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HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEE Report by Directors of Operations
The Board is asked to:
Note that the Highland Health & Social Care Governance Committee met on Thursday 1 March 2018 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.
Present:
Melanie Newdick, Board Non-Executive Director – In the Chair James Brander, Board Non-Executive Director Ann Clark, Board Non-Executive Director (Videoconference) Georgia Haire, Area Manager (Mid Division)(Videoconference) Alison Hudson, Area Clinical Forum Representative (Videoconference) Tracy Ligema, Deputy Director of Operations, North and West Joanna Macdonald, Director of Adult Social Care Cllr Ronald MacDonald, The Highland Council (Teleconference) Deirdre MacKay, Board Non-Exec Director (Teleconference) Margaret MacRae, Staffside Representative David Park, Chief Officer, The Highland Partnership Ann Pascoe, Board Non-Executive Director Kenny Rodgers, Interim Head of Financial Planning. Michael Simpson, Public/Patient Representative Cllr Nicola Sinclair, The Highland Council (Videoconference) Cllr Kate Stephen, The Highland Council
In Attendance:
Gaye Boyd, Deputy Director of Human Resources (Videoconference) George McCaig, Head of Business Support Brian Mitchell, Board Committee Administrator Donna Smith, Head of Planning and Performance (Videoconference) Simon Steer, Head of Strategic Commissioning
Apologies:
Adam Palmer, Board Non-Executive Director Shirley Christie, Staffside Representative Norman Houston, Carer Representative Donna Mitchell, Public/Patient Representative Dr Chris Williams, Area Medical Committee Representative Mhairi Wylie, Public/Patient Member Representative – Voluntary Sector 2
AGENDA ITEMS
Appointment of Committee Vice Chair Carers Act and Self-Directed Support Policy for the Management of Return Outpatients in NHS Highland Arrangements for Adult Social Care Fee Setting Assurance Report from 11 January 2018 Sub Committee Reports Performance Information Operational Units Report Monitoring the Delivery of Adult Social Care Contracted Services Care Inspectorate Summary Report Director of Adult Social Care Report Financial Position as at 31 January 2018 Children’s Services
DATE OF NEXT MEETING
The next meeting will be held on Thursday 3 May at Caithness General Hospital. 3
1 WELCOME AND DECLARATIONS OF INTEREST
At the commencement of the meeting the following Declarations of Interest were received:
Melanie Newdick – Family members in receipt of care. Ann Pascoe – Chair of Dementia Friendly Communities (Helmsdale) Nicola Sinclair – Founder member of Caithness Health Action Team (CHAT) Kate Stephen - Employed by University of Highlands and Islands
The Committee so Noted.
2 STRATEGY AND HORIZON SCANNING
2.1 Policy for the Management of Return Outpatients in NHS Highland
D Smith spoke to the circulated draft Policy document, representing an Addendum to the NHSH Local Patient Access Policy, and which sought to modernise Outpatient activity in Highland. She advised the document outlined a variable and flexible approach, and stated not all elements would apply to all specialties. The NHS Board would be asked to ratify the final Policy document at their meeting to be held in May 2018. She added a number of NHS Boards in North Scotland were also considering adoption of this document.
During discussion, concern was expressed regarding Policy elements relating to “patients not incurring unnecessary inconvenience” and patients who “Did Not Attend”, in particular how these could potentially impact individuals with Mental Health conditions. Noting that there were mitigating processes in place in relation to these matters, D Smith agreed to reflect further on the points made in discussion. Whilst reminding members that the Policy would apply to existing patients, it was confirmed that patients could opt to wait for more local appointments, as per the Local Patient Access Policy, where clinically appropriate. Discussion moved on to the current consultation process in relation to new Policies and it was noted the closing date for comments would be end March 2018. D Park directed that the draft document also be considered by all Operational Unit Senior Management Teams.
The Committee otherwise Noted the draft Policy document.
D Smith left the meeting at 12.50pm
2.2 Appointment of Committee Vice-Chair
M Newdick advised the Committee had, to date, been operating without a Vice-Chair and asked that members consider the appointment of the same.
After discussion, K Stephen Proposed the Motion that A Pascoe be appointed Committee Vice-Chair, this being Seconded by J Brander. There being no counter proposals, the Motion was carried.
The Committee Approved the appointment of A Pascoe as Vice-Chair.
2.3 Carers Act and Self-Directed Support
J Macdonald advised key aspects related to the role of NHS Highland staff in completing assessments and appraising individuals as to the 4 Support Options available. The level of funding available, and what this could be applied to, remained the subject of discussion. 4
There continued to be national discussion on a number of these aspects at which NHSH was appropriately represented. She advised that the relevant funding had not been specifically allocated to the Carers Act itself. D Park added that Carers may have a raised expectation as to the level of funding that may be allocated and as such it would be essential to ensure appropriate guidelines as to equity and reasonableness of allocations; and with a view to protecting overall affordability for the NHS Board. It was noted that relevant legislation would come in to effect from 1 April 2018.
A Pascoe stated the underlying aim of the Act was to ensure the voice of Carers was heard and was advised a Carers Improvement Group had been established. A small group of senior managers from both NHSH and THC, led by J Macdonald, had met Carers Groups to provisionally discuss relevant points and this activity would continue. K Stephen referenced aspects relating to Care Plan production, and the role of “Connecting Carers”, adding there would clearly be a need for consideration to be given as to eventual allocation levels.
The Committee:
Noted the position outlined. Agreed there be further discussion at the July 2018 meeting.
2.4 Arrangements for Adult Social Care Fee Setting
D Park introduced the circulated report, outlining the way in which Fees for Adult Social Care were considered and planned for, and how the contracts/business support team were provided with direction to undertake negotiations and transactions with Care Providers. The Adult Social Care Fees – Commissioning, Briefing and Instruction Group had been established in 2017 to ensure consistency of approach across the North Highland Partnership area. The report outlined a proposed Role, Remit and Reporting schedule for the Instruction Group, with the aim that this would consider all Adult Social Care Fee related issues and prepare fee and contract recommendations for consideration by the Finance and Performance Sub Committee of this Committee.
There followed discussion, during which issues relating to process transparency were raised. Mr Park advised the proposal sought to formalise the process that already took place out with the Committee framework, and provide appropriate governance oversight.
After discussion, the Committee:
Agreed to Approve the proposed reporting route via the Finance and Performance Sub Committee. Noted the Finance and Performance Sub Committee meeting schedule would shortly be issued to relevant members.
3 PERFORMANCE AND DELIVERY
3.1 Assurance Report from Meeting held on 9 November 2017
There had been circulated draft Assurance Report from the meeting of the Committee held on 11 January 2018.
The Committee Approved the circulated draft Assurance Report. 5
3.2 Matters Arising
3.2.1 Timeframe for Review of Payment Levels for Home Carers
J Macdonald advised the Adult Social Care Commissioning Group had picked up this issue and were considering matters relating to both fee payment levels and associated impact. She advised Stephen Pennington, Managing Director of Highland Home Carers would be leading the relevant Working Group.
3.2.2 Update on Care at Home Planning Outcome Based Approach
J Macdonald advised NHS Highland continued to work with Care at Home service providers to ensure daily discussion was held in relation to individual care level requirements, thereby enabling flex of the same and the provision of less or more support as identified. G Haire indicated activity to date had resulted in increased care packages and further work was required to ensure packages both decreased and increased according to identified need. J Macdonald emphasised the importance of engaging and building relationships with care providers to ensure success in this area.
3.2.3 Verification of Outpatient Waiting Times Data
G McCaig confirmed the relevant dataset was complete and would be reported under Item 3.4 on the agenda.
3.2.4 Clarification of CNORIS Payback Criteria
K Rodgers advised the criteria applied in relation to payback from the national CNORIS Fund was the same as that applied in relation to initial annual contributions, this being proportionate to the relative risk assessed for each member organisation.
The Committee otherwise Noted the updates provided on the matters raised.
3.3 Sub Committee Reports
The Chair advised there were no updates for the meeting, with Sub Committees having yet to start meeting on a formal basis. The issue of Sub Committee Terms of Reference was raised and it was stated these would be for this Committee to determine and agree. The aim was to ensure the three Sub Committees would provide a detailed level of scrutiny of relevant matters that was unachievable in the main meetings. These arrangements represented a reflection of the governance arrangements in Argyll and Bute where the Integrated Joint Board was in operation.
ACTION: Agreed draft Terms of Reference for the three Sub Committees be brought to the next meeting – M Newdick ACTION: Agreed a indicative NHSH governance framework Organogram be issued to members – B Mitchell
After discussion, the Committee Noted the position in relation to Sub Committees.
3.4 Performance Information
3.4.1 LDP Standards
G McCaig spoke to the circulated report and Scorecard document for Quarters 1 to 3, incorporating those changes in content and format agreed at the last meeting of the 6
Committee. It was noted that Other Standards indicators, as identified by the Committee, would be incorporated into the LDP Scorecard for future iterations. All relevant data would continue to be gathered and used for management purposes. Work was underway to ensure future performance information was presented on a North Highland basis. The report also provided an update on the requirement for all NHS Boards in Scotland to submit an Operational Plan, the key areas of focus for which were outlined, to the Scottish Government for 2018/19 whilst a national review of LDP Standards for all Boards was undertaken. Operational Plans had been due for submission to the Government by 28 February 2018.
Noting that the Committee could request data in relation to a number of Standards, A Pascoe stated she would like to consider relevant trend analysis in relation to aspects such as High Risk Complaints and Dementia. She was advised that extensive Complaints data was considered by the Clinical Governance Committee. N Sinclair asked that trend analysis be appropriately annotated by reporting officers and was advised this would improve over time and would be presented as and when specific data was requested by the Committee.
With regard to Operational Plans, members were advised these concentrated on a number of Key Performance Indicators and would require to be ratified by NHS Boards. Mr Park advised these Plans would represent proposals by individual NHS Boards, and would be relatively brief in nature. The NHS Highland Plan would be presented to a future meeting of the Committee.
ACTION: Agreed an example of complaints data, as reported to the Clinical Governance Committee, be circulated to members – B Mitchell
After discussion, the Committee:
Otherwise Confirmed it was Assured with regard to the delivery of the Local Delivery Plan targets in 2017/18. Noted that Government guidance for 2018/19 may require changes to the suite of performance indicators reported. Noted the Government requirement to produce an Operational Plan for 2018/19 which, in turn, would be brought to a future meeting of the Committee for review.
3.4.2 Health and Wellbeing Outcomes for Commissioned Services
G McCaig spoke to the circulated report and Scorecard document illustrating progress and evidencing the effectiveness of the services Adult Social Care provides. A Clark referenced Sepsis as a key Objective and there was agreement it should be established if relevant data was being reported to the Clinical Governance Committee.
ACTION: Agreed existing reporting arrangements for Sepsis data be clarified – G McCaig
After discussion, the Committee:
Confirmed it was Assured with regard to the delivery of the Health and Wellbeing Outcomes relating to Commissioned Services in 2017/18.
3.5 Operational Units Report
D Park spoke to the circulated report, providing updates in relation to each of the individual Operational Units as follows: 7
3.5.1 South and Mid Division
Updates were provided in relation to Recruitment and Sickness Absence, Quality and Safety, Care (Service and Delivery) and Finance. On the matter of development of a Care Home Strategy, D Park advised the Directors of Public Health and Adult Social Care had been requested to jointly produce a paper that could be applied in Policy and which would be submitted to the NHS Board for consideration at their next meeting prior to being brought to this Committee to consider how this could then be best implemented. Liaison with Staffside on this subject had been limited to date. M Macrae referred to the first phase of bed reconfiguration on the New Craigs site and was advised consideration of this, by the Asset Management Group, would take place later in 2018. A Pascoe, noting the number of Rapid Process Improvement Workshops being undertaken, questioned as to whether there was a system in place to capture associated impact and emergent improvements.
ACTION: Agreed the Staffside liaison process be further considered – M Newdick/D Park ACTION: Agreed the process for capturing RPIW impact and improvements be further investigated – M Newdick
3.5.2 North and West
Updates were provided in relation to People and Staff Morale, Quality and Safety, Care (Service and Delivery), Finance, Caithness General Maternity Services and Skye and Lochalsh Midwifery Service, Out of Hours (Transforming Urgent Care)(Hosted Service) and Skye, Lochalsh and South West Ross.
D Park took the opportunity highlight a number of matters including the success of the “Near Me” service where demand was outstripping capacity. Emphasising the importance of service sustainability, and the ability to retain staff, he advised that recruitment remained an issue for NHS Highland, with NHS managers increasingly utilising their time to ensure services remained functional. Particular staffing and recruitment issues across North Highland were then discussed. It was stated this highlighted the need for greater community engagement/resilience and multi-agency public sector working, examples of which were given. The view was expressed recent organisational changes presented an opportunity to provide a framework of comprehensive reporting for and across North Highland, showing areas of commonality and variance across Operational Units, and consequently helping communities to understand a compelling need for change. This was accepted, with the Chair stating the Committee would have an increased role to play in consideration of these matters under a revised governance framework and this would be reflected in future agendas.
3.5.3 Raigmore Hospital
Updates were provided in relation to People, Quality, Care (Service and Delivery) and Finance. D Park highlighted the impact of recent events such as Flu and interruptions to the availability of Theatres whilst achieving positive movement in relation to both TTG and Outpatient Waiting Times. Members took the time to acknowledge positive movement in a number of areas and asked that all staff be commended for their work in these areas.
The Committee otherwise:
Noted the detail of the Operational Units Report. Noted the circulated exception reports. 8
3.6 Monitoring the Delivery of Adult Social Care Contracted Services
There had been circulated a report summarising outcomes from 47 contracts monitored during Q3. A further 8 monitoring visits were undertaken for The Highland Council. Monitoring of the payment of the Living Wage for care staff remained a priority, with all outstanding issues now resolved. It was noted contract monitoring activity regularly highlighted issues and concerns requiring follow up action and review. Three main areas had been identified and acted upon, including in relation to management/staffing, service delivery and quality, and contractual compliance.
The Committee Noted the outcomes from third quarter reviews and progress made in resolving issues highlighted in previous reviews.
3.7 Care Inspectorate Summary Report
There had been circulated a Summary Report in relation to Care Homes and Care at Home services for the period 1 April to 31 December 2017. During discussion, it was stated that recruitment and retention issues within the Care Home sector can have a major impact on the quality of service provision. It was acknowledged that a number of facilities were achieving the highest Grade levels.
ACTION: Agreed to establish the current number of Care Homes in Highland signed up to “My Home Life” – S Steer
The Committee otherwise Noted the Care Inspectorate Summary Report.
3.8 Director of Adult Social Care Report
J Macdonald spoke to the circulated report providing an update in relation to learning from a recent study visit to Sweden as well as notification as to the success of a NHSH Nutrition and Dietetics Advisor having successfully become the co-author of an international journal relating to her specialist area. She advised all Care Home Managers in Highland were now registered with the Scottish Social Services Council.
The Committee otherwise Noted the circulated report.
3.9 Financial Position 2017/18
K Rodgers spoke to the circulated report advising as to the Highland Health and Social Care Partnership financial position, reporting a revenue budget overspend of £11.9m and a potential projected out-turn overspend of £13.6m. Overall, £2.6m of savings remained unidentified, £5.9m of previously identified savings had yet to be realised and £5.1m of additional cost pressures had been factored in. The report provided subjective analysis of the position by Operational Unit, highlighted aspects relating to pay and non-pay budgets, and outlined progress on savings plans to date. It was stated significant efforts were required in order to deliver financial targets, including the delivery of identified savings targets and the continued management of in year financial pressures.
There followed discussion, during which it was advised supplementary staffing rates can vary between agencies, and with regard to provision in remote and rural areas. NHSH continued to work with providers on Adult Social Care package levels and activity continued with regard to moving to a ‘discharge to assess’ model to improve flow and reduce hospital costs. 9
The Committee:
Noted the M10 year to date position of an £11.9m overspend on budgets, and a projected overspend of £13.6m. Noted the forecast comprised £5.9m of savings not achieving, £2.6m of savings still to be identified and £5.1m of cost pressures.
3.10 Children’s Services - Assurance Report to Commissioner and Children’s Services Assurance Report
There had been circulated a report, which provided an update to the Committee on the consideration of the associated Assurance Report and Balanced Scorecard, also circulated, prepared by the Director of Care and Learning and submitted to the People Committee (The Highland Council) at their meeting held on 25 January 2018. The report sought to provide assurance to NHS Highland in relation to services commissioned and delivered through Highland Council. It was noted the associated performance appendix had been presented in a revised format with more comment and data analysis. There remained a continued focus on Allied Health Professions activity and the impact of staff vacancies on the delivery of service, with a summary of the current recruitment strategy and activity having been included in the report.
ACTION: Agreed the number of schools involved in the School based immunisation pilot be established – Head of Children’s Services (Highland Council)
The Committee:
Noted the content of and comment on the assurance Report as submitted to the People Committee at their meeting held on 25 January 2018. Noted the progress being made to improve service provision. Noted the risks and pressures for service provision.
4 ANY OTHER BUSINESS
4.1 RPIW Activity
Members Agreed to receive an update at a future meeting in relation to RPIW activity on the recruitment process for Allied Health Professions and Speech and Language Therapists.
4.2 Committee Function and Administration
Members Noted that Management Action Plans would be developed and prepared for this and future Committee meetings.
5 DATE OF NEXT MEETING
The next meeting of the Committee will take place on Thursday 3 May 2018 in Caithness General Hospital.
The Meeting closed at 3.15pm 10 11 Feedback to Health and Social Care Committee from Finance and Performance Sub Committee 21st March 2018
Present: David Park, Chief Officer, NHS Highland (Chair) Ann Pascoe, Non Executive Director Frances Gordon, Interim Finance Manager, South and Mid Division George McCaig, Planning and Performance Manager Georgia Haire, Deputy Director of Operations, South and Mid Division Gilliant Grant, Team Leader (Contracts), Business Support Directorate Katherine Sutton, Deputy Director of Operations, Raigmore Kenny Rodgers, Interim Head of Financial Planning James Bain, team Leader, Planning and Performance
Comments from the Committee:
Schedule of monthly meetings now in the diary – alternating between finance and performance. Balanced scorecards will now go to the sub committee for more detailed scrutiny alongwith looking at areas of performance in more detail. Performance and Delivery
Operational Units Reports None at this meeting
Exception Reports None at this meeting
Balanced Scorecard Local Delivery Plan replaced with Operational Plan focussing on “core standards” including cancer wait times, treatment time guarantee, outpatients, diagnostics, mental health, Accident and emergency performance, workforce indicators and finance.
Finance Month 11 forecasting £13.5 million overspend for Health and Social Care Committee This is made up of £5.9 million of savings not achieving, £2.7 million of unidentified savings and £4.9 million of cost pressures. For 2018/19 forecasting savings target of £27-£31 million (for the health and social care committee) = 8.3% on baseline from the board
Action Points Paper on impact of changes to adult social care fees and charges to come back to next sub- committee meeting. 12 13
Highland Health & Social Care Committee Report
1. INTRODUCTION
This report will provide an overview of activity in North Highland and will highlight areas of focus as well as areas of further opportunity.
2. PEOPLE 2.1 Recruitment and Selection
South & Mid Division:
Nursing and Midwifery
Recruitment is becoming an increasing challenge for nursing and midwifery in many areas and South & Mid Division staff will be participating in a Scottish Recruitment and Jobs Fair to try and attract staff to the Board and in particular to more challenging areas of recruitment such as mental health nursing and midwifery.
North & West Division:
North
Nurse staffing in Wick Town & County Hospital continues to be challenging with long and short term sick leave. Patient safety remains paramount; therefore the reduced bed numbers remain in place, retaining 6 beds within the hospital. Both sites form part of the Caithness Redesign consultation. Staffing remains an issue in the Dunbar Hospital, District Nursing and Bayview Care Home. District nursing in both integrated teams in Caithness have had a number of retirements, resignations and maternity leave therefore staffing within the teams is fragile at present. Posts have been advertised and applications received. Bayview Care Home has had to close 2 beds due to staffing levels. Posts are currently being advertised. The Community Mental Health Team in Caithness has recruited to its last vacancy which is positive for the team. There will be a retirement in psychological therapy which might be difficult to recruit to, the post covers both Caithness and Sutherland. There have been a number of applicants for the Advanced Physiotherapy Practitioner Post working in Primary Care across three GP practices in Caithness, with interviews planned for early May 2018. In Sutherland recruitment remains a challenge in more specialised areas. E.g Difficulty in recruiting to vacancies in Social Work and Mental Health Nursing (Migdale Hospital) and a Physiotherapy post in East Sutherland which means that these services are currently providing a skeletal service only.
West:
Domestic staffing in Portree remains fragile although it is hoped this will improve over the next
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month. Nursing vacancies and long term sick leave continue to cause significant pressure across the two hospital sites. Posts are going through vacancy monitoring with a view to recruiting as soon as possible. Every possible avenue is being followed. However there is a high level of concern around sustainability of services in Skye. The administration team across the District is under pressure at the moment due to long term sickness and vacancies. This will potentially impact on hospital reporting, coding and back office support On Raasay, we have recruited to one of the vacant posts. A 22.5 hour vacancy remains; this post has gone back out to advert for the sixth time. Ideally it would be good to recruit on the island, with training being provided. There has been successful recruitment into the five Care at Home posts in North Skye that were recently advertised In Portree 1.5 Whole Time Equivalent posts remain vacant in Supported Independent Living in the Community (SILC) which is placing significant pressure on the service for people with a learning disability. This is likely to result in consolidating day services for older people with services for people with a learning disability in order to staff shifts. There has been a recent successful recruitment campaign for Advanced Nurse Practitioner posts within the Rural Support Team, with 3 ANP’s appointed. There is still 1 Whole Time Equivalent vacancy within the Rural Support Team for Skye and West Ross, which may necessitate continued use of agency and locum cover as required to fill service gaps in order to keep an Out of Hours / urgent care centre operational in North Skye. Even with these efforts some shifts have proved impossible to fill, resulting in consolidation of the Out of Hours service to a single site in Broadford. Surgical staffing in Belford Hospital remains a problem with all consultant posts being covered by locums. A Highland wide approach is being progressed and the posts will be re-advertised on that basis in the near future. Significant staffing and recruitment issues continue within Telford Centre in Lochaber, however, all vacancies have received applicants with interviews planned this month. There is also significant redesign being progressed including social enterprise options and cluster housing which may enhance recruitment options There has been successful recruitment to outstanding Social Work posts, with the service now at full compliment. The Advanced Nurse Practitioner post in Lochaber has a number of shortlisted applicants and interviews are planned for May 2018. There is currently a vacancy within the Substance Misuse service in Lochaber. This will have an impact on the waiting time for initial assessment in this service.
2.2 Staff Experience 2.2.1 Learning and Development
South & Mid Division:
The midwifery service in South & Mid Division have worked with colleagues in education and the NHSH Head of Midwifery to secure funding for a pilot to secure the return of midwifery education to the area which will see the University of the Highlands and Islands deliver a shortened 20 month programme for registered nurses, staring in 2020 with a cohort of around 20 students.
North & West Division:
TURAS System – The TURAS Appraisal which replaces e-Knowledge and Skills Framework for the
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KSF/Personal Planning Development and Review process was launched across NHS Scotland on Monday 2nd April 2018. A reminder has been sent to all teams and departments throughout North & West Division Operational Unit, asking them to ensure that they have logged into the TURAS system and have checked that their details are correct.
2.3 Sickness Absence
Jan 2018 % Feb 2018 % Cumulative Annual % at Feb 2018
South & Mid 6.37% 5.5% 5.34% Division
North & West 6.62% 5.58% 5.32% Division
3. QUALITY & SAFETY 3.1 Improvement Activity
South & Mid Division:
Mental Health Discharge Planning Rapid Process Improvement Workshop March 2018:
Patients given an estimated discharge date in their first 24 hours has improved from 0% to 90%. Immediate discharge letters completed and given to patients on discharge has improved from 40% to 80%. 12 Standard Operating Procedures are now in place and being tested. Ward Rounds are scheduled with Community Mental Health Teams phoning in to join in discussion for their patients.
Pharmacotherapy Service:
The Pharmacotherapy Service is a priority area of the new Scottish GMS Contract 2018. In NHS Highland we are establishing a Pharmacotherapy Working Group that, along with GP colleagues, will aim to develop a Highland-wide service specification for services that pharmacy teams can offer to GP practices. The first meeting for this working group has been scheduled for 26 April 2018.
It is a three tiered service, which is to be implemented in a phased approach over the next three years. Local delivery of the service will be dependent upon capacity of pharmacy teams as well as experience and training of individuals. The aim is for all Scottish GP practices to, as a minimum, have access to level one services by March 2021.
Level one (basic clinical) activities are at a generalist level and focus on a range of acute and repeat prescribing and medication management activities. They involve supporting safe and effective systems and processes including authorising repeat and serial prescribing. These are core activities that will be provided to all GP practices.
Levels two (advanced) and three (specialist) are additional services of progressively advancing clinical pharmacy practice and experience. They include medication and polypharmacy reviews/clinics for vulnerable patients, those with complex care needs and resolving high risk medication problems.
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These services will utilise the skills of pharmacist independent prescribers to prescribe, monitor and adjust treatment.
Value Management:
Ruthven and Maree Wards in New Craigs progressing with standard work from RPIW held 26 February – 2 March 2018.
Royal Northern Infirmary hospital continue with work to reduce falls. All wards reporting out on weekly basis.
North & West Division:
Pharmacy:
Quality improvement in community pharmacies continues through the national contract. Quality improvement support packs have been produced and provided to community pharmacies on request: the number of community pharmacies voluntarily participating reached 100% of all community pharmacies in December 2017. It has been announced that a quality improvement bundle based on the NHS Highland bundle will be spread nationally in April 2018.
Primary Care:
Learning from Intermountain to reduce clinical variation continues to be tested in two clinical areas: an electronic tool embedded in the GP clinical system for chronic obstructive pulmonary disease (COPD) in one GP practice and for medication review in three GP practices.
Community Hospitals:
Following the Highland wide Community Hospital Patient Safety event where hospitals were able to “show case” some of the work, a formal education framework to support the building of Quality Improvement capability and capacity is now being developed. A draft proposal will be developed by February 2018 for approval. Work continues to further improve the use of Scottish Patient Safety Programme (SPSP) methodology and care bundles in practice across all sites focusing on the area where gaps have been identified as a result of the mapping exercise shown in the previous report
Daily Dynamic Discharge:
As part of the National 6 Essential Actions to Improve Unscheduled Care, Daily Dynamic Discharge (DDD) is to be rolled out to community hospitals. An initial launch was held at a WebEx session with further sessions planned to share learning and monitor progress held in March, June and early December 2018. As part of the highland wide implementation, a gap analysis has been carried out, highlighting the areas which require additional focus going forward.
Advanced Practice:
Advanced Nursing Practice – A key element of the redesign in out of hours services is the introduction of Advanced Nurse Practitioner roles. In order to ensure robust clinical and educational governance, an
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Advanced Nurses and Advanced Paramedics Competency Framework and Training Toolkit 2017 has been ratified for use across NHS Highland. The Framework includes a ‘validation’ process for those who are in development roles to ensure completion of their core education programme at Masters level and evidence of competencies are achieved prior to practice at Advanced level.
There is also a national transforming roles programme of work led by the Chief Nurse for Scotland. This programme of work aims to provide strategic oversight, direction and governance to the development and transformation of advanced nursing roles to meet the current and future needs of Scotland’s health and care system. NHS Highland’s Framework is in line with the national recommendations.
NHS Highland submitted bids to National Education Scotland (NES) to support practitioners’ education and training needs against the Scottish Government funding of £3 million available for all NHS Boards across Scotland and it has been confirmed that North and West Highland will receive a total of £23,500 to support training and development of advanced practice to meet the requirements of the Scottish Government who have stated that this funding is to support an additional 500 Advanced Nurse Practitioners across Scotland. A North of Scotland ‘Academy’ is also being developed in collaboration with Grampian, Highland, Orkney, Shetland and the Western Isles which is a very exciting development.
3.2 WaitingTimes
3.2.1 Out-patients
In the North area local outpatient specialties have 3 medical patients breaching, and one surgical patient breaching. The Ophthalmology service has a backlog of return patients which are under review by Raigmore. A locum ophthalmologist has been recruited to provide monthly cataract sessions from May 2018 and this will have a positive impact on the current waiting list. Meetings are ongoing with the ophthalmology team in Raigmore to review current service provision. An Optical Coherence Tomography scanner has been purchased to introduce regular nurse led clinics in Caithness General Hospital to improve local services, reduce the number of people who have to travel to Raigmore and create capacity in Raigmore.
In the West area local outpatient specialties are all within Referral to Treatment (RTT) dates. Three Dermatology clinics have recently been cancelled with no rescheduled dates. New patients for this specialty have been waiting since February 2018 with return patients waiting from December 2017. Gynaecology clinics are currently suspended at Belford Hospital due to reduced Consultant numbers in Raigmore. All referrals and return patients have been changed to the Raigmore waiting list. Monitoring and assurance ongoing. Discussions ongoing to ensure that Gynaecology clinics will return to Belford Hospital and that a regular Dermatology Clinic will be back in place as soon as possible.
3.2.2 Treatment Time Guarantee
See appendix 2 & 3
3.2.3 Key Diagnostic Tests
North & West Division:
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North – Endoscopy - Caithness General Hospital currently has no Urgent Suspected Cancer patients waiting for appointments. There are no patients un-booked for Ultrasound colonoscopy, and there are 17 patients waiting for a return Endoscopy appointment. Colorectal surgeons have increased their Thursday morning sessions from 10 to 12 points. There is ongoing screening of referrals/return patients undertaken. A review of endoscopy equipment has been undertaken with a view to increasing the number of Gastro Scopes from 3 to 4 to maximise the allocated list time.
North - Non-Obstetric Ultrasound – Staffing issues at Caithness General Hospital has had a significant impact on current waiting times. One Sonographer is currently on maternity leave, and there are ongoing recruitment difficulties with this type of post. Routine Out Patient Referrals currently have a 13 week wait. Patients triaged as ‘soon’ are seen within 5 -6 weeks. Urgent Cancer Referrals are routinely seen within 2 weeks. Additional Ultrasound Sonography lists are scheduled for Lawson Memorial Hospital in Golspie, with support staff deployed from Caithness General Hospital, maximising the use of the equipment on site at Lawson Memorial. Patients will be offered appointments in Golspie. An additional Wednesday morning Ultrasound clinic is currently being provided to see routine out patient referrals. It is expected that we will continue to see an increase in Ultra sound waiting lists with the reduced staffing capacity.
West – Endoscopy - Belford Hospital - there are currently no patients waiting beyond breach date for a new endoscopy appointment. There are problems with capacity for all Bowel Scope Screening colonoscopies. Referrals from Skye GP’s for endoscopy, along with queries regarding current active status of Capsule Endoscopy Service, resulting in referrals being sent to Belford Hospital for assessment and booking. Work continues to ensure no new patients wait beyond breach date and return patients are booked within their recall month.
3.2.6 ED 4hr Compliance
Both Caithness General Hospital and Belford Hospitals continue to consistently achieve the required standards for ED waits.
Belford Hospital is currently achieving 98.5%, whilst experiencing high numbers of A&E presentations due to increasing tourist numbers at the local skiing resorts.
Caithness General Hospital is currently achieving 98.5% compliance as at 8th April 2018.
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Belford Hospital will see a reduction in Junior Doctor staffing levels towards the end of May, 2018, and therefore anticipate difficulties in sustaining the ED rota and this will have a detrimental effect on the 4 hour ED target.
3.2.7 Cancer Access & Treatment Times
Caithness General Hospital has no patients waiting for appointments for Urgent Suspected Cancer.
3.4 Infection Prevention & Control
South & Mid Division:
Compliance with Standard Infection Prevention and Control Precautions Monthly audit results across all inpatient ward settings in New Craigs and the 6 South & Mid Division Community Hospitals remain compliant with hand hygiene and standard infection control precautions. Heat Targets 2017-2018 SAB – There has been one case attributed to the RNI Community Hospital which is currently under review C difficile – There has been a total of 20 cases in South & Mid Division which are predominantly community acquired cases over the last year which is an increase from the 16 cases last year. All cases are reviewed and any learning feedback to clinicians.
7 20
North & West Division:
Clostridium Difficile Cases (C Diff) During the reporting period 2017/18, there were a total of 20 cases of toxin-positive Clostridium difficile infection (CDI) in the Operational Unit: 9 in the North, 11 in the West Area, 8 of these being acquired in the community. There does appear to be an increasing incidence of CDI in the community. Nationally, 27% of CDI cases in Scotland are associated with acquisition within the community and most take place outwith the care home setting.
Antibiotic prescribing is closely monitored and a year-on-year reduction is the target: this aims to minimise both the development of antibacterial resistance and the risk to patients of significant side effects such as CDI. Figures for the quarter Oct/Dec 2017 were lower than for the same period the year before and there was peak in January 2018. Information around any outliers in prescribing will be fed to the GP Cluster Quality Leads on a regular basis going forward. Within the hospital setting, the ongoing empirical (local) audits are a more useful reflection of anti-microbial prescribing practice on a daily basis. Point prevalence audits are undertaken on an annual basis
8 21
Staphylococcus aureus bacteraemia (SAB) Incidence: During the reporting period 2017/18, there were a total of 5 SAB infections in the North and West Division (4 in Caithness General Hospital and 1 in Belford Hospital).
Tissue Viability
North & West Division:
Community: As shown in the table below there has been an increase in incidence since October 2017. There have been five grade 3 pressure ulcers arising in the community since January 2018 (one in Caithness, one Sutherland, two in Lochaber and one Skye, Lochalsh). Root Cause Analysis is undertaken for every grade 3 or 4 pressure ulcers to identify any learning or improvements in care required. As part of this a focused education and training programme is to be undertaken in 2018 with care at home staff. Currently prevention of pressure ulcers are not included within the Care at Home service induction programme and this will be addressed in collaboration with the service.
Table 1: Incidence of pressure ulcers arising in the community excluding Grade 1.
Hospitals: There has been no grade 4 pressure ulcers recorded in our hospitals as of end August 2017 since 2012 and only one Grade 3 in the Belford, 2016.
Table 2, below, shows incidence across all the Operational Units including North & West Division.
Table 2:
9 22
3.5 Patient Safety 3.5.1 Scottish Patient Safety Programme
South & Mid Division:
Mental Health
Audit of IDL documents ongoing as part of Vale management project in two wards at New Craigs Hospital.
A ward safety briefing is being used throughout New Craigs Hospital and a Hospital Huddle has commenced using telephone conferencing. Currently nursing staff are involved in this but will become more multi-disciplinary.
Medicines management
A new High Dose Protocols has been developed in Intensive Psychiatric Care Unit with links to new ward round sheet.
Community Hospital
Work is currently focussing on the consistent use of the safety brief in our 6 sites. As part of the ongoing focus on improving patient flow, 2 community hospitals are revalidating and testing the delayed hospital discharges in efforts to ensure that a minimum of 40% of people are discharged before 12 midday.
North & West Division:
In Belford Hospital, Fort William there is continued sustained improvement in National Early Warning Score (NEWS) in the Combined Assessment Unit.
Peripheral Vascular Catheter (PVC) in Ward 1 is showing a drop but this was due to low numbers.
Sepsis Data has been passed to Dr Kollar, Sepsis Lead and we are looking to start collecting data in Ward 1.
10 23
In line with the Scottish Patient Safety Programme (SPSP) we are aiming for;
25% reduction in all falls as defined by SPSP by Dec 2017 20% reduction in falls with harm as defined by SPSP by Dec 2017
To achieve this there has been significant effort in testing the Falls care ‘bundle’ which requires an initial risk assessment and continuous attention to detail in terms of reducing the risk of falling, ‘cohorting’ at risk patients, providing individual support where required and balancing risk of falls with the need to maintain mobility and promote enablement.
Table 4 below shows a further sustained improvement in the incidence of hospital falls
The Quality Improvement Facilitator posts for the North and West Division in place and the share and spread plan is being rolled out which is being overseen by the Associate Lead Nurses for the North and West Division. Monthly falls prevention ‘huddles’ have been established and the new falls point of care ‘bundles’ are being introduced alongside other measures to identify individual risk factors, manage any risks without reducing mobility and where a fall does occur to utilise the multi-disciplinary post falls review process to learn and prevent further falls.
Table 4: All Patient Falls – North & West Division a further positive shift of 7 months
4. CARE
Service and Delivery
4.1 Adult Social Care 4.1.2 Care at Home (including commissioning)
Development work has been taking place in Lochaber to create new areas of independent sector provision allowing in house services to be reallocated. In the North, work is ongoing regarding developing services and appropriate housing provision.
The Inverness Overnight Care Service has had an extension to the contract term and continues to operate. Work is ongoing to support a potential new provider in Nairn and alternative provision is being sought in the Drumnadrochit area following the local provider giving notice to withdraw from delivering a care at home service.
For both operational units, the reduction in tariff rate from April is impacting care at home development and the transfer of new cases. Work is ongoing to develop new models of provision and to reach a solution which is affordable to NHS Highland and which creates an appropriate framework for growth. The Chief Officer is meeting with care at home providers in late April 2018 to set out the opportunities
11 24 and future direction of care at home commissioning in North Highland.
The numbers of Care at Home hours delivered in North and West Division are charted below.
Chart 1
Chart 1 shows, over time, the significant rise there has been in the “external” hours provided to clients in the North. This is Care at Home provided by Independent Sector organisations to complement our own “in-house” provision. “SDS2” hours are also provided by Independent Sector colleagues – but here the increases in provision have been relatively quite modest.
“SDS2” is usually known as an “Individual Service Fund”. This is a self-directed support option which the Scottish Government is promoting to increase the ability of individuals in receipt of support to direct that support flexibly to meet their needs and deliver the personal outcomes they want.
Chart 2
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Chart 2 demonstrates that there has also been an increase in “external” provision of Care at Home in the West. This has been more limited than in the North; however the proportion of “SDS2” hours provided has seen quite a marked increase.
4.1.3 Care Homes
National Care Home Contract
Cosla and Scottish Care have successfully renegotiated the National Care Home Contract for 2018- 2019. As of 9 April 2018, the fee rate for care homes for older people are as follows:
Nursing Care Rate - £689.73 per person per week Residential Care Rate - £593.89 per person per week
The financial settlement requires all providers delivering publicly funded care to pay all care workers, regardless of age, experience or time in employment, a minimum of £8.75 from 1 May 2018. The contract also commits providers employing nurses and delivering publicly funded care to pay Nurses on average agenda for change band 5.
The National Care Home Contract has therefore been varied for 2018-2019 to ensure:
Any provider delivering publicly funded care must pay all care workers a minimum of £8.75; Any provider delivering publicly funded care must pay nursing staff on average at Agenda for Change band 5; Providers agree that remuneration can be periodically monitored by the commissioning authority, including direct verification with employees of the provider; There will be no displacement of other costs onto staff by the employer.
Providers in Highland are required to agree to these terms before the 3.39% uplift is applied.
Highland Care Home Strategy Work continues to progress regarding the development of a care home strategy.
As previously advised:
Three internal sessions have now taken place with operational directors, clinicians, public health, finance and commissioning staff, to review available data, understand the current position, flow and current projections into the future.
A briefing was provided to a board development session in October 2017 in order to facilitate a shared understanding by Board Members of the issues and challenges. Following on from the second session, a short and accessible summary of the key points from the data wall is in preparation, to assist communicate the messages of and challenges around this work with wider stakeholders.
The third session took place on 12 February 2018, which looked to articulate the Board’s proposed strategy and delivery plan.
The NHS Board considered a report on care homes at its meeting on 27 March 2018. Further work is being undertaken to map out a clearer proposed strategy for in house care home provision, and it is
13 26 intended this will be available for the next Board meeting on 29 May 2018.
North & West Division:
Current published grades for Registered Care Home Services for Older People in North & West Division Highland are shown in the table below
Invernevis House: The service recently received an Inspection report which identifies Care and Support as “Weak”. This Grade reflects significant weaknesses in some care practices in relation to medication administration and across our care-planning. It is understood that difficulties in recruitment – leading to high levels of agency staffing – have contributed to discontinuities of care.
However NHS Highland’s Improvement Lead for Care Homes took on interim Management and Leadership responsibilities to effect significant progress in these areas: and this is being consolidated by an experienced Care Home Manager coming into post. In particular we have seen significant reductions in the levels of agency staff covering shifts. This appears to have been achieved through the deployment of a new systematic rota.
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4.1.4 Delayed Hospital Discharge
South & Mid Division:
Hospital Care at Home Placements Complex Total
RNI COMMUNITY 12 0 0 13 HOSPITAL RAIGMORE 14 3 0 17 HOSPITAL TOWN & COUNTY 4 0 0 5 HOSPITAL NAIRN IAN CHARLES 1 1 3 3 HOSPITAL ROSS MEMORIAL 1 1 3 5 HOSPITAL COUNTY 4 2 3 10 COMMUNITY HOSPITAL NEW CRAIGS 2 5 2 13 HOSPITAL Total 66
As at 24 April 2018 South & Mid Division has 66 patients delayed in hospital. This includes all patients in Raigmore and New Craigs hospitals which cover the whole of North Highland other Board area patients. Care at Home delays in establishing new packages of care is a significant challenge at this time with independent sector meetings in progress to address this.
North & West Division:
As at 12 April 2018 the North & West Division report 11 patients who are delayed in our Hospitals.
Individual Position:
HOSPITAL NO OF DELAYED DISCHARGES Portree 1 Mackinnon Memorial 0 Belford 1 Caithness General 0 Lawson Memorial 3 Migdale 0 Dunbar 2 Town & County, Wick 4
The chart below shows the overall reducing trend in total numbers of Delayed Discharges in the North & West Division as at 12th April 2018.
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Meetings have been arranged to discuss the ongoing issue in the North in relation to Mental Health Officer (MHO) allocation/involvement within Caithness, along with utilisation of Hospital Home Bundle and utilising Code 13ZA where appropriate in relation to Adults with Incapacity.
Integrated Teams & hospital staff continue to work to get people out of hospital as quickly as possible and to keep people out of hospital. The expectation is that delays will reduce with the increase in care at home and care home capacity, and further development of the senior health & social care support worker role and daily dynamic discharge.
4.1.5 Self Directed Support
South and Mid Division:
As of 10 April 2018 the number of people accessing a Direct Payment across South and Mid Division are distributed as follows:
The current 4 weekly payments at a district level are as follows:
Total 4 Weekly Area Number Active Payment
East Inverness 61 £100,323
West Inverness 34 £44,621
Nairn & Ardersier 16 £18,125
Badenoch & Strathspey 18 £21,253
Mid Ross 43 £61,651
Easter Ross 37 £51,062
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No one-off payments have been made for 2018/2019 yet.
There are currently 209 active Direct Payment service users with a total 4-weekly payment of £297,035.
North & West Division:
As of 10 April 2018 the number of people accessing a Direct Payment across North and West are distributed as follows:
The current 4 weekly payments are as follows:
Total 4 Weekly Area Number Active Payment
Caithness 32 £46,861
Skye & Lochalsh 55 £49,989
Wester Ross 17 £11,806
Lochaber 27 £49,432
Sutherland 18 £21,365
No one-off payments have been made for 2018/2019 yet.
There are currently 149 active Direct Payment service users with a total 4-weekly payment of £179,453.
4.1.6 Carers
Work is ongoing to ensure that we are in a position to implement the new Carers (Scotland) Act. To raise awareness of the coming changes our partners in Connecting Carers have been delivering training, which has been well received, to a broad range of Health and Social Care Professionals in our Integrated Teams. Work will also need to progress quickly to ensure that our new statutory duties are properly incorporated into our existing care planning and resource allocation processes.
4.2.3 Older People in Acute Hospitals (OPAH)
South & Mid Division:
Falls Reduction An intensive and focussed improvement plan to reduce the number of falls across all inpatient wards has been in place since January 2018 to date – this work aimed to reduce the number of falls and also increase quality improvement methodology knowledge and skills across the division.
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Early results are encouraging in terms of overall reduction and monitoring is taking place at ward level and at Unit level via the Quality & Patient Safety Group
North & West Division:
The updated Healthcare Improvement Scotland’s (HIS) Care of Older People in Hospital: Standards (2015) work contains 16 standards. NHS Highland has completed an OPAH Self-Assessment in advance of a visit by an Inspector from the Quality Assurance Directorate of HIS who visited Highland in September, to review the Board’s Self-Assessment. North and West has a comprehensive 40 page ‘action plan’ which sets out the priorities in order to meet the requirements of the 16 standards.
On 4 October 2017, Belford Hospital received an unannounced Health Improvement Scotland (HIS) Inspection. The final report is public and NHS Highland has submitted a 16 week update on progress to HIS in response to nine areas for improvement cover. The Head of Quality Care, Healthcare Improvement Scotland said all the patients were positive about the care they were given in the Belford Hospital. They were happy with the care received, staff were polite and caring. It was noted that staff ensured they were comfortable and happy and were treated with respect. There were eight areas of good practice identified in the report.
Person centred care planning was highlighted as a requirement and this remains a priority for improvement across Highland with the development of nursing assessment and care planning documentation which supports nurses to deliver high standards of care across Highland and avoid over processing.
A review of the current versions is underway with the final amendments out for comment across Highland at present. The aim is to roll out the revised version of a ‘standard admission’ document which will be used alongside the mandatory nursing assessment booklet. The short stay version will be discontinued as a result of evaluation and feedback from staff in practice. The Lead Nurse is also working with the Patient Management System Clinical Lead to integrate the documentation and assessment tools within TrakCare Patient Management System.
4.4 Mental Health & Learning Disabilities and Drug & Alcohol Recovery 4.4.1 New Craigs hospital
Staffing pressures have led to temporary reduction in General Adult beds of 6. This follows a reduction of 6 in August 2017. Registered Mental Nurse (RMN) vacancies remain at 25 WTRE. Recruitment efforts to date have not resulted in securing nursing staff. Other mitigation measures are in place managing the situation on a twice daily basis.
4.4.2 Community Mental Health Services
South & Mid Division:
Since July 2017 a project identifying all mental health clients has been in place. This was to clarify everyone who had care packages organised from the 5 districts prior to Mental Health services accepting responsibility for them. This is now complete and reviews have commenced. Three Social Worker posts are currently vacant and permission to recruit has been sought.
18 31
North:
There is currently a waiting list for Guided Self Help services in the Sutherland area, and there has been no Adult Psychologist support in place across Sutherland since December 2017. It is anticipated that there will be increased contact with GP services and consequently repeated referrals to Community Mental Health Team as a result of this.
West:
Within the West area, the Lochaber team are in the process of recruiting to a Substance Misuse post. The full extent of this vacancy on the waiting times target is not known at this time.
Dr Boyd Peters is planning a review of the Psychiatry service provision in the Lochaber area.
There are no significant issues to report with the Learning and Disability service apart from the increased demand as a result of the number of young adults within the transitions process with significant learning disability. This has resulted in an increase in Self Directed Support (SDS) and Individual Service Funding (ISF) packages.
4.4.4 Learning Disabilities and Autism
A Head of Service has been appointed. Arlene Johnstone commences post on 7 May 2018. First priority will be to complete the LD services review and develop the implementation plan.
4.4.5 Support for People with Dementia and their Families
The review of the National Dementia Strategy has finished with a set of recommendations made to the ACSG. These were accepted last week and work is underway to develop the expected outcomes for Child Parent Psychotherapy (CPPs) to achieve.
4.5 Out of Hours
North & West Division:
Work continues to progress the redesign plan as outlined in the September 2016 paper to the NHS Highland Board.
The emergency planning exercise held in Glenelg will be replicated in Lochinver and the North Coast using scenarios from local communities.
Discussion is ongoing with communities in the North after discussions about the direction of travel there. Two meetings of a working group have been held so far, with a model proposed but not accepted by the GPs. One Advanced Nurse Practitioner (ANP) in the north is now up and running, with a second in training, though mentorship capacity is a challenge. This situation continues with both Tongue and Armadale practices continuing to provide Monday to Thursday Out of Hours.
Applecross out of hours provision remains stable with cover from local General Practitioner and members of the Rural Support Team. Meetings have been held with Wester Ross GPs, Applecross and Lochcarron community councils. The advice at present time is that there is unlikely to be any financial gain from making a change to the current OOH arrangement for Applecross. However should there be any change to the current staffing model and contract in Applecross this will need to be reviewed.
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“Clinical Guardian” is now live to enable governance, and clinician feedback following OOH consultations. This marks a significant step forward in our oversight of OOH. We are now approaching agency locums to add them into this system. Recommendations have been produced by a short life working group to add MIU consultations into this system (dependent on a move to Adastra for Minor Injury Units).
We have not yet progressed the new contract for Out of Hours sessional work. Human Resources have expressed significant concern around the ‘employed’ status of workers under this arrangement, and we are working through the issues.
We are awaiting the outcome of the independent review of unscheduled care in Skye, chaired by Sir Lewis Richie. This may have wider implications for, e.g. Glenelg and Raasay.
4.8 Midwifery - Community Midwifery Units
Caithness Community Midwifery Unit continues to function with local birth for low risk women. There has been interest in the Band 7 Charge Midwife / Training post and three applications for the Band 6 midwife post. Interviews will take place in the next few weeks.
Caithness maternity survey continues to run with response rate so far sitting at around 24%. Results will be reviewed and an interim report provided at the end of April / six month period.
Caithness Maternity Caseload data: 1st Jan – 31st March 2018
Pregnancy Local Raigmore Maternal Neonatal Bookings Births Births Transfers Retrievals (inter- hospital)
72 7 42 20 0
Service development continues with the use of video conference consultation and the aim of using Near me technology for some antenatal clinics and the specialist diabetic clinic.
Skye & Lochalsh Midwifery Service has experienced significant staffing shortages since November 2017 leading to the temporary suspension of Out of Hours Services (1700-0900). The service continues 09.00 – 17.00 hrs 7 days per week including weekends. The staffing situation has improved with no sickness absence at present and the recruitment of 2 midwives, one who started in post mid March 2018 and the other who will commence post in May 2018. The local birth service Out of Hours will remain suspended until these midwives have had full orientation and familiarisation with regard to Remote and Rural service provision and on call working.
Routine midwifery services continue as normal with the team managing a caseload of approx 80 women. The caseload is spread across a remote geography and midwives travel across the island and mainland providing antenatal, intrapartum and postnatal care for mothers and babies at home, in hospital and health centres. Midwives liaise with child protection, health visiting and social work colleagues in relation to the management plans for vulnerable women and families. High risk maternity
20 33 cases are managed in conjunction with the Raigmore Consultant obstetric team, with local midwives being the gatekeeper and co-ordinator of care.
Negotiation and discussions are ongoing with regard to future sustainable on call model and the resumption of a local birth option for low risk women. It is hopeful that resolution will be reached in the coming months.
4.10. Highland Sexual Health
Dr Bridie Howe has been successfully appointed as consultant within Highland Sexual Health as a result of Dr Gordon MacKenna’s retirement. Dr Howe will commence her role in the autumn 2018.
4.11 Technology Enabled Care
South & Mid Division:
The Diabetic Specialist Nursing (DSN) team have been testing the use of Florence to support people to self-adjust their own insulin in an effort to improve their individual self-management and diabetic control and reduce their reliance on nurse specialists in the community.
Through the development of a clinical protocol with individually tailored pre-set targets on the Florence system, individuals receive prompt messages via text which offers them support and advice and, where necessary, guidance to titrate their insult does. This service is delivered under the direction of an insulin does adjustment algorithm and in conjunction with a patient education programme delivered by the DSNs. This system enables the DSN to monitor individual’s blood glucose levels remotely and follow up with targeted telephone or face to face consultations where necessary.
Initial feedback suggests that Florence provides frequent and sustained support and prompts, at a level which could not be provided within the current DSN resource, in addition to encouraging proactive insulin adjustment. Eight patients, five new to insulin and three already receiving insulin therapy, in South & Mid Division have signed up.
North & West Division:
With 129 patients enrolled on Florence during February 2018 and 132 during March the total number of patients who have benefited from Home Health Monitoring using Florence had reached 1935 by the end of March 2018
21 34
The most used Florence protocol is still the Electronic Asthma Action Plan for patients with severe asthma. This has resulted in: An increase in engagement, adherence and medication prescriptions A reduction in Did Not Attends, clinic appointments, hospital admissions and bed days In addition, the protocol is being used to monitor patients treated with biologics, who attend the clinic for their injection each month. During February and March there has again been a noticeable increase in the use of Florence for BP monitoring (by GP practices), and also to support mental health patients attending courses – including Decider Skills and STEPPS.
GP Engagement Engagement work with community teams (including mental health, physiotherapy, diabetes and dietetics teams) and with GP practices has been ongoing, with the results of the GP engagement activities shown in the following table.
Current status Number Decision %
Trained and using Florence or about to start 15 Accepted 12 for BP monitoring 31%
Training date scheduled 5 Accepted
22 35
Contacted – no decision yet made about a visit 1 Undecided 13% Visited–butnotheardiftheywanttogoahead 7 Undecided
Visited – Florence declined after visit 12 Declined
Contacted – visit declined at present, may Declined 56% 6 reconsider
Contacted – visit declined 18 Declined
Total GP practices 64
Reasons given for declining Florence:
Reason given No. % Poor signal in area 11 31% Small GP practice – know all patients well 7 19% Too much going on at the moment – might reconsider later 7 19% Use of Florence would not improve current care 6 17% Might reconsider if Florence integrated with clinical systems 6 17% Few suitable patients – e.g. many elderly with no phone 5 14% Lack of research evidence of benefits 2 6% No reason given 7 19%
Other reasons given include: Do not want staff to have to log into another system Assumption that “somebody is making a lot of money out of this” Our GP practice likes to follow rather than lead
N.B. the total adds up to more than 100% since GP practices often gave more than one reason for declining.
5. FINANCE
South & Mid Division:
2017-18 has been a challenging year for South & Mid Division given the significantly higher savings targets than allocated in previous years (£3.1m 2016-17 and £8.6m 2017-18). Whilst initiatives introduced this year have realised savings, the unit was unable to fully meet its target as it emerged that the Division was unable to manage both cost pressures and savings associated with prescribing and adult social care, resulting in a £3.5m shortfall against the savings delivery.
Moving forward into the next financial year; the Division has proposed a 3 year plan with various initiatives in order for them to meet the forthcoming savings target. This plan will drive forward change that will not only focus on quality but also delivering a sustainable service within the resource available.
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North & West Division:
The March 2018 financial statement reports a year end overspend of £6.5m against an annual budget of £136.7m. The significant recruitment and retention issues from the past three years have continued leading to the ever increasing need for locums, particularly in the Rural General Hospitals, Out of Hours and vacant practices. This issue cannot be addressed until there is a change in models of care.
This is being implemented in Caithness General Hospital and the pressure in the current year has reduced significantly from the prior year as a result of the revised medical model starting to bear fruit. There is however a concern that the decision to stop the £60 per hour rate for internal locums will put significant pressure on the hospital in the forthcoming year.
The high need for locums at Belford Hospital has continued and Highland-wide options to tackle the vacant consultant posts are being considered. These must be agreed as soon as possible.
The Unit is currently reviewing options for the provision of care at the three salaried practices in Caithness to relieve the vacant practice pressure including use of NHS Near Me, revised workforce and greater collaboration between the three practices.
The Unit also continues to suffer from recruitment and retention issues across a variety of other workforce areas including in-house care homes and this has contributed significantly to the current overspend due to high agency use. This has dropped significantly in recent months following management intervention however, work remains to progress this further.
The pressures remain similar to last year: Adult Social Care (£4.0m), Out of Hours (£1.5m) and additional locum costs for vacant posts (£1.8m) within Caithness General Hospital, General Practices and Belford Hospital partly offset by pressure funding (£2.0m). The Unit was issued with a savings target of £8.2m and achieved £5.3m of this but as the majority of this was non-recurring, there is a savings carry forward of £6.1m.
The Senior Leadership Team is continuing to develop the 3 year plan with a view to redesigning services to contribute to the Board’s legal requirement to maintain financial balance
24 37
Raigmore Hospital
2. PEOPLE 2.1 Recruitment and Selection
Recruitment to Radiology is continuing with International recruitment interviews on going. Recruitment to additional areas also on-going with urology and respiratory being particularly challenged currently. Two ENT Consultants have been recently recruited bringing the department to a full compliment.
2.2 Staff Experience 2.2.1 Learning and Development
2.3 Sickness Absence
Jan 2018 % Feb 2018 % Cumulative Annual % as at Feb 2018
5.56% 5.05% 4.49% 3. QUALITY & SAFETY 3.1 Improvement Activity
Progress this Month
Value Continuing in the 9 areas. Ward 3A to commence VM on the back of their Management RPIW when coaching and finance resource available.
Discharge Roll out of use of Fit and Confirm buttons on Wardview linked to a pts Process EDD continues on 5C, 3B and 2C. 3A now been given the standard work and have started this week. 5A and 7C aware of the work but not been given instructions yet.
HLVS – Post Acute HLVS development day with Celeste from VMI recently. 3 Hospital, pieces of improvement work identified at the event. Gill McVicar submitting requests for these to the KPO. Ambulatory, Post Acute, Home
Post Acute Lower numbers this month and DD lowest for over 3yrs. Capacity in the Patients hosp remains high despite this. Better understanding of the occupied bed days of these patients, and the implications this would have on a post acute ward (see issues arising) Murdina happy to explain the data to anyone interested.
Training HQA Lean Intermediate Training Course will be run in June – dates to be confirmed. 2 days training with completion of an improvement project required 6-8 weeks after. Aimed at Band 7’s and team leaders. Max 12
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places.
RPIW 1. Request submitted to the KPO for Improving the Process for Starting a New Care Package. 2. Admission to First Senior Clinician Review in Paediatrics
Other Pre-op Assessment – Helping with various process improvements and introduction of Joy at Work. Infusion Suite – Supporting Mairi Fraser and Evelyn Gray to get data on the current state & begin a programme of improvement work linked to value management Complaints in Paeds – Looking at themes and linking improvement work to their value management performance measures
3.2 Waiting Times 3.2.1 Out-patients
As at month ending 28 February 2018, there were 2,615 outpatients waiting over 12 weeks for a first appointment with NHS Highland. The target was to deliver a maximum number of 2,876 beaching outpatients by 28 February 2018. NHS Highland were ahead of forecast by 249. Significant progress continues to be made with outpatient transformation work and waiting list validation, which has continued into the last quarter and increased in the new financial year. Alongside this, there has been some additional activity provided in order to address the backlog. This was agreed with the Access Support Team at the Scottish Government who have funded additional capacity. The waiting time issues within a number of specialties have been addressed and significant progress has been made to reduce the number of breaching patients. The specialties with the highest number of breaching outpatients are Ophthalmology, Orthopaedics, Dermatology and Paediatric Medicine.
Every effort has been made to reduce the longest waiting patients who have waited longer than 26 weeks for a first appointment; there will be a continued focus to further reduce this cohort of patients. At the end of February 2018, there were 499 patients waiting over 26 weeks, this was 148 ahead of forecast.
3.2.2 Treatment Time Guarantee
As at month ending 28 February 2018, there were 1,992 TTG patients waiting over 12 weeks for treatment with NHS Highland. The target was to deliver a maximum of 1,389 breaching TTG patients by 28 February 2018. NHS Highland has seen an increase due to additional outpatient activity providing patients with a diagnosis. The specialties with the highest number of breaching TTG patients are Orthopaedics, ENT, General Surgery and Ophthalmology. The difference from forecast is largely due to theatre issues in January and February which has meant some patients have been cancelled and clinical prioritisation has had to be made.
There are now plans in place to treat cataract breaching patients in Quarter 4 by utilising theatre capacity at Raigmore, Caithness and Elgin. Other operating specialties are now working on a plan to continue activity throughout the Theatre Upgrade Project. There is a focus on specialties
26 39 working in a different way to minimise the loss of theatre capacity at Raigmore, this includes working at other Highland sites and Elgin. This has been shared with Scottish Government Access Support Team.
3.2.3 Key Diagnostic Tests
As at month ending 28 February 2018, there are currently 175 Scope patients and 667 Radiology patients waiting over six weeks under NHS Highland.
Endoscopy have been running additional clinics to reduce the breaching number, specifically targeting upper endoscopy patients.
Of particular note is that there is an external provider, funded via Scottish Access Support team, to provide MRI scanning capacity on site at Raigmore. This will continue in Quarter 4 due to the replacement of a scanner in-house.
3.2.4 ED 4hr Compliance
The ED performance in this past period was severely impacted on by the high numbers of people presenting with flu. Fortunately Inverness was spared the attention of the ‘Beast from the East’ which had such a devastating impact on performance elsewhere in the country. Raigmore ED performance for April is currently sitting at 91.1% which is above the Scottish average of 86% and puts Raigmore in the top 25% performing sites. Whilst this is a positive position there is no complacency with everyone working to achieve the 98% standard which is well recognised as contributing to the most reliable and safe patient experience. This hides a challenging period which saw 3 medical wards closed at the same time due to Norovirus. This had a significant impact on patient flow with only 1 medical wing ward (7c) available for transfer downstream. This clearly put pressure on the ward which at one point has some 26 patients boarded out.
3.2.7 Cancer Access & Treatment Times
Appendix 5
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4. CARE
Service and Delivery
4.1 Adult Social Care 4.1.4 Delayed Hospital Discharge
Delayed discharge numbers are the lowest for a significant period of time currently sitting at 7 patients within Raigmore
4.2 Hospital Inpatients 4.2.1 Older People in Acute Hospitals (OPAH)
An unannounced OPAH inspection took place on the 17 and 18 April 2018 at the time of writing the report the output has not been made available.
4.6 Modernisation of Hospitals and Community Services
Initiatives to reconfigure beds within Raigmore are being progressed. This will result in a smaller footprint for Surgical beds and the creation of a Post Acute Ward which will cater better for patients needs who are beyond the acute phase of their in-patient stay. The expectation is that the creation of this ward will reduce length of stay and prevent patients being boarded from medicine into surgical beds.
5. FINANCE
For the end of the financial year 2017/2018, Raigmore is reporting a draft overspend of £10.5m, subject to audit, against an annual budget of £161.8m.
The main components of the overspend remain as previously reported -
£3.3m underlying deficit £4.4m unachieved savings – increased by £200k this month £1.9m drugs (spread across 6 areas incl Homecare drugs for GI and for Paeds, Cancer (Oncology & Haematology), Rheumatology, Neurology and Ophthalmology) – an increase in the final month of £400k £634k medical pay costs (includes out-sourcing for Radiology net of vacancies)
Raigmore has successfully delivered £6.3m of savings in the year with £2.2m of these being recurrent. The plans to deliver in line with the revised targets across the non-pay and agile admin projects progressed well with the savings being achieved by the year end. The newly formed non- pay governance committee is now becoming well-established with multiple plans underway to ensure that non-pay and procurement savings are delivered into next year; the membership now includes the Value Management Project Lead and Head of eHealth. Housekeeping savings delivered £1.1m of the £1.5m target whilst drugs over-achieved their target of £750k by delivering £815k within the year.
The main areas for continued work are locums and drugs and there are new meetings being
28 41 convened with a range of consultant staff to discuss how to improve the management of the drugs spend going forward.
29 42
Appendix 1
NORTH & WEST DIVISION OPERATIONAL UNIT: ACCESS TARGETS – 12 WK OUTPATIENT/TREATMENT TIME GUARANTEE (TTG)/REFERRAL TO TREATMENT (RTT) REPORT
1 CURRENT POSITION
NORTH
Inpatients:
Surgical – no patient breaching, 26 patients on waiting list with an average wait of 10 weeks Chronic Pain – 22 patients on waiting list for Caithness General Hospital, 42 patients on waiting list for Lawson Memorial Hospital, with an average wait of 11 weeks with one patient breaching Gynaecology – 7 patients breaching. 23 patients on waiting list with an average wait of 13 weeks. Cataract – 71 patients on the waiting list, only 6 sessions available at present. 55 patients breaching with an average wait of 8 months
Out Patients:
Chronic Pain – 0 patient breaching Medical – 3 patient breaching, all awaiting 24 hr Holter monitoring Surgical – 1 patient breaching Gynaecology – 0 patients breaching. Ophthalmology backlog of return patients by consultant under review by Raigmore.
WEST
Inpatients – currently meeting Treatment Time Guarantee (TTG) dates. With significant endoscopy referrals, theatre time is limited. Several patients on Inpatient waiting list showing as breaching TTG are from Raigmore Consultants and have breached before appearing on Belford list. Outpatients – local specialties are within Referral to Treatment (RTT) dates. Visiting Consultant clinics are regularly breaching due to insufficient new patient appointment slots and number of consultant visits. In particular, 3 upcoming clinics for Dermatology have been cancelled with no rescheduled dates. New patients for this specialty have been waiting since February 2018 with return patients waiting from December 2017. Gynaecology clinics are currently suspended at Belford due to reduced Consultant numbers in Raigmore. All referrals and return patients have been changed to the Raigmore waiting list.
30 43
2 ACTION PLANS TO ADDRESS
NORTH
Theatre utilisation has been reviewed and Pre Operative Assessment (POA) appointments have been increased and an additional session arranged to reduce waiting times. POA service has been transferred to the Surgical Suite. Staff training completed to improve capacity and efficiency. Referrals are being triaged by Raigmore and Locum Consultants Discussions are ongoing with visiting Surgeons who will assist in managing the current position. Visiting Consultants notified of available theatre sessions. The rotational Raigmore consultants have been requested to provide additional theatre sessions when covering their locum week. Inpatient Treatment Time Guarantee weekly meetings in place to closely monitor position to take necessary action to improve performance. Cataract Surgery – Waiting times increased following the retirement of one of the ophthalmologists. It has been confirmed that a locum ophthalmologist has been recruited to provide monthly cataract sessions from May 2018 which will have a positive impact on the current waiting list. Meetings are ongoing with the ophthalmology team in Raigmore to review current service provision. An Optical Coherence Tomography scanner has been purchased to introduce regular nurse led clinics in Caithness General Hospital to improve local services, reduce the number of people who have to travel to Raigmore and create capacity in Raigmore. Staff training in progress for visual fields, OCT and biometry.
WEST
Inpatients – Treatment Time Guarantee monitored to ensure and maintain no local breaching patients. Outpatients – Patients on waiting list for visiting Consultants offered Raigmore appointments where there is availability but this is very limited due to pressures on Raigmore waiting lists. Updates have been requested with regard to Gynaecology and Dermatology. Referral to Treatment times monitored to ensure no local speciality breaching. Breach report provided to Rural General Hospital Manager and Area Manager on a monthly basis.
3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE
NORTH
Improvement in Pre-Operative Assessment process will improve the gynaecological targets
31 44
Cataract Surgery – difficult to predict. Ongoing discussions with Raigmore to review and improve current services.
WEST
Maintenance of Treatment Time Guarantee and Referral to Treatment targets for all local specialities and reduction of breach times for patients awaiting appointments for visiting consultant clinics. Expected return of visiting Gynaecology consultants to Belford.
4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)
North
Cataract surgery – Cataract waiting times are expected to improve following the appointment of a locum ophthalmologist
West
Planned performance currently being met for patients on lists of local specialties and plans in place to maintain this. Monitoring and assurance required that Gynaecology clinics will return to Belford Hospital and that a regular Dermatology Clinic will be back in place as soon as possible.
RGH Managers Belford Hospital & Caithness General Hospital 17.04.2018
32 45
Appendix 2
NORTH & WEST DIVISION OPERATIONAL UNIT: 8 Key Diagnostic Tests - Endoscopy
1 CURRENT POSITION
North – Caithness General Hospital
There are currently no patients un-booked for Ultrasound colonoscopy
Routine endoscopy - 10 patients currently un-booked with a 3-4 week waiting time. There are 17 patients waiting for a return Endoscopy appointment.
West – Belford Hospital Fort William
There are currently no patients waiting beyond breach date for a new endoscopy appointment. There are problems with capacity for all Bowel Scope Screening colonoscopies. Referrals from Skye GP’s for endoscopy, along with queries regarding current active status of Capsule Endoscopy Service, resulting in referrals being sent to Belford Hospital for assessment and booking. Limited number of appropriate consultants to undertake endoscopies within Belford has had an impact on number of sessions available. Theatre time required to undertake endoscopies due to high number of referrals and limited number of appropriate consultants to undertake endoscopies. Return endoscopy patients waiting: 3 patients from January 2018, 4 patients from February, 2018 and 8 patients from March 2018.
2 ACTION PLANS TO ADDRESS
North
Endoscopy sessions – Colorectal surgeons have increased their Thursday morning sessions from 10 to 12 points. Ongoing screening of referrals/return patients undertaken. Review endoscopy equipment with a view to increasing the number of Gastro Scopes from 3 to 4 to maximise the allocated list time. Day case capacity is limited, funding identified to progress to the next stage of the day case redesign project to increase capacity. Plans currently being drafted. West
Continued assessment and review of waiting list for return patients. Plans to have return patients waiting seen as soon as possible, but impacted by number of new referrals. Escalation of any potential patients breaching their target date to Consultant/Hospital Manager Continued monitoring of waiting lists to ensure patients are seen within target date.
33 46
Discussion at weekly Theatre and Waiting List meeting.
3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE
North
To continue with improvement on the current position West
All patients seen within their target date and return patients seen within the month of their recall date.
4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)
North and West
To continue to ensure no new patients wait beyond breach date and return patients are booked within their recall month.
34 47 Appendix 3 NORTH & WEST DIVISION OPERATIONAL UNIT: 8 Key Diagnostic Tests – Non Obstetric Ultrasound - Caithness General Hospital (North Area)
1 CURRENT POSITION
Ultrasound Sonography (Non Obstetric)
Routine Out Patient referrals (136) – currently have a 13 week wait. 5 patients have been triaged as ‘soon’ and will be seen within 5-6 weeks. 71 patients are on the long stop pending list and are due to be scanned at specific timed intervals. Urgent cancer referrals are routinely seen within 2 weeks Only 2 trained Sonographers at Caithness General Hospital with one currently on Maternity Leave. Recruitment difficulties with this type of post has an impact on waiting times There is only one ultrasound room and scanner which is fully utilised Currently 10 Ultrasound Sonography sessions per week are available however 4 sessions per week are dedicated to Obstetrics (including Early Pregnancy Assessment Unit) leaving 6 sessions for all others.
2 ACTION PLANS TO ADDRESS
Additional Ultra sound Sonography (USS) lists are scheduled for Lawson Memorial Hospital, with staff deployed from Caithness General Hospital to support – enhancing use of equipment on site. Patients will be offered appointments with travel expenses. Additional Wednesday morning routine Ultrasound waiting list provided. Lawson Sonographer deployed to Caithness General Hospital two days per month to maintain competence/skills/team working. Bank general Sonographer from Raigmore has been requested to provide cover for some dates during planned annual leave. This will ensure quality of performance with no equipment training issues, and reduces total reliance on Lawson radiographer/sonographer and associated back- fill. All scan referrals are vetted by a Sonographer to approve justification of scan, and to ensure that destinations of referrals are appropriate. Regular liaison with GP Practices in the area to ensure that they are aware of the capacity issues within the service, and to ensure that clinical information contained within the referral is categorised appropriately at point of referral. Staff development in Ultra Sound Sonography to be planned to ensure future workforce planning and sustainability of services. 2 x Abdominal Aortic Aneurysm (AAA) screening training posts have been approved. 3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE
Ultra sound waiting lists are expected to increase with reduced capacity due to staffing issues.
35 48
4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)
Difficult to predict
Rural General Hospital Manager Report Date: 17.4.2018
36 49
Appendix 4
NORTH & WEST DIVISION OPERATIONAL UNIT: Chronic Pain Management Service North NHS Highland
CURRENT POSITION
The Chronic Pain service has received 877 new referrals in the year April 2017 to March 2018. All referrals meet the criteria for NHS Highland Chronic Pain Management Service referral pathway. Staffing - New lead Physiotherapist commenced in post in March 2018 - Specialist nurse - currently on a 6 month contract for 17.5 hours per week. This has allowed 4 Lidocaine infusions list per month to be undertaken. Issues with increasing demand and capacity for this end line treatment continue. Ongoing discussions regarding an increase in Infusion bed capacity to allow 2 infusions to take place at the same time with the same staffing levels. Theatre Procedure patients (TTG target) - As at end March 2018 there are 2 patients who will breach the new In-patient waiting targets. - At present the service is unable to offer two TTG appointments for new in-patient treatments within target times.
Returns waiting list (only included waiting list that has significant wait times or where there has been a significant reduction) as at the end of March 2018: - Theatre procedure repeat injections: 202 patients with a waiting time of 8 to 9 months - Dr Reviews: 101 patients with a waiting time of 8 months - Psychology: Previous waiting list has been dealt with – 13 patients to book with longest patient waiting since 17/2/2018 - Pain management programme: 10 patients; longest patient waiting since 17/2/2018. All 10 will be given a place on next pain management introduction session. - Distance pain management programme: 10 patients with longest patient waiting since 14/2/2018 - Pain education session – all new referrals placed into sessions at Inverness and Wick, the service is currently over booking these sessions to account for increased referral rate. The Fort-William Pain Education class is unable to run due to current staffing but this will be addressed in April/May 2018.
The number of patients presenting at the Chronic Pain Service over the past 2-3 years have more complex pain issues therefore requiring increased level 2 and 3 care and support.
Due to the specialised work of the service it is makes it difficult cover any periods of staff leave as we are unable to locate appropriate locum cover. Increase in the number of patients who CNA (Could Not Attend) on the day before, or on the day of appointment
37 50 and unable to fill that slot due to short notice of cancellation.
2 ACTION PLANS TO ADDRESS
Demand for the chronic pain management service continues to outweigh capacity available. Achieving 40% of out-patient appointments (new and review) by tele-health clinics Theatre clinic at Lawson and Caithness sites running at approximately 97 – 98% % occupancy level All Consultant clinic waiting lists have been reviewed and all patients currently on the waiting list are appropriate and require Consultant review. The service has changed criteria for patient repeat injection procedures to ensure that only patients that get a good response are going forward for repeat procedures The services ensure that all Could Not Attend (CNA) theatre and other clinic slots are filled where possible. Despite all the service redesigns been put in place this has not made any significant impact on reducing the number of new patients referrals and waiting time for all clinics. Plans in place for a service review now that all new staff are in post – discussions ongoing with Michelle Johnston Area Manager (North).
3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE
As demand continues to outweigh capacity it is difficult to plan for any return to trajectory
4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)
As demand continues to outweigh capacity it is difficult to plan for any return to trajectory
Jackie Milburn (Clinical Nurse Manager, NHS Highland Chronic Pain Management Service 23.04.2018
38 51
Appendix 5
CANCER STANDARDS UPDATE
1 CURRENT POSITION
31 Day Performance – Quarterly to end March 18 ( Including estimated March 18 performance)
( From “decision to treat” to treatment for all patients regardless of the route of referral)
Chart 1 - Number of Patients Treated and Breached
400
350 26 15 11 21 18 22 11 9 12 15 8 14 300 11 11 9 10 12 12 11 10 5 250
200 317 321 150 300 295 309 305 308 303 302 292 295 294 291 274 267 269 277 258 260 268 276 100
50
0 201320132013201320142014201420142015201520152015201620162016201620172017201720172018 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
Treated Breached
Performance against 95% Standard 99.0 97.0 98.1 96.9 97.3 96.8 95.0 96.0 96.3 96.4 95.9 96.0 96.3 96.1 95.9 96.0 95.1 95.2 95.5 93.0 94.9 94.3 91.0 93.1 93.1 91.5 89.0 87.0 85.0
31 Day Performance against 95% Standard As can be seen above, the Board continues to meet this Standard on a regular basis unfortunately performance in the latest Quarter dipped as a result of the theatre shutdown and
39 52 the clinical prioritisation of cases deferred. Failures tend to be within Urology in the main.
62 Day Performance – Quarterly to end March 18 ( Including estimated March 18 performance)
(From date of referral to treatment, for all patients referred urgently with a suspicion of cancer)
Chart 3 – Number of Patients Treated and Breached 300
250 31 37 25 200 23 26 27 16 25 13 18 11 13 7 22 9 12 10 21 12 150 13 21
218 100 207 208 191 188 185 181 187 178 178 167 175 171 166 165 174 166 145 153 156 145 50
0
Breached Treated
Chart 4 – Performance Against 95 Per Cent Standard
100.0 62 Day Performance against 95 Per Cent Standard 95.0
90.0
96.0 85.0 93.8 94.6 93.9 92.7 92.4 92.8 91.4 92.2 91.0 89.7 88.0 86.7 88.0 80.0 86.2 86.5 86.2 85.5 85.8 85.6 82.1
75.0 201320132013201320142014201420142015201520152015201620162016201620172017201720172018 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
40 53
As can be seen above, the performance against the standards, particularly the 62 Day Standard continues to be a significant cause for concern, both locally but also Nationally where the 62 Day Performance in January 18 was 81.3 per cent.
The major of the patients who breach continue to be within Urology and its sub specialties. Minimising the number of Urology patients breaching their target would almost certainly ensure that the target was met as a Board.
31 Day Target
Jan Apr Jul Oct Jan April July to Oct Jan to to To To to to Sept to to Mar Jun Se Dec Mar Jun 17 Dec Feb 16 16 p 16 17 e 17 17 18 16 Other (Non 6 4 3 1 3 6 4 6 5 Urology)
Prostate 3 1 1 3 Bladder 2 2 31 Renal 6185237 42 TotalUrology 14 5 14 9 5 12 12 11 10
(March 18 to be confirmed)
The numbers of patients breaching within Urology are due to pressures at almost every stage in the pathway but given that this target measures the time from “decision to treat” to treatment it is clear the patients are breaching as a result of delays to both surgery and also Radio Frequency Ablation for Renal Cancer.
62 Day Target
Jan Apr Jul Oct Jan Apr July to Oct Jan to to To To to to Sept to to Mar Jun Sep Dec Mar Jun 17 Dec Feb 16 16 16 16 17 e 17 18 17 Other (Non 3 14 9 12 10 16 8 13 10 Urology)
Urology Bladder 1 22 13 Prostate 5 7 11 7 11 8 13 10 16 Renal 30321 4 72 TotalUrology 12 21 24 21 12 16 27 31 31
As reported before Urology is the specialty with the greatest challenges as a result of limited capacity within Bladder, Prostate and Renal Pathways. Despite additional utilising additional theatre and clinic capacity the latter two pathways in particular suffer from their dependency upon single handed practitioners.
41 54
There is also an emerging pressure as a result of a greater number of patients being referred to Endoscopy following the introduction of the FIT test (Faecal Immunochemical Test) test as part of the National Bowel Screening Service in November 17. This should be a temporary pressure until the thresholds and sensitivity for referral are moderated nationally.
A poor performance in February caused by the Theatre closures has been remedied in March with an improved performance of 92 per cent. Considerable effort is required to bring about a sustained improvement given the underlying capacity issues.
In March the dedicated TRUS Biopsy Room within OP has been commissioned in order to provide a permanent location for the service. The SMT has also approved the introduction of FIT as part of the Symptomatic Bowel patient pathway, as a result there is expected to be a 14 per cent deduction in demand for Endoscopies. Immediate actions over the next two months are concentrating upon other actions to improving performance including:
Developing an agreed action plan to bring about additional staffing capacity for the TRUS Biopsy Service focusing upon completing the training plan for the staff appointed in 2017.
Continuing to work with the Urology service in order to establish an on-call service at NP level freeing up the Consultants to provide additional capacity.
Continuing in our efforts to appoint to the vacant 6th Consultant Urologist post.
42 55
DIRECTOR OF ADULT SOCIAL CARE REPPORT Report by Joanna Macdonald, Director of Adult Social Care
The Health and Social Care Committee is asked to:
Note the contents of the attached report.
Joint Health and Social Care Transitions The implementation of the Inner Moray Firth 14-25 Joint Transitions Team is progressing well and on target for the team becoming operational in June 2018.
There are a number of steering groups across both The Highland Council and NHS Highland providing support and governance and providing the specialist guidance and detail required to enable the Joint Transitions Team to commence with confidence.
Two Community Learning Disability Nurses are being recruited from existing vacancies within the Inverness and Nairn community team. The leadership for the team is progressing with the practice lead from Highland Council recently recruited, and the adult team lead from NHS Highland currently advertised with a plan to interview w/b 14th May.
These two posts will work in partnership to lead the team and provide the required support and guidance to staff across the 14-25 age range including the necessary statutory leadership for care and protection of young people.
The office base for the team has been identified as Kenneth Street Inverness, which is the current location of the Deaf Service Inverness.
Deaf Services and Sight Action The See Hear Improvement Group (SHIG) has developed priorities for closer working between Deaf Services and Sight Action.
Deaf Services are currently located in Kenneth Street in Inverness and accommodate a Drop In centre Monday to Friday for aids and adaptations as well as accommodation for a Saturday Deaf Club.
The Drop In Centre and Saturday Deaf Club are in the process of relocating to Sight Action’s premise in Beechwood Business Park, in line with SHIG’s development plan with the moves due to be completed by end of May 2018.
Dietetics and Nutrition in Care Homes Evelyn Newman, nutrition and dietetics advisor for care homes, has led a successful multi disciplinary review of nutritional product prescribing over the past year. 56
A more proactive “FoodFirst” approach is being encouraged and directed across all Highland primary care settings and care homes.
The work is part of a wider “Once for Scotland” approach with NHS Highland has taken a number of decisive, risk-assessed actions to deliver a faster programme of change than other boards.
Following extensive consultation a new, more focussed, prescribing formulary has been developed; guidance for prescribers has been issued; and the use of longterm nutritional supplements is currently being targeted and phased out.
It is positive to note that there have been no negative concerns raised by care homes, prescribers or service users and no reports of any negative impact from these actions.
Significant, recurrent financial savings have already been established and this transformational work has been selected for a workshop presentation at the NHS Highland “realistic medicine” event later in June 2018.
Joanna Macdonald Director of Adult Social Care April 2018
2 57 Health & Social Care Committee Item xxx
FINANCE REPORT Report by Kenny Rodgers Interim Head of Financial Planning
The Committee is asked to:
Note: Month 12 draft position of a £13.1m overspend on budget
Note: The position comprises £6.5m of savings not achieving, £2.6m of savings not identified and £4.m of cost pressures.
Headlines
The Health & Social Care Partnership’s month 12 position indicates a draft (subject to year- end processes and annual accounts) overspend of £13.1m and the high level breakdown of this is shown in table one below.
Table 1
Position Against Budget The revenue position for the financial year (April to March 2018) is an overspend against budgets of £13.1m Table 2 below demonstrates the overspend by Unit, and table 2b by type of spend.
Table 2a
1 58
Analysis
The table above represents the position by management unit within the HSCP This table shows that there is an overspend within the South & Mid division of £4.8m, Raigmore has an overspend of £10.5m while North & West Division has an overspend of £6.5m giving an overall position of £21.8m for the 3 operational units. This is mainly due to unachieved and underperforming savings of £10.8m as shown in Table 1 above, and £11m of cost pressures. Offsetting benefits and any agreed allocation slippage held within other and central areas bring the overall projection for HHSCP to £13.1m
HHSCC Finance Table month 12 can be seen in App A and has further information on the financial position at month 12
Pay Budgets
The effective management of pay budgets in delivering our services remains a key challenge. There are a number of ‘hard-to-fill’ posts critical to service delivery (particularly in relation to medical staff but also in other disciplines) where vacancies may exist for an extended period of time. Many of these are filled with locum or agency staff, whose costs tend to exceed the salary budget available to cover the cost (often by a significant amount).
These excessive costs for key medical posts have still to be met within the overall pay budget so savings have to be generated elsewhere. This is done mostly through the turnover of staff or vacancies being carried for a period of time. These excessive costs for key medical posts have still to be met within the overall pay budget so savings have to be generated elsewhere. This is done mostly through the turnover of staff or vacancies being carried for a period of time.
In a large organisation, a level of staff turnover is inevitable. NHS Highland’s annual turnover tends to run at around 8-9%. There is generally a gap between a member of staff leaving and a new member of staff starting – this generates a non-recurring savings usually referred to as a ‘vacancy factor’ and most pay budgets are set based on an expected level of natural vacancy factor. Pay has an underspend of £1.6m to month 12
Non Pay
The key pressures on non-pay are Social care services with an overspend of £6.4m, hospital drugs & prescribing of £2.8m and clinical non-pay budgets of £2m, with some offsetting underspends on a range of general non-pay budgets, non pay overall is projected to overspend by £10.3m
Savings unachieved of £9.1m (detail below) along with income and commitments bring the overall year end position to £13.1m.
The spend by type is shown on table 2b below;
2 59 Table 2b
Savings
For 2017/18, the HSCP was allocated a savings target of £39.6m. To date, £30.4m has been identified, leaving £9.1m of unachieved or unidentified savings It should be noted that of the £30.2m achieved and forecast to achieve only £6.8m of that is recurrent. Some full year effect recurrent savings have been identified of £10.4m leaving just over £22m to be taken forward to the 2018-19 plan. Table 3 below show the savings by Unit and table 3b by category
Table 3 – Savings
3 60 Table 3a
Conclusion
The HSCP has overspent by £13.1m on revenue for the year. Emerging and ongoing cost pressures within Social care and Out of Hours along with outstanding savings are the contributing factors for the overspend.
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. The financial position is scrutinised in a wide variety of governance settings in NHS Highland.
Risk Assessment
Risks to the financial position are set out in a specific risk section above. There is an over- arching entry in the Strategic Risk Register.
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 services.
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 4 61 considered at the full Board meeting on a regular basis. All these meetings are also open to the public and are webcast.
It is recognised that NHS finances are complex and often jargon is used. The report aims to convey the key messages in non-technical language. There is also a glossary of key terms used in Appendix B
Kenny Rodgers Interim Head of Financial Planning
5 62
Highland Health and Social Care Expenditure & Savings (£000's)
Month 12 March 2018 App A
% of total Achieved Achieved Current Current Savings Annual % of area Health & Variance as % of local Recurrent Non Rec % of savings Budget to Spend to Target for the Budget local budget Social Care at month 12 budget savings to Savings to achieved date date year Budget month 12 month 12 £000's £000's £000's £000's £000's £000's £000's £000's South and Mid 204,853 100.0% 34.0% 204,853 209,649 (4,796) 8,601 4.2% 1,621 3,433 58.8% Easter Ross 19,719 9.6% 3.3% 19,719 20,104 (385) Mid Ross 19,211 9.4% 3.2% 19,211 20,010 (799) Inverness East 35,293 17.2% 5.8% 35,293 36,534 (1,241) Inverness West 25,621 12.5% 4.2% 25,621 25,737 (116) Nabs N&A 13,522 6.6% 2.2% 13,522 14,190 (668) Nabs B&S 13,624 6.7% 2.3% 13,624 14,145 (521) S&M Central inc Management 7,378 3.6% 1.2% 7,378 9,861 (2,482) South Area Other 1,684 0.8% 0.3% 1,684 1,607 77 Care at Home 15,754 7.7% 2.6% 15,754 15,665 90 Comm Mental Health 9,093 4.4% 1.5% 9,093 9,425 (332) Adult Mental Health* 17,806 8.7% 3.0% 17,806 17,737 69 Dental Services* 19,948 9.7% 3.3% 19,948 18,765 1,183 Learning Disabilities* 3,597 1.8% 0.6% 3,597 3,460 136 Drug & Alcohol Recovery Service * 2,604 1.3% 0.4% 2,604 2,410 194
South & Mid Health 127,012 62.0% 21.1% 127,012 129,758 (2,747) South & Mid Social Care 77,841 38.0% 12.9% 77,841 79,891 (2,049)
Raigmore 161,794 100.0% 26.8% 161,794 172,286 (10,492) 10,660 6.6% 2,201 4,107 59.2% Surgical Specialties Division 63,103 39.0% 10.5% 63,103 64,282 (1,180) Medical Division 52,850 32.7% 8.8% 53,744 55,331 (1,587) Cancer Services 12,372 7.6% 2.1% 11,478 11,701 (223) Raig Senior Mgt & Central Cost (2,567) -1.6% -0.4% (2,567) 5,297 (7,864) Clinical Support Division 30,558 18.9% 5.1% 30,558 30,417 141 Quality & Safety Division 6,536 4.0% 1.1% 6,536 6,348 188 ACT * (1,058) -0.7% -0.2% (1,058) (1,090) 32
North and West 136,713 100.0% 22.7% 136,713 143,260 (6,547) 8,189 6.0% 1,768 3,509 64.4% Lochaber 35,238 25.8% 5.8% 35,238 37,210 (1,972) Skye, Lochalsh & W Ross 29,148 21.3% 4.8% 29,148 30,886 (1,738) Caithness Acute 13,474 9.9% 2.2% 13,474 13,690 (216) Caithness District 27,551 20.2% 4.6% 27,551 30,133 (2,582) Sutherland 22,182 16.2% 3.7% 22,182 22,658 (476) NW Management 4,717 3.5% 0.8% 4,717 4,419 298 Sexual Health * 1,679 1.2% 0.3% 1,679 1,484 195 Highland Hub * 865 0.6% 0.1% 865 879 (14) Chronic Pain Service * 307 0.2% 0.1% 307 395 (88) Highland Hospice * 1,550 1.1% 0.3% 1,550 1,505 46
North West Health 92,271 67.5% 15.3% 92,271 94,831 (2,561) North West Social 44,442 32.5% 7.4% 44,442 48,429 (3,986)
Other North Highland 99,982 100.0% 16.6% 99,982 91,265 8,717 12,132 100.0% 1,180 12,626 113.8% Adult Social Care - Central (2,620) -2.6% -0.4% (2,620) (3,369) 749 357 2.9% 357 100.0% Facilities 22,592 22.6% 3.7% 22,592 22,930 (339) 968 8.0% 757 211 100.0% Integrated Pharmacy 5,305 5.3% 0.9% 5,305 5,146 159 0 e health 10,264 10.3% 1.7% 10,264 10,243 22 317 2.6% 66 251 100.0% Tertiary 20,635 20.6% 3.4% 20,635 20,455 180 0 Other 2,502 2.5% 0.4% 2,502 2,473 29 0 Central services 41,304 41.3% 6.8% 41,304 33,386 7,918 10,490 86.5% 12,164 116.0%
TotalHHSCP 603,342 100.0% 603,342 616,460 (13,118) 39,582 6,771 23,674 76.9% 6 63 Glossary of Key Terms Appendix B
RRL – Core Revenue Resource Limit. The majority of the Board’s revenue income comes in the form or Core RRL from the Scottish Government. The Board has a duty to break-even on RRL each and every financial year.
Revenue - generally relates to ‘day-to-day’ expenditure such as staff salaries, drugs, surgical dressings etc and this represents the vast majority of expenditure.
Recurring – ongoing (i.e. income or expenditure that is expected to continue for the foreseeable future).
Non-recurring – one-off (i.e. income or expenditure that is ‘one-off’ in nature and is only expected in a single financial year). However, it is the case that there is always a level of non-recurring income or expenditure every year. Therefore, whilst individual items might be viewed as ‘non-recurrent’, as a general assumption there will always be some level of non- recurrent activity in any given year.
Saving – a reduction to a budget to reflect a firm plan for delivering a saving. The savings will be expected to reduce expenditure, therefore allowing the budget to be reduced without generating an overspend.
Cost reduction – a reduction in expenditure. Generally, the difference between this and a saving is that a cost reduction usually refers to a reduction in an overspend against a budget. In order to deliver a saving, further reductions usually have to be made so that the budget can be reduced.
Cost pressure – usually refers to expenditure that cannot be contained within an existing budget.
Vacancy factor – usually refers to a reduction in a pay budget in anticipation of savings arising from vacancies. A level of turnover of staff is inevitable in a large organisation. The gap between a member of staff leaving and their replacement starting often generates a non- recurring saving. Most pay budgets are set with an in-built shortfall to reflect this fact – known as the ‘vacancy factor’. All units begin the year with an assumption that this vacancy factor will be achieved – so it is generally just noted in their financial risks (and monitored monthly) rather than featuring as a forecast overspend. There is a solid history of achieving vacancy factor targets.
Forecast – the financial forecast represents the best estimate of the year-end position based on current known facts and the anticipated impact of actions being taken or planned. It is crucial to appreciate that the forecast is only an estimate and reflects how the position might be at year-end. The forecast is not a mechanical calculation – there is considerable uncertainty and hundreds of variables are involved - so it requires professional judgement. Clearly, the level of uncertainty reduces as the financial year progresses.
Risk – in the context of this report, risk relates mainly to financial risk (i.e. the possibility of an overspend materialising which is not currently built into a forecast). Risks are generally managed at unit level and it is the unit that will judge whether a risk can be held outside the forecast or not. Usually this requires a mitigation plan. Another related risk factor is the operational risks associated with achieving financial targets (e.g. a savings plan may be low risk in financial terms – i.e. there is high degree of confidence in delivering a cash saving – but might be high risk in terms of an operational impact). Unless otherwise stated, the risks (and risk ratings) referred to in this report relate to the risk of an adverse financial impact (rather than any other risks such as operational or reputational).
7 64
8 65
CAITHNESS MATERNITY AND GYNAECOLOGY | SERVICE USER FEEDBACK
Report by Mary Burnside, Interim Head of Midwifery
The Committee is asked to:
Note the feed-back from service users following the move to establish a midwife-led Community Maternity Unit. Provide direction around any change in approach required to gain further and future feed-back.
1. Summary
This paper summarises a number of approaches to gain service user feed-back since the move to establish a midwife-led Community Maternity Unit in December 2016 including:
o Maternity questionnaire developed in partnership with service users o Informal group and individual facilitated maternity feed-back o Pilot VC for antenatal clinic
Overall the feed-back on maternity was mixed for some aspects of services delivered both in Caithness and in Raigmore
Notably there appears to be very differing opinions from service users but it is clear, that in general, convenience is important
While just under half say they did not have a named midwife the vast majority, almost nine out of ten, say they saw their midwife as much as they wanted
Eight out of ten people rated their care as excellent or good
Feed-back about support for Infant Feeding was very positive
Around 80% said they had adequate pain relief (or didn’t need it) prior to transfer
Concerns around the delivery of safe care were not raised as an issue by service users
There are, however, ongoing issues around accessing and differing expectations around accommodation in Raigmore
The VC Clinic for antenatal to reduce travel was received very positively.
Further scrutiny and actions is required to achieve greater consistency of delivery of services
The Lead Midwife and Midwifery Team are reviewing feedback on a regular basis and where possible are making changes to address some of the concerns identified on an ongoing basis. 66
Further thought should be given to increasing response rates for Caithness mothers and families.
2. Background
On 29th November 2016 NHS Highland Board approved the recommendations of ‘‘Caithness Maternity and Neonatal Services – A Public Health Review’ . This included the move to set up a midwife-led Community Maternity Unit (CMU). The designation formally changed on Monday 4th December 2016 but in effect had been operating as CMU since November 2015 when interim arrangements were put in place pending internal and external reviews.
An interim report on progress with establishing the CMU was presented to the board in May 2017. There was a further update to the board on 28th November, including a summary of clinical activity up until 1st November 2017.
Over the twelve month period from 1st December 2016 to 1st Dec 2017 there had been a total of 196 births to women resident in Caithness. Of these, 177 births were in Raigmore Hospital, 19 in the CMU and one planned delivery elsewhere.
Transfers and retrievals were lower than in the previous arrangements. This is considered to be an important indicator that the new arrangements are working as planned.
It was agreed on 28th November 2017 that future updates on the service would be referred to the Highland Health and Social Care Committee, including any service user feedback. This paper summarise some of the service user feed-back.
3. Methodology
Questionnaire | Maternity Services
A Local Community Maternity and Gynaecology Group (CMAGG) was established to support awareness of the CMU and provide feed-back and support around some of the practical arrangements. The Group include representatives from community councils, Scottish Ambulance Service, NHS Highland, Breast Feeding peer volunteers and members of the public. The Group is chaired by local GP Dr Alison Brooks.
The Group prepared a questionnaire as one way of getting service user feed-back. They took the national maternity survey as a starting point and highlighted all the areas thought to be relevant to the local situation. They then looked at adding specific questions based on well known local concerns. Questions, based on research, which would give a measurable idea of their overall experience was also included. It was developed and tested through a series of Plan Do Study Acts cycles of change with service users before being finalised. This took a number of months in the preparation https://www.surveymonkey.com/r/SMYWQPX 67
The Objective of seeking feed-back was to understand what is important to women in the provision of safe maternity services locally and in Raigmore to support continuous improvement.
The survey was issued in November 2017. There were 42 questions, and on average the survey took around 10 minutes to complete.
The questionnaire was issued to mums six weeks post-discharge. Hard copies (with Freepost envelope) and electronic versions were available. It was also issued to all mums who had given birth since Jan 2017 and is ongoing. Therefore some of the feed-back dates back to 2016 while some of the responses are recent.
To date 152 copies have been issued with 37 responses giving a (response rate of 24%).
Informal Group and Individual Feed-Back | Maternity
Peer-Volunteers also carried out three informal group sessions to gauge feed-back. These were held as part of Postnatal / Infant Feeding support group on September 2017, November 2017 and April 2018. There were 18 people in total who took part with 12 people completing questionnaires giving a response rate of 67%.
While in September and November 2017 feed-back was via group sessions in April 2018 it was via 1:1.
VC Clinics | Antenatal
A survey was also prepared to review feed-back on a VC Clinic for antenatal women run by Dr Lucy Caird. The clinic was held on 16th January 2018.
4. Results | Summary of Feed-Back
Questionnaire | Maternity Services
The full collated responses (N=37) is provided in Annex 1 with the main findings summarised below.
Of those who responded (Q1), 11% gave birth in the CMU in Caithness General, 81% in Raigmore and 8% ‘other’; other was made up of Wick, Aberdeen and home birth.
In terms of choice (Q2), just over one quarter (27%, n=10) were offered a choice of giving birth in the local midwife led unit; over one third (35%, n=13) were advised to give birth in a consultant led unit due to medical reasons, and 30% (N=11) responded that they were not offered choice.
Two thirds (67%, N=24) felt they got enough information to help make a decision where to have their baby (Q4); 62%, N=23) said they did not have a named midwife (Q5), but everyone (100%) said they had a contact number for their midwife (Q6). Of those who needed to contact their midwife 57% always got a response, 27% 68 sometimes got a response, 14% did not need to make contact, and one person (2.7%) said they did not get a response (Q7).
Questions 10 and 11 were related to ante-natal education.
84% were offered ante-natal classes. Of the antenatal classes available 43% did not want/need classes; 34% thought it was about right, and 23% felt it was not enough.
At the start of labour 44% thought they were given clear instructions when they contacted the hospital, and a further 44% did not contact the hospital. Four mothers (12%) felt they did not get clear instructions. During labour 63% responded that they always had enough pain relief; 11% sometimes; 17% stated they did have enough pain relief and (9%, 3 mothers) did not want / need pain relief.
All babies were born in hospital with the exception of one home birth.
Of the mothers travelling to Raigmore to give birth, 88% (N=29) used their own car, one came by Ambulance, one by air ambulance and one by air ambulance and ambulance (Q15). When using their own transport only half said they were given information around what to do in an emergency situation (Q16).
Prior to transfer to hospital three people (10%) required pain relief while the remaining 26 (90%) did not (Q17).
There were 37 deliveries: 24 (65%) were vaginal and 13 (35%) were caesarean section, including seven emergency sections (Q18). 95% said they were able to have the people they wished to be with them during labour and delivery; two people responded that they were not able to.
Questions 21 to 23 were about accommodation. Three quarters required accommodation (Q21), broken down as follows (Q22):
Who % N Myself 11.1 4
Forbirthpartner 61.1 22
Family accommodation 8.3 3
I did not require 19.4 7 accommodation
One question on accommodation was freetext “Were there any problems/issues with accommodation? Please state what these issues were. The individual responses are included in full (Annex 1) with some of the comments highlighted below:
Reflecting the positives
No issues None No problem, very helpful 69
Reflecting concerns
We don't have much support so staying in Inverness for three days 100 miles away from my other children was a problem My partner and I had separate single bedrooms and had to share a bathroom with other people Not available until late at night No one knew much when we arrived - no keys ready. Not well organised Not booked for longer than 3 days There were no problems with the accommodation we booked, but it was at cost to ourselves
Other comments
Only received one night. Had to find alternative accommodation for the rest of the stay Only given accommodation for one person (partner) my mother stayed in B&B. Emergency accommodation required had to wait for it to be sorted Went to collect keys - advised that no booking was recorded. Had to be resolved by my Husband himself None, however I did not get any visitors after the birth from close family due to having baby in Inverness (instead of Wick) which was quite sad on hindsight. If we were based in Wick this wouldn’t have been a problem as family members could visit in the evening after their work.
Length of stay in hospital ranged from up to 12 hours to five days or more. Overall around half staying for two days or less and half three days or more (Q 24). About 65% thought their length of stay was just about right; 19% too short and 16% too long (Q25).
There was a series of questions about feeding (Q26 to Q33). 87% (N=34) felt they received relevant information about feeding their baby; one person said they did not and three did not want information. 84% (32) had contact with an Infant Feeding Support Worker during their pregnancy while 16% (N=6) did not. 79% (N=29) responded that they had enough practical help and support regarding feeding in hospital whereas as 20% (N=21) did not.
Turning to formula feeding and information/support, approximately half responded that they got information and support on: Sterilising equipment, using stage one milk for first year, pacing feeds and signs that baby is receiving enough milk (Q 29).
70 to 75% all responded positively to a series of questions around receiving information to get breast feeding off to a good start (Q30).
82% (N= 31) were confident with feeding prior to discharge (Q 31) and everyone who breast-fed received support in the community once they were discharged from hospital (Q32) and almost all felt the level of support was about right (Q 33).
One person did not have a telephone number for a midwife or midwifery team post discharge (Q34). While just under half (45%) did not have a named midwife (Q35) the vast majority (85%) saw their midwife as much as they wanted (Q36). Overall 70 one person rated their care as poor and 31 (82%) as excellent or good (Q37); two people responded that their personal needs were never met (Q 38).
71% (N=27) felt that staff were always caring towards them with a further 18% often and 11% sometimes (Q 39). The results from Question 40 about care and 41 about safe care are shown below
The final Question provided an opportunity for additional comments to be included. This has still to be analysed, themed and reviewed to ensure any patient identifiable information is removed.
Informal Group Feed-Back | Maternity
Based on three informal groups, totalling 18 people, the following points were highlighted: 71
September 2017
Caithness Great experience delivering in Caithness General
General Comments Increased negative press and social media causing worry and concern Came off Facebook during pregnancy. No sharing of positive CMU or Raigmore stories or information Would like a post natal survey, felt this was a positive idea
November 2017
Caithness Good experiences and interactions with Caithness midwives
Raigmore Hospital Felt Raigmore midwife discussed things well and explained options regarding pain relief Liked that staff handover happened at bedside as this gave reassurance Positive experience with Raigmore staff Positive overall experience having her baby Raigmore was very busy Unable to access booked accommodation due to time of arrival (1am). Felt pressure to leave due to limited nights accommodation Discharge from Raigmore after 7pm meaning a late arrival home Unnecessary trip to Raigmore for monitoring. Felt they left hospital sooner than they wanted to be closer to family in Caithness Extra trip for a scan in Raigmore only a few days after having one in Wick.
April 2018
Caithness Feeding support was good. Found home visit support from Infant Feeding Support Worker was very beneficial. Timing of visits between midwife visits and health visitor visits meant if felt like I always had support. Enjoyed the antenatal classes. The Hypnobirthing classes were good and was able to use the techniques learnt. Initially was discharged from Raigmore to my mothers house and on return to Caithness was appreciative of the extended time that midwives kept in contact for support. Discharge on day five after a section still felt too early but did have the option to stay with family near Inverness rather than travel home to Caithness Explanation regarding ‘choice’ of place to give birth was not done early enough. Explanations/conversations later in pregnancy gave a better outline of choice, risks etc so they felt they could make an informed choice. Midwife appointments always being on a Wednesday morning in Thurso was not suitable due to work commitments. Good having a named midwife and felt they really got to know and build a relationship with their midwife. 72
Raigmore Found care to be good Positive experience in Raigmore. Husband was able to stay with me on the ward until early hours of the morning post delivery giving support and didn’t feel rushed to leave Did build a good rapport with staff which hadn’t expected. ‘I had the image of a conveyor belt’ Good experience in labour ward and post natal ward in Raigmore. Poor communication while in ante natal ward. Staff seemed very pressured and busy Kyle court was good
Scottish Ambulance Service Ambulance transfer in labour was not what was expected. Felt comfortable, was able to adjust position even with leg strap in place, was sitting up not on my back. Had been very worried about this due to stories heard and descriptions of what to expect. Midwife kept me calm. Felt relaxed and used hypnobirthing breathing techniques.
VC Clinics | Antenatal Clinic
Eight attendees who attended a test VC Clinic were invited to provide feed-back. Five people took the opportunity to respond (62.5%). The comments received are summarised below.
Very happy with care Very happy with consultation Excellent information VC not too dissimilar from face to face clinic I would use VC facilities again for this type of appointment Personally I like seeing someone face to face as first option but this was an excellent option over travelling to Raigmore Video consultation is very good Could this be bettered still by arranging for Thurso medical centre or Dunbar? Minimises cost and time associated with travelling to Inverness or the consultant travelling to Caithness
5. Conclusions
The number of responses is low and so it’s important to gather more feed-back using a variety of approaches. Importantly concerns around the delivery of safe care were not raised. However, overall some of the feed-back on aspect of maternity services was mixed for services delivered both in Caithness and in Raigmore.
Outcomes have been reviewed and discussed within the Caithness midwifery team. The response regarding named midwife (Q.5) may be due to the fact that the midwifery model has been under development with the midwives moving from a team approach to a caseload holding model.
Half of the women stated that they didn’t get information regarding what to do in an emergency situation when travelling to Inverness in their own transport (Q.16). This 73 may have been because they did not come to the CMU for assessment prior to travel and did not receive this information direct from the midwife. Information regarding these two points has now been added to the CMU Information Leaflet and the named midwife will be discussed with all women and documented on the hand held maternity record.
Further scrutiny and actions is required to achieve greater consistency of delivery of services.
Best Start is the Scottish Government’s Five-Year Forward Plan for Maternity and Neonatal Care in Scotland. The main aim is to improve continuity of care across community and acute maternity care teams. Every woman will have a primary midwife for the majority of their care, and that obstetricians will be linked with midwives in multi-disciplinary teams.
In this regard the implementation of Best Start should be positive and some of the baseline audit taking place as part of this work will further help to inform progress with regard to aspects such a continuity of care and named midwife. 74 Caithness Mater75nity Questionnaire
Q1 A1. Where did you have your baby?
Answered: 37 Skipped: 0
Caithness General...
Raigmore Hospital
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Caithness General Hospital 10.81% 4
Raigmore Hospital 81.08% 30
Other (please specify) 8.11% 3 TOTAL 37
Q2 A2. How many weeks pregnant were you when you had your baby?
Answered: 37 Skipped: 0
Before 37 weeks
After 37 weeks
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Before 37 weeks 10.81% 4
After 37 weeks 89.19% 33
TOTAL 37
1 / 28 Caithness Mater76nity Questionnaire
Q3 B1. Were you offered a choice about where you had your baby?
Answered: 37 Skipped: 0
I was offered a choice of ...
I was offered a choice of ...
I was offered a choice to...
I was not offered any...
I was advised to give birt...
I can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
I was offered a choice of a midwife led unit 27.03% 10
I was offered a choice of a consultant led unit 8.11% 3
I was offered a choice to give birth at home 0.00% 0
I was not offered any choices/my choices were not clear 29.73% 11
I was advised to give birth in a consultant led unit due to medical reasons 35.14% 13
I can't remember 0.00% 0 TOTAL 37
Q4 B2. Did you feel that you got enough information from your midwife/doctor to help make a decision on where to have your baby?
Answered: 36 Skipped: 1
2 / 28 Caithness Mater77nity Questionnaire
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes 66.67% 24
No 30.56% 11
Don't know / Can't remember 2.78% 1 TOTAL 36
Q5 B3. Did you have a named midwife?
Answered: 37 Skipped: 0
Yes and saw them all/mos...
Yes and saw them some of...
Yes but I did not see them
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes and saw them all/most of the time 16.22% 6
Yes and saw them some of the time 8.11% 3
Yes but I did not see them 2.70% 1
No 62.16% 23
3 / 28 Caithness Mater78nity Questionnaire
Yes Don't know / Can't remember 10.81% 4 TOTAL 37
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes Q6 B4. Did you have contact telephone numbers for a midwife or No midwifery team that you could contact? Don't know / Can't remember Answered: 36 Skipped: 1
Q7 B5. If you did contact the midwife or midwifery team did you get the help that you needed?
Answered: 37 Skipped: 0
100.00% 36
0.00% 0
0.00% 0
TOTAL 36 4 / 28 Caithness Mater79nity Questionnaire
Yes, always
Yes, sometimes
No
I did not need to contact them
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes, always
Yes, sometimes
No
I did not need to contact them
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
5 / 28
56.76% 21
27.03% 10
2.70% 1
13.51% 5
TOTAL 37
Q8 B6. Did you have contact with the Liaison Officer during your pregnancy?
Answered: 37 Skipped: 0
10.81% 4 Caithness Mater80nity Questionnaire
Yes
No
I didn't require any...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
I didn't require any input from the Liaison Officer
Q10 B8. Were you offered access to antenatal education during your pregnancy (antenatal classes, hypnobirthing classes or one to one discussion with your midwife).
Answered: 37 Skipped: 0
6 / 28
No 62.16% 23
Don't know / Can't remember 27.03% 10 TOTAL 37
Q9 B7. Did you receive the help you required from the Liaison Officer?
Answered: 32 Skipped: 5
6.25% 2
31.25% 10
62.50% 20
TOTAL 32 Caithness Mater81nity Questionnaire
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know / Can't remember
About right, I felt informe...
Not enough, I still had ar...
I did not want/need...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
About right, I felt informed and prepared for the birth of my baby
Not enough, I still had areas I was unsure of
I did not want/need antenatal education
Q12 C1. At the start of your labour did you feel that you were given clear
7 / 28
83.78% 31
13.51% 5
2.70% 1
TOTAL 37
Q11 B9. Do you think the antenatal education available to you was..
Answered: 35 Skipped: 2
34.29% 12
22.86% 8
42.86% 15
TOTAL 35 Caithness Mater82nity Questionnaire
Yes
No
I did not contact the...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
I did not contact the midwife or hospital
Q13 C2. Did you feel that you had enough information and support to enable you to cope with your pain during labour?
Answered: 35 Skipped: 2
Yes, sometimes
Yes, always
No
I did not want/need help
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
8 / 28
instructions when you contacted the midwife or hospital?
Answered: 34 Skipped: 3
44.12% 15
11.76% 4
44.12% 15
TOTAL 34 Caithness Mater83nity Questionnaire
In hospital
At home
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
In hospital
At home
Other (please specify)
Q15 C4. How did you get to hospital if travelling to Raigmore?
Answered: 33 Skipped: 4
9 / 28
ANSWER CHOICES RESPONSES
Yes, sometimes 11.43% 4
Yes, always 62.86% 22
No 17.14% 6
I did not want/need help 8.57% 3 TOTAL 35
Q14 C3. Where was your baby born?
Answered: 36 Skipped: 1
97.22% 35
2.78% 1
0.00% 0
TOTAL 36 Caithness Mater84nity Questionnaire
Own transport
Ambulance
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Own transport
Ambulance
Other (please specify)
Yes
No
Don't know
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know
10 / 28
87.88% 29
3.03% 1
9.09% 3
TOTAL 33 Q16 IF USING YOUR OWN TRANSPORT..C5. Were you given information on what to do in an emergency situation?
Answered: 28 Skipped: 9
50.00% 14
50.00% 14
0.00% 0
TOTAL 28 Caithness Mater85nity Questionnaire
Yes
No, I did not require any...
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No, I did not require any pain relief
Don't know / Can't remember
Q18 C7. What type of delivery did you have?
Answered: 37 Skipped: 0
11 / 28
Q17 C6 Did you require pain relief to aid your comfort prior to transfer to hospital (tablet, TENS, Gas & Air)?
Answered: 29 Skipped: 8
10.34% 3
89.66% 26
0.00% 0
TOTAL 29 Caithness Mater86nity Questionnaire
A normal vaginal...
An assisted vaginal...
A planned caesarean...
An emergency caesarean...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
A normal vaginal delivery
An assisted vaginal delivery (forceps)
A planned caesarean section
An emergency caesarean section
Q19 C8. Were you able to have those you wished to be with you, during labour and delivery?
Answered: 37 Skipped: 0
12 / 28
59.46% 22
5.41% 2
16.22% 6
18.92% 7
TOTAL 37 Caithness Mater87nity Questionnaire
Yes, all of the time
Yes, some of the time
No
I did not wish/want...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes, all of the time
Yes, some of the time
No
I did not wish/want anyone with me
Q20 C9. Did you require accommodation for yourself or birth partner during your pregnancy/labour/hospital stay?
Answered: 37 Skipped: 0
13 / 28
78.38% 29
16.22% 6
5.41% 2
0.00% 0
TOTAL 37 Caithness Mater88nity Questionnaire
Yes
No
Was not required
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Was not required
Other (please specify)
Q21 C10. What accommodation did you require?
Answered: 36 Skipped: 1
For myself
For birth partner
Family accommodation
I did not require...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
14 / 28
75.68% 28
16.22% 6
5.41% 2
2.70% 1
TOTAL 37 Caithness Mater89nity Questionnaire
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know / Can't remember
Q24 C13. How long did you stay in hospital?
Answered: 35 Skipped: 2
15 / 28
ANSWER CHOICES RESPONSES
For myself 11.11% 4
For birth partner 61.11% 22
Family accommodation 8.33% 3
I did not require accommodation 19.44% 7 TOTAL 36
Q22 C11. Were there any problems/issues with accommodation? Please state what these issues were.
Answered: 23 Skipped: 14
Q23 C12. Did you receive help to resolve these issues?
Answered: 15 Skipped: 22
26.67% 4
66.67% 10
6.67% 1
TOTAL 15 Caithness Mater90nity Questionnaire
Up to 12 hours
More than 12 hours but le...
1-2 days
3-4 days
5 days or more
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Up to 12 hours
More than 12 hours but less than 24 hours
1-2 days
3-4 days
5 days or more
About right
Too short
Too long
Don't know
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
16 / 28
2.86% 1
22.86% 8
17.14% 6
31.43% 11
25.71% 9
TOTAL 35 Q25 C14. Do you feel that your length of stay in hospital was?
Answered: 35 Skipped: 2 Caithness Mater91nity Questionnaire
Yes
No
I did not want / need this...
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
I did not want / need this information
Don't know / Can't remember
Q27 D2. Did you have contact with an Infant Feeding Support Worker during your pregnancy?
Answered: 36 Skipped: 1
17 / 28
About right 65.71% 23
Too short 17.14% 6
Too long 17.14% 6
Don't know 0.00% 0
Other (please specify) 0.00% 0 TOTAL 35
Q26 D1. During your pregnancy did you receive relevant information about feeding your baby?
Answered: 37 Skipped: 0
86.49% 32
2.70% 1
8.11% 3
2.70% 1
TOTAL 37 Caithness Mater92nity Questionnaire
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know / Can't remember
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know / Can't remember
18 / 28
83.33% 30
16.67% 6
0.00% 0
TOTAL 36 Q28 D3. Do you feel that you had enough practical help & support regarding feeding your baby in hospital?
Answered: 36 Skipped: 1
77.78% 28
22.22% 8
0.00% 0
TOTAL 36 Caithness Mater93nity Questionnaire
Sterilising equipment
Using stage one milk for...
Pacing feeds/respon...
Signs that baby is...
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
YES NO DON'T KNOW TOTAL WEIGHTED AVERAGE Sterilising equipment
Using stage one milk for first year
Pacing feeds/responsive feeding
Signs that baby is receiving enough milk
Q30 D5. If breastfeeding, did you receive guidance while in hospital on getting feeding off to a good start?
Answered: 24 Skipped: 13
19 / 28
Q29 D4. If formula feeding, did you receive information/support on sterilising equipment, using first milk for the first year, pacing feeds, signs that baby is receiving enough milk.
Answered: 19 Skipped: 18
52.63% 36.84% 10.53% 10 7 2 19 1.58
55.56% 38.89% 5.56% 10 7 1 18 1.50 52.63% 36.84% 10.53% 10 7 2 19 1.58 47.37% 47.37% 5.26% 9 9 1 19 1.58 Caithness Mater94nity Questionnaire
Effective positioning ...
Feeding cues
Responsive feeding
Signs baby is receiving...
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
YES NO DON'T KNOW TOTAL WEIGHTED AVERAGE Effective positioning & attachment
Feeding cues
Responsive feeding
Signs baby is receiving enough milk
Yes
No
Don't know
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
20 / 28
75.00% 25.00% 0.00% 18 6 0 24 1.25
70.83% 29.17% 0.00% 17 7 0 24 1.29
70.83% 29.17% 0.00% 17 7 0 24 1.29 58.33% 41.67% 0.00% 14 10 0 24 1.42 Q31 D6. Did you feel confident with feeding prior to discharge from hospital?
Answered: 36 Skipped: 1 Caithness Mater95nity Questionnaire
Infant Feeding Support Worker
Peer Support
Group Support
Other (please specify)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Infant Feeding Support Worker
Peer Support
Group Support
Other (please specify)
Q33 D8. Do you feel that this support was..
Answered: 25 Skipped: 12
21 / 28
Yes 80.56% 29
No 19.44% 7
Don't know 0.00% 0 TOTAL 36
Q32 D7. If breastfeeding, did you receive support in the community once discharged from hospital?
Answered: 21 Skipped: 16
85.71% 18
0.00% 0
4.76% 1
9.52% 2
TOTAL 21 Caithness Mater96nity Questionnaire
About right?
Not enough?
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
About right?
Not enough?
Yes
No
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes
No
Don't know / Can't remember
Q35 E2. Did your named midwife see you at home following discharge from hospital?
Answered: 36 Skipped: 1
22 / 28
84.00% 21
16.00% 4
TOTAL 25 Q34 E1. Did you have a telephone number for a midwife or midwifery team that you could contact?
Answered: 37 Skipped: 0
94.59% 35
2.70% 1
2.70% 1
TOTAL 37 Caithness Mater97nity Questionnaire
Yes always
Yes sometimes
No
I did not have a named midwife
Don't know / Can't remember
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Yes always
Yes sometimes
No
I did not have a named midwife
Don't know / Can't remember
More often
Less often
I saw them as mush a I wanted
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
More often
23 / 28
19.44% 7
16.67% 6
13.89% 5
47.22% 17
2.78% 1
TOTAL 36 Q36 E3. Would you have liked to have seen a midwife?
Answered: 37 Skipped: 0
8.11% 3 Caithness Mater98nity Questionnaire
Excellent
Good
Fair
Poor
Very poor
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Excellent
Good
Fair
Poor
Very poor
Q38 My care met my personal needs...... ( examples may include, personal circumstances being taken into account when planning care, being given time to ask questions and discuss care needs, being involved in decision making regarding your care).
Answered: 35 Skipped: 2
24 / 28
Less often 5.41% 2
I saw them as mush a I wanted 86.49% 32 TOTAL 37
Q37 Thinking about the care you received during pregnancy, in hospital and at home postnatally, answer the following questions and add any additional comment you wish to.Overall how would you rate your care?
Answered: 36 Skipped: 1
38.89% 14
41.67% 15
16.67% 6
2.78% 1
0.00% 0
TOTAL 36 Caithness Mater99nity Questionnaire
Never
Occasionally
Sometimes
Often
Always
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Never
Occasionally
Sometimes
Often
Always
Q39 Staff were caring towards me.. (examples may include, introduced themselves, were polite and courteous, listened to me, treated me with dignity).
Answered: 36 Skipped: 1
25 / 28
2.86% 1
5.71% 2
14.29% 5
31.43% 11
45.71% 16
TOTAL 35 Caithness Mate100rnity Questionnaire
Never
Occasionally
Sometimes
Often
Always
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Never
Occasionally
Sometimes
Often
Always
Q40 I felt I was able to get the care that I needed.. ( examples may include, knowing how to access care, knowing where to get extra support, there were no barriers stopping you getting the care you needed).
Answered: 35 Skipped: 2
26 / 28
0.00% 0
0.00% 0
11.11% 4
19.44% 7
69.44% 25
TOTAL 36 Caithness Mate101rnity Questionnaire
Never
Occasionally
Sometimes
Often
Always
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Never
Occasionally
Sometimes
Often
Always
Q41 I felt I received safe care.. ( examples may include, receiving appropriate interventions, receiving the correct medication, staff washed their hands before and after contact with me or my baby, the hospital environment was clean).
Answered: 33 Skipped: 4
27 / 28
0.00% 0
5.71% 2
17.14% 6
34.29% 12
42.86% 15
TOTAL 35 Caithness Mate102rnity Questionnaire
Never
Occasionally
Sometimes
Often
Always
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANSWER CHOICES RESPONSES
Never
Occasionally
Sometimes
Often
Always
Q42 ANY ADDITIONAL COMMENTS
Answered: 26 Skipped: 11
28 / 28
0.00% 0
9.09% 3
3.03% 1
12.12% 4
75.76% 25
TOTAL 33 103 Highland Health and Social Care Committee 3 May 2018 Item ?
MONITORING THE DELIVERY OF ADULT SOCIAL CARE CONTRACTED SERVICES
Report by Simon Steer, Head of Strategic Commissioning, on behalf of Deborah Jones, Director of Strategic Commissioning, Planning and Performance.
The Committee is asked to:
Note the outcomes of the fourth quarter reviews and progress made in resolving issues highlighted in previous reviews.
1. Background
1.1. On 10 January 2013, the Health and Social Care Committee agreed a contract monitoring framework to provide information on adult social care contracts.
1.2. This report details the outcomes of the monitoring process for Quarter 4 (January to March 2018).
2. Reviews Undertaken
2.1. Financial Year 2017-18 (1 April 2017 to 31 March 2018) A total of 126 dedicated contract monitoring visits were undertaken between 1 April 2017 and 31 March 2018.
2.2. Quarter 4 (January to March 2018) A total of 26 dedicated contract monitoring visits were undertaken in Quarter 4, monitoring a total of 38 contracts for NHS Highland during this period. For information, a further 4 monitoring visits were undertaken for The Highland Council, under agreed shared service arrangements.
2.3. A summary of those monitored in Quarter 4 for NHS Highland is provided 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.
2.4. In addition to the dedicated contract monitoring visits, monitoring is also undertaken through operational meetings with providers.
2.5. Following the Scottish Government’s new Living Wage requirements from 1 May 2017, and NHS Highland’s subsequent uplift to relevant care at home, care home, day care, housing support, and support contracts, monitoring of the payment of the Living Wage (£8.45 per hour) for care staff has become a priority.
3. Progress in Resolving Issues
3.1. Contract monitoring regularly highlights issues and concerns, which involve further follow up action and review. In Quarter 4 (January to March 2018), 9 main issues/concerns were identified, which are currently being acted upon. These include management/staffing issues; service delivery and quality concerns; financial viability concerns; and actions around withdrawal and transfer of service. There has also been 104
progress and ongoing follow-up with a number of providers regarding service delivery concerns; and resolutions with two providers regarding ASP/LSI concerns, as identified in previous quarters.
4. Conclusion
4.1. Routine contract monitoring continues to identify and resolve issues in relation to adult social care contracted services and the intention remains to focus effort on priority areas.
Simon Steer Head of Strategic Commissioning April 2018
2 105
Annex 1
Contract Monitoring Visits Undertaken in Quarter 4 (January to March 2018)
Area Service Type Issues Identified / Concerns / Comments
Care at Home Service No issues highlighted.
Care at Home Service / Support A high number of missed visits for care at home Service (2 contracts, 1 provider) service (the majority of which were due to adverse weather); the situation is being monitored by NHS and the provider and processes are being reviewed Pan (meeting in mid April to review).
Third Sector Service Provider to review all policies and prepare various policies, including recruitment, training, and data protection; provider to prepare business continuity plan.
Care Home Service / Care at Home NHS not invited to Care Inspectorate feedback. Service / Day Care Service / Residential Respite Service (4 contracts, 1 provider)
North and Care Home Service / Day Care No issues highlighted. West Service (2 contracts, 1 provider) Operational Unit Care Home Service No issues highlighted.
Third Sector Service x 3 No issues highlighted with two of the services. Concerns with business continuity identified with one service, and subsequently addressed by provider.
Care Home Service x 5 No issues highlighted with three of the care homes. No customer satisfaction survey held in the last year at one care home, though new format was being developed by the provider. Oversight with non- payment of Living Wage for a member of staff in one care home, which was subsequently rectified and back-dated by the provider.
Care Home Service / Day Care No issues highlighted. Service (2 contracts, 1 provider)
Care Home Service / Housing No issues highlighted. Inner Moray Support Service (2 contracts, 1 Firth provider) Operational Care at Home Service No issues highlighted. Unit Care at Home Service / Housing Issues identified regarding recruitment references. Support Service / Support Service Evidence of annual review of staff motor vehicle (3 contracts, 1 provider) insurance required. Support Service / Housing Support Follow up contract monitoring visit, following issues Service (2 contracts, 1 provider) identified at an earlier visit. Variance in NHS allocated hours against service assessed hours. NHS auditing. Third Sector Service x 7 No issues highlighted for five of the services. A number of issues identified with one of the services: new manager in place, awaiting registration with SSSC; a number of issues identified during a recent fire inspection, including updating of Health and Safety
3 106
policies and training, which is currently being undertaken before a follow-up fire inspection later in year; business continuity plan in development; new internal quality system in progress; work ongoing to bring training policy and practice up to date, but not yet completed. Concerns about professional / clinical support to staff within one service, which is under review.
4 107
HIGHLAND LEARNING DISABILITY DAY CENTRES /SERVICES
Report by Arlene Johnstone, Complex Case Planning Manager, and Donellen Mackenzie, Area Manager (Adult Social Care) on behalf of David Park, Chief Officer, Highland Partnership
The Committee is asked to:
Note the need for change and redesign in relation to in-house and commissioned day centres, services and opportunities for people with learning disabilities across Highland to ensure increased choice, control and opportunities as approved at the NHS Highland Board meeting of 27th March. Note the recommendations identified in the report, in particular that all day support opportunities for people with learning disabilities should be person-centred and asset based, in keeping with the recommendations of The Keys to Life (2013). Recognise the requirement for a consultation and engagement process to co- produce an options appraisal to identify how best to meet the needs and aspirations of people with a learning disability living in Highland, and to ensure that solutions are person centred, sustainable and affordable.
1. Introduction 1.1 This paper describes current day centre provision across North Highland and presents the case for change. 1.2 The current position within North Highland is described within the context of the wider national strategic and legislative context and highlights a range of challenges in striving to ensure safe, efficient and effective delivery of person-centred services that reflect an asset based approach to meeting identified needs that are affordable and sustainable.
2. National and Local Strategic and Legislative Context
2.1 NHS Highland’s Quality and Sustainability Plan, approved by NHS Board in May 2017, set out a compelling case for change as NHS Highland addresses a range of challenges related to increasing costs and demands on services, staffing pressures, savings targets and traditional service models that do not fit well with legislative requirements and strategic direction.
2.2 There have been a number of important strategic and legislative changes in recent years.
2.3 The Same as You? (2000) was the first major Learning Disability Strategy document from the Scottish Government and was the initial catalyst for change. The strategy promoted that day centres should become more community focused by helping people with learning disabilities to access continuing education, real jobs, achieve their desired outcomes and become more involved in their communities. 2.4 The Keys to Life (2013) reviewed progress across Scotland in the period from publication of The Same as You? and noted considerable change in the way in which day services were delivered across Scotland. 2.5 A range of models are now in place across Scotland, some of which involve little or no contact with day centres, and others that involve a balance of centre-based and community activities. 108
2.6 In Highland there has been a gradual decline in the number of people with learning disabilities attending day centres and an associated increase in the number of adults with learning disabilities with alternative day opportunities. The Corbett Centre in Inverness, for example, had at one time in excess of 100 registered attendees. It now has 29. This is a pattern that is reflected across Highland. 2.7 The Keys to Life (2013) set out a vision for future and ongoing development of day opportunities which tasked partnerships with having in place arrangements for individuals to access a comprehensive network of opportunities and resources that meet the broad range of needs of people with learning disabilities. 2.8 The Keys to Life (2013) recognised that for people with more complex needs and people with profound and multiple learning disabilities, day centres may continue to be an important part of their overall support arrangements. However, it also highlighted the importance of services continuing to make progress towards community-based models of care and to support people currently dependent on buildings-based support to graduate into alternative opportunities that would better meet their individual interests, talents and aspirations. 2.9 The report reflected that the goal for many people with learning disabilities should be employment and meaningful activities and highlighted that services can have a role in supporting people towards this goal through close partnership working with colleagues in further education, training, supported employment and the independent and third sectors. 2.10 The Keys to Life has been updated and sets all future developments within a framework of 4 Strategic Outcomes:
A Healthy Life: People with learning disabilities enjoy the highest attainable standard of living, health and family life. Choice and Control: People with learning disabilities are treated with dignity and respect, and protected from neglect, exploitation and abuse. Independence: People with learning disabilities are able to live independently in the community with equal access to all aspects of society. Active Citizenship: People with learning disabilities are able to participate in all aspects of community and society.
2.11 The Social Care (Self-Directed Support) (Scotland) Act 2013 gives people a range of options for how their social care is delivered following an assessment of need. It empowers people to decide how much ongoing control and responsibility they want over their own support arrangements. The Act places a duty to offer people four options as to how they receive their social care support. These are detailed below: Option Description 1 A Direct Payment made to the individual or family to buy their own support 2 An Individual Service Fund (ISF) paid on behalf of the individual to a service provider with whom the individual or family negotiate their care 3 Traditional in-house service provision 4 A combination of any of the first three options
2.12 It is noted that NHS Highland does not currently have a local Learning Disability Strategy. The new post “Head of Service – Learning Disabilities and Autism” will lead on the development of a Highland Learning Disability Strategy in partnership with people with a learning disability. A Draft Strategy will be available for comment late 2018. This document will support the need for redesign of Learning Disability Day Services and opportunities in accordance with the Keys to Life Strategic Outcomes with a view to ensuring greater equity, fairness and transparency in the provision of support and targeting of limited resources. 109
3. Current Position in North Highland
3.1 Demographics:
Adults with a Learning Disability in Highland 1039 16 – 34yrs 42% 35 –49yrs 23% 50+ yr 35% Age (no. of people) (437) (238) (364)
In 7% Attend 17% In Further 12% Activity Employment (70) Day (178) Education (124) Centre Source: Learning Disability Statistics Scotland 2017, SCLD (referred to as LD Stats)
3.2 The number of young people with complex needs Age Number % requiring skilled and intensive support is 14 5 11% increasing. Research completed by the NHS 15 5 11% 16 8 17% Highland Epidemiology & Health Sciences 17 9 19% (Public Health) team in May 2017 evidenced the 18 4 9% projected figures of young people with complex needs 19 5 11% 20 1 2% requiring skilled and intensive support. 21 3 6% 22 5 11% Additionally more people with a learning 23 1 2% disability are living into older adulthood 24 1 2% Total 47 100% and existing older adult services are often Age distribution of numbers of young people unable to meet their specific needs. considered to have high need. Data Source: extract from Care First as at March 17
3.3 Day centre provision for adults with a learning disability has not been systematically reviewed across North Highland for nearly 30 years. Individual centres have been redesigned without an overarching strategic plan. This has resulted in a lack of clear definition of what they should be providing and inequity of service provision across North Highland. 3.4 Current day service provision is a mix of in-house and commissioned services. In- house day centres are based in NHS managed buildings and were established in the late 1980’s / early 1990’s. The majority of in house and commissioned day provision operates Monday - Friday, between the hours of 9am – 5pm.
Total No. of IN HOUSE PROVISION Cost to NHS People Highland (max per day) Corbett Centre Inverness S&M 542,865 29 (23) B Isobel Rhind Ctre Invergordon S&M 716,992 53 (33) B Caberfeidh Kingussie S&M 75,415 4 B Montrose Centre Fort William N&W 373,971 15 B Thor House Thurso N&W 159,147 13 B TOTALS 1,863,390 114 Beachview Brora N&W Provides support to older adults and Tigh-Na-Drochaid Portree N&W people with a Learning Disability 110
COMMISSIONED PROVISION B: Block SP: Spot Purchase Grigor House Nairn S&M 30 SP L’arche Workshop Inverness S&M 127,721 9 B Leonard Cheshire Inverness S&M 83,959 12 B Nansen Highland Muir of Ord S&M 221,591 14 B Health & Happiness All Highland All 100,000 B Kyleakin Connections Skye N&W 38,069 8 B Watermill Croy S&M 32,541 B Cantraybridge College Croy S&M SP TOTALS 603,881 73
4. Challenges
4.1 Existing premises and services are not able to adequately support the wide variation in both physical and psychological needs of the supported people who are now attending the centres – i.e. people with profound and multiple physical and learning disabilities, people who may present behaviours that challenge and pose risk to others, people with autistic spectrum disorder, people with mental health needs, or those who present with a combination of the above. 4.2 Support provision in the day centres does not generally reflect the Keys to Life Strategic Outcomes. The majority of activities are social and leisure based including board games, kitchen skills, sensory activities and arts and crafts (with the exception of the Montrose Centre in Fort William where the focus is on employability). 4.3 Day centres also operate as a base to enable people to access activities in the community e.g. Puffin Pool, Horse riding. The majority of these activities are not with other people living in communities and therefore again do not meet the Strategic Outcomes identified in the Keys to Life particularly Active Citizenship and the inclusion in a range of shared, mainstream activities. 4.4 There are no recognised, consistent or agreed staffing ratios within Day Centres. Staffing is currently based on individual risk assessments. Additional 1:1 support in Day Centres, for which there is no national guidance or standard criteria, is provided both in-house and spot purchased via third sector support providers. This has led to an inconsistent approach across Highland and for a growing number of people with complex needs represents “double funding”, whereby people are accessing traditional day services as well as being supported via an SDS Option with additional 1:1 support.
4.5 Existing day services and opportunities do not currently maximise the potential of partnership working across sectors to enable community inclusion and citizen participation. The role of employment, further education, volunteers and existing community resources has not been developed or fully explored to enable choice, control and independence for adults with a learning disability. It is anticipated that stronger links with these partners would lead to improved outcomes in keeping with strategic directions and impact positively upon the budget, leading to increased sustainability and ensuring better targeting of limited resources 4.6 The existing model of support delivered in building based day services lacks flexibility and is not resourced to enable individuals with a learning disability to learn the skills they require to move onto alternative options.
4.7 Individual opportunities for creative alternatives to traditional day support through the range of SDS options are increasing but this has not led to associated reductions in traditional buildings based day services leading to effectively “double running” costs, an outdated model of service provision and significant budget pressures. 111
4.8 The total spend in in-house adult day service provision is £1,863,390 (excluding costs in resources that meet the needs of individuals with different needs eg Brora Hub). The total Adult Social Care overspend is £5.287m Highland wide, of which all Learning Disability commissioned Independent Sector Care, SDS Options 1 & 2 and day service provision contribute a combined pressure of £2.116m. Work is progressing at a broader level to introduce additional frameworks, guidance and support to staff to embed more of an asset based approach to practice and to ensure greater equity, transparency and consistency in targeting of resources.
5. Considerations for Next Steps
5.1 NHS Highland has committed (via the signing of the Charter of Involvement) to ensuring that the voice of people with learning disabilities is included in decision making.
5.2 It is planned that the following options are discussed with a wide range of stakeholders (people with a learning disability, advocacy, third sector partners, families, other interested parties):
Increase supported employment opportunities, vocational support, social enterprises (both product & service based), asset based community developments, as alternative to day centres i.e. close building based day services Tender all building based day service contracts to 3rd Sector (as a block contract) Increase capacity in building based day services (number of people in day service) and redesign activities offered Transfer resource to independent Sector. Individuals purchase own support provision (via SDS Options or private arrangement) Increased use of buildings as community hubs to meet the needs of a range of individuals Mix of above options / different solutions in different localities / other solution identified throughout consultation period 5.3 The urgency to begin the process of change is recognised and therefore it is proposed that a detailed and costed options appraisal will be complete by July 2018. 112 113
Finance and Performance Sub Committee Terms of Reference Terms of Reference
To meet monthly to carry out scrutiny on the finance and performance aspects of North Highland To scrutinise financial information, performance information, balanced scorecards, children’s services, operational reports and any other information required to provide the necessary assurance to the Health and Social Care Committee To provide feedback on the level of assurance to the Health and Social Care Committee highlighting any areas to be considered in the future, or any concerns. Membership
Ann Pascoe – Non Executive Director Ann Clark – Non Executive Director Melanie Newdick – Non Executive Director David Park – Chief Operating Officer Tracy Ligema – Operations Manager North and West Georgia Haire – Operations Manager South and Mid Katherine Sutton – Operations Manager Raigmore Kenny Rogers – Finance Joanna Macdonald – Head of Adult Social Care
Meetings
Monthly Summary report to be submitted to Health and Social Care Committee with meeting papers 114 115
NHS Highland Health and Social Care Committee Annual Report
To: NHS Highland Audit Committee
From: Melanie Newdick, Chair of Health and Social Care Committee
Subject: Committee Report – 17/18
1 Background
In line with sound governance principles, an Annual Report is submitted from the Health and Social Care Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts.
2 Activity 1st April 2017 – 1st April 2018
The number of meetings during the year, that the Minutes have been submitted to the Board along with reports relating to key items and a list of members and their attendance at meetings etc).
In response to changes in our terms of reference we introduced a year planner to ensure we covered all the aspects of our remit. This planner covers what topics will be looked at in the main meeting as well as the sub committees.
We have also appointed a Vice Chair of the committee.
An online portal was introduced but committee members have not yet been able to access this information.
We carried out development sessions on the role and remit of the committee, understanding performance information and balanced scorecards.
At every meeting we have reviewed operational reports, balanced scorecard, social work and children’s services reports. We have reviewed financial information in all but one meeting.
We have also reviewed/discussed; Care Inspectorate reports Regional planning Advocacy Plan approved Transitions Team approved Palliative Care Sustainability Plan Mental Health High Value Work Streams
We have reviewed exception reports through the year.
We have also met at Invergordon Hospital during the year. 116
The performance team have worked really hard to adapt this information for the committee and to help improve understanding of these metrics. They have also introduced a “Quid” which is a one page quick view of 6 key performance indicators and financial performance for the whole of North Highland.
3 Sub Groups
There have been two Finance and Performance Sub Group meetings. There is a clinical governance sub committee planned as well as a Partnership Forum. Due to a lack of admin support neither of these groups have met. There are plans to recruit an additional administration person to provide this support.
4 External Reviews
No significant external reviews
5 Any relevant Key Performance Indicators
We are responsible for managing key performance indicators relating to North Highland including; Finance Balanced Scorecard Health and Wellbeing Scorecard Adult Social Care Children’s Services
6 Emerging issues and key issues to address/improve the following year
We are awaiting administration support to help our sub committees to operate. We are planning on having further meetings away from Inverness with one taking place in Wick and another in Fort William.
We are working to resolve the access issues to the performance information.
7 Conclusion
At present the committee feels it is operating adequately.
Melanie Newdick Chair Health and Social Care Committee 2nd April 2018