award for excellence in sporting provision, could be rolled out throughout Highland; and  a number of schools had annual Highland Games and some aspects of Highland Games were included in most schools' PE programmes. However, the provision of traditional Highland sports could be incorporated within the PE Plan.

Thereafter, the CommitteeAGREED:-

i. to endorse the Highland PE Plan; ii. that an interim report be presented to Committee in September 2013; and iii. that the provision of traditional Highland sports be incorporated within the PE Plan.

14. School Handbook Review Ath-bhreithneachadh air LeabhranSgoile

There had been circulated Report No ACS/38/12 dated 17 September 2012 by the Director of Education, Culture and Sport which summarised new requirements for school handbooks and sought endorsement for an implementation approach for Highland schools.

During discussion, Members suggested that information on the availability of health services and support for children with health problems be incorporated in the school handbooks.

In response to questions, it was explained that:-

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 in relation to parents’ surgeries, Invergordon Academy had implemented telephone drop-in sessions with the Head Teacher, complemented by face-to-face sessions between 5.00 pm and 7.00 pm on given nights during the week. Feedback from parents had been very positive in that they appreciated the opportunity to engage direct with the Head Teacher and discuss issues informally. This approach was replicated in other primary and secondary schools throughout Highland;  the Council had developed extensive guidance on cyberbullying and the responsible use of digital technology by young people and it was confirmed that electronic links to the relevant policy documents could be incorporated in school handbooks.

Thereafter, the Committee AGREED:-

i. the draft aide memoire for school handbooks in Highland; ii. to endorse the approach of “working towards” the content changes and deadline in the current session with full implementation in session 2013-2014; and iii. that school handbooks should also include:-  information on the availability of health services and support for children with health problems; and  electronic links to policy/guidance documents in relation to cyberbullying and the responsible use of digital technology by young people.

15. Consultation Response on Children and Young People Bill Freagairt Cho-chomhairle mu BhilenaCloinneagus nan DaoineÒga

Declaration of Interest:

Mrs G McCreath declared a financial interest in this item as a foster carer and advised that if there was any specific discussion in relation to fostering she would leave the room.

There had been circulated Report No ACS/39/12 dated 17 September 2012 by the Director of Health and Social Care which proposed a response to the Scottish Government’s consultation on the proposed Children & Young People Bill (the Bill)

The Director explained that, as the deadline was 25 September 2012, the response had been submitted but it could be amended on the basis of Members’ comments. It was also highlighted that, since the report had been written, an addition had been made to the response which proposed that the Named Person role referred to at Q19 should begin with the midwife pre-birth, not at birth as stated in the consultation paper.

During discussion, the following comments were made:-

 the clear, robust response was welcomed;  one in four young people in Scotland was unemployed and greater emphasis should be placed in the Bill on the transition into work;  in relation to the duties to be placed on public sector bodies, this should include third and private sector partners including Job Centre Plus and Skills Development Scotland;  many of the priorities in the Bill were reflected in the Council’s programme;

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 whilst more work needed to be done to get young people into work, the Scottish Government’s Opportunities For All agenda guaranteed every young person in Scotland a place in further or higher education or an apprenticeship and youth unemployment was bucking UK trends; and  the Council, through support for the role of the Youth Convener, Highland Youth Voice and the Scottish Youth Parliament, had demonstrated its commitment to the ethos of the Bill.

Thereafter, the CommitteeAGREED the proposed response to the Scottish Government consultation on the Children & Young People Bill subject to the proposed amendment by the Director in relation to the Named Person and the comments made during discussion regarding the duties of public/private sector partners including Job Centre Plus and Skills Development Scotland being passed on.

16. Minutes Geàrr-chunntas

In relation to the Education Transport Entitlement Review Sub-Committee, Members emphasised the importance of considering the safety of the child as well as the nature of the route in question. In addition, concern was expressed that a DVD shown at the Sub-Committee had been filmed in good weather and was not representative of the usual conditions.

With regard to the Duncraig Trust Scheme Sub-Committee, the proposed review of the criteria against applications were assessed was welcomed as was the mounting of a plaque in the new extension to Plockton High School to commemorate the bequest by the Hamilton family.

The Committee NOTED, and APPROVED where necessary, the following Minutes of Meetings:-

i. Education Transport Entitlement Review Sub-Committee of 27 August 2012; and ii. Duncraig Trust Scheme Sub-Committee of 30 August 2012.

The meeting concluded at 3.00 pm.

22 165 Highland NHS Board 4 December 2012 Item 4.2

DEVELOPING A FRAMEWORK FOR USE OF SOCIAL MEDIA IN NHS HIGHLAND

Report by Maimie Thompson, Head of Public Relations and Engagement on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Note the context and back-ground for the use of social media by NHS Highland as part of wider communications and engagement strategy.  Be aware of the benefits, risks and considerations.  Endorse the recommendation to explore the principle of opening up social media in the work place, initially through controlled access.

1 Executive Summary

1.1 Social media describes online technologies, tools and practices that are used to share opinions, information, promote discussion and build relationships. The most well known include Twitter, Facebook, Blogs and YouTube.

1.2 The rise of social media has the potential to significantly change the way NHS conducts elements of its communications. Millions of people use social media every day and it is becoming an increasingly important communication tool.

1.3 To be effective, however, social media must form part of a wider communications and engagement strategy. NHS Highland has been using Twitter and Facebook for some time but there are now a growing number of requests from staff to participate. Recent tests of change using twitter have proved to be effective.

1.4 There are, however, some risks to increasing use of social media which can be split into four categories: Public Relations, HR, Governance and Technical.

1.4.1 Public relations – damage to reputation through failure to participate in a professional manner and not adhering to good practice guidelines 1.4.2 HR – inappropriate use of staff time in the work place or abuse of staff, or NHS Highland 1.4.3 Governance - potential to cut across complaints and feed-back systems which if not understood and managed could undermine elements of existing processes 1.4.4 Technical – significant increase in use of some social media could have an adverse impact on the data network.

1.5 NHS Highland will not make its self immune from potential PR, HR or Governance risks by choosing not to use social media or block its use in the work place. While a range of counter measures exist for these categories, however, there is an outstanding issue on the technical side still to be considered and resolved.

Recommendation Some of the risks of opening up access to social media are unclear and some further work is required specifically around impacts on the data network. In general, however, it is recommended that NHS Highland should move to having more open access in the work place, initially through controlled access, managed by an application process. 166

2 Background and National Context

2.1 A paper was presented to the Board of NHS Highland in June 2012 which set out a high level work programme for communications and engagement. One of the areas identified was to develop a strategy for the greater use of Social Media.

2.2 Social media is a term used to refer to online technologies and practices which promote discussion, share opinions and information. It involves a combination of technology, telecommunications and personal interaction.

2.3 The growth of mobile application (though phones etc) is allowing far greater access to social media, and with increasing ease, speed and at the point of need. Its popularity in both a professional and personal capacity is growing, including in the NHS.

2.4 NHS Scotland set up a Social Media Network Group who published a best practice Tool Kit in February 2012.

2.5 The work of that Group was based on some research: “Harnessing online social networking within NHS Scotland: How does social media support eHealth strategic aims”, and (ii) what are the security risks and how can they be mitigated.

2.6 These papers set out a framework and recommendations for prioritising initial use. Low risk priorities recommended included using social media tools to promote: a) news and announcements, b) professional networking, c) public education health campaigns, d) understanding and monitoring public opinion and e) business continuity communications.

2.7 NHS Highland is in the process of developing a local Tool Kit which draws heavily on the guidance provided by NHS Scotland. This is being produced in collaboration with HR, Staff-side, E-Health and NHS Scotland Social Media Group.

2.8 Prior to finalising the Tool-Kit a strategic decision is required regarding to what extent to open up social media channels for use by NHS Highland in the work place. And whether to have blanket open access or controlled access.

2.9 This paper summarises some of the key issues, principles and context to stimulate this discussion and help inform a decision and some next steps.

3 Introduction

3.1 Most NHS Boards in Scotland are using social media to some extent. In most cases information posted on-line is immediately in the public domain. This means comments are permanently available and can be instantly and rapidly be republished at the press of a button.

3.2 This can be picked up by traditional broadcast and print media and in doing so attract wider interest. This carries both benefits and risks.

3.3 The full potential of on-line social networking has yet to be fully exploited by public health organisation for many reasons, including:

 concerns over lack of control,  risk to reputation,  breaches of confidentiality  volume of use and impact on existing services –related to availability of bandwidth

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4 NHS Highland context

4.1 NHS Highland has been using social media: Twitter (www.twitter.com/nhshighland), Harm Reduction www.twitter.com/NHS_HRM_REDUCT and Learning Disabilities - www.twitter.com/LDHighland, Facebook (www.facebook.com/nhshighland), Harm Reduction - http://www.facebook.com/?sk=welcome#!/harmreduction.nhshighland?fref=ts; Performance Enhancement (steroids) http://www.facebook.com/?sk=welcome#!/nhshighland.piedspage?fref=ts and Patient Opinion (www.patientopinion.org.uk) for some time.

4.2 The most popular NHS Highland Social media account is Twitter which currently has 1,500 followers.

4.3 There have been a growing number of requests from NHS Highland staff to set up Twitter and Facebook accounts for work. These requests have tended to come into the eHealth Department but there has been no clear process, rationale or criteria to decide whether to provide access or not.

4.4 More recently some small tests of change have been used to pilot increased corporate use of twitter. This has included the establishment of a corporate brand for twitter through the label @nhsh. This was piloted by the Chief Executive (www.twitter.com/nhshem) and Head of Public Relations and Engagement (www.twitter.com/nhshmt) and has been ongoing since June 2012.

4.5 This has further highlighted the need to brand corporate use and also some standardisation of statements about how accounts will be used. It is recommended that the following will be used for official NHS Highland users:

This is a formal NHS Highland account. For specific health queries contact your GP or NHS24. If your communication or feed-back is of an official nature, please use our standard communication channels –www.nhshighland.scot.nhs.uk. This account is not monitored 24/7

4.6 Setting up series on twitter “Who We Are” on 25 June 2012 has been well received and brought about a doubling of followers to our corporate twitter account. It was also linked to one formal complaint. The investigation into this brought about some learning and a number of changes were introduced, including setting up a dedicated account (www.twitter.com/NHSHWhoWeAre)

4.7 Although there has been no survey of staff about how they use, or wish to use, social media, it is known that more are using it in a personal capacity and in doing so refer to their position within NHS Highland.

4.8 The eHealth department also receives many requests to allow access to web streaming sites (u-tube). As part of granting access, users are made aware that this does not guarantee that the web streaming session will work. Successful web streaming is dependent on a number of factors including:

 The time of day  Where the web streaming is being hosted from  The speed of the PC where the web streaming is being viewed.  Availability of audio speakers (Some PC’s may not have speakers attached)

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4.9 For example a web streaming session hosted external to the NHS network in the afternoon may be problematic. Staff are, therefore, advised that once access is granted they should carry out tests to ensure themselves that the web streaming performs adequately.

4.10 It is recognised to more confidently embrace social media as part of NHS Highland’s wider corporate communications and engagement strategy, there needs to be appropriate guidelines and protocols in place as well as an understanding of links with existing policies and procedures.

4.11 Moreover any opening of access will need to take into account the impact that any increase in volume of activity may have on the provision of essential services. Further analysis is required to assess proportionate impact of different elements, for instance twitter versus web streaming.

5 Assumptions

5.1 NHS Highland wants to strengthen its strategic use of social media but not at the expense of impacting on essential services.

5.2 The use of social media per se does not make for effective communications or engagement. It must, therefore form part of an overall communications and engagement strategy.

5.3 Any benefits or risks to public relations will be more easily managed if part of an overall strategy, rather than the alternative - individuals pressing on in isolation without support or part of a plan.

6 Scope

6.1 The initial focus will be to support staff to consider appropriate use of social media around five key areas: a) news, announcements and raising profile, b) professional networking, c) public education health campaigns, d) business continuity.

6.2 Guidance will apply to all NHS Highland employees regardless of grade, length of service or working pattern/hours, and to trainees employed by NHS Highland. It will also apply to contracted staff or anyone else acting on behalf of NHS Highland. 6.3 It will include applications for mobile access and cover business and personal use. This means anyone who identifies their association with NHS Highland while on-line. This may be through displaying an @nhs.net e-mail address or identifying the organisation itself.

6.4 The guidance will not be intended to cover all circumstances or types of external social media but the principles, opportunities and approach to managing risks will apply equally to all forms and use of social media. Initial focus will be on our use of twitter, blogs and web streaming.

6.5 There is potential to use the web for patient transactions such as health appointment bookings, data checking, e-prescriptions. This is out-with the scope of any guidance at this stage.

6.6 Similarly there is potential for social media to support internal communications. This will also not part of this guidance but it is recognised that these strands would benefit from being pulled together under one strategy.

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7 Guiding principles of on-line participation

7.1 As part of NHS Scotland’s Social Media best practice Tool Kit they identified a number of basic principles of on-line participation. These will form the basis of the principles to be adopted by NHS Highland. The criteria are mutually reinforcing (Appendix 1).

7.2 These principles will underpin the corporate development and implementation of social media methods and tools across NHS Highland Board area. They will also provide a framework for the participation of individual employees for personal use.

7.3 Employees using social media for personal or business uses should also seek out any guidance from their own professional bodies and make sure they are familiar with it and adhere to any guidance. Non-adherence might affect registration and/or professional standing.

7.4 In addition there is no shortage of guidance, training and media coverage about use of social media.

8 Overview of potential benefits, concerns and considerations

8.1 Effective use of social media can help us to understand better, respond to and attract the attention of specific audiences.

8.2 It facilitates more real-time conversations as well as dissemination of information and opinions to people already actively engaging.

8.3 But it is not always the most appropriate option. And there are also some potential pitfalls and limitations.

8.4 Taking these points together the use of social media needs to be looked at along side the overall communications strategies, e-health, HR to identify the business need, opportunities, risks and constraints.

8.5 In terms of identifying the appropriate official use of social media channels the types of issues to be considered will include:

8.5.1 Does on-line social media offer something which existing communication channels can’t? Such as wider reach, quicker, more convenient?

8.5.2 Does the staff member have full support of management for official online participation;

8.5.3 Can it be managed in such a way so as to not conflict with other corporate messages or procedures?

8.5.4 What resources are in place to generate or monitor content?

8.6 There is the potential to cut across other systems (eg complaints and feed-back) which if not managed appropriately will undermine elements of governance / process.

8.7 Currently NHS Highland blocks access to some or all social media sites. If staff are to be encouraged to make greater use, having more open access would be desirable.

8.8 But this needs to be balanced with the risk of increased activity having an impact on smooth running of existing services. For instance access to eHealth systems from out with the Inverness area is considerably slower than from within Inverness area. This is

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due to the combination of lower network connections and also the need to transfer large Radiology images from rural general hospitals.

8.9 Opening up access, therefore is a key issue for consideration and potentially influences how other elements are handled. Having a clear decision on the way forward will inform how some next steps are handled.

9 Risk Assessment and Counter Measures

Public Relations and HR

9.1 Including within the NHS Scotland Social Media best practice Tool Kit was a detailed risk matrix. This has been completed for NHS Highland.

9.2 While the risks are not new the scale or impact has the potential to be bigger / quicker and therefore are elements which pose a higher risk.

9.3 There are now a number of cases in which NHS Scotland employees have been dismissed for inappropriate use of a social website or other media.

9.4 Most of the risks, however, can be addressed by implementing sensible and proportionate counter measures. These broadly fall into three categories:

9.5 (i) Governance, (ii) Guidance (iii) Education/Awareness – and can be covered under existing policies and procedures including professional guidance.

9.6 But some additional specific guidance and protocols to support awareness and understanding is being prepared.

9.7 Even is NHS Highland decided not to use Social Media it would not avoid risks due to growing proportion of staff participating.

Technical

9.8 The specific issue of opening up access is currently unknown, but depending on the volume of traffic could have an impact on the data network. Should this turn out to be problematical the options to mitigate risk would include: (i) stopping open access, or (ii) increase the bandwidth which would have significant recurring cost implications.

10 Governance Implications

10.1 Staff Governance

10.1.1 Having guidance in place together with appropriate education will safeguard individual staff as well as the organisation. Existing HR and Complaints policies exist to handle any potential misuse.

10.2 Patient Focus and Public Involvement

10.2.1 Social media, as part of wider communications and engagement strategy will support further ways to promote and facilitate involvement.

10.2.2 Recently a public member was recruited to support redesign of internet through responding to twitter.

10.2.3 Blog sites have been established to facilitate exchange of views around some of the

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key issues relating to different areas such Islay, Badenoch and Strathspey, Lawson Memorial Hospital site improvements. These are being hosted through NHS Highland website but are at an early stage of development.

10.3 Clinical Governance

10.3.1 There is the potential to cut across other systems (eg complaints and feed-back) which if not managed appropriately will undermine elements of governance/process. Safeguards are place to manage these scenarios. These were developed on the back of NHS Highland using Patient Opinion and increasing enquiries coming in via the website.

10.4 Financial Impact

10.4.1 A financial impact assessment has yet to be carried out. In terms of communications and engagement, if well managed, it could be a very cost effective way of increasing awareness and networks.

10.4.2 Any impacts on the increased use of the network would have recurring financial implications if the decision was to increase bandwidth.

10.5 Planning for Fairness

10.5.1 This specific report does not require a planning for fairness assessment. However, impact assessment is already underway to support key work streams, including the development of the new website.

10.6 Communications and Engagement

10.6.1 Developing guidance to implement social media has already been identified by the Board as one element of NHS Highland’s communications and engagement strategy. This paper supports this work.

Elaine Mead Maimie Thompson Chief Executive Head of Public Relations and Engagement

23 November 2012

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Appendix 1 Basic principles of on-line participation

Criteria Supporting Statement Accountable:  Online participation is a multi-stakeholder process where everyone is accountable for their own actions. Alert:  Use of social media should not confuse or compromise existing mechanisms in place to deal with, for instance, complaints. This is not the forum to deal with individual issues or queries. Appropriate channels should always be used Aware:  Remember: Participation online results in your comments being permanently available and open to being republished in other media. You may attract media interest in you as an individual, so proceed with care. Careful:  Whether you are participating in a professional or a personal capacity pause and think before posting. If you would not say something (content or in a tone of voice) at a meeting or in a paper or other ‘public situation’, don't say it on a social media platform of any kind. If in doubt don’t make a posting. If you have any doubts, take advice from your line manager Clear:  Use of social media must form part of wider communication strategy – it is not a stand-alone activity. What story are you trying to tell, to whom and why? Are you clear how social media can help and benefits outstrip any possible pitfalls (Section) Collaborate:  When you gain insight share it with others where you can; Make y effort to be helpful and inclusive connecting with relevant communities etc Confidential  Under no circumstances ever breach patient, client staff confidentiality. Think very carefully to make sure you are not breaching any confidentiality. If you have any doubts, take advice from your line manager. Corporate:  As an NHS Board, we have a reputation to uphold and the public must be able to trust the integrity, confidentiality and values of the NHS Highland and its staff at all times including through personal use of social media. Creative:  New tools means new approaches Credible:  Stick to your area of expertise and be balanced Effective:  Have criteria to assess success and set up systems for monitoring. Judicious:  Stick within the law. Libel, defamation of character, copyright and data protection laws all apply. Personable:  Participating online is not about delivering staid corporate messages. It’s about conversations between individuals and should be treated that way; Professional:  You are a representative of the organisation and your own professional body. In certain networks you might be the sole voice. If you are a member of a professional body, pay particular attention to their policies: non-adherence might affect your registration and/or professional standing. Respectful:  When disagreeing with other opinions, keep it appropriate and polite. Responsible:  Be aware of and follow all relevant guidelines, Data Protection, HR Policy, Social Media Policy; Guidelines from your professional body (Section). Let you line manager know if you ….. and identify any conflicts of interest Responsive:  Visit the online spaces where you have a presence regularly and respond positively and promptly to conversations Safe and  Use your common sense. Never give out personal details like your home address sensible: or phone number. Never put your own, NHS Highland, NHS or partner agencies, reputation at stake. If you have any doubts, take advice from your line manager. Strategic:  Wherever possible, align online with offline communication. Social media should form one strand of a wider communications strategy. Transparent:  Wherever possible, disclose your position as a representative of your organisation. If you’re not using a NHSH account but talking about your work, use a disclaimer.

8 173 Highland NHS Board 4 December 2012 Item 5.2

AREA FINANCIAL POSITION AT 31 OCTOBER 2012

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the current forecast remains break-even by the end of the financial year.  Note an improvement in the forecast operational position of £5.1m from the August position, reported to the Board in October.  Note the need for further improvements within the financial position of £6.9m by the end of the year, split between; - NHS Care £4.9m - Adult Social Care £2.0m

1 INTRODUCTION

This report is based on information as at the 31 October 2012 and highlights a current forecast of break-even for the financial year. However, the underlying operational positions, including adult social care, indicate an in-year shortfall of £6.9m, an improvement of £5.1m on the position reported to the October Board.

2 FINANCIAL POSITION OVERVIEW

As previously highlighted, the position at the end of October (Month 7) continues to show a forecast of financial breakeven, recognising that this depends on the full delivery of units’ savings targets, realising an element of financial benefit from the Highland Quality Approach together with the appropriate management of emerging, in-year cost pressures.

The operational position to date is detailed in Table 1 (attached) and the management of this forecast is being addressed through a range of management actions, local and Highland- wide, to deliver the projection of financial breakeven. In addition, specific measures are being targeted at Raigmore which have previously been detailed.

At present, the current operational forecast can be broken down as follows;

Breakdown of Month7 Forecast Overspends Operational Unit N&W S&M Raigmore Tertiary Others HSCP A&B Corp. Quality Central Total Heading £m £m £m £m £m £m £m £m £m £m £m

Savings Operational Savings not yet achieved/identified (1.9) (0.1) (2.0) (0.4) (2.4) Highland Wide Quality Initiatives 0.0 (4.5) (4.5) In year non-recurrent benefits applied 0.0 4.7 4.7 Pressures Adult Social Care (0.9) (2.6) 1.5 (2.0) (2.0) In-year cost pressures (0.5) (0.6) (1.5) (1.2) (0.6) (4.4) (0.1) (4.5) Offsetting underspends/benefits 0.6 0.6 1.2 0.4 0.2 1.8 Forecast Position (1.4) (2.6) (3.4) (1.2) 1.4 (7.2) 0.0 0.1 (4.5) 4.7 (6.9)

Previous Board Report (Mth 5) (1.8) (2.0) (3.9) (1.2) 1.0 (7.9) 0.0 0.0 (4.5) 0.4 (12.0)

Change 0.4 (0.6) 0.5 0.0 0.4 0.7 0.0 0.1 0.0 4.3 5.1 174

Financial tables are attached as follows;

 Table 1 presents the overall income and expenditure position, inclusive of adult social care funding transferred in from Highland Council and excluding funding transferred out to Highland Council relating to children’s services. The funding figures differ from the amounts in the Partnership Agreement primarily due to the fact that the position relating to overheads and baseline quantum are not yet fully resolved.

 Table 2 provides more detail on the overall expenditure position. The budgets for South & Mid Highland and North & West Highland operational units are now integrated budgets inclusive of adult social care relating to their areas.

 Table 3 shows the same information but excluding Adult Social Care.

 Table 4 shows the total position on adult social care alone. It should be recognised that the position shown in Table 4 needs to be treated with caution. The overall forecast is based on the Council’s system and with intelligence from former Council employees.

 Table 5 summarises the position against savings. This highlights the fact that there is still significant work required to identify sufficient savings to deliver the financial plan.

 Table 6 summarises the position with regards capital expenditure.

3 COST PRESSURES AND OPERATIONAL PERFORMANCE

The £5.1m improvement is extremely positive in terms of moving towards break-even however the vast majority of this has come from fortuitous non-recurrent savings rather than planned savings initiatives. The main components of this are;

 Reduction in Raigmore position £0.5m  Other operational reductions £0.2m  Generic Price Reductions £1.0m  Non-recurrent/allocation slippage £2.6m  CNORIS premium reduction £0.8m

The CNORIS premium reduction relates to the national risk-share for clinical negligence and other risks – the benefit relates to a lower overall national spend than previously expected. The generic price reductions relate to drugs coming off patent. This is the only benefit set out above that is fully recurring. The vast majority of the above are non-recurrent benefits which do not improve the underlying reliance on non-recurrent resources.

The main issues which make up the bulk of the forecasted operational position remain the same as reported to previous Board meetings:

 Raigmore position £3.4m  Tertiary (out of area) expenditure £1.2m  Adult Social Care £2.0m  System savings unidentified £4.5m  In year benefits per above (£4.7m)

Specific issues within operational units are as follows (this excludes Adult Social Care, which is described separately):

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3.1 Argyll & Bute CHP – Breakeven A&B is currently forecasting a breakeven position although the CHP has still to fully identify around £0.4m of savings which is being offset by underpends in other areas. However, the Management team are confident that break-even can be achieved and are working to identify areas for recurrent savings to reduce the underlying deficit.

3.2 North and West Unit – £0.5m NHS Overspend The unit is expecting to meet its savings target, but is reporting financial pressures in medical vacancies, prescribing and the cost of supporting vacant GP practices which are being managed. In addition, specific cost pressures due to the laboratory service contract and Out of Hours in the West are proving difficult to manage.

3.3 South and Mid Unit – NHS Break-even S&M continue to project a small underspend of £50,000.

3.4 Raigmore Hospital – £3.4m Overspend The Raigmore Programme Board has been formed and will continue to oversee measures to further improve the position with the ultimate objective of returning to financial balance within an agreed timescale.

Currently, the Programme Board has set the Raigmore Management team an initial target of identifying a £1m improvement in the Raigmore forecast, to be identified by the end of the calendar year and as a result, the Raigmore position has improved by £0.5m since the Month 5 report, primarily due of a more robust review of budgets, costs and vacancies.

Raigmore’s overall improvement was £1.2m however this is reduced by a risk assessment of existing savings schemes which are highly unlikely to realise benefits in the current year. In addition, this improvement also takes account of a number of extraordinary requirements for Consultant locum cover which was identified in month 7.

3.5 Tertiary – £1.2m Overspend The vast majority of the current estimated overspend relates to an increasing number of expensive forensic psychiatry placements which is currently estimates at a total cost of between £1.2m and £1.7m depending on potential length of stay.

In addition to this, a provision has been made for three potential expensive cardiology treatments (TAVI) totalling £100k.

3.6 Facilities – £0.1m Overspend The Facilities overspend is estimated at £0.1m and relates mainly to utility costs at Raigmore, where energy overspends are the subject of ongoing investigation. The proposed biomass installation (approved in principle at the previous Board meeting) will eventually make a significant impact on this.

3.7 Highland Quality Approach; System-wide initiatives The financial plan for 2012/13 includes a northern Highland-wide target totalling £4.5m (full year effect £9m). As requested and agreed by the Directors of Operations, the work of the financial benefits realisation will now be included in a meeting chaired by the Chief Operating Officer – this recognises the need to connect this work with operational matters and to rationalise the number of meetings. No significant financial benefits are expected to be realised directly and explicitly against this heading within the current year. However, it must be emphasised that this does not mean there are no efficiencies flowing from the Highland Quality Approach – but these efficiencies are currently being scored against individual units’ savings’ targets rather than against the system-wide target.

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3.8 Adult Social Care At the time of writing this report, the forecast overspend on Adult Social Care remains at £2m based on October figures. There is no change in this forecast from those previously reported to the Board. The Board continues to work very closely with Highland Council to find a resolution to this issue – both organisations remain absolutely committed to achieving a break-even outturn. It is anticipated that a way forward will have been agreed by the time the Board meets to consider this report

4 Capital

The Board will be aware that the Asset Management Group has been re-constituted as a formal committee of the Board with a non-executive chair. The AMG has detailed oversight of the capital plan on behalf of the Board. The key changes since the previous report are further slippage on the Oban dental scheme (funding to be transferred into 2013/14 as agreed with the Scottish Government), removal of the potential subordinated hubco debt associated with the Tain development (if financial close is reached this financial year the sub- debt will be covered by the Scottish Government), removal of Resource and expenditure relating to items that are now chargeable to revenue following changes in accounting regulations and the inclusion of expected Resource and expenditure relating to the Raigmore biomass proposal.

5 Conclusion

The improvement with the month 7 forecast position is very positive albeit mainly the result of fortuitous or non-recurrent items. It is likely that some further non-recurrent resources will be available during the remainder of the year to offset the position further.

In addition, work is currently ongoing on a second phase of fixed asset accounting changes around asset lives as well as accurately identifying any further benefits as a result of impact of the off patent drug price reduction and a reasonable estimate of all of those items could be as much as £3.5m however, there needs to be a concerted effort to deliver further improvements at operational level in order to deliver a beak-even position. At the same time, it must be recognised that there remains an over-reliance on non-recurrent savings and the current projection (as set out in Table 7) shows an anticipated carry forward of unmet recurring savings of £7.5m. This must be reduced over the remainder of the financial year in order to reduce the scale of the challenge for 2013/14 and also if the Board is to remain in course to eradicate its underlying deficit by the end of 2014/15.

6 Governance Implications

Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and Patient and Public Involvement.

7 Risk Assessment

Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly.

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8 Planning for Fairness

A robust system of financial control is crucial to ensuring a planned approach to savings targets – this allows time for impact assessments of key proposals impacting on any changes to services.

9 Engagement and Communication

The majority of the Board’s revenue budgets are devolved to operational units, which report into two governance committees that include staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public. The overall financial position was described in “Health Check” which was sent to every household in Highland.

Nick Kenton Director of Finance

23 November 2012

5 NHS Highland178 TABLE 1 Income & Expenditure Report as at OCTOBER 2012

Annual Plan Position to Date Forecast Outturn Prev month Initial Current Plan Actual Variance Forecast Variance from Forecast Movement Plan Plan Summary Funding & Expenditure to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

496,043 496,157 SEHD -Baseline Funding 273,614 273,614 0 496,157 0 0 0 0 7,962 - Recurring Supplemental Allocations 4,645 4,645 0 7,962 0 0 0 0 (13,791) - Non Recurring Supplemental Allocations (8,045) (8,045) 0 (13,791) 0 0 0 496,043 490,329 Sub total - SGHD Core RRL 270,214 270,214 0 490,329 0 0 0

0 23,687 - Non Core Funding 13,817 13,817 0 23,687 0 0 0

496,043 514,016 SGHD Funding as at July 2012 284,031 284,031 0 514,016 0 0 0

38,543 39,411 - FHS Non Discretionary 22,990 22,990 0 39,411 0 0 0 55,697 55,697 - FHS GMS Allocation 32,490 32,490 0 55,697 0 0 0 10,048 2,743 - Recurring Pending allocations 1,600 1,600 0 2,743 0 0 0 6,783 2,551 - Non Recurring Pending allocations 1,488 1,488 0 2,551 0 0 0

607,114 614,417 TOTAL SGHD Funding 342,599 342,599 0 614,417 0 0 0

84,890 84,197 Add- Adult Social Care Funding 58,778 58,778 0 84,197 0 0 0 (3,420) (7,429) Less - Childrens services 0 (7,429) 0 0 0

688,583 691,185Funding 401,377 401,377 0 614,417 0 0 0

Health & Social Care Partnership

118,123 117,457 North & West Operational Unit 67,125 68,565 (1,440) 118,811 (1,353) (1,790) 437 163,221 164,829 South & Mid Operational Unit 95,971 98,310 (2,339) 167,439 (2,612) (1,954) (658) 4,368 3,823 Adult Social Care - Central 9,018 7,421 1,598 2,328 1,495 1,226 269 131,330 133,517 Raigmore 76,864 79,187 (2,323) 136,924 (3,408) (3,900) 492 19,768 19,545 Facilities 11,281 11,334 (53) 19,685 (140) (242) 102 4,801 4,929 Integrated Pharmacy 2,876 2,878 (2) 4,966 (37) (28) (9) 4,433 6,781 e health 3,882 3,874 8 6,781 0 0 0 16,995 17,428 Tertiary 10,166 11,137 (970) 18,628 (1,200) (1,200) 0 15,854 14,272 Other HCP 8,351 8,349 2 14,253 19 (16) 35

478,893 482,582 TOTAL H&SCP 285,534 291,054 (5,522) 489,815 (7,236) (7,904) 668

172,888 176,704 Argyll & Bute CHP 100,472 100,431 41 176,704 0 0 0

Cental Services 16,297 17,857 Corporate Services 9,655 9,515 140 17,736 121 (3) 124 20,505 18,543 Central Costs & Reserves 5,717 3,379 2,340 13,847 4,696 410 4,286 (4,500) (4,500) Quality Agenda Savings 0 0 0 0 (4,500) (4,500) 0

688,583 691,185TotalExpenditure 401,377 404,379 (3,002) 698,102 (6,919) (11,997) 5,078

Manangement Planned Actions 0 (6,919) 6,919 (11,997) 5,078

0 0Surplus/DeficitMth7 0 3,002 (3,002) 691,183 0 0 0

Finance - Monitoring 5.2 Area Finance Report to 31 10 12-APPs.xlsx Total Summary 23/11/2012 09:55 Income & Expenditure Report as at OCTOBER179 2012 Table 2 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Summary Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Health & Social Care Partnership to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 34,037 34,248 North Area - Caithness District 19,865 20,223 (357) 34,108 140 91 49 18,082 18,966 - Sutherland District 11,006 11,089 (83) 18,923 43 (197) 240 23,824 22,651 West Area - S,L, & WR District 13,499 14,362 (863) 23,224 (573) (1,192) 619 30,189 30,159 - Lochaber District 17,725 18,054 (329) 31,411 (1,252) (691) (561) 10,297 9,590 North & West Area Mgt 3,984 3,620 364 9,222 368 255 113 116,429 115,613 N & W Sub Total 66,079 67,348 (1,269) 116,888 (1,274) (1,734) 460 1,127 1,149 Sexual Health Services 652 712 (60) 1,200 (51) (25) (26) 568 695 Highland Hub 394 505 (111) 723 (28) (31) 3 1,695 1,844 N & W Hosted Services 1,046 1,217 (171) 1,923 (79) (56) (23) 118,123 117,457 Total North & West 67,125 68,565 (1,440) 118,811 (1,353) (1,790) 437

South & Mid Operational Unit 24,814 24,551 South Area - Inverness West District 14,301 15,306 (1,004) 25,652 (1,101) (768) (333) 30,153 30,448 - Inverness East District 17,775 18,790 (1,015) 31,213 (765) (392) (373) 27,163 26,793 - NABS district 15,588 15,360 228 26,525 268 312 (44) 16,485 16,445 Mid Area - Easter Ross District 9,621 9,971 (350) 17,407 (962) (996) 34 19,596 19,712 - Mid Ross District 11,380 12,692 (1,312) 20,380 (668) (938) 270 711 South & Mid Midwifery Services 414 449 (34) 763 (52) (52) 5,805 6,472 South & Mid Unit Central 3,818 2,867 951 6,043 429 698 (269) 124,016 125,134 S & M Sub Total 72,897 75,434 (2,537) 127,983 (2,851) (2,084) (767) 18,129 18,174 Adult Mental Health 10,420 10,340 80 18,148 26 11 15 1,248 1,217 Learning Disabilities 710 664 46 1,184 33 32 1 1,496 1,611 Substance Misuse 873 832 40 1,500 111 74 37 18,332 18,693 Dental Services 11,071 11,039 31 18,624 69 13 56 39,205 39,695 Sub Total SE CHP Hosted services 23,074 22,876 198 39,456 239 130 109 163,221 164,829 Total South & Mid 95,971 98,310 (2,339) 167,439 (2,612) (1,954) (658)

4,368 3,823 Adult Social Care - Central 9,018 7,421 1,598 2,328 1,495 1,226 269

Raigmore Operational Unit 49,399 48,680 Surgical & Anaesth. Divison 28,449 30,998 (2,548) 53,075 (4,395) (4,459) 64 73,671 71,964 Medical & Diagnostics Division 41,629 41,631 (2) 72,277 (313) (943) 630 4,367 4,184 Raigmore Hotel Services 2,378 2,507 (129) 4,445 (261) (300) 39 3,590 4,195 Patient Support Division 2,419 2,615 (195) 4,470 (275) (349) 74 302 4,493 Raigmore Central 1,989 1,437 552 2,657 1,836 2,151 (315) 131,330 133,517 Total Raigmore 76,864 79,187 (2,323) 136,924 (3,408) (3,900) 492

Other H&SCP Services 19,768 19,545 Facilities 11,281 11,334 (53) 19,685 (140) (242) 102 4,801 4,929 Integrated Pharmacy 2,876 2,878 (2) 4,966 (37) (28) (9) 4,433 6,781 e health 3,882 3,874 8 6,781 0 0 0 16,995 17,428 Tertiary 10,166 11,137 (970) 18,628 (1,200) (1,200) 0 15,854 14,272 Other HCP 8,351 8,349 2 14,253 19 (16) 35 61,851 62,955 36,556 37,572 (1,016) 64,313 (1,358) (1,486) 128

478,893 482,582 Total Health & Social Care Partnership 285,534 291,054 (5,520) 489,815 (7,236) (7,904) 668

17,739 18,393 A & B CHP- Oban, Lorn & Isles 10,645 10,793 (148) 18,786 (393) (497) 104 16,270 16,545 Mid Argyll, Kintyre & Islay 9,586 9,598 (12) 16,669 (124) (310) 186 7,392 7,774 A&B MH In-patient Services 4,316 4,331 (15) 7,774 0 0 0 12,564 12,670 Cowal & Bute 7,309 7,426 (118) 12,860 (190) (230) 40 5,211 4,938 Helensburgh & Lomond 2,821 2,759 62 4,813 125 10 115 3,383 4,847 Other clinical services 2,612 2,617 (5) 4,900 (53) (36) (17) 15,112 15,284 GMS 8,777 8,875 (98) 15,434 (150) 0 (150) 18,311 17,297 Prescribing 9,927 9,463 465 16,547 750 350 400 11,901 12,471 FHS Non Disc. Services 6,967 6,967 (0) 12,471 0 0 0 45,872 47,075 HCP - Glasgow & Clyde 27,169 27,169 0 47,075 0 0 0 3,823 3,879 HCP - Other 2,275 2,360 (85) 4,148 (269) (267) (2) 4,435 4,538 Resource Transfer 2,647 2,647 0 4,538 0 0 0 10,875 10,992 Central & Corporate 5,421 5,426 (5) 10,688 304 980 (676) 172,888 176,704 Total A&B CHP 100,472 100,431 41 176,704 0 0 0

Central Services 16,297 17,857 Corporate Services 9,655 9,515 140 17,736 121 (3) 124 25,005 18,543 Central Costs/Reserves 5,717 3,379 2,338 13,847 4,696 410 4,286 (4,500) (4,500) Quality Agenda Savings 0 0 0 (4,500) (4,500) 0

688,583 691,185 Total Net Expenditure 401,377 404,379 (3,002) 698,102 (6,919) (11,997) 5,078

Finance - Monitoring 5.2 Area Finance Report to 31 10 12-APPs.xlsx Fin Position 23/11/2012 09:55 Income & Expenditure Report as at OCTOBER180 2012 Table 3 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Summary Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Health excluding Adult Social Care to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 26,200 26,447 North Area - Caithness District 15,333 15,423 (91) 26,626 (179) (128) (51) 12,265 13,158 - Sutherland District 7,627 7,441 186 12,995 163 135 28 16,698 15,879 West Area - S,L, & WR District 9,316 9,756 (440) 16,123 (244) (415) 171 21,150 21,302 - Lochaber District 12,565 12,806 (241) 21,875 (573) (314) (259) 8,366 7,653 - West Area Mgt 2,535 2,233 303 7,260 393 261 132 84,679 84,440 N & W Sub Total 47,377 47,659 (282) 84,879 (440) (461) 21 1,127 1,149 Sexual Health Services 652 712 (60) 1,200 (51) (25) (26) 568 695 Highland Hub 394 505 (111) 723 (28) (31) 3 1,695 1,844 N & W Hosted Services 1,046 1,217 (171) 1,923 (79) (56) (23) 86,374 86,284 Total North & West 48,423 48,876 (453) 86,802 (519) (517) (2)

South & Mid Operational Unit 14,368 14,138 South Area - Inverness West District 8,244 8,321 (77) 14,255 (117) (130) 13 17,860 18,171 - Inverness East District 10,627 10,594 34 18,028 143 72 71 18,437 18,080 - NABS district 10,508 10,555 (47) 18,223 (143) (145) 2 11,338 10,772 Mid Area - Easter Ross District 6,325 6,395 (70) 10,888 (116) (107) (9) 11,807 11,920 - Mid Ross District 6,842 6,911 (69) 11,974 (54) (207) 153 711 South & Mid Midwifery Services 414 449 (34) 763 (52) (52) 1,435 2,142 South & Mid Unit Central 685 540 146 1,991 151 386 (235) 75,244 75,934 S & M Sub Total 43,647 43,766 (118) 76,122 (188) (131) (57) 18,129 18,174 Adult Mental Health 10,420 10,340 80 18,148 26 11 15 1,248 1,217 Learning Disabilities 710 664 46 1,184 33 32 1 1,496 1,611 Substance Misuse 873 832 40 1,500 111 74 37 18,332 18,693 Dental Services 11,071 11,039 31 18,624 69 13 56 39,205 39,695 Sub Total SE CHP Hosted services 23,074 22,876 197 39,456 239 130 109 114,448 115,629 Total South & Mid 66,721 66,641 79 115,578 51 (1) 52

Raigmore Operational Unit 49,399 48,680 Surgical & Anaesth. Divison 28,449 30,998 (2,548) 53,075 (4,395) (4,459) 64 73,671 71,964 Medical & Diagnostics Division 41,629 41,631 (2) 72,277 (313) (943) 630 4,367 4,184 Raigmore Hotel Services 2,378 2,507 (129) 4,445 (261) (300) 39 3,590 4,195 Patient Support Division 2,419 2,615 (195) 4,470 (275) (349) 74 302 4,493 Raigmore Central 1,989 1,437 552 2,657 1,836 2,151 (315) 131,330 133,517 Total Raigmore 76,864 79,187 (2,323) 136,924 (3,408) (3,900) 492

Other H&SCP Services 19,768 19,545 Facilities 11,281 11,334 (53) 19,685 (140) (242) 102 4,801 4,929 Integrated Pharmacy 2,876 2,878 (2) 4,966 (37) (28) (9) 4,433 6,781 e health 3,882 3,874 8 6,781 0 0 0 16,995 17,428 Tertiary 10,166 11,137 (970) 18,628 (1,200) (1,200) 0 15,854 14,272 Other HCP 8,351 8,349 2 14,253 19 (16) 35 61,851 62,955 36,556 37,572 (1,016) 64,313 (1,358) (1,486) 128

394,003 398,384 Total Health & Social Care Partnership 228,563 232,276 (3,713) 403,617 (5,234) (5,904) 670

17,739 18,393 A & B CHP- Oban, Lorn & Isles 10,645 10,793 (148) 18,786 (393) (497) 104 16,270 16,545 Mid Argyll, Kintyre & Islay 9,586 9,598 (12) 16,669 (124) (310) 186 7,392 7,774 A&B MH In-patient Services 4,316 4,331 (15) 7,774 0 0 0 12,564 12,670 Cowal & Bute 7,309 7,426 (118) 12,860 (190) (230) 40 5,211 4,938 Helensburgh & Lomond 2,821 2,759 62 4,813 125 10 115 3,383 4,847 Other clinical services 2,612 2,617 (5) 4,900 (53) (36) (17) 15,112 15,284 GMS 8,777 8,875 (98) 15,434 (150) 0 (150) 18,311 17,297 Prescribing 9,927 9,463 465 16,547 750 350 400 11,901 12,471 FHS Non Disc. Services 6,967 6,967 (0) 12,471 0 0 0 45,872 47,075 HCP - Glasgow & Clyde 27,169 27,169 0 47,075 0 0 0 3,823 3,879 HCP - Other 2,275 2,360 (85) 4,148 (269) (267) (2) 4,435 4,538 Resource Transfer 2,647 2,647 0 4,538 0 0 0 10,875 10,992 Central & Corporate 5,421 5,426 (5) 10,688 304 980 (676) 172,888 176,704 Total A&B CHP 100,472 100,431 41 176,704 0 0 0

Central Services 16,297 17,857 Corporate Services 9,655 9,515 140 17,736 121 (3) 124 25,005 18,543 Central Costs/Reserves 5,716 3,379 2,337 13,847 4,696 410 4,286 (4,500) (4,500) Quality Agenda Savings 0 0 0 0 (4,500) (4,500) 0

603,693 606,988 Total Net Expenditure 344,406 345,601 (1,196) 611,904 (4,917) (9,997) 5,080

Finance - Monitoring 5.2 Area Finance Report to 31 10 12-APPs.xlsx Health 23/11/2012 09:55 Income & Expenditure Report as at OCTOBER 2012 181 Table 4 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Summary Adult Social Care to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 7,836 7,800 North Area - Caithness 4,533 4,800 (267) 7,482 318 219 99 5,818 5,808 - Sutherland District 3,378 3,647 (269) 5,928 (120) (332) 212 7,126 6,773 West Area - S,L, & WR District 4,183 4,606 (424) 7,101 (328) (777) 449 9,039 8,857 - Lochaber District 5,160 5,248 (88) 9,536 (679) (377) (302) 1,931 1,936 North & West Unit Central 1,448 1,388 61 1,962 (26) (5) (21) 31,749 31,174 Total North & West 18,702 19,690 (987) 32,009 (835) (1,272) 437

South & Mid Operational Unit 10,447 10,413 South Area - Inverness West District 6,057 6,984 (927) 11,397 (984) (638) (346) 12,293 12,277 - Inverness East District 7,147 8,196 (1,049) 13,185 (908) (465) (443) 8,726 8,714 - NABS district 5,079 4,805 275 8,302 412 457 (45) 5,148 5,674 Mid Area - Easter Ross District 3,296 3,576 (280) 6,519 (845) (889) 44 7,790 7,793 - Mid Ross District 4,538 5,780 (1,243) 8,406 (613) (731) 118 4,370 4,330 South & Mid Unit - Central 3,133 2,327 805 4,052 278 312 (34) 48,773 49,200 Total South & Mid 29,250 31,669 (2,419) 51,861 (2,660) (1,954) (706)

4,368 3,823 Adult Social Care - Central 9,018 7,421 1,598 2,328 1,495 1,226 269

84,890 84,197 Total Net Expenditure 56,970 58,780 (1,808) 86,198 (2,000) (2,000) 0

Finance - Monitoring 5.2 Area Finance Report to 31 10 12-APPs.xlsx Adult Social Care 23/11/2012 09:55 NHS Highland 182 Savings 2012/13 Position as at OCTOBER 2012 Table 5

Savings Target Position to Date Forecast to achieve In Year Next Year Rec Non Rec Achieved YTD Forecast Balance Forecast Outstanding Target Target Total Savings REC Non Rec REC Non Rec To Achieve FYE 2013/14 C/Fwd £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 H&SC Partnership

1,530 1,530 North & West Operational Unit 878 379 274 (0) 378 1,658 1,658 South & Mid Operational Unit 819 839 (0) 106 732 4,366 4,366 Adult Social Care 815 1,564 1,987 1,987 0 4,063 4,063 Raigmore 1,079 345 169 549 1,921 171 2,644 321 321 Facilities 209 28 84 0 28 123 123 Integrated Pharmacy 60 63 63 205 205 e health 96 113 (4) 109 12,266 0 12,266 Sub Total H&SC Partnership 3,956 1,703 2,091 549 3,967 2,265 3,954

2,828 2,828 Argyll & Bute CHP 2,173 248 407 44 363 3,347 3,347 Central Costs & Reserves 1,000 5,347 (3,000) 500 (1,500) 795 795 Corporate Services 568 223 4 71 157

15,889 3,347 19,236 Total Efficiency Savings 7,696 7,274 2,339 549 1,378 2,880 2,974

4,500 4,500 System Wide Quality Initiatives 4,500 4,500 0 - Harm 0 0 0-Waste 0 0 0-Variation 0 0

20,389 3,347 23,736TotalCRS 7,696 7,274 2,339 549 5,878 2,880 7,474

TRUE

Finance - Monitoring 5.2 Area Finance Report to 31 10 12-APPs.xlsx CRS 23/11/2012 09:55 183 Capital Income & Expenditure Report Month 7 - 31st October 2012 Table 6

Annual Plan Position to Date Forecast Outturn Original Plan to Actual to Variance Forecast Variance from Plan Current Plan Summary Funding & Expenditure Date Date to Date Outturn Current Plan £000's £000's £000 £000 £000 £000 £000

FUNDING 5,421 5,435 NHS Highland Capital Allocation (Formula) 3,161 3,161 0 5,435 0 265 265 Radiotherapy replacement 155 155 0 265 0 1,200 700 Mull & Iona 408 408 0 700 0 2,796 1,900 Oban Dental 1,108 1,108 0 1,900 0 35 NOSCAN Funding 20 20 0 35 0 9,682 8,335 Allocation letter Oct 2012 4,853 4,853 0 8,335 0

245 - Non Core Funding IFRS 245 245 0 245 0

9,682 8,580 SGHD Funding 5,098 5,098 0 8,580 0

- Pending allocations 500 Mull & Iona 292 292 0 500 0 (411) Oban Dental (240) (240) 0 (411) 0 12 Revenue to Capital Virement 12 12 0 12 (564) (564) Reversionary Interest - PFI's (329) (329) 0 (564) 0 (265) Radiotherapy replacement (155) (155) 0 (265) 0 (245) UK GAAP Capital (143) (143) 0 (245) 0 (750) Capital to Revenue Virement (438) (438) 0 (750) 0 31 HFS Equipping Funding 18 18 0 31 0 1,372 Carbon Reduction Programme 800 800 0 1,372 0

9,118 8,260 Total SGHD Capital Funding 4,916 4,916 0 8,260 0

Expenditure/Commitments 1,200 1,085 Mull & Iona 633 843 210 1,085 0 2,796 965 Oban Dental 563 55 (508) 965 0 265 0 Radiotherapy replacement 0 0 0 0 0 80 160 Greater Inverness Masterplan 93 12 (81) 160 0 215 Lifecycle Costs ERPCC 125 124 (1) 215 0 30 Lifecycle Costs Mid Argyll 18 18 1 30 0 50 Capital Salaries 29 0 (29) 50 0 32 LinAcc Raigmore 32 31 (1) 32 0 0 Hubco SubDebt 0 0 0 0 0

4,341 2,537 Commitments 1,493 1,083 (410) 2,537 0

Rolling Programmes 2,029 3,355 Estates Backlog Main. 2,032 466 (1,566) 3,355 0 550 550 Medical Equipment 321 165 (156) 550 0 401 407 eHealth Replacement 240 18 (222) 407 0 750 750 Radiology 313 0 (313) 750 0

3,730 5,062 Rolling Programmes 2,905 649 (2,256) 5,062 0 Other 400 150 Raigmore SSD washer/disinfectors 88 0 (88) 150 0 0 32 A&B 2 Washer/Disinfectors 19 0 (19) 32 0 35 NOSCAN Equipment 20 0 (20) 35 0 12 Revenue to Capital Virement 6 12 6 12 0 647 432 Contingency 252 (12) (264) 432 0 0 228 NBV Disposals 133 0 (133) 228 1,047 889 Other 518 0 (518) 889 0

9,118 8,488 Gross Capital Expenditure 4,916 1,732 (3,184) 8,488 0

(228) NBV Disposals 0 0 0 (228) 0

9,118 8,260 Net capital Expenditure 4,916 1,732 (3,184) 8,260 0

0 0 SURPLUS/DEFICIT MONTH 7 (0) (3,184) (3,184) 0 0 184 185 Highland NHS Board 4 December 2012 Item 5.3

ANNUAL ACCOUNTS 2011/12

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the 2011/12 year end position for NHS Highland.  Note the completion of the audit work, the approval of the Accounts by the Board In Committee on 18 June 2012, and the subsequent Parliamentary process.

1 INTRODUCTION

The 2011/12 Annual Accounts were considered by the Audit Committee on 18 June 2012 and subsequently approved by a special In Committee meeting of the Board on that day. Following this process, the Accounts were submitted by the External Auditor to the Scottish Government, for onward submission to the Scottish Parliament, where the NHS Highland Accounts, along with those of other NHS Boards have now been approved.

2 KEY OUTCOMES

In 2011/12, NHS Highland achieved the statutory Financial Targets, and this was reported to the Audit Committee. It should be noted that performance against the revenue target was a minor undespend of £85,000 on the £606m Revenue Resource Limit, which is in line with Financial Reports submitted to the NHS Board during the year, and which has been carried forward into 2012/13. The capital position was that the Board operated within its limit of £13m. The confirmation of these results was included within the Auditors Final Report to Members, and the External Audit Certificate was unqualified.

3 CONCLUSION

This paper concludes the formal process for the 2011/12 Annual Accounts. The full set of Accounts is available on the NHS Highland website.

4 CONTRIBUTION TO BOARD OBJECTIVES

The delivery of an audited set of Accounts for the year is a statutory requirement for the NHS Board.

5 GOVERNANCE IMPLICATIONS

As well as being a statutory requirement, the presentation, discussion and agreement of the Annual Accounts – with independent professional audit scrutiny – confirms the delivery of overall Financial Governance within NHS Highland. 186

6 PLANNING FOR FAIRNESS

The Annual Accounts summarise the Board’s Financial Performance for the year, reflecting the financial impact of the delivery of the full range of NHS services which have been subject to equality impact assessment.

7 ENGAGEMENT AND COMMUNICATION

The Annual Accounts reflect the financial position as reported to the Board in public throughout the financial year 2011/12.

Nick Kenton Director of Finance Assynt House

23 November 2012

2 187 Highland NHS Board 6 December 2012 Item 5.4

DRAFT SCOTTISH GOVERNMENT BUDGET 2013-15

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the draft Scottish Government Budget 2013-15 and its impact on the Board’s Local Delivery Plan.

1 Purpose of Paper

To inform the Board of any potential implications that the draft Scottish Government budget for 2013-15 has for Highland NHS Board’s financial revenue plans as set out in the Local Delivery Plan.

2 Background

The Board prepares a Local Delivery Plan each year, which includes a five-year financial plan. At the Board meeting on 3 April 2012 the Local Development Plan for 2012-17 was approved. This plan included assumptions about future revenue income and expenditure for 2013-15.

The Cabinet Secretary for Finance, Employment and Sustainable Growth in the autumn of each year announces the government expenditure plans and assumptions that public sector bodies should assume in planning future sustainable delivery plans for services. The Cabinet Secretary announced the draft plans for 2013-15 on 22 September 2012. The Chief Executive for the NHS in Scotland has advised the outline implications of this statement to all health boards (see attached).

3 Review of Implications

The Local Development Plan for 2012-17 included assumptions about the level of core funding (based on the national funding formula (NRAC)) and these are outlined in Table 1 below.

(NB: Table 1 states the financial position in round thousands rather than millions to one decimal place as used in the Scottish Budget announcement. However converting the local development plan to the same level of detail would produce the same numbers).

The assumed underlying inflation assumption for 2013-14 in table 1 at 2.8% matches the advised rate. The figure for 2014-15 at 2.6% is marginally lower than the advised rate of 2.7%. The Cabinet Secretary for Finance, Employment and Sustainable Growth also announced the Scottish Government’s proposal in respect of Public Sector pay awards for 2013-14.

The key features of the 2013-14 policy are:

 a one per cent cap on the cost of the increase in basic pay for staff earning under £80,000 188

 maintaining a pay freeze (zero percent basic award) for staff earning £80,000 and above  specific measures for supporting the lower paid  suspension of non-consolidated performance related pay discretion for individual employers to reach their own decisions about pay progression.

Table 2, below, outlines the assumptions in the Local Delivery Plan in respect of pay for 2013-15.

These assumptions are broadly in line with the Scottish Government pay policy although it should also be noted that, at present, the only staff the Scottish Government directly control pay decisions for locally are the staff members within the NHS Executive and Senior Management cohort

All other staff are employed under Agenda for Change and Medical and Dental terms and conditions that are currently subject to subject to national negotiation.

4 Conclusion

The draft Scottish Government Budget for 2013-15 currently places no material changes to the allocation or pay assumptions made in the 2012-17 Local Development Plan. This Budget is subject to the parliamentary process (which is not due to be formally concluded until February 2013) but there is not expected to be any material change to the draft Budget as a result of this process.

Governance Implications

A robust financial plan is a key plank of financial governance. A revised five-year financial plan is due to be presented to the Board in April 2013 for consideration.

Risk Assessment

The revised financial plan to be presented to the Board in April 2013 will include an assessment of key financial risks.

Planning for Fairness

A robust financial plan is crucial to the Board remaining in financial balance and avoiding the need for unplanned service changes in response to financial pressures.

Engagement and Communication

The financial plan will be considered by the Board in public. The plan will be made up of a significant number of elements and there will be engagement at local level via operational units.

Nick Kenton Director of Finance

23 November 2012

2 189 Highland NHS Board 4 December 2012 Item 5.5

DINGWALL HEALTH CENTRE – STANDARD BUSINESS CASE

Report by Michael Waters, Capital Support and Project Manager on behalf of Nick Kenton, Director of Finance

The Board is asked to:

 Approve the attached Standard Business Case for the final phase of development of Dingwall Health Centre.  Agree that the Standard Business Case can now be submitted to the Scottish Government Capital Investment Group for their approval.

1 Background and Summary

This Standard Business Case covers a revised Phase 3 to complete the redevelopment of Dingwall Health Centre, which had previously been approved from within the Board’s Capital allocation with a start date in 2010. Phases 1 and 2 have been completed but, due to the restricted availability of capital, Phase 3 could no longer be funded from within the Board’s formula Capital allocation.

A revised Phase 3 solution has been agreed with the users within the £1.5m allocation agreed by the Scottish Government. As NHS Boards are required to engage with the Scottish Futures Trust (SFT) hub programme for the provision of community facilities, hub North Scotland Ltd (hubco) were approached, but they felt that with the in-house background knowledge and expertise, a better value for money solution could, in this case, be achieved by retaining the project within the Board.

The additional running costs of £73,000 can be met from within the Operational Unit.

2 The Development of Primary Care Services in Dingwall

The Board has previously recognised the need to replace/upgrade Dingwall Health Centre, which is no longer fit for purpose, with more appropriate facilities which will enable clinical staff to deliver quality services to the people of Dingwall and the surrounding district.

Planning Approval for the original proposal was granted by Highland Council and their agreement to the revised Phase 3 proposal is being sought. As the revised proposal does not involve extensions to the existing building and all work will be carried out within the existing footprint, it is not envisaged that there will be any Planning Approval issues.

The redesigned premises will improve co-operation between primary and secondary care services as well as extending collaboration with other agencies such as Social Work as part of the integrated working being promoted by NHS Highland and Highland Council. The provision of additional and/or enhanced services will be possible utilising the existing pool of experienced staff. Patients will be seen more quickly and conveniently and this will lead to a reduction in the impact on Acute Services. As an alternative to hospitalisation, the extension of the scope of care within the community will be in keeping with national and local policies. 190

3 Contribution to Board Objectives

This project will contribute to achievement of”Better Health, Better Care, Better Value” in the Dingwall area by providing the facilities to assist clinicians improve the health of the population. The new facility will enhance the experience of care for individuals and allow for integrated team working. The building will be more energy efficient and cost effective to operate than it is at present.

4 Governance Implications

 Staff Governance

Staff working in the current premises have been fully consulted and involved in the design of the facility

 Patient and Public Involvement

The Head of Public Relations & Engagement is a member of the local project group and a communications plan is in place to keep stakeholders informed including the general public and their representatives. A patient representative is a member of the local project group.

 Clinical Governance

Local clinicians are members of the project group and have been involved in Benefits Realisation workshops.

 Financial Impact

The financial impact is detailed in the attached paper; additional costs have been identified and will be funded by local savings.

5 Risk Assessment

The project has its own Risk Register which is contained as Appendix 3 of the Business Case.

6 Planning for Fairness

An Equality and Impact Assessment meeting is being arranged.

7 Engagement and Communication

The project has an established governance structure with the Director of Finance as the Senior Responsible Officer. The local project group is chaired by the Area Manager Mid Operational Unit and includes representatives of the Dingwall medical practice and community as well as a patient representative. The Head of Public Relations & Engagement is also included and a communications plan is in place to inform stakeholders including the general public and their representatives.

Michael Waters Capital Support and Project Manager Corporate Services – Finance - Capital & Property Planning

23 November 2012

2 191 Highland NHS Board 4 December 2012 Item 5.6

NHS HIGHLAND – PROPOSED IMPLEMENTATION OF THE NATIONAL PATIENT MANAGEMENT SYSTEM (PMS)

Report by Bill Reid, Head of eHealth on behalf of Deborah Jones, Chief Operating Officer

The Board is asked to:

 Agree the need for replacement of the current legacy Patient Administration Systems with a modern Patient Management System;  Consider the more detailed content of the attached draft Business Case;  Agree that NHS Highland commence implementation of the National Patient Management System from April 2013;  Agree the required local funding to allow the implementation to commence.

1 BACKGROUND AND SUMMARY

On 6 December 2009 NHS Scotland announced that the successful prime supplier for the national Patient Management System (PMS) was Intersystems Corporation with the Trakcare product. The procurement of the new PMS was conducted on behalf of the Scottish Health Service by a Consortium of Boards comprising NHS Ayrshire & Arran, NHS Borders, NHS Grampian, NHS Greater Glasgow & Clyde and NHS Lanarkshire.

The Boards had agreed to undertake the procurement of a new “fit for purpose” PMS on behalf of the NHS in Scotland.

The procurement was successful in that it resulted in the selection of a modern suite of systems and services that are capable of delivering on current clinical demands and having sufficient flexibility to deliver against future service need.

The procurement also led to a framework agreement with catalogue pricing which allows other NHS Boards outwith the consortium to implement the PMS System without the need to go through their own discrete procurement process.

Implementation of the nationally procured Patient Management System across NHS Highland is a key component of the current NHS Highland eHealth Delivery Plan. It is planned that implementation will commence in the 2013/14 financial year.

The Initial Agreement was submitted to, and approved by, the NHS Highland eHealth Strategy Group as was an early draft Business Case. The current Business Case has been submitted to, and agreed by, the NHS Highland Asset Management Group, the NHS Highland Senior Management Team and the NHS Highland eHealth Strategy Group. The purpose of this paper and attached Business Case is to seek approval and funding to implement PMS across our Board area commencing in April 2013.

It is acknowledged that the Argyll & Bute Community Health Partnership of NHS Highland with its patient flows predominantly to NHS Greater Glasgow & Clyde creates specific issues in system implementation terms. These issues are around the patient pathway and clinical continuity in respect of the material number of our patients referred out of area. NHS Highland is working with the supplier and other NHS Boards who have similar issues to ensure that a cost effective and pragmatic solution is reached. 192

The implementation of PMS will be the most significant system work undertaken across NHS Highland. The eHealth function will require to review all existing and prospective workload with a view to ensuring that adequate capacity is created in resource terms.

2 PATIENT MANAGEMENT SYSTEM – NHS HIGHLAND

Currently NHS Highland operates two separate Patient Administration Systems (PAS), iSOFT iExpress in Northern NHS Highland and the ATOS Origin Helix System in the Argyll & Bute Community Health Partnership (CHP).

Each of these systems is approaching “end of life” in terms of support and functionality. These existing PAS Systems have little or no clinical functionality. They are administration systems, not patient management systems.

In addition, utilising two discrete systems across one Board area for clinically focussed patient-centric data and information means that a patient centred approach to records and clinical information across our area is not currently possible.

In contrast, the PMS is at the core of many NHS Scotland eHealth initiatives. NHS Boards who are already implementing the PMS are looking to maximise the use and benefit by utilising the functionality inherent in the system.

NHS Highland requires modern information systems to support clinical staff in the provision of high quality care. An integrated suite of systems, in this case the proposed PMS, is built to support current and future clinical requirement, including patient pathway tracking allowing the identification and analysis of variation. This implementation will represent the core of the future NHS Highland eHealth work-plan and is articulated in the NHS Highland eHealth Delivery Plan as formally approved by the Scottish Government eHealth Directorate earlier in 2012.

The new PMS will also ensure that patient journeys across the Acute Sector are fully reflected in an emerging Electronic Health Record (EHR). In summary PMS implementation will:

 engage our clinical community in the potential of eHealth to support the delivery of safe, effective, timely, equitable and efficient care to patients;  enable information flows that improve the safety and quality of care for our patients;  support the NHS Highland Delivery Plan particularly in areas such as 18 Weeks Referral to Treatment, the Treatment Time Guarantee (TTG) and HEAT Targets;  support and enhance the key Highland Quality Approach (HQA); and  support and enable service planning and redesign by delivering patient centred data and information across NHS Highland.

The current indicative costs which are not expected to show material variance from the actual costs are as follows:

Non-recurring

Intersystems Implementation Costs £ 1,450,000 Hardware Costs £ 500,000 (Refresh 2018/19) Local Implementation Costs £ 842,000

Total Implementation (Phased Years 1 and 2) £ 2,792,000

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The Scottish Government Health Department (SGHD) has responded to NHS Highland and confirmed that some central funding will be available towards implementation. We have been informed that this funding will be a total of £1,700,000 leaving £1,092,000 to be funded from NHS Highland resource over the two year implementation period.

Recurring

NHS Scotland has purchased a national licence for PMS; this was funded from capital and is available to NHS Boards. The associated capital charges become the responsibility of the local NHS Board. The full year revenue impact may be summarised as (rounded to £ ‘000):

Capital Charges (Licence) £ 240,000 Capital Charges (Hardware) £ 100,000 Annual Support (Intersystems) £ 687,000 Hardware Support and Staffing £ 173,000

Total £1,200,000

The figure above will be “offset” to an extent by the current cost of existing PAS Systems support which equates to £324,000 leaving a recurrent funding requirement of £876,000 per annum in respect of NHS Highland (full year).

3 CONTRIBUTION TO BOARD OBJECTIVES

The proposed implementation of the Patient Management System will significantly contribute to the delivery of improved services to patients through effective clinical systems and information provision. The NHS Highland Quality and Efficiency Plan is built upon the foundation principles of reducing harm, manage variation and reduce waste.

Implementation of the PMS will facilitate seven specific key contributions to NHS Highland Corporate Objectives. These contributions have been identified as tangible improvements in the following areas:

 patient care  access to care  bed management and discharge planning  patient safety  clinical communication  clinical effectiveness  service planning

4 GOVERNANCE IMPLICATIONS

Staff Governance

There are significant implications for staff, both clinical and non-clinical. The implementation of PMS will result in a reconfiguration of service design and clinical work-flows. The formal project management process includes ensuring staff involvement in, and knowledge of, the streamlined processes which will result.

Patient and Public Involvement

There will be patient and public representation on the key Project Boards. The implementation of a Patient Management System is a significant event for NHS Highland and our users and periodic updates will be issued.

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Clinical Governance

The implementation of a modern and integrated Patient Management System will make a significant contribution to the improvement and maintenance of robust clinical governance across the NHS Highland area. This will include the ability to establish and monitor clinical pathways.

Financial Impact

While implementation of a modern patient management system will lead to significant costs being incurred there will be a longer term benefit in ensuring the most effective utilisation of our resources.

5 RISK ASSESSMENT

The implementation of PMS will be undertaken using formal Project Management techniques, based on Projects in a Controlled Environment (PRINCE 2) and LEAN Principles. This approach ensures a continual process of risk assessment involving the maintenance of formal Risk Registers and audit trails around risk mitigation.

6 PLANNING FOR FAIRNESS

PMS implementation will require reconfiguration of individual service delivery elements. This reconfiguration process will be subject to formal impact assessment as an inherent element of the project management process.

7 ENGAGEMENT AND COMMUNICATION

Approval of the Business Case will result in the establishment of a Programme and Project Board. Engagement and communication will be an inherent and formal element of this structure. A Clinical Focus Group has already been established to ensure early clinical participation and engagement at an early stage.

In addition, communication with staff at all levels of the organisation will be through cascade from senior management, staff briefings and the joint staff governance approach along with the NHS Highland Communications Department.

Bill Reid Head of eHealth Corporate Services

23 November 2012

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DRAFT

BUSINESS CASE

PROPOSED INTRODUCTION OF

Trak Patient Management System (PMS)

To NHS HIGHLAND 196

VERSION AND CONFIGURATION MANAGEMENT

Configuration History Sheet Version Date Details of Changes included in Update No. 1.0 07/09/2011 eHealth Strategy Group 2.0 03/08/2012 Redraft (I Ross, L Kirkland) 3.0 07/08/2012 Re-write (External Contractor) 4.0 12/09/2012 Major re-write/structure (Head of eHealth) 4.1 24/09/2012 Final 4.2 15/11/2012 Further Revision (Head of eHealth)

The issue of this document requires the approval of the signatories below on behalf of the Project Board.

Name Title Signature Date

Distribution Version No. Date 4.1 05/09/12 B Reid, I Ross, J Brass 197

CONTENTS

1 EXECUTIVE SUMMARY 1

2 INTRODUCTION 2

2.1 Purpose 2 2.2 Current Position 3 2.3 Current Requirement 4

3 SHORTLIST OPTIONS 7

4 IMPLEMENTATION OPTIONS 8

5 BENEFITS 12

APPENDIX A (ECONOMIC AND FINANCIAL APPRAISAL) 17

APPENDIX B (PROGRAMME MANAGEMENT) 20

APPENDIX C (BACKGROUND TO NATIONAL PROCUREMENT) 22

APPENDIX D (CONTRACTUAL FRAMEWORK) 24

APPENDIX E (HIGH LEVEL IMPLEMENTATION PLAN) 28

APPENDIX F (FINANCIAL COSTS) 30 198

1 EXECUTIVE SUMMARY

INTRODUCTION

The purpose of this Business Case is to seek approval from NHS Highland to invest in the implementation of a new Patient Management System (PMS) which will support NHS Highland’s mission “to provide patient-centred services tailored to people’s needs in a systematic and consistent way – to provide quality care to every person every day”.

PMS implementation will ensure that patient journeys in acute services are fully recorded in the Electronic Health Record; the PMS has much greater functionality than the current Patient Administration System (PAS) and will:

 engage the clinical community in the potential of eHealth to support the delivery of safe, effective, timely, equitable and efficient care to patients;  enable information flows that improve the safety and quality of care for patients;  support and enable the NHS Highland Local Delivery Plan around objectives such as 18 Week RTT and HEAT targets;  support and enhance the key Highland Quality Approach (HQA); and  support and enable service planning and service redesign by delivering NHS Highland–wide data and information in a patient and service orientated way.

The PMS will facilitate the achievement of objectives in the eHealth Delivery Plan such as:

 the provision of real-time, accurate data to make informed decisions;  enabling integration/collaboration between hospital departments;  minimise variation in hospital schedules, emergency arrival patterns, and support Clinical Governance.

The proposed implementation of PMS is in compliance with the eHealth Strategy and Delivery Plan agreed by NHS Highland on 26 January 2012.

BACKGROUND

On 6 December 2009 NHS Scotland announced, after a major procurement exercise, that the successful Prime Supplier for the National PMS solution was Intersystems Corporation with the Trakcare PMS product. The procurement of the new PMS was conducted by a consortium of Boards comprising NHS Ayrshire & Arran, NHS Borders, NHS Grampian, NHS Greater Glasgow & Clyde and NHS Lanarkshire on behalf of the Scottish Health Service. The objective of this procurement was the selection of a modern suite of systems and services that are capable of delivering upon current demands and having sufficient flexibility to deliver upon future service need.

This process was conducted in accordance with European Union Procurement Law and was devised to ensure that the selected supplier offered the best:

 functional product;  technical compliance with NHS requirements;  implementation support;  financial and economic best value, and;  strategic fit.

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NHS Scotland, through National Services Scotland (NSS) entered into a framework contract that gives individual NHS Boards access to ‘call off contracts’.

The Framework Contract means that there is no requirement for NHS Boards to undertake their own procurement thus simplifying the NHS Highland intention to replace the current PAS.

Intersystems currently is working with the 5 Consortia Boards to implement the new system within their Board areas. In addition, NHS Lothian was implementing the system prior to the procurement and continue to use the system as their Patient Management System. Intersystems has a strong track record of delivering Healthcare Information System across the world. They have demonstrated a high level of understanding of NHS Scotland’s requirements and have proposed and are now delivering a suite of products and an implementation process that is credible and appropriate to the needs of NHS Highland.

The contractual terms and conditions that have been agreed are commensurate with the need for NHS Scotland to have a contract that mitigates risk and provides an incentive for successful delivery.

RECOMMENDATION

This Business Case presents reason for the need for the new Patient Management System, the financial and economic case for adoption of a new PMS and associated change management activities together with options for systems and implementation approaches.

In conclusion, this Business Case recommends:

Implementing a single PMS solution for the whole of NHS Highland and investigating with Intersystems options for connecting the functionality within the PMS systems of NHS Highland and NHS Greater Glasgow & Clyde so that clinicians within NHS Greater Glasgow & Clyde can have visibility of both NHS Greater Glasgow & Clyde patients and also NHS Highland patients who are on the local system. This aspect refers to our patients who are domiciled in the Argyll & Bute Operational Unit and whose referral pathways may be to NHS Greater Glasgow & Clyde services.

This will facilitate the most dedicated patient centred system which will ensure the greatest detail of the patient journey is available for clinicians in one record and which is managed totally by NHS Highland.

ACTION REQUIRED

NHS Highland is requested to accept the above recommendation, including financial commitment, which will enable progress towards commencing implementation of the new PMS in April 2013.

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2 INTRODUCTION

2.1 Purpose

NHS Highland accepted in principle in January 2012 that the National PMS should be implemented across the Board area. This paper establishes why this decision should now be implemented.

2.2 Current Position

NHS Highland currently operates the following Patient Administration Systems:

 iSOFT iExpress PAS – Northern NHS Highland  ATOS Origin Helix PAS – Argyll & Bute

The iSOFT iExpress Patient Administration System (PAS) has provided good service for the last 20 years but effectively comes to its “end of life” in March 2014. PAS within NHS Highland was initially implemented to manage the tracking of paper patient health records (case notes) but has been enhanced over the years to cater for out-patient and in-patient management and waiting list functions. Similar considerations exist for the Helix PAS. A PAS is critical for the operational management of acute services. The current PAS systems can no longer support the required changes in current service and clinical needs and cannot be upgraded to support any future needs. We are now looking for formal approval to invest in an enhanced replacement system.

The nationally procured Patient Management System (PMS) provides a much more extensive patient record than the current system. PMS includes Order Communications (electronic requesting and reporting of Laboratory and Radiology tests and examinations within the acute services), Bed Management, Mental Health Administration and Complex Scheduling as part of the core package. In addition there is a tool to allow NHS Highland to develop fully integrated pages for clinical notes and information.

In addition, PMS comes with a range of optional modules which, if adopted, can all be fully integrated with the core PMS package. The optional modules include Maternity, Neonatal and A&E. The PMS Catalogue has already been used by NHS Highland to procure and implement the JAC Pharmacy System.

The procurement and implementation proposes the following system replacements and additions:

1. Replacement of the current Patient Administration Systems (PAS) with a Patient Management System; 2. Addition of an Order Communications System for the Acute Service (this is a core module of PMS); and 3. Addition of a Bed Management System.

The system implementation will be supported by formal PRINCE 2 Programme and Project Management, management of change, extensive training and familiarisation and will provide enhanced patient information for clinicians.

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Exclusion

This PMS Business Case specifically does not, at this time, include the following:

 Accident and Emergency PMS module;  Maternity PMS module;  Neonatal PMS module;  Hospital Electronic Prescribing and Medicines Administration (HEPMA); and  Casenote Scanning.

2.3 Current Requirement

Currently NHS Highland operates two different PAS systems. In Northern NHS Highland the iSOFT iExpress system is used and in the A&B CHP area the ATOS Origin Helix system is used. Both systems are functionally at “end of life”. In addition, using two different systems for clinical patient-centric data means that providing a patient centred approach to the patient record and information cannot be done at the basic patient level.

The two systems are quite different and each has strengths and weakness but share the following issues are common to both:

SUPPORTABILITY iSOFT PAS

The iSOFT PAS was implemented within NHS Highland in 1988 and since then has been upgraded a number of times to ensure that functionality is up to date. Although the system has been upgraded, the underlying technologies are no longer ‘current’ and the system is very complex to manage.

NHS Highland is currently the only NHS Board in Scotland that is continuing with iSOFT as a supplier (NHS Greater Glasgow & Clyde are still using iSOFT, however, this will cease when they have concluded their own PMS implementation).

As a result of this significant reduction in business within Scotland iSOFT have reduced their support staff and NHS Highland is finding it increasingly difficult to get the level of support required to run a complex system such as PAS.

Helix PAS

The Helix system, an evolution from the COMPAS PAS is a Crown Copyright system supported and developed by ATOS Origin under a contract with NHS Scotland since 2006. A consortium of Health Boards contribute to the costs of support and development with a decreasing number of Boards participating as TrakCare PMS is implemented nationally. Whilst the associated support costs also decrease, a ‘tipping point’ will be reached as fewer Boards remain involved where continued support and development of the system is no longer financially viable.

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FIT FOR PURPOSE iSOFT PAS and Helix PAS

Although the PAS systems have been upgraded, there are areas of the system that are not ‘fit for purpose’. A major benefit of PMS is that the system is patient centred hence enabling the enhancement of patient care and safety, there are also major benefits in areas of reporting.

Modern systems are patient centred and ensure that patient tracking is easier; this obviously enhances the handling of pathway tracking particularly around 18 weeks RTT which means that staff cannot ‘break’ these pathways by mistake. Systems now are also more intuitive and user friendly to use hence reducing the amount of training required.

Modern clinical systems also have easy to use functionality for the electronic management of referrals including the ability for clinicians to electronically vet referrals.

Electronic vetting of referrals means that this process is more efficient and effective and means that referrals cannot ‘go missing’ within the system.

FUTURE INITIATIVES

The PMS is at the core of all new NHS Scotland eHealth initiatives. NHS Boards who have invested in the PMS are now looking at maximising its use by increasing both the functionality within the system as well as broadening the user base. This means that NHS Highland will find it increasingly difficult to implement new quality and clinical initiatives unless it moves to a modern, supportable system like the PMS.

PATIENT JOURNEY DATA INTEGRATION

NHS Highland currently operates two completely different PAS systems, this means that when activity data is produced for the whole Board and not just elements of the Board, the data from each of the PAS systems must be ‘joined’ together to give a Board view. This ‘joining’ is carried out within the recently developed NHS Highland data repository. The data structure from each PAS system is not the same thus this requires the datasets to be manipulated to allow for a complete view of NHS Highland activity. In a “Board- wide” PMS environment producing this universal view of data will be straight forward with minimal manipulation of data required.

ROADMAP TO ELECTRONIC HEALTH RECORD (EHR)

The current PAS systems in use in NHS Highland have little or no clinical functionality. They are administrative systems, not patient management systems. A cornerstone of Delivering for Health is that a fully integrated Electronic Health Record (EHR) will be key to the successful delivery of the health care that the population of Scotland requires. The PMS system is the cornerstone of the EHR.

STRATEGIC CONTEXT

The current NHS Scotland eHealth Strategy covers 2011-2017.

This eHealth Strategy builds on the direction and achievements of its predecessor which ran from 2008 to 2011.

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The Strategy reaffirms the Scottish Government’s view that information and communication technologies are important to the improvements in quality and the ambitions set out in The HealthCare Quality Strategy for NHS Scotland to actively support and enable quality improvements in healthcare services across Scotland.

The Strategy reinforces our move from a focus on technology products, services and their suppliers toward a focus on benefits and outcomes experienced by NHS Scotland (NHSS) professionals in helping them to re-design and improve services, and the citizens of Scotland who will benefit from those improvements. It endorses the incremental approach to information and communication technology enabled changes, and that such changes will be planned and driven from closer to the front line of service delivery and aligned more closely with the improvement planning processes in Boards and workforce development. In particular, it recognises the importance of clinical leadership and clinical engagement in developing and delivering successful eHealth initiatives.

The Strategy sets out five new strategic eHealth aims which will be developed with a focus on outcomes and real benefits delivered rather than technologies measured by the development or implementation of information and communication technology products or related services. Unlike the previous Strategy it is intended to run for six years, with nine Scottish Spending Review 2011 (SSR11) deliverables to be achieved across NHSS by 2014. The Strategy will be reviewed and refreshed in 2014, to concur with the next Spending Review, and deliverables for 2017 will be developed.

The Strategy has been agreed with NHSS. It is not a top down mandated set of tasks but an agreed direction and set of goals. Where it mandates it does so because NHSS has agreed with the Scottish Government that joint action is the most appropriate way forward. It uses the word “we” because of the shared nature in which the Strategy has been developed, because the expectation is that NHS Boards will work in partnership with each other and with the Scottish Government to deliver it, and because we have developed the partnership structures which underpin collective endeavour.

The eHealth Strategy has been set in the context of The Healthcare Quality Strategy and aims to build upon existing foundations and ensure that going forward all work is integrated and aligned to deliver the highest quality healthcare services to people in Scotland, and in doing so provide recognised world leading quality healthcare services. It sets out three Quality Ambitions which provide a consistent description of quality for NHSS, and work is underway to streamline and align all work programmes with these three Ambitions. These Quality Ambitions act as the focus for priority action for all health services.

 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;

 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;

 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.

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To contribute to the national Strategy the suite of systems comprising PMS needs to include:

 real time electronic records that are patient centred, including a single record of their healthcare history providing up-to-date patient information at the point of treatment;  streamlined and more accurate identification of patients based on universal use of the Community Health Index (CHI) to support improvements in patient safety;  scheduling, whereby all required transactions and interventions, both clinical and administrative, are available ‘on-line’ including full electronic referring, vetting and appointing of patients;  bed management functionality enabling better internal co-ordination of admission, transfer and discharge;  integrated waiting list management features including the facility to track and monitor patients according to specialty and disease specific pathways;  resource management functionality linked to capacity planning that enables optimum use of available facilities, equipment and staff;  facilities that directly reduce clinical time spent on administration and reduce paper documentation;  more integrated working with primary care, including support for electronic discharge letter production;  improved co-ordination of discharge arrangements with primary and social care through the appropriate and secure sharing of data;  facilities that ensure the security of person identifiable data and provide auditable traceability of access to information;  facilities that support collaborative care between clinical professions and across agencies, such as development of patient care pathway, multi-disciplinary care records, guidelines and alerts;  provision of better management information to support appraisal of clinicians, peer review and planning of clinical services. This will be facilitated by a robust reporting tool or set of tools. The system will also facilitate measurement of other HEAT targets including quality measures.

There is considerable importance attached to clinical ownership of the PMS system and NHS Highland will continue to encourage clinical engagement and participation in the commissioning and implementation stages.

NHS Highland’s eHealth Strategy 2009-2012 and subsequent eHealth Delivery Plan 2011-2014 highlighted the importance of the procurement of a PMS to replace the existing PAS and this has been extensively communicated. This system will provide the backbone to an NHS Highland EHR.

PMS along with the additional modules will be the largest system implementation that NHS Highland has ever undertaken.

3 SHORTLIST OPTIONS

The following four options have been considered for NHS Highland:

Option A - Do nothing. Leave current applications in place and provide in house support and maintenance once the iSOFT PAS contract has expired. This option carries very significant risks for NHS Highland. This option will incur high costs as resource will be required to continue maintenance of legacy products.

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Conclusion - discounted since this posed the highest business risk to NHS Highland.

Option B - Negotiate extension to current PAS Contract. The original iSOFT contract was due to expire in March 2009. After negotiations, NHS Highland was able to extend the contract until March 2014. Since the national procurement of the PMS, NHS Highland has seen a reduction in the number of experienced iSOFT staff that are available to support the current PAS. Continuing with the use of iSOFT as a PAS supplier is considered a very high risk.

The support and development costs associated with the Helix PAS will increase considerably as other Boards discontinue their involvement in the Helix consortium.

Conclusion - discounted due to the high risk of operating systems with a reducing support service leading to an unreliable and unpredictable situation.

Option C - Accept and implement the PMS procured by NHS Scotland. This option would facilitate a joined up electronic record solution across the acute sector providing functionality and capability that has been missing from the current applications and a developing path that is in alignment with national strategy.

Conclusion - preferred option which will be flexible enough to meet NHS Highland’s current and future needs while supporting national and local strategic aims. This is the only option acceptable to the National eHealth Programme Board.

Option D – Procure another system. This option would allow NHS Highland to undertake their own specific procurement.

Conclusion – discounted as this would be very costly and time consuming and would not be supported nationally.

4 IMPLEMENTATION OPTIONS

The 6 Boards that have implemented PMS have all done so using the model of a single system for the whole Board area. NHS Highland, however, needs to consider if this is the best option given that for the Argyll & Bute CHP area there is significant patient flow to NHS Greater Glasgow & Clyde. The Argyll & Bute CHP also has visiting NHS Greater Glasgow & Clyde clinicians who will need to electronically triage NHS Highland referrals.

NHS Highland is not unique in this regard as other Scottish NHS Boards experience material cross-border flow.

To inform the process of option appraisal some basic activity analysis is as follows:

 In the three months from May 2012 6,528 electronic referrals were made by Argyll & Bute CHP GP Practices of which 44% (2,866) were accepted in Argyll & Bute CHP hospital with the remaining 56% (3,662) accepted in NHS Greater Glasgow & Clyde sites.

 A simple analysis of time to vet for this same three month period indicates 67% of referrals were eVetted within 7 days of the date of the referral.

 Over the past three years an average of 82,346 outpatient appointments have been made each year for Argyll & Bute CHP residents.

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. of these on average 54% (44,356) were appointed to Argyll & Bute CHP hospitals, the remaining 46% (37,990) were in NHS Greater Glasgow & Clyde hospitals; . of those appointments in Argyll & Bute CHP hospitals 58% (25,812) were serviced by Argyll & Bute CHP consultants with 42% (18,543) serviced by NHS Greater Glasgow and Clyde consultants.

 For elective and emergency episode admissions over the same three year period there were on average 26,030 episode admissions each year

. of these admissions 30% (7,703) were in Argyll & Bute CHP hospitals with the remaining 70% (18,327) within NHS Greater Glasgow & Clyde hospitals.

(Figures derived from SCI Gateway, SMR00, SMR01 and the AcaDME data mart - excludes mental health)

Argyll & Bute CHP laboratory services and the underlying information systems are integrated into NHS Greater Glasgow & Clyde.

These issues mean that the configuration of a PMS system within NHS Highland must be considered to ensure the most complete patient record. In discussions involving Northern NHS Highland, Argyll & Bute CHP, NHS Greater Glasgow & Clyde and Intersystems, three architectural designs have been identified.

Option 1

Implement a single PMS solution for the whole of NHS Highland.

Pros

 All NHS Highland patients’ activity within NHS Highland hospitals would be held within a single system hosted within NHS Highland;  Would promote single way of working across NHS Highland;  Can be implemented starting in April 2013 across all of NHS Highland;  Data reporting and management will be more straight forward (no joining of data);  Cost effective.

Cons

 Does not fit with the patient flows from Argyll & Bute CHP toward NHS Greater Glasgow & Clyde with difficulties such as liaison with outreach consultant’s secretaries/medical records staff and electronic vetting of referrals and for appointment management to their clinics in NHS Greater Glasgow & Clyde hospitals;  NHS Greater Glasgow & Clyde activity would not be included in the Argyll & Bute CHP patient’s EHR (46% outpatient and 70% inpatient activity would be missing) ;  Implementation of the Order Communications module within Argyll & Bute CHP would need further consideration as laboratory services are integrated to NHS Greater Glasgow & Clyde;

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 Complex communication arrangements will need to be established between Argyll & Bute CHP and NHS Greater Glasgow & Clyde to manage waiting times information such as 18 week RTT (ie. where Board of Referral differs from that of Treatment) and Treatment Time Guarantee;  Difficult to support other closely related systems such as the infection control system (ICNet) to provide efficient access for Argyll & Bute CHP clinicians to NHS Greater Glasgow & Clyde based activity;  NHS Highland single way of working may not be appropriate for NHS Greater Glasgow & Clyde consultants.

Option 2

Implement a dual PMS solution with Northern NHS Highland utilising servers based in Inverness and the Argyll & Bute CHP utilising a service hosted by NHS Greater Glasgow & Clyde.

Pros

 Would fit with the patient flows of Argyll & Bute CHP towards NHS Greater Glasgow & Clyde and reduce difficulties in liaison with outreach consultants secretaries and medical records staff;  Would allow Argyll & Bute CHP and NHS Greater Glasgow & Clyde clinicians to have single system of working providing . the most efficient pathway management e.g. electronic vetting between Argyll & Bute CHP and NHS Greater Glasgow & Clyde based activity where clinicians service clinics in both locations supporting the most efficient management of waiting times such as 18wk RTT & Treatment Time Guarantee; . more transparency regarding patient choice of appointments especially for those existing clinics where capacity is already an issue (ie. both outreach clinic in Argyll & Bute CHP and NHS Greater Glasgow & Clyde clinics would be accessible in same system);  Provides comprehensive EHR for Argyll & Bute CHP patients as NHS Greater Glasgow & Clyde activity, clinical letters etc will be available within Argyll & Bute CHP;  Implementation of the Order Communications module within Argyll & Bute CHP would be implemented in line with laboratory services and the underlying information systems integrated to NHS Greater Glasgow & Clyde;  Provides the most efficient means of supporting other closely related systems such as the infection control system (ICNet) and Chemocare (Argyll & Bute CHP is part of West of Scotland Cancer Network (WoSCAN) not North of Scotland cancer Network (NoSCAN));  Co-ordinated approach to appointing, adding to waiting lists and admissions whether patient activity occurs in Argyll & Bute CHP or NHS Greater Glasgow & Clyde;  Argyll & Bute CHP’s involvement in the NHS Greater Glasgow & Clyde TrakCare will facilitate access to other NHS Greater Glasgow & Clyde systems such as their clinical portal which hold important clinical information on Argyll & Bute CHP patients;  Reduced number of users with TrakCare calls to be fielded by the NHS Highland eHealth Service Desk;  Enhances the clinical pathway communication and interface between secondary care and primary care clinicians;

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 Discussions with NHS Greater Glasgow & Clyde senior management has approved in principle a single integrated TrakCare system.

Cons

 NHS Highland patients would not be held in one single system;  NHS Highland would have responsibility for all patients records but would not have control over all the systems they populate;  NHS Highland data within the NHS Greater Glasgow & Clyde would be tagged as NHS Greater Glasgow & Clyde activity therefore national and local reporting will be more complex;  Service Level Agreement has to be agreed and be defined with NHS Greater Glasgow & Clyde hosting of the NHS Highland Argyll & Bute CHP service. No cost information or detail of NHS Greater Glasgow & Clyde commitment for this option is available and at this stage there is, therefore, medium/high risk regarding implementing this option  Due to the lack of agreement with NHS Greater Glasgow & Clyde no start date for implementation is currently available although this would be expected to commence following the implementation of the last site in NHS Greater Glasgow & Clyde before the implementation resources dissipate, their TrakCare rollout is scheduled for completion in March 2013;  May be more costly than option 1;  Argyll & Bute CHP will need to adopt NHS Greater Glasgow & Clyde working practices which although consistent with consultant’s normal working practices may be different to some of NHS Highlands

Option 3

Implement a single PMS solution for the whole of NHS Highland and investigate with Intersystems options for connecting the functionality within the PMS systems of NHS Highland and NHS Greater Glasgow & Clyde so that clinicians within NHS Greater Glasgow & Clyde can have visibility of both NHS Greater Glasgow & Clyde patients and also NHS Highland patients who are on our local system. This option is being considered as a National development sponsored by NHS Lanarkshire (who also have significant patient flows into NHS Greater Glasgow & Clyde) and with possible funding being available via the Scottish Government. Workshops are currently being arranged to progress this work NHS Highland is involved.

Pros

 All NHS Highland patients’ activity within NHS Highland hospitals would be held within a single system hosted with NHS Highland;  Would promote single way of working across NHS Highland;  Can commence implementation starting 1 April 2013 across all of NHS Highland,  Data reporting would be more straight forward (no joining of data);  Potential for system to be configured to accommodate patient flow requirements of the Argyll & Bute CHP.

Cons  Implementation of the Order Communications module within Argyll & Bute CHP would need further consideration as laboratory services and the underlying information systems are integrated to NHS Greater Glasgow & Clyde;

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 Dependent upon Intersystems development of the necessary functionality and may incur extra cost;  Significant activity occurring for Argyll & Bute CHP patients within NHS Greater Glasgow & Clyde might still not be visible as part of the EHR (46% outpatient and 70% inpatient activity);  May affect clinical pathway and communication between primary and secondary care;  May be difficult to support other closely related systems such as the infection control system (ICNet) to provide efficient access for Argyll & Bute CHP clinicians to NHS Greater Glasgow & Clyde based activity;  Whilst this potentially provides a solution it is not known what is achievable but will require development or configuration of both the NHS Highland and NHS Greater Glasgow & Clyde implementations to deliver the necessary integration and is assessed as high risk at this stage;  May be more costly than option 1.

For all options the migration of current NHS Highland data will be undertaken.

RECOMMENDATION

NHS Highland to commit contractually to Intersystems for the provision of TrakCare on the basis of a single implementation.

MANAGEMENT OF CHANGE

PMS has the potential to enable a wide range of business change that will realise significant benefit to NHS Highland. Commitment from senior management and clinicians to undertake and manage these business changes is essential to realise the full benefits that PMS can enable as the technology alone will not deliver the desired benefits.

Key stakeholders for each business change area will be engaged in developing the change management plans. This will require ‘buy-in’ and commitment from senior representatives in all areas including clinical, operational and service improvement.

Developing the change management plans will involve:

 Being clear on objectives and service requirements driving the PMS;  Identification of stakeholders affected by change;  Communication of the benefits of change;  Analysis of current processes;  Redesign of new processes; and  An agreed action plan for implementing change including addressing skill mix and training.

Change management plans will be essential to deliver the significant benefits that will be realised through full exploitation of PMS.

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5 BENEFITS

The NHS Highland Quality and Efficiency plan is built upon the foundation principles of Reduce Harm, Manage Variation and Reduce Waste.

The PMS implementation will be clinically led and eHealth supported so that it is focussed on delivering benefits to patients, clinicians and the service.

It is acknowledged that advances in eHealth systems alone will not deliver the objectives of this without parallel changes in culture, clinical behaviour, business practice and process and capacity. Implementation of PMS will, therefore, interface with the improvement programmes within the Highland Quality Approach which are already underway including service redesign. PMS implementation will be the catalyst and enabler of further fundamental service redesign.

Lean methodology has been adopted by NHS Highland as an important tool to support its commitment to more clearly define patient pathways and remove avoidable delays and/or steps that fail to add value. Work is underway to further promote and embed Lean, working with staff on specific work programmes to streamline pathways, remove or limit service variation, increase efficiency and deliver improved productivity. The relationship will evolve with joint working on initiatives to deliver mutual objectives to the benefit of NHS Highland and the introduction of PMS will serve to support and enable these business changes.

From a benefits perspective, extensive work has been undertaken to assess the potential of the selected solution. NHS Highland expects to realise benefits from PMS and the changes to business processes under a number of broad headings which will directly contribute to delivery of patient services that are efficient, effective, timely and safe.

Seven key benefits driven by the foundation principles of Reduce Harm, Manage Variation and Reduce Waste have been identified that will be realised through implementation of PMS. These are:

1 Improve Patient Care – Patient Journey Correctly Reflected – Pathway Improvement

 A significant challenge for NHS Highland is delivery and sustained achievement of 18 weeks Referral to Treatment (RTT). The proposed replacement PMS will be central to achieving that objective. At present there is no electronic capability to link different stages of the patient journey to enable performance measurement of that journey to take place. PMS will have the functionality to enable NHS Highland to measure delivery of the guarantee that from receipt of GP referral to treatment will not exceed 18 weeks (admitted and non admitted patients).

Clinical champions will work with the implementation team to achieve the necessary changes in behaviour and practice to deliver a sustainable solution to 18 weeks RTT with robust monitoring and reporting capabilities as part of the new system.

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There is considerable importance attached to clinical ownership of the system and NHS Highland will continue to encourage clinical engagement and participation in the commissioning and implementation stages. A clinical focus group has already been established to take these elements forward.

 A major component of the Highland Quality & Efficiency Framework is that of the development of patient pathways. This will be a key driver and enabler to manage variation and reduce potential for harm. The current PAS system does not lend itself to this approach as it is not an integrated system, this will be rectified with PMS implementation.

2 Access to Care

 Scottish Care Information (SCI) Gateway is an electronic communication system that enables General Practitioners to send referrals electronically to secondary care services. SCI Gateway has been used by NHS Highland and other Scottish NHS Boards to minimise delays in receipt of referrals as well as improve the quality of communication. It has not been possible to integrate electronic referral management by clinicians into the existing PAS systems. This system limitation has resulted in referrals being transferred onto paper to facilitate consultant vetting. The new PMS system will enable full integration of referrals. This integration will improve and enable the referral management process by eliminating paper based processes that exist at present. This will minimise the inevitable human error element and release staff time for other tasks and/or redeployment.

 Full referral integration with PMS will eliminate the risk of ‘lost’ referrals, avoid transcription errors and improve the timeline at this first stage of the patient journey. Consultant vetting will be undertaken ‘on line’ with savings made in staff time enhancing clinical governance. It will also enable information on receipt of referral and action taken to be communicated back to the General Practitioner.

 The waiting times targets within cancer pathways and the 18 RTT Programme are a challenge. Every delay in processing of referrals, triage and administration can result in delays to treatment and at times additional cost, through waiting list initiatives.

In summary, the current PAS systems are not integrated with other clinical systems and so the “linkages” between various parts of a patient pathway can be broken or unseen.

 PMS will bring together a number of features that support changes to how care is delivered. Integrated Care Pathways (ICP) define what steps are completed, when and in which order to provide the appropriate care for a condition or set of conditions. PMS will provide a number of features including order communications and scheduling that are available to ensure that appointments for tests and care interventions are booked in the right sequence and at the right time. This will deliver a number of benefits once definition of each ICP is concluded.

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 The ability to track patients on time-lined patient pathways will improve compliance with agreed patient pathways and reduce unnecessary delays. Access to relevant and timeous patient information will provide the opportunity for improved communication between NHS staff and stakeholders including patients, carers, relatives and other care providers.

 Use of PMS features will release staff time on management of waiting lists. The performance of the Referral Management Service will also be improved through access to improved referral information. The requirement to track patient interventions will reduce with direct access to comprehensive patient information through PMS.

 Improved management information including waiting list and referral to treatment will enable NHS Highland to more effectively manage delivery of waiting time guarantees in the context of 18 Weeks Referral to Treatment (RTT) and Treatment Time Guarantees (TTG). Staff time will be saved through avoidance of manual information collection with the potential for improved planning in use of resources through increased efficiency and improved productivity. Improved information will also inform further development of clinical job plans.

3 Bed Management and Discharge Planning

 PMS implementation will improve patient admission, patient tracking and discharge of patients in secondary care. The functionality of PMS will enable patients to be tracked throughout their hospital stay with identification of all relevant clinical interventions. In addition, PMS will provide the capability to improve discharge planning that enables a patient’s predicted length of stay to be monitored and managed from admission to discharge.

 Increase in the use of predicted and/or planned length of stay in a patient pathway will facilitate patient flow and improve the patient pathway. PMS functionality will release staff time in sourcing empty beds and provide the opportunity to more effectively maximise use of beds and, through appropriate intervention, improve bed efficiencies including length of stay. This functionality also facilitates improved compliance with infection control procedures and will provide a learning process for staff that offers the potential for improved efficiency, output and quality of care. In addition, PMS implementation will improve communication with patients and carers and inform effective bed management and discharge planning.

4 Patient Safety

 The lack of universal clinical visibility of where patients are within the hospital environment at any point in time can cause significant issues with regards to patient flow and patient safety. Patients can be moved from ward to ward for clinical reasons but the medical staff may be unaware or lack visibility of where patients are in the system at any point in time. This lack of current information can result in “safari ward” rounds which, at best, is inconvenient but, at worst, can result in patients not receiving the timely medical care they require.

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 PMS will enable the Community Health Index (CHI) number to be the single Master Patient Index (MPI) across NHS Highland. The CHI number is the current NHS Scotland unique patient identifier.

 Use of CHI will improve the patient experience through improved transfer of information including demographic information thereby reducing the number of times patients are asked for the same information. It will enable patients to be identified with more efficient and effective matching of health records. Use of CHI will also improve data quality and reduce duplicate records. Improved electronic tracking of patients will reduce the number of duplicate tests and investigations undertaken.

 Appointment booking processes are currently linked to Case Reference Numbers (CRN) that are linked to hospital sites. This limits flexibility as patients are booked to the hospital associated with their Case Record Number. Use of CHI will increase the ability to implement flexible booking.

5 Communications

 Communication within healthcare is crucial, and in particular communication between clinicians and clinical systems. The development of recording of the patient journey through PMS will facilitate better communication based on greater information being available for decision making at the right time and the right place.

 Order communications in PMS eliminates paper based diagnostic requests and results reporting. Order communications will enable clinical information to be transmitted more quickly between primary and secondary care and within secondary care, and facilitate information sharing to the benefit of the patient. Order communications will eliminate registration errors related to transcription.

In addition, order communications will provide visibility of previously ordered diagnostic tests and results. This has the potential to reduce unnecessary or duplicate tests. Bar code labels and scanning will replace hand written forms. This change will release laboratory staff time for other tasks. Electronic solutions will replace paper reports with consequent savings in staff time and use of paper consumables.

 Access to electronic discharge letters will improve the flow of information and ensure that information is available to community and primary care colleagues at point of patient discharge. This will enable continuous care to be delivered to the patient at home or in a community setting. It will also, as required, facilitate the booking of patient transport.

6 Efficiency

 PMS will ensure that the CHI number is the single Master Patient Index (MPI) across NHS Highland. This is in line with NHS Scotland requirements.

 Order Communications (electronic requesting and reporting of Laboratory and Radiology tests and examinations within the Acute Services) as detailed above will streamline processes.

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 Pathway development and compliance monitoring as detailed above will bring efficient ways of working which can be monitored.

 Delivery and sustained achievement of 18 weeks Referral to Treatment (RTT) as detailed above. In addition PMS comes with a range of optional modules (at additional cost) which, if adopted, can all be fully integrated with the core PMS package and will add benefits to care and enhance reporting capabilities.

 PMS will provide functionality that will reduce dependency on paper and paper based case notes. PMS will enable NHS Highland to start the migration in the direction of a paper-less organisation. Significant resources are currently expended in storing, moving and handling paper records. A commitment to reduce paper will enable resources to be released for alternative use and may encourage the move to scanning of casenotes to a more comprehensive paperless record.

 PMS through order communications, access to electronic letters and the ability to electronically link different parts of the patient journey will reduce reliance on paper. Integration of SCI Gateway to PMS to SCI Store electronic referrals will further promote the commitment to a paper light organisation.

 Clinical information held electronically will reduce current difficulties of accessing fragmented, and on occasions episodic, paper records held on different sites. Paper records can be lost or mislaid. Missed files can occur that may impact on the quality of care delivered. Electronic patient record solutions help eliminate lost records and offer improved quality of care. Maximising use of PMS offers the opportunity to deliver an equitable and effective service regardless of where the patient presents.

7 Service Planning

 Accurate, timely service planning is crucial to maintaining service delivery across NHS Highland, in particular with the change in demographics and patient need.

The PMS solution will deliver an integrated clinically focussed data set that will underpin service planning decisions.

 The PMS will be an enabling system for all of NHS Highland’s strategic objectives by supporting the realisation of:

1. Improved capacity and demand; 2. Improved patient safety, traceability and identity management; 3. Improved availability of clinical information and business intelligence; 4. Improved end to end patient pathway and processes; 5. Improved communications and ordering process; and 6. Improved clinical management of patients.

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APPENDIX A (ECONOMIC AND FINANCIAL APPRAISAL)

BACKGROUND

This section sets out the economic and financial analysis in support of the projected investment. It considers:

 the available sources of funding;  the affordability of the proposed investment;  the financial Risks; and  the economic analysis.

FUNDING SOURCES

Key Assumptions regarding Funding Sources

The key assumptions with regard to the funding sources for the project are:

 the Scottish Government will provide capital to cover the cost of the software licences on an unsupported capital basis;  NHS Highland will provide capital to cover the costs of hardware and infrastructure;  NHS Highland will use supported capital, where available, and the impact of funded capital charges is taken into account;  NHS Highland will capitalise implementation costs where appropriate and where funding is available;  a flexible package of funding from Scottish Government eHealth is available and is allocated to NHS Highland on the basis of supplier cost profiles. NHS Highlands apportionment is £1.7m; and  the payment profile of NHS Highland will be the subject of final ‘sign off’ between the Board and Intersystems at Call-off contract stage.

A financial summary relating to implementation costs and the forward revenue consequence is provided below. A more detailed ten year forecast of the financial implications, recurring and non-recurring, is also attached as Appendix F.

This forecast has been used as the basis of assessing the affordability of the project for NHS Highland.

The financial requirement for the period of implementation spanning two years is as follows:

Capital Costs

Intersystems costs (Implementation Services) £1,450,000 Hardware Cost £ 500,000 Local Project costs (Largely staffing) £ 842,000

Total cost over 2 years £2,792,000

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The Scottish Government Health Department (SGHD) has responded to NHS Highland and confirmed that some central funding will be available towards implementation. We have been informed that this funding will be a total of £1,700,000 leaving £1,092,000 to be funded from NHS Highland resource over the two year implementation period.

Revenue Costs

Although NHS Scotland has purchased a National license for PMS the associated capital charges are the responsibility of each NHS Board. For NHS Highland this means an annual charge of approx. £240,000 as well as a further capital charge of £100,000 per annum as a revenue consequence of the capital funded hardware. The annual support costs for PMS are approx. £686,594, additional to this hardware support and staffing costs are £173,000.

The total annual revenue costs of PMS are therefore approx. £1,199,594. This figure can be offset by the current cost of supporting the iSOFT PAS (Northern) and Helix PAS (Argyll & Bute). The annual cost of support for these systems is £323,442 which leaves a revenue funding gap of £876,152 per annum.

Summary of Costs

Capital

NHS Highland to fund £1,292,000 over the next two years.

Revenue

NHS Highland to fund £876,152 increase in revenue costs

The following funding sources have been confirmed:-

Capital Funding

SGHD Capital Funding to cover the capital cost of the software licences from Intersystems. This totals £2.4m plus VAT for NHS Highland.

Notes

 Capital charges have been calculated using a depreciation period of 5 years for hardware and 9 years for software/implementation costs. The period for software licences/implementation costs is based on discussions with external auditors to a Consortium Board and the potential length of the contract. i.e. the current advice is that the contract could be extended up to 13 years;

 All other costs will be charged against revenue funds. This will include supplier maintenance and support costs, the local Managed Technical Service costs, capital charges on hardware, software licences and supplier implementation, and NHS Highland internal implementation costs

 VAT costs have been allowed for at 20% in line with the rate expected to apply at contract call-off. This will apply to software licence costs and hardware for the purposes of the calculation of capital charges.

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 VAT can be reclaimed on service contracts. VAT is payable on hardware purchases.

The Intersystems costs are at a September 2012 price base and will be subject to indexation, where appropriate, under the contractual arrangements.

6.4 Financial Risks

Most of the financial risks have been eliminated following the comprehensive national briefing and tendering process. This process has included considerable discussion with suppliers and due diligence to test implementation plans and requirements. It has resulted in a fixed price, subject to the Consortium working together with Intersystems in the agreed approach.

Scottish Government eHealth expects that national value will be reflected through the maximisation of shared solutions and interoperability and the adoption of business as usual mechanisms of co-operation.

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APPENDIX B

PROGRAMME MANAGEMENT

NHS Highland has established a governance infrastructure that will be responsible, on behalf of the NHS Board, for the delivery of the programme of work facilitated by the PMS in line with the Highland Quality Approach. The programme will be undertaken in accordance with the NHS Scotland approved approach to Managing Successful Projects and will adhere to the PRINCE 2 methodology.

The Programme will be clinically led with a strong focus on enabling benefits for patients. It has been recognised that the PMS Programme is more about service change than the information system implementation. The Information Systems are seen as an enabler of a wider change programme. For this reason, the PMS Programme Board will be chaired by a Non-Executive member of NHS Highland Board and will consist of the following members:

 Medical Director as the Executive Director with clinical responsibility;  The Chief Operating Officer as the officer responsible for operational areas most initially impacted by the proposed change programme;  Director of Nursing with responsibility for staff involved mostly in Order Communications and Bed Management;  Head of Business Transformation responsible for the service review required to meet NHS Highlands needs;  Head of eHealth as the Manager responsible for the staff involved in facilitating this implementation;  Head of Finance and Planning;  Patient representative;  Partnership representative;  Supplier.

The Programme Director will attend the Programme Board to provide the main programme reporting.

A Programme Advisor will be a member of the Board with a responsibility for programme assurance, contractual issues, government eHealth reporting and programme promotion.

The Programme Board will be supported by workstreams of Benefits, Communications and Training and Development.

The Programme Management Board will report to NHS Highland Board.

Members of the Programme Board will report and communicate with their relevant professional groups within NHS Highland and at Scottish Government level.

In addition to the Programme Management Board, a project sub-structure has been established to ensure that appropriate delivery accountability is established and stakeholder involvement is in place.

From a contract management perspective, arrangements are established to ensure that the implementation, acceptance and ongoing operation of the PMS aligns with both supplier and customer obligations set out in the Framework and Call Off Contracts.

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NHS Highland will embed risk management in its Programme Governance Framework. This approach will accord with the principles of Risk Identification and Management recommended by the UK Government Office for Government Commerce approach to ‘Managing Successful Projects’.

A risk within the context of the PMS project is classified as any uncertain event which, if occurred, would have a positive or negative impact on the project.

Specifically, a Risk Register has been created to ensure that identified risks are captured and routinely reported to the Programme Board. It will be the responsibility of the Programme Board, as the main governance body associated with the PMS Programme, to ensure that risks are assessed, recorded, mitigated and appropriately managed. This approach to risk management will operate in parallel with the risk management approach that is well established within NHS Highland and the approach to risk assessment will include the NHS QIS Risk Matrix.

Table

Risk Description Action Identifying implementation resource Early creation of an implementation plan. Detailed discussion with supplier during November and December

The service cannot absorb the level and Early service engagement and pace of change in practice required to implementation planning to assess deploy PMS impact. Make links with other service change programs (LEAN & RTT) to ensure that activities are aligned

Implementation Timeline and “Go Live” Detailed discussion with supplier and may not fit NHS Highland requirements other Boards to determine running order and readiness

Costs may be higher than anticipated A robust governance process is in place making the programme unaffordable centred on the business case to ensure that cost control is established in accordance with agreed financial allocations

Inability to provide continuity of A detailed plan will be developed that operational requirements during the ensures all transition risks are identified. systems transition period Operational service engagement in, and understanding of risks will be a feature of the plan

The number of concurrent users Develop implementation plans and model increase after year 1 incurring additional the concurrent use required. Plan for costs early implementation of all likely functionality by end of year 1 after go live

Anticipated benefits are not delivered Develop benefits realisation plan. Assign benefits owners and monitor against the plan. Ensure benefits realisation is integral to implementation plans

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APPENDIX C (BACKGROUND TO NATIONAL PROCUREMENT)

In September 2006 the NHS Scotland eHealth Strategy Board agreed that a national approach should be taken to the procurement of a Patient Management System (PMS). This decision was taken in recognition that PMS represents an important cornerstone of the National eHealth Strategy, and that all but one of the existing NHS Board commercial contracts was due to expire between 2008 and 2010.

A consultation exercise was undertaken with each NHS Board to understand their current systems and future requirements. The term PMS was adopted to describe the overall solution and was delineated into ‘core’ and ‘optional’ modules. This would enable Boards to define their individual requirements according to a set of predefined modules.

The National eHealth Strategy Board required that an Outline Business Case (OBC) be developed to examine the options in more detail prior to a decision being taken to move to procurement.

The OBC was approved by the National eHealth Strategy Board in June 2007 with the following actions:

. the document to be circulated for wider consultation to NHS Boards; . the project to move forward to the requirement definition stage; . production of an Output Based Specification (OBS) which would allow NHS Scotland to provide suppliers with sufficiently detailed information about its requirements.

The OBS defines the requirements for the national PMS system and associated services, and identifies requirements in terms of compliance with national standards for interoperability, interfacing, national statistical and clinical coding, and information governance. The OBS also sought to ascertain a budgetary cost for the programme.

At the National eHealth Strategy Board meeting, in January 2008, it was agreed that PMS should progress to procurement.

The preferred model of procurement was that it should be led by ‘stakeholder’ Boards and that the ensuing supplier choice should result in the award of a Framework Contract to be entered into by National Services Scotland on behalf of all Boards. A consortium of NHS Boards led by NHS Lanarkshire and involving NHS Ayrshire & Arran, NHS Borders, NHS Greater Glasgow & Clyde and NHS Grampian was formed to lead the procurement Programme. A Commissioning Brief was formally issued to the PMS Consortium Management Group at its first meeting in January 2008.

Fundamental to the procurement approach has been a focus on patient benefits and a requirement for clinicians to be central to the procurement process. With this in mind, comprehensive stakeholder involvement processes was designed into the procurement project and upwards of 200 stakeholders including clinicians from all relevant disciplines have been engaged in the programmes governance, the requirements specification and the evaluation process.

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The Procurement Process was conducted in accordance with U.K. Government Office for Government and Commerce best practice and followed the ‘Competitive Dialogue’ approach. This engaged the Consortium Team in an iterative engagement process that refined supplier responses to the ‘best fit’ in accordance with the Output Based Specification.

Outcome and Current Position

The outcome of the procurement has resulted in the award of a Framework contract to Intersystems Corporation. The Intersystems contract will provide financially and economically viable solutions and services compliant with NHS Boards’ current and perceived future needs. Intersystems Corporation have worked with the Consortia Boards and have implemented the core system in NHS Borders, NHS Grampian, NHS Ayrshire & Arran, NHS Lanarkshire and are working with NHS Greater Glasgow & Clyde on their implementation.

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APPENDIX D (CONTRACTUAL FRAMEWORK)

The overall contractual framework consists of a Framework Agreement, which National Services Scotland (NSS) signed on behalf of the NHS in Scotland, and which allows Customers (NHS Scotland Health Boards as well as other NHS Scotland bodies and NHS Northern Ireland bodies) to call off a system and services from the chosen supplier. The form of Call Off Contract to be used by Customers is appended to the Framework Agreement and has been negotiated with Intersystems, such that at the time of call off by the Board, only those issues specific to the Board will need to be negotiated and agreed with the supplier. Such issues include:

 the Specification of the Board's chosen System;  the Implementation Plan;  the Acceptance Tests applicable to the System; and  the Pricing/Payment Schedule.

The Framework Agreement is best described as an "enabling agreement" in that its purpose is to facilitate call off by Health Boards of their chosen solution. Call Off Contracts will be entered into between Intersystems and the Board. Under the Call Off Contract, Intersystems commits to implement and provide support services for the System, which is the PMS core solution and any optional modules that the Board opts to take.

The Call Off Contract covers two main phases:

. the Implementation Phase; and . the Support Phase.

Linked to these phases is the agreed warranty of the System to be provided by Intersystems, which is a 3 month period from the date when the System goes live.

Implementation Phase

During the Implementation Phase of the Call Off Contract, Intersystems will deliver a System that meets the agreed Specification in accordance with the agreed Implementation Plan. The Board will test the delivered System in accordance with agreed Acceptance Tests and, should the System pass the Acceptance Tests, it will go live. The Implementation Plan will be agreed between the Board and Intersystems prior to signature of the Call Off and will contain key implementation milestones (we expect milestone payments to attach to at least some of these) and the Board's corresponding responsibilities in connection with the implementation.

Provision has been made for Liquidated Damages to attach to some (if not all) of the implementation milestones, which provides an additional remedy for the Board should Intersystems be late in delivering against that milestone.

The development of agreed functionality around Clinical Support Tools (CST) has been identified as a key milestone by Boards, which has been considered sufficiently important as to merit specific treatment. Intersystems are being asked to confirm that CST development will be a key milestone in Intersystems Implementation Plan with Boards and that the CST milestone will have attached to it:

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 a milestone payment, which shall not be payable until successful delivery against the milestone;  liquidated damages, which will provide further remedies for the Board should Intersystems fail to deliver on time;  a right for the Board to terminate the Call Off Contract if Intersystems fails to deliver on time.

Support Phase

Following go-live, the Call Off Contract enters the Support Phase, where Intersystems offers support and maintenance services for the System. The support and maintenance services are to be provided in accordance with agreed service levels, to which service credits attach for failure to adhere. As well as measuring response and fix times according to agreed priority levels of incidents, InterSystems is also measured against overall System availability.

Legal Relationships

The legal relationships between the various parties can be summarised as follows:

INTERSYSTEMS FRAMEWORK AGREEMENT NSS

PRICING AND PAYMENT INTERSYSTEMS HEALTH BOARD AGREED CALL OFF ACCEPTANCE CONTRACT TESTS

IMPLEMENTATION PLAN

SPECIFICATION FOR CHOSEN SOLUTION

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SUMMARY OF MAIN PROVISIONS OF THE CONTRACT

 Term and Termination

The term of the Call Off Contract is to be agreed at the time of calling off, but Intersystems have been asked to provide prices on the basis of a 10 year term. The Board has the ability to terminate the Call Off Contract for convenience, but will have to pay Breakage Costs to Intersystems in the event of such a termination.

In addition to termination for convenience, the Board is also entitled to terminate the Call Off Contract in various other circumstances, including: insolvency, material breach, damage to the Board's reputation, extended step-in, built-up Service Points, change of control, drop in Intersystems financial standing or termination of the Framework Agreement.

Intersystems does not have the ability to terminate the Call Off Contract, except in circumstances of non-payment by the Board and then only after additional time has been given to pay.

 Intersystems Liability

Intersystems have accepted an obligation to warrant that the System complies with the Specification throughout the life of the Call Off Contract. Therefore, if the System was found not to comply then the Board would be entitled to exercise contractual remedies against Intersystems, including service credits, damages for breach, step-in and termination.

The System will not exit the Warranty Period successfully until certain criteria are met, which are that during the period of one month (which period starts no more than two months after the Go-Live Date), there have been no Severity Level 1 Problems.

In addition, Intersystems has agreed to a Warranty Retention sum, the amount of which will be agreed on a case by case basis, and which will not be released to Intersystems unless certain criteria are met, which are that the System has no unresolved Severity Level 1 and Severity Level 2 Problems and that the number of Severity Level 3 and Severity Level 4 Problems has fallen by 50% from the number reported two months after the Go-Live Date . Intersystems has negotiated liability caps which are based on a fixed financial cap, regardless of the price due under the Call Off Contract. The cap is £10m during the Implementation Phase and £5m during the Support Phase. In addition, the chosen supplier has negotiated a global liability cap of £25m, which applies across all Call Off Contracts.

The liability cap does not apply to the indemnities which have been granted by Intersystems in relation to death or personal injury, breach of data protection law, breach of the data protection, confidentiality and Freedom of Information (FOI) clauses in the Call Off Contract and Intellectual Property (IP) infringement.

 Intellectual Property

The overall position in relation to intellectual property rights (IPR) is as follows:

27 225

. Intersystems retains ownership of its pre-existing IPR and licences this to the Board; . the Board retains ownership of any pre-existing IPR required in respect of the System and licenses this to Intersystems for the purposes of delivery of the System only; . where Intersystems develops software specifically for the Board ("Specially Written Software"), ownership of this is assigned to the Board. To be part of the category, the software must be created specifically to meet the Board's Requirements, be used to provide services under the Call Off Contract to the Board and be paid for by the Board; . the Board is granted a licence to use Intersystems Background IPR for the purposes of making use of the Specially Written Software, provided that the Board commits that it will not seek to unbundle any embedded Background IPR or use that Background IPR on a stand-alone basis.

Intersystems software licensing has been agreed to be on a concurrent user basis. This means that a specified number of users will be licensed by each Board to access the System. NHS Highland has agreed a licence allocation of 0.3 licences per acute hospital bed. This accords with supplier experience elsewhere. It should be noted, however, that this agreed licence position will be reviewed after a period of 12 months from the go-live date. Any additional use of the system at that date will result in an up-rating of licence entitlement at no additional cost to the Board.

If the actual number of concurrent users is less than the number estimated per the table above then the Board can either keep the additional concurrent user capacity or choose to drop down to the lower amount in order to lower ongoing support costs (albeit that there will be no licence fee refund). When the required concurrent user capacity has been determined for a Board, any additional user capacity must be purchased by the Board.

 Customer Responsibilities/Assumptions and Dependencies

Intersystems' responsibilities under the Call Off Contract are subject to the Board meeting its agreed "Customer Responsibilities" and to certain agreed "Assumptions and Dependencies" remaining true. The consequences of failure of either of these are relief for Intersystems from its contractual obligations. This relief can take the form of an extension of time and/or compensation for loss suffered by Intersystems.

 Governance

The Call Off Contract contains a governance structure whereby Call Off Contract Representatives from each of the NHS Boards and Intersystems meet regularly to manage the Call Off Contract. In addition, the Call Off Contract envisages a Call-Off Level Management Forum, which has the role of providing executive level review of the delivery and receipt of the services and the System, providing a holistic review of the overall commercial and strategic relationship between the Board and Intersystems and discussing and sharing areas of common interest in relation to overall business strategy.

 Compliance with Standards and Policies

Intersystems is obliged to comply with the NHS Scotland standards and policies and security requirements, as well as any additional standards and policies that apply "locally" to the Board and which are agreed as part of the Call Off Contract.

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APPENDIX E

NHS HIGHLAND HIGH LEVEL PMS IMPLEMENTATION PLAN

ACTIVITY/MONTH Apr Jun Aug Oct Dec Feb Apr Jun Aug Oct Dec Feb Apr May Jul Sep Nov Jan Mar May Jul Sept Nov Jan Mar May PHASE 1 PMS Preparation

PHASE 2 - 8th/9th November PMI Go Live Inpatients Go Live Outpatients Go Live Waiting List Go Live Medical Records Tracking Go Live Clinical Coding Go Live Reporting Go Live Current Interfaces Go Live Bed Management Preparation

PHASE 3 Bed Management Go Live

PHASE 4 Order Communications Preparation Order Communications Go Live

PHASE 5 Review and Final handover to Operational

29 Appendix227 F NHS Highland Patient Management System Business Case Financial cost, funding and requirement 2012/22

Year 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 Total

£ £ £ £ £ £ £ £ £ £ Costs Non Recurring

Preparatory Works (Revenue) 59,000 59,000 Hardware Purchase 500,000 500,000 1,000,000 Intersystems Costs 1,094,327 355,673 1,450,000 Local Implementation Costs (Staff) 576,674 265,326 842,000

Total Non Recurring Costs 59,000 2,171,001 620,999 0 0 0 500,000 0 0 0 3,351,000

Funding Non Recurrent eHealth Strategy Funding -59,000 -592,000 -651,000 NHS Highland Capital -500,000 -500,000 -1,000,000 Scottish Government - Revenue -1,079,001 -620,999 -1,700,000

Total Non Recurrent Funding -59,000 -2,171,001 -620,999 0 0 0 -500,000 0 0 0 -3,351,000

Funding Requirement (non recurrent) 0 0 0 0 0 0 0 0 0 0 0

Recurring Costs

Capital Charges (Licence) 0 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 240,000 2,160,000 Capital Charges (Hardware) 0 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 100,000 900,000 PMS Support 0 171,649 686,594 686,594 686,594 686,594 686,594 686,594 686,594 686,594 5,664,401 Hardware Support/Staff 0 173,000 173,000 173,000 173,000 173,000 173,000 173,000 173,000 173,000 1,557,000

Total Recurring 684,649 1,199,594 1,199,594 1,199,594 1,199,594 1,199,594 1,199,594 1,199,594 1,199,594 10,281,401

Helix/iSoft Termiation 0 -161,721 -323,442 -323,442 -323,442 -323,442 -323,442 -323,442 -323,442 -2,425,815

Funding Requirement (recurrent) 0 684,649 1,037,873 876,152 876,152 876,152 876,152 876,152 876,152 876,152 7,855,586

Costings at 2012/13 values 228 229 Highland NHS Board 4 December 2012 Item 5.7

CARBON MANAGEMENT PLAN

Report by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance

The Board is asked to:

 Approve the NHS Highland Carbon Management Plan.  Approve the target of a 33% Carbon reduction by 2016.  Note the progress made in improving our Carbon management arrangements.  Support the improved arrangements for local responsibility for Carbon Management.

1 Background

In 2008 NHS Highland produced its first Carbon Management Plan, published in 2009. This plan was an excellent starting point to ensure understanding of the carbon consequences of our activities, but it reflected the reality of the data available. A lot of work has been undertaken in the last 4 years and much has been achieved in managing carbon.

However it was recognised that the original targets reflected the situation 4 years ago, some of them were realistic and met, and others were wrong targets. The Carbon Management Board decided the plan needed updated and it was agree to do this in partnership with the Carbon Trust using their carbon revisited scheme. This scheme is for public sectors bodies and is regarded as representing best practice in carbon management. NHS Highland is one of only two boards to complete this programme out of an initial list of 11.

2 Carbon Management Plan

The Carbon Management Plan attached sets some challenging priorities to contain and reduce our energy costs and reduce our impact on the environment. This plan differs from the previous in that it looks much more holistically at our activity.

The projects identified in the plan to our carbon footprint cover a wide range of our activity, not only capital projects. These are included and in the case of Raigmore Biomass work is ongoing on this project. Capital Investment remains a main plank of improving our energy efficiency however in the current economic climate this alone will not deliver our requirements. It is essential that operational units engage fully in the carbon reduction process, there are few other cash saving opportunities that can be achieved so easily so this should be seen as a valuable contribution.

The proposals contained in this plan cover a much wider range of issues and set a way forward for much greater user engagement in order that we reduce energy usage, the most effective energy reduction of all. There are areas where we have data deficits, these are highlighted in the plan and we are working to positively address these. Some of the solutions required for example on business mileage paid for use of private cars, known as the grey fleet require national co-operation, Highland are at the front of pushing this. This involves modifying existing software to provide information in a more useable format.

The new Carbon Management Plan identifies clear targets for reducing our overall carbon footprint by 33% by March 2016. This is an ambitious target however the plan identifies a clear path to achieve this. 230

This would position NHS Highland very much as leaders within the NHS on carbon reduction. If we achieve this target this also makes a significant reduction in our Carbon Reduction Commitment Bill, the cost of this is likely to rise over the years with plans already in place to increase the original £12 per tonne to £16 within the next 3 years, so any effort made in this area really make a significant difference. This cost will only rise in the future.

It is also worth pointing out that evidence exists to show that improvements in the environment have health benefits so it is entirely consistent with our fundamental purpose as an organisation that we are leaders in this area in Highland.

3 Contribution to Board Objectives

This work contributes to the Board’s financial targets and to our commitment to work sustainably within the environment. It also contributes directly to the Heat target on the energy and environmental performance and if implemented will exceed our target performance quite significantly.

4 Governance Implications

Progress on this will be monitored through the Asset Management Group which is a standing committee of the board.

 Staff Governance

There are no staff governance issues.

 Patient and Public Involvement

This plan does not require patient or public involvement.

 Clinical Governance

There are no clinical governance issues

 Financial Impact

This plan should reduce energy costs if implemented in full and will contribute towards the organisations savings targets.

5 Risk Assessment

The main risks around this project centre are non-engagement of staff and failure to get the investment for the projects. The individual projects have risk mitigation processes in accordance with project management procedures.

6 Planning for Fairness

There are no issues in this respect.

2 231

7 Engagement and Communication

If approved a communication strategy for this work will be developed as this is a good news story. It is expected that as we implement the projects regular communication with both staff and press will be carried out.

8 Conclusion

The Board is asked to endorse this ambitious plan that will make a significant impact to the Highland environment and the running costs of NHS Highland. If this is fully implemented we will be amongst the leaders in Carbon Management and will also reduce our payments in respect of the Carbon Reduction Commitment.

This is an innovative programme of behaviour and physical changes to the estate fabric and usage, which will have a positive environmental impact and represents a real commitment to improving our environment for our staff and patients.

Eric Green Head of Estates NHS Highland

23 November 2012

3 232 233 Highland NHS Board 4 December 2012 Item 5.8

RESTORATIVE DENTISTRY

Report by Roseanne Urquhart, Head of Health Care Strategy Development on behalf of Ian Bashford, Board Medical Director

The Board is asked to:

 Confirm approval of the business case for restorative dentistry that was developed in collaboration with north of Scotland colleagues.

1 BACKGROUND AND SUMMARY

The Board is asked to confirm approval of the business case for Restorative Dentistry that was developed in collaboration with North of Scotland (NoS) colleagues. The business case has been agreed in principle by the NHS Highland Executive Group.

2 CURRENT SERVICE PROVISION

The current Consultant Restorative Dentistry service in north Highland is delivered through a historical, loosely defined arrangement within the acute service level agreement with NHS Grampian, and is supplemented by waiting list initiative clinics delivered by a Locum Consultant, who attends Raigmore Hospital from his base in London.

There is no access to specialist treatment in all areas of restorative dentistry and very little access to treatment planning.

The current service in north Highland does not meet demand and is unable to deliver the 18 Week Referral to Treatment Target, given that the average wait is 16-18 weeks for initial appointment and approximately two years for treatment. As these issues are replicated in NHS Grampian, it was decided to collaborate at a regional level to explore a solution.

3 PROPOSED SERVICE

A Business Case (attached) has been developed by the North of Scotland Planning Group, which seeks to expand the capacity of consultant led Restorative Dentistry services in the NoS, through the appointment of two additional Consultant posts (one based in Highland and one in Grampian), and to develop, through education, training and support, a network of primary dental care teams across the NoS to support the network and provide intermediate care services in primary care, thus reflecting the geography and the need of the North of Scotland.

The clinical risks of not developing the network as proposed include:  Inability to meet waiting time targets;  Inequity of access to specialist treatment for all patients;  Inappropriate referrals to secondary care services and to General Dental Practitioners with lack of appropriate training; and  Risk of loss of Head and Neck cancer status in NHS Highland

The network model will see the development of an integrated service between primary and secondary care, and will have agreed acceptance and discharge criteria for each tier of care. This is in accordance with the recommendations of the SDNAP Report1.

1 Scottish Dental Needs Assessment Programme (SDNAP), (July 2012), Restorative Dentistry Needs Assessment Report 234

There are significant clinical gains that would result from the development of the network approach, including:

 providing services as locally as possible and providing support for local dental services for communities across the North of Scotland;  provide equitable access to care and treatment based on clinical need;  provide safe and effective services, which will improve quality and clinical outcomes;  providing sustainable services across the region both primary and secondary care;  supporting teaching within Aberdeen University, University of the Highlands and Islands and at the Dental Outreach Centres in Western Isles, Inverness, Elgin and Aberdeen; and  supporting other consultant led services such as the oral cancer and cleft palate networks.

4. CONTRIBUTION TO BOARD OBJECTIVES

This paper recognises that the current delivery of the restorative dentistry service across the North of Scotland does not meet the demand and is unable to deliver the 18 week Referral to Treatment waiting times target.

The developments contained within this proposal will assist NHS Highland to achieve its Vision and Strategy as it will help with the delivery of the HEAT Targets, deliver Improvement and Change through the development of an appropriate service for patients. This service development will enable the delivery of patient centred care as locally as possible through the optimisation of skillmix. This proposal will also help to deliver a more efficient service as there were will be no need to utilise expensive locum services and a more effective service due to the joint working across primary and secondary care of an established team

One of the key objectives this proposal will address is the delivery of a Safe and Effective Service by ensuring patients are seen and treated within the appropriate time scales as locally as possible. Dental Teams will have opportunities to develop the skills and knowledge to manage patients locally where appropriate referring only those requiring specialist care.

5. GOVERNANCE IMPLICATIONS

 Staff Governance

A North of Scotland approach to the development of a Restorative Dentistry Service will ensure longer term stability of the service encouraging improved recruitment and retention of staff. One of the other key benefits of this proposal will be the opportunities for primary care dental teams to develop their skills which will enable greater opportunities for patients to be seen where appropriate as locally as possible.

 Patient and Public Involvement

An improved Restorative Dentistry service will reduce the number of complaints NHS Highland receives in relation to waiting times and clinical concerns. The provision of a North of Scotland service will provide equity of access for all patients based on clinical need.

 Clinical Governance

The provision of a North of Scotland solution for Restorative Dentistry will ensure patients have equity of access to specialist care according to clinical need. The new service will reduce the number of inappropriate referrals to other centres in Scotland and inappropriate referrals to other specialist services. Local Primary Care Dental Teams will have

2 235 opportunities to access training locally and this will enhance the skills available within Primary Care with the impact that only those patients requiring specialist input will be referred into the Secondary Care services. Restorative Dentistry is a key component of the rehabilitation of the patient following treatment for head and neck cancer and the lack of availability of a sustainable and appropriate restorative dentistry service may impact on NHS Highland status as a Head and Neck Cancer Centre. This would have a significant impact across a number of other services currently provided by NHS Highland.

 Financial Impact

The financial contribution for the development of the NoS restorative dentistry network has been calculated on a population basis; the NHS Highland contribution is £103,000.

NHS Highland is establishing a Restorative Dentistry Group to explore how these costs can be identified within existing resources; specifically from the dental services and educational budgets. Over 50% of these costs have already been identified to-date from the aforementioned budgets. It is expected that the costs of this service will be met from the overall dental budget.

There has been positive discussion with the Scottish Government Access Support Team who have affirmed their broad support for the development of the NoS Restorative Dentistry Service. There are some outstanding issues which have been raised by the Chief Dental Officer, which require to be addressed before any funding can be released. However once resolved, Scottish Government have confirmed that they will contribute £100k to support the establishment of the NoS restorative dentistry service. This sum will be earmarked non- recurrently for 2013/14.

6. RISK ASSESSMENT

The North of Scotland Planning Group report on Restorative Dentistry services contains a section on the current clinical risks and identifies how these risks will be addressed through the implementation of the preferred option.

7. PLANNING FOR FAIRNESS

Planning for Fairness will require to be undertaken during the development of the proposed Restorative Dentistry Network across the North of Scotland.

8. ENGAGEMENT AND COMMUNICATION

Once the proposal for a North of Scotland Restorative Dentistry Network has been progressed, NHS Highland will work with colleagues in the North of Scotland Planning Network to develop a communication plan across the area.

Ian Bashford Medical Director

23 November 2012

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NORTH OF SCOTLAND PLANNING GROUP

Restorative Dentistry in the North of Scotland

October 2012

North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles 237

Contents

Executive Summary ...... 2

1. Introduction/Background ...... 3 1.1. What is Oral Health? ...... 3 1.2. Restorative Dentistry...... 3 1.3. Growth in Dental Referrals ...... 4 1.3.1. Increase in dental registrations ...... 4 1.3.2. Ageing population ...... 5 1.4. Changes in clinical practice...... 7 1.4.1. Demand for more complex (and expensive) treatments such as dental implants to restore the ageing dentition instead of plastic dentures...... 7 1.4.2. Changes in the disease patterns in oral health in children related to treatments such as general anaesthesia...... 7 1.5. Reduction in waiting time guarantees...... 8 2. Strategic Objectives for restorative dentistry...... 8 3. Description of current service ...... 8 3.1. NHS Grampian ...... 9 3.1.1. Service Overview...... 9 3.1.2. Demand ...... 9 3.1.3. Workforce Profile...... 10 3.2. NHS Highland...... 10 3.3. NHS Orkney ...... 11 3.4. NHS Shetland...... 12 3.5. NHS Western Isles ...... 12 4. Risk Assessment...... 12 5. Options ...... 13 5.1. List of options ...... 13 5.2. Preferred option ...... 13 6. Proposed model: North of Scotland Managed Service Network for Restorative Dentistry...... 14 7. Finance ...... 18 8. Clinical Benefits...... 19 9. Outcomes ...... 19 10. Links to the NHS Scotland Quality Strategy ...... 19

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11. Regional Planning in the North of Scotland...... 20 12. Affordability ...... 20 13. NHS Boards Approval...... 20

Appendix 1: Estimated demand and consultant service needs based on Glasgow/West of Scotland demand levels...... 21 Appendix 2: Definition of Restorative Dentistry Service ...... 22 Appendix 3: Costs by Board of Treatment ...... 23 Appendix 4: Discussion of options...... 24

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Executive Summary

This Business Case seeks to expand the capacity of consultant led Restorative Dentistry services in the North of Scotland (NoS), through appointment of two additional Consultant posts, and to develop, through education and training, a network of primary care teams across the NoS to support the network and provision of specialist services in primary care, thus reflecting the geography and the need of the North of Scotland.

There are currently 2.4 wte Consultants in Restorative Dentistry within the North of Scotland, based in Aberdeen and providing a service to the population of Grampian, and a visiting service to Highland, Orkney and Shetland (approximately 811,478 people 1 ).

The current service does not meet demand and is unable to deliver the 18 week referral to treatment target, given that the average wait is 16­18 weeks for initial appointment and in the region of two years for treatment.

The clinical risks of not developing the network as proposed include:

• Inability to meet waiting time targets; • Inequity of access to specialist treatment for all patients; • Inappropriate referrals to secondary care services and to GDPs with lack of appropriate training; and • Risk of loss of Head & Neck cancer status in NHS Highland

The network model will see the development of an integrated service, between primary and secondary care services, and will have agreed acceptance and discharge criteria for each tier. This is in accordance with the recommendations of the SDNAP Report2 .

There are significant clinical gains that would result from the development of the network approach, including:

• providing services as locally as possible and providing support for local dental services for communities across the North of Scotland; • provide equitable access to care and treatment; • provide safe and effective services, which will improve quality; • providing sustainable services across the region; • supporting teaching within Aberdeen University, University of the Highlands and Islands and at the dental Outreach centres in Western Isles, Inverness, Elgin and Aberdeen; and • supporting other consultant led services such as the oral cancer and cleft palate networks.

1 GROS 2010 based population projections. NHS Highland population quoted excludes Argyll & Bute. 2 Scottish Dental Needs Assessment Programme (SDNAP), (July 2012), Restorative Dentistry Needs Assessment Report

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1. Introduction/Background

1.1. What is Oral Health?

Oral health is achieved when the mouth is free of chronic disease and sepsis, facial pain, oral and throat cancer, acute oral mucosal lesions/conditions, birth defects (e.g. Clefts), periodontal disease, tooth decay and tooth loss and the effects of other diseases affecting the mouth and oral cavity (e.g. diabetes).

Oral health is integral and essential to general health and is a determinant factor in quality of life. Poor oral health affects people physically and psychologically. It influences how they grow and develop; influences how they enjoy life, look, speak, taste and chew food, socialise and also impacts on self esteem and well being. It is known that decayed and extracted teeth not only affect quality of life but also contribute to depression of mood.

Globally, oral diseases are amongst the most expensive to treat and prevention plays an important role in securing oral health. The publication of the Action Plan for Improving Oral Health & Modernising NHS Dental Services 3 , has resulted in capacity building in both oral health improvement programmes and access to primary care dental services through the expansion of the dental workforce and premises.

Presently Scotland has the highest percentage of the population ever registered with the NHS. As primary care dental services expand to cover the whole population, there will be increased demand for specialist restorative services, especially in the older age groups, where the largest improvements are being seen.

1.2. Restorative Dentistry

Restorative dentistry is the study, examination and treatment of diseases of the oral cavity, the teeth and their supporting structures. Restorative Dentistry covers the General Dental Council recognised specialities of periodontology, endodontics and prosthetics (see Appendix 2) with patients requiring care across a combination of, or commonly all three specialities.

The specialty provides a comprehensive diagnostic and treatment planning service for a wide range of congenital and acquired diseases/disorders affecting the mouth, face and jaws. Consultant Restorative Dental Services are distributed mainly in Scotland in Glasgow, Edinburgh, Dundee and Aberdeen.

Typically treatment plans frequently extend over several visits with early planned intervention and preventive regimes increase the efficiency of care delivery, improves the patient journey and reduces costs.

The Consultant in Restorative Dentistry provides:

• Advice and treatment planning for General Dental Practitioners and the Salaried Dental Service; and • Treatment of multi and inter­disciplinary cases in conjunction with other specialties, with a major role in the delivery of multi­disciplinary care. In particular, restoration of the oral and dental functions in cases of Oral cancer and Cleft Palate.

3 Scottish Executive (2005) “An action plan for improving oral health and modernising NHS dental services in Scotland”

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The following list is not exhaustive but reflects the broad scope of restorative dentistry 4 :

• Management of pain and anxiety • Tempero­mandibular dysfunction • Prosthetic rehabilitation of cancer/trauma • Implantology • Endodontics including periradicular surgery • Management of diseases affection the periodontal tissues • Management of dental caries • Tooth wear including attrition, abrasion and erosion • Aesthetic/Cosmetic Dentistry • Replacement of missing teeth other than by implants • Care of medically compromised patients • Care of patients with special needs

Patients with congenital facial defects or major dental abnormality require carefully planned treatment as an integral part of a combined orthodontic/oral surgical and restorative therapy. Similarly patients with acquired defects either through trauma or as a result of treatment for head and neck tumours require restorative management and intervention. Guidelines for Head and Neck Cancer produced in 2007 5 recommend that the Restorative Dentist should be a member of a multidisciplinary group involved in the care of patients treated with radiotherapy and chemotherapy.

1.3. Growth in Dental Referrals

1.3.1. Increase in dental registrations

The levels of dental registration in the population are rising for all ages, although rates still vary across age groups.

The main gatekeeper for restorative referrals is the primary care dentist. The North of Scotland has experienced significant challenges in providing access to primary care dentistry for the resident populations, with the result that many outpatients have been without care for considerable periods of time. It is anticipated that with the increase in the number of dentists and improved landscape in terms of access as measured by NHS dental registrations, referrals to restorative services will increase due to the burden of complex treatment need, the result of failure to provide access to enable early intervention, and appropriate monitoring of heavily restored dentitions in a population who now retain teeth into older age.

Those who are not registered with a dentist are perhaps more likely to present to secondary care regardless of the severity of their condition.

4 British Dental Association, (November 2005) “Consultant Practice in the Dental Specialties” 5 Scottish Intercollegiate Guidelines Network (October 2006) “Diagnosis and Management of Head and Neck Cancer: A national clinical guideline, (10) 1 905813 007

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Percentage of people registered as at 31 st March 2012

Age groups All 0­2 3­5 6­12 13­17 Children NHS Board Scotland 43.9 90.6 99.1 96.7 87.5 Grampian 31.6 77.8 86.6 85.0 74.9 Highland 41.4 87.0 95.1 96.0 85.5 Orkney 67.0 99.8 97.6 92.2 91.3 Shetland 70.7 97.2 98.6 96.2 93.1 Tayside 35.9 86.0 95.0 93.1 82.9 Western Isles 26.3 66.4 76.3 74.8 67.0

All All 18­24 25­34 35­44 45­54 55­64 65­74 75+ Adults Ages NHS Board Scotland 84.8 85.3 80.3 78.0 69.9 66.6 56.0 75.7 78.0 Grampian 72.4 61.1 53.1 51.4 47.3 45.7 31.5 52.6 57.0 Highland 84.0 66.1 58.4 57.1 53.2 54.1 46.9 58.7 63.9 Orkney 74.8 52.9 56.5 64.5 58.7 54.9 42.7 58.0 64.5 Shetland 94.3 68.7 72.5 75.6 69.4 65.9 54.4 71.6 76.3 Tayside 79.8 83.9 80.3 78.1 70.2 67.3 54.9 74.2 75.9 Western Isles 71.8 66.5 72.8 74.6 66.8 63.1 43.4 66.1 66.3 Table 1: Dental registrations Source: ISD Scotland, MIDAS

1.3.2. Ageing population

The current population of the North of Scotland 6 is reported as 1,329,509 7 . For the purpose of this business case, Tayside and Argyll & Bute have been excluded, therefore the population is reported as 837,668.

The population projections available identifies that the population is projected to increase by 18% (148,948 persons) over the next twenty five years, however, the increasing population will consist of older people, with a 76% increase in the number of people aged 65 or over by 2035. Those in the over 65 age group are projected to account for 26% of the total population by 2035 and those aged 15 and under will account for 17%.

NoS Population (excluding Tayside and Argyll & Bute) Percentage change 2010­2035 103%

90% 53% 65% ns o

rs 40% e 7% 6% 18% P 12% 15%

­10% ­1% 0­15 16­29 30­49 50­64 65­74 75+ Total Age group

Chart 1: Population percentage change 2010­2035

6 The North of Scotland includes Grampian, Highland, Orkney, Shetland, Tayside and Western Isles. 7 GROS (2010) “Projected population of Scotland (2010 based)” www.gro­scotland.gov.uk

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The ageing population will result in more complex treatment needs and will require more specialist dentists. This is because older people are retaining their own teeth for longer, which means that the complexity of treatment increases. There will need to be an appropriately trained workforce to manage this.

Historically, the pattern of care relied considerably on a large number of extractions of teeth as opposed to restoration of the dentition.

The normal prosthetic replacement has been predominantly plastic dentures (part or full) and over the period 1972­2010 the percentage of people using plastic dentures has declined from 64% to 32.85%, as over the last 20 years the emphasis has moved to restoration of the dentition, with significant increases in endodontics, dental bridges, crowns, veneers and implants with associated restoration.

Between 1972 and 2010, the percentage of the population who have their own teeth and require complex care has increased in each age group:

Age group % increase

55 – 65 66.2 65 – 74 63.4 75+ 48.4 Table 2: Percentage increase in population with own teeth

In order to gauge the magnitude of this trend, which will continue over the next 20 years, the number of teeth requiring care (potential restoration), treatment for gum disease and other oral problems will also increase considerably. The number of teeth is illustrated by using the change in the number of people with 20 or more teeth. Chart 2 below illustrates that between 1993 and 2010, there was a 31.4% increase in the number of 55­64 year olds with 20 or more teeth.

Percentage of adult population with 20+ natural teeth in Grampian 1993­2010

100

90

80

70

60

50

40

30

20

10

0 25­34yrs 35­44yrs 45­54 yrs 55­64 yrs 65­74 yrs 75 yrs 1993 20+ teeth 89.3 75.2 47.9 24.9 13.1 2.1 2010 20+ teeth 94.4 89.5 74.4 56.3 30.7 15.7 Chart 2: Percentage of adult population in Grampian with 20+natural teeth

As older people keep their teeth, there is ample evidence from America and Scandinavia of increased demand for advanced restorative procedures such as bridges and implants, substituting the replacement of lost teeth with plastic dentures. Scotland and the UK have not moved as quickly on these issues as other countries, with levels of bridges and implants remaining low in the UK. Also evidence for the adult dental health survey – England.

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1.4. Changes in clinical practice

1.4.1. Demand for more complex (and expensive) treatments such as dental implants to restore the ageing dentition instead of plastic dentures.

The adult dental health survey in Grampian in 2010 recorded that 4.9% of the adult population in Grampian had implants. There are few surveys that give equivalent statistics across Europe, however, a comparison of implants across several countries based on sales/usage shows the UK (Scotland) to be at the bottom of the league table on usage of dental implants, with places such as Switzerland using 10 times as many per head of population. This is despite the fact that Scotland has some of the worst oral health in Europe. The majority of these implants in Europe are delivered within primary care services, whilst in Scotland, the largest numbers in the NHS are in secondary care, complemented by a flourishing private sector service.

1.4.2. Changes in the disease patterns in oral health in children related to treatments such as general anaesthesia.

The previously high levels of dental disease in Scotland have reduced dramatically over the last 20 years to levels of oral health in children which previously were only thought achievable through water fluoridation. These changes, plus those associated with different pathways of care such as sedation (relative analgesia) or stainless steel crowns, both delivered in primary care, have resulted in major reductions of expensive day care general anaesthesia.

Chart 3 below shows that NHS Grampian has seen a fifty per cent reduction in dental general anaesthetic day cases, resulting in significant savings, with an estimated reduction in NHS costs of acute care of £1m per annum in Grampian alone. There have been similar reductions in paediatric dental general anaesthetic day case activity in other Boards delivering similar reductions in costs on this type of activity.

Grampian Dental Child General anaesthesia 2005­10

2000

es as c

f 1000 o

o N 0 2005 2006 2007 2008 2009 2010 Total 1664 1560 1388 1285 1134 844 RACH 1408 1276 1220 1160 982 734 Moray 265 230 168 125 152 110 Year Chart 3: General Anaesthesia in children (Grampian, 2005­10)

These significant changes will have a continuing effect on the levels of dental care as demand for better dental services continues well on into the next decade.

The changes in other dental/oral diseases, such as oral cancer, are less predictable until the effect of a reduction in smoking and drinking levels impact on the older populations.

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1.5. Reduction in waiting time guarantees

The Scottish Government set out the vision for a stronger NHS which would make better use of our capacity to deliver a better deal for patients. A major element in achieving this vision was the national waiting time guarantee:

“A whole journey waiting time target of 18 weeks from all source referral to treatment….by December 2011” Cabinet Secretary for Health and Wellbeing Scottish Parliament – Official Report, 28th June 2007

The Dental Specialties Task and Finish Group reinforced this commitment and underlined that all dental specialties are included in this guarantee. 18 Weeks will therefore be the maximum wait from receipt of referral into secondary care, to the start of the first definitive treatment, for all non­emergency conditions.

Sustainability of the Restorative Dentistry service across the North of Scotland has long been an issue. The current service is struggling to meet demand and North Boards are experiencing considerable pressure in complying with Scottish Government’s 18 week referral to treatment standards. This will be exacerbated by the 12 weeks Treatment Time Guarantee 8 for inpatient and day case procedures. It should be noted however, that dentistry is almost unique in that the vast majority of treatments and procedures carried out in hospital are undertaken as outpatient appointments rather than as inpatient or day case operations.

2. Strategic Objectives for restorative dentistry

The NoS is committed as follows;

“To design and deliver equitable access to specialist restorative dental services across Scotland, organised as a network, which supports local care timeously for all patients across the North of Scotland.” 9

Specifically, this will:

­ provide services as locally as possible and support local dental services for communities; ­ provide safe and effective services, which improve quality; ­ provide sustainable services in a challenging rural environment; ­ provide equitable access to care and treatment in a remote and rural region; and ­ ensure that services reflect effective planning and use of resources.

3. Description of current service

NHS Consultant led Restorative Dental care is available for primary care referrals. In addition, consultant support is provided for tertiary referrals, Oral and Maxillofacial Surgery multi­disciplinary teams and other dental specialties, for example, Orthodontics.

The nature of restorative dental care means that the treatment burden is high, both in terms of the number of required treatment sessions and also the length of the treatment sessions. On average, a patient will require fourteen (14) appointments, and for implants, this will rise to twenty seven (27).

8 Patient Rights (Scotland) Act 2011; www.scotland.gov.uk/Topics/Health/PatientRightsBill 9 NoS Restorative Dentistry workshop 2010

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Not all return appointments will be delivered by the Consultant, and some treatment sessions will be delivered by lower grade staff or Dental Therapists/Hygienists, where appropriate.

3.1. NHS Grampian

3.1.1. Service Overview

The work of the Department consists of new patient diagnostic clinics, multidisciplinary clinics with colleagues in Orthodontics and Oral & Maxillofacial Surgery and specialist treatment. Treatment includes:

• Fixed & Removable Prosthodontics; • Prosthetic rehabilitation of cancer/trauma; • Implant dentistry (placement and restoration); • Endodontics, including peri­radicular surgery; • Periodontics, including periodontal surgery; • Management of tooth wear cases; and • Treatment of congenital conditions including hypodontia.

Patients accepted for treatment in the Department are prioritised in terms of need.

Consultant clinics are held for the assessment and treatment planning of new patients. The maximum waiting time for assessment is 12 weeks from referral.

Multidisciplinary clinics are held weekly with colleagues in Orthodontics and Oral & Maxillofacial Surgery to enable planning of cases requiring combined care, for example hypodontia, cleft lip and palate, and facial deformity.

A monthly implant clinic runs with Oral & Maxillofacial Surgery. Patients are referred initially for a new patient consultation to assess suitability/eligibility for implant treatment. Each case is assessed on an individual basis but the Department follows the NHS Guidance on Implant Placement within the NHS, which can be broadly divided into rehabilitation of the following groups:

• trauma; • cancer; • hypodontia; • severe denture intolerance; and • those patients who simply can not be reasonably treated by an alternative approach.

Restorative Dentistry also forms part of the hospital’s multidisciplinary team for the treatment and rehabilitation of patients with head and neck cancer.

The Restorative Dentistry department is actively involved in teaching and training of undergraduates and postgraduate trainees.

3.1.2. Demand

Demand in the north is already increasing with:

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2009/10 2010/11 2011/12 Total referrals 805 1257 1085 Removals 148 210 295 Net Demand 657 1047 795 Table 3: Net demand 2009/10 – 2011/12

New outpatients The number of patients waiting for their first outpatient appointment is 326. The maximum wait for new outpatient assessment of 12 weeks is not being met and the average wait is currently 16—18 weeks.

Treatment waiting list There are 240 patients waiting for treatment and the wait can be up to two years if non urgent.

3.1.3. Workforce Profile

Headcount Clinical wte Consultant 2 2.00 Consultant (Honorary) 1 0.20 Staff Grade 1 1.00 STR 2 1.80 SHO 2 2.00 DF2 1 0.30 Hygienist 1 0.20 Table 4: Workforce

Aberdeen Dental School contributes to clinical services through the Honorary Consultant(s). The complement will rise to 2.4 wte from September 2012.

3.2. NHS Highland

NHS Highland has a historical, loosely defined, longstanding Service Level Agreement with NHS Grampian to deliver two sessions per month in Restorative Dentistry. Regrettably, however, Grampian Consultants have been unable to commit to these sessions due to, for example, the increase in demand in Grampian, annual leave, and conflicting local holidays. The Service Level Agreement includes a sum of £5,486 although payment is made for the visits actually received and evidence would suggest that around 25% of visits are cancelled in any one year. New patients only are seen and no treatment is undertaken. The service is supplemented by waiting list initiative clinics by visiting Locum Consultants from Scotland and London. Like the service from Grampian Consultants, only new patients are seen and no treatment is undertaken. Locum costs are in the region of £8­10k per annum.

Treatment planning and advice is provided to General Dental Practitioners, many of whom have intimated that they do not have the skills to carry out the sometimes complex treatment required for their patients. In addition, a review of some of the patient pathways indicates multiple referrals including out of area, duplication of resource and a failure to provide the patient with definitive treatment within a reasonable timeframe. This is not a quality service.

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Demand

Data on current activity levels does not reflect the need for this service as soft information and feedback from primary care practitioners suggests that patients are not being referred into the service because of the current capacity issues.

MONTH CON DEN DS GP TOTAL Apr­11 4 9 13 May­11 5 6 11 Jun­11 1 1 17 1 20 Jul­11 2 15 17 Aug­11 1 18 1 20 Sep­11 11 11 Oct­11 10 10 Nov­11 2 10 12 Dec­11 13 1 14 Jan­12 1 8 9 Feb­12 9 9 Mar­12 1 1 10 12 TOTAL 17 2 136 3 158 Table 5: New referrals

With an increasing elderly population retaining their teeth for longer, there is a greater need for a consultant led service to support primary care dental providers in the planning and provision of more complex cases. The case mix is changing in terms of secondary/tertiary referrals and the recent experience in NHS Grampian is evidence of the suppressed demand for this service and would be a useful modelling exercise in which to predict future demand.

The SDNAP Report 10 confirmed that “…there is an inequality in access to secondary care restorative dentistry services due to unavailability of treatment locally in more remote or rural areas”.

The recent appointment of a second Consultant OMFS surgeon is placing significant demand on this resource as the majority of the NHS Grampian team’s time is taken up with tertiary referrals.

Treatment

Although it is noted above that no treatment is provided in Inverness, a total of 77 patients attended Aberdeen for treatment in 2011/12. This had doubled from the previous year. The average number of attendances per patient range from 14 to 20.

There are also a number of out of area referrals for treatment.

3.3. NHS Orkney

A visiting service is provided by NHS Grampian, comprising two visits per year, each of two days duration. An average of fifteen patients are seen, although the service does not meet the needs of the patients. A contribution of £1,245 is included in the SLA with NHS Grampian.

10 Scottish Dental Needs Assessment Programme (SDNAP), (July 2012), Restorative Dentistry Needs Assessment Report

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The dental registration rate is currently 64.5% in Orkney and there are over 2,000 patients on the waiting list for registration, with 1,000 of these waiting for two years or longer. Plans are in place to increase capacity by September 2012 and it is expected that this will in turn increase the requirement for specialist dentistry.

3.4. NHS Shetland

No service is available locally, however patients are referred to Aberdeen as and when opinion is required.

3.5. NHS Western Isles

No service is available locally, and patients are referred mainly to Glasgow, although some are referred to Dundee.

4. Risk Assessment

The clinical risks of current service arrangements are summarised in table 6 below.

Risk area Inability to meet treatment • NHS Boards currently do not meet the 18 week referral to treatment targets standards. Equity of access to specialist • There is inequity within the existing service delivery model. Patients are treatment for all patients being disadvantaged, particularly within NHS Highland, in not having access to specialist care compared with other parts of Scotland. • Patients are not being referred early enough in their journey to enable more simplified and therefore less costly, treatments to be provided. Feedback from primary care dental colleagues is that there is little point in referring due to the limited access to Consultant advice and treatment. • Late presentation results in more complex treatment requirements, additional resource implications and treatment plans often requiring months to complete. • Patients needing specialist care may receive inappropriate treatment such as the extraction of strategically important teeth or the execution of inappropriate treatment plans that would have benefited from Consultant input, resulting in consequent problems for the patient and subsequent corrective costs. • Patients are losing teeth that could otherwise be restored as the primary care practitioners have reported they do not have the advanced planning and operative skills.

Inappropriate referrals to In the absence of a satisfactory restorative service, patients are sometimes other secondary care referred to other secondary care clinicians (i.e. Orthodontists and Maxillofacial services and Oral Surgeons) who do not have the appropriate training or expertise to address the problem as they have followed a completely different training pathway.

Inappropriate referrals to Clinical teams are doing their best and getting by but patients are being GDPs with lack of referred to salaried dental teams who have not had the appropriate level of appropriate training training.

Impact on resources Inappropriate referrals impact on the resources available in the other specialties for appropriate cases. Risk of loss of Head & Neck Restorative Dentistry is an essential component of all head and neck MDTs to Cancer status in NHS enable restoration of function and minimise disability after surgery and/or Highland radiotherapy. The absence of a Restorative Dentistry service could place the

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recognition of Raigmore as a Head & Neck Cancer Unit at risk.

SIGN 9011 indicates that patients should have access to a consultant restorative dentist.

Impact on Head and Neck Head and Neck cancer patients within NHS Highland are not being seen Cancer timeously by the Consultant in Restorative Dentistry from NHS Grampian with the following implications:

• Detriment to oral rehabilitation and reduced quality of life due to the lack of restorative input at the pre surgical planning stage. • Avoidable complications develop such as osteo­radionecrosis which create additional burden on OMFS capacity both for inpatient and outpatient services. • Poor functional outcome in terms of mastication, swallowing and speech. • Poor nutrition as a result of eating difficulties. • Psychosocial effects due to poor aesthetics. • Slower rehabilitation and reintegration back into society and the workplace.

Lack of awareness of Lack of awareness of modern restorative techniques and their contribution to modern techniques rehabilitation impacts on quality of life, dental anxiety status and the patients’ ability to achieve oral health and be discharged into continuing care within the primary dental care sector.

Impact on patients Restorative dentistry is a fundamental part of the multi disciplinary approach to rehabilitating patients following trauma, those with hypodontia, clefts and other cranio facial deformities and those who have lost teeth following surgery for large cysts.

Table 6: Risk factors

5. Options

5.1. List of options

Option 1 Do nothing Option 2 Refer NHS Highland patients to a non­Scottish provider Option 3 Develop a shared post between NHS Grampian and NHS Highland Option 4 Develop additional Consultant capacity in both Aberdeen and Inverness, in the context of a regional network Option 5 Disinvest in Restorative Dentistry within NHS Highland

Table 7: Options

A summary of the discussion of the options is included at Appendix 4.

5.2. Preferred option

The preferred option is therefore Option 4, which will deliver services in line with need, future demand and Scottish Government standards, and will minimise almost all the clinical risks previously identified. Options 1 and 2 will not significantly impact on the identified risks.

11 http://www.sign.ac.uk/guidelines/fulltext/90/index.html

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Indications are that all Scottish providers are under pressure in terms of restorative dentistry and would not have the capacity to provide additional support to the North. Option 4 therefore presents the most sustainable solution for patients in the North, with the establishment of two new Consultant posts, jointly funded with part­time academic remits.

6. Proposed model: North of Scotland Managed Service Network for Restorative Dentistry

To address the challenges and risks faced by the service, it is necessary to consider an alternative service delivery model, which will include:

• treatment by the right person, at the right time, and in the right place; • regional clinical network; and • up­skilling of local practitioners.

This approach will ensure the most effective and efficient use of resource and workforce. Throughout the patient pathway, the patient is seen by the health professional with the most appropriate skill set, is seen at the optimum treatment time to prevent deterioration in their condition, and ensures the most effective treatment outcome. These principles are at the heart of the regional clinical network model, and this approach will enhance skills at all levels.

A network approach would encompass the following principles:

• Optimisation of scarce resources; • Clarity of roles within the multi­disciplinary team; • Builds on existing skills; • Be as local as possible; and • Provide equitable access to specialist service.

A formalised network for Restorative Dentistry will harness the knowledge, skills and competencies of dental healthcare professionals from primary care, the hospital based Restorative Dentistry service, academic restorative dentistry, NHS Education Scotland and others involved in the delivery of the service.

The service would provide a comprehensive treatment planning and advisory service and would accept referrals for second opinions and treatment plans from referring dentists as well as tertiary referrals from Hospital Consultants, including OMFS and ENT, for patients requiring oral maxillofacial re­construction and rehabilitation following surgery/trauma to the head and neck. The service would optimise the primary/secondary care interface for the benefit of patients supporting the delivery of intermediate care in the primary care setting.

The service would target the following high priority groups:

1. Head and Neck Oncology; 2. Multidisciplinary Care; 3. Severe Medical Compromise; and 4. Training.

Demand in the West (Appendix 1), highlights a potential demand within the NoS network of approximately 2,000 new patients per year and the need for approximately 4.00 wte NHS consultants to meet such a potential demand. In order to provide such a service, the appointment of two additional Consultant posts is required, based in Aberdeen and Inverness.

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Treatment of lower priority groups will be prioritised by Intermediate specialists/dentists with additional skills and training, supported within a Consultant led network.

1. Endodontics (Root Canal treatment); 2. Periodontics (gum treatment); 3. Removable Prosthodontics; 4. Tooth Wear; and 5. Fixed Prosthodontics.

Development of the network

The development of a variety of local specialist skills within the primary care team will be key to ensuring sustainable change and future capacity growth potential. This would not only centre upon developing restorative mono specialist skills at local level but also the development of GDS/Primary Care Dentists with a special interest (DwSI), dental therapists and clinical dental technicians. An investment in local skills would support a network approach and help address perceived local need and equity of access. This will be complementary to, and does not replace referral to specialist services within secondary care or care provided by general dentists. Instead, this provides an option for referral where treatment falls between specialist and generalist care. The benefit of this option is that care is delivered locally, and is provided at the right time, in the right place, and by the right person.

In addition, some patients may be appropriate for teaching and could be appropriately referred to the Aberdeen Dental Hospital or the Inverness Dental Centre. This would provide an alternative route for patients appropriate for teaching and ensure a continuous pool of patients consenting to be treated in a teaching institution.

The primary care network would be developed on a core team of:

• Senior salaried dentist; • Dental therapist/hygienist; and • Support staff.

The primary care teams, whilst having more specialised areas of expertise, would be required to have a generic restorative remit with links to/support for special dental care services. In addition, they will require to have a more specialised remit such as endodontics or periodontology.

The periodontal element of the restorative network would be delivered through optimising the contribution from therapists/hygienists to enable them to have a significant role in managing and treating periodontal disease, whilst in a similar way to the dentists above, the therapists would support special care as well as delivering periodontal care in a locality.

These proposals are in line with recommendations in the SDNAP national review12 on restorative dentistry.

Enhanced Skills Practitioners

Practitioners with enhanced skills will be vital in the establishment of the regional network.

This role has not yet been formally established within Scotland, however, the role of Dentist with a Special Interest (DwSI) has been clearly defined by the Department of Health in England:

12 Scottish Dental Needs Assessment Programme (SDNAP), July 2012, Restorative Dentistry Needs Assessment Report

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“A dentist working in the primary care setting who provides services which are in addition to their usual and important generalist role. The DwSI provides a service which is complementary to the secondary services but does not replace that provided by a dentist who has undergone the training required for entry to a specialist list. The DwSI is an independent practitioner who works within the limits of their competency in providing a special interest service, and who refers on where necessary.

The DwSI may deliver a clinical service beyond that normally provided by a primary dental care practitioner or may deliver a particular type of treatment. Individual DwSIs will be able to demonstrate their competencies in their special interest areas. Special interests may be demonstrated by dentists through the completion of formal training programmes and/or experience based evidence.” Department of Health/FGDP(UK) 2004 13

Enhanced Skills Practitioners will have a generic restorative remit, although will specialise in one of the monospecialties of Restorative Dentistry: Endodontics, Prosthodontics, Conservation and Periodontology, with Dental Therapists/Hygienists having a significant role in periodontal care and treatment.

This role will add capacity, reduce the number of inappropriate referrals into secondary care, reduce waiting times for secondary care services, and provide a more convenient service in a local setting.

Referral pathway

Figure 1 below illustrates the linkages between different parts of the services and the referral route.

General Dental Practitioner Hospital Consultant Established multi­disciplinary (GDP) pathway

Referral to Hospital Dental Service

Referral triage and clinical Inappropriate and assessment using agreed incomplete referrals acceptance criteria returned to referrer

Treatment plan / advice

Patient discharged Intermediate Primary Hospital Established Medically Suitable cases back to GDP with Care Services (DwSI) Dental Service Compromised Service appropriate for advice teaching (undergraduate /postgraduate)

Figure 1

13 2006, DoH, Dentists with Special Interests (DwSIs). A step by step guide to setting up a DwSI service

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Network Activity

The following table highlights the potential workforce and activity associated with the proposed NoS Restorative Network.

Care groups Staff Number / Estimated workload distribution Consultant Most challenging cases including ADHS 1500 referrals per annum services oral cancer, cleft cases, etc. 3.00 wte

Teaching As above plus Training support to 3.00 wte 500 referrals per year services develop the network 3 Intermediate care staff per annum in training Primary care Difficult/challenging cases in sub­ 4 P/t endodontics 1000 endodontic cases per year specialists specialty areas: 1000 periodontology cases per year /Intermediate • Endodontics 3 P/t periodontology 1000 cases fixed and removable per year care • Periodontics • Fixed and removable appliances 3 P/t fixed/removable Circa 3000 to 4000 cases per year

Estimated 10 teams Circa 3/5 wte per team

Primary care All routine care All centres pop > 15,000 root canal treatments per year 3000 1000 complex periodontal cases per year 10,000 crowns per year 2000 bridges per year Table 8: workload

NHS Grampian has the lowest rate or number of endodontic cases in Scotland per population, with less than half of that of an equivalent size board, for example, NHS Lanarkshire. If the North of Scotland had an equivalent rate to that of NHS Greater Glasgow and Clyde, the NoS would need to deliver over 20,000 cases in primary care per year, which is well over double the present rate.

The North is not presently delivering restorative care to the population at anything similar to the rates seen in the West of Scotland.

Treatment item; Root treatments ­ Items 15, 44(c)(d), 58(f), 60(c)(d) & 63(c)(d)(e)(f) Number of teeth Number per Value (£) root treated 100 courses Scotland 130,556 8,674,867 3.4 Ayrshire & Arran 10,146 660,346 3.2 Borders 1,524 91,302 2.2 Dumfries & Galloway 2,377 156,947 2.7 Fife 6,744 448,403 2.7 Forth Valley 7,739 506,455 3.2 Grampian 6,816 446,983 2.7 Greater Glasgow & Clyde 40,380 2,702,115 4.2 Highland 5,693 374,395 3.7 Lanarkshire 16,676 1,092,532 3.9 Lothian 22,333 1,546,984 3.3 Orkney 290 18,685 4.6 Shetland 283 17,557 2.0 Tayside 8,793 562,019 2.5 Western Isles 762 50,143 6.1 Table 9: Primary care services in Endodontics 2010/11 by Health Board

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Development and funding of the intermediate tier

It is proposed to establish one Primary Care Salaried Dental Services Restorative team per 100,000 population (between 8 and 10 support teams across the North).

Currently there is a wide range of primary care senior salaried posts contributing to some aspects of restorative care, however, there is no formal network, structure or governance framework in place to support the network.

There are also a range of practitioners currently undertaking further study to Masters level in Restorative Dentistry, Endodontics, Periodontics or the Postgraduate Diploma in Dental Studies through Bristol University (BUOLD). The network will further develop over a period of time, as individuals are identified within suitable locations and relevant training is undertaken.

Funding of the intermediate tier of the network will primarily be through existing General Dental Services (GDS) spend. There will however be a requirement for Salaried Primary Care Dental Services to review priority areas for re­design and identify opportunities to re­profile the establishment funded through the General Dental Services (Scotland) 2010 Regulations. In NHS Highland, for example, there are already a number of skilled individuals in post, hence any additional funding sought will contribute to a governance framework (audit, meetings etc).

All patients would be subject to NHS standard charges.

7. Finance

The additional cost for provision of Secondary care services is:

NHS Academic TOTAL wte £ wte £ wte £ Consultant: Post 1: NHS Highland 0.7 84,000 0.3 36,000 1.00 120,000 Post 2: NHS Grampian 0.5 60,000 0.5 60,000 1.00 120,000 Support costs: Band 4 Nurse 1.6 40,000 ­ ­ 1.2 40,000 Technician 1.0 30,000 ­ ­ 1.0 30,000 Materials 26,000 ­ 20,000 46,000 TOTAL 240,000 116,000 356,000 Table 10: staff costs

Academic costs have been discussed and agreed with Aberdeen University and NHS Education for Scotland (Dental ACT).

The contribution, calculated on a population basis, required from NHS Boards is:

NHS Board Funding contribution (£) Grampian 117,098 Highland 103,390 Shetland 6,360 Orkney 5,760 Western Isles 7,392 TOTAL 240,000 Table 11: NHS Board contributions

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8. Clinical Benefits

The perceived clinical benefits of a network approach to the delivery of Restorative Dentistry services include:

Support to Clinicians: decision­making, emergency management, skill sharing and inclusivity.

Patient and Access Benefits: less travel to access expertise, more rapid access, better distribution and utilisation of resource, and shorter waiting times.

Educational Benefits: shared learning; common learning pathways; development and maintenance of skills, and inclusivity and the sense of belonging to a wider network.

Governance: setting standards, audit improving and adjusting standards.

9. Outcomes

The creation of a network of services, including an appropriate intermediate level of specialist care, will provide improved local access to services and improved timeliness of treatment for patients. This reconfiguration of services will avoid unnecessary referrals to inappropriate clinicians/services and will be better able to cope with existing demand and projected demand for restorative dentistry referral services resulting from an improved service to NHS Boards and the increase in the ageing population.

Defined outcomes will include:

• Strengthening the delivery of primary care dental services across the North; • Supporting Restorative Consultant services on the Islands and at distributed centers throughout the North including Inverness; • Supporting the development of special care dental services throughout the North; • Supporting teaching within Aberdeen University, University of the Highlands and Islands and at the dental Outreach centres in Western Isles, Inverness Elgin and Aberdeen; • supporting other consultant led services such as the oral cancer and cleft palate networks; • A unified approach to the delivery of Restorative Dentistry services across the North of Scotland; • Equity of service delivery across a remote and rural region of Scotland /service across the North of Scotland; • HEAT targets are met; • Quality outcomes are uniform and agreed across the North of Scotland; • Compliance with 18/52 Referral to Treatment (RTT) standard; • Unified corporate and clinical governance issues are addressed; • Public value for money; and • Meeting the pledges contained in Patient Rights Bill.

10. Links to the NHS Scotland Quality Strategy

The Restorative Dentistry service in the North of Scotland will be designed to deliver the six dimensions of healthcare quality and meet NHS Scotland Healthcare Quality ambitions:

Quality Dimension

Safe • Right treatment at the right time, in the right place, by the right person. • Appropriately trained and validated. • Appropriate skills and competences.

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• In an environment where CPD is encouraged and supported.

Timely • At the right time for the stage of clinical presentation: o acute versus chronic issues addressed o assure avoidance of deterioration o proactive engagement early in the pathway o ensure the capacity exists in system for continuing care o schedule of care delivered at appropriate stage of care: clinical, administrative and managerial

Equitable • Same standard and quality of care based on clinical need, delivered as locally as possible and not dependant on geographic location; • Access to the full range of clinical expertise locally, including intermediate and specialist level practitioners.

Efficient • Optimal use of resources, recognising this is not the same as working at 100% of capacity; • Avoiding unnecessary referral to inappropriate clinicians from the point of view of professional training level or specialty; • Workforce and skill mix appropriate to delivery of care; • Flexible use of resources, for example, accommodation and personnel; • Reflected in job planning.

Effective • Clinical outcome – right first time; • Patient satisfaction; • One­stop multidisciplinary team development and delivery; • GDP satisfaction; • CPD education/training.

Patient centred • Access to MDT for reduced number of visits and enhanced care; • Full range of clinical expertise to allow even complex care to be delivered.

11. Regional Planning in the North of Scotland

The North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles.

The North of Scotland Maxillofacial, Oral and Dental Health Project Board are committed to developing a regional network for Restorative Dentistry. NHS Tayside have indicated that they do not want to be included in this proposal.

12. Affordability

It is recognised that stakeholders are under significant financial pressure, given the current financial climate.

13. NHS Boards Approval

This Business Case seeks approval from NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland and NHS Western Isles to the costs above.

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Appendix 1: Estimated demand and consultant service needs based on Glasgow/West of Scotland demand levels

Column1& 2 3 4 5 6 7 8 9 10 11 12 New Crude Crude Expected Expected Numbers Academic Present Present Present Predicted need for patients 9664 population pop demand demand if of NHS consultant rude estimated need for consultant sess based on ratios if based based on consultant NHS sess @ estimate new/yr / consultant based on Av 52 most up to ratio on North West sessions 2 sess of total consultant sess based new/session/yr date using demand demand nhs/wte NHS sess session on Av 52/ and West demand estimates North available (efficiency ) session & (C6). This includes as 1 present 2sessions/wte demand Academic consultant (increase)

Glasgow /West Scotland 5,443 2.5m 2.63 1972.5 5443 62.5 12 75 73 73 10 wte (+2.5WTE)

Aberdeen /North of 750 Scotland 0.950m 1 750 2070 20 2 22 34 39 4 wte (+1.8WTE)

Edinburgh /Dundee East 3,471 Scotland 1.8m 1.84 1380 3808 48 16 64 54 71 7.0 wte (+0.6WTE)

Totals 9,664 5.25m 4102.5 161 Average 54 ISD/SDNP ISD/ From 674xC4 C4 x SDNAP SDNAP Present Efficiency Workforce Predicted SDNAP C3 5443/2.7 workforce complexity need workforce need SDNAP indicator working to working to av C2/C9 a efficiency efficiency and west and west demand levels levels C6/54 activity Col6 C2/54

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Appendix 2: Definition of Restorative Dentistry Service

Restorative Dentistry is the study, diagnosis and integrated effective management of patients with diseases of the oral cavity, the teeth and supporting structures, including the care of those who have additional needs associated with disability or medical problems too difficult to manage in Primary Care or Community Service 14. The scope of the role includes activities associated with Endodontics, Periodontics, Prosthodontics and Implantology.

Endodontics: Endodontic treatment removes infected or damaged tissue from inside a tooth. This tissue, called the pulp, contains nerves and blood vessels that help nourish the tooth. After the pulp is removed, the pulp chamber and root canals are cleaned, disinfected, filled and sealed. Endodontic treatment saves teeth that would otherwise need to be extracted. Although the pulp is removed, the treated tooth remains functional, nourished by the surrounding tissues. The most common cause of pulp damage is severe decay or a fracture that exposes the pulp to bacteria that may cause infection. Other causes of pulp damage include traumatic injury such as a blow to the mouth, a cracked or loose filling or repeated fillings in a tooth, and occasionally periodontal disease. The alternative to endodontic treatment is extraction of the tooth. Loss of a tooth could create a functional problem such as compromised chewing or an aesthetic problem. Restoring the lost tooth may involve the provision of a prosthetic replacement such as a denture, bridge or a dental implant the costs of which are variable 15 .

Periodontics: Periodontal disease is a disease of the gum tissue and underlying bone. Unlike gingivitis, periodontitis is associated with irreversible loss of the underlying bone that retains the teeth. Soft tissue pockets usually open up between the tooth and gum and act as reservoirs for bacteria unless treated. The rate of bone loss varies very much from individual to individual, but if untreated may well lead to tooth loss. Up to 80% of the population will probably get some periodontal disease, and 15­20% of people will suffer from aggressive disease and will lose a significant number of teeth if they do not receive treatment. Like gingivitis, periodontitis is usually painless, and by the time people become aware of problems, usually teeth becoming loose or drifting out of alignment, serious damage has been done. If caught early enough, most periodontal disease can be treated. The most common type of gum treatment brings together two components;

1. Oral hygiene (home care plaque control); and 2. Meticulous removal of plaque and calculus (tartar) from the periodontal pockets (debridement). In this way, treatment targets the causes and effects of gum disease, namely the bacteria initiating disease at the edge of the gum and the bacteria progressing the disease within the gingival/periodontal pockets 16 .

Prosthodontics: Prosthodontics is also known as dental prosthetics or prosthetic dentistry. Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes. Prosthodontics is the branch of dentistry that deals with the replacement of missing teeth and related mouth or jaw structures by bridges, dentures, or other artificial devices.

Implantology: A dental implant is essentially a substitute for a natural root and commonly it is threaded cylinder shape. Each implant is placed into a socket carefully drilled at the precise location of the intended tooth. In order to support replacement teeth, dental implants normally have some form of internal screw thread or post space that allows a variety of components to be fitted. If an implant has a screw­thread on its outer surface it can be screwed into position and if it does not, it is usually tapped into place. Once fitted, these components provide the foundation for long­term support of crowns, bridges or dentures. The main aim during installation of any implant is to achieve immediate close contact with the surrounding bone. This creates an initial stability, which over time is steadily enhanced by further growth of bone into microscopic "roughnesses" on the implant surface. Almost all dental implants in use today are made from titanium or titanium alloy, materials that have been shown over many years to be well tolerated by bone. The terms 'Osseo integrated implants' or 'endosseous implants' are widely used to describe dental implants that can develop and maintain a close union with bone in order to support replacement teeth 17 .

14 British Dental Association, (November 2005) “Consultant Practice in the Dental Specialties” 15 http://www.britishendodonticsociety.org.uk 16 http://www.periodontics.co.uk/faqs.htm#periodontal 17 http://www.adi.org.uk/public/implant/whatis.htm North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles Page 22 of 27 260

Appendix 3: Costs by Board of Treatment

Financial Year Ending 31st March NHS Board of Treatment 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 p

NHS Scotland 18,228.0 21,093.0 19,611.0 15,019.0 13,127.0 13,120.0 9,943.0 8,800.0 9,909.0 10,054.0 Ayrshire and Arran 0 0 0 0 8.0 2.0 0.0 1.0 0.0 1.0 Borders 0 0 0 0 0 0 0 0 287.0 288.0 Dumfries and Galloway 0 0 0 0 0 0 0 0 0 0 Fife 19.0 0 0 0 0 0 0 0 0 0 Forth Valley 527.0 538.0 433.0 193.0 93.0 151.0 14.0 0.0 0 0 Golden Jubilee National Hospital * x x x x .. .. 0 0 0 0 Grampian 242.0 217.0 259.0 320.0 393.0 438.0 551.0 519.0 503.0 616.0 Greater Glasgow and Clyde 3,839.0 4,448.0 4,127.0 4,527.0 4,435.0 5,515.0 5,411.0 4,970.0 5,625.0 5,731.0 Highland 63.0 73.0 147.0 53.0 43.0 137.0 116.0 96.0 158.0 131.0 Lanarkshire 0 0 0 0 0 0 0 0 0 0 Lothian 4,984.0 7,884.0 7,500.0 2,512.0 1,757.0 1,331.0 1,431.0 796.0 916.0 916.0 Orkney Islands 15.0 18.0 5.0 0 0 0 0 0 0 0 Shetland Islands 0 0 0 0 0 0 0 0 0 0 Tayside 8,539.0 7,915.0 7,140.0 7,414.0 6,398.0 5,546.0 2,420.0 2,418.0 2,420.0 2,371.0 Western Isles 0 0 0 0 0 0 0 0 0 0

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Appendix 4: Discussion of options

OPTION Advantages Disadvantages 1. Do nothing. § Cost neutral therefore no resource implications. § This is not feasible as NHS Grampian has indicated that they cannot continue to provide a visiting Restorative Dentistry service to NHS Highland indefinitely. § Clinics within NHS Highland are frequently cancelled and the service is spasmodic, at best. § There is no treatment service within NHS Highland and the current service is limited to advice. § Complaints are frequently received by NHS Highland regarding a lack of service provision. § Risk of loss of head and neck cancer centre status in NHS Highland as no involvement in MDT. § The impact of travelling time on a Consultant job plan and reduction in availability of clinical time impacts on and limits the service to patients, particularly the provision of treatment. 2. Refer NHS Highland patients to a § It is not ideal to send very ill patients with head and neck trauma/cancer § NHS Highland will require to find additional resource. non Scottish provider to England for oral health treatments. However it may be possible to § The impact of travelling time on a Consultant job plan and reduction procure a visiting service from elsewhere in the UK. in availability of clinical time would impact on and limit the service to (There is no capacity within Scotland § To our knowledge there is no capacity in other UK services to accept patients, particularly the provision of treatment. In addition the for NHSH activity). This service referrals and initial enquiries suggest that it is likely that an alternative costs of travel time and accommodation need to be factored in. would be supported by VC MDT provider would also need a commitment to funding to enable additional § At the NHS Highland workshop, feedback from primary care (PC) intervention plus a visiting service recruitment to create the required capacity. colleagues was unanimous in that the use of locum consultants from from a non­Scottish provider. outwith Scotland resulted in inappropriate treatment plans that could not be followed through, and ineffective liaison with PC colleagues which led to a lost opportunity to optimise the PC resource. § Relying on VC to support the MDT is a significant compromise and would require careful co­ordination to avoid treatment delays and does not compensate for the fundamental requirement to examine and treat the patient in complex, multi disciplinary cases jointly with OMFS and ENT colleagues, speech and language therapists and nutritionists. 3. Develop a shared Consultant § A high level shared Restorative Dentistry service with clear access criteria § NHS Highland will be required to find additional resource. Restorative Dentistry post would address the current capacity issues in both NHS Highland and NHS § A single post shared with NHS Grampian may be insufficient to meet between NHS Grampian and NHS Grampian. demand – there will therefore need to be a clear commitment to Highland and work on a North of § The post holder would provide crucial training and professional support to developing skills in primary care to help manage demand locally. Scotland network basis. This post primary care colleagues thus enhancing skills to facilitate a shift in the § The demand may increase when it is known that there is a service would be based in Inverness and balance of care. available and there will then be a call and need for additional undertake clinics in Elgin to capture § The post would provide the crucial “missing link” to the existing OMFS capacity and staffing. the west Grampian activity. service enabling compliance with SIGN guidelines for the Head & Neck § Identification of accommodation within the existing dental estate Cancer MDT. may displace elements of current service provision. § Costs of the post would be shared between NHS Highland and NHS Grampian. § This would improve the reputation of NHS Highland as an area to work and may improve recruitment / retention to Primary Care Dental Services. §

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4. Develop additional Consultant Improve outcomes for patients through: capacity within both NHS Grampian and NHS Highland, § Supporting primary care dentists. working within a North of § Providing access to a service that is currently not available within Scotland network. NHS Highland § Improving recruitment and retention of Primary care Dentists and Two posts would be created, based Consultants in the Dental specialties. in Aberdeen and Inverness and § Enabling compliance with Head & Neck cancer MDT guidance. include an element of academic § Improving the rehabilitation of Head & Neck cancer patients. work.

5. Disinvest in Restorative § Whilst being politically unattractive, it may be prudent to make a decision § Current funding is no more than £16k per annum. Dentistry within NHS Highland. to disinvest in Restorative Dentistry rather than provide a second­rate § Lack of primary care dental services due to lack of Consultant back service for this vulnerable group of patients whose quality of life is already up and support. greatly reduced. § The reputation of NHS Highland as an attractive place for primary § This would free­up resource for investment in other specialties or to care dental service providers to live and work would be reduced support training in intermediate skills for primary care teams. further impacting on recruitment and training opportunities. § No Consultant Restorative service would significantly compromise the OMFS Service as Restorative Dentistry is an essential component of all head and neck MDTs to enable restoration of function and minimise disability after surgery and/or radiotherapy. § The absence of a Restorative Dentistry service might place the recognition of Raigmore as a Head & Neck Cancer Unit at risk. § Impact on future secondary care staff recruitment.

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INFECTION PREVENTION & CONTROL REPORT

Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Consultant Microbiologist, on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

The Board is asked to:

 Note the performance position for the Board.  Note the progress to keep infection under control.

1 Aim

The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and infection control measures in NHS Highland. This new format is being developed to improve clarity of information about Infection Control.

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 Scaling factor used in reporting incidence rates To ensure consistency with wider UK and European Centre Disease Prevention & Control (ECDC) reporting and in light of decreases in the observed rates, Health Protection Scotland (HPS) have changed the scaling factor used in reporting incidence rates to ‘per 100,000 bed days’ instead of the previously used ‘per 1000 bed days’. The Clostridium difficile target for example, now shows as 39 rather than 0.39.

It should be noted that NHS Highland figures for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile are provisional until validated by HPS on a quarterly basis.

Summary

Table 1 NHS Highland infection prevention & control targets and performance data

Group Target NHS NHS Highland Scotland Clostridium Age 65 and 39.0 30.8 For 32.8 Green difficile over (100,000 period For OBDs) April – period June 12 April – June 12 Staphylococcus Age 15 and 26.0 30.2 30.2 Amber aureus over (100,000) For period For bacteraemia OBDs April – period June 12 April – June 12. 264

Annual rate is 23.39 which means that the Board is still on track to meet the HEAT Target Hand Hygiene 95% % 98% Green

Cleaning 90% % 96% Green

Antibacterial Hospital- Compliant Yes Green prescribing based Empiric prescribing Surgical Compliant Yes Green antibiotic prophylaxis Primary Care Compliant Yes Green empirical prescribing

Source: - Health Protection Scotland/ISD/Local data.

4 Achievements The Norovirus outbreaks in 3 hospitals have been managed well and quickly brought under control. As discussed in the previous Board report, Hydrogen Peroxide Vapour (HPV) decontamination went ahead in Ward 4C, Raigmore Hospital on 3rd October 2012.

5 Challenges To continue to reduce Clostridium difficile (CDI) and Staphylococcus aureus bacteraemia (SABs) Nationally the Norovirus season has started early and there are already significant ward closures across Scotland.

6 Risks There is always a risk that NHS Highland may not achieve the March 2013 HEAT target for CDI and SAB. However the annual rate (still to be validated by HPS) for Clostridium difficile October 2011 – September 2012 is 32.15 per 100,000 bed days and for Staphylococcus aureus bacteraemia is 23.39 per 100,000 AOBDs.

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Emma Watson – Consultant Microbiologist Liz McClurg – Infection Control Manager

Date: November 2012 NHS Highland Healthcare Associated Infection Report –November 2012

Section 1 – NHS Highland Board Wide Issues

Key Healthcare Associated Infection Headlines

 Primary care prescribers across Highland have sustained low rates of antibiotic prescribing.

 Norovirus Season has started: 3 outbreaks in hospitals in Highland.

1 Clostridium difficile

1.1 Clostridium difficile Testing Regimen

The new testing regimen, instituted in North Highland on 14th May 2012, utilises a more sensitive test which has increased the detection rate. An increased detection rate significantly improves patient safety as, through better detection, improved preventative measures can be put in place to reduce the spread of infection. It is anticipated that rates will, in time, subsequently begin to fall below current levels.

The National Target is based on toxin positive cases only.

1.2 National Context

National data published by Health Protection Scotland (HPS) identifies that the overall Clostridium difficile infection (CDI) rate for NHS Scotland during the period April – June 2012 in patients aged 65 and over was 30.8 cases per 100,000 total occupied bed days (OBDs).

NHS Highland’s rate for the same period was 32.8 cases per 100,000 OCBDs.

The annual rate (unvalidated) for NHS Highland, October 2011 – September 2012 is 32.15 cases per 100,000 bed days (National target March 2013, 39 cases per 100,000 OCBDs) which means the Board is on track to meet the National HEAT Target.

2 Staphylococcus aureus bacteraemia

National Context

National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate April - June 2012 was 30.2 per 100,000 acute occupied bed days (AOBDs).

NHS Highland’s rate was also 30.2 per 100,000 AOBDs (19 SABs), 3 MRSA and 16 MSSA, (5 True Community, 3 Contaminated blood cultures and 11 acquired in the community or hospital, mainly due to invasive devices). This is an increase on the previous quarters, (January – March 2012 there were 15 SABs, October – December 16 SABs).

Each SAB is reviewed in Microbiology and if it is felt that the SAB could have been avoided or prevented, then a clinical review meeting is held with the relevant clinical team which is 3 266 responsible for ensuring that learning outcomes are disseminated to staff and that processes are in place to monitor practice.

July - September 2012 (unvalidated data) there were 8 SABs, all MSSA, (1 True Community and 7 acquired in community or hospital)

The annual rate (invalidated) for NHS Highland, October 2011 – September 2012 is 23.39 per 100,000 AOBDs (National target March 2013, 26 per 100,000 AOBDs)

4.1 MRSA Screening

NHS Boards are required to ensure MRSA screening becomes part of their local integrated approach to improving the quality of person centred, safe and effective patient care. All Boards have received the final tranche of non recurring funding. Work is ongoing to minimise the financial risk when this funding ends.

NHS Highland is one of 7 Boards taking part in a pilot to test the audit tool which will measure compliance with MRSA screening. A report will be submitted to the Board in six months time.

5 Anti Microbial Prescribing

National Report on Primary Care Antibiotic Prescribing Indicators

Primary care prescribers across Highland continue to have low rates of antibiotic prescribing. Preferred antibiotics now account for more than 80% of prescriptions with the 4C’s antibiotic use falling from 19.9% in 2007/8 to 10.4% in 2011/12.

NHS Highland is one of only two Boards in Scotland to achieve the prescribing indicator for reduced seasonal variation in prescribing of quinolone antibiotics.

Prescribers in primary care have acted upon the best practice messages regularly provided by the Antimicrobial Management Team in conjunction with the GP sub-committee and the primary care prescribing advisors.

Table 2 shows NHS Highland progress against the 3 national indicators.

Antimicrobial Indicator NHS Highland progress

Hospital-based empirical prescribing Compliant In acute admission areas, antibiotic Two areas are monitored, as required, in prescriptions are compliant with the local Raigmore Hospital. Acute Medical antimicrobial policy and the rationale for Admissions Unit and Surgical Admissions treatment is recorded in the clinical case note Ward (4A), data for August and September in above 95% of sampled cases. shows compliance with guidelines above the target of 95%.

Surgical antibiotic prophylaxis Compliant. Duration of surgical antibiotic prophylaxis is Data to the end of July 2012 shows less than 24 hours and compliant with local continuing compliance above 95% with antimicrobial prescribing policy in above 95% antibiotic choice and duration of prophylaxis. of sampled elective colorectal surgical cases. Further data collection is currently being undertaken.

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Data collection for urological surgery commenced in November 2012.

Primary care empirical prescribing Compliant. Seasonal variation in Quinolone use Data to the end of March 2012 indicates (summer months vs. winter months) is less continuing compliance with this measure. than 5%. NHS Highland is one of only two Boards in Scotland to demonstrate compliance with this quality indicator for every year since it was first measured in 2008/09.

6 Hand Hygiene

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 98% compliance for September and October 2012.

Non compliance with hand hygiene requirements is unacceptable and all staff must comply with the NHS Highland Hand Hygiene Policy. Hand hygiene audits are undertaken monthly by all clinical areas and the results are displayed.

Hand hygiene training is provided across NHS Highland and is also available via E-learning on LearnPro NHS, the uptake of which has been steadily increasing since its launch.

7 Cleaning and the Healthcare Environment

Domestic Service teams continue to carry out monthly cleaning and estates audits as per NHS Scotland National Cleaning Services Specification. Compliance with cleaning and estates across NHS Highland was 96% in September and October 2012.

The new National Electronic Domestic Monitoring tool is currently being rolled out across Scotland. This tool is based on the National Monitoring Specification which determines the frequency of monitoring according to the national codes and applies dates for completion against the various areas to be monitored. There are still some anomalies in the system which are being worked on to ensure that it is fit for purpose in Highland where areas in all hospitals are monitored each month to ensure that deviations from compliance can be rectified and standards maintained.

Ward 4C, Raigmore Hospital closed for 24 hours at the beginning of October 2012 to enable Hydrogen Peroxide Vapour decontamination to take place. A detailed risk assessment was carried out prior to the cleaning process which was provided by a team of specialists to ensure successful completion.

7.1 HEI Inspections

The action plan developed following the HEI inspection to Raigmore Hospital on 26th and 27th June 2012 is being progressed and monitored by the Raigmore Hospital Healthcare Environment Improvement Group. A progress report will be submitted to NHS Highland Control of Infection Committee in December 2012.

An unannounced HEI visit was undertaken in Caithness General Hospital on 3rd & 4th September 2012. They found the hospital clean and well maintained, with evidence of good compliance with sharps and linen management and the use of personal protective equipment (PPE), up-to-date audit and surveillance data was displayed on the wards and they saw staff washing their hands and using the hand gel available. There were 3 requirements and 6 recommendations.

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Table 3 HEI unannounced inspection Caithness General Hospital September 2012 Requirements & Recommendations

Requirements Recommendations

Ensure that domestic staff have written and Review the documentation used to record formal allocation of cleaning duties and the maintenance and checks of PVCs to responsibilities, and effective systems to provide a consistent process for staff to demonstrate adherence to the NHS Scotland follow where possible. National Cleaning Services Specification (2009)

Ensure that there is an effective system in Provides clear guidance on the timescales place to ensure that patients are receiving for replacing suction catheters which are left appropriate information regarding infection open for use within maternity and accident prevention and control and HAIs. and emergency.

Develop clear roles and responsibilities for all Reinforce the guidance on the appropriate staff involved in audit activity. course of action for staff to take when the temperature levels of the fridge used to store drugs are above recommended safe limits.

Carry out a risk assessment of patient bed bays where there is one sink to every six beds, in line with SHFN 30 version 3– Infection control in the built environment: Design and planning (9.209) (2007).

Implement a system of sign off for domestic and nursing cleaning schedules. Implement a system to inform senior charge nurses of all issues reported to estates and the outcomes of these, relating to their ward or department

8 Outbreaks/Incidents

Norovirus

Norovirus is prevalent in the community throughout Scotland. The outbreaks across Highland were recognised and brought under control quickly and effectively with all staff from ward to Board working in partnership. Strict infection control precautions are put in place which include restricting visiting to affected wards and asking people not to visit if they have had any vomiting or diarrhoea within the previous 48hrs. Staff movement into the affected wards is also restricted. These measures help to reduce the risk of infection spreading.

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Table 4 Norovirus outbreaks in NHS Highland

October 2012, MacKinnon Memorial Hospital 5 Patients & 21 Staff

October 2012, Ward 2A Raigmore Hospital 15 Patients & 13 Staff

November 2012, Ward B Lorn & Islands 4 Patients & 8 Staff Hospital

Health & Safety Executive Visit

NHS Highland is working with the Health and Safety Executive on two strands of infection control work; one relates to improving the arrangements for managing infection control in NHS Care Homes, the other relates to community nursing staff.

A total of 60 x 3 hour training sessions have been delivered by Infection Prevention & Control Nurses to 93% of the staff (434) in the 15 care homes which have been incorporated into the Board following the integration process.

Training and education arrangements with respect to infection control in the community have been reviewed. The action plan must be implemented no later than 3rd December 2012.

9 Surgical Site Infections (SSI)

Colorectal Surgical Site Infection

NHS Highland has been carrying out colorectal surveillance since June 2011. January – August 2012, 102 elective procedures were performed with 19 infections (18.5%). Overall the rate of elective colorectal surgical site infections has not changed since surveillance commenced. The HAI Executive Lead has asked for a detailed report for the next Board Meeting.

Orthopaedic Surgical Site Infections

Orthopaedic surgical site infection rates remain low in the procedures monitored.

Caesarean Section Infections

Health Protection Scotland conducted a supplementary analysis of the caesarean section surgical site infections in September 2012. Retrospective analysis of caesarean section data from NHS Highland showed there was no statistical difference in the distribution of intrinsic and extrinsic risk factors when the patient populations in Quarter 2 2011 and Quarter 1 2012 were compared. As the numbers of SSIs detected within NHS Highland were small it was not possible to perform detailed statistical epidemiological analysis. From Quarter 1 2012 (January – March 2012), SSIs identified following caesarean section procedures were all post discharge and all have been superficial.

NHS Highland closely monitors caesarean section SSI rates and continue with the measures outlined in the action plan.

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10 Decontamination

The Central Decontamination Unit is CE Certificated with the Medicines and Healthcare products Regulatory Agency (MHRA) which is subject to the successful application of ISO 13485:2003, Quality Management System – Medical Devices and satisfactory surveillance auditing. Following a successful bid at the Asset Management Group the washer disinfectors will be replaced in early 2013.

An option appraisal paper on delivering compliant endoscope decontamination facilities for NHS Highland was submitted to the Senior Management Team for consideration and was approved. A plan has been developed to enable a compliant endoscope decontamination facility to open on the Raigmore site initially with a staged approach throughout 2013 for the peripheral sites.

The Head of Decontamination is now responsible for the training, assessment and audit of staff undertaking endoscope decontamination as well as the de-cluttering and improvements in housekeeping and record keeping in all existing endoscope decontamination units.

Compliance within the Independent Dental Practitioner setting will be monitored as per the recent Chief Dental Officer (CDO) letter. The CDO has written to all independent GDP with the offer of providing compliant washer disinfectors. A recent audit of GDPs was undertaken and over 80% of units were compliant.

A working group has been established to look at what needs to be done to enable all local decontamination in theatres to be halted by the end of 2014.

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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 for each acute hospital (Raigmore, Caithness General, Belford and Lorn & Islands), and the community hospitals within each Operational Unit/CHP. The information includes the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections as well as hand hygiene and cleaning and estates compliance.

The out-of-hospital infections report card identifies infections as having been contracted from outwith hospital.

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 and the community hospitals within each CHP broken down by month. 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

For each acute hospital and community hospitals in each CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out-of-hospital” report card.

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 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 and estates 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 table form.

Understanding the Report Cards – ‘Out of Hospital Infections’

Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries, care homes and the community itself. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

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Abbreviations

ADTC Area Drugs & Therapeutics Committee 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 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 Hemi arthroplasty An operation used to treat fractured hip similar to a total hip replacement, but involves only half of the hip. HPS Health Protection Scotland HSE Health & Safety Executive 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 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

11 274

Staphylococcus Aureus Bacteraemia (SAB) criteria

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

 Staphylococcus aureus isolated from blood cultures taken 48 Hospital acquired hours 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: 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

12 275 Quarterly rolling year Clostridium difficile Infection Cases per 1000 total occupied bed days for HEAT Target Measurement

0.45

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Actual Performance 0.34 0.26 0.26 0.22 0.28 0.30 Target 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39

Quarterly rolling year Staphylococcus aureus Bacteraemia Rates per 1000 Acute Occupied Bed Days for HEAT Target Measurement

0.30

0.25

0.20

0.15

. 0.10

0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Jan11- Apr11- Jul11- Oct11- 10 - JulJan 10 12 - - Oct Apr 10 12 - -Apr e 2 M r 1Mr11 JunDec 11 12 Sept Mar 11 13Mar Dec 11 Mar 12 Jun 12 Sept 12 Actual Performance 0.21 0.21 0.21 0.21 0.20 0.23 Target 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 276 Pan Highland Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

Data on Estates Monitoring Compliance available only from April 2011 6 4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 4 6 7 3 4 4 5 5 3 3 4 2 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 97 97 97 97 97 97 97 97 98 98 98 99 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 8 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 94 94 94 94 93 95 95 92 96 96 96 96 6

4

2

Estates Monitoring Compliance (%) 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 95 96 95 96 95 96 96 95 97 96 96 96

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 1 0 3 1 1 0 1 1 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 404 6 2 4 20 2 0 0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 5 5 15 8 5 13 10 5 8 11 5 6 3 6 4 2 3 4 4 4 3 3 4 2 277

Raigmore Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 2 4 1 2 1 0 1 2 2 1 1 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 96 93 96 95 96 96 97 97 98 96 99 95 MRSA Bacteraemia Cases - (All Ages)

12

10 Cleaning Compliance (%) 8 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 93 93 93 93 93 95 93 95 93 94 93 94 6

4

2

Estates Monitoring Compliance (%) 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 97 95 95 95 97 96 94 95 98 98 96 96

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 1 0 0 0 0 0 0 1 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 404 6

4 202 2 0 0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 1 2 10 4 4 3 1 1 5 4 2 4 1 4 1 2 1 0 1 1 2 1 1 0 278 Caithness General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 98 98 99 98 98 99 100 99 100 100 98 100 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 8 95 94 95 95 90 95 99 94 96 99 96 95 6

4

Estates Monitoring Compliance (%) 2 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 96 98 97 98 98 96 99 98 96 98 96 97 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12100 16 10 14 80 12 8 60 10 6 8 40 6 4 4 220 2 0 00 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11Nov-11 Dec-11 Jan-12 Feb-12 Dec-11 Mar-12 Apr-12 Jan-12 May-12 Jun-12 Feb-12 Jul-12 Aug-12 Sep-12 Mar-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 1 0 0 1 1 1 2 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 279 Belford Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 0 0 1 0 0 0 0 0 0 0 1 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 98 99 97 92 99 100 100 98 96 99 100 98 MRSA Bacteraemia Cases - (All Ages)

12

10 Cleaning Compliance (%) 8 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 92 94 90 96 93 95 96 90 94 97 97 97 6

4

2 Estates Monitoring Compliance (%) 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 96 98 99 99 97 98 97 95 100 98 96 96 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12100 16 10 14 80 12 8 60 10 6 8 40 6 4 4 220 2 0 00 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11Nov-11 Dec-11 Jan-12 Dec-11 Feb-12 Mar-12 Jan-12 Apr-12 May-12 Feb-12 Jun-12 Jul-12 Mar-12 Aug-12 Sep-12 Apr-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 1 2 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 280 Lorn & Islands Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 96 98 96 100 99 99 99 100 100 98 98 100 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 8 97 96 97 97 96 95 96 93 98 96 97 99 6

4

Estates Monitoring Compliance (%) 2 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 93 95 94 95 94 93 95 93 96 95 92 98 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12100

16 10 14 80

12 8 60 10 6 8 40 6 4

4 20 2 2

0 00 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11Nov-11 Dec-11 Jan-12 Dec-11 Feb-12 Mar-12 Jan-12 Apr-12 May-12 Feb-12 Jun-12 Jul-12 Mar-12 Aug-12 Sep-12 Apr-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 281 Argyll & Bute CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

Argyll & Bute Community Hospitals include Argyll & Bute Hospital, Lochgilphead, 8 Campbeltown Hospital, Cowal Community Hospital Dunoon, Dunaros Community 6 Hospital, Isle of Mull, Islay Hospital, Mid Argyll Community Hospital & Integrated Care Centre Lochgilphead, Victoria Hospital & Annex Rothesay 4

2

0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 97 97 97 94 95 95 94 96 97 98 97 98 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 8 94 95 94 95 95 95 95 93 96 97 97 98 6

4

Estates Monitoring Compliance (%) 2 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 96 97 95 96 94 97 96 96 97 95 98 97 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12100 16 10 14 80 12 8 60 10 6 8 40 6 4 4 220 2 0 00 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11Nov-11 Dec-11 Jan-12 Dec-11 Feb-12 Mar-12 Jan-12 Apr-12 May-12 Feb-12 Jun-12 Jul-12 Mar-12 Aug-12 Sep-12 Apr-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 282 Out of Hospital Infections Clostridium difficile Infection Cases

12

10

8

6 .

4

2

0 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 3 1 5 3 0 5 6 3 3 5 2 2

MSSA Bacteraemia Cases MRSA Bacteraemia Cases

12 12

10 10

8 8

6 6

4 4

2 2

0 0 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 2 2 2 0 2 4 3 3 1 2 2 2 0 0 3 1 1 0 1 0 0 0 0 0 283

NW Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

The North West Operational Unit comprises Dunbar Hospital, Thurso; Town & 8 County Wick; Lawson Memorial Hospital, Golspie; Migdale Hospital, Bonar Bridge, 6 Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, MacKinnon memorial Hospital, Broadford & Portree Hospital Isle of Skye. 4

2

0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 97 96 98 99 99 99 99 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 8 97 95 91 97 95 95 97 6

4

Estates Monitoring Compliance (%) 2 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 98 97 98 96 96 98 96 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 12100

10 10 80

8 8 60 6 6 40 4 4

2 220

0 00 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12Jan-00 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 284

South Mid Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10 The South Mid Operational Unit comprises Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, RNI Community Hospital Inverness, 8 Town & County Hospital Nairn, Ian Charles Community Hospital Grantown on 6

Spey, St. Vincents Hospital Kingussie. For the purposes of monitoring New Craigs 4 Psychiatric Hospital is included in this report card. 2

0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 97 95 93 96 95 98 98 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 8 96 96 92 96 95 96 95 6

4

Estates Monitoring Compliance (%) 2 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 97 94 92 95 96 96 96 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 10012

10 10 80 8 8 60 6 6 40 4 4

2 202

0 00 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Jan-00

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 1 1 0 0 0 0 0 0 0 0 0 0 0 0 285

Highland NHS Board 4 December 2012 Item 5.10

CHIEF EXECUTIVE’S AND DIRECTORS’ REPORT EMERGING ISSUES AND UPDATES

1 DEVELOPMENT OF PRIMARY CARE SERVICES IN TAIN – OUTLINE BUSINESS CASE ADDENDUM

The Board approved the above at its meeting on 6 November 2012. By the time the Board meets on 4 December 2012, the Addendum will have been considered by the Scottish Government Capital Investment Group. A revised timetable has been proposed and agreed with a plan to reach financial close before 31 March 2013 with the single Forres, Woodside & Tain (FWT) Full Business Case being brought back to the Board in February 2013 and not in May as described at the 6 November meeting.

For this timetable to be achieved, the Scottish Government, Scottish Futures Trust and Board approval processes will need to run in parallel with the Stage 2 process (rather than sequentially). Both the Scottish Government and the Scottish Futures Trust are comfortable with this, as is NHS Grampian. In practical terms, this means that a Full Business Case (FBC) would need to come back to the Board in February 2013, it will seek the Board’s approval up to a predicted maximum value (i.e. rather than of a definite figure) since at that time it is likely that the financial terms relating to the senior debt will still be subject to change – indeed they remain subject to change right up until the date of financial close (the Board are presented with an FBC Addendum after financial close confirming the deal, within the limits outlined in the agreed FBC).

The intention would therefore be to seek Board approval up to a maximum value (an FBC maximum value buffer would be agreed with our financial advisors based on the market at the time) and seek delegated authority for the Chief Executive and Director of Finance to conclude the arrangements to financial close – this would avoid the need to revert to the Board if the lending market changes around the time of financial close.

2 LETTER FROM MINISTER ON NHS HIGHLAND ANNUAL REVIEW

NHS Highland has now received the feedback letter from Alex Neil, Cabinet Secretary for Health and Wellbeing on the NHS Highland Annual Review held on 5 September 2012. A copy of the letter is circulated as Supplementary Paper 1 to this update.

3 REGIONAL PLANNING – NORTH OF SCOTLAND PLANNING GROUP AND WEST OF SCOTLAND PLANNING GROUP

A copy of the Briefing for October 2012 from the West of Scotland Planning Group is circulated as Supplementary Paper 2 to this update. There is no update this month from the North of Scotland Planning Group.

Chief Executive’s Office Assynt House

23 November 2012 286 287 288 289 290 291 292 293 SUPPLEMENTARY PAPER 2

WEST OF SCOTLAND REGIONAL PLANNING GROUP

Briefing Paper

The following is a resume of the key points from the minutes of the West of Scotland Regional Planning Group Meetings held on the 19th October 2012.

1. Healthcare and Forensic Services for People in Police Custody

The introduction of a single police force in Scotland will be effective from 1st April 2013. In advance of this Health Boards need to define a service model and recruit the workforce, which was proving challenging (identifying willing and competent medical/nursing practitioners), but it was recognised that in reality it was unlikely that changes would be in effect by April 2013.

Members discussed the work was being done at national level to define a service model and clarity around the legal position. The expectation was there would be standard roles but that models would need to be flexible due to local variation e.g. Island Boards. Regarding the legal situation, Ms Minnie Mishra from the Scottish Government was leading the work on this and had sought legal advice from the CLO; the advice given had confirmed that a transfer to healthcare would not require legislative change. It was noted the SGHD was to take forward a National Network for the delivery of healthcare for people in police custody.

After a lengthy discussion, mainly around the financial implications, it was agreed that a further paper should be prepared which summarised events to date, listed the risks and the actions being taken to manage these risks. The paper should also include a target implementation date. This to be presented to the of CEs in November and would be circulated to the RPG in advance

2. West of Scotland Satellite Radiotherapy Facility – Initial Agreement for Business Case

The Initial Agreement had now been submitted to the Capital Investment Group at Scottish Government for consideration.

3. National Review of Regional Planning – Review of Potential Solutions

A report had been presented to CEs at their September meeting and it was noted that regional planning had broadly achieved the original policy aims but also that it had developed quite differently across the 3 regions. In light of this Boards were asked to work within their respective RPGs to consider the potential solutions

Mr Calderwood reflected that CEs had welcomed the need to continue with regional working and that each RPG would work with their own model the next step should be for the WoS to look at the existing architecture to determine if it remained fit for purpose, RPG colleagues supported this suggestion and agreed that the work would be taken forward by the Specialist Services Group. An update on progress would come to the RPG in due course.

The RPG also noted that the Director of Planning post in the North of Scotland Planning Group had now been advertised.

4. Regional Spinal Surgery Implementation Group – Options

The WoS RPG considered the report provided and outlined the aims of the implementation group. The group had considered several options for service provision; this had been narrowed down to three options: 294

i. To continue with the existing service model ii. To expand the current service to incorporate a regional service model with staff employed within GG&C (orthopaedics and neurosurgery) iii. To utilise available capacity at GJNH with joint working between neurosurgery and orthopaedics for non-complex cases

The Treatment Time Guarantee would come into force on 1st October, 2012, however a stay of execution had been granted to allow time for further discussions to take place. Heather Knox and Jonathan Best would meet with Mr Mike Lyon at Scottish Government and Eric Ballantyne, Clinical Lead for the National Neurosurgery Managed Service Network to discuss the options and agree the next steps to work up the detail of the option.

After discussion, the RPG noted the work completed to date and endorsed the next steps.

5. Vascular Services

Mr Ross informed the RPG that a paper confirming approval for the recommended approach to engagement on Vascular Services had been discussed at the National Planning Forum meeting on 9th October 2012. He had written out to CEs to inform them that the Regional Vascular Services Group would be reconvened as soon as they confirmed Board nominations. It was anticipated that the first meeting of the group would be arranged to take place before Christmas in order to reach agreement on implementation. He also noted that the Vascular Group would adopt the model used previously for the Optimal Reperfusion Service.

After discussion, the RPG noted the position and it was agreed that an update paper would come to a future meeting of the RPG.

6. Efficiency & Productivity – Prescribing – Medicine Waste

An update paper from the West of Scotland Prescribing subgroup was circulated in advance. The group had been asked to consider wider pharmacy related areas e.g. polypharmacy, medicines waste and rolling out of best practice across the region. The group was also asked to review the remit and membership of the group to ensure there is a more strategic approach to the pharmacy developments whilst also continuing work within the specific disease groups. The report which made the following recommendations:

 The refreshing of the Acute Prescribing Steering Group membership and Terms of Reference, to allow a more strategic, outcomes driven approach  A Regional Medicine Waste Campaign led by NHS Forth Valley Communication Team.

After discussion the RPG were content that the prescribing group was re-established and a new ToR should be drawn up with the new membership. It would also be important to link with Scottish Prescribing Advisors Group (SPAG) to check the plans around a national campaign.

Stephen Whiston Head of Planning, Contracting and Performance Argyll & Bute CHP

14 November 2012

2