Highland Health & Social Care Committee 20 March 2014 Item 3 HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEE Report B

Highland Health & Social Care Committee 20 March 2014 Item 3

HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE 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 9 January 2014 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present: Myra Duncan, Board Non Executive Director – Chair Jan Baird, Director of Adult Care Helen Bryers, Head of Midwifery Shirley Christie, Staffside Representative Mr Quentin Cox, Area Medical Committee Representative – Consultant Dr Paul Davidson, Chair, Professional Executive Committee David Flear, Patient/Public Representative Gavin Hogg, Patient/Public Representative Deborah Jones, Chief Operating Officer Linda Kirkland, Interim Director of Operations, Raigmore Hospital Rhona MacDonald, Board Non Executive Director 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 Katherine Sutton, Associate Director, AHPs Dr Chris Williams, Area Medical Committee Representative – GP

In Attendance: David Alston, Board Non Executive (to 12.15pm) Garry Coutts, Board Chair (from 11.30am) Dr Michael Foxley, Board Non Executive (from 9.45am) Gillian Grant, Team Leader (Contracts)(from 10.30am) Nick Kenton, Director of Finance (from 9.45am) George McCaig, Head of Business Support, Adult Social Care Brian Mitchell, Board Committee Administrator Kenny Oliver, Board Secretary Dr Margaret Somerville, Director of Public Health Simon Steer, Head of Strategic Commissioning (from 1030am) Maimie Thompson, Head of Public Relations and Engagement

Apologies: Dave Garden, Head of Financial Planning Bren Gormley, Elected Member, Highland Council Linda Munro, Elected Member, Highland Council Adam Palmer, Staff Side Representative Bob Summers, Head of Health & Safety Philip Walker, Head of Personnel Sarah Wedgwood, Board Vice Chair Mhairi Wylie, Public/Patient Member Representative – Voluntary Sector AGENDA ITEMS

 Feedback from Development Session on 1 November 2013  Possible Major Service Redesign Update

 Financial Position Report as at 31 October 2013

 Adult Services Balanced Scorecard

 2013/2014 Highland Health and Social Care HEAT Targets Balanced Scorecard and Exception Reports from Improvement Committee

 Strategic Commissioning Plan and Commissioning Intentions

 Review of NHS Highland Response to Deterioration in the Quality of Care in an Independent Care Home  Establishment of a Commissioning Hub  Augmentative and Alternative Communication Update  Chief Operating Officer Report

 Operational Unit Reports

 Consideration of Future Agenda Items

 Committee Function and Administration

DATE OF NEXT MEETING

The next meeting will be held on Thursday 20 March 2014 in the Board Room, Assynt House, Inverness at 9.30pm.

2 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 9 January 2014

1 TOPIC: Declarations of Interest Issues Assurance Actions Do members have any interest to No declarations were made. declare in relation to any Item on the agenda?

2 TOPIC: Assurance Report and Rolling Action Plan – 7 November 2013 Issues Assurance Actions Need to update Rolling Action Agreed regular updates required from Named Action: Plan Officers.  Action Plan to continue to be updated – Named Officers/ Committee Administrator

3.1 TOPIC: Area Clinical Forum Membership Issues Assurance Actions Are Healthcare Science and Area QC had requested assurance that these groups Psychology Fora represented on were represented and it was confirmed this was the membership of ACF? the case. 3.2 TOPIC: Professional Executive Committee – Verbal Update – Dr Paul Davidson, PEC Chair Issues Assurance Actions What progress is being made in PD advised first meeting had been held. relation to PEC? Committee comprised a small membership and would meet every two months. Officers with areas of special interest may be invited to attend and contribute. Guidance and feedback would be sought from this Committee.

3.3 TOPIC: Update on Performance and Finance Sub Committee Issues Assurance Actions What progress is being made in It was advised that a schedule of meetings for relation to Sub Committee? 2014 had been established and that Dr Rhona MacDonald had agreed to Chair.

3.4 TOPIC: Provision of Services to Ex Military Service Personnel Issues Assurance Actions What are the implications of Not seen as a cost pressure by the Board as part Action: providing services for ex-military of the general population that we have  Agreed detail of Briefing be circulated to members service personnel? responsibility for caring for. Treatment prioritised – Committee Administrator if condition linked to active service and no one in general population with greater need. No specialist services specifically for ex military servicemen (specialist service may require out of area referral) however do employ staff with specific skill sets to be able to care for certain conditions such as limb damage.

4 3.5 TOPIC: HHSCC Development Session 1 November 2013 – Formal Feedback – Myra Duncan, HHSCC Chair Issues Assurance Actions What were the outcomes from the Circulated report by Chair summarised Action: Development Session on Review discussion and outlined a series of questions for  Agreed full discussion notes be circulated to of Governance? members to consider as part of a review of members – Committee Administrator governance role of Committee. Noted need to consider Partnership Agreement and Commissioning Group aspects as part of review. Agreed Local Delivery Plan (LDP) to form basis for future HHSCC activity.

What is the position in relation to NHSH still host number of relevant services.  Agreed report outlining scope of services for Childrens Services? Commissioning Group would benefit from Children and Young People be submitted to next discussion at and reporting to this Committee. meeting – Director of Public Health DPH annual report includes feedback from children and young people. View expressed Committee need to seek assurance from those who are commissioning services to enable informed decisions to be taken and direction to be given.

How should matters be taken Overall agenda structure and scheduling to be  Agreed report on agenda restructuring and linkages forward? further considered. Links with other relevant be submitted to next meeting – Chair/Chief Governance Committees to be further Operating Officer considered and discussed.

5 4 TOPIC: Possible Major Service Re-Design Update – Directors of Operations (South and Mid & North and West) Issues Assurance Actions What are the strategic cases for Circulated report indicated that the four hospitals Action: service redesign and are these subject to review no longer conducive to delivery  Agreed to ratify strategic case for change across regarded as Major Service of modern, integrated health and social care. Badenoch & Strathspey and Skye, Lochalsh and Change? Service redesign process subject to separate Wester Ross – G McVicar/N Small engagement exercises with local communities over previous 18 months. Reviews being  Agreed to ratify the approach taken to conducted under advice from Scottish Health communications and engagement. Council Service Change Advisors and in line with national Guidance. Consultation established broad consensus for significant organisational and service change and likely this will be designated as Major Service Change. This means proposals must be subject to formal public consultation and a final Ministerial decision. Robust formal Options appraisal exercise on short list of options to be undertaken and outcomes reported to NHS Board. Once agreed Options identified then Business Case processes will commence.

What are the preferred Options? Circulated report outlined high level descriptions  Noted the preferred Options for each area. of the short list of Options for each area which would be subject to detailed appraisal exercises. In North and West area the Community Resource Hub and Spoke approach was the preferred Option however additional consideration of aspects of potential radical redesign of services had been requested. In Badenoch and Strathspey, the Community Resource Hub approach was favoured and although this involved a series of access issues there would be no impact on existing GP/GDS services. They had been fully engaged to date.

6 5.1 TOPIC: HHSCC Financial Position as at 31 October 2013 – Nick Kenton, Director of Finance Issues Assurance Actions What is the financial position in Report indicated position to 31 October 2013, Action: year and where are current highlighting forecast overall breakeven position financial pressures? by 31 March 2014, subject to the improvement of £6.5m required to deliver the forecast. A break down of the current reported overspend forecast was given, including positive movement since last reporting. It was reported negotiation continued with Highland Council in relation to possible additional funding for Adult Social Care. Much work was required in the final quarter to achieve overall financial balance and a number of specific actions taken to date were outlined. It was emphasised that clinical and care needs of service users were paramount in decision making relating to expenditure. Can NHSH demonstrate any NK confirmed existing reporting arrangements  Agreed the need to ensure improved additional funding allocated will can provide that assurance. Noted THC to Communications – Director of Adult Care go directly to ASC? consider the issue in March 2014 at meeting of Full Council. Noted NHSH can also evidence appropriate scrutiny of care package approval and improved quality of care. In process of improving communications with THC and Councillors. Care Home establishment reviews required. Noted process for ensuring needs of clients and carers are addressed is improving. Key is to manage expectations whilst ensuring all service areas improved.

7 5.2 TOPIC: Adult Services Balanced Scorecard Issues Assurance Actions What is current performance Circulated report outlined progress against Action: against targets? relevant targets. It was confirmed that these  Agreed need to ensure legibility of report – Board matters were being monitored by the Secretary Improvement Committee and would be scrutinised by the Performance and Finance Sub Committee.

5.3 TOPIC: HHSC HEAT Targets Balanced Scorecard – Kenny Oliver, Board Secretary Issues Assurance Actions What are HEAT Targets relevant Copy of Balanced Scorecard circulated, along Action: to Health and Social Care and with exception reports relating to Delayed  Agreed clarification be given as to use of ‘NA’ what is current performance Discharge, CAMHS, Stroke Services, Cancer annotation – Board Secretary against these? Services, 12 Weeks Access Targets for Raigmore Hospital, Treatment Time Guarantee Access Targets for Raigmore Hospital, and Key Diagnostic Tests at Raigmore Hospital. Noted these are monitored by the Improvement Committee.

What is the role of Committee in Advised Committee role to seek assurance that consideration of Scorecard? Directors of Operations have actions in place to address identified issues.

6.1 TOPIC: Strategic Commissioning Plan and Commissioning Intentions – Simon Steer, Head of Strategic Commissioning Issues Assurance Actions What is the approach being taken Presentation given and circulated report Action: and progress made to date? indicated development of Strategic  Agreed full Commissioning Plan be submitted to Commissioning Plan requires to be underpinned the next meeting – S Steer by clear project structure, co-production  Agreed members be provided with further detail in approach, governance arrangements and relation to membership of Improvement Groups, communication plan. Planned that scope of the including Staffside representation – S Steer project will encompass all Adult Care services 8 both provided and commissioned by NHSH including specific cohorts such as older people, dementia, learning disability, mental health, adults with brain injury, and carers. Initially will be particular focus on older people and aspects relating to Telecare, step up/down and intermediate care at home services, quantity and range of quality care home/care at home services, preventative measures to assist avoidable admissions, and quantity of experienced/trained care staff. The project would deliver a five year strategic commissioning plan and a one year statement of interim commissioning intentions. Setting out priority actions for reducing/increasing activity. Progress to date was outlined including establishment of a Project Team, Advisory Panel and Project Board (Adult Services Commissioning Group). Partnership working was welcomed. The specifics and detail of commissioning intentions will be developed through February 2014. Improvement Groups would be required to expand the evidence underpinning respective priorities, set out how the market needs to change, and quantify investment and disinvestment. This will enable further development of priorities, proposals and route for transitions. This will also enable consideration of appropriate change metrics to be applied. How successful will a zoning/tariff SS advised single tariff with graduated approach commissioning approach be? to reflect relevant complexity issues. Work to date suggests a zoning approach can be successful. DJ advised work to date with providers has led to real change opportunities. Aim is to enable viable, sustainable mixed care provision. Local approach tailored to need is required.

9 TOPIC: Review of Response by NHS Highland to Deterioration in the Quality of Care in an Independent Care Home – Jan Baird, 6.2 Director of Adult Care Issues Assurance Actions What action was taken in Circulated report detailed the review undertaken, Action: response to the care concerns with focus on capturing learning from the  Agreed the proposals in the report. raised in relation to the Care response initiated by the South and Mid  Agreed an Action Plan be prepared and submitted Home in question and what Operational Unit, and giving an update on the to the next meeting - Director of Adult Care learning is being applied as a actions taken to ensure learning was being result? applied across care homes in Highland. Meetings had been held with staff, professional leaders and Operational Unit Managers, with independent contractors and Board Nurse Director having the opportunity to contribute. The formal report concluded that the deterioration in the level of care being provided had been unacceptable. A quick and targeted response had been initiated. It was important to capture relevant learning points from the process and ensure everything is done to prevent this happening in any other care home in Highland. The report detailed a series of recommendations intended to inform NHSH as to what could be progressed to prevent similar deteriorations in quality of care, to improve readiness of the organisation should a similar situation arise and to recognise the implications that spread beyond the remit of NHSH. The recommendations related to seeking assurance from Social Work as to ensuring levels of care are in place and monitored, the Adult Support and Protection Committee reviewing training and procedures, consideration of development of an escalation process, and consideration of the inclusion of care quality schedules in future contracts.

Will GPs be informed as to future Advised that District Managers would seek to action? alert GPs as to position. GPs also to be enabled to escalate concerns where appropriate. 10 6.3 TOPIC: Establishment of a Commissioning Hub – George McCaig, Head of Care Support Issues Assurance Actions What is the proposed approach Circulated report indicated that a number of Action: for establishment of a parallel workstreams to be brought together to  Agreed the Committee be kept informed as to Commissioning Hub? form a coherent approach to commissioning. development of the Hub – George McCaig The Hub would be responsible for a range of activity within adult social care, taking a lead from the Commissioning Strategy. The Hub itself should be seen as a set of commonly understood business processes with the Contracts Team having a key role in the coordination, reporting and driving forward the aims and objectives agreed in the Commissioning Strategy. The aims and objectives for the Hub were outlined and it was stated the increased emphasis on quality of care based around a quality schedule and measurement of outcomes also fitted well with a Self Directed Support approach. Business process improvement would involve a series of processes including in relation to service quality, contract management and audit base data. Next steps included confirming detail of business processes with Directors of Operations, agreement of self-assessment packages and spot-check schedules, development of quality schedules and development of area commissioning plans in accordance with agreed priorities.

What will be the lines of Advised will be a virtual Hub and lines of accountability? accountability still to be fully scoped and defined. There will be Executive Director involvement.

11 7 TOPIC: Augmentative and Alternative Communication Update – Jan Baird, Director of Adult Care Issues Assurance Actions What progress is being made in JB advised that Project Manger had been Action: relation to this subject? appointed and that relevant funding now in place.  Agreed full report to be submitted to next meeting – Full report, including update in relation to scoping Director of Adult Care work for Speech and Language Therapy Service will be prepared.

8.1 TOPIC: Chief Operating Officer Report – Deborah Jones, Chief Operating Officer (COO) Issues Assurance Actions Delayed Discharge Position remains challenging due to combination Action: of factors, with over 20 individuals waiting for  Agreed further progress reports be provided to Care at Home packages. The suspension of Committee – Simon Steer admissions to Care Homes, and closures, were having an impact with particular issues in the North area. As at 12 December 2013 there were 48 individuals subject to delayed discharge. Areas of success were identified as the Raigmore Community Support Initiative, leadership from the Chief Operating Officer, collaboration with third sector to increase Care at Home capacity and provision of support to Care Homes with a view to lifting embargoes. Anticipated that NHSH will attain the zero target in 2014 but significant system change required to sustain progress. Highland Quality Approach RPIW Advised there are now nine accredited Lean Update leaders within NHSH. 14 Rapid Process Improvement Workshops and 1 Kaizen event completed, with a number having reported out at the NHSH Board and to Operational Units. Weekly Report Outs taking place. Further five RPIWs planned to May 2014 and this likely to increase to 50 events over 2014/2015.

12 District Partnerships Seminar relating to development of District Partnerships was held. Key role for Partnerships identified in relation to Community Planning and this may help move the Partnerships into more proactive role, with wider focus. Guidance for District Partnerships continues to be revised. Partnerships should not be seen as route for escalation of issues and concerns should be raised with Management Teams. Partnerships to seek to provide innovative solutions to issues raised through a community-based approach.

Care at Home Finance and Work continues to develop in-house Care at Staffing Home service in advance of devolution to Operational Units later in 2014. Includes a revised management structure and a workforce review to identify pressure areas. Specific area of work to establish scheduling tool to ensure fit for purpose and will deliver anticipated efficiencies. This will inform delivery and management of service as well as workforce planning. Work to be taken forward in context of Strategic Commissioning and development of new models of integrated care.

Care Inspectorate actions relating Progress continues to be made against Action to Care at Home Plan including in relation to client care reviews, staff supervision and training, and documentation for care plans and risk assessments. All service users surveyed in attempt to gain feedback to inform redesign and quality improvements. Follow-up inspection anticipated for early 2014.

Patient Management System Work progressing well and system due to go live on 3 March 2014. Extensive data migration work continues to be progressed to merge patient data from existing systems to new unified system. Data testing to continue until February 2014. 13 Activity in relation to building clinics continues, and work on letter templates for communication with patients is about to begin. Creation of Standard Operating Procedures for all administrative processes at an advanced stage and will allow training packages to be created and delivered in early 2014. Training will be delivered using an innovative blend of methods. Work continues to ensure all technical components required are in place. Staff will be provided with training prior to system going live.

8.2 TOPIC: Operational Unit Reports – Directors of Operations Issues Assurance Actions North and West Operational Action: Unit Report Reported position improved but pressures Financial Position remain in relation to locum costs for RGHs, Out of Hours and vacant Practices. Difficult to identify recurring savings due to service pressures in Health and Social Care. Continue to work to scrutinise all spend and identify other areas for potential savings.

Waiting Times Belford Hospital Radiology waits remain an issue, resulting from limited visits from Oban. Patients are offered appointments in either Oban or Raigmore if appropriate. In Caithness General Hospital additional endoscopy sessions have improved position however service remains vulnerable.

Delayed Discharge Caithness position improved with Care Homes operating phased return to normal practice. All on waiting list currently being reassessed. Sutherland area remains a concern. 14 Review of Adult Services, Caithness is a proposed pilot site for Programme  Agreed detailed report on workstreams and activity Caithness Budgeting and Marginal Analysis activity by be provided to next meeting including identification Glasgow Caledonian University. One day and analysis of relevant risk areas – Director of workshop agreed process to be embedded in Operations (North and West) current redesign activity to enable workstreams to prioritise decisions required to develop plans. Adoption of an analytical approach anticipated to help identify the effects of resource shift and areas of potential disinvestment. Specific work commenced in CGH in relation to flow and process within the surgical ward. Collaborative working with community organisations showing potential for increasing local capacity, with examples highlighted in report.

Lawson Memorial Hospital First phase of redesign substantially complete and outstanding works being progressed in line with Building Control requirements. Cambusavie Unit continues to operate with three closed beds at this time. Plans progressing regarding the redevelopment of the old wards into outpatient clinical accommodation, with room layouts being prepared and final costs calculated. Co-location of staff complete. Old Golspie Health Centre declared surplus to requirements.

Falls Prevention A number of activities in progress including  Agreed further detailed report on Falls Prevention unscheduled care work with Scottish Ambulance work across North Highland be presented to next Service (SAS) as part of Caithness redesign. meeting – Associate Director (AHPs) Falls unscheduled care pathway implementation to begin with Golspie in early 2014 and working with SAS and Red Cross as responders for people who fall but do not require transfer to hospital. Six North and West care homes signed up to take part in national workstream to implement guidance for falls prevention and management.

15 Work with Housing HQA charter developed to support work around improving access to care and repair services through up skilling of care and repair staff to deal with basic equipment and adaptation needs in the community. Will initially be implemented in Sutherland and rolled out across North and West. Housing Department looking to roll out model across North Highland and allocated £22k to allow secondment of Occupational Therapist to support initial implementation.

Remote and Rural Sustainability Steering Group met for second time and agreed  Agreed detail of ‘Being Here’ Conference to be establishment of wider Reference Group. Also circulated to members – Committee Administrator agreed workstreams relating to Recruitment, Education and Training, a ‘Rural Parliament Approach’, and the holding of an appropriate Conference. Noted visit by key personnel from the South Central Foundation in Alaska planned for 21 February 2014 and hoped they will address the ‘Being Here’ Conference on 22 February 2014.

South & Mid Operational Unit Advised that delivery of services to formally  Agreed to note the risk identified and ongoing Police Scotland – Custodial and transfer to NHS Board from 1 April 2014, this actions to manage that risk. Forensic Services having been delivered by NHSH to Northern Constabulary since 2012. Main services delivered at Burnett Road, Inverness and Service Level Agreements for doctor led services in Fort William, Wick and Skye. Police Scotland centralised management of custodial services and revised funding formula being developed which was anticipated to impact on resource given to NHSH to deliver service. Significant risk that level of resource will not be sufficient to maintain current high service level.

HEAT Target Monitoring Reports Update on position relating to performance against relevant HEAT Targets given.

16 Financial Position Forecast of a £4.3m overspend, relating entirely to Independent Sector Care budgets. Savings Plan for Health and Adult Social Care budgets on target.

Raigmore Operational Unit Report indicated forecast overspend of £8.985m,  Agreed future reporting on access targets not refer Financial Position with contributing factors outlined. The position to ‘Breachers’ - Interim Dir of Operations deteriorated slightly from that for Month 7. Cost (Raigmore Hospital) pressures relating to locum spend, access targets and drug spend. Recovery Plan being developed with initial focus on improving governance arrangements and internal controls. Stage 2 of Recovery Plan to involve HQA in delivering patient centred services, enhancing value for patients and clients through elimination of wasteful processes and procedures. Focus on three main strategic areas of Outpatient Redesign, Flow and Unscheduled Care, and Theatre Redesign. Also to be development of ‘waste nugget’ on Intranet site. Fully costed plan expected mid January 2014 and will be operational in 2013/14 and 2014/15.

Older People in Acute Care Inspection was considered positive with areas of  Agreed OPAC report on Care and Comfort be (OPAC) – Unannounced strength evidenced and areas where brought to next meeting - Interim Dir of Inspection improvement required identified. Staff Operations (Raigmore Hospital) recruitment in specialty areas proving difficult. Significant locum use in Orthopaedic service with view to achieving catch-up by 31 March 2014. Action Plan developed and relevant Steering Committee reconvened on monthly basis. 15 places allocated to NHSH on next cohort of Dementia Champions, a number of whom will be Raigmore Hospital nurses.

Nursing Establishment Review Review undertaken, in Partnership, using  Agreed assurance relating to relevant partnership (Medical and Surgical) appropriate workforce tools. Overall requirement working arrangements to be included in report to in terms of additional registered nurse numbers next meeting- Interim Dir of Operations identified as 7.21wte and 3.93wte of non- 17 registered with a total increased spend of £255k. (Raigmore Hospital) It was noted that operationally establishments are augmented by supplementary staffing. The review in relation to Ward 8 was being retaken following reconfiguration of beds. A number of areas still to be reviewed and timetable for completion circulated.

Capital Projects An update was given in relation to the Critical Care and Theatre Upgrade, redesign of Wards 8 to 10 including relocation of Endoscopy Services, Endoscopy Decontamination, Children’s Ward (ARCHIE), and relevant Fire Improvement Works.

9 TOPIC: Committee Function and Administration Issues Assurance Actions What are the proposed schedules Noted provisional schedules circulated for both Action: for meetings in 2014? Highland Health and Social Care Committee and  Agreed further consideration be given to dates in also Finance and Performance Sub Committee. March and September 2014 to avoid clashes with THC meetings – Committee Administrator

Can improvements be made to Agreed to include greater reference to Items  Amend Agenda structure – Chair/Chief Operating the structure of the Agenda for relating to Childrens services. Noted members Officer/ Committee Administrator meetings moving forward? can suggest Items for consideration at any time.

18 10 FUTURE AGENDA ITEMS AND DEVELOPMENT SESSION TOPICS

Meeting on 20 March 2014:  Report on Financial Impact of Enforcement of Embargoes on Admissions to Care Homes (and include as part of future reports on Contract Monitoring) – David Garden  Suspension of Admissions to Care Homes – Discretionary Lifting of Embargoes – Brian Robertson  Anticipatory Care Planning Activity – Ken Proctor  Report on Adult Support – Jan Baird  Progress on Evaluation of Service Integration – Brian Mitchell  NoSPG Report on Review of Oncology Services – Chief Operating Officer  Exception Report on drug expenditure at Raigmore Hospital – Dir of Operations, Raigmore  Update on monitoring of Care Home contracts, single point of contact and escalation routes – Jan Baird  Monitoring the Delivery of In-house Services – George McCaig  Draft Commission for Integrating Care in the Highlands Legal Services – Jan Baird  Local Delivery Plans Year End Progress Report – Directors of Operations

Items for 20 March 2014 – from Assurance Report:  Report on Scope of services provided to Children and Young People – Director of Public Health  Report on restructuring of Agenda and linkages to Governance Committees – Chair/Chief Operating Officer  Timetable for Response to Deterioration in Quality of Care in an Independent Care Home – Director of Adult Care  Augmentative and Alternative Communication Update – Director of Adult Care  Report on Review of Adult Services, Caithness including risk analysis – Director of Operations (North and West)  Report on Falls Prevention Activity – Associate Director (AHPs)  Older People in Acute Care (OPAC) Report on Care and Comfort – Interim Director of Operations (Raigmore)  Assurance relating to Partnership Working Arrangements in Raigmore (DOOs report) - Interim Director of Operations (Raigmore)  Strategic Commissioning Plan – Simon Steer

Future Meetings:  Quarterly – Risk Registers – Directors of Operations in Operational Unit Reports then quarterly thereafter  Quarterly – Care Inspectorate Inspection Reports in Highland (incl comparator data pre and post integration, Action plans, timescales for action and interim support arrangements) – Brian Robertson  Standing – Adult Support and Protection Committee Minutes  Standing – Suspension of Admissions to Care Homes – Exception Reports – Brian Robertson  Standing – Assurance Report from Performance and Finance Sub Committee - Adult Social Care Balanced Scorecard, financial position, HEAT targets and standards  Minutes/Assurance report from Professional Executive Committee (part of COOs report)

19  Transitions – update on progress with Strategy – Chief Executive  Report on Implications of Welfare Reform on Charging for Social Care Services (include relevant trends, risks etc) – Brian Robertson  Reablement Strategy – Brian Robertson  Case mix profile for relating to Emergency Department admissions – Deb Jones/Margaret Brown (include in COO report) – Report to NHS Board October 2013  Local Delivery Plans Six Monthly Update – due May 2014 – Directors of Operations  Report on Charging – Brian Robertson/George McCaig – due May 2014  Health and Safety Update  Care Home Risk Management Processes – George McCaig  Strategic Commissioning and Training 2014-2019 – Deb Jones (COOs Report Item)  Managing Patient Choice Communications Plan – Chief Operating Officer  Update on associated activity affecting Maternity Services, including pre-birth activity – Dir of Social Work, Highland Council  Consideration of Patient Feedback/Stories  Infection Control Arrangements within Care Homes

Development Sessions:  Self Directed Support (DVD Presentation) – RAS monitoring, mgt of identified risks, identification of ‘What Ifs’, and Staff Awareness  Primary Care  Care Inspectorate Inspection Criteria

11 DATE OF NEXT MEETING

The next meeting of the Committee will take place on Thursday, 20 March 2014 in the Board Room, Assynt House, Inverness at 9.30am

20 DRAFT FOR CONSIDERATION Highland Health and Social Care Committee 20 March 2014 Item 3.3(3)

FOLLOW UP FROM HIGHLAND HEALTH AND SOCIAL CARE COMMITTEE ACTION PLANS – SEPTEMBER 2012 ONWARDS Those items shaded grey are due to be removed from the Action Plan. Item Action / Progress Lead Outcome/Update

07/09/2012 Care Homes for Older People Assurance reports be established for both Care B Robertson COMPLETE - Home Inspectorate Reports/external placements. incorporated in routine DoOs/Contract Monitoring reports as appropriate Health and Safety Agreed assurance report be submitted to January B Summers COMPLETE - 2013 meeting incorporated in routine DoOs Report HHSCC Risk Register To be discussed further with Dirs of Operations. D Jones COMPLETE- Operational Agreed further consideration be given as to where I Gibson/ D Jones Plans to include risk best relevant risks are reported. identification and 01/11/2012 Risk Registers Agreed Operational Unit registers be reviewed D Jones management. Routine quarterly. performance monitoring of Plans. Patient/Client Administration Systems Report on progress to be submitted to future D Jones COMPLETE meeting. Implementation of national reviews in Assurance required that national report issues B Robertson COMPLETE – social care settings have been addressed. incorporated in routine DoOs/Contract Monitoring reports as appropriate Agreed to set up Development Session with Care Director of Adult Care November Update - Inspectorate to better understand their role and Matter being progressed establish collaborative working arrangements. with Care Inspectorate. Strategic approach to development sessions to future meeting. 10/01/2013 Infection Control Need for consideration of how best to capture Director of Public COMPLETE – impact of joint working arrangements through Health incorporated into assessment of qualitative and quantitative Commissioning strategy measures. and performance Consider utilising Change Fund resource to Director of Public monitoring. enable Senior Citizens Framework to evaluate Health COI exception reporting impact of joint working. part of DoO reports Agreed there be development of specification G McVicar Being Here conference relating to rural resilience and service delivery in circulated February 2014. remote and rural areas. Report to future meeting on actions being taken forward in N Highland. Charging for Social Care Services Further reports on Welfare Reform and Head of Adult Social COMPLETE - Annual implications for charging to be brought to Care process of bringing Committee as detail emerges. charging policy to Agreed to consider inviting Council Income I Gibson/ D Jones meeting then to Board Maximisation Team to address future meeting. Operational Units to be given resource and D Jones capability to manage community service elements and be provided with support where trend analysis highlights areas of concern. First monitoring report to be submitted to Head of Adult Social COMPLETE – routine September 2013 meeting. Care contract monitoring reporting 14/03/2013 Professional Executive Committee Agreed paper to be prepared for consideration by D Jones COMPLETE – Action to PEC on issues raised re Terms of Reference review passed to PEC to Agreed to keep PEC under review, including D Jones bring to HH&SCC March NMAHP membership. 2015 (Put on future Agreed further report to HHSCC including detail of D Jones agenda list) proposed review. Development Session Agreed to include Reablement, Delayed B Mitchell Strategic approach to Discharge and Shifting Balance of Care. development sessions to future meeting. Adult Social Care Practice Forum Agreed effectiveness of Forum be reviewed and B Robertson COMPLETE – Action to assessed after one year. review passed to Forum to bring to HHSCC March 2015 (put on future agenda list) Emergency Department 4 Hour Target Service Planning Team be requested to conduct D Jones/M Brown COMPLETE case mix profiling of admissions with view to reducing readmission rates. Management of Patient’s Paper Records Agreed report on actions to be included in COO D Jones COMPLETE – Included in report to next meeting. CoO report DALLAS Scheme Action Plan to be presented to NHS Board J Baird COMPLETE – Launched Development Session at Board 4 March 2014 02/05/2013 Local Delivery Plans Report on patient/public engagement to be M Thompson COMPLETE - NHS Board presented to NHS Board in June 2013. June 2013

2 Financial Position Agreed small Group be established to develop D Garden/D Jones/ COMPLETE – proposals for future reporting, including L Munro/G McCreath/ Performance and consideration of financial plans and budget K Sutton Finance Sub Group profiling activity. remitted to consider reporting Agreed consideration be given to greater reporting Head of Financial detail on locum and transport spends. Planning Agreed definition of ‘acute hospital admissions’ Head of Care Support (Item 3.2) be clarified. Agreed further report be provided to September Head of Adult Social 2013 meeting. Care Overview of Care Inspectorate Inspection Agreed future reports include assurance relating Head of Adult Social COMPLETE – Reports in Highland 2012/2013 to Action Plans, including timescales and interim Care Incorporated in routine support arrangements. contract monitoring reporting Agreed SMT report on improvement activity and Head of Adult Social COMPLETE – Reported enforcement of embargoes also be submitted to Care to HHSCC July 2013 this Committee. Agreed seek to learn from third sector activity to Head of Adult Social COMPLETE – ensure this is applied as part of any in-house Care Incorporated in Strategic service improvement. Commissioning Plan and performance monitoring thereof OPERATIONAL UNIT REPORTS – Agreed results of Tissue viability activity to be B Mitchell To be included in North and West circulated to members. DOO’s report on exception basis Raigmore – Treatment Time Guarantee Agreed need for further clarity on patient number L Kirkland COMPLETE – and categories. Performance and Agreed need to improve patient information L Kirkland Finance sub committee relating to Out of Area referrals. remitted to scrutinize data and information 04/07/2013 Committee Reporting Format Agreed to discuss format of report at M Duncan/ COMPLETE - HHSCC Development Session. B Mitchell Development Session November 2013 Professional Executive Committee Agreed to circulate Terms of Reference to D Jones/ COMPLETE Professional Advisory Committees once finalised B Mitchell and agreed. Self Directed Support Agreed DVD presentation be given to B Robertson/ Information on training Development Session B Mitchell sessions circulated February 2014. Strategic approach to development sessions to future meeting

3 Agreed SDS form Standing Item on Finance Sub D Garden COMPLETE – Committee Agenda. Performance and Finance sub committee remitted to scrutinize data and information Agreed Development Session include aspects B Robertson/ Information on training relating RAS monitoring, Management of M Duncan/ sessions circulated Identified risks, identification of ‘What Ifs’, and B Mitchell February 2014. Strategic staff awareness. approach to development sessions to future meeting Agreed relevant reporting group be established. D Garden COMPLETE – Performance and Finance sub committee remitted to scrutinize data and information Financial Position at 31 May 2013 Agreed further report on impact of embargoed B Robertson/ COMPLETE – beds to next meeting. D Garden Incorporated in routine contract monitoring reporting HHSC Financial Plan 2013/2014 Agreed Plan for 2013/2014 be submitted to next D Garden COMPLETE – meeting. Performance and Finance sub committee remitted to scrutinize data and information Agreed draft Strategic Commissioning Plan be J Baird/ COMPLETE - HHSCC submitted to Committee early 2014. S Steer January 2014 Adult Services Balanced Scorecard Agreed L Munro be briefed in relation to Indicators B Robertson 44, 56a and 56b outwith meeting. Agreed Strategic Key Performance Indicator D Jones COMPLETE Group consider relevancy of listed Indicators. Agreed consideration be given to reporting on D Jones COMPLETE – exception Respite Care activity. report submitted to HHSCC September 2013 Suspension of Admissions to Care Homes Agreed relevant contract monitoring include B Robertson COMPLETE – reference to implementation of actions, their Incorporated in routine respective timelines, and associated impact on contract monitoring services. reporting Agreed number of admission suspensions lifted B Robertson through discretionary arrangements be reported to Committee. Agreed Committee receive full report on all B Robertson aspects in first instance and receive quarterly exception reports thereafter. 4 Agreed issues relating to Inspectorate Gradings D Jones COMPLETE between Third Sector Homes and NHS Homes be considered on a shared learning basis by Strategic Commissioning Group. Chief Operating Officer Report Agreed further detail on Commissioning be D Jones Future HHSCC meeting brought to future meeting. COMPLETE South and Mid Operational Unit Report – Noted Initial Agreement document to be submitted N Small COMPLETE – Report Development of Single Hospital Site in to future meeting. submitted to January Badenoch and Strathspey 2014 meeting Raigmore – Review of Nurse Staffing Outcomes from review to be reported to next L Kirkland HHSCC 12/09/2013 Levels across Medical and Surgical meeting. COMPLETE Division GMS Contract (Scotland) Agreed further update be provided to next Dr K Proctor Strategic approach to meeting. development sessions to Primary Care Activity Agreed consideration be given to a Development M Duncan future meeting Session relating to Primary Care Activity. 12/09/2013 Professional Executive Committee Agreed Minutes from Committee to be submitted D Jones/ COMPLETE to HHSCC. B Mitchell Financial Position to 31 July 2013 Performance and Finance Sub Committee to D Garden COMPLETE – consider issues on reporting, data analysis and Performance and planning issues, especially at local level. Finance sub committee remitted to scrutinize data and information Agreed report on impact of services for ex-military H May COMPLETE – January service personnel be provided to Committee. 2014 meeting and information circulated February 2014 Report on progress with actions and work on Drs of Operations COMPLETE – planning to next meeting. (N&W, S&M)/Head of Incorporated in DoOs Childrens Services Reports Performance and Finance Sub Committee to D Garden COMPLETE – provide assurance to this Committee. Performance and Agreed update in relation to forward/scenario Director of Human Finance sub committee planning at strategic level to next meeting. Resources remitted to scrutinize data and information

Agreed NoSPG review of Oncology services Chief Operating Officer March 2014 (COOs report to next meeting. Report) ASC Contracted Services Quarterly Report Agreed next report to include issues discussed in Head of Care Support COMPLETE – this meeting. Incorporated in routine contract monitoring reporting

5 Adult Services Balanced Scorecard Agreed to include narrative as part of exception D Jones COMPLETE – reporting process. Performance and Finance sub committee remitted to scrutinize data and information Agreed presentation and layout to be K Oliver Issue also raised at reconsidered in terms of legibility. January 2014 meeting. HHSCC HEAT Targets Balanced Scorecard Agreed report on 2013/2014 activity to next K Oliver HHSCC 07/11/2013 meeting and to include other standards. COMPLETE Delayed Discharge Agreed implications of relevant Choice and D Jones/S Steer For Future Agenda Transport Policy to be considered by Committee and Highland Partnership Forum. Care Homes Report on activity of short life working group and Head of Care Support Report submitted to risk management process to future meeting. January 2014 meeting and action plan to March 2014 meeting Care Inspectorate Inspection Reports Agreed need to identify priority areas for Service Head of Adult Social COMPLETE – Part of Improvement Lead. Care routine contract Agreed Third sector issues be considered by Chief Operating Officer monitoring and Adult Strategic Commissioning Group, with report commissioning reporting back to Committee. to the committee Agreed to consider Care Inspectorate Inspection M Duncan/D Jones/B Strategic approach to criteria at a future Development Session Mitchell development sessions to future meeting Strategic Commissioning and Training Noted report on training outcomes to be submitted Chief Operating Officer 2014-2019 to future meeting. Skye, Lochalsh and Wester Ross Services Initial Agreement to be submitted to Committee in G McVicar COMPLETE – Report Redesign January 2014. submitted to January 2014 meeting Dir of Operations Report (Raigmore) Further data on HSMR to be sought from ISD and Dir of Operations - Incorporate in DoOs analysed. Report on outcomes of analysis to Raigmore report for assurance and future meeting. then on exception basis 07/11/2013 Operational Unit Local Delivery Plans Agreed include reference to aspects relating to Dirs of Operations Operational Plans to May inequalities. 2014 meeting Financial Position Agreed exception report on Raigmore drug D Garden HHSCC January 2014 – expenditure be brought to next meeting. now to March 2014 Respite Care Services Agreed to be an area of focus in next Operational Dirs of Operations Operational Plans to May Unit Delivery Plans. 2014 meeting Report on contracts and monitoring, single point J Baird March 2014 meeting of contact and escalation routes to next meeting. Promoting Safe, Effective and Quality Agreed Communications Plan be developed and D Jones Future HHSCC Discharge – Managing Patient Choice submitted to Committee.

6 Update on Maternity Services Agreed update be provided on associated activity Dir Social Work Future HHSCC affecting Maternity Services, including pre-birth activity. Integrating Care in the Highlands – Legal Draft Commission to be submitted to next J Baird HHSCC January 2014 Services meeting. 09/01/2014 Development Session - 1 November 2014 Agreed full discussion notes to be circulated to B Mitchell COMPLETE members. Committee Agenda and Associated Agreed report on restructuring of Agenda and M Duncan/Chief HHSCC March 2014 Linkages linkages to Governance Committee be submitted Operating Officer to next meeting. Children and Young People Services Report on scope of services to next meeting. Dir of Public Health HHSCC March 2014 Adult Social Care Agreed need to ensure improved communications J Baird with THC and Councillors. HEAT Targets Balanced Scorecard Agreed clarification be given in relation to ‘NA’ K Oliver annotation. Strategic Commissioning Plan and Agreed members to be provided with detail in S Steer Commissioning Intentions relation to Improvement Groups. Review of Response by NHSH to Agreed Action plan be submitted to next meeting. J Baird HHSCC March 2014 Deterioration in Quality of Care in COMPLETE Independent Care Home Augmentative and Alternative Agreed full report to next meeting. J Baird HHSCC March 2014 Communication COMPLETE Review of Adult Services, Caithness Agreed detailed report on activity to be provided G McVicar HHSCC March 2014 to next meeting including risk analysis. COMPLETE Falls Prevention Activity Agreed detailed report to next meeting. K Sutton HHSCC March 2014 COMPLETE Remote and Rural Sustainability Agreed detail of ‘Being Here’ Conference to be B Mitchell COMPLETE circulated to members. Raigmore Hospital Financial Position Agreed not to use phrase ‘Breachers’ in future L Kirkland reporting. Older People in Acute Care Agreed OPAC report on Care and Comfort be L Kirkland HHSCC March 2014 brought to next meeting. COMPLETE Partnership Working in Raigmore Hospital Agreed assurance relating to Partnership Working L Kirkland HHSCC March 2014 arrangements be provided to next meeting.

Highland Health & Social Care Committee 20 March 2014 Item 5.1

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.nhshighland.scot.nhs.uk

DRAFT NOTE of MEETING of the Performance and Finance Sub Thursday 20 February 2014 – 10.00 am Committee Board Room, John Dewar Building

Present: Dr Rhona MacDonald, NHS Board Non-Executive (Chair) Mr David Garden, Head of Financial Planning Ms Deb Jones, Chief Operating Officer Mrs Linda Kirkland, Interim Director of Operations, Raigmore Hospital Mrs Gillian McCreath, NHS Board Non-Executive Mrs Gill McVicar, Director of Operations (North and West) Mr Nigel Small, Director of Operations (South and Mid) (from 10.10am) Ms Kate Stephen, Highland Council

In Attendance: Mr Brian Mitchell, Board Committee Administrator

1 WELCOME AND APOLOGIES

1.1 Welcome

The Chair welcomed those present and advised the purpose of this meeting was to discuss and agree relevant processes and reporting requirements for the Sub Committee moving forward.

1.2 Apologies

Apologies for absence were received on behalf of Mrs M Brown, Mr Q Cox, Mr K Oliver and Ms L Munro.

2 ROLE OF SUB COMMITTEE

Dr MacDonald advised the Highland Health and Social Care Committee had approved the Terms of Reference for this Sub Committee, the purpose of which would be to “provide oversight and scrutiny of performance against HEAT Targets, Integrating Care, Finance, and Operational Delivery/Change.” The role of the Sub Committee had been defined as to monitor performance, agree actions to mitigate the risk of adverse performance and provide assurance that Operational Delivery Plans are delivered. The Sub Committee would review all aspects of performance but would focus on the exceptions to assist and support Operational teams to focus on critical priority areas. It was anticipated there would also be regular reports on good practice. The Sub Committee would report to the Highland Health and Social Care Committee. Ms Jones emphasised the role of the Sub Committee in providing relevant scrutiny of performance in a supportive and enabling manner, with particular focus on Adult Social Care. It was anticipated that once fully operational the Sub Committee would subsume much of the work of the current Improvement Committee.

3 DISCUSSION

After discussion, the following points were noted and agreed:

 The Improvement Committee and Performance & Finance Sub Committee would overlap for an initial period until such time as the Sub Committee could subsume the work of the Improvement Committee.  The Sub Committee required the ability to be able to scrutinise issues in detail, have appropriate and honest dialogue to seek necessary assurance, and be able to have such discussion in private and for every member to adhere to the terms of engagement relating to openness, honesty, trust and mutual respect.  Because of the need to be consistent with regard to reporting to the Sub Committee, in a manner that was not an industry unto itself and in line with Lean methodology, it was agreed that a paperless approach be adopted. Reports would be on an SBAR(Situation, Background, Assessment and Recommendation) approach, short in nature, to allow more time for discussion and scrutiny at meetings. It was agreed that Financial reports would require greater detail.  Reports to the Sub Committee should focus on key issues at Operational Unit level and further discussion on these issues would be a key component of the work of the Sub Committee.  Operational Units were responsible for scrutiny of delivery on relevant Targets and provision of assurance reports to the Highland Health and Social Care Committee. Matters being reported to the Sub Committee would be the key issues requiring consideration.  With particular reference to Finance, there would be a need to consider not only how this was being utilised, but also to consider any reasons for deviation from Plan and what actions were being taken to mitigate associated impact.  Discussion on HEAT targets would focus on those deemed most important but there would also be an annual review of all HEAT Targets.  Further discussion would be required, with the Director of Public Health in relation to reporting on respective Public health Targets.  The Sub Committee would not be considering issues relating to Strategy but could consider key blockages to implementing Strategy.  The Sub Committee would provide an Assurance Report to the Highland Health and Social Care Committee. The Assurance Report would be agreed by all Sub Committee members prior to submission.

It was noted that in relation to the Balanced Scorecard there was a move to electronic data input and reporting that would allow for much more in-depth interrogation.

2 4 OUTCOMES

The Outcomes from this meeting were agreed as:

 The Terms of Engagement are that meetings would be conducted in an honest, open and confidential manner where relevant information was provided and issues shared. All members should be signed-up to these Terms of Engagement.  Reporting to the Sub Committee will be on the basis of an Assurance Report, in an SBAR-type format and the Sub Committee will report back to the Highland Health and Social Care Committee in a similar format.  As stated, all those present at meetings would approve the respective Assurance Report prior to submission to the Highland Health and Social Care Committee.  Reports will relate to key HEAT/Operational Unit Targets, variance from Operational Unit Local Delivery Plans as well as relevant blocks to implementing Strategy where appropriate.  A Corporate Parenting approach would be adopted whereby Non-Executive Board members would provide support etc to Operational Units on the basis of Dr R MacDonald (North & West), Mrs M Duncan (Raigmore Hospital) and Mrs G McCreath (South & Mid).  There would be both a formal and an informal session at Sub Committee meetings.  All processes will be kept under consideration and would be developed as the Sub Committee matures.  Moving forward, ideally, meetings should be scheduled for the second half of the respective month.

5 DATE OF NEXT MEETING

The next scheduled meeting will be held on 3 April 2014 at 10.00 am in the Board Room, Assynt House, Inverness. This date and time will be subject to change in line with the agreement reached above in relation to scheduling.

The meeting closed at 11.45 am.

3 Suggested Lines of Reporting

PERFORMANCE

HEAT ALL OTHER ACTIVITY

GOVERNANCE GOVERNANCE OPERATIONAL

Improvement Health and Social Senior Management Committee/ Care Committee Team/Highland Performance and Quality Approach Finance Sub Leadership Committee Group/Operational Unit Meetings

4 Improvement Committee 3 March 2014 Item 3a(i)

Financial Position at 31 January 2014 (month 10)

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note: The continued forecast out-turn of break-even overall.  Note: The considerable challenges in delivering break even.  Note: The requirement of a £5.5m improvement by the end of the financial year.

1 Introduction

This paper highlights the financial forecast and progress on savings plans as at 31 January 2014 (Month 10)

2 Key Messages

 An overall break-even position forecast by 31/3/14  Considerable challenge to deliver this within timescales  The year to date overspend is £4.9m  The current reported potential overspend forecast at £5.5m  An improvement of £0.1m on the month 9 position previously reported

 The current overspend is split between;

. Savings to be identified - units £3.2m . Adult Social Care (mainly S&M) £2.4m . Pressures less offsetting benefits £6.1m . Non-Recurrent Benefits Expected (£6.2m)

 The Month 10 forecast in the previous year was a potential overspend of £4.6m

3 Financial Position Overview

Previous reports predicated a break-even position on an improvement in operational forecasts of £2m in the last 3 months of the financial year. The month 10 forecast has improved by only £0.1m with a £0.5m overall improvement offset by an adverse movement in Raigmore of £0.4m

The Month 10 position is detailed in Table 1 (attached) and the current forecast is summarised in the following table; Fig 1

Breakdown of Month 10 Forecasts Operational Unit N&W S&M Raigmore ASC HQ Tertiary Others HSCP A&B Corp. Central Total Heading £m £m £m £m £m £m £m £m £m £m £m

Savings Operational Savings not yet achieved/identified (0.6) (2.5) (0.1) (3.2) 2.6 (0.6) In year non-recurrent benefits applied -Central 0.0 3.6 3.6 Pressures Adult Social Care (0.1) (5.0) 2.7 (2.4) (2.4) In-year cost pressures (2.0) (0.5) (7.0) (0.8) (0.4) (10.7) (1.3) (12.0) Offsetting underspends/benefits 1.2 1.3 0.4 2.9 2.6 0.4 5.9 Forecast Out-turn (1.5) (4.2) (9.5) 2.7 (0.8) (0.1) (13.4) 1.3 0.4 6.2 (5.5)

Previous Report - month 9 (1.5) (4.2) (9.1) 2.5 (0.7) (0.2) (13.2) 1.3 0.3 6.0 (5.6)

Change 0.0 0.0 (0.4) 0.2 (0.1) 0.1 (0.2) 0.0 0.1 0.2 0.1

Table 5 identifies savings achievement by Unit and also highlights the increasing reliance on non-recurrent savings, currently estimated at £8.6m.

As highlighted in previous reports, the adult social care forecast needs to be considered as a whole, as well as a part of South and Mid Highland’s forecast, as the Unit positions are distorted by the removal of Care at Home budgets to a central area. This resulted in the removal of prior year underspends in South & Mid and overspends in North & West.

The usual 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.

 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.

 Table 5 summarises the position against savings..

 Table 6 summarises the position with regards capital expenditure.

2 4 Operational Performance

In summary, the breakdown of the position by unit is:

£m  Raigmore (9.5)  South & Mid (ASC) (4.2)  Adult Social Care - Central 2.7  Argyll & Bute 1.3  North & West (1.5)  Forecast non-recurrent benefits 6.2  Tertiary (0.7)  Others (inc Corp) 0.2

Specific issues within operational units are as follows;

4.1 Argyll & Bute CHP- £1.3m Underspend

A&B CHP’s forecast remains unchanged.

4.2 North and West Unit - £1.5m Overspend

N&W Unit’s forecast for traditional NHS services deteriorated by £0.2m, mainly due to continued costs in respect of locums and vacant practices. This is entirely offset by improvements in the forecasted cost of ISC placements in adult social care.

Overall the forecast remains the same.

4.3 South and Mid Unit - £4.2m Overspend

S&M are also reporting an unchanged forecast although a £0.1m improvement in NHS services is offset by increases in ISC costs.

ASC overspends in units are partially offset by an underspend of £2.7m within the central Adult Social Care budgets.

4.4 Raigmore Hospital - £9.5m Overspend

The Month 10 position shows an adverse movement of £0.4m on the previous report and the majority of this movement relates to increases in Theatres, Orthopaedics and Cancer Drugs.

Interim management arrangements have now been put in place at Raigmore and it is expected that this will result in improvements however, this will take time and it is now not clear whether there will be any significant financial benefits in the current financial year.

4.5 Out of Area (Tertiary) -£0.8m Overspend

The forecast for tertiary has deteriorated by a further £0.1m due to high cost CAHMS placements in the private sector.

5 Actions Being Taken

As described in previous reports, a co-ordinated approach is required to improve the financial position further with all parts of the organisation needing to contribute. Detailed actions are taking place with regular meetings with Operational Units to measure progress and, in line 3 with previous years’ improvements. It had been expected that this will generate further benefits of circ £2.0m in the final quarter of the year however, the month 10 position has not demonstrated any movement in this direction.

In line with a number of other Boards, NHSH wished to revise the policy for defining asset lives and therefore reducing expenditure costs for depreciation but was nationally constrained from doing this due the way depreciation is funded across Scotland. However, it appears that this constraint could now be lifted and the Board has been given approval to investigate the impact this would have in year. It had been expected that this could potentially bring a benefit totalling some £2.0m however work has progressed on this and the benefit is now likely to be £1.6m.

Positive discussions have taken place with senior officials of Highland Council regarding the financial pressures being experienced in the Adult Social Care budget. It is mutually acknowledged that there needs to be greater clarity regarding the sharing of financial risks and that a three year planning horizon would be beneficial. Agreement has been reached in principle that a recommendation will be made to the March Council meeting that the Council should contribute non-recurring financial support of £1.0m towards the Adult Social Care budget in 2013/14.

Overall, further benefits of £2.9m need to accrue to the bottom line to deliver break-even in the final 2 months of the year.

6 Conclusion

The month 10 position is extremely disappointing given the need to deliver month on month improvements to achieve break-even. There is now a requirement to deliver £2.9m of further benefits in the final two months of the financial year in order to break-even. We are in close dialogue with colleagues in the Scottish Government regarding the options for managing this position.

7 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.

8 Risk Assessment

Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly.

9 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.

4 10 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 24 February 2014

NHSHighland TABLE1 Income & Expenditure Report as at JANUARY 2014

r v m n hoiintoPrev Date monthPosition Forecast OutturnAnnual Plan 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

509,790 509,718 SEHD -Baseline Funding 418,481 418,481 0 509,718 0 0 0 22,337 - Recurring Supplemental Allocations 18,614 18,614 0 22,337 0 0 0 (1,049) - Non Recurring Supplemental Allocations (874) (874) 0 (1,049) 0 0 0 509,790 531,006 Sub total - SGHD Core RRL 436,221 436,221 0 531,006 0 0 0

0 25,374 - Non Core Funding 21,145 21,145 0 25,374 0 0 0

509,790 556,380 SGHD Funding 457,366 457,366 0 556,380 0 0 0

24,992 26,110 - FHS Non Discretionary 21,758 21,758 0 26,110 0 0 0 55,697 56,299 - FHS GMS Allocation 46,916 46,916 0 56,299 0 0 0 25,734 70 - Recurring Pending allocations 58 58 0 70 0 0 0 12,174 704 - Non Recurring Pending allocations 587 587 0 704 0 0 0

628,386 639,564 TOTAL SGHD Funding 526,686 526,686 0 639,564 0 0 0

85,966 86,449 Add- Adult Social Care Quantun Funding 71,932 71,932 0 86,449 0 0 0 (7,710) (7,878) Less - THC Childrens services Transfer (5,953) (5,953) 0 (7,878) 0 0 0

706,642 718,135 Funding 592,665 592,665 0 718,135 0 0 0

Health & Social Care Partnership

108,421 111,292 North & West Operational Unit 92,899 94,101 (1,203) 112,836 (1,544) (1,544) 0 145,611 160,786 South & Mid Operational Unit 132,950 136,322 (3,371) 164,951 (4,165) (4,192) 28 20,969 21,155 Adult Social Care - Central 17,857 16,631 1,226 18,391 2,764 2,563 201 132,417 136,410 Raigmore 115,264 121,636 (6,372) 145,942 (9,532) (9,111) (421) 19,812 20,080 Facilities 16,485 16,503 (19) 20,093 (13) (14) 1 4,823 4,857 Integrated Pharmacy 4,039 4,198 (158) 5,031 (174) (197) 23 4,380 9,444 e health 8,074 8,089 (15) 9,441 3 2 1 19,119 19,000 Tertiary 15,818 16,547 (729) 19,750 (750) (700) (50) 14,483 14,259 Other HCP 11,892 11,955 (63) 14,249 10 9 1

470,034 497,283 TOTAL H&SCP 415,277 425,981 (10,704) 510,684 (13,401) (13,184) (216)

179,644 180,967 Argyll & Bute CHP 150,073 149,118 954 179,667 1,300 1,300 0

Cental Services 17,257 17,933 Corporate Services 14,232 14,148 84 17,541 392 295 97 39,706 21,953 Central Costs & Reserves 13,082 8,308 4,776 15,714 6,239 6,039 200

706,642 718,135 Total Expenditure 592,665 597,555 (4,890) 723,606 (5,469) (5,550) 81

Manangement Planned Actions 0 (5,469) 5,469 5,550 (81)

0 0 Surplus/Deficit Mth 10 0 4,890 (4,890) (0) (0) (0) 0 Finance - Monitoring 3a(i) Tables month 10 Total Summary 27/02/2014 10:16 Income & Expenditure Report as at JANUARY 2014 Table 2 YTD Position Forecast Outturn Budget Prev monthAnnual 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 32,739 33,616 North Area - Caithness District 28,052 29,044 (992) 34,760 (1,144) (1,196) 52 17,753 18,256 - Sutherland District 15,199 14,731 468 17,719 537 505 32 20,703 21,716 West Area - S,L, & WR District 18,239 19,197 (958) 22,746 (1,030) (1,080) 50 28,026 28,884 - Lochaber District 24,210 24,715 (505) 29,512 (628) (335) (293) 5,441 4,964 North & West Area Mgt 4,102 3,263 839 4,175 789 630 159 104,662 107,436 North & West Operational Sub Total 89,802 90,949 (1,147) 108,912 (1,476) (1,476) 0 3,759 3,856 N & W Hosted Services 3,096 3,152 (55) 3,924 (68) (68) 0 108,421 111,292 Total North & West 92,899 94,101 (1,203) 112,836 (1,544) (1,544) 0

South & Mid Operational Unit 21,030 21,821 South Area - Inverness West District 18,176 19,242 (1,067) 23,155 (1,334) (1,198) (136) 27,459 28,642 - Inverness East District 23,846 24,458 (612) 29,325 (683) (807) 124 25,053 25,753 - NABS district 21,420 21,108 311 25,415 338 232 106 3,334 3,306 - South Other services 2,733 2,476 257 2,997 309 287 22 15,733 16,069 Mid Area - Easter Ross District 13,387 14,585 (1,198) 17,574 (1,505) (1,502) (2) 17,286 17,357 - Mid Ross District 14,429 15,669 (1,240) 19,030 (1,673) (1,543) (130) 3,604 4,368 - Mid Other services 3,630 3,654 (23) 4,407 (39) (43) 5 2,912 2,856 South & Mid Unit Central 1,781 1,851 (70) 2,719 137 131 7 116,411 120,173 South & Mid Operational Sub Total 99,402 103,043 (3,642) 124,622 (4,449) (4,445) (5) 18,124 18,287 Adult Mental Health 15,174 15,113 61 18,231 56 61 (5) 1,214 1,190 Learning Disabilities 986 923 62 1,119 71 69 2 1,755 1,564 Substance Misuse 1,196 1,206 (9) 1,504 60 53 7 8,107 19,572 Dental Services 16,193 16,036 157 19,475 97 69 28 29,200 40,614 Sub Total SE CHP Hosted services 33,549 33,279 270 40,329 285 252 32 145,611 160,786 Total South & Mid 132,950 136,322 (3,371) 164,951 (4,165) (4,192) 28

20,969 21,155 Adult Social Care - Central 17,857 16,631 1,226 18,391 2,764 2,563 201

Raigmore Operational Unit 49,547 52,058 Surgical & Anaesth. Divison 43,418 47,223 (3,805) 56,596 (4,538) (4,192) (346) 73,889 77,325 Medical & Diagnostics Division 64,220 65,245 (1,025) 78,116 (791) (668) (123) 2,044 2,049 Raigmore Hotel Services 1,712 1,690 22 2,026 23 (2) 25 3,132 3,408 Patient Support Division 2,847 2,999 (153) 3,666 (258) (279) 21 2,023 (493) Raigmore Central 1,667 3,146 (1,479) 3,505 (3,998) (4,006) 8 130,635 134,347 Raigmore Divisions 113,863 120,303 (6,440) 143,909 (9,562) (9,147) (415) 416 549 Research & Development 353 351 2 547 2 4 (2) 1,365 1,514 ACT - Additional cost of Teaching 1,048 982 66 1,486 28 32 (4) 132,417 136,410 Total Raigmore 115,264 121,636 (6,372) 145,942 (9,532) (9,111) (421)

Other H&SCP Services 19,812 20,080 Facilities 16,485 16,503 (19) 20,093 (13) (14) 1 4,823 4,857 Integrated Pharmacy 4,039 4,198 (158) 5,031 (174) (197) 23 4,380 9,444 e health 8,074 8,089 (15) 9,441 3 2 1 19,119 19,000 Tertiary 15,818 16,547 (729) 19,750 (750) (700) (50) 14,483 14,259 Other HCP 11,892 11,955 (63) 14,249 10 9 1 62,617 67,638 56,307 57,292 (985) 68,564 (924) (900) (24)

470,034 497,283 Total Health & Social Care Partnership 415,277 425,981 (10,704) 510,684 (13,401) (13,184) (216)

18,737 19,369 A & B CHP- Oban, Lorn & Isles 16,076 16,503 (427) 19,919 (550) (500) (50) 16,869 17,232 Mid Argyll, Kintyre & Islay 14,263 14,176 86 17,106 126 140 (14) 7,320 7,542 A&B MH In-patient Services 6,113 5,914 199 7,227 315 300 15 12,508 12,794 Cowal & Bute 10,636 10,730 (93) 12,894 (100) (150) 50 4,857 4,930 Helensburgh & Lomond 4,110 4,015 95 4,830 100 140 (40) 9,231 8,704 Other clinical services 7,080 7,084 (4) 8,683 21 7 14 15,404 15,630 GMS 12,884 13,031 (147) 15,830 (200) (213) 13 17,075 17,010 Prescribing 14,193 14,079 114 16,910 100 80 20 7,781 7,781 FHS Non Disc. Services 6,695 6,695 0 7,781 0 0 0 49,437 49,517 HCP - Glasgow & Clyde 41,264 40,440 824 48,528 989 1,004 (15) 4,074 3,995 HCP - Other 3,318 3,577 (259) 4,392 (397) (313) (84) 4,603 4,658 Resource Transfer 3,882 3,882 0 4,658 0 0 0 11,748 11,806 Central & Corporate 9,557 8,991 566 10,910 896 805 91 179,644 180,967 Total A&B CHP 150,073 149,118 954 179,667 1,300 1,300 0

Central Services 17,257 17,933 Corporate Services 14,232 14,148 84 17,541 392 295 97 39,706 21,953 Central Costs/Reserves 13,082 8,307 4,776 15,714 6,239 6,040 200

706,642 718,135 Total Net Expenditure 592,665 597,554 (4,890) 723,606 (5,469) (5,550) 80

Finance - Monitoring 3a(i) Tables month 10 Fin Position 27/02/2014 10:16 Income&ExpenditureReportasat JANUARY2014 Table 3 YTD Position Forecast Outturn Prev Budget monthAnnual 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 26,058 26,804 North Area - Caithness District 22,343 22,951 (608) 27,512 (709) (666) (43) 12,843 13,384 - Sutherland District 11,125 10,616 509 12,824 561 509 52 15,438 16,209 West Area - S,L, & WR District 13,640 14,470 (830) 17,044 (834) (874) 40 20,749 21,509 - Lochaber District 18,097 18,945 (848) 22,574 (1,065) (685) (380) 4,646 4,104 - West Area Mgt 3,379 2,598 780 3,385 719 570 149 79,735 82,011 North & West Operational Sub Total 68,583 69,580 (997) 83,339 (1,328) (1,146) (182) 3,759 3,856 N & W Hosted Services 3,096 3,152 (55) 3,924 (68) (68) 0

83,494 85,867 Total North & West 71,679 72,731 (1,052) 87,263 (1,396) (1,214) (182)

South & Mid Operational Unit 12,985 13,398 South Area - Inverness West District 11,161 11,066 95 13,330 68 58 10 16,707 17,565 - Inverness East District 14,626 14,610 16 17,567 (2) (24) 22 17,379 17,854 - NABS district 14,840 14,812 28 17,858 (5) 15 (19) 3,334 1,273 - South Other services 1,029 975 54 1,195 79 63 16 11,009 11,159 Mid Area - Easter Ross District 9,298 9,385 (87) 11,281 (122) (134) 12 10,595 10,622 - Mid Ross District 8,824 8,638 185 10,472 151 142 9 3,604 4,368 - Mid Other services 3,630 3,654 (23) 4,407 (39) (43) 5 728 3,122 South & Mid Unit Central 2,048 1,828 220 2,688 434 427 7 76,340 79,361 South & Mid Operational Sub Total 65,457 64,969 488 78,797 564 503 61 18,124 18,287 Adult Mental Health 15,174 15,113 61 18,231 56 61 (5) 1,214 1,190 Learning Disabilities 986 923 62 1,119 71 69 2 1,755 1,564 Substance Misuse 1,196 1,206 (9) 1,504 60 53 7 8,107 19,572 Dental Services 16,193 16,036 157 19,475 97 69 28 29,200 40,614 Sub Total SE CHP Hosted services 33,549 33,279 271 40,329 285 252 32

105,540 119,974 Total South & Mid 99,006 98,247 759 119,126 849 755 93

382,286 409,890 Sub Total 342,256 349,906 (7,649) 420,895 (11,003) (10,470) (534)

Central Services 17,257 17,933 Corporate Services 14,232 14,148 84 17,541 392 295 97 39,706 21,953 Central Costs/Reserves 13,082 8,307 4,776 15,714 6,239 6,039 200

618,894 630,743 Total Net Expenditure 519,644 521,479 (1,835) 633,817 (3,073) (2,837) (237)

Finance - Monitoring 3a(i) Tables month 10 Health 27/02/2014 10:16 Income & Expenditure Report as at JANUARY 2014 Table 4 YTD Position Forecast Outturn Budget Prev monthAnnual 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 6,681 6,813 North Area - Caithness 5,709 6,093 (384) 7,248 (435) (530) 95 4,910 4,871 - Sutherland District 4,075 4,116 (41) 4,895 (24) (4) (20) 5,264 5,507 West Area - S,L, & WR District 4,599 4,727 (127) 5,702 (195) (206) 11 7,276 7,374 - Lochaber District 6,113 5,770 343 6,938 437 351 86 796 860 North & West Unit Central 723 664 59 790 70 60 10 24,927 25,425 Total North & West 21,219 21,370 (150) 25,573 (147) (329) 182

South & Mid Operational Unit 8,045 8,423 South Area - Inverness West District 7,014 8,176 (1,162) 9,825 (1,402) (1,256) (146) 10,753 11,077 - Inverness East District 9,220 9,848 (628) 11,758 (681) (783) 102 7,674 7,899 - NABS district 6,580 6,296 284 7,557 342 217 125 4,723 4,911 Mid Area - Easter Ross District 4,089 5,201 (1,111) 6,293 (1,383) (1,368) (15) 6,691 6,734 - Mid Ross District 5,605 7,031 (1,426) 8,558 (1,824) (1,685) (139) 2,185 2,033 South Area Other Services SW 1,704 1,501 203 1,802 230 224 6 (265) South & Mid Unit - Central (267) 22 (289) 31 (296) (296) 0 40,070 40,812 Total South & Mid 33,944 38,075 (4,129) 45,825 (5,014) (4,947) (67)

20,969 1,407 Adult Social Care - Central 1,843 259 1,584 (1,292) 2,699 2,685 14 17,109 - Care at Home 13,801 14,521 (720) 17,436 (327) (239) (88) 2,639 - Business support 2,213 1,851 362 2,247 392 117 275 20,969 21,155 17,857 16,631 1,226 18,391 2,764 2,563 201

85,966 87,392 Total Net Expenditure 73,020 76,076 (3,053) 89,789 (2,397) (2,713) 316

Finance - Monitoring 3a(i) Tables month 10 Adult Social Care 27/02/2014 10:16 NHS Highland Savings 2013/14 Position as at JANUARY 2014 Table 5

Position to Date Forecast to achieve In Year Target Next YearSavings B/fwd New N/R ASCAchieved YTD Forecast Balance Forecast Outstanding Target Target 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 £000 £000 H&SC Partnership

252 1,352 507 2,111 North & West Operational Unit 705 620 151 635 4 1,402 197 1,543 426 2,166 South & Mid Operational Unit 404 1,762 0 960 802 1,935 1,797 (933) 2,799 Adult Social Care 450 2,346 3 (0) 2,349 2,595 2,478 5,073 Raigmore 2,101 38 417 2,517 77 2,895 0 365 365 Facilities 365 0 0 63 77 140 Integrated Pharmacy 44 31 65 96 109 85 194 e health 116 58 20 0 78 5,151 7,697 0 12,848 Sub Total H&SC Partnership 4,185 4,855 0 591 3,217 1,041 7,622

312 2,088 2,400 Argyll & Bute CHP 1,897 103 400 0 400 2,000 2,000 Central Costs & Reserves 4,008 592 (2,600) 0 122 1,000 1,122 Corporate Services 525 606 (9) 41 556

5,585 10,785 2,000 0 18,370TotalCashEfficiencySavings 6,607 9,469 103 1,583 608 1,082 8,578

Finance - Monitoring 3a(i) Tables month 10 CRS 27/02/2014 10:16 Capital Income & Expenditure Report Month 10- 31st January 2014 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 5,892 5,895NHSHighlandCapitalAllocation(Formula) 4,913 4,913 0 5,895 0 1,589 1,451Radiotherapyreplacement 1,209 1,209 0 1,451 0 896 896ObanDental 747 747 0 896 0 1,000 1,500NDBHubDingwall 1,250 1,250 0 1,500 0 4,000 4,000Raigmore/SatelliteEndoscopy 3,333 3,333 0 4,000 0 1,300 1,078RaigmoreC.I.F. 898 898 0 1,078 0 200 200RevenuetoCapitalVirement 167 167 0 200 0 700 700RaigmoreBiomass 583 583 0 700 0 1,520 1,520CEEFEcoHospitals 1,267 1,267 0 1,520 0 110 0RetainedCapitalReceipts 0 0 0 0 0 (304) (304) UK GAAP Capital (253) (253) 0 (304) 0 162 0 Tain Sub Debt 0 0 0 0 0 91DetectingcancerEarly 76 76 0 91 0 266LochgilpheadMHU 222 222 0 266 0 55CancerModernisation 46 46 0 55 0 (700) Capital to Revenue (700)

17,065 16,648 Allocation Letter Jan 14 14,457 14,457 0 16,648 0

304 304 -NonCoreFundingIFRS 253 253 0 304 0

17,369 16,952 SGHD Funding 14,710 14,710 0 16,952 0

- Pending allocations 71NSSEquippingfunding 71

17,369 17,024 Total SGHD Capital Funding 14,710 14,710 0 17,024 0

Expenditure/Commitments 1,679 1,726ObanDental 1,721 1,720 2 1,726 0 1,589 0Radiotherapyreplacement 0 0 0 0 0 0 0GreaterInvernessMasterplan 0 0 0 0 0 1,000 1,100 Dingwall Health Centre 738 487 251 1,100 0 1,959 1,879 CEEF Schemes 843 743 100 1,879 0 1,216 2,917 Raigmore Biomass 850 832 18 2,917 0 3,550 2,810 Raigmore Endoscopy 2,023 1,071 952 2,810 0 0 860 LIDGH/CGH/Belford E.D.U. 717 417 299 860 0 1,300 100RaigmoreC.I.F.TowerBlock 83 42 41 100 0 242 242LifecycleCostsERPCC 202 202 0 242 0 62 62LifecycleCostsMidArgyll 52 52 0 62 0 50 50CapitalSalaries 0 0 0 50 0 162 61TainEnablingWorks 49 49 0 61 0 0LochgilpheadMHU 0 0 (0) 0 0 505 ReversionaryInterest

13,314 11,807 Commitments 7,278 5,614 1,664 11,807 0

Rolling Programmes 1,985 2,585EstatesBacklogMain. 1,547 1,618 (71) 2,585 0 530 530MedicalEquipment 363 363 0 530 0 582 1,213eHealthReplacement 545 546 (1) 1,213 0 837 861Radiology 726 757 (32) 861 0

3,934 5,189 Rolling Programmes 3,180 3,284 (104) 5,189 0 Other 100 5RaigmoreSSDwasher/disinfectors 4 4 0 5 0 91DetectingCancerEarly 0 0 0 91 0 200 200RevenuetoCapitalVirement 187 187 0 200 0 100 100DentalEquipment 70 70 0 100 0 0 18BelfordFoodTrolley/DW 18 18 0 18 0 0 130PortAppinGPSurgery(RetainedReceipt) 11 11 0 130 0 0 55CancerModernisation 48 48 0 55 0 0 285EquipmentStoreHelensburgh 3 3 0 285 0 76RaigmoreObs&Gynaeequipment 0 0 0 76 0 42A&BNasoendoscopes 37 37 0 42 0 (279) (100) Contingency 1 1 0 (100) 0 839 0NBVDisposals 0 0 0 0 0

960 902 379 376 3 902 0

18,208 17,899 Gross Capital Expenditure 10,836 9,274 1,563 17,899 0

(839) (875) NBV Disposals (875) (875) 0 (875) 0

17,369 17,024 Net Capital Expenditure 9,961 8,399 1,563 17,024 0

0 0 SURPLUS/DEFICIT MONTH 10 (4,749) (6,311) 1,563 0 0

Improvement Committee 3 March 2014 Item 2a(i)

Care at Home Services Report by Jan Baird, Director of Adult Care

1 CURRENT POSITION

The In house Care at Home service remains managed centrally but plans are well underway to devolve the service to the Operational Units from April 1st. In preparation for this considerable work has been focussed on establishing training and supervision, bringing reviews up to date and reviewing the structure to reflect two Operational Units.

Care at home recording on the balanced scorecard indicates a decline in the number of care at home hours delivered to those over 65 years of age when expressed as a rate per thousand of those aged 65 or over.

There may be a variety of reasons for this which require interrogation. This may indicated that the reablement approach is having a positive impact in reducing the reliance on ongoing care at home. This results in fewer hours being delivered but more people being able to access the service. It may also of course be linked to the increase in demand and the need to spread the service more thinly.

2 ACTION PLANS TO ADDRESS

There appears to be a considerable shortfall in meeting demand and some focussed redesigned work – RPIW, small tests of change have looked at the process of referral to service provision as well as the logistics.

Work is also progressing with the Independent and Third sectors particularly in the Inner Moray Firth area to provide additional capacity which reflects the Strategic Commissioning approach being developed across the sectors. A joint recruitment fair is being developed with venues in Inverness and Dingwall suggested and timed to attract young people leaving school and looking for permanent or holiday employment. There is a lead-in time for recruitment following this so it should not bee seen as a quick fix. However it is a significant step in terms of working together with the Independent and third sectors.

All providers in the Inner Moray Firth area and beyond have been approached with a view to increased funding to meet the growing demand. Some providers have been able to provide some capacity but where recruitment of carers is required there is a lead-in delay to allow employment checks and core training to be completed.

Covering of sickness and planned absences has been flagged as a time intensive process for Care at Home Officers. Work is progressing towards the development of a staff bank which will eventually be integrated across Highland with current bank activity and will provide a wider poll of staff from which to fill rotas. This will take a few months to establish formally but it is hoped to try out a small test of change in some of the areas. A small test of change has been initiated in Nairn where consolidation of business support into the Inverness HUB is expected to deliver more efficient business support and enable the Officers in Nairn to concentrate on staff development, recruitment, supervision and reviewing of care plans. Joint allocation meetings involving all sectors have been established in Inverness with some success. This allows all providers to consider the service pressures and work more closely together to provide care packages. This approach is to be initiated in Nairn and recommended across the areas recognising that is some more rural areas it may be more of a virtual meeting.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

As stated above most of the actions will have medium to longer term benefits but the local meetings allow a weekly focus on demand and capacity and build relationships across the sector.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

Due to the length of lead in time this is difficult to assess but all efforts are being made to increase capacity as quickly as possible. Improvement Committee NHS Highland - "At A Glance" HEAT Targets 3 March 2014 Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 3rd March 2014 Item 4 Targets with a delivery date by the end of March 2014 e d n t e t o u t e i s t r t d B i i e a o s d p D M e W o r n e y r P a & o & r l e h d l h m h t r t v t y g i n a r i u l g o o a o r e o

B Target M R N S A D Child Healthy Weight Interventions Sep-13 N/A N/A N/A Mar-14 Smoking Cessation - 2 most deprived data zones Sep-13 N/ACurrently reported at Board Level Only Mar-14 Smoking Cessation - general smoking population Sep-13 N/A N/A N/A Mar-14 Child Fluoride Varnish Applications Mar-13 N/ACurrently reported at Board Level Only Mar-14

Financial Performance Dec-13 Mar-14 Cash Efficencies Dec-13 Mar-14

Rate of attendances at A&E Dec-13 N/A Mar-14 Targets with a delivery date beyond March 2014 e d n t e t o u t e i s t r t d B i i e a o s d p D M e W o r n e y r P a & o & r l e h d l h m h t r t v t y g i n a r i u l g o o a o r e o

B Target M R N S A D Early Access to Antenatal Services Dec-13Currently reported at Board Level Only Mar-15 Detect Cancer Early Apr-13Currently reported at Board Level Only Apr-15

Reduce Carbon emmissions Dec-13Currently reported at Board Level Only Mar-15 Reduce Energy Consumption Dec-13Currently reported at Board Level Only Mar-15

Faster Access to Specialist CAMHS - 18 weeks Dec-13 Dec-14 No Trajectory Reduce IVF Waiting TimesData sources being developed Mar-15 4 Hour A&E Wait Dec-13 Sep-14 Faster Access to Psychological Therapies Dec-13 N/A Dec-14

Reduction in Emergency bed days for patients aged 75+ Aug-13 N/A Mar-15 Delayed Discharges - 14 days Jan-14 Mar-15 No Trajectory Access to Dementia SupportData sources being developed Mar-16 MRSA/MSSA Bacterium Sep-13Currently reported at Board Level only Mar-15 C. Diff Infections Sep-13Currently reported at Board Level only Mar-15

NHS Highland - "At A Glance" Standards e d n t e t o u t i s r t d B i i e o s d p M e W o r n e r P a & o & l h d l h m h t r t t y g n a r i u g o o a o r o

B Target M R N S A Alcohol \Brief Interventions Dec-13 N/A Standard Inequalities Targeted Cardiovascular Health checks Dec-13 N/A Breastfeeding at 6-8 week- Target 36% Jun-13 N/A N/A N/A MMR uptake rates - target 95% at 5 years old Sep-13 N/A

Sickness Absence - 4% target Dec-12 Standard SMR return rate - 90% of SMR1 returns received within 6 weeks Nov-13 No Trajectory Complaints Mar-12 Awaiting measure from Clinical Gov Comm. No Trajectory Same Day Surgery Rate N/A Outpatients - DNA rate - Target 6.9% Dec-13 No Trajectory Reduce Pre Operative stay N/A eKSF & PDP's - Target 80% Jan-14

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Sep-13Reported at Board Level only Standard All Cancer Treatment (31days) (Due for Delivery Dec 2010) Sep-13Reported at Board Level only Standard 18 weeks Referral to Treatment (Due for Delivery Dec 2010) Jan-14Currently reported at Board Level only Standard New Outpatient Waiting times - 12 weeks - Ongoing Dec-13 New Outpatient Social Unavailability New Outpatient Medical Unavailability 12 week Treatment Time Guarantee (TTG) - Completed Waits Dec-13 12 week Treatment Time Guarantee (TTG) - Ongoing Waits Dec-13 Admission Waiting List - Social Unavailability Admission Waiting List - Medical Unavailability Hip surgery - 98% of patients treated within 24 safe operating hrs Jan-14 N/A N/A N/A 8 Key Daignostic tests - Completed Waits N/A 8 Key Daignostic tests - Ongoing Waits Dec-13 N/A Return Waiting List - Completed Waits Return Waiting List - Ongoing Waits Insulin Pumps - Under 18's Jan-14 Reported at Board Level only Insulin Pumps - Over 18's Jan-14 Reported at Board Level only Drug & Alcohol Treatment: Referral to Treatment Sep-13 N/A N/A N/A N/A Standard

Reduce Occupied Bed days for long term conditions Jun-13 N/A Reduce Average Length of Stay for Continuous Episode of care N/A End of Life Care Measure Dementia (Unvalidated - validated position available annually) Jan-14 N/A Standard 90% of patients diagnosed with stroke admitted to a stroke unit Dec-13 N/A Standard Improvement Committee 3 March 2014 Item 4

Improvement Committee 3 March 2014 Item 4.1a

Detect Cancer Early (DCE) Programme Report by Dr Rob Henderson, Consultant in Public Health and Derick MacRae, Service Manager - Cancer Services

1 CURRENT POSITION

 The HEAT target associated with the DCE Programme is that 29% of patients diagnosed with breast, colorectal & lung cancer (combined) during the calendar years 2014 & 2015 should be diagnosed at the earliest stage.  The latest data received from ISD, covering the calendar years 2011 & 2012, states that 23.1% of patients diagnosed with breast, colorectal & lung cancer (combined) were diagnosed at the earliest stage. The equivalent proportion for Scotland was 24.0%.  This combined proportion masks differences between the tumours. The proportion of patients with breast, colorectal & lung cancer diagnosed at the earliest stage during 2011 & 2012 is shown below:  Breast cancer – 38.2% (Scotland – 39.0%)  Colorectal cancer – 20.0% (Scotland – 17.9%)  Lung cancer – 9.2% (Scotland – 14.7%)  Please note that at the time of writing, the data within the second & third bullet points above is provisional & not yet in the public domain. When published during late February 2014, the final data may differ from that above.

2 ACTION PLANS TO ADDRESS

 Breast cancer - Initiatives to raise awareness of the Scottish Breast Screening Programme, with the aim of encouraging eligible women to consider taking up invitations to be screened, will continue. - A review of workload within the Symptomatic and Screening Services in order to align the capacity with large variation in demand from month to month, varying between 137 and 222 with an average per month of 181, 10 more than last year. - Publication of revised SIGN referral guidelines to NHS Highland GPs, with further guidance when to refer women with breast pain.

 Colorectal cancer - Initiatives to raise awareness of the Scottish Bowel Screening Programme, with the aim of encouraging eligible men & women to consider taking up invitations to be screened, will continue. - GP Practices have been invited to participate in a national initiative in which they will encourage eligible individuals registered with them to consider taking part in screening. - A significant proportion of the DCE monies has been utilised to contribute towards the relocation of the expanded Endoscopy Suite within Ward 8 at Raigmore Hospital.  Lung cancer - A cross-system group will be established to review & develop NHS Highland’s lung cancer pathway. - In the absence of a lung cancer screening programme, consideration should be given to local initiatives to raise public awareness of the signs & symptoms of lung cancer. It is anticipated that this will be discussed within the lung cancer pathway group given the implications of such initiatives for both Primary & Secondary Care services.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

 With respect to breast and colorectal cancer respectively, the NHS Highland position is on a par with and exceeds that for Scotland as a whole. The impact of initiatives to raise awareness of the respective screening programmes will therefore be to maintain & build upon the current position. However, as we’re already starting from relatively good positions, the potential for significant improvement is modest  With respect to lung cancer, it is anticipated that reviewing and developing the pathway would lead to an increase in the proportion of patients diagnosed at the earliest stage. It is hoped that by doing this NHS Highland will reach the proportion achieved by the best performing Boards. However, we can not say with certainty when this will be realised.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

 The baseline – the proportion of patients diagnosed during the earliest stage during the two years 2010 & 2011 – was 25.4%. The target is to increase this to 29.0% during the two years 2014 & 2015.  Therefore, drawing a straight line between these two points would suggest that the proportion of patients that should be diagnosed at the earliest stage during the 2yr periods 2012 & 2013 and 2013 & 2014 should be approximately 27% and 28% respectively.  This is a very challenging set of targets and it is quite unlikely that the target of 29.0% will be met during the two year period ’14 & ’15 unless initiatives with potential to significantly improve the situation can be implemented rapidly. We aim to use the newly established Lung Care Pathway Group as a forum to improve communication between colleagues in Primary and Secondary Care in order to address this issue.

Dr Rob Henderson Consultant in Public Health

Derick MacRae Service Manager - Cancer, Obstetrics, Gynaecology and Breast Service

24 February 2014

2 Improvement Committee 3 March 2014 Item 4.2a

HEAT A11 Standard – Wait Times for Alcohol & Drug Treatment Report by Suzy Calder, Head of Service – Substance Misuse on behalf of Dr Margaret Somerville, Director of Public Health

90% of clients referred for treatment will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery and no-one will wait over 6 weeks.

1 CURRENT POSITION

Preliminary internal reporting would indicate that although there has been further improvement, NHS Highland have not yet hit 90% referral to treatment within 3 weeks.

Referral to treatment within 3 weeks HADP - 83.8% ABADP - 96.6% NHSH - 87.4%

July – September was 78.5% within 3 weeks.

See attached graph Appendix 1.

Argyll & Bute are now achieving the standard.

The key challenges in north Highland have related to service capacity particularly in Caithness where the team had 50% long term absence with limited alternative service provision, high referral rates and no appropriate bank cover to add enough support. This is resolving with absent staff members expected back in full by April.

Other waits were existing within Osprey House where there are vacancies. Additional staff were recruited and waits have improved already as a result however service is compromised by long term absence and promotion of staff to community posts. Currently staff capacity reduced by 3 WTE Band 6. Bank Nurse options limited.

The full-time Consultant in Addictions, Dr Stewart, leaves service in March and although the post will be recruited to, there will be a period without that cover. This impacts on the wider medical team.

Significant progress has been made in terms ensuring consistent service provision and treatment options including the introduction of supervised Buprenorphine across NHSH, this is in line with best practice and the recommendations within the Opiate Replacement Therapy review. Increased access to prescribing treatment, nurse prescribing model in Campbeltown and a new model of access through the Rural Practitioners in Skye & Lochalsh.

2 ACTION PLANS TO ADDRESS

Attached improvement plan (Appendix 2) as submitted to Scottish Government. Feedback positive with support to look at creative options to provide service in remote and rural locations. A provisional date for a VC meeting is scheduled for 26th March and an invitation has been extended to representatives to attend the next Highland Alcohol & Drugs Partnership meeting on 13th May. Scottish Government has provided some initial feedback on the improvement plan and has offered to support us to explore other creative solutions to providing a service e.g. a mobile unit. There has yet to be a discussion on the model or resource. A more effective way of releasing capacity in Caithness where the particular issues have occurred, would potentially be to add additional, alternative service provision for example, the caseload is currently comprises of poly drug / alcohol users who also have significant problems with new psychoactive substances and there could be an opportunity to consider piloting a service for this client group thereby releasing staff capacity for traditional treatment and support interventions.

Service Level Agreements currently under review to ensure partnership in providing a seamless recovery pathway and in order to have faster access to appropriate treatment and support options.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

Further progress towards hitting 90% referral to treatment although the caveat being that vacancies are all recruited to and staffing levels are maintained.

Osprey House is experiencing complex staffing issues, resolution of these would enable the service to hit the HEAT standard however, this not a short term concern and as such progress may fluctuate.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

The recruitment of staff in Argyll & Bute will significantly improve access on Bute. It is anticipated that they will maintain their achievement and exceed 90% referral to treatment.

Full staffing in Caithness will significantly reduce the wait times however the balance is in maintaining this longer term. Exploration of alternative service provision for onward referral is a priority.

2 Appendix 1 Improvement Committee 3 March 2014 Item 4.2a Appendix 2

NHS HIGHLAND HEAT A11 Standard Action Plan February 2014 Priority Update Constraints Timescale Monitoring reports  Monthly monitoring reports Works a month behind Ongoing  Identification of long waits and detailed exploration of reason with service Relies on staff availability to address concerned inaccuracies  Teams trained to run and use reports for internal monitoring Access to database for data input  Service planning provides internal monitoring reports for LDP and Health Improvement updates on a quarterly basis Service capacity  Planned absence is accounted for and  Staff vacancies / managed in advance Unexpected absence / sickness Ongoing recruitment  Training package being developed to  Absence support Bank Nurses to have the NHS recruitment processes followed  Limited skill base and necessary skill base (already piloted in and inevitably creates a gap in service limited pool of staff out Fort William). Substantive post in while being progressed, staff move with service e.g. bank Lochaber currently covered using a around nurse Bank Nurse through this process, post  Limited prescribing places advertised awaiting recruitment Releasing staff to undertake the non in community  Wider workforce development strategy in medical prescribing training development in north Highland, links established with Argyll & Bute Bank Nursing is limited and relies colleagues to share best practice and upon interest in field of work join up resource to support this work  Vacancies lead to post review and skill In some teams, 1 vacancy or absence mix discussion, bandings have altered can be the difference between hitting as a result or not hitting target (small staff numbers) Priority Update Constraints Timescale  Mentoring model being developed to increase staff confidence and clinical Limited third sector options supervision particularly in areas out with Inverness  Enhanced agreements in place with third sector partners, SLA’s in the process of No additional financial resource being reviewed through contracts to ensure formalising commitment to HEAT National policy e.g. DWP and A11 achievement Universal credit a potential risk to  Non-medical prescribing model being future sustainability developed, staff being trained  Prescribing clinic under development in Geography reduces option to support Clinic Skye & Lochalsh. CPN(A) service across boundaries commences partnered up with existing Rural April 2014 Practitioners, commences April 2014, new CPN(A) starts 17th February  Posts progressed in Argyll & Bute, induction in Jan – March quarter, anticipated improvement over the forth coming months particularly in Bute DCAQ – Improvement work in Facilitated by Service Improvement Leads June 2014 north Highland area Workstreams include  Revising referral process Resource availability  Assessment documentation reviewed, includes outcomes and refers to WT and Robust process, takes time SMR requirements  Risk Assessment May identify a lack of capacity  Interventions  Demand and capacity diary review Competing priorities – clinical versus  Drug Screening improvement work  Workforce development  Overall service pathway Priority Update Constraints Timescale  Use of technology in service delivery  Examination of DNA / CNA information

Drug & Alcohol Policy support staff invited to run the Drug & Alcohol Improvement Game in May 2014, may need to rearrange to allow for DCAQ to embed

Extended long waits identified in  Drop in assessment clinics developed in Limited third sector availability in the Clinics April specific services Caithness, will cover both Wick and area reduces options for onward 2014 Thurso. Anticipated that this will reduce referrals. Distance to nearest wait times and make more effective use alternatives a barrier. of time with targeted interventions. Service capacity increases from April.  Service Level Agreement review Contract discussions take time to underway with Crossreach (residential resolve and limited resource April 2014 waits are long). Contract monitoring in progress. Potential to restructure elements of outreach and preparatory support to enhance interventions and reduce waits.  Service Level Agreements with counselling services also under review with options and recommendations on April 2014 changes that would allow greater coverage including Caithness (currently have no alcohol counselling service) Improvement Committee 3 March 2014 Item 4.2b

Cancer Services Report by Derick Macrae, Service Manager – Cancer Services on behalf of Linda Kirkland, Interim Director of Operations – Raigmore Hospital

1 CURRENT POSITION

The purpose of this report is to a) provide an analysis of patients breaching the cancer targets for the last two months to end January (since the last report) b) to report on the Action Plans in place to mitigate the situation.

Table 1 - Performance 2010 to date: The Targets are reported and published nationally on a quarterly basis and the performance since monitoring began is shown below. The monthly performance since the last quarter is also shown.

62 Day - Urgent Referral to Treatment 31 Day - Decision to Treat to Treatment Referred Treated Breached % Referred Treated Breached % 2010 Q1 to end Mar 153 150 3 98.0 299 273 26 91.3 Q2 to end Jun 169 165 4 97.6 307 282 25 91.9 Q3 to end Sept 166 164 2 98.8 317 310 7 97.8 Q4 to end Dec 186 179 7 96.2 332 316 16 95.2 2011 Q1 to end Mar 199 195 4 98.0 326 310 16 95.1 Q2 to end June 158 147 11 93.0 297 282 15 94.9 Q3 to end Sept 176 172 4 97.7 309 294 15 95.1 Q4 to end Dec 179 172 7 96.1 288 281 7 97.6 2012 Q1 to end Mar 158 153 5 96.7 278 272 6 97.8 Q2 to end Jun 164 158 6 96.3 314 305 9 97.1 Q3 to end Sept 202 195 7 96.5 338 320 17 94.9 Q4 to end Dec 178 166 12 93.3 307 290 17 94.46 2013 Q1 to end Mar 164 148 17 89.6 288 276 12 95.8 Q2 to end Jun 187 175 12 93.58 304 292 12 96.05 Q3 to end Sept 178 164 14 92.14 308 298 10 96.75 Q4 to end Dec 167 157 10 94.01 319 304 15 95.3 2014 To end Jan 14 62 59 3 95.2 101 95 6 94.1 (estimate)

As can be seen above, Over the 16 completed quarters since January 2010 there have been

 Six failures of the 62 Day Target  Three failures of the 31 Day Target o Quarter 2, to end June 2011, o Quarters ending March 2010, o Quarter 4, to end December 2012 o end June 2010 o Quarters 1, 2, 3 and 4 in 2013. o end June 2011

Unfortunately for the first month of this current quarter the 62 Day Target was met but the 31 Day Target was not. The position is now of such concern that the SGHD Cancer Delivery Team will be meeting the Cancer Team in March in order to assess progress against the Board’s Action Plan to return to balance.

62 Day Target The chart attached at Appendix A illustrates the monthly performance which shows that whilst the target was not achieved in the four completed quarters of 2013 it was met in six of the last 12 months. The quarterly performance can be easily affected by the poor performance in one particular month. The tolerances are very small and the difference between passing and failing the targets will often come down or one patient breaching. Case by case management of each patient is therefore vital.

The position has improved in recent months in Urology in particular as a result of us being able to offer treatment within private sector facilities in Edinburgh and Glasgow. Many patients however chose to wait an extra small number of days to be treated locally instead. This is illustrated in the table below where some of the patients, particularly breast patients, who have breached have waited “only” one, two days beyond their target time.

Table 2 - Length of Wait by Patients who Breached The table below shows the actual position for nine breaching patients in January 2014.

Cancer Target Breaches – Days Waited by Patient, Cancer Type and Breach Reason

62 Day Target 31 Day Target

Breach Reason l l a a t t l c y c y a L t t e g e g c i s s r r A o o g v l l a a o o T l r l n o o e e o e r o r r r O u T B C C U B C L U 1. Delays to 7 2 30 1,2,7,9,10 Surgery 2. Radiotherapy & 2 15 2 Oncology Capacity Total 9 1 1 1 5 1

These are the adjusted days waiting times beyond the target time which excludes patient thinking time, patient unavailability such as leave, and any tests and investigations outwith the normal pathway. As can be seen, patients in January have waited a relatively small time over the target time to be seen

The failures in this three month period fall into the categories: 1 - Lack of Urology Capacity, 2 – Lack of Breast Capacity, 3 - Radiotherapy Delays and Oncology Capacity.

1. Delays to Surgery ( Urology and Breast) 1.1 Lack of Urology Capacity

The position in Urology is not evident in the analysis of the January performance but from an examination of the December and also the unvalidated February performance it is clear that in recent months the lack of capacity within the Urology service is the main reason for patients breaching the target. This was more evident problematic before the fifth Consultant took up post in January.

2 In recent weeks a significant amount of work has been undertaken in order to address the pathway and capacity problems with Urology and thereby minimise the risk of breaching. These include:

 Renal cancer patients are now prioritised for surgery with slots ring-fenced for potential cancers at an early stage.  Providing an additional fourth protected MRI and Bone Scan slot per week for assessment of cancer patients.  Additional sessions by the existing staff being carried out where possible

Patients have also been offered treatment dates in the rest of Scotland where possible but this is less of an option now as the other centres are also experiencing capacity problem.

Delays were also experienced at the beginning of the pathway where patients were waiting longer that the recommended 14 days for their biopsies and as a result this created pressure at the end of the target time for patient requiring to be operated on. There is a continuing demand for six sessions per months but current demand provides for only four sessions. The additional sessions are being provided on ad hoc basis but work is on-going to make this a permanent increase by re-organise the job plan of the Nurse Specialist concerned.

The Department has had a significant increase in the number of Haematuria and Prostate referrals, perhaps as a result of the English “blood in your pee” media campaign. 50 patients with Haematuria were referred in one week at the end of January, more than would be expected in one month. These patients are now being referred for an ultrasound scan as part of the triage process in order that those requiring a scope can be quantified at an earlier stage

1.2 Breast Capacity The number of patients requiring to be seen varies significantly from month to month and the inflexibility of the Theatre schedule to cope with peaks in demand are being addressed. Theatre sessions from other specialities without cancer patients to be seen are now actively being offered to Breast and other specialties. It is recognised that this may lead to TTG patients having to miss their guaranteed dates but Cancer patients will be prioritised for care.

Discussions are also on-going in order to provide a regular Monday operating list in main Theatre rather than the Day Case theatre. The majority of breast cancer patients require to have a Sentinel Lymph Node Biopsy as part of their surgery. This cannot currently be carried out on a Monday because of the location of the theatre in the Day Case Theatre and the non availability of trained staff. This is now being addressed with some patients expected to be treated there during March.

2. Lack of Radiotherapy Capacity and Pathway Inefficiencies A 90 Day progress report on the Rapid Process Improvement Week facilitated by the Chief Executive took place during May as part of the Service Redesign of Radiotherapy in order to review the pathway and minimise any inefficiencies. The outcomes from this work are quite significant with some with the waiting time from referral to radiotherapy treatment start reducing by some 60 days to 32 days initially. Unfortunately the waiting times have increased as a result of the retiral of the Head of Equipment and Dosimetry in November.

The difficulties in staffing the Radiotherapy Planning Service have been discussed in some detail in previous reports. Following the successful re-banding of the vacant posts for Head of Equipment & Dosimetry and two Radiotherapy Planners, interviews were held at the end of November and two appointments made, one to an internal candidate. An offer for the former, most senior post, was also made but the candidate is likely to take up an alternative offer in New Zealand. The posts are now being re-advertised with a closing date at the end of February.

3 3. Lack of Oncology Capacity The lack of Oncology capacity at Consultant and Radiotherapy Physics level is more evident in ensuring that patients requiring follow up ( adjuvant) chemotherapy or radiotherapy treatment are treated timeously but is has resulted in two breaches against the these cancer targets which measure first ( neo adjuvant) treatment.

The establishment of four Clinical Oncologists, will at the end of March reduce to 2.4 as a result of Dr Whillis retiring and a Consultant who has been on Sick Leave returning to work for two days a week. The service will be sustained in the immediate term with  the recruitment of a Medical Oncologist for about four months  the return of Dr Whillis to work for one day a week until the end of June  the use of colleagues from Aberdeen and Dundee to see GI, Lymphoma and Breast patients  the use of an external agency to see and plan radiotherapy treatment for Breast patients during three weekends on March/April

This work is being co-ordinated with colleagues in NOSCAN

Adjuvant Waiting Times There is no national target for Adjuvant Radiotherapy waiting times ( secondary treatment after initial surgery). The Service Redesign work mentioned above has resulted in a reduced waiting time to within the clinical recommended times of 8-13 weeks after surgery for Breast patients.

2 ACTION PLANS TO ADDRESS

Urology 1. The provision an additional fifth protected MRI and Bone Scan slot per week for assessment of cancer patients – March 2. Given that so many patients, miss the target by a small number of days, minimise small delays incurred in the reporting of results by ensuring that they are pushed from the Labs systems to a printer with the Urology Nurses office immediately as they become available - March 3. Seeking additional capacity elsewhere in Scotland on a case by case basis – on-going 4. Providing an additional two sessions per month for TRUS ( Trans Rectal Ultrasound) biopsies

Breast 5. Continued access to other lists for additional activity when required and re-organisation of theatre timetable to facilitate Monday operating – immediate 6. A review of the Theatre timetable to provide additional lists in appropriate Theatres on Mondays and Tuesdays - April 7. The provision of additional evening clinics to reduce the number of patients having to wait for more than 21 days for their one stop triple assessment - March

Oncology 8. Work with national colleagues to improve the recruitment of Oncologists to Scotland and the North – on-going. 9. Recruitment of Radiotherapy Physics posts ongoing. 10. Re-advertisement of Dr Whillis’ replacement at Medical Oncologist rather than Clinical Oncologist level- March

4 3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

The various issues in cancer services are all interrelated and it is essential that there is a broad understanding that there is no simple or single fix. However the various actions planned are being taken with the intention of creating a robust, sustainable service going forward.

The support of the SHGD Cancer Delivery Team during March is expected to significantly improve compliance with the targets.

We are also working closely within colleagues in NOSCAN and the other Cancer Centres to sustain the service. We will be working with the National Cancer Delivery Team in order to ensure compliance with the targets as quickly as possible.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (i.e. Trajectory)

Cancer target performance is a major priority for NHS Highland and all efforts are being made in order to bring performance back in balance.

5 Appendix A – Cancer Target Run Charts

62 Day ( Urgent Suspected Cancer to Treatment) Target Jan 10 to Jan 14

31 Day ( “Decision to Treat” to Treatment)

6 Appendix B – National and Local Targets

The two National and Local cancer waiting times targets are:  A 62-Day Target: time between urgent referral with suspicion of cancer to first cancer treatment.

 A 31-day Target: time between the decision to treat (regardless of the route of referral) to first cancer treatment.

A 5% tolerance level is applied to these targets, as for some patients it may not be clinically appropriate for treatment to begin within target. Therefore, 95% of all eligible patients should wait no longer than 31 or 62 days.

In any month, NHS Highland would expect an average of 106 patients against the 31 Day Target and 60 against the 62 Target.

Improvement Committee 3 March 2014 Item 4.2c

Access Targets

Report by Linda Kirkland, Interim Director of Operations, Raigmore Hospital

1 CURRENT POSITION

This paper summarises performance against 3 Access targets and 4 Key Endoscopy Diagnostic Tests (4 Key radiology Diagnostic tests are detailed in a separate paper)

 New Outpatient waiting times – maximum wait of 12 weeks from GP referral (Target is 100% compliance).

 Treatment Time Guarantee (TTG) admission waiting times – maximum of 12 weeks from decision to treat. This is a legal requirement.

 Referral to Treatment Time (RTT) – maximum of 18 weeks from referral to treatment. (Target is 90% of patients)

 4 Key Endoscopy Diagnostic Tests – No patient will wait over 2 weeks for urgent/urgent suspected cancer (USC) or 6 weeks for a routine appointment. NHS Highland has set a local target of 4 weeks for routine.

Outpatients

Table 1 shows the number of patients at month end waiting over 12 weeks and 15 weeks for the Outpatient Waiting Time Target as at end of January 2014

Table 1

There are a number of specialties which are problematic and the actions taken to address the specialties under pressure are outlined in greater detail under Section 2 below. The main challenges are ENT, OMFS and Orthopaedics. Wait Band Specialty 13-15 weeks >15 weeks Total Breast Surgery 2 1 3 Cardiology 4 4 Clinical Genetics 1 1 Dermatology 4 4 Ear, Nose and Throat 116 133 249 Gynaecology 60 16 76 Neurosurgery 13 7 20 Ophthalmology 3 3 6 Oral and Maxillofacial Surgery 110 20 130 Orthodontics 2 1 3 Orthopaedics 223 350 573 PaediatricMedicine 2 2 Plastic Surgery 1 1 Respiratory Medicine 2 2 Restorative Dentistry 1 1 Urology 27 6 33 Total 564 544 1108

Treatment Time Guarantee (TTG)

Table 2 below outlines the completed Treatment Time Guarantee (TTG) performance for the months of April 2013 to January 2014 and shows the number of TTG completed waits over 12 weeks by specialty. Action Plans to address pressures are detailed in Section 2 below.

Table 2

Completed waits

April May June July August September October November December January Orthopaedics 51 56 41 4 5 13 13 3 5 6 ENT 117201 01 1 Urology 15 10 2 2 4 1 2 3 2 4 Ophthalmology 20 21 23 5 1 2 2 OMFS 612 2 0 0 0 0 Gynae 1 0 0 0 0 1 1 1 1 Breast 00000 00 1 2 Colorectal 1 0 0 0 1 0 0 1 1 Upper GI 0 0 0 0 0 1 0 1 1 Vascular 0 0 0 0 0 0 0 Plastic Surgery 0 2 0 0 0 0 0 CommDental 1 0 0 0 0 0 0 PainMgt 0 0 0 0 0 0 0 1 2 Surg Paeds 0 0 0 0 0 0 0 General Medicine Total 106 108 70 11 12 18 19 11 8 17

2 4 Key Diagnostic Tests – Endoscopy

Table 3 below shows the waiting times for urgent suspected cancer (USC), urgent and routine referrals.

Table 3

Current Endoscopy Waits as at 25th February 2014

Category Wait 0-2 weeks Waits 2-4 weeks Wait >4 weeks Urgent/USC 21 94 49 Routine 1 40 57

This demonstrates that there is work to be progressed regarding the correct scheduling of patients as routine patients have been booked within two weeks using capacity more appropriate for urgent/USC referrals.

Table 4 below shows the number of patients that have waited over 4 weeks from their referral to endoscopy test from April 2013 to January 2014

Table 4 April May June July August September October November December January Endoscopy 19 16 27 34 9 10 12 29 46 23

Referral to Treatment Time (RTT)

Overall performance is above the 90% target. However, the overall linked pathway performance demonstrates that not all patient pathways are being captured and measured. Work is ongoing to improve percentage of linked pathways as this will give a more accurate percentage figure in relation to RTT performance against the 90% target.

2 ACTION PLANS TO ADDRESS

The actions that are being worked through to improve the delivery of both the Treatment Time Guarantee (TTG) and the outpatient waiting times are set out by specialty below:-

Orthopaedics

TTG

Additional capacity has been identified in the Private Sector in Glasgow at Ross Hall Hospital to support local capacity. NHS Highland has agreed that exceptional circumstances apply in accordance with the Board’s Access Policy and that offers made to patients in the Private Sector can be considered a reasonable offer. This is for a temporary period for those patients with a TTG date up to 31 March 2014. There are two streams of orthopaedic patients being sent to Ross Hall. Those who convert from outpatient appointment as part of the Ross Hall “see and treat” project and those who are already on the surgical waiting list and accept an offer of Ross Hall as an alternative to waiting for a date in NHS Highland.

The Raigmore consultants have been asked to provide additional theatre capacity to the end of March 2014. The dispute in relation to job plans and payments has been resolved.

3 Outpatients

Throughout 2013 the priority was given to TTG targets which has resulted in a backlog of new outpatients. There have been discussions with the Golden Jubilee National Hospital (GJNH) to provide a “see and treat” agreement to clear the orthopaedic backlog, however there is no capacity available within the GJNH until after April 2014. Discussions are continuing with GJNH about capacity for 2014/15.

Therefore an alternative option was sourced with support from colleagues at the National Access Team. An agreement with a Ross Hall, a private sector hospital in Glasgow has been established delivering capacity for 300 outpatients and associated surgery.

This project has been successfully completed with 3 weekends of clinics provided by Ross Hall consultants at Raigmore Hospital. The required number of outpatients were seen but the conversion rate to surgery was higher than expected.

There is continuing work to ensure that all existing outpatient clinic templates are fully utilised. A detailed review of orthopaedic activity has been undertaken by Service Planning to update demand and capacity to inform job plans and service delivery for 2014/5.

Urology

TTG

There have been a small number of breachers each month, in the main due to cancer patients taking priority for theatre space. There is a consultant on Maternity Leave and this is being covered by an in house middle grade acting up. Cover for the middle grade has been problematic.

Outpatients

Due to the maternity leave and the delay in appointing the 5th Consultant (not able to start until January 2014, 6 months after interview), delivery of the outpatient waiting times have been affected by the demand to deliver TTG and cancer waiting times. From 20th January 2014 the 5th Consultant is in post and with locum cover for the Maternity leave, will enable the provision of clinics over the last quarter of 2013/14 financial year to bring new outpatients back in balance.

ENT

The ENT Service has been dealing with a significant gap in its capacity due to consultant maternity leave and long term sickness and a retiral of an Associate Specialist.

TTG

The consultant has now returned from maternity leave but there are two senior medical vacancies due to ill health retiral and age retiral. The consultant post has been advertised but there were no applicants. The post will be readvertised. There is locum cover in place to cover some of the vacant posts commitments. The main pressure is in outpatients rather than TTG.

Outpatients

The above prioritisation has resulted in a significant impact for the outpatient waiting times. Currently a recovery plan is underway. This plan will involve a locum picking up additional

4 outpatient clinics per week and additional temporary EPAs offered to existing consultants to deliver additional clinic capacity.

Ophthalmology

TTG

Replacement of vacant posts within the service through 2013 has resulting in the delivery of the TTG target over the past few months.

Outpatients

Due to TTG pressures a significant backlog had developed within the service for both new and return outpatients. The appointment to all vacant posts has resulted in an improvement in delivery of new and review outpatients over the past few months. Outpatient capacity is also supported by sessions from a recently retired ophthalmology consultant working at standard rates.

The plan through 2014 is to look at service redesign to reduce the reliance and pressure on consultants by developing the service support staff. e.g. developing nurses to undertake injections previously only done by medical staff.

OMFS

TTG

Although OMFS has continued to deliver the TTG target since June 2013, there is significant pressure with the difficulty of attracting a consultant to the vacant 2nd post. The difficulty of matching theatre capacity with paediatric bed capacity also causes TTG problems. Currently discussions are underway with NHS Grampian to manage major head and neck surgery across the OMFS network but this is adding pressure to TTG compliance.

Outpatients

As priority has been given to the delivery of TTG significant pressures remain for the delivery of outpatients.

Although the 2nd consultant has now left, some locum cover has been secured on an ad hoc basis. An NHS Grampian consultant, through a Locum Agency has been assisting.

Gynaecology

TTG and Outpatients

Middle grade maternity leave and consultant vacancy have put pressure on waiting time targets. A locum consultant commenced one month later than planned in February 2014 and it is anticipated that this will address waiting times targets by the end of March 2014.

Medical & Diagnostics Division

The pressure points within the Medical & Diagnostic Division continue to be Cardiology, Rheumatology, Respiratory Medicine and Gastroenterology with capacity concerns continuing for new and return patients. Additional clinics are being provided by substantive consultants and in some specialities these are being supplemented by Synaptek an external agency.

5 8 Key Diagnostic Tests

Endoscopy

As previously reported there is a capacity shortfall of 5 sessions per week which may be further added to as consultants formalise compliant job plans as part of the 2014/15 job planning process.

There are many work streams in progress. In the short to medium term additional sessions are created by Waiting List Initiative (WLI) but the aim is to cease the reliance on this.

Attempts to appoint a further Gastroenterologist have not been possible despite many recruitment attempts. This lack of recruitment has also hindered the implementation of “gastroenterologist of the week” which will create capacity.

Attempts are being made to reduce the consultant administrative time by assessing what additional secretarial support is required to to free up clinical capacity to deliver more sessions

The clinical lead for endoscopy in Scotland has been contacted for support and advice but could give no solutions and advised that other units have similar problems. The Golden Jubilee National Hospital (GJNH) has been contacted to explore whether their endoscopists can provide services at NHSH and also as to what capacity they could provide if patients were willing to travel.

Radiology

See separate Improvement Committee Paper.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

Specialty Impact

Orthopaedics As indicated above consultants have been asked to provide additional Admissions theatre capacity. It is unlikely that a zero TTG position will be reached for (TTG) 31 March 2014.

Orthopaedic The “see and treat” package is complete in terms of outpatient activity Outpatients and resultant surgical cases will be operated on by 31 March 2014 will not begin to impact until January 2014. This exercise is still not enough capacity to deal with the outpatient pressures and there will be a breach position of over 500 at the end of March 2014. Improved utilisation of the existing clinics, particularly peripheral clinics will continue.

Urology Cancer pressures will continue to impact on TTG and may require Admissions continued used of Private Sector to support TTG patients to free capacity (TTG) for cancer patients. The aim is to have no TTG breaches by March 2014.

Urology The impact of the actions above will take effect during January to March Outpatients 2014 and therefore no patients will wait longer than 12 weeks for outpatient appointments.

6 ENT It is anticipated that the ENT recovery plan will deliver a zero outpatient Outpatients position at the end of March 2014 OMFS It is anticipated that the assistance of the Grampian consultant will deliver Outpatients a zero outpatient position at the end of March 2014

4 FORECAST OF RETURN TO PLANNED PERFORMANCE

TTG: - At the end of March 2014 all specialties apart from orthopaedics are planning to be achieving TTG. However, patient cancellations and cancer cases are a risk that may contribute to TTG breaches.

Outpatients: - At the end of March 2014 all specialties apart from orthopaedics are planning to return to planned performance of meeting 12 weeks.

Regular monitoring of the progress against all the above plans will take place on a weekly basis as part of the weekly Raigmore Hospital Access meeting.

Linda Kirkland Interim Director of Operations Raigmore Hospital 27 February 2014

Improvement Committee 3 March 2014 Item 4.2d

Diagnostic Radiological Tests and Investigations Raigmore Hospital

1 CURRENT POSITION

This report describes the position with regard to performance against standard for the 4 key diagnostic radiological tests and investigations of CT and MRI scanning and Barium and Ultrasound examinations, all of which must be performed and reported within 6 weeks.

NHS Highland internal targets require that 90% of reports be available within 7 days of examination, 100% within 14 days, meaning that the wait for diagnostic imaging to be performed should in principle not exceed 4 weeks.

Capacity – Scanning and Reporting

Both of the above elements have been affected by capacity issues - wait to examination by the number of scanning slots available and - wait to report by the number of consultant radiologists available to perform this task.

Graph 1 below shows how the difference between MRI scanning capacity (number of patients that can physically be scanned per week) and waiting list demand has created a shortfall which currently stands at an average of 22 patients per week:

NHS HIGHLAND • RAIGMORE HOSPITAL MRI Demand and Activity - Weekly April 2012 to March 2013 Demand Activity Average Demand Average Activity 300

250

200 s t n e i t a P f

o 150 r e b m u N 100

0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------l l l l l t t t t r r r r r r r r r r c c c c c v v v v y y y y g g g g n n n n p p p p p n n n n b b b b u u u u u c c c c a a a a a p p p p p e e e e e a a a a o o o o u u u u a a a a e e e e e e e e e u u u u J J J J J J J J J J J J J - - - - - O O O O A A A A A S S S S S F F F F D D D D D A A A A N N N N ------M M M M M ------M M M M ------1 8 5 2 9 ------6 3 0 7 3 0 7 4 7 4 1 8 1 8 5 2 9 2 9 6 3 0 3 0 7 4 2 9 6 3 0 0 0 1 2 2 5 2 9 6 4 1 8 5 3 0 7 4 1 6 3 0 7 0 1 2 2 0 1 1 2 0 1 2 2 0 0 1 2 2 0 0 1 2 3 0 1 1 2 0 0 1 2 3 0 1 1 2 0 1 1 2 0 1 1 2 3 0 1 2 2

Source: Referrals & Activity extracted from RIS Week Ending Author: Sammy MacDonald, Service Planning Department Graph 1 – Difference between capacity and demand in MRI

Graph 2 below shows how the use of outsourcing for reporting of any appropriate case over 10 days old has resulted in a downward trend, the spike in January caused by the ‘See and Treat’ orthopaedic MRI cases and additional CT weekend lists. Cross Sectional Imaging - Weekly Reports Outstanding

450

400

350

300

250 CT MR 200

150

100

0 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 / / / / / / / / / / / / / / / / / / / 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 / / / / / / / / / / / / / / / / / / / 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Graph 2 – Backlog of CT and MRI reports

Barium cases are few in number and reported within a week, and Ultrasound cases are reported predominantly by the sonographers within a day or two of the examination taking place, and therefore these two modalities are consistently within the 6 week target.

Current performance

The time spent waiting to perform and report the examination is reviewed weekly.

On February 17th 2014 the waits and reporting performance* were as shown below:

No. waiting 4 No. waiting over % (number) % (number) weeks or less** 4 weeks** for unreported unreported for scan scan after 1 week after 2 weeks CT 201 123 39% (76) 1% (3) MRI 352 85 59% (140) 12% (28) Barium 7 0 11% (1) 0% (0) Ultrasound 517 2 6% (3) 4% (2)

*The above data has not been adjusted to reflect patient choice in appointment date ** 6 week cut off for ultrasound

The data above shows that on February 17th 2014 there were 216 patients for CT and MRI breaching the internal 4 week target waiting to be scanned, compared with 400 presented in the January report.

2 Graphs 3 and 4 below show performance for both scanning and reporting against target:

CT Run Chart (Completed Waits) 2013-14 Inpatients & Outpatients

100.00 90.00 80.00 70.00 % within 4 weeks for appointment 60.00 % within 2 weeks for report 50.00 40.00 % within 6 weeks overall 30.00 20.00 10.00 0.00

3 3 3 3 3 3 3 3 4 4 4 1 1 1 1 1 1 3 1 1 1 1 - - - l- - - -1 - -1 - - - r y n u g p t v c n b r p a u J u e c o e a e a A M J A S O N D J F M

Graph 3 – Completed waits for CT patients (reported in month)

MRI Run Chart (Completed Waits) 2013-14 Inpatients & Outpatients

100.00 90.00 80.00 70.00 % within 4 weeks for appointment 60.00 % within 2 weeks for report 50.00 40.00 % within 6 weeks overall 30.00 20.00 10.00 0.00

3 3 3 3 3 3 3 3 4 4 4 1 1 1 1 1 1 3 1 1 1 1 - - - l- - - -1 - -1 - - - r y n u g p t v c n b r p a u J u e c o e a e a A M J A S O N D J F M

Graph 4 – Completed waits for MRI patients (reported in month)

3 2 ACTION PLANS TO ADDRESS

Taking each modality in turn the action plan to bring performance up to standard is as follows:

CT & MRI  Firstly to continue to outsource to Medica Reporting Ltd, such that no case will go longer than 14 days unreported. Those cases deemed inappropriate for outsourcing (for clinical or operational reasons) will remain in house and time to report monitored.  Secondly (and in parallel) to continue recruitment efforts. Outsourcing will be used as backfill as required, to ensure lack of substantive posts does not compromise the reporting performance.  Thirdly to deliver on the RPIW findings and implement a changed rota to utilise additional staff resource to deliver an increase in the number of hours available for scanning patients. The rota is due to be implemented on March 3rd 2014.  Fourthly to extend the working day as well as utilising Caithness and Belford capacity will allow the waiting lists that grew slightly during the CT replacement period to be reduced again. Uplifting capacity at the Rural General Hospitals to allow 9am to 5pm scanning Monday to Friday would require utilisation of bank staff at Caithness General (cost approximately £400 per week) and a locum radiographer at Belford Hospital (cost approximately £1,500 per week) – either option would deliver the scanning of around 20 additional patients per week.  Fifthly to discontinue acceptance of Cardiac CT referrals from NHS Grampian, releasing up to 10 CT slots per month. This additional capacity will be fed into the ongoing job plan reviews to ensure that service delivery is enhanced as a result.

Barium & Ultrasound As noted above, barium and ultrasound examinations are comparatively small in number and reported within one week and one to two days respectively, allowing consistent achievement of the 6 week standard for 98-100% of cases. Prolonged wait of 4-6 weeks for ultrasound appointment can on occasion happen for musculoskeletal (MSK) cases which are performed by consultants but the almost immediate reporting mitigates the effect.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

Scanning capacity Implementing an extended working day in the MRI section was recognised during the RPIW as the best means to ensure all patients are seen within the target of a maximum 4 weeks wait. The rota will be in place by from March 3rd 2014. However similar work is required to deliver improvements in CT performance, as without it the numbers will only decline as and when ad hoc additional sessions are delivered.

Reporting capacity The most noticeable impact, until recruitment to vacant posts is successful, will continue to come from use of outsourcing, which delivers a far greater degree of control over backlog size (and departmental performance) than previously.

4 4 FORECAST OF RETURN TO PLANNED PERFORMANCE (i.e. Trajectory)

An element of outsourced reporting will be continue to be used on an ongoing basis, all cases meeting the appropriate criteria unreported after 10 days will still be allocated to this pathway. Should the desired maximum wait for report be reduced then this can be reflected in the protocols put in place within the department although until consultant numbers are stabilised this would be challenging.

Waiting times for scans however will not improve until the capacity issues have been resolved. The formal rota change on March 3rd 2014 is designed to achieve this in relation to MRI, and the graph below shows that, based on the number of patients currently waiting more than 4 weeks and on the number of patients booked to be scanned each week, by March 31st 2014 all MRI patients will be being scanned within target.

Number of MRI patients waiting >4weeks

250

200

150 No. >4weeks Projected 100

0 4 4 4 4 4 4 4 4 4 4 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 / / / / / / / / / / 1 1 2 2 3 3 3 4 4 5 0 0 0 0 0 0 0 0 0 0 / / / / / / / / / / 6 0 3 7 3 7 1 4 8 2 0 2 0 1 0 1 3 1 2 1

Graph 5 – Number of MRI patients waiting more than 4 weeks for scan

CT performance Similar work is ongoing for CT patients, subject to the resource outlined above being approved to allow fuller utilisation of Caithness and Belford CT scanners. The extra capacity this would provide would allow the number of patients waiting more than 4 weeks to be brought to zero by the end of March 2014, but in the absence of a capacity increase (whether by ad hoc means or a structured, formal approach) the number of patients waiting more than 4 weeks will remain static or indeed rise along with demand.

Highland Health & Social Care Committee 20 March 2014 Item 5.5.1

Assynt House Beechwood Park Inverness IV2 3BW ACTION PLAN Tel: 01463 717123 Fax: 01463 235189 www.nhshighland.scot.nhs.uk PROFESSIONAL EXECUTIVE 19 DECEMBER 2013 – 9.00 am

Present: Paul Davidson (PD) [In the Chair] In Attendance: Helen Bryers (HB) Elaine Mead (EM) – to 11.30 am (for Deborah Jones) Rod Harvey (RH) Lorraine Power (LP) Ken Proctor (KP) - to 11.40 am Brian Robertson (BRb) Ian Scott (IS) Nigel Small (NS) Cameron Stark (CS) Katherine Sutton (KS) – to 11.05 am

Apologies: Deborah Jones (DJ) and Gill McVicar (GMcV)

SUBJECT REPORT

Prior to the commencement of business PD welcomed everyone to the inaugural meeting of the Professional Executive Committee (PEC). He advised that the first meeting would consider the Terms of Reference, membership and workplan for the Committee. EM confirmed that she was attending in the absence of Deb Jones.

1. PRESENTATION BY CHAIR OF PEC

1.1 PD gave a short presentation to the Committee to stimulate discussion around the PEC, including the role of the PEC, issues of clinic leadership, influencing change and the future work programme. Some of the points highlighted included:  Raising the volume of the clinical voice;  Constructive clinical input into strategic cross boundary issues;  Recognising the overlap between managerial/clinical leadership;  Action of leadership between people/silo’s/issues;  Reports to HH&SC Committee;  Supports operational delivery with close liaison with COO;  Promotes, influences and advises on organisational and strategic change.

2 DISCUSSION – TERMS OF REFERENCE

2.1 There followed a detailed discussion on the terms of reference of the Professional Executive Committee including the role and function and membership. During discussion the following points were highlighted:

 Potential to integrate understanding across professions.  The Committee should be “person-centred” rather than “patient centred”, which should be reflected in the Terms of Reference. There was a need to be task focussed on person-centred care.  Uncertainty that the average clinician understands the role of ACF or AMC etc and this committee would only work if clinicians know about it and use it.  Need to express what the difference and benefits are of PEC e.g. raising clinical voices and input.  RH welcomed the smaller membership of PEC which he felt would be better able to make decisions and potentially could be different from the professional advisory committees which were not necessarily well represented or effective.  Need to think about how people feed into PEC and to hear about issues “from the coal face”  Potential for managers and clinicians working together and cross-boundary working / influencing strategy from a clinical / professional perspective.  This was a unique opportunity to integrate different professional perspectives in one group, a forum to bring together different clinical perspectives. Not just about what tasks, but about how we engage.  Need to consider the social care model of engagement in engaging with people in their communities and promote self sustainability and community resilience.

KS referred to some work linked to her professional leadership role with AHPs and confirmed she was happy to meet with PD to share her learning. EM advised that she was excited by the discussion and the will for a different kind of committee which would genuinely give professional leaders in H&SC a voice. There was a need to remember that the best decisions include those providing the service and those receiving it. Consideration should be given to involving the public / patient group that EM was currently working with. There was also a need for absolute clarity about the Clinical Strategy for NHSH.

There was some discussion around the nature of the committee and whether its role was strategic or operational. It was generally felt that the role was strategic and that there was a need to align the activities of the committee with relevant strategies. There was an enthusiasm for thorough patient engagement in relation to the work of the committee. The Chair felt that it was important not to exclude working in any way and to ensure that the work was patient centred and the voice of the patient heard via different routes. There was a general consensus that the PEC should continue although it was recognised that there was further work to be done in relation to how the Committee would work in practice and to ensure that it was adding value. It was suggested that the group needed to “think out of the box” in relation to how services would be delivered in the future.

NS suggested that there was a need for a focussed work plan for the first 6 – 12 months, with clear priorities. It was also felt that there should be a focus on areas where a real difference could be made.

In relation to membership of the Committee, it was noted that Helen Morrison who had been recommended as the Lead Nurse on the Committee had recently retired and this vacancy would need to be filled. PD referred to the previous report submitted to the Health & Social Care Committee when option 3 had been recommended as the preferred membership of the group. He suggested that this should form the core membership but with the flexibility to invite individuals to meetings related to their specialty or area of expertise. EM highlighted the fact that those people not directly involved with a service often had a better insight into the issues. There was some discussion around structure and the fact that the Committee was a sub-group of the Highland Health & Social Care Committee and would therefore report to the HH&SCC who would then report to the Board. It was agreed that a small and professionally diverse membership of the PEC was preferred with the ability to co-opt additional members in relation to specific topics.

KS left the meeting at 11.05 am.

ACTION  Agreed that the PEC should continue meantime, with PD as Chair.  The membership should remain small and professionally diverse, with the ability to co-opt additional members in relation to specific topics.

2 3. WORK PLAN FOR PEC

3.1 There followed a discussion on the Work Plan of the Committee. A question was raised whether the Committee would set its own agenda or whether this would be set by the HH&SCC as the parent committee. EM confirmed that items would be discussed at the PEC prior to being submitted to HH&SCC. CS highlighted the need to think about who needs to be at future meetings and any pre-work required prior to an item being considered by the Committee. During discussion a number of potential items for discussion by the PEC were suggested:  GPs contribution to Health & Social Care services of the future  Being able to keep older people at home for longer  What OOH and emergency rural services might look like in future  The future of RGHs  Obstetrics in Caithness  MSK Triage and the impact on orthopaedic services.  NHS Highland Consultants working across NHS Highland  Health Inequalities  Primary Care and Secondary Care and how they work together across boundaries  How to delivery Cancer Services in the future – local / community and hospital services  The move from healthcare dependency to healthcare resilience  Opportunity for comment / advice on the 5 year commissioning strategy  Compliance with European Working Time Regulations (EWTR)

EM left the meeting at 11.30 am. KP left the meeting at 11.40 am. IS referred to the Remote and Rural Workshop arranged for 22 February 2014 and advised that this might provide additional information which would be useful to PEC. It was agreed that PD would feedback on discussion at today’s meeting and potential future agenda items to the next meeting of the HH&SCC in January. It was generally agreed that MSK, Out of Hours and Cancer cut across most of the suggested topics and these should be considered initially by PEC.

ACTION  Chair to feedback on discussion at first PEC meeting and potential PD – HH&SCC future agenda items to the next meeting of the HH&SCC. 09/01/14  PD, DJ & LP to meet following January HH&SCC to discuss next agenda. PD / DJ / LP

4. DATE OF NEXT MEETING

4.1 The next meeting will be held on Thursday 27 February 2014 at 9.00 am in the Board Room, Assynt House. PEC Dates for 2014  27 February 2014  24 April 2014  26 June 2014  28 August 2014  30 October 2014  18 December 2014

The meeting closed at 11.55 am.

Highland Health & Social Care Committee 20 March 2014 Item 5.5.2

Approved by Professional Executive Committee 19 December 2013

PROFESSIONALEXECUTIVECOMMITTEE TERMSOFREFERENCE

1. Committee Remit

The remit identified by the Committee is:

Overall Remit

The guiding principles of a North Highland PEC are that it:

 is patient and client focussed care to promote the health and wellbeing of communities, promotes and provides a high quality of patient care across the continuum. provides strong clinical / professional leadership,  brings together the clinical aspects of decision making across the operational units in a collaborative fashion,  is an integral part of the HH&SC Governance and Accountability Framework.

The PEC is constituted effectively as a Sub Committee of the HH&SC Governance Committee and is accountable to the Chief Operating Officer. The Chief Operating Officer in agreement with the Health and Social Care Committee Governance Committee will determine the mode of operation and work plan of the PEC.

Specific Responsibilities

The role and function of the PEC is as follows,  To provide clinical advice and comment on relevant issues and decision making across North Highland Operational Units to the COO and thereby the HH&SC Governance Committee.  To ensure operational collaboration and alignment across the 3 North Highland Operational Units.  To provide clinical leadership and empowerment to ensure a high quality, sustainable service across the continuum of care.  To maintain a patient and client focus of care.  To champion and facilitate change and transformational redesign and innovation.  Highlight and identify health promotion and disease prevention in the elimination of health inequalities.  To develop links with key professionals and other stakeholder organisations.  Support the quality of care with the financial balance.

The PEC does not have a professional representative function. 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 of Last Meeting  Other agenda items to be confirmed: o Operational o Governance Issues o Strategy and Vision

Boundaries and Accountabilities

The accountability and reporting arrangements will be to the Chief Operating Officer, who has an operational responsibility for care provided by the Operational Units across NHS Highland, and is a member of the HH&SC Committee.

The substance of the reports by the PEC will include operational decision making, governance issues and the development of strategy and vision, and these would be reported to the HH&SC Committee through the Chief Operating Officer and or Chair of the PEC.

Administrative Arrangements

The PEC will meet every two months synchronised at a defined time period with the HH&SC Committee meeting.

Chairmanship

The chairman will be initially appointed by the Chief Operating Officer to support the creation and early development of the PEC with a view to formally establishing an election process within 6 months of the first meeting taking place.

The PEC chair will rotate every two years through nomination and election from within the committee

The PEC chair will be invited to become a member of the HH&SCC

Administrative Support

The Committee will be serviced within the NHS Highland Committee Administration Team and minutes will be included within the formal agenda of the Highland Health & Social Care Governance Committee.

2 Committee Membership

The membership of the Committee is agreed by the Highland Health & Social Care Committee.

Chief Operating Officer Clinical Director, North & West Clinical Director, South & Mid Clinical Director, Raigmore Director of Operations, North & West Director of Operations, South & Mid Director of Operations, Raigmore Lead AHP Lead Nurse Lead Midwife Lead Social Worker Associate Medical Director (Primary Care) Quality Hub/ Public Health member

The Committee Chair is appointed by nomination and election. A quorum for Committee meetings will be at least one third of Committee members.

The membership should remain small and professionally diverse, with the ability to co-opt additional members in relation to specific topics.

Highland Health & Social Care Committee 20 March, 2014 Item 6.1(1)

NORTH AND WEST OPERATIONAL UNIT REPORT Report by Gill McVicar, Director of Operations

The Committee is asked to Note the content of the report.

Introduction This report will provide an overview of activity in the Unit and will highlight key pieces of work and areas of concern.

1. Financial Position The Operational Unit is forecasting an overspend of £1.55m at year end and this may still worsen due to pressures on budgets that have not found cash releasing savings. This was predicted at the start of the year and is made up of three key aspects:- Out of Hours cover, especially in Wester Ross, Skye and Lochalsh; Locum cover in the Rural General Hospitals; Vacant GP Practices requiring locum cover. Adult Social Care is also overspent but not by as much as previously anticipated particularly in Independent Sector Care. This may be a false picture due to the number of beds that have been embargoes in the past year and the number of delayed discharges that have resulted. The teams are continuing in their efforts to pull back on spending and to find other non recurring savings.

2. Waiting Times Targets

Belford Hospital The Radiology waits remain problematic due to limited visits by the Radiologists from Oban. Patients are being offered appointments in either Oban or Raigmore if necessary.

Belford is also required to pick up Ultrasonography appointments to support in the absence of Sonography services in Skye following retiral of Sonographer and inability to recruit replacement.

Caithness General Hospital Challenges remain in the endoscopy service and this is likely to worsen due to the leave of absence of one Endoscopist and the resignation of another. This situation is being closely monitored.

Chronic Pain Unfortunately the challenging Consultant staffing situation continues and the lack of experience locums in this field means that we are unable to meet waiting times targets. The Team is doing an excellent job in managing the priorities and urgent overload but inevitably people are having to wait longer than anyone would want and several complaints have been received.

Service Improvement work continues but it is extremely challenging to do any more with insufficient resources and the sustainability of the service in its current form is in question. 3. Delayed Discharge

The position has improved in the West. There is a concerted effort to proactively ‘pull’ patients from hospital setting with active inreach to hospitals from community teams. However, capacity within Care@Home remains a problem.

In the North, the situation is more challenging. At the time of writing, there are 19 people in a delayed discharge situation. Six of these are X coded which means that they are either awaiting Guardianship processes to be completed or are exercising choice with regard to Care Home placements. The recent CEL on Choice of Care Home and Interim placements is being followed but in the case of the far North, choice is extremely limited and there are clinical reasons why some of these patients should not undergo two moves. The position in Sutherland is of particular concern due to the lack of availability of Care Home places and also Care at Home packages.

One of the solutions being explored is the future use of NHS Care Homes which at present are for residential care only and the demand for those beds are not as high as that for Nursing Homes. There is consideration of whether or not the Homes could become dual registered and therefore be able to provide care to those with higher level needs. We have experience of supporting a Third Sector Home to achieve this and therefore believe it to be worth pursuing.

4. Review of Adult Services, Caithness

This is a significant piece of work and there is a separate report to Committee to update on activity.

The key aspects are that there are currently 5 work streams which have their own action plans and we have begun some work on the use of the health economic approach, Programme Budgeting and Marginal Analysis, to support the next steps in decision making. The work on Caithness General Redesign has stalled due to lack of capacity and therefore, the Associate Lead Nurse for North and West has agreed to project lead the CGH work as from 1st March. A revised project charter has been developed and driver diagram and change package are being developed. This process will involve local staff to enable engagement and ownership. Regular ‘report out’s’ are planned in addition to the local project team.

5 Obstetric Services, Caithness General Hospital

The staffing situation for Consultant Obstetricians in the North has been precarious for some time, but recently the situation has become even more fragile. One of the three Consultant Obstetricians in Caithness left the area in December. An appointment to a long term locum position was made and we received the tragic news that this person had died very suddenly. This, together with leave commitments, leaves a very challenging staffing situation and therefore a fragile service. Attempts are being made to secure the services of other locums but this has so far been unsuccessful. Business continuity plans are in place and contingency plans are being constantly updated with predicted activity figures to ensure a safe service. All women have risk assessments and some of these will be reviewed in light of the fragility of the service.

The contingency plan, if enacted, will entail moving to day time obstetric and gynaecology services only, with out of hours maternity services continuing to be midwife led supported by Raigmore Obstetricians when required. Most women assessed as being at higher risk are already booked with Raigmore for delivery and the vast majority of women deemed to be low risk are receiving midwife care.

It must be stressed that the Midwifery service is strong and continues 24/7. Midwives are highly experienced autonomous practitioners who are very well placed to support normal births and to detect any abnormalities. They are also trained and experienced in Paediatric Life Support. Many other areas have midwife only units and therefore it is important that women do not become overly anxious about the situation. Their care team will discuss the plan with them individually and only those deemed to be at high risk of requiring specialist intervention will be required to travel to Raigmore. The contingency planning process has involved Raigmore and staff there are able to support any small increase in numbers that may result should the plan have to be implemented.

6. Skye, Lochalsh and Wester Ross Redesign

A paper was presented to a special meeting of NHS Highland Board requesting permission to move to formal consultation on options and to conduct an options appraisal on location. This was agreed and a workshop was held on 11th March. The workshop reviewed each of the shortlisted options for locations, examined each one against a set of criteria, developed by the group on the day and then scored each option.

The Steering Group selected Broadford for the new-build hub facility and Portree as the location for the spoke.

While Broadford and Portree emerged as the preferred hub and spoke locations respectively, no decisions were taken on the actual sites. Further work will now take place to assess the feasibility of a number of sites and to ensure that all potential sites have been identified. However, NHS Highland owns land adjacent to the new health centre in Broadford and this will be investigated in the first instance. The preferred locations having been chosen, a recommendation will now be made to the April meeting of the NHS Highland board for a formal, three-month consultation on the full service model and possible site locations. When that is complete a final recommendation will be made to the board and then to Scottish Government ministers.

7. Riverbank Medical Practice, Thurso

As has been previously reported, this Practice became vacant in December 2012. Significant development work has been undertaken and a Patient Participation Group has been established whilst the N&W Operational Unit has been running the Practice on a temporary basis. Despite that, advertising for independent GPs to take on the Practice has not produced any feasible applications and therefore it has been decided that the Practice will become salaried. This does not mean that the Practice could not become independent in the future but it will allow us to move to recruit now to permanent posts to bring about some stability and consistency for patients. That said, we have been very fortunate in the calibre of locum Dr and the continuity that they have been able to provide in the Practice and we are indebted to them for their commitment.

8. Care Homes

As a result of integration, Care homes are now being supported by the Associate Lead Nurse who has been actively involved with Riverside, Seaview, and Bayview in Caithness. Action plans have been developed for Seaforth, Sinclair Court and Loch Broom and the Telford centre. Recent feedback from the Care Inspectorate has highlighted the benefits of our involvement and significant improvements have been made which have resulted in improved grading, for example Bayview has just received scores of 4 and Telford Centre have scored 5.

An update on current work streams follows:-

 Prescribing

The new Medicines Management Support Service for Care Homes includes a nursing post as part of this service’s outline. The nurse’s role is to undertake reviews of wound management, continence care and falls, plus cognitive impairment screening and support non medical prescribers in the community. The post is currently being advertised.

 Dementia

‘Getting to Know Me’ is being rolled out. As part of the person centred Health and Care Programme, reliability of spread will be audited. Opportunities to introduce within the community setting are also being explored, this way the document will follow the individual into any care setting.

9. Multi Disciplinary Team (MDT) documentation and discharge planning

o The Admission Discharge and Transfer policy review is now out for wider consultation o The Highland wide review of nursing documentation is in progress and includes a revised version of the ADT checklist o The Common Assessment Document (CAD) is being tested in the community in Lochaber and work is ongoing to ensure that it fits well with the Personal Outcome Plan (POP) and that it meets the needs of all members of the integrated teams to avoid duplication and add the potential to use the same assessments and reviews more widely. o Standard processes are being developed in relation to MDT meetings and the community ward approach and anticipatory care provision are currently being tested in Skye.

10. The Care Experience

Care Assurance

This work is supported by the standards are based around the Clinical Standards for Older People in Acute Care (2002). The programme of observation and formal audits across all hospital sites continues. A formal leadership structure has now been identified for North and West reporting to the N and W Leadership Group.

Francis Report

The North and West Extended Senior Management Team held a Francis report workshop called ‘the patient comes first’ in November. This provided an overview of the key messages with conversation space to consider the ‘how do we’? The outputs inform the OPAC and person centred programme which are work streams which will directly influence experience of care and are being incorporated in the updated Delivery Plan. There is a range of other work streams in place which will support improved care experience and increase patient safety as follows;

 Falls Prevention

The programme continues as described in previous reports and includes a range of preventative measures, assessment tools, audit and monitoring processes across hospital and more recently care home sites.

A sustained improvement is being maintained with falls incidence below their baseline in Newton and Dunbar.

 Tissue Viability September and December

Measuring improvement

There is strong evidence emerging of improved patient outcomes as a results of the Tissue Viability Advanced Practitioner, Senior Practitioner and SSKIN Bundle Facilitators. The facilitators aim to improve the prevention of pressure ulcers in community. Some examples:-

 There have been no reported grade 3 or 4 PU for 60 days (quarter 4). In quarter 3 there were 2 grade 2 and one grade 4 pressure ulcers recorded.  Between 2012 and 2013 there has been an 87% reduction in hospital admissions secondary to pressure ulcers. The remaining admissions are all long term patients with non healing chronic wound of many years. A Complex Pressure Ulcer Register is being developed and supported by wide ranging MDT.  There is also evidence that the service is having an impact on healing rates in long standing chronic ulcers which previously would have been dealt with by the Vascular Nurse Specialist who is currently on long term sick leave.

These improvements are the result of improvement work which includes;

Easy access E-clinic - This has been in use in Raigmore Hospital for the past 2 years. It is now being used in the community/community hospitals. It involves taking images of complex/static wounds that would benefit from a Tissue Viability review. This approach to reviewing wounds reduces the waiting time that, at times, can be lengthy

Introduction of Talley Pumps – many teams now have pumps in base for use with patients who require Topical Negative Pressure which will eliminate the daily £18.50 hire charge that was applied to each pump on hire. Staff training has been rolled out across Highland and can be repeated for those teams that request.

Appropriate Pressure Relieving Equipment – The steering group have now agreed to a long term plan which will see NHSH move towards a ‘3 Tier Mattress System’. Mattresses and cushions will be categorised into A B and C grades. Work has now started on a Policy to guide staff when considering purchasing new equipment, as well as narrowing the choice of equipment this will simplify the request process and greatly reduce the risk to patients requiring specialised equipment. A new Mattress selection guide is now available. A shortage of ‘very high risk’ mattresses has been identified. An SBAR has been submitted to Board Director of Nursing.

Pressure Ulcer Prevention - robust education programme continues to all NHSH care homes. This includes SSKIN Bundle training, presentations on ‘Care of the Older Adults Skin’ and ‘Itch/Pruritis’. Education - Compression bandaging/support hosiery – training programme to be delivered across region early in 2014, topical Negative pressure

 Continence improvement work

The continence service review led by the Lead Nurse for North and West unit is now also focussing on testing patient first level assessment. A review of process, cost and type of containment products used is also being undertaken and financial savings are anticipated. Product guidance is also being developed.

This work is being built into the review of nursing documentation and care and comfort rounds.

 Control of Infection

The agreed HAI education programme as a result of the HSE improvement notice continues with success and uptake is being monitored carefully across Highland led by Lead Nurses

 Scottish Patient Safety Programme

The 10 PATIENT SAFETY ESSENTIALS AND SAFETY PRIORITIES have been outlined in CEL (2013) 19. The SPSP Leadership Group has asked that SPSP is spread to our community hospitals. It is evident that many sites have adopted elements of SPSP already for example SBAR as a communication tool, Safety Brief and mortality reviews. However, it is not a standard approach and there is currently no way to measure improvement. A working group has now been established to agree the priorities and determine how improvement will be measured.

 Respiratory service

The North and West COPD Senior Practitioner / Practice Educator has successfully completed a Level 11 through Respiratory Education UK, affiliated to University of Hertfordshire with a 92% pass mark.

Other improvement work includes;

 COPD discharge bundle been through PDSA cycles in Rosebank Wing CGH. Last test of change now inclusive of patient feedback. Once this is evaluated, bundle ready to be rolled out.  The Annual NHSH Respiratory network education day, "Breathing Matters”, took place on Feb 13th in Centre for Health Sciences which was a multidisciplinary event and attracted an audience of 65. Evaluation was very positive with practice changes identified including work on practice protocols, COPD care bundle development and promotion of activity.

 Hotel Services – Healthy living Award Plus – sign of healthier food

All hospitals in North and West who should register have now achieved the above award which applies for 2 years. Some of our smaller hospitals are exempt. 11 . Infection Prevention and Control

11.1 Hand Hygiene

Hand hygiene audits continue to be undertaken monthly by all clinical areas, the results are displayed at ward level and any non compliance addressed.

All 18 departments/wards are consistently reporting compliance of over 95% target across the unit. The average score between October 2103 and January 2014 are shown below.

Table 1 Hand Hygiene Results

Month Average Hand Hygiene results %

October 13 to Jan 14 98%

11.2 Health Care Environment

Health Care Environment Inspections

Following HEI inspections to Belford and Caithness General last year the 16 week updates have been provided to the HEI Inspection Team and all improvements and recommendations have been addressed.

Domestic Service teams continue to carry out monthly cleaning and estates audits as per NHS Scotland National Cleaning Services Specification. All sites in North and West have achieved the 90% (with the exception of Lawson) compliance rate for domestic monitoring and Estates Monitoring in October 2013 as follows.

Table 2 Cleaning audit results January 2014

Dunbar 94.8 Broadford 96.2 Lawson Memorial 96.2 Migdale 96.5 Portree Comm Hos 95.5 Wick Town & County 92.9 Belford 96.4 Caithness General 96.4

Table 3 Estates audit results December 2014

Dunbar 100 Broadford 93.2 Lawson Memorial 88.6 Migdale 100 Portree Comm Hos 98.7 Wick Town & County 97.2 Belford 95.54 Caithness General 98.9 11.3 Clostridium difficile cases (C Diff)

As previously reported, North and West are investigating why Clostridium Difficile incidence is not decreasing. In particular, since beginning of April 2013, there have been a total of 17 toxin positive cases in the North Area of which 8 are within CGH, compared to 10 in CGH during 2012/13 of Clostridium difficile positive as at March 2013

Table 4 Clostridium difficile cases (C Diff) in North Area

CGH LAWSON GP

2013/14 (to date) 8 1 8

2012/13 10 0 11 . NHS Highland reports all C diff toxin positives to Health Protection Scotland. Surveillance shows that North Area figures are not showing a significant increase, however, there has not been any decrease from year to year.

Of the cases detected, 4 refer to patients who suffered a recurrence of infection out with the surveillance protocol cut off of 28 days, so are reported as new infections. 1 patient has had 3 recurrent episodes.

3 patients have had previous admissions to Raigmore Hospital within previous 12 weeks. None of these patients have been found to have links during their stays in Raigmore or with any of CDiff incidences in Raigmore.

The community cases are from different locations and no link has been detected related to hospitalisation or other healthcare event. 2 patients had been on holiday prior to symptoms commencing, but not in the same place.

A North Area C Difficile Working group has now been established which has multi disciplinary engagement and a work plan has been developed which includes measures such as a review of prescribing of antibiotics, standards of cleaning and appropriate use of Actichlor.

The gentacmycin testing equipment is now in place but not yet being used due to training requirements in CGH. Anti microbial prescribing audits are being undertaken. The situation is being closely monitored.

Table 5 Clostridium difficile cases (C Diff) in West Area

MMH Belford GP 0 1 4 2013/14 (to date)

11.4 SAB Incidence - Cumulative SAB Positive Totals

There have been 7 cases in total (three Rosebank, one in MacKinnon and three in the Belford

11.5 Outbreaks

There have been no recent outbreaks. 12. Supporting Activities

12.1 Rural Resilience

The Remote and Rural Building Sustainability (now renamed, ‘Being Here’), Steering Group, hosted an excellent, well attended seminar entitled ‘Being Here- Supporting Strong Communities’ on 22nd February. We were extremely fortunate in having a team from the South Central Foundation in Alaska, who spoke about their Nuka model of care.

The Alaskan team's presentation was extremely well received and that interest has been maintained ever since. We have been providing further information to some people who would like to explore the Nuka model further.

The professionals were impressed by the team approach and the mutuality of the customer- owner relationship of rights, responsibility and shared accountability. At least one GP has since made contact to find out more.

The community representatives too, were interested in the co ownership concept and also in the community health aid role in remote communities. We have been exploring that with residents of the Small Isles, some of whom were able to be with us at the event and who have been in touch, expressing an interest in taking this further. To enable that, contact has been made with key education providers; NES, Scottish School for Rural Health, and Scottish Ambulance Service, with a view to building on existing training programmes for Health and Care Support Workers and Emergency Responders, to create a learning programme for people appointed to Community Health Assistant roles, from within the communities. It is early days but there has been an encouraging response and there will be meetings over the next few weeks to progress some aspects of this.

To underpin this work, participants were struck by the concept of the Health Representative Panel that the South Central team described, whereby the communities each elect someone who is fully mandated by them and therefore supported to speak on their behalf on development, delivery and monitoring of services. We are keen to explore how that might work here and have already had some interest from the community representatives. This Panel would be strategic, to include the Health Representatives, senior managers and clinical directors and would be distinct from Practice Patient Participation Groups, which are much more local and focused on day to day operational issues.

Another fascinating session at the seminar was led by Arran Resilience and focused on how Volunteers and Public Sector can work together to strengthen the response in emergency situations and the spin off benefits that can ensue from that. This again was very well received and there are some discussions ongoing around what lessons can be learned in Highland to support our local Resilience Partnerships. One of those key aspects was the removal of artificial barriers to partnership working.

The afternoon session was led by Irwin Turbitt from the Kafka Brigade, and previously of the Northern Irish Constabulary who is a Consultant focusing on Wicked problems and Adaptive Leadership. He spoke about ‘Meaningful Conversations’ and then led the delegates through some group work to help demonstrate how conversations with communities could be more effective and productive.

The seminar evaluated very positively and was a good foundation on which to build future events.

The proceedings were recorded and that is now available to view on Inverness TV – www.invernesstv.net

It will also be available through the RuralGP website. NHS Highland and NHS Grampian were fortunate to have had a smaller meeting with the Alaskan Team the previous day. That was stimulating and we will be progressing the learning from that as well.

12.2. eKSF (Knowledge and Skills Framework)

In order to ensure bank staff have a KSF and PDP completed, an implementation plan has been developed to understand how best to reach this group of staff, particularly bank only (those staff that have no other post than a bank post). There are 760 bank only nurses in total across NHS Highland of which 356 are Raigmore based.

In order to address the immediate risk, drop in sessions in Raigmore are being held for bank staff to ensure where a KSF has already been completed for a substantive post, it is used for their bank post.

12.3 Person Centred Health and Care

The Lead Nurse for North and West and Clinical Governance Manager are leading this work for Highland on behalf of the Board Director of Nursing. An engagement event is being planned for NHS Highland May 1st 2014. A planning group has been set up to agree the content of the event and the aims are to get a flavour about people’s experience of care within Highland, identify gaps where person centred approaches require further development and measures of reliability are required. The focus of the event will be around the ‘5 Must Do With Me’ elements and supporting interventions for person centred health and care. NHs Highland is also expected to be in line with the Person Centred Health and Care Collaborative measurement framework

Gill McVicar Director of Operations 13 March, 2014 Highland Health & Social Care Committee 20 March 2014 Item 6.1(2)

SOUTH & MID OPERATIONAL UNIT REPORT Report by Nigel Small, Director of Operations

The Committee is asked to Note the content of the report.

1. Scottish Government Mental Health Strategy Review

The Board Improvement Committee and MH Strategy Group recently considered the feedback correspondence from the SG MH Review Team following its visit prior to Christmas 2013. Rather than reproduce the letter which was brief, and has been considered elsewhere, this report provides more detail on the issues raised by the Team and outlines NHS Highland’s response with examples from South and Mid Unit. The SG topics are in bold below with NHS Highland’s response follows:

- Dementia - the HEAT target on a minimum of 1 year of post-diagnosis support (we hope to use the data you have submitted to ISD for this discussion) and on-going work to support early diagnosis. It would also be helpful if you could provide an update on progress with dementia diagnosis.

This is included as part of the Dementia sub Group work plan. A planned event will take place will take place with link workers and consultant Psychiatrists and GPs in Spring 14 to assess the first 6 months of HEAT target for post diagnostic support. The Early diagnosis HEAT target measured by GP registers achieving 50% of the expected prevalence in the practice population remains variable. For example, South and Mid Area have practices ranging from achieving 38% of the target to one practice having reached 208%. The Unit performance is 99%. This target is a proxy for reaching more people with dementia and ensuring they have access to the right support. The introduction of the 12 month post diagnostic support guarantee in April 2013 is helping with this. However, NHS Highland commissions Alzheimer Scotland to perform this function on its behalf using Change Fund money.

Target: 50% of expected prevalence to be on GP practice dementia registers

Unit Target % total at Jan ‘14 Argyll & Bute 890 91% 812 North & West 765 97% 742 South & Mid 1240 99% 1222 Grand Total 2895 96% 2776

- Integration of health and social care – we are interested to hear about plans for integration and where mental health services fit with the local picture. We also want to take the opportunity to discuss criminal justice and mental health, picking up issues around prisoner healthcare, transfer of custody healthcare and community justice.

All CMHT’s are managed with an integrated approach at the moment. A review of the future management structure required across the S&M unit is underway, reporting in March 2014. Custody suite health services staff have been undertaking a training programme with the Inverness CMHT and out of hours services to increase their mental health knowledge and skills. The Team Leader is a member of the Mental Health Operations Group and is involved in developing closer working across the services. Dr Hay Forensic Consultant Psychiatrist recently increased his role to full time to improve links and increase input to Porterfield Prison and the Criminal Justice service.

- Family involvement, rights, recovery, peer to peer work, employability – we will provide a short update on the national work in these areas. We would welcome a brief discussion of progress locally but we intend to include a more substantive discussion in the spring visit agenda.

Peer support workshop facilitated took place in November 2013 with an aim to introduce Peer Support Workers to the CMHTs across S&M Unit as vacancies arise. The redesigned Community Rehabilitation Service, created from the closure of the inpatient Ward at New Craigs Hospital, includes an Employment Specialist seconded from Job Centre Plus to increase the number of clients achieving employment. NHS Highland has aimed to become an exemplar employer and offer work placements, experience and jobs. A number of clients have now benefitted from this with two now in permanent employment with NHS Highland.

- Prevention and Self-Management – we are interested in discussing the priorities your local partnership(s) have identified to ensure a greater focus on “prevention, anticipation and supported self-management” of common mental health problems.

Mainstreaming Mental Health work led by Imran Arain from Public Health has reached out to various organisations raising the profile of maintaining good mental health. The QOF/QIP event this year focused on anxiety and depression. The referral pathway has been amended after full GP involvement encouraging greater use of National Living Life services via NHS 24 and co-ordinating our Guided Self Help Worker time across service as a collective resource. A planned significant increase in group based activities will also improve access to care and treatment for this client group e.g. Stress Pack sessions.

- Veterans – we have been in discussion with the Board regional development of Veterans First Point. We want to discuss with you progress you have made locally in considering whether and how a V1P service could be developed to support service delivery.

NHS Highland has been approached to become involved in providing a Northern Scotland branch of the NHS Lothian service to Veterans. This entails a commitment from NHS Highland to abide by the Lothian model and after two years of this LIBOR funded service accept the risk for continued funding from within our own resources. The service will cost approximately £350k per annum to operate.

- Mental Health – Access to psychological therapies – We will continue the discussion we had at the spring visits and would welcome an update on developing data on access to psychological therapies by age, gender and ethnicity, diagnosis and outcomes. We will include a discussion of a new Board profile that QuEST is developing on the mental health access targets (psychological therapies). These will be shared with you as management information in confidence.

There has been focused work addressing the achievement of this target. Average waits continue to decrease and are approaching the stepped target of no patient waiting more than 36 weeks. The target is that by Dec 2014 at least 90% of patients will wait no longer than 18 weeks from referral to treatment. In January 2014 across NHS Highland 76% of patients waited no more than 18 weeks. 2. Police Scotland: Custodial and Forensic Services

At the previous HHSC Committee, it was reported that there is currently a significant risk that the funding formula, which will determine how much NHS Highland will receive for provision of this service, will not provide the level of resources required to ensure continuity of the existing service. This situation has not been resolved. There is significant discussion at national level on this issue.

- Formal responsibility for the delivery of Police Custodial and Forensic Health Services is due to transfer from Police Scotland to NHS Boards from 1 April 2014. - NHS Highland has been delivering the services since December 2012. This commenced early due to problems being experienced by Northern Constabulary with a private contractor. - A partnership agreement has been in place between NHS Highland and Northern Constabulary which covered finance, standards and service delivery. The main services are located at Burnett Road Inverness which is a combined Nurse/Police service; in addition Service Level Agreements are in place covering Doctor lead services in Fort William, Wick and on Skye. - Since April 2013, a new Police custody division has taken control of custodial responsibilities on behalf of Police Scotland and the services are managed centrally not locally as was previously the case. - It is intended to keep the Committee updated on progress around finalising the required level of funding. It remains unclear whether rationalisation of the existing services is required in order to work within the allocated budget.

3. HEAT Monitoring Reports

The South and Mid Unit performance against the following targets is set out below:

- Alcohol Brief Intervention: Ahead of trajectory. - Smoking Cessation: Targets have been exceeded. - Keep Well: Currently behind target however 6 GP Practices in Inverness have signed up to become involved in the Keep Well programme and this will increase activity numbers. - Suicide Prevention Training: Ahead of target. - Ethnicity Reporting: Achieving 95% target figure. - Drug and Alcohol Referral to Treatment: (90% of patients to begin treatment within 3 weeks of referral) the HHSCC Area currently is at 83.8% in the latest reporting period to December 2013. An action plan is in place to help in achieving the target and the matter was discussed at the recent Board Improvement Committee. - Sickness/Absence: The Unit rate at end of December 2013 was 4.60% (Highland average is 4.44%) - Complaints Monitoring: The Unit achieved 82% (target is 80%) at the end of the last reporting period. This relates to complaints responded to within 20 days.

4. Unit Financial Position

The Unit financial position at the end of Month 10 is summarised as follows:

- £4.2m forecast overspend (improvement of £100k on previous month) - Health budgets on target to break-even. - Savings plan for Health & Adult Social Care budgets on target to be delivered. - Unit overspend relates entirely to Independent Sector Care budgets. The reasons remain as per the report to the previous HHSCC Committee meeting. 5. Unit Quality and Patient Safety Group

In order to provide assurance to the HHSC Committee that the Unit is proactively dealing with matters relating to Quality and Patient Safety, summarised below are details of discussion topics at the recent Unit meeting, including a meeting attended by the Deputy Board Chair (more details can be provided as required):

Operational Unit Risk Register

- Top Ten Risks - New Risks for Discussion - Risk Register Process - Examples of risks discussed - Patients Subject to MAPPA - Independent Care Homes

Quality & Patient Safety

- Clinical Governance Report as prepared by Clinical Governance Department, including information on Incidents, Training on Datix for logging Incidents & SERs, brief reports on SERs and outstanding SER actions, Complaints, both within NHS Highland and with the SPSO, and safety alerts. - Complaints Report - SPSO News - Clinical Governance Committee Assurance Report

Significant Event Reviews (SERs)

- Use of Datix – Status Update - Update on Ongoing SERs - Review of SER Action Plans - Update from SER Learning Event - Adverse Events Implementation Group

Professional Issues

- AHP Issues - Dental Services - Nursing Issues - Mental Health Services - Pharmacy Issues

5. Complaints Review Committee

In accordance with Section 52 of the NHS and Community Care Act 1990, The Highland Council has a responsibility to establish a Complaints Review Committee [CRC] to review Social Care complaints at Stage 3 of the Complaints process.

Outlined below are summary details of a recent CRC. The full details have been summarised in order to protect the anonymity of the complainant and the staff involved.

The complaint involved a male service user who was unhappy that housing support services had been withdrawn and who had raised concerns both about the process of the withdrawal, the subsequent assessment process which he had requested to in order to seek reinstatement of the service and communications around both these matters. The complaint had three main elements:

1. The alleged confusion about the meeting arrangements in February 2013 and the conduct of a Social Worker and member of staff from an independent sector service.

Findings: The CRC made no findings about this element of the complaint but was extremely dissatisfied with the lack of detail provided by the service in this regard.

2. The alleged events leading up to the withdrawal of the Housing Support service and the alleged failure of the service to re-assess.

Findings: This complaint was upheld. The CRC was not satisfied that there were any valid reasons to justify the service being discontinued. [It is worth noting that the service had already been re-instated before the CRC took place following assessment]

3. The alleged failure of the service to respond to the service users original correspondence, the alleged failure to issue minutes of a meeting and the alleged failure to keep the service user appraised of his right to challenge decisions made.

Findings: This complaint was upheld.

The CRC made several recommendations. These are as follows:

- All documentation should be made available to the CRC - The Complaints Procedure in place for Social Work Complaints should be familiar to staff and adhered to at all times. Services users should be apprised of the status of their complaint and the timescales. - To deal with an apparent confusion about the policy and procedure for handling of health or social work complaints - To ensure all steps are taken to ensure that where service users are to have a service withdrawn that the reasons are clearly stated, recorded and agreed with the service user. Where a service user disagrees, this must also be recorded and an opportunity afforded to challenge the decision. Where an assessed need is established which meet eligibility criteria the service users needs must be met promptly and fully. - The service should review the standards of housing support providers and amend the contract terms where necessary.

It should also be noted that the staff involved within the CRC Process have raised concerns about the nature of the hearing and this is currently subject to investigation.

Nigel Small Director of Operations (South/Mid Unit) 4 March 2013

Highland Health & Social Care Committee 20 March 2014 Item 6.1(3)

RAIGMORE HOSPITAL – DIRECTOR OF OPERATIONS REPORT

Report by Linda Kirkland, Interim Director of Operations and Director of Quality Improvement

NHS Highland Health and Social Care Committee is asked to:

 Note the contents of the report.

1 FINANCE

The month 10 position shows a forecast overspend position of £9.562M for Raigmore. The below table provides an analysis of the factors contributing to the overspend:

Medical & Patient & Central Surgical Diagnostics Hotel Services Total Services £M £M £M £M £M PAY COSTS Locum Costs (1.110) (1.576) (2.686) Access Targets (1.331) (0.169) (0.069) (1.569) Staff Costs (1.022) 1.503 (0.128) (0.096) 0.258

NON PAY COSTS Drugs (0.081) (0.669) (0.007) 0.021 (0.736) Clinical Supplies 0.027 (0.119) 0.020 (2.064) (2.136) Access Targets (0.872) (0.872) Other (0.173) 0.200 (0.045) 0.753 0.735 Savings 0.023 0.040 (0.005) (2.613) (2.555)

TOTAL (4.539) (0.790) (0.234) (3.999) (9.562)

The forecast at month 10 showed a deteriorated position from month 09 by £0.415M mainly due to increased costs associated with locum cover, meeting access targets, increased non pay costs and drugs, particularly cancer drugs.

Forensic work has been undertaken into the underlying influences for these movements and improvements in process have been implemented including:

1. An increase linkage between access data and requests for additional activity. 2. Refocusing on service planning and as a result meet target. 3. Improving the understanding of job plans and the creation of service plans. 4. Improving the use of job planning monitoring to maximise capacity and throughput. 5. Increasing the understanding, across the hospital, of how services can be delivered without always resorting to incurring additional cost. There are a number of forecast process issues which have also been highlighted and changes are currently being progressed, these include:

1. Service Manager “ownership” of forecast outputs. 2. Standardisation of Finance processes and information. 3. Communication between the service management and Finance regarding forecast assumptions and reasons for changes from previous month. 4. Increased Senior Management Team scrutiny of the forecast prior to submission.

1.2 Action Plans to Address

The management team continue to implement the recovery plan, based on the Highland Quality Approach.

Recent progress includes;

The out patients redesign group have planned for 3rd and 4th April open sessions for staff and patients to describe their views and visions for a redesigned outpatients. Plans are also well in hand to merge all outpatients together to ensure consistency and standard work.

The theatre redesign group have developed a process map and started observations in theatres to understand flow. This work has been broadly supported by clinical colleagues. We are grateful to colleagues in north and west operational unit for anaesthetic support to help take this forward.

The flow redesign group have implemented changes in the early morning bed meeting and are working with wards on discharge processes to ensure that patients are discharged by 11am.

It is becoming ever clearer that all these work streams are inter-related and the challenge is in bringing them together at the appropriate touch points.

Whilst this will no doubt have an impact both from a quality aspect and a financial one, it is clear that this is extremely unlikely to have significant benefit for the remainder of this financial year. The measures of tight management of spend have been reinforced with the full management team and the Clinical Directors and active cascade of this message has been implemented across the whole hospital.

2 ACCESS

2.1 TTG/Outpatient Waiting Times

Plan that no patient waiting more than 12 weeks at end of March 2014 except Orthopaedics. Plan that no Inpatient/Daycase waiting more than 12 weeks at end of March 2014 except Orthopaedics.

Orthopaedic See and Treat project saw 300 outpatients seen at Raigmore hospital by Ross Hall consultants. Those patients requiring surgery will be operated on at Ross Hall in Glasgow.

Patients on the IP/DC waiting list have also been offered Ross Hall. Those patients who refuse a reasonable offer at Ross Hall have unavailability added to their waiting time.

2 There are discussions underway with the Golden Jubilee National Hospital (GJNH) to explore an Orthopaedic See and Treat exercise using their consultants with outpatient consultation at Raigmore and surgery at GJNH.

2.2 Radiology

End to end performance has improved on last month, particularly in MRI where additional weekend and evening sessions have been required to deal with the influx of cases from the See and Treat orthopaedic activity. In February for example 62% of the MRI reports issued were for patients with a completed wait of less than 6 weeks, compared with 46% the previous month. A radiographer new rota, which was recommended following the RPIW in the MRI service, went live on March 3rd 2014, which will allow the service to bridge the capacity deficit in MRI previously identified and to bring it back into balance; similar analysis and action is required for the CT service with a planned RPIW in the near future. As an interim measure additional CT sessions have been delivered at weekends and over some evenings, this being designed to bring the number of patients waiting over 4 weeks for a scan to zero by the end of March 2014; currently there are 50 CT and 54 MRI patients in this position, down from 160 CT and 108 MRI patients one month ago. All new appointments are now being offered within 4 weeks.

3 DIVISIONAL REPORT

3.1 Medical

3.1.1 Out of Hours (OOH)

GP cover continues to be challenging with contingency plans required most weeks to work around a lack of sessional GP cover both in the evenings and over the weekend. The lack of OOH cover can also impact on the Emergency Department as the Emergency Practitioner (EP) may be diverted to Out of Hours work, which has the potential to slow down senior clinical decision making within ED.

Redesign work is ongoing to make optimum use of the UCP (Unscheduled Care Practitioners) who complement the GPs in the Out of Hours period. This group of practitioners have now built up significant skills and experience; and there is an expectation that they could contribute further in the out of hours period and reduce reliance on GP cover.

Meetings including consultants, EPs, UCPs, senior general and nursing management have commenced and we are hoping to finalise agreed hours that the UCPs could undertake by the end of March 2014.

3.1.2 Cancer Services

Discussions with colleagues in the other two Centres in NOSCAN are at an advanced stage in order to develop mutual aid support in the immediate term for the next six months to cover the gap following the retirement of one of the four NHS Highland Consultant Oncologists (Dr Whillis) who retires on 22 March and as a result of the continued sickness of another colleague. Support for the 1.5 WTE gap is being provided by a combination of 1 locum at Medical Oncology grade, the return of Dr Whillis for one day a week for ten weeks to the end of June and support from colleagues in Aberdeen and Tayside to provide cover in Breast and GI Oncology. This support is also being supplemented by weekend locum support at weekends and by the recently retired past President of the Royal College of Radiologists for six weeks.

We are also working with colleagues in the SGHD Cancer Delivery Team to improve performance against the National Waiting Times Targets. Like several other Boards, we

3 have been continuing to narrowly fail as a result of theatre capacity problems and scheduling in Breast and Urology in particular made worse by peaks in demand. We are confident that the performance will improve as from March as a result of the strict prioritisation of theatre time for Cancer patients, with Breast especially. Further work is required to address the pathway issues within Urology at the beginning of the referral process.

3.2 Surgical

3.2.1 Consultant Staffing

There is a vacant consultant in obstetrics and gynaecology which is currently covered by a locum. The substantive post is to be advertised again after no appointment was made.

There is a vacant consultant in ENT which is covered by a locum. The substantive post is to be advertised again after no application were received.

There is a vacant oral and maxillo facial consultant post and discussions about replacing this post are ongoing with NHS Grampian as part of the OMFS Clinical Network.

4 FLOW AND BEDS

There continues to be significant pressures with bed availability within Raigmore. Two secondments commenced on 20th January 2014 for six months in the first instance. Francis Gair will be working as the Patient Flow Manager for Community Care. Evelyn Gray will be working as the Patient Flow Manager for Acute. It is expected that these posts will provide the necessary project management and leadership to unscheduled care planning and to help support an integrated system wide approach to transforming services and improve patient flow. Primary focus will be on robust discharge planning and utilising the opportunities that integration provides to explore alternatives to admission and early supported discharge. The work will be underpinned by Highland Quality Approach.

5 RESTRUCTURE

Plans are being developed to restructure the management team. This will support a focus on emergency and elective patients in separate flows. Partnership and HR are assisting with the work. Further details to follow.

Linda Kirkland Interim Director of Operations and Director of Quality Improvement Raigmore Hospital 13 March 2014

4 Highland Health & Social Care Committee 20 March 2014 Item 6.2

CHIEF OPERATING OFFICERS REPORT

Report by Deborah Jones, Chief Operating Officer, NHS Highland

The Committee is asked to Note the contents of this report.

1 PURPOSE

The purpose of this paper is to provide the Health and Social Care Committee with an update on current HEAT performance (exceptions only) and operational issues not addressed through operational unit papers.

2 PERFORMANCE

2.2 Delayed Discharge

In January 2014 it was reported that the NHS Highland position was exceptionally challenging. In line with experience across Scotland, the position has deteriorated since then:

Position on February Census (15.2.14) Total (excluding complex delays) 76 Over 6 weeks 21 Over 4 weeks 35 Over 72hrs 61

The high levels of delayed hospital discharge are due to a combination of factors:

 A seasonal increase took place as expected during the festive period, despite rigorous attempts to manage this, and has shown no sign of reducing.  The number of people delayed awaiting Care at Home packages was 29, reflecting an over dependency on a struggling in-house service; relatively low levels of capacity within other sectors and the lead in time required to recruit to the independent sector.  The impact of depressed Quality Grades awarded on the Care Home provider base was also leading to suspension of admissions or even closure. Again, work is being undertaken to redress this, but this takes considerable time.  The impact is felt most acutely in the North, where no Care Home beds with nursing care were available; and where the options for interim placements were hours away from relatives and friends.  Complex delays include 6 Choice Exceptions (patients where an interim placement is not possible due to remoteness or condition) and 6 related to Guardianship legal process.

What is working?

Raigmore Community Support initiative saw delayed discharge reduce from 30 to zero in six weeks. Achieving a position of no 4 week breaches. Unfortunately, as Care at Home capacity has been utilised, and care home placements have become harder to access, the position has deteriorated. It is now clear that a broader approach to supported discharge

1 (across the whole care system) will be required to match good discharge planning practice with capacity and options for intermediate care now being pursued.

Leadership; a high profile has been maintained with regards to the delayed discharge agenda. The big issue being currently addressed to promote a strong sense of District level management ownership.

Collaboration with the 3rd and Independent sectors has enabled a rapid growth in Care at Home capacity. This is currently stretched as the sector are taking on work previously held by the in House service Recruitment to build capacity is underway, but there is a lead in time. It is hoped that improved capacity will be evident during mid March

Improvement Support to Care Homes with depressed quality grades has resulted in improved grades and the lifting of suspensions of admission. This work is ongoing.

Actions

 Innovative practice in Raigmore is modelling safe and effective discharge practice. This will be shared and spread across the Highlands through 2014.  Whole system development, including the development of intermediate care models, is being taken forward  Collaboration with the 3rd and Independent Sectors has reduced delays relating to Care at Home capacity as far as possible, but now requires the establishment of further physical capacity.  Supportive work with Care Home providers has reduced delays in re-opening for admission (where this is appropriate).  Clear, enforced, escalation policy has developed increasing local ownership of the issue.

Forecast

It cannot currently be assured that we will again attain the zero target (for delay tolerance below four weeks) in 2014:

 Inspection related depression of quality grades is: o Leading to temporary suspensions of admissions o Impacting on the financial stability of a fragile local market.

 Recruitment to Care at Home posts is challenging.

 A seasonal increase took place as expected during the festive period, despite rigorous attempts to manage this, and has shown no sign of reducing.

This means that significant system change will require to be achieved to sustain progress in the long term, and to have any chance of achieving target position in the short term.

2.3 Commissioning Hub

Work is progressing to produce the Commissioning Strategy going to Board on 1 April 2014, initially concentrating on older people. Care Support is also working with the operational areas to flesh out the role, responsibilities and contracts allocated to the designated mangers. The contract monitoring process is operational and the subject of a separate report to this Committee. Work is also underway to determine how the output of individual client reviews is captured to support the designated manger in their tasks. This last area is also linked to the implementation of the personal outcome plan which is currently being trialled.

2 3 OPERATIONAL ISSUES

3.1 Patient Management System Go Live Update

The migration to the PMS took place over the weekend commencing Friday 28th February. The two former Patient Administration Systems (PAS) were switched off and data was uploaded to the PMS system during the Friday night. The data migration exercise was completed with a very low error rate (100% of appointments migrated) largely due to the extensive preparation work.

System testing by users took place over the transition weekend and any issues were resolved. The Programme Executive Group (PEG) met and took stock on the Saturday evening and formally agreed that implementation could continue. This resulted in the system going ‘live’ on the Sunday afternoon. While there have been issues none have been insurmountable and the implementation has been a success.

The opportunity should be taken to thank eHealth and service staff right across our area for the efforts put into ensuring the successful transition. NHS Highland, for the first time, has a single PMS system across our area.

3.2 Older People in Acute Hospitals Care and Comfort

The progress against the Older People in Acute Hospitals (OPAH) Action Plan is a standing agenda item at Raigmore Hospital Senior Charge Nurse (SCN) meetings and Divisional Meetings and the published report has been highlighted to all staff groups.

Dignity, Compassion and Respect Awareness sessions continue to be provided for multidisciplinary staff (Using a “Tale of two wards” resource). Thirty five staff have attended training since December 2013. A programme of observational visits has been arranged for 2014 to observe interactions and language used between staff and patients.

To help support the care delivered to patients with cognitive impairment, Raigmore has secured eleven places on the 2014 Dementia Champion course at University of the West of Scotland (UWS). This includes a Senior Nurse Manager.

The NHS Highland Documentation Steering Group met in January to discuss draft documentation and implementation of care and comfort rounding to deliver quality nursing care. The approach is currently being evaluated, using improvement methodology i.e. Plan, Do, Study, Act (PDSA) approach and is aligned with the testing of the new documentation. A meeting of clinical staff takes place at the end of February to agree the draft documentation for pilot sites.

As the Chief Operating Officer for NHS Highland I am overseeing a review of discharge planning. A Rapid Process Improvement Workshop (RPIW) relating to discharge planning was carried out and lessons learned are being shared across the hospital. A Senior Nurse has been seconded to review discharge processes, and identify areas for improvement and development. Awareness sessions around Estimated Discharge Dates (EDD) have been delivered by Consultant Head of Service to raise the profile with Senior Charge Nurses’ and medical colleagues. A review of accuracy of EDD and predicted discharge activity against actual discharges is reviewed daily and a formal audit will take place during February to inform the improvement process.

3 The Four Question Assessment Tool (4AT) is now the agreed and only screening tool for assessing cognitive impairment in Raigmore Hospital. This tool has been incorporated in to the Medical Common Admission Document and will be included into the next version of the Surgical Common Admission Document. In the interim the 4AT tool is used as a standalone document in these areas. A compliance audit of use of the tool is underway.

A PDSA approach to the implementation of care plans for patients with dementia is underway and the “Getting to know me” document is available and used appropriately.

Recording of power of attorney (POA) will be included in the new documentation. Draft POA Guidance has been issued to clinical areas for comment and the guidance will be finalised for use by the End of February 2014. In the interim POA is recorded in the admission documentation.

The Lead Nurse has discussed the hospital wide signage with the Divisional General Manager for Patient Services and the Patient Council who were involved in the development of the signage and who indicated their satisfaction with the current system. The Lead Nurse and Alzheimer’s Scotland Nurse Consultant are reviewing all ward areas to ensure appropriate toilet and shower signage is in place and each ward has completed an assessment of their area.

The Lead Nurse is reconvening the NHS Highland Food Fluid and Nutrition (FFN) Steering Group and a Nutritional Care Plan process will be agreed, implemented and used until the implementation of the new documentation is complete. The MUST screening tool has been implemented in all wards and all previous versions removed. Assistant Divisional Nurse Managers (ADNMs) meet weekly with domestic supervisor regarding collection of meal trays. Development of knowledge and skills amongst staff is ongoing and will be included in NHS Highland and local FFN action plans. Annual update training is available and ward based training is available via the dieticians. Staff training records are available in all wards and department and include a record of the nutritional training. The information regarding ward based snacks has been re-circulated to all areas. The red tray system has been implemented where appropriate and a draft Standard Operating Policy (SoP) on meal times has been developed. There is an audit planned within the time line. The Meal Coordinator role has been agreed and will be rolled out by June 2014.

An audit on completion of documentation for the management of pressure ulcers was completed by the Raigmore Tissue Viability Specialist Nurse and improvements in compliance were evidenced from last audit in July 2013. This will be included in new documentation and care planning.

Deborah Jones Chief Operating Officer Deputy Chief Executive

The Highland Council Agenda 7ii. Item ADULT AND CHILDREN’S SERVICES COMMITTEE Report ACS/22/14 No 19 February 2014

Assurance Report – Lead Agency Delivery of Children’s Services

Report by Director of Health and Social Care

Summary

The purpose of this paper is to provide assurance to NHS Highland in relation to services commissioned and delivered through Highland Council. It will be presented to the appropriate strategic committee of NHS Highland.

1. The Commission

1.1 The lead agency delivers a range of children’s services on behalf of NHS Highland. For each service there is a broad service descriptor which is reviewed annually with revisions agreed between the Child Health Commissioner and the Head of Health. This has taken place for 2013/14.

Improvement plans for elements of service were developed at transition to the Lead Agency Model and these have been acted upon. Improvement priorities for 2014 onwards will be incorporated into the work of the Improvement Groups and will be reported on as part of the For Highland Children’s Service Plan. (FHC4)

1.2 Health Visiting Service Health Visitors provide a universal and early intervention service to children and families from birth to school entry. Universal input is based on the current Hall 4 requirements for health improvement information and health and developmental screening. Early interventions are planned and agreed with families based on the Highland Practice Model. The Health Visitor has the support of other team members and early years workers to assist in providing the agreed early interventions.

Each Health Visitor has a defined caseload, normally based on a geographical area closely linked to Associated School Groups (ASGs) and has the role and responsibilities of Named Person for this caseload. Currently, caseloads in Highland vary from 150 to 320 children per full-time equivalent Health Visitor. Work is ongoing to realign caseload sizes to between 200 and 250 per whole time equivalent, depending on local deprivation and/or rurality factors.

1.3 School Nursing School nurses in Highland currently require to have a Public Health Nurse qualification to act as a caseload holder. They are normally allocated to an ASG. Caseloads for school nurses vary between 600 and 2000. However, where caseloads are high, staff nurses are employed to assist with the workload. Caseload sizes have not been addressed at the moment, while we await national work into the role. This has been prompted by the introduction of the school based influenza vaccination programme, which has highlighted significant differences in services provided by school nurses across Scotland.

1.4 Allied Health Professionals Community allied health professions delivered within Highland council consist of the following services:

1.4.1 Speech and language therapy – Teams based in localities deliver a universal, targeted and specialist service for children and young people experiencing a speech, language and communication need, or eating, drinking or swallowing difficulties.

1.4.2 Occupational therapy – The integrated occupational therapy service works across Highland to enable children and young people experiencing difficulties due to: sensory-motor integration, sensory processing, sensory modulation, neurological or musculoskeletal problems; to participate in daily life to their personal potential. This is achieved through direct therapy intervention and/or the provision of equipment and adaptations.

1.4.3 Physiotherapy – Provides community intervention to children and young people across Highland with a primary focus on neurodevelopmental conditions or other conditions where there is a long term impact on educational and recreational activities such as complex orthopaedic cases, chronic fatigue syndrome and cardiac conditions.

1.4.4 Nutrition and dietetics - Dietitians provide services across acute, primary, community, education and social care, focusing on maximising the nutritional health of individuals as well as the population as a whole. The strategic approach for nutrition and dietetics services advocates three main areas of practice: health improvement, clinical nutrition and institutional nutrition.

1.4.5 There are proportions of AHP posts funded through the North of Scotland Planning Group that are scrutinised and reported on to the Scottish Government as part of the National Delivery Plan for specialist children’s services on a bi annual basis

1.5 Primary Mental Health Worker Service The overall purpose of this service is to provide the link between specialist Child and Adolescent Mental Health Service and primary care. PMHW’s work within universal and targeted services to support and improve the mental health and wellbeing of children and young people. Where appropriate, they provide direct clinical time with children and young people, and provide an interface with the Tier 3 CAMH’s service.

1.6 Child Protection Advisory Service The Child Protection Service provides a specialist health resource to support child protection policy, multi-agency public protection arrangements (MAPPA) and multi-agency risk assessment conference (MARAC). The key function of the service is to build capacity within the workforce and to enhance practice across NHS Highland and Highland Council.

1.7 Looked After Children Health Service The LAC health service is a specialist support service aimed at improving health outcomes for a group of young people whose experiences tend to result in poorer health than their peers. The main function of the service is to co- ordinate the health information and assessment for LAC, to provide advice and support to ensure the assessments are of an adequate quality and are available for Child’s Plan meetings.

1.8 Learning Disability Nursing Service The learning disability nursing services are based in a number of locations across Highland, including Drummond School in Inverness. They work as part of the learning disability team to support the health and wellbeing of children and young people with complex physical and mental health needs who are cared for in residential settings.

1.9 Health Improvement / Health Promotion This service is a specialist function working to support universal services and targeted / additional needs services. It supports the overall service with specialist knowledge and skills in specific health improvement programmes and aims to provide specialist advice and training across the lead agency, primarily around midwifery, nutrition and support for parents.

1.10 Monetary Value of the Commission The budget transferred at the beginning of the commission was £7.257m, which included a savings target of £0.399. As further services have transferred across to the Council, the budget has been increased to reflect this. There have also been some in-year adjustments to reflect changing circumstances. Currently the budget transferred from the NHS to support the commissioned service stands at £7.938m.

2 Service Delivery - Performance Framework for Commissioned Service

2.1 The full performance framework is set out in the previous report at this meeting of the Committee. It includes the following performance targets.

Performance Target Status Comment Effective Handover of planning Amber Chief Executives are leading and support arrangements for on this work young people with continuing needs No young people to wait long than Green 26 weeks for access to primary Mental health Worker 95% uptake rate of MMR1 (% of 5 Green year olds) 36% of new born babies Amber Exception report attached exclusively breastfed at 6-8 week (February 2014) review 95% return rate for the 6-8 week Red Ongoing work with GP review practices to improve returns to Child Health Surveillance Team Allocation of Health Plan indicator Green at 6-8 week from birth Achieve 641 interventions for child Green Target exceeded healthy weight programme for 2 - 15 year olds over 3 year period by March 2014 Completion of P1 Child health Amber ISD not expected to publish assessment 2012/13 data until Feb 2014 P1 Body Mass index every year Amber ISD not expected to publish 2012/13 data until Feb 2014 P7 Body Mass Index every 4 years Amber ISD not expected to publish 2012/13 data until Feb 2014 95% of statutory health Red/ Exception Report Attached assessments to be done within 4 Amber (January 2014) weeks of becoming looked after 95% of initial Lac health Red Exception Report Attached assessments to be included in (January 2014) Child’s Plans

3 Commissioned Improvement Priorities

3.1 CEL (2009) 16: Implementation of Action 15 of the Looked After Children and Young People Report - We can and must do better

A number of requirements were outlined and there is good progress in the implementation of them. 1) NHS Highland has a nominated NHS Board Director for looked after children through the Director of Public Health. 2) The LAC notification process is in place and ensures that nominated Directors, LAC Services and relevant health practitioners are notified when a Highland LAC moves to another NHS Board area. The role of the Lead Nurse for looked after children has been developed to include an overseeing role for all Highland children placed out with the region. 3) Each looked after child should have a health assessment within 4 weeks of becoming looked after. Work has been undertaken to improve processes, staff responsiveness and the quality of the health assessment and there is evidence of continuous improvement. The role of the Lead Nurse has been developed to provide leadership, support and supervision to staff, along with performance monitoring. 4) Joint e-systems and processes have been in place for a number of years which allow early identification of all Highland’s looked after children. This has been central to reducing the impact to health as children are tracked across placement and health information is co-ordinated appropriately. 5) The CEL recommends that each looked after child has a mental health assessment at point of entry to care and that this should be in place by 2015, in line with the Mental Health Framework. It is proposed that the Mental Health Improvement Group reviews a number of screening tools with a view to health staff using one alongside the My World Assessment to review general mental and emotional wellbeing within the initial health assessment. This improvement to the initial assessment for looked after children will be phased in prior to 2015 in line with the Mental Health Framework and whilst awaiting direction from the national LAC Health Working Group.

3.2 CEL (2012) 4 Insulin Pump Therapy for People with Type 1 Diabetes

The CEL outlined the Scottish Government commitment to substantially increasing the availability of insulin pump therapy across Scotland. Targets to be achieved are a quarter of young Scots with Type 1 diabetes to have access to insulin pumps by March 2013, and by March 2015 the number of insulin pumps available to people of all ages with Type 1 diabetes in Scotland will almost triple to more than 2000. Performance data against this target is held within the NHS. The decision to introduce an insulin pump is taken by the children’s diabetes team with the children’s dieticians’ providing one to one support to enable a child/young person and those caring for them to manage the system; and working closely with community dietician colleagues to monitor the child locally through the transition.

3.3 CEL (2013) 13: Public Health Nursing Services – Future Focus

The recommendation is that Public Health Nursing redefines itsself into 2 separate but complementary functions of Health Visiting & School Nursing.

This work is being led nationally by the Children, Young People & Families Working Group which reports to the Chief Nurse. It has commissioned 4 short life working groups to 1) define the universal pathway for preschool children 2) develop a HV caseload weighting tool 3) define the role of the school nurse 4) review post-registration educational requirements for HVs and School Nurses.

Highland has a representative contributing to the work of each of the subgroups with the ability to give a Highland perspective. This work is to be welcomed in Highland; it links well to our Highland Practice Model and fits neatly into our planned Family Teams where early years and schools based work are identified functions within the integrated teams

3.4 CMO (2013) 07: Short Catch Up Campaign for measles immunisations in Scotland 2013

The MMR is being offered to all S3 pupils when they attend for the DTP booster at school based sessions. Uptake however has been low and there have been issues around pupils having already received their booster from GPs but this not being notified to Child Health prior to the school based session. Child Health have undertaken a data update programme with GP Practices. In the Thurso area GPs have traditionally undertaken the DTP booster, rather than having a school based programme. This year however the school nurses are undertaking this, as well as offering the MMR catch-up with the hope of increasing uptake.

3.5 CMO (2013): Reducing the Risk, Important Changes to the Scottish Immunisation Programme in 2013/14 extension of seasonal influenza vaccination programme (children aged 2-17 years)

It has already been reported through NHS Highland that the extension to the school based immunisation programme will be a challenge from within existing resources. Nationally, information is being collected about the opportunity costs resulting from this extension. In Highland the additional workload poses a risk to other performance measures reliant on the school nursing service e.g. LAC health assessments, P1 child health assessments etc.

4. Governance and Risk Management Arrangements

4.1 The Health and Social Care Service has a Governance and Risk Management Group with representation from both the Council and NHS Highland. One of the functions of the group is to maintain and review a risk register and to escalate significant risks. The risk register is tabled at the Children & Young People Commissioning Group.

The role of the Governance and Risk Management Group is to provide assurance to NHS Highland and the Highland Council that there are systems and processes in place to effectively govern and manage the commissioned children’s service.

4.2 The specific responsibilities of the Group are: • To develop a reporting template which meets the needs of both NHS Highland and the Highland Council. • To oversee the implementation and monitoring of best practice guidelines, policies and protocols. • To review the outcomes of relevant audits and ensure recommendations are implemented. • To review trends from complaints to ensure appropriate actions are taken, within agreed timescales and lessons learned are disseminated. • To review trends from incidents (DATIX), ensuring that actions are appropriate and lessons learned are shared across the organisation. • To ensure that risk management systems are developed (risk register) and appropriate actions taken to reduce risk. • To develop systems to ensure that health staff are appropriately registered. • To ensure that systems are in place so that staff have access to appropriate continued professional development opportunities and that these are monitored. • To ensure that staff have adequate health and safety support and advice. • To ensure that the budget for the commissioned service is appropriately managed

4.3 Membership involves the following, and will be supplemented by co-opted attendees to provide additional knowledge or expertise: • Head of Health (Chair) • Principal Officer for Nursing • Principal Officer for Allied Health Professionals • Area Managers • Lead for Child Protection • Link member of NHS Highland Governance Support Team • Child Health Commissioner

4.4 Meetings will take place every two months. A reporting framework will be agreed and made available to the NHS Highland Clinical Governance Committee. An annual report will be provided for the NHS Highland Clinical Governance Committee and the Highland Council Education, Children and Adults Committee.

5. Exception Reports

Exception reports are attached in relation to the following performance targets:  Looked After Children assessments  Breastfeeding

6. Implications

6.1 Risk Implications It is intended that this new reporting framework will better manage risk in the Partnership Agreement

6.2 Equalities Implications Many of the services detailed in this report, make a significant impact on health and social inequalities

6.3 There are no resource, legal or carbon clever implications from this report.

Recommendation

Members are asked to consider and comment on the issues raised in this report.

Bill Alexander Designation: Director of Health and Social Care

Date: 9 February 2014 Author: Sheena MacLeod, Head of Health

Looked After Children Statutory Health Assessments

95% to be completed within 4 weeks of a child becoming Looked After 95% of health assessments to be in the child’s plan within 6 weeks of a child becoming Looked After

1 Current Position

The Looked After Children (Scotland) Regulations 2009 set out a requirement for children to have an health assessment when they become Looked After. CEL 16 (2009) recommend that this assessment be carried out within 4 weeks of the child becoming Looked After. The health information should be available at the Childs Plan meeting which is required by regulation at the 6 weeks after the child becomes LAC.

In Highland we now have a performance monitoring pathway to support the achievement of these two targets This pathway: a) Drives up quality through ensuring the health assessment meets an agreed standard before it is accepted b) Ensures staff development and support through formal feedback for each assessment and through supervision for all health visitors and school nurses with LAC on their case load. c) Supports achievement of deadlines for both targets through an escalation process

TABLE 1 – Performance July 2011 – Dec 2012)

TABLE 2 – Performance Indicator 15 (Jan 2013 – Oct 2013)

It should be noted that a) In August the number of children becoming Looked After was unusually small, therefore zero breaches were required in order to achieve the 95% target. b) Health assessments are undertaken by School Nurses and Health Visitors who are the health partner to the Childs Plan. Staffing difficulties across Highland has meant that achieving deadlines within performance indicator 15 has been challenging. c) The additional support provided to the Public Health Nursing teams by the Lead Nurse for LAC across September and October has resulted in improvement in the performance

TABLE 3 – Performance Indicator 16 (Jan 2013 – Oct 2013)

It should be noted that a) The notification and follow through process continues to be implemented b) The new format of the Childs Plan is not accessible on Care First – this makes quality assurance of Indicator 16 challenging

3. ACTION PLANS TO ADDRESS

In order to continue to improve performance the following actions will be taken  Continue with monthly reporting and escalation through to Area Managers and Head of Health  Recruitment to vacant school nursing and health visiting posts within the East Area teams is underway.  Additional training, support and supervision being provided by the Lead Nurse for LAC, to newly appointed Health Visitors and School Nurses to carry out assessments.  Access to the Childs Plan on team E drives in order that quality assurance of Performance Indicator 16 can be achieved

3 EXPECTED IMPACT OF ACTIONS

 Increased confidence and competence of newly qualified health staff to undertake health assessments.  Continued improvement towards the 95% target  Improvement in the quality of decision making for the child as the Childs Plan contains contribution from the initial health assessment of need.

Jane Park Lead Nurse LAC January 2014

Breastfeeding Report Target: 36% of babies to be exclusively breastfed at 6-8 weeks

1 CURRENT POSITION

Nationally the target for the proportion of babies to be exclusively breastfed has been set at 33.3%. In Highland the target was set at 36% and this still remains the standard. NHS Highland is above the national average at every stage of breastfeeding.

TABLE 1 – Exclusive Breastfeeding Rates at 6-8 Weeks

It is important also to look at breastfeeding rates at birth, discharge and 10-14 days. Breastfeeding rates at birth and discharge from hospital have been static for the past 2 years. For breastfeeding rates to increase at 6-8 weeks there needs to be an increase in initiation rates and support for breasting is fundamental to ensure this, especially when 10% of mums stop breastfeeding while in hospital.

TABLE 2 – Breast Feeding Rates at Birth, discharge and 10-14 days

2. ACTION PLANS TO ADDRESS

In order to continue to improve performance the following actions are being taken  Continued recruitment of volunteer breastfeeding peers to support mothers. There are 47 peers in North Highland and their main role is to provide telephone contact for mothers, but will undertake home visits in some circumstances.  In house training programme to train breastfeeding peers based on the UNICEF Baby Friendly Initiative programme.  All health visitors and nursery nurses undergo regular breastfeeding updates, paying particular attention to the induction of new staff.  Regular facebook consultation with women to gauge what they want and feedback on services including breastfeeding peers.  Improvement work is focused through the Maternal Infant Nutrition and Early Years Improvement Groups.  Improvement work is ongoing with practices to improve the return rate of the 6-8 week review. Return rates are improving, and this is monitored through the Early Years Improvement Group. These improvements are not yet reflected in the national data set due to time lags. It is recognised that improving the rate of return for the review forms doesn’t in itself increase breastfeeding rates, but does improve the accuracy of the data

3. EXPECTED IMPACT OF ACTIONS  Increase in breastfeeding rates at 6-8 weeks, particularly through breastfeeding peers.  Increased % of Child Health Surveillance forms returned, resulting in more accurate statistics

Karen Mackay, Infant Nutrition Advisor Sheena Macleod, Head of Health Highland Health & Social Care Committee 20 March, 2014 Item 7.1

CAITHNESS ADULT SERVICES REVIEW UPDATE

Report by Gill McVicar, Director of Operations (North and West)

The Committee is asked to Note the content of the report.

1. Introduction and Background

This report will provide a brief background to the re design work in Caithness and will update on the work that is ongoing. The Review of adult services in Caithness has been ongoing since an initial workshop was held in December 2012 and a consensus on the need for change established. Previous attempts to make changes to service configuration in the locality had met with anxiety in the communities and so an inclusive approach was taken to ensure that the issues and solutions had ownership of a wider group of people. Those who attended the initial workshop were invited to continue as a Reference Group. A Programme Board was set up and several work streams were established with sub groups overseeing the work. More recently, the District has been chosen as a pilot site for Programme Budgeting and Marginal Analysis (PBMA), supported by the Joint Improvement Team (JIT) in Scottish Government and Glasgow Caledonian University

2. Initial Workshop

There was a wide distribution list for the invitations to the initial workshop which was held in December 2012 and approximately 50 people attended, comprising members of communities, voluntary sector organisations, Local Members, health and care staff and managers. The day was led by the Director of Operations and was very interactive and productive. Delegates gave positive feedback and committed to making change for the better that would build in sustainability for the future.

There were sessions on current issues and challenges and also visioning for the future, and delegates were prolific in their responses. These were rationalised into key themes and key priorities. The themes were agreed as being:-  Partnership  Person Centred  Sharing  Vision  Community Focus

The priorities were identified as being:-  Enhance home and community based services before reducing hospital beds  Community capacity building  Recruitment and retention  Improved communication between all services keeping the person in the centre  Dementia Care A What’s happening, what’s missing exercise was helpful in developing a shared understanding and prioritising action. The key work streams and subgroups were agreed as being:-  Community Rehabilitation and Re ablement  Palliative and End of Life Care  Home based services  Dementia and Older Adult Mental Health  Caithness General Hospital Re design

The delegates had gelled so well that all were invited to continue to be a Reference Group to oversee the work and to come back together periodically to hear what had been happening and to focus on some aspects of the work.

A Charter was also developed and a Programme Board, chaired by the Area Manager (North) was established.

2. Work Stream Progress

The work streams have been reporting to the Programme Board by using ‘flash reports’ and also to Reference Group by means of presentations. Brief updates are provided below.

2.1 Community Rehabilitation and Reablement

The group has identified some key themes for work, namely reablement and physiotherapy. It has also identified the need to support existing rehab initiatives e.g. COPD, Cardiac and Exercise after Stroke, as well as falls. Rather than duplicate work happening elsewhere the group agreed to work with the other groups to take forward some of these initiatives e.g. the Community Development and Home-based Services Group to take forward the falls agenda and similarly to take forward training for the leisure industry on Postural Stability Instructor to support exercise after stroke.

The group has carried out some detailed work on the reablement pathway for Caithness, looking at its current state and highlighting where changes/improvements can be made to better support people to maintain their independence for as long as possible. Issues identified are broadly similar to those identified elsewhere in the Operational Unit. In particularly it has highlighted the reliance on one profession (OT) to coordinate the service, to act as the lead professional and the documentation. It has responded by drafting criteria to identify those suitable for reablement and a pathway for access. The group has identified the role of the Health & Social Care Coordinator as a key development for the service.

With regards the physiotherapy issues the group is keen to progress a longer term solution to the building related issues experienced in the Thurso area. Work on this theme is at an early stage at present. The group is keen to involve all relevant partners in all discussions regarding its priorities and is liaising with organisations such as Highlife Highland regarding future collaboration.

2.2 Palliative and End of Life Care

There has been exploration of what is required to support people to stay at home at the end of life if that is what they choose to do. Support for Carers and families in the out of hours period is of particular concern. The main focus is how packages of care can be tailored to meet individual needs. In some cases admission is required for symptom control and the group is examining options to provide a Palliative Assessment and re ablement Unit with Advanced Practitioners in Palliative Care and would concentrate skills and expertise in close liaison with experts such as MacMillan and Highland Hospice. The unit would assess the needs of not only the patient but the family too. It would involve a holistic assessment of care needs; nursing, care at home, reablement, Macmillan, finance, aids and adaptations etc. While there is a wish to increase availability in the community there is a desire to see from the group to support assessment in one place at the onetime.

Some people choose to die in an institutional setting and the challenge is to make that place as homely as possible. The group is also exploring how best to achieve that in Caithness.

2.3 Home Based Services

The Home-based Services Group continues to have good representation from local providers (statutory, independent and voluntary sector). Following on from the SWOT analysis of services the group have mapped ‘Services for Independent Living’; from this they propose the development of a Caithness Independent Living Services Framework; it is felt this will support local service development and the commissioning process.

One of the gaps identified relates to specialist homecare for people with dementia, based and an enabling approach. The group are working on the proposal for the development of such a service provision (this work relates to and links with the work of the Older Adult Mental Health and Dementia Workstream).

2.4 Community Development and Service Capacity

There has been much discussion on falls prevention and one of the gaps in provision at present is response in the home when someone has fallen but who does not require medical or nursing treatment. It has also been identified that a lack of emergency responders for Telecare is a barrier to service uptake/provision. The suggestion is that there is the development of retained emergency responder volunteers, trained to SVQ 3 level, to assist with SAS and ‘Helpcall’ alerts. The group is working with British Red Cross who have secured funding from Land Rover to progress this work with Scottish Ambulance Service. This will enable those who do not require to be admitted following a fall, to be assisted and supported at home and those without family / friends to act as Telecare responders to register with the emergency responders. This is an excellent example of a community resilience partnership approach.

Additional work on the falls prevention agenda also continues including the roll out of Otago Falls Prevention Exercise, the development of a community falls prevention worker and Postural Stability Exercise Instructor Training.

A review of current day care provision has been completed; a proposal for enhanced service provision is being developed.

The group are also in the process of mapping community assets under the categories of: Support Groups, Activities, Halls, Accessible places to visit and stay. It is acknowledged that community health and well-being activity is of importance and that this supports quality of life and independence; with the correct support this can provide an alternative to formal day care for some. The group are considering the development of a tool kit to support community groups and organisation to establish activity in their community in line with a framework for ‘Standards of Good Practise’. 2.5 Dementia and Older Adult Mental Health

The group has been looking at patient journeys for older people who have mental health problems, in particular, Dementia. They have also been exploring what community support is required to help people to stay at home for as long as possible, the skill mix of staff and the range of community based services that may be required into the future. Staff from Harmsworth Unit have been redeployed temporarily into the community teams and this is proving beneficial so one of the recommendations at present is to establish two skilled support worker posts to work with the Community Psychiatric Nurses for Older Adults.

The group have completed a comprehensive review of current services and mapped the service pathway. From this work the group are now developing options for service improvement including the potential for a Dementia Link Worker to support post diagnosis care and Dementia Support Workers to support those in the mid and later stages of dementia reducing ‘crisis’ and hospital admissions.

There is a sub group looking at Respite and Residential Care (specifically for people with dementia). The sub group have reviewed the current statistics and bed occupancy rates for respite in Caithness and plan further work to clarify / interpret their findings. The group are currently working on a proposal to develop a home-based respite service; this is based on good practise and carer feedback. It is felt that the development of a home-based service could provide a cost effective, person centred service that will reduce the pressure on residential respite.

2.6 Caithness General Hospital Redesign

Scoping work has been done on key priorities for change in the hospital and an open day was held to allow people using the services and staff to highlight issues for them and to identify waste in layout and processes.

It is clear that the present layout is not efficient and is not effectively supporting the current patient pathways. There are many more people receiving care and treatment on a day case basis and beds/bays for this use are scattered throughout the hospital. It has therefore been agreed that a dedicated Day Case Unit needs to be created. In order to support faster and better supported assessment for patients, another priority is to create a clinical assessment unit where a multi professional team will be available to support holistic assessment, triage and urgent care.

Work on possible layout changes has begun but this is a major piece of work and it has been slow to progress due to managerial capacity issues. In order to expedite the work, Pam Garbe, Associate Lead Nurse has been appointed as Project Leader and will begin this role this month.

Although the Maternity Unit has not yet been involved in the redesign, there are opportunities presented by the physical layout of the Unit that could be helpful. In addition, there have been recent problems with Obstetric staffing and so a more formal review of Obstetric Services will be carried out in the next few months and will become a key work stream for the programme.

2.7 Overlapping Themes

Crisis response, particularly during the out of hours’ period is a theme which has emerged from almost all if not all of the groups. Not knowing who to turn to for advise and not having someone to speak to for reassurance has been identified in the SWOT analysis undertaken in the groups. It has been agreed that the groups should work together on this building on the work ongoing with organisations such as the Red Cross to support development of a local crisis response service. 3. Programme Budgeting and Marginal Analysis (PBMA)

When working with communities on change, there is always anxiety about potential loss and there is often emotional attachment which ties people to the status quo. Despite concerted efforts and immense levels of input to provide open and honest information, statistics and expert opinion, engage and involve people in decision making, often change efforts fail due to the adverse reactions to proposals. Clearly, the current economic situation is not going to improve dramatically for many years and some tough decisions will have to be made on how best to provide services. Scarcity is here to stay and in order to ensure that key priorities are addressed, lesser priorities will have to be traded off. It is of vital importance that the public is involved in assisting with this difficult decision making and in order to provide a structure that helps with objectivity and deals with the emotional aspects, a rigorous approach is required.

The Scottish Government, through the Joint Improvement Team, has commissioned Glasgow Caledonian University to test the use of the health economics tool, PBMA. Caithness redesign was chosen as one of the pilot sites. This has been embraced by the Programme Board and Reference Group, some of whom have agreed to also act as the Advisory Panel for the process.

PBMA is used widely across the world and increasingly in health systems, 150 worldwide, to assist with investment and disinvestment decision making. It provides a structured way of thinking about planning service delivery and adapts well to suit local circumstances. As a starting point, the way resources are currently used is examined and the focus is resource and not need. The opportunity costs, that is the things that cannot be done if investment is made in one area, are clearly identified and therefore assists with planning and making difficult choices. The aim to maximise the benefit to the population with the limited resources available and the marginal analysis more objectively supports decision making. If the marginal benefit per £ from programme x is greater than that from programme y, then resource should be taken from y and invested in x to achieve greater overall benefit. This should begin to achieve a better balance of provision and more targeted and efficient commissioning of services.

Two meetings have been held, the first to explain the approach and to achieve buy in from the Advisory Panel and the second to take the process on to the next stage of identifying and weighting criteria against which decisions would be made. The Advisory Panel has agreed the following criteria:-  Access  Equity  Improved Outcomes  Effective Practice  Sustainability  Culture and Values

At their next meeting on 18th March, they will confirm the criteria, weighting and scoring and do a worked example, taking it to a business case which will demonstrate how the option meets agreed decision making criteria using supporting evidence and expert opinion. When each of the options has reached this stage, ranking will be done and recommendations for resource allocation made.  In summary then PBMA approaches needs assessment by asking five questions about resources:-  What resources are available now?  In what way are these currently spent?  What are the main candidates for more resources and what would be their effectiveness and cost?  Are there any areas of care which could be provided to the same level of effectiveness but with less resource, so releasing those resources to fund other candidates?  Are there areas of care which, despite being effective, should have less resources because a proposal from 3 above, is more effective (for £ spent)

This approach will take time but should be robust and worth the time and effort in achieving shred understanding, priority setting and decision making that will have longer lasting benefits and should hopefully avoid time wasting in having to continually review processes and decisions. It is open and transparent and the wider public will be kept up to date with media releases, newsletters, focus groups and through established community groups.

The work streams will formally report out at a Reference Group workshop led by the Director of Operations on the 29th April.

4. Community Engagement

There has been a good level of interest and attendance at Reference Group and Programme Board levels and some of the subgroups have had good participation by community representatives. However, there is some concern at present that wider community involvement has not been as much as we would like. For example events aimed at the public and in particular, people with Dementia, their Carers and families, were poorly attended. The input from those who did attend was very worthwhile and helpful but numbers were low.

The Programme Board has discussed ways of improving this and will attend Community Councils and other community groups, to raise awareness and hopefully to engender interest. The Community Development Officer and Community Networker are also assisting in community engagement by raising awareness in the groups with whom they are working.

More targeted engagement through focus groups will happen through the work streams as they firm up their priorities.

5. Conclusion

This redesign work has been ongoing for 15 months and progress has not been as fast as anticipated. Nevertheless a lot of ground work has been done and there is a clear understanding of the key challenges and priorities for action. The decision making phase on investment and disinvestment is always the most difficult and this programme is no different. There is no new money, in fact there are overspending budgets in the District and there is also a requirement to find cash releasing savings and therefore some difficult decisions will have to be taken in order to ensure that the available resource is targeted to best effect. The PBMA approach should support that and already has high levels of support and commitment. Efforts to engage and inform the wider population are being stepped up and this too will assist with local ownership of final investment decisions.

A summary of the report out workshop in April will be included in a future report to Committee.

Gill McVicar Director of Operations, North and West Highland 13 March, 2014 Highland Health & Social Care Committee 20 March 2014 Item 7.2

REVIEW OF THE RESPONSE BY NHS HIGHLAND TO THE DETERIORATION IN THE QUALITY OF CARE IN AN INDEPENDENT CARE HOME- ACTION PLAN AND PROGRESS REPORT

Report by Jan Baird, Director of Adult Care

The Committee is asked to Note the action plan and reporting arrangements.

1 BACKGROUND AND SUMMARY

In January 2014, a report was submitted to the Health and Social Care Committee detailing the outcome of a review of the response by NHS Highland to the deterioration in the quality of care in an independent care home.

A number of recommendations were captured in the report and these were assigned to different individuals and groups to take forward. The committee asked for the action plan relating to this report and it is attached for information.

The Adult Support and Protection Committee will oversee progress against these actions which will be delivered through the Improvement Group.

2 ACTION PLAN AND PROGRESS

Following a review of the approach taken in response to a failing care home within the Independent sector, recommendations were presented to the Health and Social Care Committee and the Adult Support and Protection Committee. As the findings related primarily to Adult Support and Protection it was agreed that this committee would monitor progress being taken forward by the improvement sub-group of the Committee.

However the Health and Social Care committee also requested sight of the action plan and an update on progress against the actions.

That action plan is attached at Appendix 1

3 CONTRIBUTION TO BOARD OBJECTIVES

The review and subsequent action plan illustrates the NHS Highland commitment to continuous improvement and to improving quality across all services – in-house and contracted. This work also reflects the focus on improving outcomes for older people.

4 GOVERNANCE IMPLICATIONS

The issues raised in the report and by staff managing the situation in the care home impact on a number of areas of governance and not least Clinical Governance.

Considerable resource and effort was deployed to ensure residents were cared for appropriately, that staff in the care home were supported to deliver the highest quality care

1 and that the NHS staff involved were supported through what was a distressing situation for them.

The learning from all of this has been captured.

5 RISK ASSESSMENT

There remains a risk that this kind of situation can occur elsewhere in Highland and indeed there has been another similar instance since this review was conducted. The Highland Quality Approach, the appointment of a service improvement lead for care homes and the development of Quality Schedules for future contracts will all mitigate against this risk in the future. The Care Inspectorate as the regulators of the service is also a key partner in improving quality overall.

Jan Baird Director of Adult Care NHS Highland

2 APPENDIX 1

Highland Health & Social Care Committee 20 March 2014 Item 7.2

Review of the response by NHS Highland to the deterioration in the Quality of care in an Independent Care Home RECOMMENDATIONS AND ACTION PLAN

Recommendation 1: NHS Highland should seek immediate assurance of the status of Social Work reviews across the Care Home sectors to ensure appropriate levels of care are in place and monitored. This should include the consideration of improving measures to engage all practitioners in the review process and especially independent contractors. This may involve the development of a standard reporting format which can be readily accessed, easily completed and simply submitted to the review meeting as it is acknowledged that attendance in person is not always possible or practical.

Action Responsibility Timeline Progress RAG

Consider existing reviewing NHS Highland Operational June 2014 March 14- initial discussions with Care G process to ensure it is fit for Units supported by the Head Inspectorate in relation to reviewing purpose of Adult Social Care approaches across Scotland and favoured by the regulator. All teams made aware of need to conduct timely reviews. Group to be established to make any changes to current documentation and process to ensure as streamlined and effective as possible.

3 Recommendation 2: It is recommended that the Adult Support and Protection Committee review training and procedures .

Action Responsibility Timeline Progress RAG

1) Effectiveness of training Adult Support and June 2014 March 14. Revised training plan including G and awareness of NHS Protection Lead Advisor and proposals for audit to Adult Support and staff - salaried or the Improvement Group Protection Committee May 2014 for contracted, who visit Care reporting into the Adult approval and action Homes in highlighting Support and Protection AS&P risks and indicators Committee. Review of ASP course evaluations of abuse to be evaluated. indicate significant increase in knowledge and confidence following face to face 2) Effectiveness of Level 1 training. training on AS&P which June 2014 Review of Level 1 face to face programme focuses on raising content will include highlight of neglect and awareness to sufficiently how it may present prepare staff to act when they suspect abuse of any Targeted learning programmes for Care kind to be evaluated Home Managers and Care Home staff will June 2014 be delivered in May/June 2014 3) The Committee to consider the current Roll out of final version of Large Scale emphasis in AS&P Inquiry (LSI) Protocol with associated training on neglect as a learning sessions possible area of abuse August 2014 with examples Link Care Inspector to attend ASP Committee in May 2014 for discussion and 4) The emphasis should be forward planning re grading and ASP made in AS&P training on concerns the importance of considering institutional ASP procedures will be amended abuse or neglect and how June 2014 following confirmation of the final version well staff are prepared to of the LSI look wider than one case.

4 5) The Committee should consider the relationship June 2014 between an unacceptably low Care Inspectorate grading e.g. 1, and an AS&P cause for concern for all of the residents.

6) Committee should provide assurance that the revised guidance post- integration recognises the impact on the nominated officer role especially where the NHS member of staff may have a Social Work background.

5 Recommendation 3 : NHS Highland should consider the development of an escalation process where deterioration in the quality of care in a care home is suspected.

Action Responsibility Timeline Progress RAG

1) Encouragement of a pro- NHS Highland Programme June 2014 March 14 -Operational Units have shared G active approach Manager – Adult Social Care their experiences by way of raising 2) An early warning system along with colleagues awareness with other staff. that gives NHS staff, care across Operational Units Situation has been raised at Council and Home staff, family and the Independent sector NHS meetings as an example of the need members and contracted for vigilance. staff a safe place for raising of concerns Large scale investigation process has informally needs to be been drafted and now tested as a result of developed. a further failing care home. This will 3) A single point of contact enable further experiential revision and the for concerns such as the process can be rolled out. A review of this District Manager to enable process will be set at that time. the building of a picture through a coordinated collation of concerns is to be established. 4) A clear escalation route through management and leadership structures is to be articulated. 5) Clarity about roles and responsibilities throughout the process recognising the impact on capacity across teams is required. 6) Clarity about the capacity of residents and the provision of advocacy when appropriate is

6 required. 7) Development of Process documentation that provides an audit trail of risk assessment and management, prioritisation, decision- making and action planning and has appropriate administrative support. 8) Clarify process including communications, involvement of regulators, support to NHS staff, scenarios and examples of triggers

7 Recommendation 4 : NHS Highland should consider the inclusion of care quality schedules in future contracts with the Independent and voluntary sectors raising the expectation of improvements in quality and reflecting the Strategic Commissioning Approach. These measures have already been considered as integral in the planning of the Strategic Commissioning Plan .

Action Responsibility Timeline Progress RAG

1) Revise commissioning of It is proposed that this June 2014 March 14- work continues on the Strategic G the service recommendations be Commissioning Plan which will be 2) Revise contract monitoring progressed by the Head of presented to the Health Board in April 3) Strengthen assurance Strategic Commissioning 2014. As part of this is the work to develop reporting and that progress is quality schedules, the contracts team and reported through the Adult the Head of Strategic Commissioning are Services Commissioning drafting these. Group and the Health and The draft Commissioning plan is explicit Social Care Committee. about this development – Developing arrangements for a cross sector and pan Highland quality schedule approach, to be co-produced with users, carers and providers of care services, and implemented from April 2015. This area of activity will also include co-producing arrangements for independently eliciting user and carer views on the services they receive

8 Highland Health and Social Care Committee 20 March 2013 Item 7.4

PREVENTION AND MANAGEMENT OF FALLS

Report by Katherine Sutton, Associate Director of AHP’s

The Highland Health and Social Care Partnership is asked to:

 Note the work ongoing across the Highland Health and Social Care Partnership to support reduction in falls.  Note social consequences to an individual and impact on health and wellbeing.  Note financial consequences of not implementing evidence based approaches and redesign of patient pathways.  Note the challenges inherent in progressing whole system change.

1 Background and Summary

The NHS Highland Falls Prevention and Bone Health Strategy, 2009 was endorsed by NHS Highland Senior Management Team on 27.01.10 and was approved by Argyll and Bute Council and Highland Council. The Strategy supported the implementation of the NHS Quality Improvement Scotland pathway “Up and About” (2009). The mapping of services nationally against the ‘Up and About’ pathway in older people in Scotland took place in 2012. Entitled ‘Up and About or Falling Short’ the mapping found “unacceptable variations in service provision and quality within and across NHS board areas in Scotland”.

While there is a robust evidence base for measures which prevent falls it is poorly and inconsistently translated into practice. Falls in older people are common and are associated with increased rates of hospitalisation, increased dependency, restriction of daily living activities and higher rates of institutionalisation among older people. Expenditure on falls was £471 million in Scotland in 2011 (4.8% of the operating cost of NHS Scotland1). At present a third of total annual spend on older people’s services in Scotland is spent on unplanned admissions to hospital. This is more than is spent on social care for older people 2 and predictions are that costs will grow incrementally as the population ages.

A report by the Unscheduled Care Task and Finish Group in Scotland in 2012 notes that 85% of older people who have fallen are taken to hospital but a small percentage of them actually have an injury. This group recognised the need to support older people at home and to reduce unnecessary conveyance to hospital by the Scottish Ambulance Service. Conveyance to hospital can be a distressing experience for older people particularly those with impaired mobility, frailty and cognitive impairment. Often these people are admitted but hospital is not the best place for older people at risk of falls. Falls are the most commonly reported patient safety incident in all acute and community hospitals and mental health units. People who have fallen are 60% more likely to fall again and falls rates are higher in older frailer people who have the greatest vulnerability to injury. People who are hospital patients when they fall generally have poor outcomes with greatly extended lengths of stay and increased dependency.

Many admissions to hospital due to falls are avoidable and community interventions to effectively manage the immediate situation and to consider further health and care needs can support an older person at home. The ability of community services to co-ordinate care

1 Scottish Health Service Costs, year ended 31st March 2011 R100 Executive Summary 2 The National Delivery Plan for Allied Health Professions in Scotland 2012-15 effectively for people who are at risk of a fall or who have fallen is key to realising benefits in primary, secondary, tertiary and long term care settings.

2 Current position The NHS Highland Falls Steering Group recently re-examined its ability to provide assurance in relation to the Delivery Framework for Adult Rehabilitation in Scotland and the National Falls Programme in relation to the findings Up and About or Falling Short (2012). Interventions to reduce falls benefit the population by improving quality of life, reducing morbidity and mortality and enabling more people to be independent for longer. Taking a Highland wide approach to identify modifiable risks by a screening process and providing evidence based interventions allows provision of an equitable service across the board area. This approach has been slow to take hold despite training and education in screening for falls risk for health and social care staff. Argyll and Bute CHP and the North and West and South and Mid Operational units have action plans which articulate how each area will implement a planned approach owned by the Operational units and A&B CHP. These provide assurance that appropriate actions are being driven forward at local level. The plans were developed using the current evidence base and aim to improve quality, efficiency and help reduce the financial risks faced in relation to prevention and management of falls. The action plans should be driven forward at local level owned by local operational management under the guidance of AHP and Nursing professional leadership.

The following bullet points represent a summary of the actions that are being progressed within each Operational Unit and Argyll and Bute CHP. The improvement work relating to falls is being progressed in the Community, Hospital and Care Home setting.

The following provides a brief over-view of the work that is being progressed across Highland:

Community:

 A focus on promotion of healthy ageing with self management approaches will encourage older people to uptake strength and balance exercises which are evidenced to reduce the risk of falls

 Multi-factorial risk screening for those at high risk of falls identifies modifiable risk factors. Evidence based interventions must subsequently be carried out to address the modifiable risks identified. The evidence base shows that successful exercise interventions for reducing falls must offer targeted resistance training and dynamic balance, be delivered for at least 50 hours, preferably at least three times each week, increase in intensity as capabilities increase and be delivered over 15–52 weeks by appropriately trained staff. Using a home based programme such as Otago requires a band 5 trained AHP instructor, visiting for a total of five times (at weeks 1, 2, 4, 8, 26).

 Education and training for all staff has been developed to support a community based approach in NHS Highland. Training resources have been developed with partner agencies including Independent Sector Providers. Locally based AHPs are supporting the facilitation and delivery of these training packages, each Operational Unit and Argyll and Bute CHP are at differing stages of introducing the training.

 The development of unscheduled care pathways with the Scottish Ambulance Service for people who have had a fall and may be frail with possible confusional state seeks to ensure people are not conveyed unnecessarily to hospital but supported at home with an appropriate and timely community response. IT infrastructure, effective communication and appropriate levels of access are vital requirements to support these pathways.

2 Hospital In-patients:

 Falls are the single biggest cause of harm in the in-patient setting, improvement work has been ongoing in hospitals across each Operational Unit as a part of the Improving Care for Older People in Acute Care Programme.

 A falls dashboard is available via the NHS Highland intranet site. The dashboard shows falls rates for all wards per occupied bed days as well as numbers of falls. This information helps monitor progress of improvement work that is ongoing across all wards.

 Actions to help reduce the potential for patients to be subject to falls have been an ongoing focus of the Care Quality Indicators through the Leading Better Care Programme.

 Falls in the inpatient setting is now a focus for the Scottish Patient Safety Programme with an objective of 25% reduction in All Falls and a 20% reduction in Falls with Harm (as defined by Scottish Patient Safety Indicator) by the end of 2015. The aim is to achieve a reduction in falls whilst promoting recovery, independence and rehabilitation.

 Information to support monitoring the progress of in-patient falls reduction is readily available on the NHS Highland intranet information portal at Board, Operational Unit, hospital and ward level.

A total of 202 falls with harm were recorded in quarter 3.

Operational unit breakdown: Argyll & Bute – 21 (10.4%) North & West – 54 (26.7%) Raigmore – 51 (25.2%) South & Mid – 76 (37.6%)

Care Homes:

 National data demonstrates that people living in care homes are three times more likely to fall than community dwelling older people. They are ten times more likely to have a hip fracture in care home than in other environments. The rate of emergency admissions due to falls in people aged over 65 living in Care Homes is almost four times higher. The cost of these admissions is estimated to be in the region of £22 million.

3  In recognition of the need to take action to reduce the rate at which people fall in care homes the Scottish Government have commissioned a project which uses the Institute for Health Care Improvement approach to quality improvement to help embed changes in practice at the point of care.

 Highland Health and Social Care Partnership has been selected as one of three test sites across Scotland to take part in phase one of the programme. The programme launched at the end of February 2014 and aims to reduce falls in the selected care homes by 50% by the end of 2015. Fourteen care homes across Highland have been selected to take part in the programme which aims to embed the resources made available by the care inspectorate titled “Managing falls and fractures in Care Homes for Older People Good Practice Resource” The fourteen care homes selected come from private sector, third sector and NHS run institutions.

. 3 Contribution to Board Objectives

The falls prevention work in NHS Highland touches on all of the10 Quality Objectives. Falls are common amongst older people and impact on their quality of life and health. Taking a person centred approach is vital as falls can lead to a loss of mobility and confidence which can result in reduced independence and social isolation for older people. The consequences and effects of falls can result in negative experiences for relatives, carers and health and social care services. A whole systems approach is required to support preventing admissions as a result of falls with investment in evidence based approaches to address falls risk and unscheduled care pathways being implemented to provide an alternative to current historical pathways. Rehabilitation and reablement after a fall is required wherever people present in the system. Supporting improvement and change in falls prevention by implementing evidence based fracture and fragility care pathways can realise better health, better care and better value.

Raising awareness of falls is a public health challenge and using an assets based approach will improve the over all health of the Highlands ageing population. Coproduction events in our communities around the development of Unscheduled Care Pathways with the Scottish Ambulance Service will involve people in the concept of delivering safe and effective integrated care in the persons own home wherever possible.

4 Governance Implications

Staff Governance:

Effective implementation will require strong leadership within each operational unit and at a senior level, this will be supported by appropriate education and training for staff.

Patient and Public Involvement

Coproduction events will take place prior to the roll out of the unscheduled care pathways for fall and frailty to involve service users and other key stakeholders. Awareness raising and public health messages will be disseminated through NHS Highland press releases, other social media and existing networks.

Clinical Governance

All health and social care staff working with older people should provide the service user and their carers with up to date information on the prevention of falls and the prevention of harm from falls. The NHS Highland pathway for prevention and management of falls requires that people over 65 yrs of age who present with the consequence of a fall, report a fall or appear

4 to be unsteady, should be offered a Level 1 risk assessment. This identifies the need for further screening (Level 2) with a multifactorial falls risk tool to identify modifiable risks. This screening can be undertaken by all grades of staff including health and social care support staff. The identification of modifiable risks directs the subsequent assessment and evidence based interventions to reduce that risk. Actions are agreed with both the patient and their carers and an agreed plan of action is provided.

Financial Impact

The cost to NHS Highland as a result of patients falling is considerable. A report by the NHS Highland Health Improvement and Knowledge Team in 2012 shows the average length of stay for a fall in NHS Highland hospitals of 22 days. In NHS Highland the cost for Occupied Bed Days in 2012 due to falls was over 12 million pounds (£7,309,886 for North Highland and £5,027,798 for Argyll and Bute).

The National Falls Programme in Scotland commissioned a health economist to evaluate the cost of falls and potential clinical and financial benefits of establishing evidence based practice to reduce falls across Scotland. The Scottish Government Health and Social Care Directorate has produced a Cost Consequence Analysis on ‘Resources, costs and benefits associated with implementing care bundles to prevent falls in the community’. This report released in October 2013 demonstrates that implementing the revised approaches to falls will support the realisation of the “triple aim” of better health, better care and better value. Implementing revised approaches to falls prevention will result in cost saving and harm reduction. The report contains a detailed forecast of social and financial benefit of implementing the care bundles to prevent falls in NHS Highland of 4.4%.The report further advises the cost of not implementing these revised approaches are forecast to rise nationally by over 40% by 2020 to £666m, such an increase will place huge financial strains on services seeking to deliver effective, compassionate and sustainable care.

To realise these changes will require a financial investment a tool is currently being developed to help inform the resources required to support this. When available this tool will be used to help develop the business case to inform the shape of resources required to progress.

5 Risk Assessment

As systems and processes are redesigned within each operational unit to accommodate new ways of working risk assessment is ongoing.

Introduction of revised unscheduled care pathways rely on the infrastructure being available to deliver safe alternative patient pathways and access to support services such as care at home in a timely fashion. Redesigning systems within significantly constrained resources and across acute and community care boundaries is challenging in terms of both the pace of change and the ability to migrate from current to future state through implementation of changes to clinical practices, culture and systems.

The introduction of multi-factorial screening as an approach to identify risk factors is challenging due to the requirement to change practice and avoid duplication of activity across clinical groups.

Information systems require developing to track impact and progress with regards to community and care homes work.

5 6 Engagement and Communication

Engagement and communication takes place through  Falls Steering Group which has a variety of stakeholders  Operational units  Partnership working  Coproduction approach and asset based approaches

Katherine Sutton Associate Director of Allied Health Professions 10 March 2014.

6 Highland Health & Social Care Committee 13 March 2014 Item 8.2

MONITORING THE DELIVERY OF CONTRACTED SERVICES

Report by George McCaig, Head of Care Support on behalf of Jan Baird, Director of Adult Care

The Committee is asked to:

 Note the outcomes of the third quarter reviews and progress made in resolving issues highlighted in the first and second quarter reviews.  Note the work underway to improve processes for knowledge capturing and sharing.

1. Background

1.1. On 10 January 2013 the Health & Social Care Committee agreed a contract monitoring framework to provide reliable management information on Adult care contracts.

1.2. This report details the outcomes of the monitoring process for quarter 3 (October to December 2013) and highlights work underway to widen the scope of the contract monitoring approach and improve the process for knowledge capturing and sharing.

2. Reviews Undertaken during Quarter 3 - October to December 2013

2.1. A total of 33 contracts were monitored for NHS Highland during this period. For information, a further 9 were monitored for The Highland Council. A summary of those monitored for NHS Highland is at Annex 1. It should be noted that some providers have multiple contracts and it is normal to monitor these in one visit and produce one report.

2.2. Thus far in 2013-14, 85 contract monitoring visits have been undertaken.

3. Progress in Resolving Issues

3.1. A total of 57 issues have been highlighted in relation to NHS Highland contracts to date, with 10 resolved and 47 ‘live’. However a number of these relate to the provider being asked to produce an annual report, so it is anticipated that these will be ‘closed’ following the end of the financial year.

4. Audit

4.1. An Internal Audit was undertaken in October and November, which recommended some improvements in the contract management process. In accordance with this, sample checks of data submitted have been introduced, and work is underway to record evidence and develop model quality schedules.

4.2. In addition, progress is being made in establishing more operational monitoring meetings with providers, and regular meetings have been established with Area Managers to highlight outstanding issues for resolution. 5. Related Activity

5.1. A third ‘Understanding the Roles’ workshop was held on 5 November 2013. This further developed the envisaged processes and clarified roles and remits. Work is ongoing with the Directors of Operations to identify Designated Managers and flesh out this role, and further work is required to explore capacity and engagement issues.

5.2. The development of the Commissioning Strategy also continues, and it is intended that Contract Monitoring will have a part to play in ensuring that the desired outcomes identified in this document are delivered.

6. Capturing and Sharing Organisational Knowledge regarding Quality of Services

6.1. The Understanding the Roles workshops coupled with recent experiences have highlighted that whilst formal contract monitoring in its current guise is worthwhile, the information gathered in this process represents just a very small part of the knowledge held by NHS Highland regarding the quality of contracted services, and therefore monitoring could become even more valuable if this information could be captured and shared.

6.2. Information currently exists in silos, being either in paper files, personal knowledge, located on different shared drives or in individual observations in the CareFirst casework system. As such, obtaining an accurate overall picture of a service, and drawing appropriate conclusions is difficult. Additionally, performance reporting is very labour intensive and usually repeated on an ad-hoc basis.

6.3. The objective is to make it as easy as possible for a wide range of information (e.g. from monitoring visits, of service utilisation, concerns, Adult Support and Protections cases, complaints) to be captured and shared. As such a requirement specification and options appraisal is being developed to progress this aim. This will focus predominantly on the utilisation of existing systems such as CareFirst, Datix and Sharepoint.

7. Conclusion

7.1. Routine contract monitoring continues to highlight and resolve issues. However, work is progressing to improve the quantity and quality of information gathered, and the analysis of this information to better inform decision making and highlight risks sooner.

George McCaig Head of Care Support 13 March 2014

2 Annex A Completed Contract Monitoring Visits on NHS contracts - October to December 2013 Note – some requirements combined

Area Service Compliance Remedial Actions Required Met Partial Absent West Care Home + Day 31 0 0 None Care South Care Home 21 0 0 None South Care Home 22 0 1 Provider – Data Protection policy to be developed South Care Home 22 2 0 South Care Home 20 2 0 Provider – implement audit process Provider – conduct resident satisfaction survey South Care Home 19 0 0 None South Care Home 21 0 0 None South Care Home 24 0 0 None South Care Home 24 0 0 None South Care Home 24 0 0 None South Care Home 24 0 0 None South Care Home 21 0 0 None South Care Home 24 0 0 None South Care Home 23 0 0 None Mid Life Skills 15 0 0 None West Support 22 0 0 None West Housing Support 21 0 0 None South Housing Support 22 0 0 None South Housing Support 20 0 0 None South Housing Support 20 0 0 None South Day Care 25 2 1 Provider – send annual report to NHS Provider – volumes average 67%, max 83% NHS – reviews required for older adults Pan Outreach 24 1 1 NHS – arrange operational monitoring meeting Provider – ensure all volunteers have PVG check South Outreach Support 18 1 1 Provider –summarise customer satisfaction / Respite NHS - arrange operational monitoring meeting Pan Community 27 0 0 Capacity and Info Pan Handyperson 18 0 0 South Transport 20 2 2 Provider – develop recruitment policy Provider – develop training plan Provider – ensure policies understood Provider – submit annual report to NHS Pan Advice, Guidance, 26 2 6 NHS – arrange operational monitoring meeting Support Provider – report annually and quarterly to NHS Provider – produce service user rights leaflet NHS – ensure sensory info is provided in SSA NHS – explain service to service users referred Pan Handyperson 14 1 1 Provider – submit annual report to NHS NHS - arrange operational monitoring meeting Mid Lunch club n/a n/a n/a Liaison visits to Grant funded organisations, to Pan Outreach n/a n/a n/a ensure required report is submitted at end of Mid Hydrotherapy n/a n/a n/a financial year.

Highland Health & Social Care Committee 20 March 2014 Item 9.1 CHIEF SOCIAL WORK OFFICER REPORT 2012/2013 Report by Director of Adult Social Care

The Committee is asked to Consider and Comment on the issues raised in the attached annual report.

1. Background

1.1 The requirement for every local authority to appoint a professionally qualified Chief Social Work Officer (CSWO) is contained within Section 3 of the Social Work (Scotland) Act 1968.

1.2 The Partnership Agreement between Highland Council and NHS Highland sets out that the CSWO will be an employee of the Highland Council. The Agreement also includes the various arrangements for professional leadership in Social Work, as part of the Lead Agency model, involving lead officers in both organisations.

1.3 The overall objective of the CSWO role is to ensure the provision of effective, professional advice to local authorities in the provision of social work services. In the lead agency model, this includes advice to officers of NHS Highland. Accordingly, this report will also be presented to NHS Highland.

1.4 The role should assist both agencies to understand the complexities of social work service delivery - including in relation to particular issues such as corporate parenting, child protection, adult protection and the management of high risk offenders - and the key role social work plays in contributing to the achievement of national and local outcomes.

1.5 The CSWO has specific responsibilities in relation to:  the placement and movement of children in secure accommodation  the transfer of a child subject to a Supervision Requirement  adoption applications;  enforcement of Community Payback Orders;  Mental Health Officers and statutory intervention under mental health legislation;  protection of adults at risk in terms of the Adults with Incapacity (Scotland)  investigation of complaints.

1.6 The CSWO also has a role to play in overall performance improvement and the identification and management of corporate risk insofar as they relate to social work services.

1.7 The attached report covers the broad period 2012/13. However, given the volume and range of current developmental activities in Social Work and Social Care in NHS Highland and Highland Council, especially associated with the ongoing processes of integration, the start and end dates of the year are not always rigidly applied. 2. Implications arising from Report

2.1 There are no resource, legal, equality or climate change implications. Appendix 1 Chief Social Work Officer: Annual Report – Highland: 2012/13

1. The Role of the Chief Social Work Officer

The requirement for every local authority to appoint a professionally qualified Chief Social Work Officer (CSWO) is contained within Section 3 of the Social Work (Scotland) Act 1968.

The Partnership Agreement between Highland Council and NHS Highland sets out that the CSWO will be an employee of the Highland Council. The Agreement also includes the various arrangements for professional leadership in Social Work, as part of the Lead Agency model, involving lead officers in both organisations.

The overall objective of the CSWO role is to ensure the provision of effective, professional advice to local authorities in the provision of social work services. In the lead agency model, this includes advice to officers of NHS Highland.

The role should assist both agencies to understand the complexities of social work service delivery - including in relation to particular issues such as corporate parenting, child protection, adult protection and the management of high risk offenders - and the key role social work plays in contributing to the achievement of national and local outcomes.

The CSWO has specific responsibilities in relation to: • the placement and movement of children in secure accommodation • the transfer of a child subject to a Supervision Requirement • adoption applications; • enforcement of Community Payback Orders; • Mental Health Officers and statutory intervention under mental health legislation; • protection of adults at risk in terms of the Adults with Incapacity (Scotland) • investigation of complaints.

The CSWO also has a role to play in overall performance improvement and the identification and management of corporate risk insofar as they relate to social work services.

This report covers the broad period 2012/13. However, given the volume and range of current developmental activities in Social Work and Social Care in NHS Highland and Highland Council, especially associated with the ongoing processes of integration, the start and end dates of the year are not always rigidly applied.

2. Public Protection

Public protection arrangements in Highland are monitored through the Safer Highland Leadership Group, involving senior officers of Highland Council, NHS Highland and Police Scotland.

The Chief Social Work Officer presently chairs the Child Protection Committee, and is a member of the safer Highland Leadership Group. There is appropriate social work and social care contribution into each public protection strategic grouping, from the Highland Council, NHS Highland and 3rd sector partners.

2 i. Child Protection

The Highland Child Protection Committee has a rolling 3 year Improvement Plan based on agreed long and short-term outcomes and including improvement objectives drawn from self-evaluation activity. This is reviewed and updated at the annual review. This assists the Committee to identify specific key priorities and to address identified areas for improvement. Further detail is included in the Biennial report, and will be available in For Highland’s Children 4.

The annual work plan is drawn from the rolling Improvement Plan and reviewed by the Child Protection Delivery Group, on an ongoing basis, using a traffic light system to track progress. Exceptions are reported at each meeting of the Child Protection Committee.

The period covered by this report involved the significant restructuring of local and national services, which impacted on all agencies involved in the Safer Highland Partnership. Throughout this time, the Committee continued to implement its Improvement Plan, as well as further actions from self-evaluation and audit work.

Achievements during 2012/13 include further improvement to governance arrangements and a number of high quality and award winning initiatives relating to e-safety, identification of sexual abuse and support for forces families.

Restructuring has allowed us to review many processes across children’s services and to further improve information sharing and joint working. As children’s workers in health, social care and ASN are being organised into new integrated teams, all guidance is being reviewed and refreshed to reflect this. An improved quality assurance framework, in line with guidance from the new Care Inspectorate is also being developed and embedded across children’s services and it is anticipated that a further self-evaluation exercise will be undertaken in 2013/14. ii. Adult Support and Protection

The Adult Protection Committee has an ongoing work plan, addressing key improvement priorities.

A Social Worker with many years of experience has been appointed to the newly created role of Lead Adviser (Adult Support and Protection), and will take up post in the latter half of November 2013. This postholder will provide professional advice and support to the Adult Support and Protection Committee, and within the organisation and partnerships. The post will report to the Head of Adult Social Care. iii. Criminal Justice

Criminal Justice Services have been involved in the following activity over the year:  Community Payback Orders (CPO) – 587  Criminal Justice Social Work Reports – 1090  Diversion from prosecution – 42  Bail supervision – 15  Statutory Throughcare (number of prisoners starting supervision in the community) – 11  Statutory Throughcare (number of prisoners starting a prison sentence) – 21  Home Circumstance Reports (for parole) – 74  Home Detention Curfew Assessments – 65

3 The number of Community Payback Orders rose in 2012/13 from 444 to 587, which represents a significant increase. This was in large part because it is the first full year since implementation.

There are nine CPO requirements (supervision, unpaid work & other activity, compensation, programme, alcohol, drug, mental health, restricted movements and conduct). Other than supervision, programme and unpaid work, these remain under utilised by the courts.

There has been a significant increase in the number of unpaid work hours made in 2012/13 from 25,862 in 2011/12 to 33,040. This is in line with many local authorities in Scotland, and has created additional pressure on resources.

Developments

A Criminal Justice sub-committee of the Adult & Children’s Services Committee was established in 2012, and met for the first time on 4 October. This is a welcome development and there has been a wide ranging agenda including women offenders, substance misuse, performance management and prison-based social work.

The Criminal Justice and Licensing (Scotland) Act 2010 involved a new duty on local authorities to submit annual reports on the operation of the CPO. The first Annual Report for 2011/12 was submitted in October 2012. The Annual Report for 2012/13 is due to be submitted in November. Criminal Justice Services (CJS) continue to look for imaginative ways to promote CPOs.

During 2012/13, CJS undertook a review of separately funded substance misuse services and, in the context of the Commission of Women Offenders Report published in March 2012, services for women offenders. This resulted in the decision to create one substance misuse team to include a dedicated Social Worker working with women offenders both in the community and in prison, including women in the Community Integration Unit (CIU) in HMP Inverness. The new substance misuse team came into being in Spring 2012 and will provide group and 1-1 interventions covering offenders subject to Drug Testing & Treatment Orders and, additionally and for the first time, CPOs. This team also contains NHS Highland Community Psychiatric Nurses (Addictions). This ensures that CJS is addressing key recommendations of the Commission of Women Offenders Report regarding establishing multi-disciplinary teams comprising, as a minimum, a criminal justice social worker, a health professional and an addictions worker to co-ordinate offending interventions and needs.

Multi-Agency Public Protection Arrangements (MAPPA)

The monitoring of sex offenders through MAPPA, a statutory set of partnership working arrangements operated by the responsible authorities (Police, Local Authorities, the Scottish Prison Service and Health) that aim to protect the public by managing offending, continues to operate effectively.

The 6th Annual Report was published and sets out key achievements, including the delivery of multi-agency training and data for Highland & Islands. This shows there were 237 registered sex offenders, of whom only 4 were convicted of further sexual or violent offences.

4 Performance

The Scottish Government collate and produce statistics annually on re-conviction rates nationally and by local authority area. One year reconviction frequency rates are at their lowest point since 1997/98: the number of offenders was 1,647 in 2010/11 (the most recent set of data published by the Scottish government in September) and the reconviction rate was 24.2% and the reconviction frequency rate 38.4%. In 2009/10 there were 1,938 offenders with a 1 year reconviction rate was 26.9% (Statistical Bulletin, Crime & Justice Series – Reconviction Rates in Scotland: 2009 – 10 Offender Cohort, Scottish Government 2012). This reflects a downward trend over the last 5 years: 2005/6 33.4%, 2006/7 31.1%, 2007/8 29.4%, 2008/9 27.8%.

This is a very welcome trend. However, it is not possible to extrapolate the specific performance of CJS from this data or, indeed, any single justice agency.

During 2012/13, a new quarterly outcome-based performance framework for the Northern Community Justice Authority (NCJA) was developed and implemented by the constituent local authorities in conjunction with NCJA Members and the Chief Officer. This details the performance of each local authority across a range of quantitative and qualitative measures and is designed to evidence the 3 key outcomes as set out in the National Outcomes and Standards for Social Work Services in the Criminal Justice System (Scottish Government, 2010) (NOS). NOS updated existing national standards and were designed to support the underlying political priorities in Scotland and Protecting Scotland’s Communities: Fair, Fast and Flexible Justice (2008), the Scottish Government’s blueprint for a modern offender management programme.

There are 3 key outcomes in NOS: • Community safety and public protection • The reduction of re-offending • Social inclusion to support desistance from offending

In respect of Highland CJS, key performance data in 2012/13, the following is noteworthy:  The number of CJSWRs submitted on time to courts – 96.7% (1048/1084)  The percentage of offenders attending unpaid work <7 days of the Order being made – 48.4% (240/496) – a number of factors influence this indicator, including offenders failing to attend or unable to attend due to employment (e.g. off-shore working).  18 sex offenders completed the Joint Sex Offender Project programme and 100% had a relapse prevention plan and 82% showed an improvement in their Stable & Acute assessment score.

5 Governance

In the Scottish Government’s response to the Commission’s report published on 20 December, the Cabinet Secretary for Justice stated that “We accept the status quo…is no longer an option” and committed to consulting on the structures that support community justice.

Redesigning the Community Justice System – A Consultation on Proposals was published by the Scottish Government. It sets out three possible options for reform which have been developed with input from a range of key stakeholders, including the Association of Directors of Social Work (ADSW), COSLA and Community Justice Authorities (CJAs). The options for reform are:  Option A: Enhanced Community Justice Authority (CJA) model, where changes are made to CJA membership and functions.  Option B: Local authority model, where local authorities assume responsibility for the strategic planning, design and delivery of offender services in the community.  Option C: Single service model, involving a new national social work-led service for community justice.

Highland Council supported Option B. The outcome of this consultation will be known later this year.

3. Mental Health

Community Mental Health Services

Community Mental Health Services are now managed by NHS Highland, as part of the lead agency model. Community Mental Health Services are now managed by NHS Highland, as part of the lead agency model.

A key factor with integration has been the embedding of the Mental Health Officer (MHO) Service (described below) within the Community Mental Health teams. Where they are not physically co-located, there is a commitment from Mental Health managers to ensure they are recognised as an integral part of the Adult Mental Health Service.

The main challenge for the community teams has been gaps in provision in the North and West Areas. Interagency discussions have acknowledged the deficiency and the NHS Highland Senior Management team is considering how the community mental health social work resource is distributed across Highland.

A recent meeting with the Mental Welfare Commission noted service improvements, including the delivery of Social Circumstance Reports and systems to manage guardianship processes. It was noted that Highland has a higher proportion of local authority guardians than in other parts of the country.

The Commission indicated that they had visited some people with intensive support packages, and expressed concern that some of these had not been reviewed. It was indicated that NHS Highland was addressing this issue.

6 Mental Health Officer Service

A dedicated Mental Health Officer Service was created within the Council, as part of the planning for integration of health and social care.

Following integration, good progress has been made in a number of areas, as the role of the MHO has been rapidly evolving. MHOs now have a clear and confirmed role as officers employed by the Local Authority and their additional training and qualification empowers them to carry out specific legislative duties under current relevant Mental Health legislation.

A significant area of progress is in the relationship between MHO and the responsible medical officer, and medical staff in general. Medical colleagues/professionals appear more informed in relation to the role and responsibility of the MHO, which differs significantly from the previous dual role, and are becoming increasingly more reliant on MHOs to support and help them navigate through complex areas of mental health law.

MHOs existing and increasing confidence in dealing with this highly specialised area of practice allows them to assist medical colleagues in the interpretation and implementation of the law. Additionally, being seen as neither medical/social work staff allows the MHO to appropriately advise and facilitate in relation to the underlying principles of the Adults with Incapacity and Mental Health legislation. An example of this can regularly be seen in relation to ‘least restrictive’ principle. Lack of familiarity/confidence in interpreting legislation can sometimes result in professionals becoming risk averse and part of the emerging role of MHO has been in supporting medical and social care teams/professionals to make decisions predicated on the underlying principles of the Acts.

MHOs now routinely attend pre guardianship case conferences. This was not the case previously, as many MHOs struggled with competing demands and lack of clarity of role. There is an acknowledgement that there have been a number of cases where this has resulted in a more productive and less antagonistic relationship between a client’s family and the hospital/care team.

Clients becoming Delayed Discharges are now identified and quickly referred for MHO allocation, allowing medical/care staff to work closely with all involved to ensure plans in place to facilitate appropriate outcomes. There can be a delay in progressing a welfare guardianship application due to difficulty in obtaining medical certificates. MHO involvement at an early stage can ensure this issue is appropriately addressed. There can also be delays when a family has expressed their intention to apply for Welfare Guardianship, but progress is slow or not happening.

An MHO duty rota is now fully operational ensuring there is always an MHO available to respond to request for intervention. There is no waiting list for Older Adults requiring intervention under Adults with Incapacity legislation. There is a waiting list in respect of Learning Disability Private Welfare Guardianship which is due to lack of Section 22 availability to complete medical reports.

At the recent Mental Welfare Commission end of year meeting (November 2012) it was highlighted that 81% of LA WG were granted within 2 months of application being made (Scottish average 75%). For Private Welfare Guardianship, the figures were 93% granted within 2 months of application being made (Scottish average 82%).

The Highland MHO service has established a programme of quarterly forums and is working to establish stronger communication with other MHO and MH services in neighbouring authorities (Argyll & Bute, Western Isles, Moray) and nationally in order to share CPD opportunities and improve communication on service developments and common themes.

7 There are 3 candidates from HC undertaking the MHO award 2013/14. The integration of Health and Social Care has created some operational challenges relating to the opportunities for potential recruits from the NHS Highland staff group, which are presently being addressed.

4. Adult Social Care

Work is progressing to create an Adult Social Care Practice Form, which will draw its membership from all areas of adult social care. The role of the Forum is to co-ordinate and formulate advice to the NHS Highland Board on matters of broad Adult Social Care practice and in particular strategic issues; provide a person-centred, Adult Social Care perspective to NHS Highland strategies and plans and to the prioritisation of the use of resources in such a way that promotes sustainability; advise on the development of Adult Social Care services, impact and risk assessment of policy and service initiatives; promote a greater awareness and understanding of the Adult Social Care perspective as it informs policy and decision- making; and ensure that professional social work values and the SSSC Codes of Practice for Employees and Employers are taken account of in formulating policies and plans and in decision-making.

The Chair of the Forum will be a member of the Highland Health and Social Care Committee and the NHS Highland Board.

Plans are in place within NHS Highland in four test sites (Nairn, Invergordon, South Skye and Sutherland) to promote the roll out of the integrated team model in each District. The new teams should enable further co-location, but this is already being taken forward elsewhere. Social Workers in adult social care in Fort William are now based in GP practices, co-located with nursing colleagues and promoting integrated working.

A number of appointments have been made to the new post of Social Work Advanced Practitioner in the Areas. This is seen as a key role supporting professional social workers in the new integrated district teams as they develop. The role will provide professional advice and support to social workers and other professionals in the teams, and will hold a caseload of complex cases

In April, NHS Highland appointed an experienced social worker and care home manager to the newly created role of Service Improvement Lead for Care Homes and Day Care for Older People. This role is seen as an important support for in-house and external providers, promoting and developing good practice, and providing support, advice and assistance to providers with low gradings. The post reports to the Head of Adult Social Care.

Also since April 2013, the Care Homes directly managed by NHS Highland have been managed by the District Managers. Work is ongoing with regard to increasing step up/down facilities, and to review staffing structures.

An apparently more robust approach by the Care Inspectorate has led to a number of care homes in the independent sector receiving lower gradings, resulting in the suspension of admissions. Through contract monitoring and the work of the Service Improvement Lead, NHS Highland is attempting to engage positively with these providers, and with the Care Inspectorate, to improve the quality of care.

Liaison meetings between NHS Highland and the Care Inspectorate take place on a regular basis and there is a now an established cycle of three-monthly reports to the Highland Health and Social Care Committee, which detail and analyse performance of all registered Adult Social Care services in Highland.

8 5. Children’s Services i Fostering and Adoption

Fostering and adoption play major roles in securing positive outcomes for children who cannot be with their birth families. Over the past decade, changes in approaches to supporting children have meant that those requiring family placement frequently pose significant challenges because of their needs.

Highland has been successful in establishing good quality services which, although under ongoing pressure, mean that the needs of these children can generally be met within the authority. The new Intensive Fostering Scheme will provide the opportunity for children with complex needs or significant behavioural issues to remain within Highland and within their communities, and this will contribute to the achievement of more positive outcomes.

The Fostering and Adoption Service is responsible for the recruitment, assessment, supervision, support, review and training of foster carers and prospective adopters. The Service continues to work with adopters post adoption when the children are no longer “Looked After” and provides a search and counselling service to adults affected by adoption.

The Highland Council is registered as both a Fostering and an Adoption Agency with the Care Inspectorate. The most recent inspection in November 2012 graded both services as being “very good”.

Fostering

The number of children placed in all categories of Foster Care peaked at 177 in November 2012, and reduced to 153 in August 2013. Of these children, seven are currently placed in purchased foster placements with independent fostering providers.

The number of “new” children who are accommodated for the first time by the Local Authority is steadily increasing, with 63 “new” children accommodated in 2012 and 73 up to August 2013.

Although the number of carers has remained relatively static at 174, it is an on-going challenge to replace those who stop caring, mainly due to retirement, employment, and changes in health and family circumstances.

Twenty seven foster carers have been approved since January 2012, with a further 10 assessments currently underway.

There is a wide range of training delivered to staff and carers with all current and prospective carers offered training, locally and centrally, during the day, evenings and at weekends and in addition 5 Fostering preparation courses held this year

Adoption

There is recognition that children who are adopted are not a distinct population, but are primarily children who have been on the child protection register who cannot return to or remain at home safely. Adoption gives these children the chance for some emotional recovery.

Outcomes for younger children who have been abused and neglected who are adopted, are generally better than for children who remain ‘looked after’.

9 Risks of adoption breakdown increase the older the age at placement and the longer the child is in care beforehand. Therefore, focussed planning and evidenced decision making are key to the process whereby delay is minimized. Proactive processes, including permanency planning and recruiting and approving adopters continuously have meant that all children are placed within Highland.

The Highland Council Fostering & Adoption Social Workers recruit and prepare prospective adopters to meet the needs of the children identified by the Permanence Panel for whom adoption is the plan.

Preparation groups for prospective adopters are planned in advance, and are usually very well attended, with two adoption preparation groups being held in 2013.

The current recruitment of adopters has ensured a reasonable number of placements, and we have been able to match within our own resources large sibling groups (of up to 4 children), as well as children with complex health needs.

We attract more adopters than we can assess, and therefore prioritise applications for those interested in adopting older children, large sibling groups and children with additional health or medical needs. There have been 9 couples and single people approved as prospective adopters in 2013, with a further 9 currently being assessed.

In 2012, there were 12 children matched with prospective adoptive parents and 2013 is already showing an increase with 14 children being matched and placed up to September 2013.

There remain a number of children who might be described as “difficult to place” and are awaiting matching with adoptive parents. All of these children have been referred to Scotland’s Adoption Register to increase the possibility of an adoptive family being identified.

We are gradually increasing the number of older children being placed for adoption or in other permanent families, and have seen an increase in the number of older children where permanent fostering is the plan. In total, 63 children have been registered for permanency by the Permanence Panel since January 2012.

Over the last two years, there have been 28 children adopted, none of whom were relinquished babies.

The Council has, in acknowledgment of the greater needs of the children being placed for adoption, developed its services after adoption. This includes: adoption support planning meetings, the adoption allowance scheme, a specialist consultation service, and the adoption forum and ongoing training. ii Residential Childcare

The Council offers a range of residential services to children and young people within the Council area, and has entered into contractual arrangements with a private provider and Barnardo’s, which supplements our own service.

As well as what could be described as “mainstream” residential childcare, the Council provides residential respite care for children and young people affected by disability, and also has a small residential unit for such children and young people in Inverness.

10 The Geographical Spread of Services

In Caithness, the Council provides a residential service at 50 Northcote Street, Wick which is registered for up to 6 young people and also has a variation on its registration for a house in Seaforth Avenue, Wick which can be used as an emergency/time out facility for one young person or a sibling group of two. Northcote Street opened in the early 1980’s, and work has commenced on the construction of a replacement 5 place unit. The service at Northcote St has been awarded grade 5 (very good) by the Care Inspectorate.

We have a respite unit for children and young people affected by disability in Thor House, Thurso, which opened in 1993. This can offer residential respite to up to 4 residents at any given time and has a total of 43 users. The Care Inspectorate have awarded Thor House grade 4 (good)

Oakwood at 1 Dochcarty Brae, Dingwall, offers residential child care to 5 children or young people. This is a purpose built unit which opened in September 2008 to replace the Lodge in Conon Bridge. The Care Inspectorate has awarded Oakwood grade 5 (very good).

Leault, in Abriachan by Inverness was extended recently, to cater for 5 children and young people. Similar to Northcote Street in Wick Leault has a satellite unit at 57 Kilmuir Road, Inverness which offers emergency accommodation for up to 28 days for one young person or a sibling group of two. Leault and Kilmuir Rd, which are registered separately, have both been awarded grade 5 (very good) by the Care Inspectorate.

122 Ashton Road in Inverness offers 5 places to children and young people and is a purpose built building which opened in December 2002. It has been awarded grade 5 (very good) by the Care Inspectorate.

The Orchard, Broom Drive, Inverness, which opened in June 1994, is the largest respite unit for children affected by disability in the Council area and can offer 9 places spread across 2 units within the same building for respite. It also has a residential unit which offers full time care to one young person and shared care to two others. The respite units offer overnight care to 62 users at varying intervals; day care to 15 users and after school activities to 12 users. The Orchard has been awarded grade 5 (very good) by the Care Inspectorate.

There is a small respite unit for children and young people affected by disability in Staffin, Isle of Skye. This unit offers respite for 2 young people at any given time and has 16 users. Staffin Respite Unit has been awarded grade 5 (very good) by the Care Inspectorate.

Contracted care within the private and voluntary sector

The Council entered into a contractual arrangement in 2012 with a private organisation called Keys Cromlet to provide 8 places for children and young people in the inner Moray Firth area and 4 in the Lochaber area. The places in the Moray Firth area are spread between Cromlet House, Invergordon and Moorhouse, by Strathpeffer. The 4 places in Fort William are provided at Birchwood in Camaghael and all are fully occupied.

Cromlet House and Moorhouse have both been awarded grade 5 by the Care Inspectorate and a report is pending on Birchwood.

The Council has also entered into a contract with Barnardo’s to provide 5 residential places for young people returning from out of authority care, at the Northern Lights Project, Scaniport by Inverness. This has operated very successfully since it was opened in February

11 2011 and is fully occupied. The Northern Lights project has to date helped return 16 young people to the care of the Council from other care providers, and subsequently reintegrated 11 to appropriate placements. Northern Lights has been graded 5 (very good) by the Care Inspectorate. iii. Out of authority placements

The definition of children in ‘out of authority placements’ that has been used over the years, involves looked after children (or children who have been looked after) in placements that are neither provided nor commissioned by Highland Council – i.e. children who are in spot purchased placements in independent sector care homes and residential schools. These placements are both within and outwith the Highland Council geographical area.

Over the year, there have been between 50 and 41 children in such placements. These involve the most expensive placements for the authority, providing significant levels of specialist support to young people with disabilities, as well as young people with challenging behaviours, including those in secure care.

There were a small number of children in secure care during the year, peaking at three at the year end. iv. Children’s Hearings (Scotland ) Act 2011.

The new legislation supersedes those elements of the Children (Scotland) Act 1995 that relate to the Children’s Hearings system. In preparation for the delivery of training to professionals in Highland, representatives from the service joined Children’s Panel members in some pre-implementation training and collaborated with the Locality Manager for the Scottish Childrens Reporters Administration. Mandatory full day training for social workers and managers (and available to other interested professionals) was provided in Thurso, Skye, Fort William, Tain and Inverness through a total of 8 sessions in May and June 2013. A further 8 half day briefings were provided in the same locations for professionals in other disciplines. Additional training sessions are arranged. The progress in implementation of the new legislation is supported by communication between the relevant agencies and general support and updated guidance to practitioners. v. Practice Leadership

The evolution of more integrated services for the communities of Highland depends on professionals with diverse identities, skills and capacities being valued, understood and strengthened. The cohort of first line managers in social work/care across children’s services have critical leadership roles in the development and support of a skilled workforce involved in complex practice. As a group, they require opportunities for peer learning, support and development within their own professional discipline, alongside programmes of interdisciplinary learning and development. Such activity is complimentary to the functions supported by local management arrangements and can significantly contribute to the development of effective services and best practice.

6. Workforce Development

A calendar of regular development sessions is in place to support this group of staff, with the opportunities as appropriate to include time with colleagues in similar social work roles in adult services. Professional leads in NHS Highland and Highland Council will co-ordinate and deliver a programme of support to newly qualified social workers who must meet specified post qualifying training and learning objectives as part of their professional registration requirements.

12 The Health & Social Care Service is prioritising social care qualifying training for CSWs (school years) as this group of staff were appointed without the same qualification requirements as CSWs (early years).

We also have staff undertaking these external accredited programmes in children’s services:  4 qualified social workers (and 1 public health nurse)completing the Graduate Certificate in Child Care & Protection Studies (Stirling University) this calendar year  6 social workers across Fostering and Adoption and Children and Families teams (in 2 cohorts) have completed the BAAF PQ course Securing Children’s Futures – Good Practice in Permanence Planning

Some senior practitioners and others have facilitated short direct practice skills and knowledge sessions for social workers and this programme of events needs to increase in range and frequency during the next year.

207 candidates have completed SVQs since 1 April 2012, as follows Health & Social Care Level 2 31 Health & Social Care (Adults) 60 Health & Social Care (C&YP) 10 Health & Social Care Level 4 6 Supervisory Award 3 PDA – Dementia 13 PDA – Medication 84

There are currently 96 working candidates, with 43 to commence shortly.

Specific courses for staff working in social care have been delivered as follows:

Course Attendees

Death, Dying & Bereavement 24 Dementia Workshop 43 Understanding & Awareness of Diversity in the Older Adult including Lesbian, Gay, Bisexuals 41 & Transgender Issues with Highland Rainbow Folk Awareness of Palliative Care within Social Care 43 Settings Sensory Awareness 36 Understanding & Working with Dementia 27 Working with Adults at Risk of Harm 31 Working with Autism 17 Managing Challenging Behaviour in Adult Care Settings 59

13 7. Complaints

With the Integration of Health and Social Care Services on 1 April 2012 and the implementation of Highland Council’s corporate complaints handling process in November 2012, there have been some changes in the way that complaints during this period have been processed.

Adult Social Care services complaints remain subject to Social Work Complaints legislation but are now dealt with by NHS Highland.

Complaints about Children’s Social Care Services, Criminal Justice Services and Mental Health Officer services remain the responsibility of Highland Council Health and Social Care and continue to be processed through Social Work Complaints legislative procedures.

Complaints about Children’s Health service regarding functions that transferred from NHS Highland into Highland Council at integration are dealt with through the Council’s corporate complaints handling procedure.

Complaints received

Most concerns are resolved at point of contact or by the local Team Manager. These are dealt with under Stage 1 of the Social Work and the Council’s corporate complaints procedure.

Where a complainant remains dissatisfied with the response at Stage 1, there is a formal investigation by a manager that has not been involved, and a Stage 2 response from a senior manager.

Where complainants are unhappy with the proposed resolution of a Social Care complaint at Stage 2, they have a right to a review of their complaint by the Complaints Review Committee.

In the case of a Health complaint that has been dealt with under Stage 2 of the Council’s corporate complaints procedure, complainants have the opportunity to refer the complaint to the Scottish Public Services Ombudsman.

Monitoring and Reporting

Complaints are actively monitored by the Customer Care Officer and the Health and Social Care Senior Management Team to ensure they are resolved within statutory deadlines whenever possible or within timescales agreed with complainants.

Weekly reports are also provided to Directors and Heads of Service by the Chief Executive’s Customer Service Team.

Performance is reported to the Chief Executive through the Chief Executive’s quarterly performance report and also by the Customer Service Team.

Stage 1 complaints

In the period 1st April 2012 to 31st March 2013, 68 Stage 1 complaints were received and recorded centrally. Other Stage 1 complaints will have been addressed locally.

Of the recorded complaints, 34 were about Adult Services and dealt with by NHS Highland, while 34 were about services that remain with Highland Council.

14 Complaints dealt with by Highland Council Health and Social Care

Of the 34 complaints received by Highland Council Health and Social Care:  24 related to children’s social care services  3 related to children’s health services and were dealt with under HC Corporate complaints procedure  5 related to Criminal Justice Services  1 related to Mental Health Officer services  1 related to Highland Council Policy regarding Adult Sheltered Housing

Service No. Topic In/out Upheld/ timescales not upheld Children’s 24 11 behaviour of staff 10 within 4 upheld services 3 service delay 10 outwith 16 not upheld (Social Care) 2 poor service 4 withdrawn 3 decisions 1 policy 1 confidentiality Children’s 3 3 behaviour of staff 3 within 1 partially upheld Services (Health) 2 not upheld CJS 5 2 reports 4 within 0 upheld 2 behaviour of staff 1 withdrawn 1 poor service MHO 1 Behaviour of staff within not upheld Other (Adult) 1 Financial outwith not upheld

5 complaints were withdrawn and therefore not progressed. Of the remaining 29:  18 were concluded within the required Stage 1 timescale (62%).  5 were upheld or partially upheld (17%).

Adult Social Care complaints dealt with by NHS Highland

Service No. Topic In/out Upheld timescales Community Care 17 9 poor service 7 within 2 upheld 3 behaviour of staff 10 outwith 15 not upheld 2 service delay 2 financial 1 confidentiality Care at Home 16 9 poor service 5 within 10 upheld 4 delay in service 10 outwith 5 not upheld 2 behaviour of staff 1 communication Deaf Services 1 delay within not upheld

 13 of the 34 complaints were concluded within required timescales (38%)  12 of 34 were upheld (35%).  1 complaint progressed to stage 2

15 Stage 2 complaints

In the period 1st April 2012 to 31st March 2013, 23 Stage 2 complaints were received. Of these, 8 were about Adult Services and dealt with by NHS Highland, while 15 were about services that remain with Highland Council.

Complaints dealt with by Highland Council Health and Social Care Service

Of the 15 complaints identified above:  11 related to children’s services  4 related to Criminal Justice Services

Service No. Topic In/out Upheld timescales Children’s 11 7 poor service 2 within 1 upheld services 3 behaviour of staff 8 outwith 9 not upheld 1 data protection 1 withdrawn CJS 4 2 communication 1 within 0 upheld 1 confidentiality 3 outwith 1 Director Review 1 report 2 to CRC

One complaint was withdrawn. Of the remaining 14 complaints:  3 were concluded within the stage 2 timescale of 28 days (21%).  One complaint was upheld (7%).

Adult Social Care complaints dealt with by NHS Highland

Service No. Topic In/out Upheld timescales Community Care 7 3 behaviour of staff 6 within 4 partially upheld 2 policy 1 outwith 2 not upheld 1 poor service 1 withdrawn 1 service delay Care at Home 1 1 poor service outwith Not upheld

One Adult Social Care complaint was withdrawn. Of the remaining complaints:  6 were concluded within 28 day timescale (86%).  4 were partially upheld (57%).

Director Review/ Complaints Review Committee

3 complainants remained dissatisfied following receipt of a Stage 2 response from the Head of Social Care. All three related to Criminal Justice Services.

Of these:  One complaint was formally reviewed by the Director of Health and Social Care and the Stage 2 response was upheld.  Two complaints were referred to Complaints Review Committee and the outcomes of these were reported separately to this committee.

16 Actions taken to improve service responses

The Service is committed to learning from complaints and taking action to improve policy and process for the benefit of service users, within the limits of the resource constraints faced by the service.

We have reviewed and updated the complaints procedure and guidance based on the Model Complaints Handling procedure developed by the Scottish Public Services Ombudsman.

In addition, the Service has continued to seek to improve its handling of complaints by maintaining an active presence within the Association of Directors of Social Work Complaints Sub-group.

Discussions are held with team managers to identify and resolve key issues in dealing with complaints, particularly looking at ways that we can focus on complaint outcomes, rather than complaint processes, thus reducing the time taken to respond.

The largest number of Stage 1 complaints received by Highland Council Health and Social Care related to the behaviour or attitude of staff. Only 3 of 17 such complaints were upheld or partially upheld (18%).

Where complaints have been upheld or partially upheld, an apology has been offered and, action identified and where necessary, support and guidance has been provided to staff.

17 should be early Member/Non-Executive engagement of these significant issues. In response the Chairman highlighted that this would be achieved through reports being submitted to the Highland Council and NHS Highland for approval and, although this was acknowledged as being correct in terms of protocol, it was felt that there should be additional engagement at an early stage of the process. Therefore, the Chairman recommended that the Terms of Reference of the group be reviewed.

The Group NOTED the current progress of the Integrating Care in the Highlands Central Support Services Programme and AGREED the Terms of Reference of the Integrating Care in the Highlands Programme Board be reviewed.

The meeting closed at 12.45 pm. Highland Health & Social Care Committee 20 March 2014 Item 10.3 HIGHLAND QUALITY APPROACH LEADERSHIP GROUP

NOTE OF MEETING held on Wednesday 22nd January 2014, Boardroom, Assynt House, Inverness

Present: Ian Bashford, Board Medical Director (Chair) Linda Kirkland, Interim Director of Operations Raigmore Anne Gent, Director of HR Adam Palmer, Employee Director Jan Baird, Director of Adult Care Gavin Hookway, Senior Quality Improvement Practitioner (LEAN) Nigel Small, Director of Operations, South Mid Elaine Mead, Chief Executive Maimie Thompson, Head of Public Relations & Public Engagement Margaret Somerville, Director of Public Health Maryanne Gillies, Clinical Governance Manager Deborah Jones, Chief Operating Officer Nick Kenton, Director of Finance Derek Leslie, Director of Operations, Argyll & Bute (via vc)

Administrator: Rachel MacDonald, PA to Interim Director of Operations, Raigmore Hospital

Item Action 1. Welcome & Apologies

Dr Bashford welcomed everyone to the inaugural Highland Quality Approach Leadership Group meeting and introductions were made.

Apologies were received from Heidi May, Board Nurse Director and Gill McVicar, Director of Operations, North West.

2. Draft Role, Remit and Membership of the Group

Dr Bashford explained the purpose of this group is to guide and direct the Highland Quality Approach while providing a high level overview of all quality improvement work being undertaken throughout NHS Highland. In order to maximise the benefit of the meeting information

The group was in agreement the HQA Leadership Group was required, to be a forum to share new information while providing direction and prioritisation on improvement activities and how this improvement will be rolled out and implemented through NHS Highland.

It was agreed to trial the group for 4 months, alternating monthly meetings with SPSP and LEAN activity. All Points for consideration for next meeting:  Where the group will report to  How to communicate HQA activity to front line staff  Most effective method of HQA branding  How to embed the patient experience into work which is being carried out  Clear overview of work being carried out in order to prioritise staff and financial resources  How to ensure that staff are aware of HQA activity Item Action  How to align training carried out with the HQA training strategy.

Membership of the group to consist of:  Executive Team  Directors of Operations  Head of Communications  Employee Director  Head of Adult Social Care  Senior Quality Improvement Leads

Role & Remit to capture:  Decision making and reporting structure  Define group as a leadership group not a strategic group.

3. HQA Database

All LEAN activity is currently logged on the HQA database. The database is accessible to all NHS Highland staff via the intranet.

It was agreed the HAQ database is the preferred method of logging improvement work.

Action: All nursing workstreams to be logged on the HQA database by February meeting. Heidi May 4. Quality Improvement Prioritisation

The group will prioritise which improvement work is carried out, in line with NHS Highland’s 3 value workstreams: Cancer Services, Patient Management System and Patient Flow.

Improvement work which falls outwith the value workstreams will be discussed and i required, guidance on where finance and resources will be diverted from will be agreed by the group.

5. Pathways and Clinical Networks

To be discussed at SMT.

6. Training

To date approximately 1400 staff have undertaken HQA training. The group must be confident of which staff are being trained, their work location and the benefits of carrying out this training.

7. Monitoring & Evaluation Framework

Carried forward.

8. AOCB

8.1 HQA Staffing & Resources

LK advised the initial one year funding for HQA staffing will be ending 31st March 2014 and consideration should be given to the ongoing funding of these posts.

LK to bring a paper on the Quality Hub for sense checking to the next meeting prior to being submitted to the February SMT. 2 Item Action

9. DATES OF MEETINGS

Venue Board Room, Assynt House

Monday 24th February 9.30am -11.30am Wednesday 26th March 2.30pm - 4.30pm Tuesday 22nd April 2.30pm - 4.30pm Friday 30th May 2.30pm - 4.30pm Wednesday 25th June 2.30pm - 4.30pm Wednesday 30th July 2.30pm - 4.30pm Friday 29th August 2.30pm - 4.30pm Thursday 25th September 2.30pm - 4.30pm – please note change of date Monday 27th October 9.30am - 11.30am Monday 24th November 2.30pm - 4.30pm Friday 19th December 2.30pm - 4.30pm