Highland NHS Board 6 October 2009 Item 4.5 CHIEF EXECUTIVE S AND DIRECTORS REPORT EMERGING ISSUES AND UPDATES

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1 CHIEF EXECUTIVE S AND DIRECTORS REPORT EMERGING ISSUES AND UPDATES Highland NHS Board 6 October 2009 Item BETTER HEALTH, BETTER CARE, BETTER VALUE There is a wide range of ongoing activities linked to raising awareness of the Board s aims and objectives, and the service redesign and improvement plan Changing for the Better. Communication is a core aspect of the many improvement action plans, and service improvement leads have been keeping staff and patients informed and involved as the various strands of work progress. These range from road shows for staff, through to detailed work with patients who use specific services, and includes discussion at key NHS Highland Committees. This engagement with staff and patients remains at the core of our approach to managing service redesign, as we continue to explore the impacts of essential change across our services to patients. 2 DEVELOPING A NEW COMMUNICATIONS FRAMEWORK NHS Highland has an existing Communications Strategy which is due to be updated this year. The aim is to produce a short, readable framework document which presents NHS Highland s strategic aims in relation to communicating with our own staff, with patients and carers, with the wider local communities, and with other external audiences. It is also being drafted to give greater clarity about the expectations and responsibilities of the wide range of NHS Highland leaders, managers and staff, all of whom have an important role as communicators. In order to ensure that the new Framework reflects current needs, we have asked a wide range of people to complete one of a series of surveys designed to help identify our strengths and weaknesses. Following a low response to the public survey, we are about to re-launch it in the hope of attracting more comment and public input. Once this is complete, all the survey findings will be incorporated into a draft Communications Framework which will then be circulated widely during November. This will include patient and public groups, our own staff, and key NHS Highland committees. A revised draft will then be presented to the Board in February HEALTH PROTECTION UPDATE The main focus of work amongst the Health Protection Team for the last few months has been H1N1 (swine) Influenza. These work streams include handling the Dunoon outbreak during the containment phase; the ongoing provision of public health advice to health professionals and the management of swine flu; ensuring and co-ordinating preparedness of NHS Highland to deal with any autumn surge of illness; and in more recent weeks co-ordinating the delivery of the H1N1 vaccination campaign to health and social care workers plus patient priority groups. This period of intense increased workload has coincided with decreased capacity as a result of Ken Oates acting as Interim DPH as well as continuing in his substantive role as Consultant in Public Health for Health Protection. Another high profile incident was the outbreak of norovirus on the cruise ship Marco Polo when more than 400 crew and passengers were affected while the ship was berthed at Invergordon. Local primary care professionals provided on-board assistance and management of patients and senior Board Officers co-ordinated the wider policy issues, multi-agency response and handling of media enquiries.

2 Efforts continue to implement the Scottish Hepatitis C action plan with the recent appointment of a Clinical Lead, Dr Wendy Beadles, and the MCN Co-ordinator, Ron Ward. A new HIV national action plan is due to be published shortly. The implementation of the Public Health Act passed by Scottish Parliament in 2008 has been brought forward to October 2009 from April Competent persons are currently being identified to replace the role of the designated medical officers within local authorities. (See separate Board paper) Many other sporadic communicable diseases continue to affect individuals within the local population including salmonella, TB, campylobacter, cryptosporidium, E coli O157, but there have been no outbreaks of these infections involving more than one individual at a time over the summer months. The HPV vaccine campaign against cervical cancer has just entered its 2 nd year and vaccination sessions are beginning again in all the Regions secondary schools. The annual seasonal flu vaccination programme will also commence this month. The Boards new Emergency Planning Officer Peter MacPhee recently took up post. 4 REGIONAL PLANNING WEST OF SCOTLAND PLANNING GROUP A copy of the Briefing from the West of Scotland Planning Group for August 2009 is circulated as Supplementary Paper 1 to this update. 5 REMOTE & RURAL HEALTHCARE PROGRESS UPDATE 5.1 Background and Summary The Remote and Rural Implementation Group (RRIG) has now entered the last year of the Implementation Programme of DFRRHC. A RRIG Sharing and Learning Event was held on 1 and 2 September to re-energise the Programme and set priorities for the last year. The event was attended by 120 delegates across Scotland. The Event Report, presentations and Storyboards showcased at the event can be accessed via the Scottish Health on the Web (SHOW) website RRIG papers, Progress Reports and workstream contacts are also available via this link. 5.2 Progress to Date: RRIG progress is described under the 5 workstreams. Obligate networks: Guidance on Obligate Networks was issued jointly by Derek Feeley, Director of Healthcare Policy and Strategy, Scottish Government Health Department (SGHD) and RRIG in March of this year. Obligate Networks which are established are: Mental Health and Learning Disability: Grampian/Orkney/Shetland Diabetes: Western Isles/Greater Glasgow and Clyde Radiology: Western Isles and Borders Obligate Networks which are in the development stage are: Radiology: Grampian/Orkney/Shetland Laboratories: Grampian/Orkney/Shetland 2

3 Surgery: Grampian/Orkney/Shetland Morbid Obesity: Grampian/Orkney/Shetland Stroke: Dumfries and Galloway (Stranraer)/Ayrshire and Arran Emergency Response Network: Orkney/SAS, Perth and Kinross/SAS Breast Imaging: Lothian/Borders Surgery: Highland Radiology: Highland Laboratories: Highland Child health: being progressed in North of Scotland by the Child health clinical Planning Group Service Models and Care Pathways: High Level Care Pathways have been developed in draft form and are designed to be underpinned by local protocols. The drafts were presented at the RRIG Event and well received. The next stage is to finalise these Pathways and create an electronic repository for the Pathways and Protocols so that they are accessible. Emergency Response and Transport: The Emergency Medical Response Service (EMRS) formal Evaluation by DTZ has a shortlist of options for possible future models and these are: Option A No EMRS. This is a de minimis option required by the HM Treasury Green Book for baseline purposes. It would see EMRS being discontinued after the pilot period finishes in March Option B An EMRS to continue to run in the West of Scotland from one centre. This is the current model of operation in the pilot phase and this option would see this operation continue. Option C An EMRS for all of Remote and Rural Scotland with an augmented team based in Glasgow. This option would see an augmented clinical team delivering the Service in the West and the North of Scotland, including the Orkney and Shetland islands. Option D An EMRS for all of Remote and Rural Scotland with two teams based in Glasgow. This option would see two fully staffed clinical teams delivering the Service from a Glasgow base to the West and North of Scotland. Option E An EMRS for all of Remote and Rural Scotland with a team in each of two separate centres. This option would see two fully staffed centres delivering the Service, one in Glasgow to cover the West, and one in the North, probably based in Aberdeen or Inverness. The next steps in the Evaluation process are to send out the Health Board Questionnaires, collect data from the SAS and Information Statistics Division (ISD), conduct an analysis of the EMRS database, complete the Literature Review and draft the final report which is to be completed by the end of November. The general Emergency Response and Transport workstream has reached a conclusion in it s work in that a Strategic options Framework (SOF) for emergency and urgent response models which are appropriate to the numerous clinical service configurations and geographical settings, including, but not exclusively, health care staffed and non-staffed islands, remote mainland and rural mainland communities is in draft form and being submitted to RRIG on the 24 th of September for approval. Thereafter the Framework will be offered to the Scottish Ambulance Service (SAS) to work with Community Health Partnerships (CHPs) for selection of a preferred option for implementation within their locality. SAS will provide assurance to RRIG that models are being implemented within the agreed timescale. 3

4 Workforce and Education: There are two main priorities for this workstream currently. The first is to influence the SGHD to reinstate the proleptic funding scheme and a meeting is planned to address this. The second priority is to hold a workforce summit to address the particular challenges of the reductions in doctors in training numbers and the impact this will have on sustainable workforce in remote and rural hospitals. Planning has commenced on organising the workforce summit. E-health and Infrastructure: The clinical functionality requirements of e-health are to be defined using patient pathways in the 3 Levels of an Obligate Network as examples; Level 1 - Clinical Decision Support; Level 2 - Clinical Decision support plus a visiting service from a larger centre and Level 3 - a Virtual Department. This information will then be mapped against the available IT infrastructure, and gaps or limitations to practice defined. The outcome of this will then be used to influence the government in terms of working across public and private agencies to release capital to improve IT connectivity where required. 6 REVIEW OF NURSING IN THE COMMUNITY 7.1 National Position The Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon, held a national meeting at end of June to review the position in relation to Review of Nursing in the Community ( RoNC). This was as a result of the ongoing concerns that had been expressed by the unions, in particular RCN, Unison and Unite. Representatives from these unions as well as the Acting CNO and Nursing Officer for Primary Care Division attended this meeting. As a result it was decided that the areas which were currently testing the Community Health Nursing (CHN) model could continue to do so in partnership, if they wished, until the evaluation is completed. A new Modernising Community Nursing Board will be established under the chair of Margaret Smith, who has chaired the RoNC Programme Board to-date. The RoNC Programme will be managed as a sub group of the Modernising Community Nursing Board, with findings being fed up to this group. The scope and remit of the Modernising Community Nursing Board has yet to be agreed. The first meeting is due to take place in October. Evaluation of the work that has been undertaken in the pilot sites will continue although the scope of the evaluation will be scaled down. Its focus will be on teams where there are staff members who have undertaken the transition education to become CHNs and it will examine the impact on patients and public as well as on the team itself. The evaluation report is scheduled for completion in July NHS Highland Position The change in the national position has caused some disquiet among staff in some of the pilot sites. This has been added to by some of the inaccurate reporting of the changes in the press. 4

5 However, each of the teams has agreed to continue to test the model; progress towards the agreed changes is continuing. The teams are all keen to demonstrate the changes which they have made and to be part of the national evaluation. Staffing and workload pressures have reduced the number of staff undertaking the transition education. Across the five pilot sites there are now 13 staff who will complete the transition programme by the end of October Two national events will be held in November and December to continue to bring those staff undertaking transition education together across Scotland. This provides an ideal forum for the exchange of ideas and practice and will allow practitioners from Highland to present the work they have been developing, and has proved to be a successful approach. In addition a number of staff nurses from the pilot sites are accessing the specialist Community Nursing programme through Robert Gordon University, to support succession planning and the achievement of a sustainable service. The standards for practice were agreed by the Board in June 2009 for implementation across NHS Highland. These Standards reflect the learning from RONC so far. They provide the tools by which the model can be operationalised. The agreement by the Board has helped staff in the pilot sites recognise the intent in Highland on developing this flexible and responsive model of community nursing. All teams across Highland are now developing implementation plans to adopt the standards. This work will be monitored by the Local Implementation Groups within the CHPs, and led by the CHP Lead Nurses. The Community Health Profiles for each of the pilot sites have been completed and work is underway with the teams to identify how they can be used to support the workforce development plan as well as to inform the health improvement/ health promotion priorities for the teams. This will lead to the development of public health plans by each team to ensure that the key national and local priorities are being addressed in a more systematic way that has happened previously. Through work with Alexa Pilch (Highland Project Lead for Anticipatory Care), the model for anticipatory care and case management has been agreed and this will be rolled out across all community nursing teams in Highland. It is critically important that the recently introduced Local Enhanced Service for Anticipatory Care is seen as part of this and that this approach links the GPs and practice teams into the wider extended community care teams. Each CHP has identified a small number of teams initially where this can be progressed. It is important that we continue to plan for the future in NHS Highland and ensure that we develop our community nursing workforce that is fit for purpose. The development session prior to the next RoNC Steering Group meeting will focus on planning beyond the life of Review of Nursing in the Community Project to ensure that we further develop our model based on the learning from this project so far and the formal findings of the evaluation. 7 WINTER PLANNING On 11 September 2009 the Scottish Government wrote to Health Boards to highlight the need for early preparations to ensure that Boards approaches to winter preparedness are timely and all-encompassing. Boards are required to demonstrate that plans demonstrate the region s ability to manage winter pressures across Health and Social Care. It is also imperative this winter to note the likelihood of significant extra pressures in relation to delivery of the H1N1 5

6 vaccination programme and to ensure that winter plans are linked directly with pandemic flu plans. Guidance in respect of exception reporting processes has not yet been received; however it is likely that, as in previous years, exception reporting will be required between December and February. NHS Highland has nominated Tracy Ligema to lead the winter planning process. The Scottish Government letter highlights the requirement for Boards to implement the recommendations from the winter 2008/09 review undertaken by Dr Dan Beckett. These recommendations include directions in respect of: Collaboration across CHPs and Social Work departments Robust escalation and bed management plans across acute and community sectors Use of system watch and rigorous use of data to inform capacity and demand management Robust bed management and involvement of Consultants in bed management issues Ensuring that appropriate numbers of Consultant medical staff are available over the festive period Elimination of boarding of patients as a solution to bed capacity problems Improvements in the level of discharges over the holiday period, including dedicated discharge ward rounds, AHP Rapid Response, access to Homecare packages, estimated date of discharge and Nurse-led discharge implementation The Scottish Government, as in previous years, stresses the importance of collaborative planning involving Ambulance Service, NHS24, Social Services, acute and community sectors. As in previous years, the NHS Highland plan will link directly with Ambulance and NHS24 plans, as well as incorporating the NHS Highland Escalation Policy and pandemic flu plans. The NHS Highland plan also expects that support services and key clinical areas, e.g. e-health, Child Protection and Estates will have considered their response to anticipated pressures. Requests for engagement in service planning processes are being made to departments and partner agencies and responses in the form of new or updated plans will be incorporated into the overall winter plan as in previous years. Following previous robust planning, it is expected that approaches to contingency planning and escalation for periods of pressure, such as are experienced during the winter period, should now be firmly embedded within normal ways of working to ensure that there is a focus on demand and capacity issues at all times. This is particularly important when anticipating the impact of unprecedented demand arising from pandemic flu. The Scottish Government letter makes it clear that if this situation does arise then planned elective treatment may need to be suspended in order to prioritise emergency admissions. Boards will be required to strive to continue to deliver HEAT standards; however it is recognised that clinical decision making in the interests of all patients is paramount. Decisions on suspending elective treatment will need to be made in discussion with the Health Delivery Directorate; further guidance on this is expected in September. All areas are aware that funding to support the cost of initiatives designed to respond to winter pressures is no longer available to NHS Boards as a discrete allocation with the result that winter pressures must be resourced from within existing revenue budgets. 6

7 Exception reporting is likely to run from mid-december 2009 to late February It is suggested that CHP/Directorate/Service local exception reporting should commence from the first week of December. True exceptions will be routed through the Board s nominated leads to the Scottish Government who will require regular updates until the situation is no longer classified as an exception. The NHS Highland winter plan will be discussed at the winter planning national event on 24 September 2009 and submitted to the Board Chief Executive for sign-off by 16 October The Scottish Government has suggested that exceptions will include, but are not limited to, the following examples: Closure of a hospital to emergencies for any reason Unplanned closure of a ward or a number of beds Cancellation of elective procedures due to a lack of capacity Trolley waits exceeding 12 hours A significant outbreak of infection A significant increase in demand or a significant increase in staff sickness/absence The preparation of the winter plan 2009/10 for NHS Highland is a requirement set out by the Scottish Government Directorate of Delivery (Health) and CHP/Service/Directorate winter plans support the delivery of CHP and NHS Highland local delivery/improvement plans. The above provides staff and managers with the opportunity for direct involvement in and contribution to the development of joint partnership winter planning arrangements and therefore meets the staff governance standard. Chief Executive s Office Assynt House 25 September

8 SUPPLEMENTARY PAPER 1 WEST OF SCOTLAND REGIONAL PLANNING GROUP Briefing Paper The following in a resume of the outcomes of the West of Scotland Regional Planning Group Meeting held on the 28 th August 2009 (extracted from the draft minutes of the meeting) 1 H1N1 Mutual Aid Proposed from a meeting of the Board Chief Executives around the H1N1 situation that Regional Planning Groups should give consideration as to how best they could provide support to Boards to assist them with planning for the potential cross boundary impact of a pandemic. It was agreed that an appropriate step would be to convene a meeting to discuss mutual support across NHS Boards within the West. Members noted that there were various pieces of work ongoing or about to start in relation to paediatric critical care and neonatology. This was a particular issue for critical care. There may be a requirement for district general hospitals to take less dependent patients from Glasgow to enable the specialist centres to care for the sickest patients. 2 Update in Sexual Health MCN review of work plan and presentation Dr Bigrigg provided an overview of the developing MCN to the WoS members, explaining that the MCN was tackling cross boundary issues, including consultant cover and appraisal and data sharing. She reported that the electronic records system was now up and running and noted that NHS Forth Valley would be going live next week, but cross board data sharing was required. The RPG asked if the MCN was keeping a tight handle on the resource implications relating to the QIS standards. Dr Bigrigg confirmed that not all QIS standards had a cost implication, however, she did point out that if the MCN did provide efficiencies in clinical actions, planning etc and this resulted in more cases of HIV being detected, there could be a cost implication. She reported that LARC (long acting reversible contraception) has an immediate cost but is cost effective as it reduces the number of unplanned pregnancies. 3 Update from West of Scotland Bariatric/Weight Management Group The RPG received an update of the progress made to date and it was noted that this was a topic for discussion at the recent meeting of the National Planning Forum, this led to a discussion about the links to SIGN and NICE Guidelines. Members noted the options being considered with GJNH assessing its potential capability to support some of the WoS Boards. A report was due back to the group before Christmas 4. Regional Workforce update 4.1 Creation of National Strategic Workforce Board The newly created Health Workforce Programme Board will have its first meeting on the 8 th of October The main aim of this new Board is to ensure strategic co-ordination and consistency of approach across existing and future SGHD led policy initiatives / projects which may impact on the NHS Scotland workforce. 4.2 Regional Workforce Steering Group

9 Professor Jim Buchan, from the School of Health Sciences at Queen Margaret s University in Edinburgh, joined the last meeting of the Steering Group to encourage debate and challenge thinking around workforce planning, focussing on: 1. Reviewing the impact of the recession and moving away from doing more of the same with a reliance on workforce growth to thinking innovatively in how the workforce needs to be deployed in the future. 2. Reviewing the demographic challenge of an ageing population and declining workforce. What will the skills of the future be and how will we ensure that we have a workforce that is equipped to deliver. 3. Looking at the international context and particularly an imminent EU green paper on health workforce issues. The meeting successfully stimulated discussion and it was agreed that the Steering Group would:- Develop a position paper on the issues raised to play into the first meeting of the Health Workforce Programme Board meeting. Identify the regional actions which will emerge from this. 4.3 Staff Group Specific Issues a) AHP A cohort of AHP staff from across Scotland is participating in a five day educational programme looking at maximising the potential of the AHP workforce. A key objective is for them to take forward projects within their Boards which mainstream AHP workforce planning within the broader planning arrangements and focus on improving productivity and capability. b) Nursing The SGHD has now pulled together the Nursing and Midwifery demand projections from Boards which, once combined with the supply information, will define the number of training places for It looks very likely that the number of training places will be reduced next year, reflecting Board plans to increase the number of Assistant Practitioner and Healthcare Support Worker roles, and reflecting that a number of students completing their training in 2009 will be unable to secure employment. c) Medical Reshaping the Medical Contribution to the Clinical Workforce The Cabinet Secretary has endorsed the work to reshape the medical workforce and has confirmed her strategic policy objective of moving to a service predominantly delivered by trained doctors. A key objective will be to make this affordable and this will require a mixed economy solution of consultants, specialty doctors and non medical roles, as well as achieving flexibility within the current consultant contract. CEL 28 (2009) Guidance on Projecting Future Medical Requirements The above document provides the planning assumptions to enable Boards to scope how they will provide services in the future with fewer trainees. Boards have been asked to focus initially on a number of priority specialties where the acute resident on call requirements currently rely on trainees, and thereafter to cover all other areas. The planning assumptions are: 2

10 The level of trainee reduction over the 5 year period to The fact that not all trainee time and activity needs to be replaced. Where CCT level skills are required consultant posts should be identified. Where CCT level skills are not required then Speciality doctors should be considered. Job plans will facilitate 24/7 working where that is required. 5. Specialist Services Work streams o Specialist Children s Services NDP - Paediatric Cancer Funding & MSN The RPG discussed the establishment of a Managed Service Network for Children and Young People with cancer. This was following a recommendation in the National Delivery Plan for Specialist Services for Children and Young People and the Cabinet Secretary s announcement that children s cancer services should be delivered as a network across four sites in Scotland. There had been lengthy discussions at the National Delivery Plan Implementation Group around funding principles and Ms Byrne explained that the West had agreed to transitional funding until 2012, this would be provided on an NRAC/Arbuthnott basis. With the agreed WoS principle for funding to be adopted namely: The cost for the service may be based on a tariff or by dividing the cost of the service by the activity delivered. Fundamentally, the cost is based on activity, however where a new service is introduced and no historical activity information is available the costs would be split for the first few years based on a population basis (weighted capitation) until robust activity information is available. 6. Update on Boards Strategic Changes NHS Ayrshire & Arran The Primary Care Strategy consultation would commence on August 31 st and would report back to the Board in November Mental Health Community based aspects of Mind Your Health were being implemented; plans were progressing for the reprovision of adult mental health inpatient services Community Hospitals The new community hospital in Girvan would be due to open next year; plans were progressing for a new community hospital in Irvine: the process had commenced for reviewing the use of the current hospital in Cumnock Acute Hospitals plans were progressing for the redesign of front door services at Ayr and Crosshouse Hospitals Integrated Resource Framework the Boards plus the three CHPs and the three Local authorities had been selected as a test site for the next stage of the development of the Integrated Resource Framework. This would build on existing service redesign work. NHS Dumfries & Galloway The Independent Scrutiny process was now complete and was now with the Cabinet Secretary. The recommendations on the consultation had not yet been considered by the Cabinet Secretary. NHS Forth Valley Mrs Ramsay reported that the new front door model for acute emergency and urgent care services had commenced on 5 th August. The services at the new Community Hospital in Clackmannan were now all in place. NHS Greater Glasgow & Clyde 3

11 a) Acute Services Review Acceleration This was essentially a programme of service reconfiguration and capital work to enable the closure of Stobhill Hospital in late 2010/11 with necessary changes to enable that at Glasgow Royal Infirmary, Gartnavel General and the Western Infirmary. b) Vale of Leven Vision Implementation A programme of work was underway to implement the vision including Acute Services and Mental Health Services. A meeting would be held with the Scottish Ambulance Service in late September 2009 and the first Monitoring Group which the Cabinet Secretary has asked GG&C to set up would be held in November c) Primary Care Framework The Framework was under development and a draft would be shared in an event with key stakeholders on 28 th October NHS Lanarkshire NHS Lanarkshire had completed an initial agreement for 130 mental health beds. Options on where to site beds was still being explored. National Waiting Times Centre Board (NWTC) Golden Jubilee National Hospital NWTC were developing their clinical strategy An outline of the first stage process would go to the NWTC Board next week. The key focus they had been tasked to address at their Annual Review was to review potential capacity to support NHSS further with a focus on services that were aligned to existing specialties to ensure sustainability. She highlighted that Heart & Lung and in particular the National Services were a priority. 7 Any Other Business Quarriers Scottish Epilepsy Centre A request from Quarriers for a capital grant from West of Scotland Boards as Quarriers were trying to relocate from their Bridge of Weir Centre to a site in Govan which they had now officially purchased. The possibility of a donation of 2 million being made was currently being explored. Following discussion, it was noted that a scoping paper would come to the RPG for consideration in October. Feedback from Regional Planning Chief Executives Sub Group meeting 25 th August 2009 Eating Disorders The national agreement with Huntercombe and the Priory does not meet European procurement guidance and was now being retendered. In the interim Boards would receive individual bills. Critical Care Transport Dr Annie Ingram was pulling together work on emergency transport including retrieval in order to establish what common ground there was to bring some of these together. Video Conferencing Review and Support It was noted there was a need for a national approach. Ms Denise Brown, Chair of Regional E-Health Group, informed the RPG that the SGHD had commissioned a series of pilots in NHS Shetland, NHS Tayside and NHS Highland to evaluate using national BT N3 support for existing video conferencing facilities assessing the cost advantages. Stephen Whiston Head of Planning, Contracting and Performance Argyll & Bute CHP 17 th September