HIGHLAND NHS BOARD MEETING OF BOARD. Tuesday 5 February 2013 at 8.30 am Board Room, Assynt House, Beechwood Park, Inverness AGENDA

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1 Date of Issue: 25 January 213 Assynt House Beechwood Park Inverness, IV2 3BW Telephone: Fax: Textphone users can contact us via Typetalk: Tel HIGHLAND NHS BOARD 1 Apologies MEETING OF BOARD Tuesday 5 February 213 at 8.3 am Board Room, Assynt House, Beechwood Park, Inverness AGENDA 1.1 Declarations of Interest Members are asked to consider whether they have an interest to declare in relation to any item on the agenda for this meeting. Any Member making a declaration of interest should indicate whether it is a financial or non-financial interest and include some information on the nature of the interest. Advice may be sought from the Board Secretary s Office prior to the meeting taking place. THE HIGHLAND QUALITY APPROACH 1.2 Highland Quality Improvement System Tier 1 Report Out to the Board Presentation by Anne Gent, Director of Human Resources and Linda Kirkland, Head of Business Transformation The Presentation will give an update on Projects in Progress and what has been achieved in 212, areas of focus for 213, an update on the Highland Quality Improvement System Methodology and Training Plans for 213. The Board is asked to: Note the Tier 1 Report to the Board on the Highland Quality Improvement System. 2 Minute of Meeting of 4 December 212 and Action Plan (attached) The Board is asked to approve the Minute. (PP Matters Arising 3 PART 1 REPORTS BY GOVERNANCE COMMITTEES 3.1 Argyll & Bute CHP Committee Draft Minute of Meeting held on 19 December 212 (attached) (PP 21 36) 3.2 Highland Health & Social Care Governance Committee Assurance Report of 1 January 213 (attached) (PP 37 52) 3.3 Audit Committee Draft Minutes of Meetings of 4 December and 11 December 212 (attached) (PP 53 64)

2 3.4 Staff Governance Committee Draft Minute of 2 November 212 (attached) (PP 65 74) 3.5 Improvement Committee Assurance Report of 7 January 213 and Balanced Scorecard (attached) (PP 75 88) 3.6 Area Clinical Forum Draft Minute of Meeting held on 29 November 212 (attached) (PP 89 96) 3.7 Asset Management Group Draft Minutes of Meetings of 2 November and 4 December 212 (attached) (PP 97 12) 3.8 Health & Safety Committee Draft Minute of Meeting of 15 November 212 (PP ) The Board is asked to: (a) (b) Note the Minutes. Note the Assurance Reports and agreed actions from the Highland Health & Social Care Governance Committee and the Improvement Committee. Council/Highland NHS Board Joint Committees 3.9 Highland Council Partnership Adult & Children s Services Committee Minute of Meeting of 7 November 212 (attached) (PP ) The Board is asked to: Note the Minute. 4 PART 2 THE HIGHLAND QUALITY APPROACH 4.1 Quality Improvement Case Study Presentation by Tommy MacLeod, Occupational Therapist Presentation by Tommy MacLeod, Occupational Therapist in NHS Highland who recently undertook a 6 week study programme in Australia supported by the prestigious Churchill Travel Fellowship. The Board is asked to: Note the Presentation. Agree to regular future Quality Improvement Case Studies to the Board. 4.2 Update Report The Highland Quality Approach to Strategic Commissioning Report by Simon Steer, Head of Strategic Commissioning on behalf of Deborah Jones, Chief Operating Officer (attached) This paper aims to provide assurance that the principles of The Highland Quality Approach to Strategic Commissioning are being implemented, and that a pragmatic approach is being used to ensure that we do not delay implementation and the achievement of benefits. (PP ) 2

3 The Board is asked to: Note work being undertaken to take forward the Highland Quality Approach to Strategic Commissioning as described. Endorse the approach being taken whereby establishing a longer term culture that embeds strategic commissioning practice is underpinned by short and medium term initiatives to build skills and knowledge. 5 PART 3 CORPORATE GOVERNANCE / ASSURANCE 5.1 NHS Highland Scheme of Delegation Report by Kenny Oliver, Board Secretary, on behalf of Elaine Mead, Chief Executive and Nick Kenton, Director of Finance The Scheme of Delegation specifies the responsibilities delegated from the Board to specified Officers. There have been a number of changes since the Scheme of Delegation was last approved by the Board in 211. The attached draft amended Scheme of Delegation takes account of these changes. (PP ) The Board is asked to: Approve the attached Scheme of Delegation. 5.2 NHS Highland Financial Position as at 31 December 212 Report by Nick Kenton, Director of Finance (attached) The Board is asked to: (PP ) Note the current forecast remains break-even by the end of the financial year. Note an improvement in the forecast operational position of 1.1m from the October position reported to the Board in December. Note the need for further improvements within the financial position of 5.8m by the end of the year, split between; - NHS Care 3.8m - Adult Social Care 2.m 5.3 NHS Highland Internal Audit Report Waiting Times Report by Nick Kenton, Director of Finance (attached) Internal Audit undertook a review of waiting times at NHS Highland between September and November 212. The review was directed by the Scottish Government Health and Social Care Directorates (SGHSCD) in response to a request by the Cabinet Secretary for Health and Wellbeing for all relevant Health Boards in Scotland to audit local waiting times management arrangements. This report was considered by the Audit Committee on 4 December 212 and is required to be considered by the full Board. (PP ) The Board is asked to: Consider the findings of the attached audit report. Note the management action plan. Remit the Audit Committee to monitor the implementation of the action plan. 3

4 5.4 The Development of Primary Care Services in Tain Forres, Woodside, Tain FWT Bundle Project Full Business Case Report by John Bogle, Acting Head of Capital & Property Planning on behalf of Nick Kenton, Director of Finance (attached) The Board approved the Tain Health Centre Outline OBC Addendum in November 212 and agreed that the Project Team should proceed to develop an FBC. As previously detailed, the Tain project is too small to achieve value for money in revenue financing terms and it was therefore bundled with 2 similar projects in NHS Grampian to achieve a critical mass for revenue funding. The 3 projects have now been brought together into one FBC for consideration by the 2 Health Boards and SGCIG. Please note that the Business Case has not been circulated. A link to the full document will be ed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP ) The Board is asked to: Consider and Approve the FWT Bundle Full Business Case (FBC). Acknowledge that the FWT Bundle FBC is based on a predicted maximum unitary charge based on the financial model developed at OBC (Outline Business Case) Addendum Stage. This sum will be regarded by the FWT Project Board as a not-to-beexceeded sum at the conclusion of Stage 2 and Financial Close. Agree that the FWT Bundle FBC is forwarded to the Scottish Government Capital Investment Group (SGCIG) with a recommendation for approval. 5.5 Drumnadrochit Healthcare Centre Standard Business Case Report by Michael Waters, Capital Support & Project Manager on behalf of Nick Kenton, Director of Finance (attached) This Standard Business Case covers the provision of a replacement facility for the current Drumnadrochit Health Centre. The need to replace the current facility has been recognised for some time and is included in the Board s Property Asset Management Strategy, but due to the restricted availability of Capital from within the Board s formula Capital allocation, it has not been possible to progress the project until now. Please note that the Business Case has not been circulated. A link to the full document will be ed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP 199 2) The Board is asked to: Approve the attached Standard Business Case for the development of a replacement Drumnadrochit Healthcare Centre. Agree that the Standard Business Case can now be submitted to the Scottish Government Capital Investment Group for their approval. 5.6 Replacement of Laboratory Information Management System within NHS Highland Report by Alex Javed, Service Manager Laboratories and Radiology on behalf of Deborah Jones, Chief Operating Officer (attached) The Business Case provides the rationale and benefits for replacing the current two Laboratory Information Management Systems (LIMS) with the preferred option of a unified system for all NHS Highland laboratory disciplines. 4

5 Please note that the Business Case this has not been circulated. A link to the full document will be ed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP 21 26) The Board is asked to: Agree the need for replacement of the current legacy Patient Administration Systems with a modern Laboratory Information System. Consider the more detailed content of the associated Business Case. Agree to the procurement of a new multi-laboratory LIMS to replace the GE Ultra product used in Pathology and LRS Medipath used in Blood Sciences and Microbiology. Agree immediate commencement of the procurement process associated with replacement of the LIMS to ensure implementation is achievable before the expiry of the GE Ultra Centricity system and associated loss of service provision for Pathology. Agree the required local funding to allow the implementation to commence in line with the schedule in the associated business case. 5.7 Integrating Care in Argyll & Bute Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive (attached) This report provides Board members with an update on work towards integrated services in Argyll and Bute and proposes a way forward for discussion and agreement. (PP 27 21) The Board is asked to: Agree in principle to the development of an enhanced Strategic Partnership in Argyll & Bute. Agree the proposed phased approach to the development of this model including the proposed timescale. 5.8 Adult Support & Protection (ASP) Self Evaluation Report Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive (attached) As part of the Quality Assurance role of the Adult Support and Protection Committee a selfassessment against National reviews has been completed. Where actions have been identified they have been extracted and compiled into an action plan to be taken forward by the ASPC Quality Assurance sub-group. This activity will be monitored by the ASPC. (PP ) The Board is asked to: Note the approach taken to ensure learning from National reviews. Note the assurance route through the Adult Support and Protection route. 5.9 Infection Prevention & Control Report Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control (attached) (PP ) The Board is asked to: Note the performance position for the Board. Note the progress to keep infection under control. 5

6 5.1 NHS Highland Organ Donation Committee Annual Report Report by Kevin Holliday, Clinical Lead for Organ Donation; Deborah Gallagher, Specialist Nurse for Organ Donation & Gillian McCreath, Donation Committee Chair on behalf of Dr Ian Bashford, Board Medical Director/Executive Lead (attached) Transplant medicine both saves lives and restores quality of life. This report outlines the developments within NHS Highland to contribute to the supply of organs for donation. (PP ) The Board is asked to: Endorse the primary message of The Organ Donation Taskforce Report of 28, that the national organ donation programme is a core activity of NHS Highland Annual Local Supervising Authority Report to the Nursing and Midwifery Council 211/12 Report by Mary Vance, LSA Midwifery Officer on behalf of Heidi May, Board Nurse Director (attached) Please note that due to the size of the Report this has not been circulated. A link to the full document will be ed to Board members once Board papers are on the NHS Highland website, one week before the meeting. (PP ) The Board is asked to: Note the LSAMO Annual Report to the Nursing and Midwifery Council. Support the implementation of the recommendations Chief Executive s and Directors Report Emerging Issues and Updates Report by Elaine Mead, Chief Executive (attached) This month s report incorporates updates on: Children & Adolescent Mental Health (CAMHs) Business Case Update Mid Year Review Letter from Scottish Government NHS Highland Newspaper Cancer Waiting Times Police Partnership Agreement Early Years Collaborative Prescribing in General Practice in Scotland Audit Scotland Report Regional Planning West of Scotland Planning Group The Board is asked to: Note the Emerging Issues and Updates Report. (PP ) 6 FOR INFORMATION 6.1 Date of next meeting The next meeting of the Board will be held on 9 April 213 in the Board Room, Assynt House, Inverness. 6.2 Any Other Competent Business 7 Close of Meeting 6

7 1 Highland NHS Board 5 February 213 Item 2(a) HIGHLAND NHS BOARD Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel DRAFT MINUTE of MEETING of the BOARD Board Room, Assynt House, Beechwood Park, Inverness 4 December am Present Mr Garry Coutts, Chair Mr Bill Brackenridge Mr Robin Creelman Mrs Myra Duncan Mr Mike Evans Dr Michael Foxley Mr Ian Gibson Dr Iain Kennedy Mr Alasdair Lawton Mrs Gillian McCreath Mr Okain McLennan Mr Colin Punler Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy Also present Mr Eric Green, Head of Estates (Item 159) Ms Georgia Haire, Area Manager, Mid (Item 157) Ms Deborah Jones, Chief Operating Officer Mrs Gill McVicar, Director of Operations, North & West (Item 15) Mrs Linda Kirkland, Head of Business Transformation (Item 15) Mr Kenny Oliver, Board Secretary Mr Stephen Pennington, Managing Director, Highland Home Carers (Item 151) Mrs Lorraine Power, Board Services Assistant Mr Bill Reid, Head of ehealth (Item 158) Mr Brian Robertson, Head of Adult Social Care Ms Maimie Thompson, Head of Public Relations & Engagement Mr Michael Waters, Capital Support and Project Manager (Item 157) Apologies Apologies were received from Dr David Alston, Cllr John McAlpine and Mrs Jan Baird. Welcome The Chair welcomed Paul McMullan, FY1, NHS Grampian who was attending the Board meeting as part of his training and development. 8

8 2 137 Declarations of Interest Board members declared the following interests: Garry Coutts Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands. Myra Duncan Member of Scottish Government Joint Improvement Team Action Group on Reshaping Care. Ian Kennedy member of the British Medical Association (BMA), Riverside Medical Practice Ray Stewart Member of Unite and Staffside Chair The Board a Noted the Declarations of Interest. 138 Minutes of Meetings of 2 October and 6 November 212 The minute of meeting held on 2 October 212 was approved, subject to the following amendment: Asset Management Group, Item 116, page 65 to amend the wording Mr Kenton confirmed that the transfer of the buildings to NHS Highland was the long term aim and a 5 year repairing and insuring lease had been agreed in the interim to Mr Kenton confirmed that the transfer of the buildings to NHS Highland was the long term aim and a one year licence to occupy had been agreed meantime, but a 5 year lease would be the most satisfactory way forward. The minute of meeting held on 6 November 212 was approved. The Board a Approved the Minute of Meeting held on 2 October 212, subject to the minor amendment. b Approved the Minute of Meeting held on 6 November Matters Arising Integrating Care in the Highlands Dr Foxley asked if any evaluation had been undertaken in relation to integration. The Chief Executive confirmed that Dr Stark, Consultant in Public Health Medicine was undertaking some evaluation and advised that it had not been possible for NHS Highland to secure university assistance at no cost. There had been some interest from the King s Fund around the process, but no formal evaluation had been undertaken. The Chair requested that Dr Stark be asked to provide a briefing for Board members on the evaluation he had undertaken to date. Dr Foxley asked if Scottish Government had been approached to assist with funding an evaluation. The Chief Executive confirmed that a request had been submitted. Dr Foxley suggested that NHS Highland should submit a further request to Scottish Government in this regard. Infection Control Report, Item 127, page 74 Mr Creelman referred to the issue he had raised at the October Meeting regarding non-compliance in relation to hospital based empirical prescribing in relation to what area of policy was non-compliance and whether this was causing risk. It was noted that it had been agreed that an update would be provided and the Chair requested that a briefing be provided and circulated to all Board members. 81

9 3 Patient / Public Representatives on Committees Mike Evans asked for an update on progress with recruiting patient and public representatives on our Governance Committees. Maimie Thompson, Head of Public Relations and Engagement advised that this was ongoing. A few people had come forward in the last couple of weeks and there would be an advertisement in the NHS Highland newspaper early in the New Year. The Chair suggested that the press might make in know that NHS Highland was seeking lay members to serve on various committees. It was also suggested that a further update could be provided for Board members in the New Year. Key Priorities in relation to Risk Management Sarah Wedgwood referred to the action on the Board Rolling Action Plan relating to a future discussion on the key priorities for the Board in relation to risk management and the governance of risks and whether some of this would be picked up in the additional Board Strategy Session scheduled for 15 January on the Local Delivery Plan (LDP) and Operational Unit Delivery Plans. The Chief Executive confirmed that this could feed into the January session to complete the outstanding action. The Board a Agreed that a briefing should be provided for Board members on the Evaluation of Integration undertaken to date and that a further request should be submitted to Scottish Government in relation to funding. b Agreed that a briefing should be provided for Board members regarding the query relating to hospital based empirical prescribing. c Noted the update on progress with recruitment of Patient and Public representatives on Committees and that a further update would be provided for Board members in the New Year. d Noted that the outstanding action in relation to key priorities for risk management could be included in the additional Board Strategy Session planned for 15 January 213. REPORTS BY GOVERNANCE COMMITTEES 14 Argyll & Bute CHP Committee Draft Minute of Meeting held on 31 October 212 Mr Creelman, Chair of Argyll and Bute CHP updated on the meeting and advised that the Mull Progressive Care Centre was now open. Regarding the recent engagement between NHS Highland and local school pupils which was presented to the October Board meeting, Mr Creelman advised that a similar project was ongoing, albeit on a smaller scale, in Argyll & Bute CHP. This was linking with the Curriculum for Excellence. Mr Creelman referred to the issue around language used regarding patient and public engagement in the West of Scotland Planning Group briefing and confirmed that he had discussed this with Mr Whiston and was content with progress. 141 Highland Health & Social Care Governance Committee Assurance Report of 1 November 212 Mr Ian Gibson, Chair of the HH&SC Committee updated on the meeting of the Committee, including Health and Safety Executive (HSE) Activity and the Improvement Notice in a Lochaber Care Home. The Chair suggested that he should have a discussion with the Chief Executive and Board Secretary regarding such reports in relation to assurance, consistency and getting feedback. The Chair thanked Mr Gibson and the Chief Operating Officer for the work done in relation to the business of the Highland Health and Social Care Committee. It was also noted that Mr Gibson s term as Chair of the Committee would be up for review in February 213 and there would be a recruitment process for appointing a new Chair to the committee. 82

10 4 142 Highland Health & Social Care Governance Committee Terms of Reference for Approval by the Board The Board approved the Terms of Reference for the Highland Health & Social Care Governance Committee, subject to the inclusion of the Director of Adult Care in the membership of the Committee. 143 Clinical Governance Committee Draft Minute of Meeting held on 13 November 212 Ms Sarah Wedgwood, Chair of the Clinical Governance Committee fed back on the issues discussed at the last meeting. This included the Screening Programmes Annual Reports, pressures on endoscopy services, the Clinical Governance Scorecard and the Maternity Services Strategy Coordination Group Annual Report It was noted that NHS Highland had recently achieved full Baby Friendly accreditation in all its operational units, only the second Board in Scotland to do so. It was also noted that there had been a presentation at the Learning and Development Session by Mr Bill Alexander, Director of Health and Social Care and Mr Brian Robertson, Head of Adult Social Care on the Implications of Integration for Clinical Governance. 144 Improvement Committee Assurance Report of 5 November 212 and Balanced Scorecard The Chair updated on the last meeting of the Improvement Committee including work in relation to Raigmore Hospital, scrutiny around Adult Social Care Services in relation to the quality of reports and the quality indicators, cancer waiting times and access to diagnostics. 145 Area Clinical Forum Draft Minute of Meeting held on 27 September 212 Dr Iain Kennedy, Chair of the Area Clinical Forum updated on the meeting including Diabetes Services Redesign in North Highland and the Endoscopy Service and Pathway particularly in relation to use of services at the Belford Hospital. The Chief Operating Officer confirmed that she had asked a member of the Quality Improvement Team to set up a working group in relation to the management of the waiting list. This work would be reported in to the HH&SCC. Reference was also made to the Scottish Patient Safety Programme (SPSP) highlighting that Hospital Standardised Mortality Ratios (HSMR) had decreased over recent years and achievements against objectives where there had been a 15% reduction in mortality and a 3% reduction in adverse events. Dr Ian Bashford, Board Medical Director advised that NHS Highland was the first mainland Board in Scotland to achieve a 4 rating in relation to SPSP (this uses the IHI assessment scale where the highest score is 5). The Chair highlighted NHS Highland s commitment to quality and credited the management teams and staff involved in this work which had saved many lives in Highland. 146 Asset Management Group Draft Minutes of Meetings held on 18 September and 23 October 212 Mr Alasdair Lawton fed back on the issues discussed at the meetings. He referred to a recent presentation to the Group by the Chief Executive of Hub North Scotland in relation to Hubco and looking at the timing of expenditure and confirmed that there was a further meeting of the Asset Management Group arranged for later today to progress these issues. Myra Duncan referred to the Patient Management System Business Case which had been considered by the Asset Management Group when it had been noted and approved at separate meetings. Mr Lawton confirmed that the AMG had approved the business case for submission to the Board and that it was simply a clear recommendation from that Group to the Board in relation to the business case. 147 (a) Pharmacy Practices Committee Minute of Meeting of 12 September 212 Gaelpharm Limited Mr Ian Gibson had chaired this meeting. He updated on the recent changes to the regulations which were complex, but confirmed that there was now evidence of the changes beginning to work. 83

11 5 (b) Minute of Meeting of 3 October 212 Mitchells Chemist Limited Mr Okain McLennan had chaired this meeting and he advised that this application had been appealed and a further report would be submitted in due course. The Board a Noted the Minutes. b Noted the Assurance Reports and agreed actions from the Highland Health & Social Care Governance Committee and the Improvement Committee. c Remitted to the Chair to write to Board members regarding the recruitment process for the Chair of the Highland Health and Social Care Governance Committee. d Approved the Terms of Reference for the Highland Health & Social Care Governance Committee, subject to the inclusion of the Head of Adult Care in the membership of the Committee. Council/Highland NHS Board Joint Committees 148 Argyll & Bute Health & Care Strategic Partnership Minute of Meeting of 3 October 212 Mr Robin Creelman updated on the last meeting of the Argyll and Bute Health & Care Strategic Partnership, including work relating to hospital admissions / re-admissions and delayed discharges. It was noted that in relation to delayed discharges that the 4 week target had been introduced in Argyll & Bute ahead of national implementation. This would be further reduced to 2 weeks from April 213. The Chair welcomed the early implementation of the delayed discharge target. He also updated that there had now been a number of discussions with Argyll & Bute Council in relation to integration and an update report would be submitted to the next meeting of the Board. 149 Highland Council Adult & Children s Services Committee Minute of Meeting of 26 September 212 The Chair highlighted the need to ensure NHS Highland received appropriate reports in relation o assurance in respect of children s services. There had been presentations at the last meeting on the New School Inspection Model, Health and Wellbeing and Carers Services. Generally health business was interspersed with business relating to education. While many of these items were interesting they did not necessarily provide assurance. The Chair highlighted work in progress where he, the Chief Executive and Chief Operating Officer were engaging with Highland Council. There was confidence that the necessary work was being done in each organisation but further work was required to ensure that the necessary assurance was available to both organisations. Mr Gibson referred to the work of the Integrating Care in the Highlands Programme Board which had a number of work streams and suggested that it would be helpful to have an update on these. The Chair updated that a Project Manager had now been appointed and was taking forward these work streams. An update report would be submitted to the Board in due course. The Board a Noted the minutes. b Noted that an update on discussions with Argyll & Bute Council in relation to integration would be submitted to the next meeting of the Board. 84

12 6 THE HIGHLAND QUALITY APPROACH 15 The Highland Quality Approach Next Steps The Highland Quality Improvement System Building Capacity and Capability Presentation by Anne Gent, Director of Human Resources, Gill McVicar, Director of Operations, North & West and Linda Kirkland, Head of Business Transformation The Highland Quality Approach captures the spirit of how NHS Highland is working to improve care and outcomes for people in Highland. It describes our ways of working, values and behaviour. It recognises how important it is to improve the health of the population and get the experience of care right for individual people, every time. The Director of Human Resources, Director of Operations (North & West) and the Head of Business Transformation had been accepted on the Lean Leader Training Programme by Virginia Mason Institute and had recently undertaken further training in Seattle. The group gave a presentation to the Board on the next steps for the Highland Quality Approach in relation to the Highland Quality Improvement System and Building Capacity and Capability. They updated on some of their learning. Anne Gent, Director of Human Resources advised that Virginia Mason, which had been voted top hospital of the decade, used Lean Modules and key concepts, some of these related to value, waste, 5S and workplace organisation and rapid improvement. She referred to the NHS Highland Strategic Framework and explained a model of The Highland House of Lean which brought together key concepts of Lean and Jidoka Building Quality in everything we do and the best use of the people, materials and machines we have. The four key concepts that NHS Highland was concentrating on at present were: Adding value Eliminating waste Standard operating procedures Leadership Gill McVicar, Director of Operations (North & West), then went on to talk about waste. Waste (or Muda ) adds no value. There was a need to determine what was waste and what had added value. Waste that could be immediately seen could be dealt with straight away e.g. wasted space or clutter and front-line staff should be empowered to deal with such issues as they were experts in their own field. A person or member of staff is never waste, the waste is the burden of work in the process. Mrs McVicar advised that the 5S s were: Sort; Simplify; Sweep; Standardise; and SelfDiscipline and did not just relate to equipment and supplies. Linda Kirkland, Head of Business Transformation then spoke about Standard Operations which had three areas takt time, standard work and standard work in progress. There were a number of benefits of standard working which were identified. Mrs Gent advised that standard work would allow clinicians to spend more time with patients. She then talked about Leadership, including the need to observe the shop floor and the delivery of core services, trusting and empowering staff and building a Lean culture. Next Steps included: Reviewing the NHS Highland Strategic Framework Reviewing the Organisational Quality Objectives Simpler Performance and Measurement Framework Rollout of the work on values and culture in the organisation Spreading the message quickly, releasing time for Leaders and embedding this as the way we do things. Consider more formal partnership arrangements with Virginia Mason Institute and Tees, Esk and Wear Valleys NHS Foundation Trust. Set up a more formal Highland Quality Improvement Office 85

13 7 Develop experts and a Lean Leaders Network Develop a Highland Quality Institute. The Board welcomed the presentation. Dr Kennedy, Chair of the Area Clinical Forum noted the example of the improvement method in a hospital setting and asked that this also be adopted in primary care. He sought reassurance that there would be investment in the right number of people and resources in primary and social care. Mrs Kirkland advised that Virginia Mason worked in primary care. The Chair advised that this was about everything we do, not just about hospitals and the methodology could be used in all areas. The Chief Executive emphasised the need to ensure that we do this properly when we do it and before we spread throughout the organisation. Mrs Kirkland highlighted that attention to detail and correct calculations were crucial to some elements of the work. While there was a need to spread the message quickly there was also a need to not rush and to do this properly, invest in rigour and stick to the process. 151 Feedback from Visit to Torbay and Southern Devon Health and Care NHS Trust Presentation by Brian Robertson, Head of Adult Social Care and Stephen Pennington, Managing Director, Highland Home Carers Mr Brian Robertson, Head of Adult Social Care and Stephen Pennington, Managing Director Highland Home Carers fed back on the recent visit to by seven people to Torbay and Southern Devon Health and Care NHS Trust on 15 and 16 November 212. Mr Robertson outlined the model in Torbay and Southern Devon and advised that they also worked over 2 local authority areas. They had a unique model of care with: Integrated teams supporting groups of GP practices Single point of contact for GP to coordinate care of most complex and vulnerable patients and to coordinate discharge from hospital Strong track record of integrated working across acute and community settings delivering efficient use of bed capacity The Community Service Model operation with co-located multi-disciplinary teams who had a Health and Social Care Co-ordinator. The Care Co-ordinator was at the centre of everything with access to all information across the various systems. It was also noted that a single care plan followed the individual regardless of the services they were accessing. One of the key aims of the Trust was Making the right thing to do the easiest thing to do. The presentation went on to detail the community service model and operational characteristics, the difference made over the seven years the Trust has been in existence, the desired service delivery structure in relation to integrated teams in NHS Highland and what they could deliver as well as some challenges and opportunities. There followed some discussion on the size of the districts and zones, the Care Co-ordinator role and how this could release clinical time and the links with voluntary organisations. The Chief Executive confirmed that there were some areas already in Highland where there were good examples of integration that could be built upon. The Chair welcomed the opportunity for the Board to hear both presentations and talk about areas for improvement. He re-affirmed the Board s absolute commitment to the Highland Quality Approach using Lean methodology and NHS Highland was now getting the learning and vision to make this a reality. The Chair suggested that the Chief Executive should plan another team visit to Torbay and Devon to see how the integrated teams work and that there should be Non-Executive involvement also. The Board a Noted the Presentation on the Highland Quality Improvement System and Building Capability and Capacity. b Noted the Presentation on Feedback from the Visit to Torbay and Southern Devon Health and Care NHS Trust. 86

14 8 c Re-affirmed its commitment to the Highland Quality Approach using Lean Methodology. d Remitted to the Chief Executive to plan another team visit to Torbay to explore further how the integrated teams work in practice. The Board adjourned at 1.45 am and resumed at 11. am. 152 Developing a Framework for use of Social Media in NHS Highland Report by Maimie Thompson, Head of Public Relations and Engagement on behalf of Elaine Mead, Chief Executive The rise of social media has the potential to significantly change the way NHS conducts elements of its communications. Millions of people use social media every day and it is becoming an increasingly important communication tool. Maimie Thompson, Head of PR and Engagement spoke to the report which, as well as highlighting some of the benefits to the organisation of using social medial also highlighted some of the risks which were split into four categories: 1. Public Relations damage to reputation through failure to participate in a professional manner and not adhering to good practice guidelines; 2. Human Resources inappropriate use of staff time in the work place or abuse of staff, or NHS Highland; 3. Governance potential to cut across complaints and feed-back systems which if not understood and managed could undermine elements of existing processes; 4. Technical significant increase in use of some social media could have an adverse impact on the data network. The report recommended exploring the principle of opening up social media in the work place, initially through controlled access. There followed a detailed discussion on the subject and a number of issues were raised: The benefits of using social media and the fact that many influential people and organisations now had facebook and twitter accounts. The need to think about protocols and guidance for use. Board liability in relation to staff comments which would be the same as any other forms of communication. The need to ensure that the use of social media was appropriate and was for the benefit of the organisation. Technical issues in relation to the capacity of the system Maimie Thompson confirmed that discussions were ongoing with the Human Resources and ehealth departments in this regard. The Director of Public Health and Health Policy highlighted the benefits of reaching a younger audience and that there was a risk of widening inequalities if NHS Highland did not take this forward. The Board a Noted the context and background for the use of social media by NHS Highland as part of wider communications and engagement strategy. b Was aware of the benefits, risks and considerations. c Endorsed the recommendation to explore the principle of opening up social media in the work place, initially through controlled access. 87

15 9 CORPORATE GOVERNANCE / ASSURANCE 153 Register of Interest of Members of Highland NHS Board The Board was advised that the Highland NHS Board of Conduct was formally adopted by the Scottish Ministers from 1 May 23. Under its terms, Board Members are required to register their interests in the Highland NHS Board Register. An exercise to update the Register had been undertaken and the formal Highland NHS Board Register had been tabled for information. The Register was required to be kept available at the Boards offices for public inspection. The Chair highlighted the need for Board members to ensure that their entry in the Register was up to date and encouraged them to update their declarations of interest regularly, not just when it was annually reviewed. The Board Services Assistant confirmed that the updated Register would be available on the NHS Highland website later that week. The Board a Noted the Register of Interests. b Noted that the updated Register would be available on the NHS Highland website. 154 NHS Highland Financial Position as at 31 October 212 Report by Nick Kenton, Director of Finance Mr Nick Kenton, Director of Finance updated on the financial position to 31 October 212 which highlighted a current forecast of break even for the financial year. However, the underlying operational positions, including adult social care, indicated an in-year shortfall of 6.9m, an improvement of 5.1m on the position reported to the October Board. The 5.1m improvement was extremely positive in terms of moving towards break-even however the vast majority of this had come from fortuitous non-recurrent savings rather than planned savings initiatives. The main components of this were; Reduction in Raigmore position Other operational reductions Generic Price Reductions Non-recurrent/allocation slippage CNORIS premium reduction.5m.2m 1.m 2.6m.8m Detailed financial positions for each Operational Units were detailed in section 3 of the report. The Raigmore position had improved by.5m since the last report to the Board, primarily due to a more robust review of budgets, costs and vacancies. The Tertiary budget was forecasting an over spend of 1.2m. The vast majority of the current estimated overspend related to an increasing number of expensive forensic psychiatry placements. In addition to this provision had been made for three potential expensive cardiology treatments totalling 1k. It was noted that the Core Clinical Advisory Group currently had work in progress to amalgamate the protocols for out of area placements in relation to both health and social care. In relation to the Highland Quality Approach / System Wide Initiatives, the financial plan for 212/13 included a northern Highland-wide target totalling 4.5m (full year effect 9m). As requested and agreed by the Directors of Operations, the work of the financial benefits realisation will now be included in a meeting chaired by the Chief Operating Officer this recognises the need to connect this work with operational matters and to rationalise the number of meetings. The Chair referred to the additional Board Strategy Session scheduled for 15 January 213 and confirmed that the delivery plans for the Operational Units would be discussed at this time, prior to submission to the Board. 88

16 1 Deborah Jones, Chief Operating Officer updated on some of the work in progress with Service Managers at Raigmore Hospital and the need to support and encourage then to deliver sustainable change. The Chair advised that there were ongoing discussions with Highland Council regarding the social care budget. The Chief Executive confirmed that both NHS Highland and Highland Council were committed to the Lead Agency Model and it was noted that an update on discussions with Highland Council regarding the social care budget would be submitted to the January meeting of the Improvement Committee. The Board a Noted the current forecast remains breakeven by the end of the financial year. b Noted an improvement in the forecast operational position of 5.1m from the August position, reported to the Board in October. c Noted the need for further improvements within the financial position of 6.9m by the end of the year, split between; - NHS Care 4.9m - Adult Social Care 2.m d Noted that an update on discussions with Highland Council regarding the social care budget would be submitted to the January meeting of the Improvement Committee. 155 NHS Highland Annual Accounts 211/12 Report by Nick Kenton, Director of Finance The 211/12 Annual Accounts were considered by the Audit Committee on 18 June 212 and subsequently approved by a special In Committee meeting of the Board on that day. Following this process, the Accounts were submitted to the Scottish Government, for onward submission to the Scottish Parliament, where the NHS Highland Annual Accounts have now been approved. The Chair acknowledged the work of all involved in the year end position for 211/12. The Board a Noted the 211/12 year end position for NHS Highland. b Noted the completion of the audit work, the approval of the Accounts by the Board In Committee on 18 June 212, and the subsequent Parliamentary process. 156 Update on Draft Scottish Government Budget Report by Nick Kenton, Director of Finance This report informed the Board of any potential implications that the draft Scottish Government budget for had for Highland NHS Board s financial revenue plans as set out in the Local Delivery Plan. The Local Development Plan for included assumptions about the level of core funding (based on the national funding formula (NRAC)) and these are outlined in Table 1 below. 89

17 11 The assumed underlying inflation assumption for in table 1 at 2.8% matches the advised rate. The figure for at 2.6% is marginally lower than the advised rate of 2.7%. The Cabinet Secretary for Finance, Employment and Sustainable Growth also announced the Scottish Government s proposal in respect of Public Sector pay awards for The key features of the policy are: a one per cent cap on the cost of the increase in basic pay for staff earning under 8, maintaining a pay freeze (zero percent basic award) for staff earning 8, and above specific measures for supporting the lower paid suspension of non-consolidated performance related pay discretion for individual employers to reach their own decisions about pay progression. Mr Kenton, Director of Finance advised that it was hoped there would be more detail by the January Board Strategy Session and the February Board meeting. The Board a 157 Noted the draft Scottish Government Budget and its impact on the Board s Local Delivery Plan. Dingwall Health Centre Business Case Report by Michael Waters, Capital Support & Project Manager on behalf of Nick Kenton, Director of Finance Mr Michael Waters, Capital Support and Project Manager spoke to the report. The Standard Business Case covered a revised Phase 3 to complete the redevelopment of Dingwall Health Centre, which had previously been approved from within the Board s Capital allocation with a start date in 21. Phases 1 and 2 had been completed but, due to the restricted availability of capital, Phase 3 could no longer be funded from within the Board s formula Capital allocation. A revised Phase 3 solution had been agreed with the users within the 1.5m allocation agreed by the Scottish Government. The Board a Approved the attached Standard Business Case for the final phase of development of Dingwall Health Centre. b Agreed that the Standard Business Case could now be submitted to the Scottish Government Capital Investment Group for their approval. 158 NHS Highland Proposed Implementation of the National Patient Management System (PMS) Report by Bill Reid, Head of ehealth on behalf of Deborah Jones, Chief Operating Officer Mr Bill Reid, Head of ehealth presented the report to the Board. Implementation of the nationally procured Patient Management System across NHS Highland was a key component of the current NHS Highland ehealth Delivery Plan. It was planned that implementation would commence in the 213/14 financial year. Mr Reid advised that six other NHS Boards in Scotland were currently implementing this system and NHS Highland would be next to implement. He emphasised that at present NHS Highland had two Patient Administration Systems and the new Patient Management System had additional benefits in that there would be significant changes to clinical practice and workflows. Dr Kennedy confirmed that the Area Clinical Forum had unanimously endorsed the proposal at their recent meeting on 29 November. 9

18 12 There followed a detailed discussion on the proposal including: A question was raised regarding integration and whether the new system would help or hinder integrated working. Mr Reid advised that this would not impact directly on integration as the new system was hospital based. It was noted that the recurrent funding of 876k had been factored into savings for future years and that Operational Units had signed up to the new system and the benefits of it. Regarding implementation it was confirmed that a Programme Manager would oversee this. It was also noted that due to the national procurement process that the costs were unlikely to change. The Board a Agreed the need for replacement of the current legacy Patient Administration Systems with a modern Patient Management System; b Considered the more detailed content of the attached draft Business Case; c Agreed that NHS Highland commence implementation of the National Patient Management System from April 213; d Agreed the required local funding to allow the implementation to commence. 159 Carbon Management Plan Report by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance The Carbon Management Plan set some challenging priorities to contain and reduce our energy costs and reduce our impact on the environment. Mr Eric Green, Head of Estates spoke to the report. The new Carbon Management Plan identified clear targets for reducing our overall carbon footprint by 33% by March 216. This was an ambitious target however the plan identified a clear path to achieve this. Mr Bill Brackenridge, who was a member of the Carbon Management Group, updated on recent funding from Scottish Government for the installation of new biomass boilers, and LED lights in Raigmore Hospital which could reduce electricity use on lighting by up to 9% and increase the life of the light bulbs to around 25 years. It was anticipated that NHS Highland would be 85% free of fossil fuel use by 215. The Chair congratulated the team involved in this area of work. Dr Foxley welcomed the work in progress and the potential impact of reduced energy consumption. The Board a Approved the NHS Highland Carbon Management Plan. b Approved the target of a 33% Carbon reduction by 216. c Noted the progress made in improving our Carbon management arrangements. d Supported the improved arrangements for local responsibility for Carbon Management. 16 Restorative Dentistry Report by Roseanne Urquhart on behalf of Ian Bashford, Medical Director (attached) The Board was asked to confirm approval of the business case for restorative dentistry that was developed in collaboration with North of Scotland (NoS) colleagues. The business case had been agreed in principle by the NHS Highland Executive Group. Dr Ian Bashford, Board Medical Director presented the report to the Board. 91

19 13 The Business Case had been developed by the North of Scotland Planning Group, which sought to expand the capacity of consultant led Restorative Dentistry services in the NoS, through the appointment of two additional Consultant posts (one based in Highland and one in Grampian), and to develop, through education, training and support, a network of primary dental care teams across the NoS to support the network and provide intermediate care services in primary care, thus reflecting the geography and the need of the North of Scotland. The financial contribution for the development of the NoS restorative dentistry network had been calculated on a population basis; the NHS Highland contribution would be 13,. NHS Highland was establishing a Restorative Dentistry Group to explore how these costs could be identified within existing resources; specifically from the dental services and educational budgets. Over 5% of these costs had already been identified to-date from the aforementioned budgets. It was expected that the costs of this service would be met from the overall dental budget. There has been positive discussion with the Scottish Government Access Support Team who had affirmed their broad support for the development of the NoS Restorative Dentistry Service. There were some outstanding issues which had been raised by the Chief Dental Officer, which require to be addressed before any funding could be released. However once resolved, Scottish Government had confirmed that they would contribute 1k to support the establishment of the NoS restorative dentistry service. This sum would be earmarked non-recurrently for 213/14. The Board a 161 Confirmed Approval of the business case for restorative dentistry that was developed in collaboration with North of Scotland colleagues. Infection Control Report Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control Ms Heidi May, Board Nurse Director updated on the Infection Control Report. The Executive Summary of the main Infection Control Report, which summarised the key information in the report, is detailed below: NHS Highland infection prevention & control targets and performance data Group Target NHS Scotland NHS Highland Clostridium difficile Age 65 and over 39. (1, OBDs) 3.8 For 32.8 Green period April For period April June 12 June 12 Staphylococcus aureus bacteraemia Age 15 and over 26. (1,) OBDs Amber For period For period April April June 12 June 12. Annual rate is which means that the Board is still on track to meet the HEAT Target 92

20 14 Hand Hygiene 95% % 98% Green Cleaning 9% % 96% Green Yes Green Yes Green Yes Green Antibacterial prescribing Hospital-based Compliant Empiric prescribing Surgical antibiotic Compliant prophylaxis Primary Care Compliant empirical prescribing Source: - Health Protection Scotland/ISD/Local data. Ms May gave an update on infection control, advising that there was a positive picture in primary care as GP prescribing of antibiotics was low. There had been three outbreaks of winter vomiting which had all been well managed. The full report had been received in relation to the recent unannounced visit by the Health Environment Inspectorate (HEI) to Caithness General Hospital. Overall this had been a fairly positive visit. Feedback indicated that the hospital was clean, well maintained and there had been good compliance by staff in relation to sharps and hand hygiene policies. There had also been an unannounced visit at Raigmore Hospital two weeks ago and it was noted that initial feedback on this had also been positive. Ms May reported on two workstreams with the Health & Safety Executive (HSE) in relation to infection control management in Care Homes; and Community Nursing Staff in Lochaber where a fully compliant notice had now been issued. In relation to Colorectal Surgical Site Infection it was noted that 18.5% of elective procedures led to infections and overall the rate of elective colorectal surgical site infections had not changed since surveillance commenced. Ms May advised that NHS Highland was one of the few Board s to monitor this and that the rates were high and challenging to reduce. Accordingly, she confirmed that a detailed report would be submitted to the next meeting of the Board on this issue. Mr Creelman asked about Hydrogen Peroxide Vapour Decontamination (Fogging) and how NHS Highland would know if this was making a difference. The Board Nurse Director advised that there was compelling evidence in relation to this reducing infection and that a monitoring system was in progress and a report would be submitted to the Board in due course. The Board a Noted the contents of the Infection Control Report. b Noted that a detailed report on Colorectal Surgical Site Infection would be submitted to the February meeting of the Board. 162 Chief Executive s and Directors Report Emerging Issues and Updates Report by Elaine Mead, Chief Executive This month s report covered the following: Development of Primary Care Services in Tain Outline Business Case Addendum Letter from Minister on NHS Highland Annual Review Regional Planning West of Scotland Planning Group Mr Kenton, Director of Finance spoke to the update on the Tain Outline Business Case and advised that Scottish Government was keen that this business case reach financial close by the end of the financial year. The Full Business Case would therefore be presented to the Board in February, rather than May as originally proposed. 93

21 15 It will seek the Board s approval up to a predicted maximum value the Chief Executive and Director of Finance be given The intention would therefore be to seek Board approval up to a maximum value, as the actual cost would not be known until the day of signing, and seek delegated authority for the Chief Executive and Director of Finance to conclude the arrangements to financial close. The Chief Executive confirmed that NHS Highland had now received the feedback letter from Alex Neil, Cabinet Secretary for Health and Wellbeing on the NHS Highland Annual Review held on 5 September 212. The Annex to the letter listed the main action points from the Review. Dr Foxley referred to the reference in the West of Scotland Planning Group update on Healthcare and Forensic Services for people in police custody and highlighted an issue in relation to healthcare for people in police custody in Lochaber. The Chief Executive confirmed that NHS Highland would take responsibility for this in the Highland Council area from 19 December 212. The Chair suggested that further information be provided for the Board on this topic. The Board a Noted the emerging issues and updates report. b Noted that the Full Business Case for the Development of Primary Care Services in Tain would be submitted to the February meeting of the Board, rather than May as originally planned. c Noted that further information would be provided for the Board in relation to healthcare for people in police custody. 163 Any Other Competent Business There was none. 164 Date of Next Meeting The next meeting of the Board will be held on Tuesday 5 February 213 at 8.3 am in the Board Room, Assynt House, Beechwood Park, Inverness. The meeting concluded at 12.3 pm. 94

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23 17 FOLLOW UP FROM BOARD ACTION PLANS JUNE 211 ONWARDS Those items shaded grey are due to be removed from the Action Plan as they have been completed, or will be considered at the next Board. Highland NHS Board 5 February 213 Item 2(b) Meeting Item Action / Progress Outcome Board 7/6/11 Audit Committee Hospital and Community Health payments to GPs in Argyll and Bute to seek clarification on this issue and report back to the Board in due course. Board Dev. 8/8/11 Archie Foundation Update The Chair advised that he felt it was necessary for a protocol to be in place regarding similar style projects to ensure that these were brought to the attention of the Board in a timely fashion. Future Board letter received from SG 21/1/11 being progressed Being reviewed by national Primary Care Leads with a view to providing additional guidance. Chair / Chief Executive to progress. Board 4/1/11 Matters Arising Patient / Public Representatives on Committees an action should be added to the Board Rolling Action Plan in relation to appointing patient and public representatives to governance committees. Report to be prepared for Board members on the support available to applicants, as the new way of working was very complex. Work in progress Patient Experience at Governance Committees To consider whether patient experiences should also be considered at the Board as well as governance committees. Chair to consider Board 6/12/11 Internal Evaluation Highland Newspaper NHS To bring forward proposals to the Board early in 212 on the production of two editions of the newspaper in the spring and autumn. 2 Edition of Newspaper to be issued. Copy now being pulled together. Issued January 213 Board 7/2/12 Highland Health & Social Care Partnership Proposed Governance Arrangements Senior Operational Management and Professional Leadership Arrangements NM&AHPs To review the governance arrangements once the structure had been operational for one year. Board June 213 A more detailed diagram of the structure to be circulated to Board members for information. Work in progress being finalised. Chair and Chief Executive to consider suggestion for a future discussion on the key priorities for the Board in relation to risk management and the governance of risks. Future Board / Brd Dev. Session To be picked up at additional Board Strategy Session on 15/1/13 To issue a structure diagram of the revised tiers of management to Board members once available. Work in progress being finalised. Process to appoint additional District Managers to North & West and South & Mid Operational Units ongoing. Pharmacy Practices Committee Board 3/4/12 Board 5/6/12 CHP Committees of Work in progress nd

24 18 Meeting Item Action / Progress Outcome Board 5/6/12 Governance Committees Review of Assurance to Board To review the mechanisms for governance committees to report to the Board. Work in Progress Board 14/8/12 Argyll & Bute Health and Care Strategic Partnership Requirement to review the constitution of the Argyll & Bute Health and Care Strategic Partnership and ensure that the Chair and Chief Executive are involved to ensure consistency between local authority areas. Robin Creelman and Derek Leslie to action. A&BH&CSP Meeting 3/1/12 Supporting Carer s Revised Carers Strategy to be presented to the December meeting of the Board. Board 4/12/12 Deferred Board 9/4/13 NHS Highland Maternity Services Strategy Approved the Maternity Services Strategy and Strategy Workplan, subject to this being refreshed during the next year as discussed. Helen Bryers to action. Highland Health & Social Care Committee To ensure appropriate patient / public and voluntary representation on this and other governance committees. Elaine Mead / Maimie Thompson to action. Work in progress Improvement Committee Report to be submitted to Board in due course on Access Policy and capacity across NHS Highland. Future Board Consideration to be given to the style of assurance report required from Highland Council as the Lead Agency for Children s Services and also the assurance report by NHS Highland as the Lead Agency in relation to Adult health and social care. Assurance style report for HH&SCC (submitted to 4/12/12 Board) Work in progress / ongoing discussions with Highland Council. Inequalities Action Plan To submit regular updates on progress to the Board. Future Boards (April and October) Director of Public Health Annual Report 212 To present Annual Report to local authority partners. NHS Highland Standing Orders Standing Orders deferred to December Board Meeting. Adult Support & Protection Follow up report on lessons learned requested by Board Chair. Dates set: Highland Council 13/12/12 A&B Council 24/1/12 Board 4/12/12 Deferred Scheme of Delegation to 5/2/13 Board Work in progress re Standing Orders. Benchmarking exercise completed with subsequent actions for discussion at ASPC delivery group. Further report to ASPC scheduled. Further update to Board 5/2/13 Board 2/1/12 Highland s Highland Council Adult Children s Services Committee & 2

25 19 Meeting Item Action / Progress Outcome Board 2/1/12 Chief Executive s Report West of Scotland Planning Group to follow up issue regarding patient and public engagement within the West of Scotland Planning Group. Robin Creelman confirmed this has been followed up in A&B CHP. Confirmed at 4/12/12 Board. Board 4/12/12 Board Minute of 2 October 212 To make minor amendment as discussed. Completed 12/12/12 LP Matters Arising Evaluation of Integration to provide a briefing for Board members on the evaluation undertaken to date. Routine performance metrics are being monitored. Work is underway on producing trend information on delayed discharges, and in social care use data. A staff survey has been completed, and will be considered by the Senior Management Team on 31/1/13. Briefing being prepared for Board members. To submit a further request to Scottish Government in relation to funding. Elaine Mead to action Infection Control Report regarding the query relating to hospital based empirical prescribing; a briefing should be provided and circulated to all Board members. Heidi May to action Lorraine Power to circulate Response to Board member following Board meeting Circulated to all NonExecs 23/1/13 Patient / Public Representatives on Committees to provide a further update on progress with recruitment of Patient and Public representatives for Board members in the New Year. Maimie Thompson to action. To discuss HSE reports in relation to assurance, consistency and feedback. Garry Coutts / Elaine Mead / Kenny Oliver To write to Board members regarding the recruitment process for the Chair of the HH&SCC. Actioned update to Board 5/2/13 Highland Health & Social Care Governance Committee To amend the Terms of Reference for the Highland Health & Social Care Governance Committee to include the Director of Adult Care. 3 Completed

26 2 Meeting Board 4/12/12 Item Action / Progress Outcome Highland Quality Approach Presentations To plan another team visit to Torbay to explore further how the integrated teams work in practice. This visit to include NonExecutives. Update to Future Board Register of Interest of Members of Highland NHS Board To ensure the updated Register is made available on the NHS Highland website. Completed 4/12/12 Financial Position as at 31 October 212 Update on discussions with Highland Council regarding the Adult Social Care budget to be submitted to the January meeting of the Improvement Committee. Improvement Committee 7/1/13 Infection Control Report Update report on Colorectal SSI to be submitted to the next meeting of the Board. Board 5/2/13 Full report to be submitted to Infection Control Improvement Group in February 213. Chief Executive s Report Full Business Case for Primary Care Services in Tain to be submitted to the February meeting of the Board. Board 5/2/13 Update to be provided for the Board in relation to healthcare for people in police custody. CEs Report Board 5/2/13 4

27 21 Highland NHS Board 5 February 213 Item 3.1 DRAFT MINUTE OF MEETING OF THE ARGYLL & BUTE CHP COMMITTEE Argyll & Bute Community Health Partnership Aros Lochgilphead Argyll PA31 8LB Queens Hall, Dunoon 19 December 212 Present Mr Robin Creelman, Chairman, Argyll & Bute CHP Mr Derek Leslie, Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Tricia Morrison, CVO Representative, Argyll & Bute CHP Mr Duncan Martin, Chairman, Public Partnership Forum Mr Michael Roberts, Vice Chair, Public Partnership Forum Ms Dawn Gillies, Staffside Representative Councillor Elaine Robertson, Argyll & Bute Council Representative In Attendance Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr David Logue, Head of HR, Argyll & Bute CHP Mr Stephen Whiston, Head of Planning Contracting & Performance, Argyll & Bute CHP Mr David Ritchie, Communications Manager, Argyll & Bute CHP Ms Viv Smith, Locality Manager, Cowal & Bute/Helensburgh & Lomond, Argyll & Bute CHP Mr Raymond Stewart, NHS Highland Employee Director Mrs Sheena Clark, PA to Director of Operations - Minute Secretary Apologies Councillor George Freeman, Argyll & Bute Council Representative Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Ms Glenn Heritage, CVO Representative Jim Robb, Head of Service, Adult Care, Argyll & Bute Council 1. CHAIRMAN S WELCOME The Chairman opened the meeting by welcoming everyone to the Queens Hall, Dunoon. 2. APOLOGIES Apologies for absence were noted as above. 3. CONFLICTS OF INTEREST No conflicts of interest were declared.

28 22 4. MINUTE FROM PREVIOUS MEETING 4.1 Minute of Meeting held on 31 October 212 The Minute of the meeting on 31 October 212 was accepted as a complete and accurate record of the meeting. The Committee: Approved the content of the Minute of the meeting on 31 October MATTERS ARISING FROM PREVIOUS MEETING HELD ON 31 OCTOBER 212 There were no matters arising. 6. NHS Highland Organisational Issues 6.1 Meeting of Highland NHS Board Meeting 4 December 212 Mr Creelman provided a verbal update on a number of points from the Draft Minute which will be circulated at the next meeting. Highland Quality Approach senior managers from NHS Highland who had been accepted on the Lean Leader Training Programme by Virginia Mason Institute had recently undertaken training in Seattle. The Board was updated on some of their learning and the next steps for the Highland Quality Improvement System and Building Capacity and Capability. Visit to Torbay & Southern Devon Health & Care NHS Trust representatives from adult social care and Highland Home Carers visited the Trust during November 212 where they were advised on the community service model with co-located multi-disciplinary teams who had a Health and Social Care Co-ordinator. Mr Creelman advised that this is a locality based system and ensures close working with GPs and there are a number of lessons to be learned from the visit and report. Proposed Implementation of the National Patient Management System (PMS) Mr Leslie advised the Committee that the Business Case also submitted to the Board described the proposals in greater detail. Mr Leslie reassured the Committee that the CHP has contributed to the preferred proposal for implementation, observing that the Argyll & Bute patient flow is predominantly to NHS Greater Glasgow & Clyde which may create specific issues and challenges that need to be addressed as the implementation of the preferred solution progresses. Assurance has been sought that Argyll & Bute based patients will not be disadvantaged and will enjoy the same equity of priority and access, particularly to outreach services provided by NHS Greater Glasgow & Clyde and discussions are continuing to ensure a positive outcome to addressing these challenges. Mr Martin expressed anxiety regarding the future clinical management of CHP patients and expressed the opinion that patients should remain on the NHS Greater Glasgow & Clyde pathway, with NHS Greater Glasgow & Clyde linking in with NHS Highland to address any issues which may arise. Mr Leslie clarified that extant patient pathways between Argyll & Bute and Glasgow would not change. The challenge was to ensure there were no unnecessary hurdles encountered from an ehealth perspective within the clinical management of that pathway. Mr Creelman provided assurance to the Committee that the CHP will continue in its proactive engagement with the wider ehealth team and Greater Glasgow to find a solution. 2

29 23 Social Media the report to the Board recommended exploring the principle of opening up social media in the work place, initially through controlled access. It was noted that to date this suggestion has not been considered by the CHP but would be explored in due course. A copy of the agreed Minute of the meeting of 4 December 212 will be circulated at the Committee meeting in February 213. The Committee: Noted the verbal update of the meeting on 4 December NHS Highland Annual Review 212 Scottish Government Summary Mr Leslie referred to the circulated letter which summarised the topics discussed and actions arising from the Annual Review in Inverness on 5 September 212. Mr Leslie highlighted the action points and in particular the first bullet point, Keeping the Health Directorates informed of progress on the Partnership Agreement in respect of integration of health and social care. Mr Leslie advised that this referred to the NHS Highland North approach regarding adult care, managed by NHS Highland and Children s Services, managed by Highland Council. Mr Leslie reported NHS Highland (with involvement from the Argyll & Bute CHP) and Argyll & Bute Council continue to discuss and work through integration proposals under the auspices of the Scottish Government Consultation. In addition, the CHP Health & Care Strategic Partnership Constitution is currently being reviewed to make it more outcomes focussed and to increase the focus on Children s Services Clinical Governance Clinical Governance & Risk Management Report Ms Tyrrell spoke to the circulated report and highlighted and summarised a number of items. Risk Management Incidents Ms Tyrrell advised that a total of 442 incidents were reported during quarter 2 of 212. Slips, trips and falls remained the highest reported category of incidents in Cowal/Bute, Mid Argyll Kintyre & Islay and Oban, Lorn & Isles, with medication and sharps incidents being the highest category in Helensburgh. Ms Tyrrell advised that there had been no change in trend since the last reporting period. There were no incidents of major or extreme consequence (including potential consequence) reported in July-September 212. Pat will confirm and advise the definition of these incidents at the next meeting. Pressure Ulcer Prevention Ms Tyrrell clarified that the information presented in the circulated report was collated from the incidences recorded on the Datix system. 3

30 24 A significant amount of work continues to be undertaken to ensure early identification and management of patients at risk of developing pressure ulcers in all settings. Improved compliance with Clinical Quality Indicators is being evidenced and reporting is showing a downward trend and consistency in preventing incidents. Investment from the Scottish Government will enable the use of improved equipment and enhancement of staff knowledge. Mr Leslie acknowledged the improvement in outcome for patients at Lorn & Isles Hospital and recognised the significant achievement for staff in achieving this positive result. Falls Prevention Ms Tyrrell advised that due to the recent transfer of Dunaros to Mull & Iona PCC, information for this area will be included in the next report. Serious Untoward Incidents Ms Tyrrell emphasised that NHS Highland have a clear policy for investigating any incidents and full reports and all key learning is addressed through the CHP Clinical Governance and Risk Management Group. External Reviews Inspection of Children s Services in Argyll & Bute Ms Tyrrell referred to the detail in the circulated report regarding the forthcoming inspection by the Care Inspectorate which is due to commence in March 213. The review will focus specifically on the outcomes for all children and young people to evidence the quality of services, particularly for those in vulnerable situations. The public report will be published within four weeks of the inspection. Quality Person Centred Care The national launch of the Scottish Person Centred Care Programme took place at end November 212 and will tie in the Patients Rights (Scotland) Act 211. All NHS Boards are expected to implement the requirements of the programme and Heidi May, Board Nurse Director is leading this work for NHS Highland. The Committee: Noted the content of the Clinical Governance & Risk Management Report. 7.2 Infection Control Report Staphylococcus Aureus Bacteraemia (SAB) Ms Tyrrell advised that since the last report to the Committee, there has been one further community acquired SAB case attributed to Lorn & Isles Hospital. The total of five cases for LIH in all appear to have been community acquired, two of which may have been healthcare associated. Ms Tyrrell confirmed that each case was subjected to enhanced surveillance and HEI standards within Primary Care are currently being reviewed. Clostridium Difficile Infection (CDI) Ms Tyrrell reported that for 212/13 there have been 4 reported case of CDI in the CHP: 4

31 25 o o o Lorn & Islands Hospital Cowal Community Hospital Campbeltown Hospital Quality assurance and compliance with good hygiene continues to be monitored. Ms Tyrrell confirmed that the involvement of the Public Partnership Forum in compliance initiatives for staff and the public will be progressed in early 213. Norovirus Ms Tyrrell highlighted the start of the Norovirus season and reported three recent outbreaks in NHS Highland. There was also one outbreak in Ward B of Lorn & Isles Hospital when 4 patients and 8 staff were affected. The information sharing pathway is utilised during such outbreaks and Lorn & Islands were complimented on the actions taken in implementing infection control procedures. Ms Tyrrell and Mr Ritchie will discuss a Press release providing public information relating to infection control procedures when attending/visiting in hospitals. HEI Inspections Heidi May, Board Nurse Director recently undertook a programme of visits to all hospitals in the CHP to support and discuss with staff the continuing work being undertaken to ensure all HAI standards are implemented and sustained in all settings. The feedback from the visits has been positive and helpful. A task forced, chaired by Mr Leslie, has been established to address the key issues within Argyll & Bute Hospital. An action plan is in place and fortnightly monitoring meetings are ongoing. Infection control nurses are delivering sessions for staff to prepare them for the inspection process and to share good practice across the CHP. The Committee: Noted the content of the Infection Control Report Financial Governance Finance Report Mr Morrison spoke to the circulated report and advised that at end November 212 the CHP recorded an underspend of 197,. Mr Morrison advised on the budgetary performance across the CHP and the CHP s satisfactory financial position which is mainly as a result of the achievement in savings in the prescribing budget. This position is due to falling prices of off-patent drugs; with a reported underspend on the prescribing budget of 47k at end November 212. Mr Creelman asked Mr Morrison for further details regarding prescribing costs. Mr Morrison replied that for the following drugs, Quetiapine, Donepezil. Olanzapin and Atorvastatin, volumes prescribed have remained fairly static, however prices have dropped significantly, creating an underspend on the prescribing budget. Although there had been an awareness of possible price 5

32 26 reductions in drugs, the extent of the cost reduction was unexpected and therefore resulted in savings beyond the level anticipated. Mr Leslie commented on the continuing cost pressure resulting from medical locum cover for vacancies, which is a challenge in all remote and rural areas. Mr Morrison reported that agreement has been reached with NHS Greater Glasgow & Clyde on an SLA value for 212/13 of m, which is in line with the CHP s budget. However, negotiations will resume next year regarding NHS Greater Glasgow & Clyde's claim that the agreed value represents a significant underpayment against the true cost of services provided. Mr Leslie credited staff and managers, particularly the prudent stewarding within the Finance Department, for their work and commitment in achieving the efficiencies enabling the reported underspend. Mr Martin queried the CHP s forecast underspend of 2k in the context of NRAC funding which is allocated by NHS Highland. Mr Leslie emphasised that the CHP is not disadvantaged by the funding received and this was confirmed by Mr Creelman. The Committee Noted the content of the of the Finance Report. STAFF GOVERNANCE 9.1 Argyll & Bute CHP Partnership Forum Draft Minute 15 November 212 The draft minute was previously circulated for information. Mr Creelman noted that the Minute reflected the variety of discussion at Partnership Forum meetings and that he was impressed by the very healthy atmosphere in which the meetings were conducted. The Committee: Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of 15 November PDP/R and eksf Implementation Mr Logue reported that at end November 212, 24.14% of all AfC staff had reviews and personal development plans signed off in eksf, which signifies an increase in activity since the last reporting period. Managers have reported that the figure of 8% completion by end March 213 is achievable and efforts are continuing to achieve this target. Mr Creelman asked if there is a quality indicator around the eksf process which informs on staff feedback and the benefits to training and the skills essential as part of the provision of patient care. Mr Logue advised that there is a focus group, in conjunction with the Partnership Forum, and he will incorporate quality assurance details as part of his next report to the Committee. Mr Leslie commented that there is a common responsibility by staff and managers to ensure delivery of the target for completion. 6

33 27 The Committee: Noted the content of the PDP/R and eksf Implementation Report 1. Director of Public Health Annual Report 212 Ms Garman commented that the report should be seen in the context of a story of good news as people are living longer, healthier lives. Improving life expectancy is the result of improvements in health care and changes in the wider environment, with a majority of older people living independently and actively and this trend should be encouraged. However, it should also be recognised that an increasing number of elderly people are living with long term conditions and service providers and staff need to recognise this and support older people to lead the lives they want as far as possible. Ms Tyrrell emphasised the need to recognise the positive aspect of the report and that older people are an asset to a community. The ongoing work for Reshaping Care for Older People within the CHP looks at how services are provided in communities. Mr Whiston commented that the report provided a good indication of trends and the current services provided within the community. Ms Garman advised on the recommendations for NHS Highland to include or consider as it is developing its strategic commissioning plan for older people over the next year. The Committee: Noted the content of the Public Health Annual Report Director of Operations Report Mr Leslie provided a brief update on a number of issues not featuring as substantive papers at today s meeting. These included: An update on performance against the target set for the staff flu immunisation programme 212/13 Confirmation of ongoing discussions with the GP community on Islay to establish workable transition arrangements to ensure continuity of, in particular, the provision of out of hours and hospital medical services. Continuing engagement with community stakeholders in partnership Argyll & Bute Council and West Highland Housing in regard to a number of operational issues arising from the commissioning of the Mull & Iona Progressive Care Centre. The centre is now operational and particular issues requiring clarification were primarily in connection with the social care element of the service. PMS referred to initially in a reflection on business discussed at the meeting of the NHS Highland Board and reaffirmation of the anxiety that implementation of the preferred solution will introduce/compromise equity of priority/access through perhaps the need to have an additional hurdle within the clinical management of the patients pathway. Discussions with all parties continuing to identify and resolve the anxiety. Locality Reports - Helensburgh & Lomond/Cowal & Bute 24/7 Review (subject of substantive paper on today s agenda) 7

34 28 Model of care a group has been established to examine a whole range of issues associated with the model of care for the older adult. Visit from the Director of Nursing to Cowal & Bute in connection with HEI issues had a positive outcome. Cowal catering proposals approved, with domestic services proposals under review. Examination of issues causing the use of additional nursing hours and bank staff in Cowal. A number of service level agreement reviews covering mental health, out of hours, dietetics and physiotherapy services to the Helensburgh & Lomond Area. Mid Argyll, Kintyre & Islay Bed modelling continuing in relation to Campbeltown community hospital. A continuing examination of the challenges associated with establishing a substitute prescribing service in Kintyre in light of changes to the medical staffing in the community. Progress of establishing a MacMillan Cancer information and support service to allow people living with and beyond cancer to improve their quality of life by ensuring they receive the right information and support at the right time, regardless of where they are on the cancer journey or where they live in Argyll & Bute. Clinical lead appointed for Islay and Jura. Phase 2 of the planned building work has commenced in Islay hospital. This is related to shifts and changes that were required following the establishment of the GP surgery in the hospital to establish new outpatient consulting areas and the re-provision of the physiotherapy department. Acknowledgement that the cost of administering biological drugs (treatments used as supporting therapies in cancer, but also administered for a range of clinical conditions, including rheumatoid arthritis, Crohn s Disease and UIcerative Colitis) in Mid Argyll Hospital will be included in the financial plan for the coming year. This improves the patient experience by reducing the need for travel to Glasgow. Oban, Lorn & Isles Provisional start for the new dental project is 7 January 213, to complete in August 213. Progress made in partnership with Raigmore to support the local urology service while preserving existing specialist patient pathways to Glasgow. Locum medical staff currently supporting the delivery of surgical and general medical services. The Committee: Noted the Director of Operations update. 12. Review of Management Structure Cowal & Bute/Helensburgh & Lomond Ms Smith summarised the background to the report and, following the recent interim management arrangements in Cowal and Bute and Helensburgh and Lomond, the proposal to redesign the management and leadership structure, together with the roles and responsibilities for the two localities. This would enable the existing structure to be adapted to enable the best use of limited senior management resources. Locality management have identified a number of issues which hinder the delivery of corporate and operational objectives and performance targets, and it is anticipated that the proposals detailed in the report would address these concerns and improve the quality of services and reduce variation and waste. 8

35 29 Mr Leslie advised that the review would need to be carried out with a consistency of approach, robustness of management and application of governance to ensure improved patient outcomes. The proposals would also require to be cost neutral as a minimum. Ms Gillies expressed concern regarding the removal of the Practice Development Nurse post from the proposed structure. Ms Tyrrell provided assurance that the role of the Practice Development Nurse would continue but would be reconfigured to be delivered in a different way. The post title would be different but the role would be the same. There will be full staff engagement during this process of management restructuring. The Committee: Considered and endorsed the recommendation detailed in the report. 13. Assessment of the Viability of a Hospital Dialysis Service in Argyll & Bute CHP Mr Whiston advised that the purpose of the circulated paper is to provide an update on the findings of the viability assessment conducted to provide a local dialysis unit in Oban and for members reference provided a reminder of the conclusion of the previous report in May 212. Work undertaken to assess the viability of a service, considered: Existing service demand and future projections of activity Feedback from users and referrers on the current service include its operation and accessibility Clinical assessment on suitability of service and size of dialysis unit. Identifying a site within LIH to locate the unit and any knock on impacts Identifying the indicative capital cost to build and the indicative revenue cost to run a unit Identifying sources of capital funding and their likely availability Assessing the affordability and value for money of the service including benchmarking to other units Identifying any additional sources of activity and income Considering alternatives - Capacity and demand profile in other units, alternative provision, mobile unit, flexible provision across units, transport implications- use of local air services Considering any other service implications e.g. transport, recruitment, training, Laboratory support, clinical governance etc CHP s strategic view re prioritisation of service development Indicative timescale- from decision to proceed to actual opening Mr Whiston emphasised that the report is not a formal business case for representation and approval, but a written report outlining the findings to establish if a viable unit could be provided in Oban and summarised the findings as follows : o o Following advice received from the NHS Greater Glasgow & Clyde Physician and the Renal Consultant at Belford hospital, it is acknowledged that a 4 station unit will meet the future projected demand of the catchment area, operating 3 days a week. Providing a unit in Oban would not necessarily provide equity of access to the catchment population it would serve. It was noted that renal patients from Cowal and Bute and Helensburgh and Lomond localities receive a renal service from Inverclyde Hospital or the Vale of Leven Hospital. 9

36 3 o o o o o o o o Significant patient benefits have been identified for having a local unit and there is also support from GPs The capital cost of the unit is significant and it is unlikely the NHS Board would be able to consider its expenditure until 214/15 and it is therefore not affordable at this time Providing a local unit would result in significant savings in transport costs and cost incurred in sending patients to Belford and this could be reallocated to meet the running costs of a local unit Opportunities exist to align and coordinate renal staffing resource and support between the Belford and LIH if a unit is located in Oban The value for money assessment illustrates that, based on related level of activity; the local unit would not rate well against other units. It would also be poorly utilised outside its core 3 day a week window. It does however offer opportunities to increase dialysis capacity in exceptional circumstances. Establishing a unit in Oban or Lochgilphead would affect the cost efficiency of the Belford unit. There are opportunities now to review existing transport arrangements and look to improve this service to patients and reduce cost. Mr Whiston reported that following discussion and consideration of the report to the CHP Management Team meeting on 11 December 212, it was agreed that the following points required further deliberation: A local unit would provide improved access to services for those in the proximity to the locality. The provision of a mobile unit on the face of it offers gains for patients, but there are a range of logistical and operational issues which do not suggest this is an elegant solution. The capital cost of a fixed unit s significant and there is not currently funding available for this. At the earliest if prioritized by the Board this would be April 215. In revenue terms a local unit does not offer value for money. It is however affordable if the cost savings in transport and repatriation of activity can be made. How important a priority is this for the CHP with regard to service provision? The top service priority issues facing the CHP and targeting its investment in services are : Mental Health modernisation Reshaping Care for Older People Sustaining our Community and Rural General Hospital core services re acute care, trauma and Out of hours services There are high quality renal dialysis units which have the capacity and capability to support patient need at this time and into the future. In these terms a local unit is not perhaps a priority at this time. There are issues regarding current transport arrangements which could be improved and these should be reviewed and alternatives examined to provide better quality of service to patients. o o o Mr Whiston acknowledged the extensive public interest in this issue, particularly in the Oban and Taynuilt area, and in order to support the viability study a patient survey was prepared to ascertain the opinions of patients who currently receive dialysis at the Belford Hospital and Vale of Leven Hospital. The survey also asked their opinion on what would make the biggest improvement to their experience of renal replacement therapy services. The survey was submitted to the Belford Hospital and Vale of Leven Hospital on 23 November 212 for distribution by staff to renal patients. A total of 7 out of 16 forms were completed and returned by the deadline of 7 December 212. The key points raised by patients were: 1

37 31 Outward journey is tiring, return journey traumatic, 3 times a week Service keeping me alive Kind, courteous and knowledgeable staff instils confidence Worry that local staff do not have much knowledge about the illness Worry that renal professionals are so far away Reduced waiting time after treatment Patients were also asked where they would prefer to receive their dialysis. 3 patients (2 Helensburgh and 1 Oban) stated they would prefer to receive dialysis within NHS Greater Glasgow & Clyde, 2 Oban patients would prefer a local satellite unit in Oban, 1 Kintyre patient indicated a preference for Lochgilphead as central to Argyll patients. 1 Oban patient did not respond to this question. It is acknowledged that improvement to a patient s experience of renal replacement therapy services is personal for each patient but it is apparent that reduced travelling time is very important for all patients. Mr Creelman thanked Mr Whiston for the detail and thoroughness of the report and enquired about the availability of home dialysis in the CHP. Mr Leslie provided an assurance that where appropriate a home dialysis unit will be available for patients but advised that this option is, on occasions, not clinically feasible. Mr Creelman asked what would be the determining factors for the location of a satellite unit in Argyll & Bute. Mr Whiston replied patient activity and projection figures will continue to change significantly. If it was decided to take forward the assessment into a business case proposal an equality and diversity assessment would require to be undertaken to identify how location and operation of a fixed or mobile unit would affect catchment populations. Councillor Robertson requested that when considering future activity and projection figures consideration is given to the recently published census results. Ms Garman commented that it is not possible to accurately predict figures. She stated that in terms of level of access to treatment, the needs of renal patients are being met. In terms of the level of experience, the needs of renal patients are not being met and further work is required to improve the patient experience. Mr Leslie advised that on considering the detail of the report and discussions, the conclusion of the Committee on the way forward for the review and outcome needed to the CHP wide, and not for a particular locality. Mr Leslie reiterated that at present this service was provided to a modest number of seriously ill patients who live throughout the whole of the CHP area. Mr Leslie referred the Committee to the other service priority issues which are facing the CHP, as detailed in the report, and which need to be considered when reaching a conclusion to this proposal. In concluding the discussion, the Committee agreed that the provision of a satellite unit in Oban or indeed elsewhere in the Argyll & Bute CHP s geographical area was not straight forward in terms of identifying a safe geographical location or likely to attract capital or revenue priority in the present climate, but recognised fundamentally that further work is required to improve patient experience, particularly with regard to transport. The Committee provided a commitment 11

38 32 to ensure that this was taken forward as a matter of urgency. The detail of the paper and the outcome will be communicated to patients and their communities. The NHS Board will be advised of the outcome of the report. Mr Martin enquired about the CHP s view on the suggestion by a local community that it may consider fundraising for the provision of a dialysis unit to be situated in Oban. Mr Leslie replied that he welcomed such initiatives proposed by the public and was agreeable to having discussions with those involved and working appropriately in partnership with them. The Committee: Considered and noted the terms of the report and specifically the viability and challenges associated with prioritising the establishment of a satellite unit in Oban and whilst progress with the establishment of such a unit was not a priority in the immediate term that CHP should work with individual patients with a view to enhancing their current experience in accessing existing services as well as addressing disproportionate travel costs. Mr Creelman welcomed the members of the public in attendance, particularly for agenda item 14, and invited them to participate in discussions. 14. Cowal 24/7 Report Mr Whiston presented the previously circulated report on the outcome of the Cowal 24/7 review. He explained that the review had examined the issues relating to the future provision of GP out of hours arrangement for Cowal, as well as reviewing the medical input into the Cowal Community Hospital particularly the clinical management of inpatient and accident and emergency activity. Mr Whiston s presentation set out the background to the review which included an examination of: o Day time Medical Input in Cowal Community Hospital (CCH) o Casualty and out of hours medical input in CCH o GP Out of Hours arrangements Dunoon & East & South Cowal o GP Out of hours Arrangements Rural Cowal (Tighnabruaich & Strachur) o GP Out of hours Arrangements Lochgoilhead Mr Whiston described the inclusive and widespread composition of the Review Group, the option appraisal methodology followed, which initially involved the identification of a long list of 17 options, reduced through the process to a short list of 7 potential, viable options. The process then appraised the options by considering benefits delivered, risk, value for money and affordability. The process had been managed in accordance with Treasury Green Book guidance in collaboration with the Scottish Health Council and the guidance contained in CEL 4 (21) concerning informing, engaging and consulting. Mr Whiston set out the various milestones in the process, leading to an outcome recommending a variation to the original option 11 (option 11b), which resulted from all the previous engagement. Mr Whiston outlined reservations expressed by those key stakeholders in the Cowal 24/7 Review Group which included the impact on medical staff groups providing the current service, concerns over continuity of service provision and medical staffing levels during the day. He explained that this had led to a pause in the project so that further specific information on these reservations could be collated, and again these were described comprehensively from a stakeholder s perspective. In conclusion, Mr Whiston explained that the Project Group had considered all of this information at its meeting on 22 November 212 and had given a detailed assessment to the evidence presented 12

39 33 and reflected on the lack of consensus on the preferred option. The Group had acknowledged that some of the concerns and reservations were valid but there were clearly solutions that would address some of these concerns. In light of this lack of consensus, and whilst there was a majority in the Group which supported option 11b, the fact that the medical stakeholders did not support the model and the changes proposed to medical staffing, the Group felt that it could not finalise the option appraisal process or make a final recommendation and agreed that all the work and findings should be remitted to the CHP s Core Management Team and subsequently the CHP Committee to establish a way forward. Mr Whiston concluded by asking Committee members to: Note the status of the review Consider the issues with regard to the identified preliminary preferred option 11b for service delivery o benefits of the model proposed o the medical stakeholders unanimous rejection of Option 11b o reservations from other stakeholders Consider the conclusion of the Cowal 24/7 Project Group Identify the way forward for the review and outcome Mrs Grier, Co-Chair of the 24/7 Review Group advised the Committee that it was her belief that the process undertaken by the Group had been thorough, transparent and inclusive. Mr Bell (member of the public) asked if there were any strategies available to the CHP to encourage GPs to undertake out of hours work. Mr Leslie advised that the CHP is required to work in compliance with extant policies and terms and conditions of employment. This requires the deployment of strategies of influence and negotiation rather than direction with GPs (independent contractors) working within the terms and conditions of new GMS rather than those who have salaried practitioner conditions of service. Mrs Grier summarised the endeavours and efforts of the Group to facilitate the engagement and involvement of GPs in the process. Mr Law, Hunters Quay Community Council Representative, stated his opinion that the CHP had created a dysfunctional service and the public wanted the best use of Cowal Community Hospital. He advised that he has requested and had been granted a meeting with Mr Alex Neil, Cabinet Secretary for Health & Wellbeing and this was noted. Mr Law asked about the number of referrals being made to Inverclyde Hospital from the Cowal Peninsula. Dr Hall advised that a recent audit of the acute ward had been undertaken to look at referral patterns which concluded that patients were being referred to Inverclyde appropriately. Mrs Grier advised that Dr Brian McLachlan, Helensburgh GP and Co-Chair of the Group had also undertaken extensive work for the review which had been presented to the Cowal GPs. Mr Leslie appreciated the attendance, interest and contributions of public members, and indeed the Review Group, at today s meeting and expressed disappointment that the review had been unable to reach a final consensus on the best way forward. Hence the referral of the outcome to the Core Management Team. Mr Leslie conveyed his thanks and appreciation to Mrs Grier and Dr McLachlan for their leadership and contribution to what had been a long, challenging but robust and transparent process. He felt that a detailed and comprehensive assessment of the issues had been undertaken in accordance with relevant guidance. The outcome had been to identify option 11b as the option preferred by the majority. Mr Leslie also reported that the CHP had received notice from the GPs in Dunoon that in light of the identification of option 11b as the preferred option of the majority, and other challenges and pressures, that they intended to cease providing a service to the Cowal Community hospital wards from the end of February 213. In view of this and 13

40 34 current vacancies in elements of the hospital service a prompt decision was required to preserve continuity of service to enable an appropriate recruitment process to be commenced. Mr Leslie confirmed that at the their meeting on 17 December 212, the Core Management Team had considered the findings of the Cowal 24/7 Review Group and recorded its appreciation and thanks for the inclusive and thorough assessment work done by the Review Group which has led to the identification of the preferred Option 11b and the Group s subsequent consideration of the concerns raised by stakeholders as detailed in the written evidence presented. The Core Management Team was naturally disappointed by the rejection of Option 11b by the medical community and having noted their intention to cease provision of medical services to the Cowal Community hospital, acknowledged the need for a timeous decision to ensure the continuation of service provision and the commencement of recruitment as soon as possible. In light of the challenges facing the current service, Mr Leslie set out the recommendations from the Core Management Team which Committee members endorsed as follows: The option appraisal process is stopped. Locality management look to progress the implementation of the integrated inpatient and casualty hospital service model as detailed in Option 11b through recruiting salaried medical staff as well as offering individual GP practices/gps the opportunity to participate in the service. Locality management progresses with the implementation of a single out of hours service for Cowal with a mix of on duty and on-call staff. A lead clinician is appointed for all aspects of the service out of hours, hospital wards and casualty (as is the model in the rest of the CHP). Nurse practitioner competencies are enhanced so that their full capability and capacity can be utilised which will release medical staff time to provide the inpatient and casualty service on a 24/7 basis. The service is configured to operate within the current budget with any efficiencies realised, used to support other locality service pressure/priorities e.g. mental health crisis support It was also recommended that a short life (1 year maximum) service implementation and monitoring group is established to report to the CHP Committee. This group will include relevant representatives from the Cowal 24/7 Working Group stakeholders. The role of the Group will be to review the implementation and delivery of the service to ensure the operating characteristics of Option 11b are met as detailed (such as the use of rural GP surgeries for rural Primary Care Emergency Centre appointments). In addition the group will undertake a process of community engagement and feedback on the service to ensure it meets service standards. 15. Mental Health Modernisation Update The report provided an update on the key issues and progress against the action plan. Mr Leslie highlighted the following points. Project Governance/Stage 1 Submission and Approvals - following discussion and a review of comments from advisors and the Project Director at the recent Capital Project Board regarding the Hubco stage 1 submission, it was agreed that significant work is required by Hubco on the stage 1 submission prior to it being accepted by NHS Highland. This has resulted in the approvals timetable being reviewed by the Project Team. A revised stage 1 report is expected to be submitted by Hubco in January

41 35 Inpatient Services the bed compliment has reduced to 3 beds, plus 3 minimal supervision places in the refurbished Firgrove building on 1 December 212. Tigh na Linne is now closed and staff have been redeployed within the inpatient service. Community Mental Health Team Bases it has been confirmed that 3k of capital funding will be available in 212/13 to undertake hospital conversion work in Campbeltown and Dunoon to accommodate the CMHS teams. The Committee: Noted the current key issues and progress against the action plan. 16. PARTNERSHIP WORKING 16.1 Argyll & Bute CHP Public Partnership Forum Draft Notes 27 November 212 The draft note was previously circulated for information. Mr Martin and Mr Roberts referred to specific discussion points from the last meeting. Patient Central Booking System - Moira Newiss, CHP Business Transformation Manager presented the outcome of the Options Development/Appraisal process which considered the future provision of the patient central booking system. Helensburgh Locality PPF - it was reported that at a recent meeting the Patients Group had decided to support the role of the locality PPF, but would not host it. Other options will now be explored to ensure the locality PPF is established as soon as possible. The Committee: Noted the contents of the Argyll & Bute CHP Public Partnership Forum Draft Notes of 27 November PERFORMANCE MANAGEMENT 17.1 Delayed Discharge/Joint Performance Report The circulated report recorded that as at 15 November 212 there were 16 delayed discharges, 15 <6 weeks and 1 >6 weeks, all of which had legitimating coding. The Committee: Noted the contents of the Delayed Discharge Report Papers for Noting Argyll & Bute ehealth Steering Group Draft Minute Mr Leslie referred the Committee to the following points from the circulated Minute: 15

42 36 TrakCare Implementation Update Use of Intranet Immediate discharge letter The Committee: Noted content of the above paper. 19 AOCB Distribution of Committee Papers Mr Leslie apologised for the late distribution of papers which was due to capacity issues within administration services. Mr David Whiteoak, Locality Manager, Oban, Lorn & Isles Mr Leslie advised members of Mr Whiteoak s retirement on 4 January 213 and recorded the CHP s and the Committee s best wishes to Mr Whiteoak and his family. Mrs Moira Newiss, Business Transformation Manager Mr Leslie reported on Mrs Newiss s resignation from the CHP to take up post as Business Manager with the Taynuilt GP Partnership and recorded his appreciation for her work with the CHP. Abdominal Aortic Aneurysm Screening Mr Roberts enquired about the uptake figures for this screening programme within the CHP. Ms Garman will provide feedback to Mr Roberts. Social Media Ms Lorna Alquist (member of the public) asked about the CHP s usage of social media sites, i.e. Facebook, Twitter. It was acknowledged that this would provide a fresh approach to communication with the public and Mr Ritchie advised that NHS Highland are currently reviewing the use of media sites and an NHS Highland Facebook site is available. Ms Alquist will discuss this further with the CHP Communications Team. 2 DATE, TIME & VENUE FOR NEXT MEETING: Wednesday 2 February 213 at 1pm in J3-J7 Mid Argyll Community Hospital & Integrated Care Centre 16

43 37 Highland NHS Board 5 February 213 Item 3.2 HIGHLAND HEALTH & SOCIAL CARE GOVERANCE COMMITTEE Report by Deborah Jones, Chief Operating Officer The Board is asked to: Note that the Highland Health & Social Care Governance Committee met on Thursday 1 January 213 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below. Present: Mr Ian Gibson, Board Non Executive Director - Chair Helen Bryers, Head of Midwifery Myra Duncan, Board Non Executive Bren Gormley, Elected Member, Highland Council Gavin Hogg, Patient/Public Representative Deborah Jones, Chief Operating Officer Chris Lyons, Director of Operations Raigmore Hospital Fiona MacFarlane, Pharmacist Representative Margaret MacRae, Staffside Representative Gillian McCreath, Board Non Executive Gill McVicar, Director of Operations North & Mid Helen Morrison, Associate Director (NMAHP Workforce Planning and Development) Linda Munro, Elected Member, Highland Council Brian Robertson, Head of Adult Social Care Nigel Small, Director of Operations South & Mid Kate Stephen, Elected Member, Highland Council Katherine Sutton, Associate Director, AHPs Dr Chris Williams, Area Medical Committee Representative GP In Attendance: Jan Baird, Director of Adult Care Liz MacDonald, Scottish Health Council Brian Mitchell, Board Committee Administrator Mr Kenny Oliver, Board Secretary Ken Proctor, Associate Medical Director (Primary Care) Margaret Somerville, Director of Public Health Sarah Wedgewood, Board Non Executive Apologies: Mr Quentin Cox, Area Medical Committee Representative - Consultant David Flear, Patient/Public Representative David Garden, Head of Financial Planning Adam Palmer, Staff Side Representative Bob Summers, Head of Health & Safety Philip Walker, Head of Personnel

44 38 AGENDA ITEMS Chief Operating Officer Report Operational Unit Reports Older Adult Mental Health Services Implementation of National Standards Highland Health and Social Care Financial Position at 3 November 212 Charging for Care Performance in Adult Services Delayed Discharge Contract Monitoring Director of Public Health Annual Report Anticipatory Care Plans, Polypharmacy Assessments and GMS Contract (Scotland) Carers Update Telecare and DALLAS Committee Terms of Reference Minute of Meeting of the Adult Support and Protection Committee held on 23 October 212 DATE OF NEXT MEETING The next meeting will be held on Thursday 14th March 213 in the Board Room, Assynt House, Inverness at 9.3pm. 2

45 39 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January TOPIC: Assurance Report from Meeting held on 1 November 212 Issues/Risks Assurance Actions Public and Patient participation at District Partnerships feed into Action: local level. Operational Unit Management Directors of Operations to ensure representatives are aware Teams. Arrangements to be of local arrangements, contact details and escalation routes reviewed after period of one year. (channels of communication etc). Director of Adult Care to consider developing locality group model for adoption. Chief Operating Officer to ensure appropriate consideration of public/patient participation issues at NHS Board level. Accurate recording of decisions and subsequent actions. 3.1 Committee Administrator prepares Action: Assurance Report and circulates to Committee Administrator to develop and implement rolling Committee. action plan. TOPIC: Professional Executive Committee Verbal Update Deborah Jones, Chief Operating Officer Issues/Risks Assurance Actions Need to ensure appropriate Chief Operating Officer met with Action: clinical engagement and Medical Director to discuss issues. A further update on the establishment of a Professional leadership arrangements. Development group established and Executive Committee to the March meeting of the HHSC to meet in February 213. To discuss Governance Committee Chief Operating Officer aspects including PEC Terms of Reference, membership, and links to Area Medical Committee and GP Sub Committee. There is a need to ensure appropriate professional advice and guidance is given. 3

46 4 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January TOPIC: Chief Operating Officer Report Deborah Jones, Chief Operating Officer (COO) Issues/Risks Assurance Actions Performance Issues - Update outlines key HEAT targets behind planned trajectory including delayed discharge, A&E rate of attendance, cancer treatment waiting times, outpatient waiting times, admission waiting times, CAMHS waiting times, and A&E waiting times. Improvement Committee received Action: presentation relating to Drug and Report on Adult Respite Care to be submitted to future Alcohol referral Waiting Times and meeting - Head of Adult Social Care Respite Care. Real progress made Drug and alcohol treatment will be managed and monitored on access to CAMHS, where staff through the Area Drug and Alcohol Committee. being actively recruited and service delivery subject to redesign activity. Highland Hospice Refurbishment Preliminary discussion indicated Fyrish Ward, Invergordon can be utilised to provide alternative inpatient facilities during refurbishment. Timescale not yet known. Winter Planning Director of Health and Social Care (THC) and COO oversee business continuity delivery through existing emergency planning arrangements. 131, received to support winter plans, including increasing short term bed capacity (Raigmore) or surge capacity. Infection Control IPC Nurse resource being assessed Action: in light of increasing rate of infection Need for consideration of how best to capture impact of joint in the community setting. Planning working arrangements through assessment of qualitative and team requested to report on success quantitative measures. Director of Public Health of joint working arrangements. GP Consider utilising Change Fund resource to enable Senior community were evidencing Citizens Framework to evaluate impact of joint working - DPH increased activity in this area. HPS 4

47 41 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 surveillance provided data relating to the community setting. Norovirus - Update indicates Closing hospital wards to admissions incidents between September and and minimising movement of staff has December 212. been successful in preventing spread of disease. Well informed, flexible team provide support in the community. Speed of response and support from GPs key aspects. Public have greater appreciation of virulence aspects. 4.2 TOPIC: Operational Unit Reports Directors of Operations Issues/Risks Assurance Actions North and West Operational Unit Report Caithness Care of the Elderly Stakeholder event held in December Action: Review process underway 212 where very strong commitment Reference Group to consider issues and agree next steps. evidenced. Issues relating to Action research approach to evaluation to be adopted. community resource development Director of Operations - North & West were raised and provide a focus for Reference Group. Skye Hospitals Unanimous support evidenced for single site approach. Wider community engagement to take place with view to development of Initial Agreement required for seeking funding resource. Initiative may be linked to similar in Badenoch & Strathspey, utilising HubCo. 5

48 42 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Acharacle and Small Isles An innovative advert inviting creative Practices wider recruitment applications for future delivery of issues of concern. services had generated number of responses. Community representatives would be involved in interview process toward end of January 213. Anticipated that model of care will change. Rural Resilience and Service Cabinet Secretary supports piece of Action: Delivery in fragile remote and work to focus on rural resilience and Develop required specification Director of Operations rural areas. development of different, more North & West sustainable models of service delivery. NHSH, in association with Dewar Group, to develop specification for this area of work. Sickness Absence increased Managers continue to apply Promoting rate post integration Attendance Policy, monitor absence, and ensure return to work interviews. Development of Integrated Teams Team Leaders to be appointed Action: benefits realisation following recent agreement of Team building sessions to be held and integrated team best structures by SMT and will help with practice adopted Director of Operations North & West team development. Linkages to District Partnerships to continue to discuss aspects relating to community groups have been links with Community Groups Director of Operations discussed at District Partnership level North and West and this would continue. South & Mid Operational Unit Reports Police Custodial and Forensic Healthcare Provision arrangements for evaluation of impact yet to be agreed. NHSH took over provision of services from 19/12/212, including 24/7 nurse cover. Aligned to NHS24 and based on temporary doctor arrangements until permanent solution identified. 6

49 43 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Legal framework to be amended to allow nursing staff to provide additional services thus allowing for greater flexibility. Northern Constabulary hold relevant resource and this is transferred to NHSH as required. Any savings equally split between organisations. Integrated Teams Configuration of teams now agreed, aligned to previously agreed Districts. Mental Health Redesign Initiatives Several major redesign underway at this time. Delayed Discharges Full time care coordinator appointed and Community Nurse now reviews Raigmore Home Care Packages. Part time Social Worker resource now attached to Ward 11. Advertising for part time Transitional Care post. To advertise for full time Social Worker to provide dedicated time to planned Hospital discharge. Delayed Discharge coordinator post to be continued. Recruited Home Care Reviewer for three months to identify capacity and assist reallocation of resources. Fortnightly meetings held to undertake review of all delayed patients in solution focussed approach. Raigmore Report Operational initiatives Action: Report on Evaluation of Redesign of Mental Health Services to future meeting Director of Operations South and Mid Unit 7

50 44 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Reconfiguration of Tower Block Work has continued to cost the requested an update on progress preferred option both from a Capital and Revenue perspective and nearly complete. Contractor engaged to develop Outline Business Case by early April 213. Appropriate discussions been held with ARCHIE. Draft report now received. Positive in Action: nature and subject to current review to Update on formal findings to next meeting of HHSC ensure action plan updated. Governance Committee Director of Operations, Raigmore Hospital Infection Control Issues effect Norovirus outbreak impact minimised on elective surgery through confinement arrangements. No other significant outbreaks. Unannounced HEI 21/11/212 Results Visit Winter Planning Arrangements Kyle Court Development Upgrade of Facilities on Relevant plans in place, including additional flexible bed capacity. Upgrade work has now commenced. With additional resource allocated from Endowment Funds there would now be increased provision of en-suite facilities. Kyle Court should re-open early April 213. Interim arrangements include use of Scotia Court for an 8 week period. Older People in Acute Care is OPAC inspection expected early in Raigmore Hospital ready for HEI 213. Progress had been made in a Inspections range of areas as detailed. Cancer Services NHSH likely to Oncology Service has raised service Action: fail 31 and 62 day targets in quality issues and has been discussed Committee to be kept informed as to progress Chief quarter at Improvement Committee. Operating Officer. Agreement reached to advertise for 8

51 45 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Cancer Planners (Radiology) internationally. Locum Consultant also to be recruited. Oncology Team have agreed to look at current systems and processes using the LEAN methodology approach. Existing waste, variation etc must be addressed before additional resource can be considered. 4.3 TOPIC: Older Adult Mental Health Services: Implementation of National Standards Director of Operations, South and Mid Issues/Risks Assurance Actions Can Highland meet challenge of meeting national standards, accommodate the expected increase in dementia sufferers, within set budget and deliver cost efficient services? Report provided update on the range Action: of initiatives to improve care in Older Update on implementation of initiatives to be provided to the Adult Mental Health Community meeting to be held on 2 May 213 Director of Operations, Services. A Highland wide approach South and Mid was being taken and changes to date had enable consideration of provision of service to those patients with ABI for the first time. Highland was confident of meeting the HEAT target on post diagnostic support. The Butterfly Scheme had been introduced to Raigmore Hospital on a pilot basis to three units. 22 staff in Highland will have completed national Dementia Champion Programme training by April 213. The Projects Manager, with support, has been requested to develop a 9

52 46 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 costed plan to establish the possibility of providing a challenging behaviour and Acquired Brain Injury Service. Savings released from Fyrish ward had led to the recruitment of additional community resource in Mid Ross. 5.1 TOPIC: Financial Position as at 31st August 212 David Garden, Head of Financial Planning Issues/Risks Assurance Actions Underlying Operational forecast overspend 7.4m split 2m Adult Social Care and 5.4m NHS Care. Ongoing budget negotiations with Action: Highland Council regarding the Presentation on year end financial position and budget forecast overspend in Adult Social proposals for 213/214 to next meeting Director of Care and both organisations remain Finance/ Head of Financial Planning committed to achieving break-even. There are expected improvements in the prescribing budget and work was ongoing in relation to accounting changes relating to asset lives. Still a reliance on non recurring savings. Care Home packages and placements an area of financial concern and the appointment of a Reviewing Officer will take time to produce results through review of all Care packages. Robust Anticipatory Care Planning was important. Tertiary Budget showing considerable overspend. a Clinical Advisory Group continues to monitor Out of Area referrals, both 1

53 47 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 new requests and existing provision. Patients repatriated where possible. 5.2 TOPIC: Charging for Social Care Services Brian Robertson, Head of Adult Social Care Issues/Risks Assurance Actions Is the NHS Board sighted on aspects relating to charging for Social Care services and planned welfare reform implications? The full impact of the Welfare Reform Act 212 is not yet known and scoping this will be complex. Report outlined key charging principles, high level COSLA principles, and key additional Social Work charging principles. National changes planned for 213 in relation to universal credit for benefits and pensions will impact on councils and services. Reform changes were likely to have an impact on income levels for service users. Any reduction in income would have an impact on the Social Care budget. Currently an income of Approx 1m - 1.5m is received annually. A working group is being established to ensure awareness of implications and organisation is able to respond. Future charges would be brought to HHSC Committee prior to recommendation for approval by the NHS Board. Action: Further reports on Welfare Reform, and implications for charging be brought back to this Committee as information becomes available Head of Adult Social Care Consideration to be given to holding Development Sessions into the future Committee Chair/ Chief Operating Officer Consideration to be given to inviting Council Income Maximisation Team to address the Committee at future meeting Committee Chair/ Chief Operating Officer 6.1 TOPIC: Development of Adult Social Care Balanced Scorecard Kenny Oliver, Board Secretary Issues/Risks Assurance Actions How to monitor performance Report outlines progress in Action: against the Adult Social care development of indicators and Consideration be given to including Health and Wellbeing measures incorporated into provides an update on the Scorecard Indicator Board Secretary/ Head of Adult Social Care 11

54 48 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Partnership Agreement Highland Council. 6.2 with layout. Issue was discussed at the recent Improvement Committee meeting. The Joint Commissioning Group would determine future amendments and national work on indicators was underway. Discussion was also being held with ehealth as to how best capture trend data. Agreed the number of Indicators be reduced where possible COO/ Board Secretary/ Head of Adult Social Care TOPIC: Delayed Discharge Simon Steer, Head of Strategic Commissioning Issues/Risks Assurance Actions Meeting Scottish Government Policy expectation of reduction of delayed hospital discharge from zero delays over six weeks to zero delays over four weeks in 213. A concerted approach has been taken Action: to reducing the immediate position Consider public communications message and messages for and circulated report illustrated staff Chief Operating Officer progress through weekly trend charts. Operational Units to be given resource and capability to Care Home capacity has been manage community service elements and be provided with increased, embargoed Care Home support where trend analysis highlights areas of concern provision has been released, Chief Operating Officer. placements outwith Highland utilised, Social Care staff flexibility used to ensure speedy assessments, and management oversight enhanced. Chief Operating Officer now receives daily update. The report outlined a set of rules relating to admission, transfer, and discharge planning to be introduced later in January 213. A longer term aspiration exists to reduce maximum length of delay for non-complex patients to 72 hours 12

55 49 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 from April 213. Plans being drawn up to identify resource, practice, and process implications. Report to Improvement Committee. Need to ensure seamless transfer of patients into Community Care. 7 TOPIC: Monitoring the Delivery of Contracted Services Brian Robertson, Head of Adult Social Care Issues/Risks Assurance Actions How will NHS Highland monitor commercial contracts for the provision of Adult Social Care Services? Presentation and circulated report Action: outlined remit of Contracts Team, Committee to receive reports relating to care Inspectorate provided analysis of current contracts, reports indicating a Care and Support Grading of 3 or below advised quality was managed through Head of Adult Social Care liaison with Care Inspectorate as part First monitoring report to be received at September 213 of routine inspection and complaints meeting Head of Adult Social Care. responses; and through a contract monitoring framework which commenced in July 212. The monitoring framework, encompassed 69 contracts to date, with initial monitoring complete by August 213 and ongoing thereafter. Principle monitoring roles are conducted by Designated Managers and Area Contracts Officer. Designated managers had yet to be agreed with relevant Directors of Operations. A continuous improvement methodology had been adopted. Six monthly high level reports would be provided on all registered services, on an exception reporting basis. It was noted in-house services would be delegated to 13

56 5 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Operational Units, to help drive up quality standards, and move toward a professional leadership structure. 8.1 TOPIC: Public Health Annual Report 212 Margaret Somerville, Director of Public Health Issues/Risks Assurance Actions How to improve the health and DPH Annual Report focuses on two wellbeing of older people. conditions that are major causes of older people requiring health care. These are falls resulting in fractures and chronic obstructive pulmonary disease. A range of activity underway in the community setting to provide a holistic approach including treatment plans, preventative action, increased community resilience activity and adoption of an integrated approach. TOPIC: Anticipatory Care Plans, Polypharmacy Assessments and GMS Contract (Scotland) Ken Proctor, Associate Medical Director (Primary Care) Issues/Risks Assurance Actions 8.2 How will ACPs and Polypharmacy Advised will be introduced through the Action: Assessments be implemented? new GMS Contract for GPs in Further report to be submitted to May meeting Associate Scotland, with a move to more Medical Director (Primary Care) focused approach. Overall success will be assessed by Leeds University. Funding will be though redeployment of existing resource. 14

57 51 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January TOPIC: Other Matters for Information Issues/Risks Assurance Actions 9.1 Carers Update No Issues Action: Strategy report to next meeting Director of Adult Care 9.2 Telecare and DALLAS No issues highlighted. Project Action: management system in place. Matter to be further discussed at next meeting Director of Project Board under review and Adult Care membership being strengthened. Project Initiation Document created, and project and action plans in progress. 9.3 HHSCC Reference Terms of No issues. Noted. 9.4 Minute of Adult Support No Issues. Noted. and Protection Committee held on 23/1/212 FUTURE AGENDA ITEMS Meeting on 14 March 213: Reablement Strategy Brian Robertson Carers Update Jan Baird Telehealth and DALLAS Jan Baird/Gill McVicar Flexibility of Respite Care Facilities Brian Robertson CHP Assurance Close Down Reports DOO s Care at Home Services targets, trajectories & actions being taken to Improve Care Commission grading Timeline for Caithness Care of Elderly Review Gill McVicar Staffing Report to be included in Director of Operations reports 15

58 52 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 1 January 213 Items for 14th March from Assurance Report Carers Strategy Report Jan Baird Rolling Action Plan Brian Mitchell Update on Establishment of PEC Deb Jones Update on Formal Findings of Unannounced Inspection report Chris Lyons Presentation on year end Financial Position and Budget Proposals Nick Kenton/ David Garden Future Meetings: Quarterly Risk Registers due 7th March 213 Directors of Operations in Operational Unit Reports Update on implementation of recommendations from National Reviews in local Care Homes due 7th March 213 Brian Robertson Progress on integration of Patient/Client information systems Update on progress with reconfiguration of Raigmore Hospital Tower Block Process for managing Care Inspectorate Action Plans Transitions update on progress with Strategy Chief Executive Self Directed Support for Adults including issues in relation to older adults Adult Respite Care Report Brian Robertson Progress on Cancer Service Waiting Times Targets Deb Jones Report on evaluation of redesign of Mental Health Services Update on Older Adult Mental Health Services: Implementation of Initiatives due 2nd May 213 Nigel Small Report on Implications of Welfare Reform on Charging for Social Care Services Brian Robertson Reports Relating to Care Inspectorate reports indicating care and Support Grading of Three or below Brian Robertson Contracted Services Monitoring Report due 12th September 213 Brian Robertson Anticipatory Care Plans and Polypharmacy Assessments due 2nd May 213 Ken Proctor DATE OF NEXT MEETING The next meeting of the Committee will take place on Thursday 14 March 213 in the Board Room, Assynt House, Inverness at 9.3am 16

59 53 HIGHLAND NHS BOARD DRAFT MINUTE of MEETING of the NHS Board Audit Committee Board Room, Assynt House Highland NHS Board 5 February 213 Item 3.3(a) Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel Tuesday 4 December pm Present: Mr Mike Evans, Chair Dr Michael Foxley, Board Non-Executive (from 1.25am) Mrs Gillian McCreath, NHS Board Non-Executive Mr Okain McLennan, NHS Board Non-Executive Mr Ray Stewart, Employee Director Also Present: Dr Ian Bashford, Board Medical Director Mr Bill Brackenridge, NHS Board Non-Executive Mr Garry Coutts, NHS Board Chair Mr Robin Creelman, NHS Board Non-Executive Mrs Myra Duncan, NHS Board Non-Executive Mr Ian Gibson, NHS Board Non-Executive Ms Deborah Jones, Chief Operating Officer Dr Iain Kennedy, NHS Board Non-Executive Mr Nick Kenton, Director of Finance Ms Sarah Wedgwood, NHS Board Vice-Chair In Attendance: Mr Chris Brown, Audit Partner, Scott-Moncrieff (Videoconference) Mrs Margaret Brown, Head of Service Planning Mrs Anne Gent, Director of Human Resources Ms Heidi May, Board Nurse Director Ms Elaine Mead, Chief Executive Mr Brian Mitchell, Board Committee Administrator Mr Kenny Oliver, Board Secretary Mrs Lorraine Power, Board Services Assistant Mr Bill Reid, Head of ehealth Ms Donna Smith, Service Performance and Partnership Manager Dr Margaret Somerville, Director of Public Health Ms Maimie Thompson, Head of Public Relations and Engagement Mr Neil Walker, Service Planning Manager 1 WELCOME AND DECLARATION OF INTERESTS 1.1 Apologies Apologies for absence were received on behalf of David Alston, Alasdair Lawton, and Colin Punler.

60 Declaration of Interests Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. Mr Ray Stewart declared that he was a member of Unite and Staffside Chair. The Committee Noted the declarations of interest. 2 INTERNAL AUDIT REVIEW OF NHS WAITING TIMES Mr C Brown spoke to the circulated report relating to a review of NHS Highland waiting times, which had been undertaken following a request by the Cabinet Secretary for Health and Wellbeing for all relevant NHS Boards in Scotland to audit local waiting times management arrangements. Results would be subject to review in 213 by Audit Scotland. In NHS Highland, as was the case in NHS Greater Glasgow and Clyde, there were data extraction issues given the use of the isoft patient management system. This resulted in the development and implementation of a revised data testing approach that took a sample population and followed these through the entire patient journey. There was close liaison with the audit team in NHS GG&C to ensure a consistency of approach across both audits. It was reported it had been concluded that there was no indication of the existence of systematic and deliberate mis-recording or mis-reporting of waiting times which would materially impact on achievement of waiting times targets. A small number of cases identified inconsistencies in the implementation of the waiting times guidance which resulted in the avoidance of a breach, when correct implementation of guidance would have resulted in a breach. From a test cohort of 133 patient journeys in north Highland, eight potential issues had been identified, as indicated, relating to the application of medical unavailability, social unavailability, and extended unavailability. These cases did not appear likely to have contributed to a material impact on reporting against waiting times targets, although did raise an issue for management in relation to consistency of application of Guidance. The circulated Management Action Plan indicated a number of areas which, if addressed, would strengthen existing waiting times processes. Overall the report was positive for NHS Highland and Ms Mead took the opportunity to thank Mr C Brown and the Internal Audit team for their work on this matter. During discussion, it was confirmed that no issues had been identified in the Argyll and Bute CHP area. Testing in that area was more targeted in nature given the different patient management system in operation. The testing regime in North Highland had been designed to provide as robust a review as possible through utilisation of a larger test sample and by following the entire patient journey. On the point raised, it was confirmed that the small number of errors evidenced showed no areas of commonality. The Committee went on to discuss the eight issues identified by the review. Mrs M Brown emphasised that the small number of cases identified had no material affect in relation to the NHS Board meeting the 18 Week RTT target of 9% compliance. She stated that in relation to the two cases where medical unavailability was recorded, one had received treatment elsewhere and the other had been subject to inappropriate recording. These record keeping issues had been discussed with relevant staff. For those cases recorded as social unavailability, the review findings had been accepted and as a result a Standard Operating Procedure had been developed and introduced (two of the cases had still been reported as in breach). The final two cases had been designated as extended unavailability as a result of failure to contact the Patient Focus Booking Service, and the associated recommendation relating to reporting of non-responders, with over seven days designated unavailability, had been accepted. 2

61 55 In conclusion, those present agreed the findings of the Internal Audit Review represented a positive report for NHS Highland. Mr Coutts stated this emphasised that the strong governance culture operated within the organisation, such as through the Improvement Committee, was proving successful. There was agreement that the circulated report should be updated to include the detail provided by Mrs Brown in relation to the individual cases highlighted prior to being submitted to the Scottish Government. It should also be highlighted that there were no issues identified in the Argyll and Bute CHP area. After discussion, the Committee: 3 Agreed to Endorse the findings contained within the report. Agreed to submit the report to the Scottish Government, subject to review and inclusion of the points raised in discussion. Agreed Internal Audit be instructed to undertake a further review in 213. ANY OTHER COMPETENT BUSINESS There were no matters raised under this item. 4 DATE OF NEXT MEETING The next scheduled meeting will be held on 11 December 212 at 1. am in the Board Room, Assynt House, Inverness. The meeting closed at pm. 3

62 56

63 57 HIGHLAND NHS BOARD DRAFT MINUTE of MEETING of the NHS Board Audit Committee Board Room, Assynt House Highland NHS Board 5 February 213 Item 3.3(b) Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel Tuesday 11 December am Present: Mr Mike Evans, Chair Dr Michael Foxley, Board Non-Executive (from 1.25am) Mrs Gillian McCreath, NHS Board Non-Executive Mr Okain McLennan, NHS Board Non-Executive Mr Ray Stewart, Employee Director Also Present: Mr Nick Kenton, Director of Finance Ms Sarah Wedgwood, NHS Board Non-Executive In Attendance: Mr Iain Addison, Head of Area Accounting Mr Chris Brown, Audit Partner, Scott-Moncrieff Ms Kay Jenks, Senior Auditor, Audit Scotland Mr Brian Mitchell, Board Committee Administrator Mrs Helen Morrison, Associate Director (NMAHP Workforce Planning and Development)(from 1.1am) Mr Ian Wallace, Internal Audit Manager, Scott-Moncrieff 1 WELCOME AND DECLARATION OF INTERESTS 1.1 Apologies Apologies for absence were received on behalf of Myra Duncan, Ian Gibson, Deborah Jones, and Iain Kennedy. The issue of attendance at meetings was raised, noting the Chief Operating Officer was now included in the membership List of Attendees. Review Sponsors were invited, on occasion, to attend relevant meetings depending upon the nature of Internal Review findings. The role of the Committee was to provide assurance to the NHS Board and Mr C Brown stated that whilst the Committee may wish to invite officers to respond to individual reports there was also a need for high level Executive attendance to provide an overall Corporate view. After discussion, the Committee Agreed that the Chief Operating Officer, or nominated deputy, be invited to attend future meetings. 1.2 Declaration of Interests Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. Mr Ray Stewart declared that he was a member of Unite, Staffside Chair, and Employee Director.

64 58 The Committee Noted the declarations of interest. 2 MINUTE AND ACTION PLAN OF THE MEETING HELD ON 11 SEPTEMBER 212 The Committee: Approved the Minute of the meeting held on 11 September 212. Agreed the Action plan be updated for the next meeting. 3 MATTERS ARISING 3.1 Incident Management Ms Wedgwood advised a short life Working Group had been established to consider a range of issues relating to Incident Management, including those raised at the last meeting. Mrs M Duncan, NHS Board Non-Executive member was Chair of the Working Group and this would report to the Clinical Governance Committee. There may be a requirement to consider amendment of the current Policy and Procedure document. The Committee Noted the position. 3.2 Fleet Management Mr Brown reported that having investigated the arrangements for Fleet Management in NHS Fife he was satisfied there were no major learning points for NHS Highland at this time. The Committee so Noted 3.3 Argyll and Bute CHP Governance and Management Mr Evans advised that further to previous discussion at the last meeting in relation to Service Level Agreements (SLAs) with NHS Greater Glasgow and Clyde (NHS GG&C), discussion had been held with Mr R Creelman, Argyll and Bute CHP Chair, as to the issues of ensuring value for money and efficiency of services. It was noted that the Head of Planning, Contracting and Performance was in contact with NHS GG&C to discuss aspects relating to the potential for regular reports being submitted to NHS Highland on services being delivered for Highland patients. The assessment of SLAs was a complex and national issue and there was a desire to improve this without creating a whole new area of activity. Consideration would require to be given to establishing a set of standard quality indicators and it was agreed there was no objective indicator relating to value for money. The views of Health Improvement Scotland should be sought on this issue. During discussion, Mr N Kenton confirmed that SLAs were subject to review arrangements and stated that there was no agreed national costing model applied to these. Mr Evans advised that a national costing group had been established and a single costing model was being considered. Mr C Brown advised the key issue for NHS Boards was to be able to receive assurance relating to service delivery, quality and efficiency. The view was expressed that such assurance would require to be considered at Board level as they would 2

65 59 be required to consider the level of associated risks involved. Ms Wedgwood reminded members the Clinical Governance Committee considered issues relating to quality of care. After discussion, the Committee: 3.4 Noted the position. Agreed the views of Health Improvement Scotland be sought. Noted a follow up report would be provided to a future meeting. Update from Meeting held on 4 December 212 Mr Evans advised that the Committee had met on 4 December 212 to consider the Internal Audit Review of Waiting Times, the final report in relation to which had been submitted to the Scottish Government and was currently subject to embargo. The report would be subject to an Internal Audit follow up report in 213. The Committee so Noted. 3.5 Audit Scotland Annual Report on the 211/212 Audit Update There had been tabled paper outlining updates in relation to the risks identified in the Action Plan considered by the Committee at their last meeting in relation to the Audit Scotland Annual Report on the 211/212 NHS Highland audit. During discussion, Mr O McLennan referred to activity relating to the use of locum doctors and was advised further detail would be submitted to the next meeting. The Committee: 3.6 Noted the content of the tabled report. Noted an update of the use of locum doctors would be submitted to the next meeting. Update on Consultant Contract Review Management Action Plan Members were advised the total number of plans signed off was 66, the number to be signed off was 25, and that there were 47 under discussion. It was noted the Staff Governance Committee was keeping a watching brief on this matter. Members requested that the Committee receive a further update in six months and were advised that a report on the position post 1 April 213 would be provided to the Committee at their meeting to be held in May 213. The Committee were advised that Internal Audit activity relating to Consultant Job Plans had been brought forward in the Audit Plan at the request of the Raigmore Hospital Director of Operations. The Committee: Noted the position. Noted a report would be submitted to the May 213 meeting on the position post 1 April

66 6 3.7 Risk Register Update Members were advised the draft corporate Risk Register was currently being considered by Executive Directors. The Risk Management Steering Group was to meet in early course and would consider issues relating to the overall Risk Strategy and associated Risk Registers. The Committee so Noted. 4 INTERNAL AUDIT 4.1 Internal Audit Summary Report There had been circulated a copy of the progress report, which summarised Internal Audit work undertaken up to 11 December 212, including four reports. One Grade 4 issue, and 1 Red Control Objective, had been raised in relation to NMAHP Mandatory Training Requirements. The report indicated that 13 out of 3 reviews had been completed on the 212/13 programme. The report also indicated those Reviews in relation to which fieldwork was in progress or now complete. The Committee then considered the following summary reports: Nursing and Midwifery Vacancy Management Mr C Brown spoke to the circulated summary report which concluded that generally the process for authorising and monitoring vacancies is operating effectively. The report indicated a number of areas, which if addressed, would support management in strengthening the system of internal control over nursing and midwifery vacancy management. These included monitoring actual staffing levels against agreed establishments, reviewing budget data to ensure this reflects agreed establishment, and monitoring and reporting on the financial impact of vacancies to ensure timely escalation of issues. During discussion, it was advised a Significant Event Review had highlighted issues relating staffing levels hence the Review concerned. Associated issues had been, and were being, considered by the Staff Governance Committee. On this point, Mr Stewart advised the Staff Governance Committee had received a follow up report on management action to address workforce issues however had not been appropriately assured on the various elements. That Committee had requested a further more detailed report be submitted to their next meeting to be held on 19 February evidencing that the relevant issues had been addressed and appropriate solutions fully implemented. Ms Wedgwood advised that concern had been raised in relation to the efficacy of the workforce assessment tool currently used. On this point, Mrs H Morrison advised that an establishment monitoring tool was in place for the hospital settings for Nursing and Midwifery staff and that monitoring was undertaken on a monthly basis. Current workforce assessment tools, a minimum of three being utilised, are triangulated to ensure current establishment setting was as robust as possible. Management of Fraud Mr C Brown spoke to the circulated summary report which concluded that Policies are in place for the effective management of fraud and suspected fraud. Awareness of staff roles and responsibilities in relation to fraud prevention continued to be raised, with the imminent launch of the Whistleblowing Policy. It was stated further awareness raising activity would be required for adult social care staff utilising NHS Highland financial systems. 4

67 61 During discussion, Mr O McLennan advised that in his capacity as Counter Fraud Champion he provided verbal updates to each meeting of the Audit Committee. He expressed concern that he had not been given the opportunity to comment on the draft review findings. With regard to providing a written report to the Committee it was stated this would require to be generic in nature, and contain no personally identifiable information. There was reference to Adult Social Care staff that transferred to NHS employment on 1 April 212, and the need for training on relevant NHS Highland Policies and procedures. Mr Addison advised that this staff cohort would continue to operate under the Policies and procedures of the Highland Council until such time as associated accounting systems had been transferred. Training would be person specific, according to need. Such system transfer, and relevant training, was anticipated to be complete by end March 213. After discussion, the Committee: 4.2 Noted the circulated review summaries. Agreed consideration be given as to the content of reports to the Committee in relation to Counter Fraud activity. Agreed an update in relation to staff transfer and associated Counter Fraud training be provided to the meeting to be held on 14 May 212. Individual Reports for Consideration Nursing, Midwifery and Allied Health Professions (NMAHP) Mandatory Training Requirements Mr C Brown spoke to the circulated report which concluded that the arrangements for developing and agreeing Personal Development Plans (PDPs) for NMAHP staff within eksf are operating effectively, with the majority of staff having assessed and identified their mandatory training requirements. However, a high number of employees had not met the full mandatory training requirements as outlined in the NHS Highland prospectus. The report indicated a number of areas which, if addressed, would continue to strengthen the NMAHP mandatory training process. These included introducing a quarterly self-certification process, re-issue of the mandatory and statutory training prospectus at key stages of the PDP cycle, and investigating the link between eksf and LearnPro to ensure completion dates for training are transferred to eksf. On the point raised it was advised that staff in Argyll and Bute CHP had not been subject to review. During discussion, it was acknowledged the review provided a snapshot survey at a particular time. It was noted that Infection Prevention and Control training had formed part of the scope of the Review. It was stated there were significant gaps in current reporting arrangements. Mr R Stewart raised the matter of lapsed qualification/planned training provision and was advised this information had not been provided as part of the Review. Concern was expressed at the number of staff not trained and advice was sought as to whether there was any consistent pattern among those not trained. Mrs H Morrison advised that the Mandatory Training Policy, and associated Training Needs Assessment (TNA) tool had been specifically designed for NMAHP staff and had been based on the risk to the patient. There had been a suggestion that an electronic system be introduced however paper records were currently used. She stated the key issue related to completion of the TNA, and subsequent monitoring arrangements. Training delivery should also be assessed in terms of efficiency and effectiveness. Mr McLennan stated there was need to provide assurance to the Clinical Governance Committee that a lack of training did not pose a risk to patients, especially in relation to infection prevention and control. It was advised that issues relating to Hand Hygiene were being scoped at this time. With regard to the management response to the findings highlighted, Mrs Morrison advised these were to be discussed by 5

68 62 the NMAHP Leadership Committee. Mandatory training requirements as set by the organisation were subject to review, and were applied across NHS Highland. The Committee: Noted the report findings. Agreed the results of discussion by the NMAHP Leadership Committee be reported to the Committee meeting to be held on 14 May 213, along with a detailed Action Plan. Mrs H Morrison left the meeting at 12.pm 4.3 Proposed Internal Audit Plan 212/13 and 213/14 At their last meeting the Committee agreed to defer consideration of the draft Internal Audit Plan for 212/213 and 213/214 pending discussion in relation to integrated services. In addition members, outwith the Committee cycle, had agreed to adjustment of the draft Plan so as to provide support for current activity around the NHS Board Savings Plan. Mr C Brown spoke to the proposed Plan, advising this would be presented to the Senior Management Team (SMT) in February 213 and brought back for final sign-off at the Audit Committee to be held on 14 May 213. The Plan included a follow up review on waiting times, deferral of work in relation to delayed discharges, and remained flexible in nature. There was discussion on a number of the planned reviews and in relation to the use of Medical Locums it was noted this would be the subject of discussion at the Clinical Governance and Staff Governance Committees. With regard to Complaints Management, Ms Wedgwood stated a Working Group had been established to consider a range of new Key Performance Indicators (KPIs) and associated processes. Mr McLennan suggested consideration be given to a review of emergency planning exercise activity. On the point raised it was confirmed that discussions were being held with Internal Auditors for the Highland Council. After discussion, the Committee: Noted the report findings. Noted the draft Plan would be presented to the SMT in February and submitted to the Audit Committee on 14 May 213 for final agreement and sign-off. 5 EXTERNAL AUDIT 5.1 External Auditors Report - Review of Internal Control Systems Mr N Kenton advised that progress was required in relation to the payroll issues previously highlighted by the External Auditors, including review of the current Scheme of Delegation. The Committee Noted the position. 6 COUNTER FRAUD Mr O McLennan advised there were three cases currently under investigation. One case was subject to a lengthy investigation process and would be followed up accordingly. 6

69 63 The Committee Noted the position. 7 CORPORATE GOVERNANCE 7.1 Standing Financial Instructions Mr I Addison spoke to a tabled summary of changes to Standing Financial Instructions and advised further changes may result from consideration of the current Standing Orders and Scheme of Delegation. Changes had been made to reflect the impact of the new Bribery Act on the organisational Fraud Policy, as well as the move from a Statement of Internal Control to a Governance Statement in the Annual Accounts. Changes would continue to be made to Delegated Levels of Authority where appropriate. The Committee otherwise Noted the changes to Standing Financial Instructions. 8 AUDIT SCOTLAND 8.1 NHS Financial Performance 211/212 The Committee were advised the report looked at the financial performance of the NHS in Scotland in 211/212, with a focus on financial sustainability. There had been circulated NHS Highland checklist detailing the action required in relation to the report. The Committee Noted the NHS Highland checklist. 9 FOR INFORMATION There were no matters raised under this Item. 1 ANY OTHER COMPETENT BUSINESS Mr O McLennan referred to previous Committee discussion in relation to Hospital and Community Health (HCH) Payments, Argyll and Bute CHP. This matter had been raised with the Scottish Government however clarification of the position relating to Para.4 of the GMS Contract Guidance Note was still awaited. There was concern that this matter continued to present a major financial burden. The Committee Noted the matter formed part of a proposed review of the GMS Contract. Mr McLennan referred to previous awareness raising activity relating to Counter Fraud and an associated DVD, which it had been suggested be distributed to managers. The matter had been actively taken forward within Argyll and Bute CHP. Mr McLennan requested that arrangements for relevant dissemination in North Highland be investigated. The Committee Agreed that dissemination arrangements for the Counter Fraud DVD in North Highland be investigated. 7

70 64 11 DATE OF NEXT MEETING The next scheduled meeting will be held on 12 March 213 at 1.3 am in the Board Room, Assynt House, Inverness. The meeting closed at pm. 8

71 65 Highland NHS Board 5 February 213 Item 3.4 Assynt House Beechwood Park Inverness, IV2 3BW Telephone: Fax: Textphone users can contact us via Typetalk: Tel DRAFT MINUTE of MEETING of the STAFF GOVERNANCE COMMITTEE Board Room, Assynt House, Inverness 2 November 212 1: Present Mr Colin Punler, Non- Executive Director (Chair) Mr Robin Creelman, Non-Executive Director (Videoconference) Mrs Myra Duncan, Non-Executive Director Mr Ray Stewart, Employee Director Also Present Ms Sarah Wedgwood, Vice Chair, Highland NHS Board In Attendance Mrs P Cremin, Workforce Planning and Development Manager Mrs Anne Gent, Director of Human Resources Mr David MacKay, Domestic Services Manager, Raigmore Hospital Mr William Craig Macleman, Raigmore Hospital Ms Margaret MacRae, Staffside Representative Mr Adam Palmer, Staffside Representative Mr Brian Mitchell, Board Committee Administrator 1 WELCOME AND APOLOGIES Apologies for absence were received on behalf of Ian Gibson, Iain Kennedy, Judith McKelvie, Elaine Mead, Philip Walker, and Emma Watson. 1.1 Declarations of Interest Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. Mr R Stewart declared that he was a lay member of UNITE Trade Union, was an employee of NHS Highland, and was Staffside Chair of the Highland Partnership Forum. 2 MINUTE OF MEETING HELD ON 22 MAY 212 The minute of the meeting held on 21 February 212 was Approved. 3 MATTERS ARISING 3.1 The Highland Quality Approach Developing Our Values and Behaviours On the point raised, Mrs Gent advised the work of the small working group, established to consider issues arising from the NHS Lothian Report, had been subsumed under the Living Our Values workstream of the Highland Quality Approach (HQA).

72 66 Issues relating to the closure of the activity of the small working group would be discussed with the NHS Board Chair. Mrs Duncan referred to proposed communication in relation to the new Staff Governance Standard and was advised an appropriate letter would be issued in association with communication relating to the next series of PIN Policies. The Committee Noted closure issues relating to the activity of the NHS Lothian Report working group would be discussed with the NHS Board Chair. 3 STAFF STORY INVERGORDON CATERING TEAM RESPECT DVD Mrs A Gent introduced the Invergordon Catering Team Respect DVD presentation, which had emerged as part of Customer Care Workstream to address systems and processes that act as barriers to staff providing the quality of care they strive to deliver on a daily basis. Key issues identified by the Invergordon team had been in relation to leadership and staff/customer behaviour i.e. respect. Those present agreed this presentation was effective in imparting the required message and on the point raised it was confirmed this had been made available to other groups as an educational resource. Mrs Gent advised a number of teams were currently involved in customer care activity. It was suggested the presentation also be utilised as part of the staff induction process. The Committee otherwise Noted the content of the DVD presentation. 4 REPORTS FROM OTHER COMMITTEES 4.1 Minutes of Meetings of NHS Highland Partnership Forum 17 August, 14 September, and 19 October 212 Mr Stewart advised he had recently attended a national NHS Endowment Funds Event where there had been agreement that current guidance to NHS Boards, in relation to the use of such Funds, for staff, remained unclear. There had been agreement that NHS Highland would continue to make contributions to staff Christmas activity. Mr Creelman stated that NHS Highland was not in breach of any legislation by taking this approach. Mrs Gent advised work continued in relation to the Highlandisation of the national Whistleblowing PIN Policy, including the potential designation of NHS Board Non-Executive Governance Committee Chairs as individuals who can act as independent brokers for the escalation of staff concerns. Mr Stewart confirmed this proposal had been reported to the Audit Committee, who had a long standing interest in this matter, although a formal approach to Board relevant NHS Board members had yet to be made. Relevant arrangements would require to be clarified, including the potential need to liaise with the NHS Board Fraud Liaison Officer (FLO). Mr Punler suggested that any agreement with Governance Committee Chairs be formalised through relevant Committee Terms of Reference. The Committee: Noted the circulated Minutes. Noted the position in relation to NHS Endowment Funds. Noted issues relating to potential independent brokerage of staff issues by Governance Committee Chairs would be discussed with relevant NHS Board members. Agreed brokerage arrangements be formalised through Committee Terms of Reference. 2

73 Draft Minute of Meeting of Health & Safety Committee 16 August 212 Mrs Gent advised the circulated Minute had been considered by the NHS Board. The Committee Noted the circulated Minute. 6 WORKFORCE PLANNING 6.1 Workforce Development Plan 212/13 Progress Against Rolling Action Plan Mrs P Cremin spoke to the circulated report giving a Month 6 update on progress in relation to the NHS Highland Workforce Plan Rolling Action Plan 212/213, this having been developed to support the delivery of the NHSH Workforce Plan throughout 212/213. Mrs Cremin took members through the relevant action points and highlighted the following: Action 1 Develop Plans to Mitigate against Workforce Risks there was need to consider how best to engage with current activity of the North of Scotland Planning Group (NoSPG). The same applied to NES, where there was a need to ensure their activity met the needs of NHS Highland and other NHS Boards. The Workforce Planning and Development Sub Group would meet to discuss how best to engage with these organisations. The matter was to be discussed by the Senior Management Team (SMT) on 2 December 212 with a view to ensuring an understanding of the key workstreams involved. Mrs Cremin stated risk identification and escalation by Operational Units was an important aspect in ensuring relevant awareness. Mrs Gent advised NES had identified an opportunity to work with Irwin Turbitt with a view to discussing an adaptive leadership approach relating to GP sustainability in remote and rural areas. The National Leadership Unit had been approached with a view to discussing pilot activity in-situ. Mrs Cremin stated the adoption of an adaptive leadership approach was positive, especially given this was a significant issue for NHS Highland. She advised Dr K Proctor was leading activity within NHS Highland and the matter was to be discussed at the meeting of the SMT in December 212. On the issue of recruitment, Mrs Cremin advised a marketing based approach was taken although Highland continued to struggle against the Central Belt NHS Boards in this regard. A study was underway to try and further understand why some individuals choose not to work in remote and rural areas. Issues relating to recruitment of locum staff were being considered by the Board Medical Director and Medical Workforce Manager. It was anticipated creation of a National Medical Bank would assist in the short-term. An update on Medical Workforce issues would be brought to the next meeting. Action 4 Integrating Care in the Highlands a number of workstreams were being progressed, such as in relation to Health Care Support Workers (HCSWs). Operational Units were being asked to articulate requirements for HCSWs. Good progress was being made. Action 1 NMAHP Workforce Planning and Development Plan members were advised that Internal Audit had recently produced a report on NMAHP Vacancy Management and this had highlighted the associated impact on the ability to respond to such issues as the recent Significant Event Review in Raigmore Hospital. There had also been circulated, as part of the report, NHSH Workforce projections for 212/213 as had been provided to the Scottish Government in line with the requirements as set out in CEL31(211) - Revised Workforce Planning Guidance. This indicated a net increase of 81.2 wte following the Planning for Integration project. On the issue of planned workforce reductions in 212/213 the circulated table indicated that progress was being made toward meeting the projected reduction of 15 wte, with wte having been 3

74 68 achieved as at 3 September 212. Mr Stewart reminded members that the figures quoted were projections, not targets. Activity relating to the pan-highland review of administrative services continued and in this regard Action Point 5 of the Action Plan should be annotated to reflect the current position. On the point raised by Mrs Wedgwood in relation to clinical staff being required to undertake administrative activity, Mrs Gent advised the current approach to reviewing Admin and Clerical processes being taken was being reviewed, with a move away from a Highland-wide based approach. It was important that waste within the admin and clerical systems and processes be eliminated where possible. This approach would reduce the burden of work on staff. The Partnership Forum: 6.2 Noted progress against the Workforce plan Rolling Action Plan 212/213. Noted Action Point 1 should be annotated yellow. Noted an update in relation to Medical Workforce issues would be brought to the next meeting. Agreed Action Point 5 Status should be re-annotated to reflect current activity. Investing in the Future Workforce Mrs Cremin spoke to the circulated report advising a number of approaches to promote health and social care careers to school students had been mainstreamed across NHS Highland. In North Highland, a Health and Social Careers Steering Group oversaw the development and delivery of a full programme of events. In the Argyll and Bute area there is a partnership agreement with the local authority within their respective Opportunities for all and youth employment approach. In the delivery of careers events and programmes, activity was supported by a range of partner agencies as outlined. A number of successful events for schoolchildren had been held to date, including the involvement of a range of clinicians, and these events were targeted in nature, based on academic integrity etc. An annual event was to take place the next day, for 1 S5/6 Highland students, the aim of which was to provide interactive presentations on advances in medical science and research in the last 5 years, to provide an insight into healthcare developments, all in association with the University of Aberdeen Medical School. In terms of career programmes, a more structured approach was being taken and further developed, with two participants recently presenting to the NHS Board their relevant experience of the Doctors at Work Programme. This Programme was to be extended in 213, delivered by NHS Highland medical staff and the wider department cohort. A pre-nursing scholarship had been developed with NHS Western Isles and University of Stirling with a view to creating opportunities for aspiring nurses in remote and rural areas of North Scotland. The scholarship involved 3 rd Year trainees acting as buddies, was linked to the academic programme, and success would be monitored over the longer term. NHS Highland also offered a range of work experience for school students in a number of clinical, non-clinical and community settings. Placements are agreed directly with guidance teacher referral, supported by Careers Development Scotland and focused on an individual s career aspirations and capability. Mrs Cremin advised she was to meet with Social Care colleagues to discuss inclusion of that area in current activity. Overall, activity in this area was about investing in a longer term, sustainable workforce through working with external organisations and sharing the relevant financial cost burden. Mr Punler welcomed the grow your own approach being taken and sought advice as to whether activity included children who were subject to Corporate Parenting. Mrs Cremin stated there was no specific activity relating to this group, although equity of access was an issue that was considered when approached by Aspire North on behalf of individuals. The Recruitment and Employment Service were actively engaged in activity and this issue would be further discussed with Highland Council. Mrs Duncan stated there were clearly opportunities to attract young people into the range of roles and careers within the organisation and Mrs Cremin confirmed that strong links had been established with both 4

75 69 Jobcentre Plus and Guidance Teachers to highlight the range of opportunities available. After discussion, the Committee: Noted the initiatives mainstreamed within the NHS Board for promoting health care careers to school students. Noted the significant investment in the future workforce. The Committee agreed to consider the following Item at this point in the meeting. 6.3 Workforce Response to Significant Event Review of the Outbreak of Clostridium Difficile Infection (CDI) in Raigmore Hospital in January 212 There had been circulated report updating on progress against three workforce recommendations which had emerged following the Significant Event Review, as discussed at the meeting held on 28 August 212. The Committee had requested a report be submitted to this meeting evidencing that issues had been addressed and relevant solutions implemented in full. The report indicated that guidelines had been established in relation to lines of responsibility for cleanliness, incorporating the philosophy of Don t Walk by. In addition, sign-in sheets had been introduced for toilet area cleaning checks. In relation to monitoring of nurse staff levels at an individual ward level, the circulated report outlined a series of data that indicated vacancies, sickness absence and occupancy levels within ward 4c in November and December 211, the relevant budgeted wte, and actual staff use, including supplementary staffing levels and skill mix during that period. In relation to addressing and rectifying the reported mismatch between patient acuity/activity in ward 4c, whilst supplementary staffing had been used as an initial measure to augment overall staffing levels, recruitment was now underway to appoint five band 2 staff, with one having already been successfully recruited. It was advised that staffing levels are reviewed on an ongoing basis and where necessary augmented by supplementary staffing. Monthly workforce statistics were now produced and reviewed to allow any deviation to be identified and addressed. There followed discussion, in particular in relation to the staffing figures, and the view was expressed the detail given did not provide sufficient assurance to the Committee that the relevant issues had been fully addressed. There was also a concern at the apparent lack of Staffside engagement in seeking to address the various issues, especially with regard to reconfiguration of domestic staffing levels. Mrs Cremin stated the inclusion of the relevant Action Plan, and annotated progress against this would have provided the Committee with greater assurance that matters had been addressed. Mr MacKay advised the configuration of domestic staffing had not changed, nor had line management arrangements. Domestic staff supported the Senior Charge Nurse (SCN) to ensure cleanliness of relevant areas and Staffside engagement was acknowledged as an important aspect. Mr Craig-Macleman further stated the introduction of a red/green card system for cleaning had been an attempt to address HEI concerns that SCNs were not responsible for directing domestic staff. In conclusion, the Committee was agreed the circulated report did not give adequate assurance to members that the workforce issues previously discussed had been addressed fully, in partnership. This in turn meant the Committee was not able to provide satisfactory assurance to the NHS Board this was the case. There was agreement a further, more detailed, report was required to be submitted to the meeting to be held on 19 February 212. The Committee Agreed that a further more detailed report be submitted to the next meeting evidencing relevant issues had been addressed and appropriate solutions fully implemented. 5

76 7 Messrs MacKay and Craig-Macleman left the meeting at 11.45am 6.4 Socially Responsible Recruitment Mrs Cremin spoke to the circulated report that indicated NHS Highland was now the largest single employer within the Highland area, and was fully committed to socially responsible recruitment. The report outlined examples of relevant activity relating to volunteering, provision of internships, and supported employment. NHS Highland had achieved the Investing in Volunteers accreditation and had introduced a Volunteering Policy. The organisation participated in the NHS Scotland Internship Programme for Nurses and Midwives, with 22 places provided. NHS Highland also participated in the in the Work Ready programme for newly qualified Physiotherapists. Further work was ongoing to explore additional opportunities for a wider range of internships. The organisation also supported a range of statutory and voluntary organisations by providing work experience opportunities to people requiring various forms of support thereby allowing these individuals to both enter and remain in the workplace. Examples of success in this area were the recruitment to substantive posts of individuals who had previously been volunteers with the Shirlie Project and Barnardo s. A meeting was to be held with representatives of Employment Services, Mental Health and Jobcentre Plus to consider a new scheme designed to help support young people with a mental illness who are looking for work. A pilot scheme was being undertaken by Mental Health Services in partnership with Jobcentre Plus. During discussion, the activity outlined in the report was welcomed as an example of good practice. It was suggested that other organisations such as the Calman Trust, and Highland Council could help support this activity and in response Mrs Cremin confirmed that both she and Mrs S Amor, Public Health Specialist/Child Health Commissioner were actively engaged with the Council. The Committee: 6.5 Noted the initiatives mainstreamed in NHS Highland to promoting socially responsible recruitment. Noted the significant Board investment in promoting socially responsible recruitment. Feedback From Workforce Information Workshop on 17 October 212 There had been circulated documentation relating to the Staff Governance Committee Workshop which had been held on 17 October 212 to discuss issues relating to the workforce information required to enable assurance in relation to Staff Governance issues. The aim was to establish and agree workforce information datasets, understand the purpose of each workforce report element, agree who receives reports and their expected actions relating to this, and finally establish a definitive data source that would allow elimination of wasted effort and management of variation where evidenced. Workforce information should be provided for the purposes of monitoring operational delivery, satisfying relevant governance requirements, support workforce planning activity, and meeting relevant Statutory requirements. The circulated documentation went on to outline the opportunities and challenges presented by the introduction of the new eess workforce system, as well as the impact on Human Resources. There was a need to consider aspects relating to both the receipt of hard data as well as sources for receipt of qualitative information. There was agreement that for the purposes of establishment of workforce profile, and for workforce planning purposes for the Staff Governance Committee, there was a need to capture and report information relating to establishments, turnover and stability rates, supplementary workforce utilisation, vacancy management information, and redeployment data. The Workshop had also discussed aspects relating to the five Staff Governance Standards, in relation to which the following was also agreed: 6

77 71 Well Informed Agreed qualitative information from Staff Survey and Focus Groups provide positive information for governance purposes, Non-Executive walkrounds provide additional information, and that understanding of Quality Objectives be monitored. Involved in Decisions Agreed HPF and LPF minutes be submitted to Staff Governance Committee to provide governance, Non-Executive Directors to attend Partnership Fora and Local Staff Meetings, and consideration be given to inviting the Area Clinical Forum Chair to join the HPF. Appropriately Trained and Developed Agreed Annual Workforce Development Plan provide Framework, feedback be received on attendance at Statutory and Mandatory Training Programmes, and that the KSF Standard provide assurance. Treated Fairly and Consistently, with Dignity and respect, in an Environment where Diversity is Valued Agreed information on formal case numbers subject to PIN Policies be continued, that key conduct issues be reviewed and greater outcome detail be provided, the use of and outcome from Mediation be monitored, and there be oversight in relation to the implementation of the Living our Values workstream. Provided with a Continuously Improving and Safe Working Environment, Promoting the Health and Wellbeing of Staff, Patients and the Wider Community Agreed Health and Safety Committee take on formal role in providing governance, continue to provide sickness absence data, review the Incident and Accident information for staff, access and outcomes relating to Occupational Health Services be monitored and improved, and an Annual Report on progress against Safe and Well at Work be provided to the Staff Governance Committee. There was agreement that there be further discussion with the Employee Director as to the development of the governance aspect of staff responsibilities, as indicated in the revised Staff Governance Standard. During discussion, members were reminded that the introduction of the eess system would allow greater reporting capacity than currently available and it was emphasised that the key aspect would be how to best use that reporting capacity. Mrs Duncan stated any information reported should be aligned to the Staff Governance Standards and that there should be further consideration of how best to evidence qualitative aspects. Mr Punler stated that moving to a system where reports were submitted to LPFs would be a positive step in terms of Non-Executive Board members receiving relevant workforce information. After discussion, the Committee: 6.6 Noted the agreed outcomes from discussion at the Workforce Information Workshop. Noted the Employee Director would discuss issues relating to staff responsibilities as indicated in the Staff Governance Standard with Staffside representatives. Noted issues relating to quantitative information reporting would be discussed with the Head of Personnel. Workforce Report There had been circulated Workforce Report to end September 212. Mr Palmer expressed concern that sickness absence levels within the Adult Social Care staff cohort were significantly higher than that for the rest of NHS Highland. NHS Highland HR Policies would now apply to this staff group and it was hoped this would help bring the absence rate down. It was reported that the sickness absence rate among Care at Home staff had already shown positive movement both pre and post integration. The issue of redeployment was raised and in response Mrs Gent stated that very few individuals on the Register were not utilised in 7

78 72 some capacity and individuals were offered relevant training opportunities etc. Ms Wedgwood raised the issue of Occupational Health Services, in particular the 1 day Referral to Treatment (RTT) target, and was advised the initial contact with staff members is made within two working days of receipt of a request to treat. Mr Stewart emphasised the difficulty in providing equity of access to Occupational Health services for those in a remote and rural setting. It was stated that Key Performance Indicators were being revised in relation to Occupational Health Services. The Partnership Forum otherwise Noted the circulated report. 7 STAFF GOVERNANCE 7.1 Implementation of Knowledge and Skills Framework There had been circulated progress report on e-ksf implementation, indicating that as at end October 212 some 11.78% of Reviews had been completed and signed-off, with 31.33% of Reviews at all stages. The latter figure indicated that Reviews are now being more evenly spread throughout the calendar year compared to previous years. The KSF team continued to discuss options with managers and Staffside colleagues to ensure that all staff are offered the opportunity to engage in meaningful Reviews. As regards Social Work staff the Committee were advised that the target had been agreed with the Head of Social Care and monitoring reports were expected to be available from December 212. It was reported there had been an increase in the number of PDP activities falling within the Mandatory priority and this was believed to be as a result of greater use of the LearnPro system. The circulated report outlined activity undertaken in relation to the bank staff cohort and indicated the remaining challenges in this area. Work has been undertaken in partnership with the Staff Bank Operational Group to develop and agree KSF post Outlines for bank staff employed at Bands 2,3 and 5. Work was nearing completion in relation to some associated Bands 4 and 6 staff. A guidance document had been developed and trialled at a recent awareness event and this had received a positive response. Bank staff would be supported to fully engage with KSF and the PDP&R process. With a view to supporting the development of Health Care Support Workers (HCSW), meetings had been held with managers and professional leads to identify and agree an educational Framework for each post. This would enable managers and staff to know what Statutory, Mandatory and Core development is required for each role and ensure this is applied consistently across the organisation. It was further reported that a business case was to be submitted to the Scottish Government in relation to an electronic solution for recording KSF development reviews post 214 and it was likely this would move to being reported via eess. Supporting activities were being maintained and the KSF Team continued to work with staff and managers to provide ongoing support. The Committee: 7.2 Noted the position regarding e-ksf and Noted the support mechanisms both in place and planned. Noted the implications arising from the introduction of eess. The Highland Quality Approach Developing our Values and Behaviours Mrs Gent advised the introduction of a new Bullying and Harassment PIN Policy, including aspects relating to Confidential Contacts etc meant a move away from the explicit Give 8

79 73 Respect Get Respect workstream previously reported. Current Customer Care activity would continue to be rolled out to a further six areas, after which appropriate cascade arrangements would be utilised. On this point, Staffside representatives had indicated they were keen to become involved and assist in delivery to staff. There was a growing acknowledgement that changes in culture and behaviour within an organisation as large and complex as NHS Highland required to be introduced from the gemba. It was advised that the Scottish Government were in the process of considering establishment of relevant Staff Governance Performance Indicators. In NHS Highland, it was considered that the adoption of a Staff Compact approach would provide a strong basis on which to meet relevant Staff Governance Standards, against which the NHS Board would be measured. Leadership for Quality Improvement Mrs Gent advised that a second Leading the Way Event had now been held, with a third Event being considered in relation to middle management. Both Events to date had received positive feedback. Highland Quality Improvement System and Associated Training Requirements Mrs Gent advised the Highland Quality Improvement System had been established, a presentation on which was to be delivered to the NHS Board at their meeting to be held on 4 December 212. That presentation would include aspects relating to relevant training, and the experience gained from collaboration with The Virginia Mason Institute and Tees, Esk and Wear Valleys NHS Foundation Trust. Twenty Leaders for LEAN activity within NHS Highland were to undertake training with a view to GE accreditation by end April 213. Communications and Engagement Mrs Gent advised the Quality Improvement Team would support access to the project Database on the Website and this would be used to highlight improvement successes across the organisation with a view to using these in a proactive manner. Ms Wedgwood suggested this resource should also be used to gauge the position across the organisation and assess how well the quality and improvement message was being disseminated to all staff. Mrs Gent suggested this could be supplemented by inclusion of an appropriate local question within the next Staff Survey. Mr R Stewart undertook to circulate the results of the Staff Experience Survey to members. The Committee: Noted the position in relation to Highland Quality Approach activity. Noted results of the Staff Experience Survey would be circulated to members. 8 FOR INFORMATION 8.1 Provisional schedule of Meting dates for 213 There had been circulated report detailing the provisional meeting dates of the Staff Governance Committee in 213. The Committee Noted the schedule of meeting dates for

80 74 9 AOCB There were no matters raised under this Item. 1 DATE OF NEXT MEETING The next meeting was scheduled for 19 February 212 at 1.am in the Board Room, Assynt House, Inverness. The meeting closed at 12.3 pm. 1

81 75 Highland NHS Board 5 February 213 Item 3.5 IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive The Board is asked to: Note that the Improvement Committee met on Monday 7 January 213 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached). Panel: Mr Garry Coutts, Chair Dr Ian Bashford, Medical Director Dr Iain Kennedy, Non-Executive Director Cllr Liz MacDonald, The Highland Council deputising for Cllr Alasdair Christie Ms Sarah Wedgwood, Non-Executive Director In Attendance: Mr Bill Alexander, Director of Health and Social Care Ms Margaret Brown, Head of Service Planning Mrs Linda Kirkland, Head of Business Transformation Mr Kenny Oliver, Board Performance Manager Mr Jim Robb, Head of Service, Adult Care, Argyll & Bute Council (item 1) Miss Irene Robertson, Board Committee Administrator Apologies: Cllr Alasdair Christie, Ms Elaine Mead, Mr Derek Leslie and Mr Nigel Small Respondents: Mr Robin Creelman, Chair, Argyll & Bute CHP Mr Ian Gibson, Chair, Highland Health & Social Care Governance Committee Ms Deborah Jones, Chief Operating Officer Dr Roderick Harvey, Clinical Director, Raigmore Hospital Mr Chris Lyons, Director of Operations, Raigmore Hospital Mrs Gill McVicar, Director of Operations, North & West Highland Operational Unit Mr Brian Robertson, Head of Adult Social Care Dr Margaret Somerville, Director of Public Health Mrs Pat Tyrrell, Lead Nurse, Argyll & Bute CHP deputising for Derek Leslie (item 1) Mrs Jan Baird, Director of Adult Care (item 2) Mr Nick Kenton, Director of Finance (item 3a ) Ms Suzy Calder, Service Manager Substance Misuse/Professional Lead (item 4.1a) Mr Simon Steer, Head of Strategic Commissioning (item 4.1c) TOPICS DISCUSSED 1. 2./ Presentation on Pyramid System

82 76 2. Integration Quality and Improvement a. Scorecard for Adult Social Care Governance and Reporting Structures Self Directed Support Adult Respite Care Complaints Psychological Therapies b. Scorecard for Children s Services 3. Review of Board Assurance Report Actions a. Financial Position: Highland and Operational Units Raigmore Programme Board Social Care Budget b. Urology Services 4. Balanced Scorecard 4.1 Heat Targets a. Drug and Alcohol Treatment: Referral To Treatment b. Child and Adolescent Mental Health Services (CAMHS) c. Delayed Discharges North Highland 4.2 Standards a. A&E waits to be a maximum of 4 hours b. Cancer Waiting Times, Raigmore 5. Local Delivery Plan DATE OF NEXT MEETING The next meeting will be held on Monday 4 March 213 in the Board Room, Assynt House, Inverness at 1.3pm. 2

83 77 IMPROVEMENT COMMITTEE ASSURANCE REPORT Meeting on 7 January 213 The Committee s role and remit is to scrutinise NHS Highland s performance and ensure remedial action is taken, as required. NOTE: To ensure the quality of reporting to the Committee those papers being submitted are required to contain more associated commentary and follow the prescribed template as agreed. 1 TOPIC: PYRAMID SYSTEM Issues/Risks Assurance Actions Presentation by Jim Robb, Head of Service, Adult Care, Argyll & Bute Council and Pat Tyrrell, Lead Nurse, Argyll & Bute CHP on the Pyramid System describing its functions and its value as a performance management tool at both strategic and operational level. The system does not have an electronic feed-in function; work is underway in this regard. Bill Alexander advised that The Highland Council uses the Pyramid system (or PRMS as it is known) as a performance management tool. The system has been running for 3 4 years enabling trends to be identified. A major advantage of the system is that it brings all the information together in one site. It is a very flexible system in terms of reporting, however its effectiveness depends on the quality of data inputted. It has the ability to provide narrative. The data can be broken down into localities and there is open access by operational managers. Stock take of current position in terms of development of data reporting systems to be undertaken and discussed with partners to ensure systems are compatible and meet everyone s requirements. Action: D Jones 2 An integrated performance system with electronic feed-in capability is currently being developed by NHS Highland. INTEGRATION QUALITY AND IMPROVEMENT Issues/Risks Assurance Actions Scorecard for Adult Social Care position as at end of first quarter: Some indicators are still under development, either in terms of outcome or source of data. A number of indicators require Work is ongoing to further develop and clarify the indicators where necessary. Discussions will take place with wide ranging representation, and factoring in learning from work already done in Argyll & Bute, with the aim of drawing Proposals for amendments to the measures currently contained with the Commission to be developed for presentation to the February meeting of the Strategic Commissioning Group, and thereafter to The Highland Council and the NHS Board for agreement. Action: D Jones

84 78 further clarification/definition of the indicator. Trajectories and targets need to be developed. Operational teams need to have a clear understanding of what is required of them to ensure integration is being delivered. up a set of proposals for measures for which will illustrate improvements and assure quality outcomes. Governance and reporting structures for Adult Care: Need to establish appropriate sequencing of assurance and scrutiny by the various committees within the governance structure for adult care, ensuring scrutiny committees receive the information they require in a timely fashion and avoiding duplication of work. The Strategic Commissioning Group Being progressed through the Strategic Commissioning Group. has progressed proposals to ensure appropriate sequencing of reporting and scrutiny and improve communication. Self Directed Support (SDS): The Social Care (Self Directed Support) (Scotland) Act 212 was passed in November 212. Confirmation is awaited of the implementation date this will likely be April 213. NHS Highland will be required to deliver SDS offering four care options in compliance with the legislation. A Resource Allocation System (RAS) needs to be developed to deliver SDS packages. As there is no new money for SDS, it will The Highland Council was previously a pilot site for SDS. A Five Year Plan is being developed by the SDS Delivery Group the first draft of which will be available at the end of January 213 with the final version completed by March 213. This Plan will assist in planning and managing demand for SDS and for the release of resources currently tied up in existing traditional services. It is intended to work up a RAS for older people by end January 213 and trial it during February April 213. There will be engagement with 4 Update for the next meeting of the Improvement Committee on 4 March 213 providing assurance that the work has been scoped out and is feeding into the commissioning process for Action: D Jones Report to be prepared for the next meeting of the Health and Social Care Committee on 14 March 213 detailing progress with the various pieces of work and the development of trajectories. Action: B Robertson

85 79 be necessary to identify and manage the impact on existing services and associated risks. Trajectories for the delivery of SDS need to be developed and built into the operational delivery plans. service users, families and older people s representative groups as this work progresses. The processes to support assessment and allocation of SDS packages have been simplified. Adult Respite Care: The target is to maintain 21/11 levels of provision of respite day hours to people aged and 65+. Currently trajectory is not being met, however following a review of day services for the elderly and younger adults a number of people who previously attended day centres have been re-assessed and in a significant number of cases other provision is now being made e.g. community lunch groups. There is thus a need to redefine targets and trajectories. Feedback on clients experience of revised care provision should be obtained. A strategic approach has been taken to reviewing day services for the elderly and younger adults whose needs have been re-assessed and alternative care options have now been provided. Complaints: Delays are occurring in the complaints process across the operational units; the 2 day response target is not being met. Actions are being taken to improve New set of indicators and trajectories being developed through the performance. A new set of indicators Clinical Governance Committee. is being developed through the Action: Clinical Governance Committee Clinical Governance Committee. Psychological Therapies: Improvements are required to achieve the target of patients waiting over 18 weeks by end December 214. Work is progressing, as part of the Being progressed through the implementation of the Mental Health implementation of the Mental Health Strategy. Strategy, to deliver the necessary Action: N Small improvements and maintain the downward trend in waiting times. 5 Consideration to be given to setting revised targets and trajectories. Data to be gathered, along with client feedback, on service provision in order to determine if people s needs are being met and to assure quality outcomes. Action: B Robertson

86 8 Scorecard for Children s Work is continuing to further develop No action required at this stage. Services: and refine the scorecard which is This is under development. scrutinised by the Adult and Children s Services Committee. 3 REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Financial Update: Further improvements of 6.2m need to be made by the end of the year: NHS Care - 4.2m Adult Social Care - 2.m With regard to the overall Highland position the current forecast remains break even by the end of the financial year. Work is ongoing to improve the position in relation to adult social care. To discuss a proposal that a group be set up to assure appropriate governance of financial issues. Action: Chair / S Wedgwood / I Gibson / N Kenton There continues to be an overreliance on non-recurring savings. With regard to end of year movement the Committee agreed it would be useful for future financial reports to include details of how money is identified to achieve break even. All areas are seeking to continue to Action: N Kenton reduce reliance on non-recurring savings. Implications of implementing national policies and initiatives. Report to be prepared for the next meeting of the Improvement Committee on 4 March 213 setting out the position in relation to the establishment of clinical leadership and management posts across the operational units, number of posts filled/vacant. The report should also include a description of the clinical leadership role in terms of both professional and corporate responsibility. Action N Kenton / D Jones / I Kennedy An issue was raised in relation to clinical leadership/management posts and the funding thereof; and what the current position is specifically in relation to unfilled medical leadership posts. North & West Operational Unit: Deteriorating position mainly due to having to provide cover for several vacant GP practices, there are also locum cost pressures in rural general hospitals. North & West: The prescribing position is improving. Redesign work is ongoing which should help to mitigate the position in future years. 6

87 81 Raigmore: Increased cost pressures particularly around locums. Scope for savings at service management level. 1m target set for which a trajectory needs to be developed. Raigmore: There has been some improvement in the position. The HQA approach is generating savings, however some of these are being offset by in-year cost pressures. The Programme Board has been effective in terms of focusing activity. Report to be prepared for the next meeting of the Improvement Committee on 4 March 213 describing the operation of the Raigmore Programme Board, its performance to date, staff engagement with it, and the impact of its activity. Action: C Lyons South & Mid: Forecast breakeven. Work is ongoing with the aim of increasing recurring savings. Argyll & Bute: Improving position relating primarily to reductions in prescribing costs. Urology Services Update: Sustainability of service. Capacity issues. Challenges around recruiting to additional Urological Consultant post. The Board has approved the Interim cover arrangements to be agreed and put in place to ensure appointment of a fifth Urological continuity of service provision. Consultant to ensure continuing Action: D Jones / Directors of Operations service provision particularly in Argyll & Bute, to meet demand on the Raigmore Hospital service and also to provide a service to patients from NHS Western Isles. Discussions are ongoing regarding interim arrangements pending an appointment being made. These include the use of facilities at the Belford Hospital to treat Argyll & Bute patients. Consideration will require to be given to the longer term position taking account of consultant retirals. 7

88 82 Stroke Update: Target of 9% of patients with diagnosis of stroke to be admitted to a stroke unit on the day of admission, or the day following presentation by March 213. The figures available for the Lorn & Isles stroke unit indicate there has been no improvement in performance during the year and it remains below target. There has been an improving position over the course of the year and it is fully expected that the panhighland target will be met. (89% was achieved at November 212). Performance at Lorn & Isles to continue to be monitored. Action: D Leslie Issue of reporting at Lorn & Isles and assuring it has equivalent beds designated for the care of stroke patients to be followed up. Action: I Bashford 4 BALANCED SCORECARD / AT A GLANCE SUMMARY Concern was expressed that the At a Glance summary appeared to indicate a deteriorating position in respect of some of the targets. Performance is good against most areas, and it was acknowledged that where targets are being missed the numbers involved are small, nevertheless there is a need to ensure that improvements continue to be made and are sustained. 4.1 BALANCED SCORECARD HEAT TARGETS Issues/Risks Assurance Actions Drug and Alcohol Treatment Referral To Treatment: Highland Alcohol & Drugs Partnership (HADP): Although on trajectory some further improvements require to be made to achieve the target. Several issues and challenges are impacting on the position including long term sickness absence, staff vacancies, limited service options, prescribing in the community, access to/availability of community support. Highland ADP: A range of actions has been implemented to address the issues identified. Significant reductions in waiting times from referral to treatment have been achieved, most clients now being seen within 5 weeks. Cautiously optimistic about achieving the target (21 days from referral to treatment) for the final quarter. Assurance to be provided on the effectiveness of the services provided in terms of quality and outcomes. Action: ADPs 8 Operational Units to monitor progress of this target for the end of March 213. Action: Directors of Operations

89 83 The number of referrals to services has increased, as has the number of active clients. Issue around data recording systems. Argyll & Bute ADP: Increased service demands, staffing capacity issues and complexity of cases have resulted in long waits in some localities. Argyll & Bute ADP: Action has been taken with the aim of reducing the length of waits in the localities identified. CAMHS: Substantial progress and To clarify and confirm referral criteria and what action is taken locally in Highland wide challenges to be improvements have been made. relation to support for individuals with complex needs in temporary care. Action: M Brown met: Confident of meeting trajectory. Sustaining improvements across all operational units to support the 26 weeks target from March 213, and achieving further improvements to achieve the 18 weeks target by December 214. Potential increase in referrals consequent on reduction in waiting times. Increased demand from April 215 when all year olds are to be seen within a CAMHS system. Issue raised in relation to referral process and availability of support for individuals in temporary care who have complex clinical needs. 9

90 84 Delayed Discharges North Highland: There are several areas where delays are being experienced such as care home placements, care at home capacity, assessments and issues around guardianship. Communication between health and social care staff and with clients and carers is a key issue. There is a need to manage patients expectations and ensure they and their families/carers understand that it may not be possible for them to have the placement of their choice. The position is improving. Actions The position to continue to be closely monitored. have been agreed with all the Action: D Jones / Directors of Operations Operational Units in the immediate and medium terms to reduce delays, and longer term plans are in development to achieve a maximum delay tolerance of 72 hours. 4.2 BALANCED SCORECARD STANDARDS Issues/Risks Assurance A&E Raigmore maximum 4 hours wait: The 98% standard was not met in December 212 (96.82% was achieved). Maintaining the standard is dependent on a number of factors, two of which are outwith the control of the Emergency Department, viz when the department has to receive medical and surgical patients due to lack of available beds in the hospital, and clinical need or complexity. Actions As a result of focused management Management actions to continue. actions taken the position has been Action: C Lyons improving over the last few months; the 98% target was achieved in November

91 85 Cancer Waiting Times, Raigmore: During September December 212 a number of breaches occurred, due mainly to the shortfall in radiotherapy planning and clinical oncology capacity. With regard to radiotherapy planning Newcastle no longer have capacity to take Highland patients and this will impact further on the position. 5 A range of actions is being taken to Position to continue to be closely monitored. Update required for the address capacity shortfall. A higher next meeting of the Improvement Committee on 4 March 213. banding has been agreed for Action: C Lyons radiotherapy planning posts which may assist recruitment, although there is an issue of market availability. A review of cancer services is to be undertaken to provide guidance on the provision of a sustainable service going forward. TOPIC: LOCAL DELIVERY PLAN Issues/Risks Assurance Actions Preparation of the Local Delivery Extra Board Development Session on No action required at this stage. Plan (LDP) is underway. In the LDP and Operational Delivery addition each Operational Unit is Plans is planned for 15 January 213. preparing an operational delivery plan for setting out how they will deliver the HEAT targets appropriate to their unit. There are 3 new targets for : Waiting times for IVF treatment Post-diagnostic support following dementia diagnosis Further reduction of HAI covering wider age groups. 11

92 86 6 FUTURE AGENDA ITEMS Meeting on 4 March 213: Adult Social Care Scorecard development of set of measures for Raigmore Programme Board Clinical Leadership and Management Posts CAMHS Update Cancer Waiting Times A&E Attendance Rates and 3 Day Guidance Pilot Evaluation Report Future Meetings: Quality Outcomes Framework Detect Cancer Early Programme 7 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 213 The Improvement Committee will meet on the following dates in 213: 8 4 March 29 April 1 July 2 September 4 November DATE OF NEXT MEETING The next meeting of the Improvement Committee will take place on Monday 4 March 213 in the Board Room, Assynt House, Inverness at 13:3. 12

93 NHS Highland - "At A Glance" HEAT Targets 87 Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 7th January 213 Delivery Date Argyll and Bute South & East North & West Raigmore Target Month reported Board Position Targets with a delivery date by the end of March 213 Financial Performance Cash Efficencies Oct-12 Oct-12 Mar-13 Mar-13 Drug & Alcohol Treatment: Referral to Treatment Faster Access to Specialist CAMHS Jun-12 Oct-12 N/A N/A Mar-13 Mar-13 9% of patients diagnosed with stroke admitted to a stroke unit Delayed Discharges - 28 days MRSA/MSSA Bacterium: 3% reduction C. Diff Infections: 3% reduction Reduction in Emergency bed days for patients aged 75+ Nov-12 Nov-12 Jun-12 Jun-12 Jul-12 Currently reported at Board Level Only Mar-13 Mar-13 Mar-13 Mar-13 Mar-13 N/A N/A Currently reported at Board Level only Currently reported at Board Level only N/A No Trajectory No Trajectory Rate of attendances at A&E Delivery Date Argyll and Bute South & East Sep-12 Sep-12 Sep-12 Jun-12 Data sources being developed Data sources being developed N/A N/A N/A N/A Currently reported at Board Level Only N/A N/A N/A N/A Currently reported at Board Level Only Mar-15 Apr-15 Mar-14 Mar-14 Mar-14 Mar-14 Sep-12 Sep-12 Currently reported at Board Level Only Currently reported at Board Level Only Mar-15 Mar-15 Trajectory in development Dec-14 Faster Access to Psychological Therapies No Trajectory North & West Reduce Carbon emmissions Reduce Energy Consumption Raigmore Target Early Access to Antenatal Services Detect Cancer Early Child Healthy Weight Interventions Smoking Cessation - 2 most deprived data zones Smoking Cessation - general smoking population Child Fluoride Varnish Applications Month reported Board Position Targets with a delivery date beyond March 213 Oct-12 N/A Mar-14 Annual Argyll and Bute South & East North & West Raigmore Month reported Board Position NHS Highland - "At A Glance" Standards Target Alcohol \Brief Interventions Inequalities Targeted Cardiovascular Health checks Breastfeeding at 6-8 week- Target 36% MMR uptake rates - target 95% at 5 years old Oct-12 Oct-12 Mar-12 Jun-12 Sickness Absence - 4% target SMR return rate - 9% of SMR1 returns received within 6 weeks Complaints - 8% of complaints completed within 4 weeks Complaints - No. over 4 working days - Target Complaints - No. of complaints received Target less than 33 Complaints - No. categorised as High Risk - Target less than 7 Day case rates - Target 78.9% Outpatients - DNA rate - Target 6.9% Reduce Pre Operative stay - Target.65 days New to Return Outpatient attendance Ratio - Target 2.2 eksf & PDP's - Target 8% Aug-12 Sep-12 Sep-12 Aug-12 Aug-12 Aug-12 Oct-12 Sep-12 Oct-12 Sep-12 Oct-12 Suspicion of cancer referrals (62days) (Due for Delivery Dec 21) All Cancer Treatment (31days) (Due for Delivery Dec 21) 18 weeks Referral to Treatment (Due for Delivery Dec 21) New Outpatient Waiting times - 12 weeks (all referral sources) Inpatient/Day Cases Waiting times - 9 weeks Cataract Waiting Times - assessment - 9 weeks Hip surgery - 98% of patients treated within 24 safe operating hrs Angiography - 4 week waiting time Daignostic tests waiting times - 4 weeks for 8 key tests A&E Waiting times - 4 hours Advance Booking - GP's Jun-12 Jun-12 Oct-12 Oct-12 Oct-12 Oct-12 Nov-12 Oct-12 Oct-12 Oct-12 Reported at Board Level only Reported at Board Level only Currently reported at Board Level only N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Cervical Screening - 8% uptake of 2-6 yr old women screened Reduce Occupied Bed days for long term conditions Dementia (Unvalidated - validated position available annually) Sep-12 Jul-12 Oct-12 N/A N/A N/A N/S : National Standard N/A N/A N/A N/A N/A N/A N/A N/A N/A N/S N/A N/A Dec-11 Dec-11 Dec-11 N/S N/S N/S N/S N/S

94 88 NHS Highland - Review of Timeliness of Data for Balanced Scorecard Targets with a delivery date by the end of March 212 Target Alcohol Brief Interventions Inequalities Targeted Cardiovascular Health checks MAY BSC Data NHSH Reported Period Time Lag Updated to SGHD Feb-11 6 weeks Monthly Quarterly Mar-11 2 weeks Monthly Quarterly Data Source Local data used Local data used Financial Performance Cash Efficencies Mar-11 2 weeks Mar-11 2 weeks Monthly Monthly Monthly Monthly Local data used Local data used Suspicion of cancer referrals (62days) (Due for Delivery Dec 21) All Cancer Treatment (31days) (Due for Delivery Dec 21) 18 weeks Referral to Treatment (Due for Delivery Dec 21) Dec-1 3 months Dec-1 3 months Feb-11 3 weeks Quarterly Quarterly Monthly Quarterly Quarterly Monthly Reduction in Emergency bed days for patients aged 75+ Dec-1 3 months Monthly Monthly NHSH Updated Monthly Monthly Monthly Quarterly Reported to SGHD Quarterly Quarterly Quarterly Quarterly Data Source Local data used Local data used Local data used ISD data used Dec-1 3 months Dec-1 3 months Quarterly Quarterly Quarterly Quarterly Environment Monitoring & Reporting Tool (emart) Environment Monitoring & Reporting Tool (emart) Drug & Alcohol Treatment: Referral to Treatment Faster Access to Specialist CAMHS Faster Access to Psychological Therapies Dec-1 3 months Feb-11 3 weeks N/A 3 weeks Quarterly Monthly Monthly Quarterly Monthly Monthly Drug & Alcohol Treatment Waiting Times Database Local data used Local data used 9% of patients diagnosed with stroke admitted to a stroke unit MRSA/MSSA Bacterium: 3% reduction C. Diff Infections: 3% reduction Rate of attendances at A&E N/A Monthly Quarterly Quarterly Monthly Quarterly Quarterly Quarterly Quarterly Scottish Stroke Care Audit Health Protection Scotland Health Protection Scotland Local data used Scottish Cancer Waiting Times System Scottish Cancer Waiting Times System Local Data used ISD data used Targets with a delivery date beyond March 212 Target Child Healthy Weight Interventions Smoking Cessation - 2 most deprived data zones Smoking Cessation - general smoking population Child Fluoride Varnish Applications MAY BSC Data Period Feb-11 N/A Feb-11 Sep-1 Reduce Carbon emmissions Reduce Energy Consumption Time Lag 6 weeks 6 weeks 6 weeks 6 months 2 months Dec-1 3 months Dec-1 3 months Feb-11 3 weeks NHS Highland - "At A Glance" Standards Target Breastfeeding at 6-8 week- Target 36% MMR uptake rates - target 95% at 5 years old MAY BSC Data NHSH Period Time Lag Updated Sep-1 6 months Quarterly Dec-1 3 months Quarterly Data Source ISD data used Health Protection Scotland Sickness Absence - 4% target SMR return rate - 9% of SMR1 returns received within 6 weeks Complaints - 8% of complaints completed within 4 weeks Complaints - No. over 4 working days - Target Complaints - No. of complaints received Target less than 15 Complaints - No. categorised as High Risk - Target less than 2% Day case rates - Target 78.9% Outpatients - DNA rate - Target 6.9% Reduce Pre Operative stay - Target.65 days New to Return Outpatient attendance Ratio - Target 2.2 eksf & PDP's - Target 8% Jan-11 Feb-11 Feb-11 Feb-11 Feb-11 Feb-11 Jan-11 Feb-11 Feb-11 Feb-11 Mar-11 6 weeks 6 weeks 6 weeks 6 weeks 6 weeks 6 weeks 2 months 6 weeks 6 weeks 6 weeks 2 weels Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Local data used ISD data used Local data used Local data used Local data used Local data used Local data used Local data used Local data used Local data used Local data used New Outpatient Waiting times - 12 weeks (all referral sources) Inpatient/Day Cases Waiting times - 9 weeks Cataract Waiting Times - assessment - 9 weeks Hip surgery - 98% of patients treated within 24 safe operating hrs Angiography - 4 week waiting time Daignostic tests waiting times - 4 weeks for 8 key tests A&E Waiting times - 4 hours Advance Booking - GP's Mar-11 Mar-11 Mar-11 Mar-11 Mar-11 Mar-11 Mar-11 Mar-1 3 weeks 3 weeks 3 weeks 3 weeks 3 weeks 3 weeks 3 weeks 3 months Monthly Monthly Monthly Monthly Monthly Monthly Monthly Annually Local data used Local data used Local data used Local data used Local data used Local data used Local data used National Audit data used Cervical Screening - 8% uptake of 2-6 yr old women screened Reduce Occupied Bed days for long term conditions Balance of care for Older People with complex care need Delayed Discharges - no clients waiting over 6 weeks Dementia (Unvalidated - validated position available annually) Dec-1 Dec-1 Sep-1 Mar-11 Feb-11 3 months 3 months 3 months 3 weeks 6 weeks Quarterly Monthly Quarterly Monthly Monthly Health Protection Scotland ISD data used Local data + Local Authority data Local data used Local unvalidated data used

95 89 Highland NHS Board 5 February 213 Item 3.6 Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel DRAFT MINUTE of MEETING of the AREA CLINICAL FORUM Board Room, Assynt House, Inverness 29 November pm Present Dr Iain Kennedy, Chair Mr Derek Brown, NMAHP Mrs Mary Burnside, Area Nursing, Midwifery and AHP Advisory Committee Mr Ryan Cooper, Area Healthcare Science Forum Mr Quentin Cox, Area Medical Committee Mr Colin Crawford, Area Dental Committee Dr Douglas Hutchison, Psychology Advisory Committee Mr Duncan Martin, Patient Representative Dr Rob Peel, Raigmore Hospital Dr Boyd Peters, South and Mid Operational Unit Dr Anne Pollock, Area Healthcare Science Forum Mrs Margaret Steventon, Area Optometric Committee representing Hugh Campbell and Donald Goskirk Mr Ray Stewart, Employee Director In Attendance Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director until 3.5pm Mr Ken Proctor, Associate Medical Director (Primary Care) Mrs Margaret Somerville, Director of Public Health (until 2.3pm) Mrs Christine Thomson, Board Committee Administrator 1 WELCOME AND APOLOGIES Dr Kennedy welcomed those present to the meeting. Dr Kennedy advised that the numbers present were unavoidably low due to a clash with a Scottish Patient Safety Programme meeting. He advised that due to the anticipated lower attendance it had been decided to defer proposed presentations by Dr Paul Davidson on his visit to Virginia Mason Medical Centre and Dr Ken Proctor on his visit to Tees, Esk and Wear Valleys NHS Foundation Trust. It was noted that these presentations would take place at the next meeting of the ACF to be held on 31 January 213. Apologies were received from Boyd Peters, Heidi May, Margaret Moss, Ken Proctor, Duncan Railton, Sheelagh Rodgers and Pat Wells. 1.1 DECLARATIONS OF INTEREST There were no declarations of interest. At this stage it was agreed to consider the presentation on the Public Health Annual Report by Margaret Somerville, Director of Public Health.

96 9 2 HIGHLAND QUALITY APPROACH (QUALITY AND EFFICIENCY) PROFESSIONAL ADVISOR GROUPS/OPERATIONAL UNITS PUBLIC HEALTH ANNUAL REPORT Margaret Somerville, Director of Public Health gave a presentation on the Public Health Annual Report. It was noted that whilst the report concentrated this year on older people the emphasis next year would be on children. The need to engage with a wide selection of people was noted and the importance of community services was noted. The Forum Noted the content of the presentation. 3 MINUTE OF MEETING HELD ON 27 SEPTEMBER 212 The minute of the meeting held on 27 September 212 was agreed subject to the following amendments: On page 3 under the report from the Area Medical Committee it was noted that the sentence commencing Such work included colonoscopy, renal function check and monitoring of drugs in psychiatry the position of the comma should be altered to read Such work included colonoscopy renal function, check and monitoring of drugs in psychiatry.. On page 4 under the report from the Area Medical Committee it was noted that the telephone reminder was sent only after an appointment had been made. In addition in the sentence commencing Colin Crawford advised...the words for dental should be inserted after the word Highland. On page 5 under the Psychology Advisory Committee report the words a 26 week referral with interim treatment targets should be altered to read an interim 26 week referral to treatment target. After discussion and noting the above the minute was accepted as a true record. 4 MATTERS ARISING 4.1 ACF Development Session Dr Kennedy advised the Committee that the proposed ACF Development Session would take place on Tuesday 12 March at 2pm in the Board Room Assynt House, where the facilitator would be Scott Dunn, Head of Leadership & Management Development at the Tayside Centre for Organisational Effectiveness. Dr Kennedy requested that should members be unable to attend deputies from professional advisory groups be requested to attend in their place. 5 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES 5.1 Area Nursing, Midwifery and AHP Advisory Committee Derek Brown advised that discussion had recently taken place on performance data and stressed that continual vigilance was required to ensure standards were maintained. 2

97 91 As regards hospital infections, discussion had taken place as to how to maintain equivalent standards in community settings as in hospital settings. As regards the Better Together Survey he reported that the issue of noise in wards at night had been raised, that a pilot on buzzers had taken place in Caithness and that intentional roundings had made an impact. Derek Brown advised that the feedback on the Virginia Mason Medical Centre would be useful in helping staff to understand the whole Quality Approach. Dr Bashford advised that the Quality Approach was patient focussed at every contact, with the patient being at the centre at all times. It was generally agreed that there was a requirement to cascade information down the organisation in order to educate for this change in culture. Derek Brown further advised that existing clinical governance arrangements would be reviewed in light of changes post service integration on 1 April 212, with a view to ensuring that these remain fit for purpose. The issue of social media had also been considered. 5.2 Area Dental Committee Colin Crawford advised that in addition to the circulated minute of 29 August 212, a further meeting had been held on 28 November 212. He advised that the number of Out Of Hours referrals was small. In addition the Health & Safety representative post remained vacant. As regards the restorative consultants, he reported that the next meeting of the Board would be asked to approve these posts. As regards decontamination he reported that the combined practice inspection final version was not yet available and practices would be required to evidence completion of relevant NES training, as well as hold an associated Action Plan. There were concerns over this and related issues. The GDP Sub Committee revised terms of reference had been approved. 5.3 Area Medical Committee Mr Cox reported that in addition to the circulated minute of 25 September 212, a further meeting had been held on 2 November 212. As regards appraisal and revalidation it was noted that this would commence in the renal department in April 213. He reported that the consultation document for consent for clinical treatment had generated much discussion with the closing date for comments being 3 November 213. Mr Cox further advised that discussion had taken place regarding the outpatient follow-up times. 5.4 Highland Area Optometric Committee Mrs Steventon advised that there was no further report. 3

98 Area Pharmaceutical Committee Ian Rudd reported that a further meeting of the Area Pharmaceutical Committee would take place on 29 November 213. He reported that Andrew Paterson, Community Pharmacist from Wick had been appointed as Chairman of the APC. He further reported that due to lack of staff there was a degree of frustration over the capacity to contribute towards the Managed Clinical Network Development. 5.6 Psychology Advisory Committee Dr Doug Hutchison reported that there was still variability in waiting lists between different specialisms in psychological services and between different geographical regions. He reported that feedback had been received regarding the length of wait for guided self help. In addition, selected patients from Clinical Psychology waiting lists had received brief Guided Self Help treatments while they were waiting which had proved to be helpful in avoiding further treatment. Also, a proposed service pilot to commence in one area from January 213 was highlighted where patients are offered a timely assessment and possibly a brief treatment prior to being placed on a waiting list for psychological therapy and it was noted that this could reduce the requirement for other treatment for some patients. 5.7 Healthcare Scientists Forum Ryan Cooper reported that there was a quality issue regarding the recording of information attached to specimens. It was noted that this would now be considered as a matter of urgency. He further reported that the annual event for Health Care Science was being held on 3 November 213 and that a large representation from NHS Highland would be in attendance. The Forum noted the updates from the Professional Advisory Committees. 6 HIGHLAND QUALITY APPROACH (QUALITY AND PROFESSIONAL ADVISOR GROUPS/OPERATIONAL UNITS EFFICIENCY) Iain Kennedy recommended that the title of this section would be altering at the next meeting of the ACF to include explicit reference to harm, waste and variation. 6.1 CEL(212)36 Appropriate Prescribing for Patients and Polypharmacy Guidance for Review of Quality, Safe and Effective Use of Long-Term Medication It was noted that clinicians were being asked to consider the appropriateness of long term prescribing both when reviewing existing treatments and when starting new medicines. It was noted that the polypharmacy guidance for 212 was the first iteration of a national approach to address the issues resulting in the use of multiple medications in the frail and elderly population and that medication was the most common form of medical intervention. It was generally considered that this was an excellent piece of work and it was noted that every patient with a repeat prescription should have an annual medication review. 4

99 93 It was further noted that at the recent Scottish Pharmacy Awards, John Cromarty, Director of Pharmacy had received a lifetime achievement award for his contribution to pharmacy services. The Forum Noted the terms of CEL(212)36. 7 AREA CLINICAL FORUM CHAIRS GROUP MEETING 28 NOVEMBER 212 Dr Kennedy advised that the last meeting of the Chairs Group had taken place on 28 November at which the Chairs had met the new Cabinet Secretary for Health and Wellbeing, Alex Neil. He highlighted various points which had arisen at the meeting. He advised that the Minister had called for accountability from all clinicians, executives and non-executive directors, this including accountability for system failure. In addition the Minister wanted more empowerment for clinicians to formulate policies and to innovate and asked to be advised about any barriers clinicians were experiencing to innovation. It was further noted that the Minister was of the opinion that there was too much centralisation in Edinburgh. Dr Kennedy further reported that the Minister was undertaking a number of unannounced back to the floor visits where he was learning a great deal from speaking to clinicians directly. As regards A&E admissions, the Minister would be scrutinising high GP referrers and had requested that Health Boards focus on reattenders. The Minister also questioned the extent of the use of external management consultants. The Minister questioned whether 2 reduction in nurses across the country was advisable stating that rightly or wrongly nurses are the face of the NHS. As regards GPs and dentists, the Minister approved the fact that they ran there own businesses although he was unconvinced about 48 hour access to GPs and the use of 1 minute appointments. In addition he had expressed frustration about the number of GP contracts and wanted GPs to have the ability to book hospital appointments while the patient was in the GP surgery. The national shortage of occupational therapists throughout the country was also highlighted. Dr Kennedy further reported that the Minister was an advocate of improvement methodology highlighting LEAN and 6 SIGMA and stressing the need to start resourcing more improvement work in primary care, including general practice, pharmacy, optometry and dentistry. It was noted that the next Chairs meeting would take place in March 213 at which Bill Scott, Chief Pharmacist, would be in attendance, and Dr Kennedy advised that he had already requested that GEMSCRIPT by included on this agenda. He requested that any other questions for Mr Scott be forwarded to himself prior to the Christmas break for onward transmission to the Minister s office. 8 NHS HIGHLAND BOARD MEETING 4 DECEMBER Developing a Framework for Use of Social Media in NHS Highland There had been circulated a report by Maimie Thompson, Head of Public Relations and Engagement, on behalf of Elaine Mead, Chief Executive. The benefits, risks and considerations of the use of social media by NHS Highland as part of wider communications and engagement strategy were noted and the Forum endorsed the 5

100 94 recommendation to explore the principle of opening up social media in the work place initially through controlled process. 8.2 Dingwall Health Centre Business Case There had been circulated report by Michael Waters, Capital Support & Project Manager on behalf of Nick Kenton, Director of Finance. 8.3 NHS Highland Proposed Implementation of the National Patient Management System (PMS) There had been circulated report by Bill Reid, Head of e-health on behalf of Deborah Jones, Chief Operating Officer. There was general support for the implementation of the National Patient Management System. 8.4 Infection Control Report There had been circulated a report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control. 8.5 Chief Executive s and Directors Report Emerging Issues and Updates There had been circulated a report by Elaine Mead, Chief Executive. The Forum Noted the circulated internal communications whilst stressing the comments highlighted. 9 FOR INFORMATION 9.1 Attendance Record Members were advised the Attendance Record would be updated and circulated after the meeting. The Forum Noted the attendance record. 9.2 Dates of Future Meetings 4 April May August September November 213 6

101 95 1 AOCB Anne Pollock advised that she had attended the recent finance training which she had found very beneficial and encouraged others to attend. As Chair of the Clinical Ethics Committee, Rob Peel reminded members that he held the Committee was available to discuss any ethical issues. It was agreed that this be kept on the rolling agenda for the Highland Quality Approach. 11 DATE OF NEXT MEETING The next meeting will be held on Thursday 31 January 213 at 1.3 pm in the Board Room, Assynt House, Inverness. The meeting closed at 4.2 pm. 7

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103 97 Highland NHS Board 5 February 213 Item 3.7(a) HIGHLAND NHS BOARD MINUTE of MEETING of the NHS Board Asset Management Group Boardroom, John Dewar Building, Inverness Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel Tuesday 2 November pm Present: Alasdair Lawton, Chair John Bogle, Acting Head of Capital and Property Planning Carol Marlin, Monitoring Accountant Malcolm Iredale, Head of Procurement Bill Reid, Head of ehealth John Crossley, Section Head, Medical Physics Ray Stewart, Staffside Representative Eric Green, Head of Estates In Attendance: Lynda Main, Personal Assistant (minutes) 1 WELCOME/INTRODUCTIONS Alasdair Lawton welcomed everyone to the meeting and everyone around the table introduced themselves. Apologies for absence were received on behalf of Bill Brackenridge, Nick Kenton, Derek Leslie, Chris Lyons, Michael Hall, Alex Javed, Ian Scott and Linda Kirkland. 2 MINUTE OF THE MEETING HELD ON 23 October 212 The minute was approved. 3 MATTERS ARISING Capital Forecasts This issue is now crucial and will be carried forward as an action. John Crossley and Bill Reid advised that they were working on lists of equipment which could be brought forward. Endoscopy A decision has been made about the location of endoscopy services. Actions: Capital forecasts are still required from all project managers.

104 98 4 FINANCE REPORT The capital to revenue virement requested last month is still to be confirmed. The total spend to month 7 is 1.732m which is only 2% of the plan. There would be slippage on Oban Dental due to an issue with planning permission.carol Marlin had not been informed of any other slippage. John Crossley confirmed the medical equipment allocation would be spent and he was also looking at a list of items which could be brought forward from next year, ehealth were doing the same and would get back to Carol Marlin before the next meeting, if the Patient Management System was approved by the Board on 4th December there would be the purchase of hardware which could be brought forward. Anything not previously in the plan would also be considered. Predicted year end spend and a list of projects which could be completed and paid for before the year end was still required from Radiology. It was requested project managers send a list of equipment which could be brought forward and a copy of the capital plan would also be issued. The decision was taken to schedule a special meeting on 4th December, solely to deal with the current predicted under spend, it was asked that everyone was represented. Biomass funding of 1.372m had been confirmed and this is now out to tender, however, it is unlikely that will be spent before the year end and guidance on procurement issues and how to accelerate spend was required, Eric Green would discuss with Malcolm Iredale after the meeting. NHS Highland has also bid for an additional 2.4m from the eco hospitals fund There will be a national procurement for containerised biomass boilers. Nick Kenton will find out more at the Directors of Finance meeting. Actions: It was requested that all project managers send details of predicted year end spend and also anything which could be brought forward from next year to Carol Marlin before the meeting on 4th December. 5 SPACE UTILISATION An information collecting exercise has been started on space utilisation, Scottish Futures Trust are assisting. The Highland Council have agreed to find some office space for the NHS employees currently in Larachan House in Dingwall, however this is still to be confirmed and could possibly only be for 2 years. The council have also reviewed their property in Fort William and as a result of this there could be opportunities for NHS Highland. Bill Reid asked that when people are moving, ehealth be given the appropriate notice. Actions: The Group will be kept updated on progress. 2

105 99 6 BROADFORD HEALTH CENTRE - MEDIATION NHS Highland had been involved in a dispute with Global Construction regarding the final account for Broadford Health Centre. A mediator was called in to help with the dispute, she concluded that a reasonable amount of compensation for Global would be 12k, this could now go to adjudication or NHS Highland could pay the 12k. Adjudication would be costly and the Group agreed the sensible option would be to pay the 12k. The Group approved 12k compensation. 7 MEETING DATES 213 The meeting dates for 213 were noted. John Bogle informed the Group that Tain Health Centre was working to an accelerated programme and there might be a requirement to alter the January meeting date so that the FBC could be considered within the necessary timescale. It was noted that the April meeting doesn t always go ahead. The Group noted the meeting dates. 8 DATE OF NEXT MEETING The next meeting will be held on Tuesday 4 December at 3pm in the Boardroom, Assynt House, Inverness. The meeting concluded at 2.45pm 3

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107 11 Highland NHS Board 5 February 213 Item 3.7(b) HIGHLAND NHS BOARD MINUTE of MEETING of the NHS Board Asset Management Group Boardroom, Assynt House, Inverness Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel Tuesday 4 December pm Present: Alasdair Lawton, Chair John Bogle, Acting Head of Capital and Property Planning Carol Marlin, Monitoring Accountant Malcolm Iredale, Head of Procurement Bill Reid, Head of ehealth Chris Lyons, General Manger, Raigmore Nick Kenton, Head of Finance John Crossley, Section Head, Medical Physics Alex Javed, Service Manager, Labs and Radiology Linda Kirkland, Business Transformation Manager Eric Green, Head of Estates In Attendance: Lynda Main, Personal Assistant (minutes) 1 WELCOME/INTRODUCTIONS Alasdair Lawton welcomed everyone to the meeting and everyone around the table introduced themselves. Apologies for absence were received on behalf of Bill Brackenridge, Derek Leslie and Ray Stewart. The sole item in the agenda will be the current predicted under spend in the capital budget and actions required to rectify this by the year end. 2 PREDICTED UNDER SPEND IN CAPITAL BUDGET Mike Baxter has confirmed that all NHS Highland slippage will have to be managed in house and if it is not spent, there will be no carry forward. The Group discussed what spend could be brought forward from next year and tables are attached from Carol Marlin giving details of this. It was asked that objections be forwarded to her by 12th December. Formal approval would be given at the next meeting on 18 December. The bids totalled 283k and the slippage available is 259k, however additional slippage is expected.

108 12 Actions: Objections to Carol Marlin by 12 December. Formal approval will be given at the Asset Management Group meeting on 18 December. 3 DATE OF NEXT MEETING The next meeting will be held on Tuesday 18 December at 2. pm in the Boardroom, Assynt House, Inverness. The meeting concluded at 4.15pm 2

109 13 Highland NHS Board 5 February 213 Item 3.8 Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel DRAFT MINUTE of MEETING of the HEALTH and SAFETY COMMITTEE Board Room, Assynt House 15 November am Present Ms Elspeth Caithness, Chair Mr Alasdair Lawton, Joint Chair Ms Pauline Craw, North Highland CHP (by videoconference) Mr Stephen Davison, SOR Mr Stephen Don - Unite Mrs Anne Gent, Director of Human Resources Mr Iain King, CSP M M Marr Mrs Mirian Morrison, Clinical Governance Development Manager Mr Stephen Raithwaite, SOR Ms Linda Rawlinson, Occupational Health Nurse Manager Mr Colin Shields, Health & Safety Manager (by video conference) Mr N Small, Director of Operations, South and Mid Highland Mrs Diane Stark, Infection Control Nurse Ms Audrey Urquhart, SOCAP Mr Andrew Ward, Commissioning Officer (on behalf of Mr Fraser Brunton, Radiation Protection Lead) In attendance Mrs Rosie Brunton, Health and Safety Manager, Raigmore Ms Fiona Campbell, Clinical Governance Manager, Argyll & Bute CHP (by videoconference) Ms Susan Glass, Senior Dental Nurse Dr Niamaka Obanor, Locum Registrar in Occupational Health Mr Eric Green, Head of Estates Mr Bob Summers, Head of Health & Safety Mrs Christine Thomson, Board Committee Administrator 1 WELCOME AND APOLOGIES Elspeth Caithness welcomed everyone to the meeting. Apologies for absence were received from Fraser Brunton, Dawn Gillies, Nick Kenton. Diane Stark, Audrey Urquhart, Una Lyon, Nigel Small, Ken Oates, Nick Kenton, Gill McVicar, Owen Rawlins, Dr Steve Ryder. 1.1 Declarations of Interest There were no declarations of interest.

110 14 2 MINUTE AND ACTION PLAN OF MEETING HELD ON 16 AUGUST 212 The minute of the meeting of 16 August 212 was approved as an accurate record with the following minor amendment: page 7 paragraph 8.3.1, sixth line delete the word all and replace with most. The minute was then proposed by Ian King and seconded by Stephen Don. The Action Plan was noted. 3 MATTERS ARISING 3.1 Provision and Maintenance of Community Equipment Bob Summers reported a number of recent incidents relating to the maintenance of equipment in both domestic and non-domestic settings in the community. He also advised that the Health & Safety Executive had become involved with respect to an adverse Insurance Report that was raised in respect of a defective hoist in the community. It was noted that the maintenance of equipment in the community was challenging and that it was necessary for all stakeholders to be sure of their precise responsibilities. It was stressed that this was a complex issue involving many areas which was further complicated by the purchase by individuals of their own equipment such as stairlifts. A precise indication of the number of incidents was difficult to ascertain due to the fact that some incidents were still being reported on the Highland Council s system as opposed to DATIX. Nigel Small also highlighted an ongoing Significant Event Review in this area. 3.2 Integrated stores Anne Gent reported that it had been considered that the proposals for a new system to help manage stores would benefit from LEAN methodology. It was noted that the two main stores were moving towards the use of MEASLES computerised system and it was agreed to postpone further LEAN work until staff were fully proficient with the MEASLES system. However, in the meantime, a group comprising the main stakeholders and involving Ian King would be established to scope out current challenges, responsibilities of the various agencies and identify a way forward. The Committee: 3.3 Agreed that a group comprising the main stakeholders and involving Ian King be established to scope out current challenges, responsibilities of the various agencies and identify a way forward. Agreed that an update would be given to the next meeting of the Committee to be held on 7 February 213. Integrating Care in the Highlands Bob Summers reported that one member of staff had been seconded from the Highland Council, Maria Carpenter, Health & Safety Manager and one other member of staff from the Highland Council, Jim McCreath was working with Moving & Handling team, until March 213. It was noted that Maria Carpenter s role would include establishing the duties of the Registered Premises Officer, establishing the Adult Social Care Health & Safety Plan, and providing reactive support to Adult Social Care issues. 2

111 15 In addition it was noted that the final transfer of resource to Occupational Health Services still required to be resolved. 4 STAFF STORY Elspeth Caithness advised that there was no specific staff story to report on this occasion but that the aim was to ensure that the Committee were kept informed of real issues affecting staff on a daily basis by identifying and highlighting issues where systems had worked well or where improvements could be made. Mirian Morrison advised that she had presented a patient story to Clinical Governance Committee which had identified system failures and improvements made. She undertook to compile a summary of how the staff story works in the Clinical Governance setting in an attempt to increase staff understanding of and confidence with the concept. The Committee: Agreed that Mirian Morrison compile a summary of the working of the staff story concept in the Clinical Governance setting for the next meeting of the Committee. 5 REPORTS BY OPERATIONAL UNITS 5.1. Verbal updates/ minutes of last operational meetings The Committee received the undernoted minutes/reports from the Operational Units Health and Safety Groups:(a) (b) (c) (d) Argyll & Bute CHP draft minute of 6 September 212 North and West Operational Unit Caithness Health & Safety Group draft minute of 28 August 212 Sutherland Health & Safety Group minute of 29 August 212 Raigmore minute of 19 July 212 South and Mid Operational Unit draft minute of 15 August 212 Argyll & Bute Operational Unit Fiona Campbell advised that the paperwork in relation to the inclusion of patient/public representatives on the Operational Group had now been completed and it was anticipated that this would be in operation early in 213. She advised that attempts were being made to ensure the robustness of systems. As regards fire safety training it was noted that core training was provided by Learnpro but that some staff still required a tailored approach to training. She also advised that ongoing work was being undertaken regarding preventing and managing stress and the implementation of the Management of Contractors Policy. As regards Violence and Aggression, she stressed the importance of ensuring appropriate undertaking of the risk assessments. It was noted that following a visit to the Intensive Psychiatric Unit at Argyll & Bute hospital it had been discovered that the policy was out of date and this needed to be addressed. The Committee were advised that work was being undertaken at national level regarding the managing of Health at Work PIN policies which would be issued shortly for consultation. As regards stress risk assessments it was noted that a further update would be available at the next meeting of the CHP Health & Safety Group. Linda Rawlinson advised that seven 3

112 16 out of nine of the localities now had focus groups in place. Elspeth Caithness stressed the importance of learning from Argyll & Bute and rolling this out across NHS Highland. North & West Operational Unit It was noted that the North and West Operational Unit had not met yet with the first meeting due to take place in December 212. Colin Shields expressed disappointment that the Operational Unit Health and Safety Group had not yet met. As regards future meetings it was anticipated that there would be one meeting for the Operational Unit and one for each of the two areas. For Caithness Health & Safety Group, Pauline Craw reported that the Health needs questionnaire was being reissued following integration. She further advised that the Caithness General Fire Policy had been ratified and would now be issued to staff. Risk assessments, fire training and partnership walkarounds were ongoing. In addition it was noted that whilst all hoists had been checked, some checks on some slings were outstanding. As regards driving in adverse conditions, it was noted that the 4 x 4 driver training for Out of Hours drivers was being repeated. He advised that visits had been undertaken to 14 care homes in the Operational Unit. Raigmore Hospital Elspeth Caithness advised that in addition to the minute of 19 July 212 a further meeting had taken place in October, but that the minute was still to be finalised. Rosie Brunton advised that a meeting would be set up to review the Raigmore Health & Safety workplan. She reported that a short life working group would be set up to provide feedback around DATIX. She advised that the risk assessment training programme would continue to take place monthly until April. It was noted that fire improvement works had commenced in ward 7a. In addition approval of traffic improvement work initially at Accident and Emergency had commenced at the rear of the hospital, reconfiguring an area at stores and pharmacy, rehatching and creating a dedicated pedestrian route. Andrew Ward also advised that the use of hydrogen peroxide had been successful in deep cleaning the Intensive Care Unit and that a similar exercise had since been completed in ward 4c. It was noted that a robust plan was now in place to cover such contingencies. South and Mid Highland Operational Unit Nigel Small advised that a further meeting had taken place in October for which the minutes were not yet available. He advised that there had been two main areas of discussion these being skin management programme and fire safety. As regards fire safety it was noted that 3 out of 6 of the community hospitals were expecting a formal visit from Highland and Islands Fire Service in December and that the priority was to ensure that appropriate systems were in place. As regards infection control, he advised that in advance of the HEI visits to community hospitals, the beds in Ian Charles had been reduced from 18 to 13 and that this was consistent with the decision previously taken at St Vincent s. Elspeth Caithness advised that there were now more staff representatives for the area which should lead to an increase in attendance at meetings. 4

113 17 The Committee: 5.2 Noted the updates/minutes. Reports by Health & Safety Representatives Elspeth Caithness advised that work was being undertaken to try to integrate new staff representatives and that more regular meetings will be started in Raigmore. It was noted that the main challenge for representatives was engaging regularly with managers, although the involvement of representatives and feedback from them and managers was beneficial when it did take place. Rosie Brunton advised that the potential hazard of working in confined spaces had been flagged up by staff reps as an issue which had been investigated and improvements made and implemented and that this was an excellent example of staff working together. Anne Gent advised that on her recent visit to Virginia Mason Medical Centre in Seattle it became apparent that one key aspect in the learning was the involvement of staff side reps and the ability of staff themselves to raise issues on a daily basis. She suggested that this was a good step towards staff bringing up issues as they occurred. Eric Green reported that the laundry had been another success story where there had been a significant improvement due to laundry staff bringing up an issue and other staff being made aware of the difficulties they had experienced. The Committee: Noted the updates. 6 ADVISER S REPORTS 6.1 Clinical Governance and Risk Management Mirian Morrison advised members that the report presented followed the dashboard style which had been developed specifically for Health & Safety incidents. Anne Gent welcomed the visual representation but stressed that this data had to be translated into information from which action could be taken. She highlighted the need to have the capacity to measure the improvements. Mirian Morrison advised that a dashboard had already been developed for slips trips and falls and that this was being further investigated at ward levei with a working group looking at falls. It was however noted that it was difficult to compare falls with different types of patients in different hospitals and it was agreed it would be preferable to focus on an area which was not being highlighted through other committees. After discussion it was agreed that SHARPS should be considered at the next meeting of the Committee to be held on 7 February 213 identifying both work being undertaken at strategic and local level. Colin Shields considered that this reporting was a huge step forward and wished to record his congratulations to the Clinical Governance support team. It was noted that a short life working group has been established to review NHS Highland s policy, procedures and approach to managing and investigating Significant Adverse Events. As part of this review Bob Summers advised that this may be an opportunity to streamline and integrate the manner in which RIDDOR reports are notified to the HSE. At present, in Northern Highland, Adult Social Care (ASC) managers report RIDDOR locally to the HSE directly, the Operational Units (excluding ASC) notify RIDDORs through DATIX centrally, and Health and Safety notify the HSE. 5

114 18 Argyll and Bute units follow a similar approach to ASC. Ideally managers should be reporting RIDDORs directly to the HSE, and taking ownership for their incidents. However it was noted that whilst there were clear benefits changing the reporting approach in the Operational Units, there were also potential risks that need to be considered. Bob Summers confirmed that he would work with the group and report findings to the Committee on the best way forward. 6.2 Facilities Speaking to his circulated report, Eric Green advised that estates staff were working hard to improve compliance on a number of fronts. It was noted that there had been a great deal of effort and a substantial degree of culture change and that the addition of dedicated Health and Safety support had been instrumental in bringing about this change. Anne Gent congratulated the Estates staff and stressed that staff were beginning to feel that they were capable of making a difference. It was further considered that this staff story could be considered at the next meeting of the Committee to be held on 7 February Infection Control Report In the absence of Diane Stark, the Committee received and noted the circulated report. 6.4 Occupational Health The Committee received and noted Linda Rawlinson s circulated report. In addition Elspeth Caithness advised that some concerns had been raised by staff regarding skin health but that this was being progressed. It was noted that the Occupational Health report did include Argyll and Bute staff. An annual report would be presented in due course which would reflect the overall situation regarding occupational health services across NHS Highland over the last year. 6.5 Radiation Protection In the absence of Fraser Brunton, Andrew Ward spoke to his circulated report. It was noted that the Radiation Protection Service continued to provide RPA advice and radiation protection support for a wide variety of work involving Ionising and Non-ionising Radiation, including procurement projects and service developments, as well as the ongoing work required to support the Board s compliance with the various radiation safety legislation. Loss of one of the Radiation Protection Service s Medical Physicists was currently impacting significantly on the Board s obligation to comply with radiation safety legislation, particularly the recently implemented Artificial Optical Radiation Directive 21 (AORD), which covers the safe use of devices generating laser and ultraviolet radiation. The Service had attempted to support the significant amount of ongoing additional work arising from this Directive, within its existing resources; this had proved challenging. The report of the recent compliance audit issued by the Health Protection Agency in October 212 had raised a number of actions in respect of laser safety that need to be addressed. This was being taken forward by the Lead RPA. Recruitment to the radiation protection vacancy was being progressed. It was noted that local IRMER Groups in Radiology, Oncology, Nuclear Medicine & Community Dentistry continued to take forward the review of department-specific standard operating procedures in line with the Board s over-arching framework. Whilst the report of the recent external IRMER audit of Oncology from the Health Protection Agency noted significant improvement and progress; it also highlighted concern about the lack of an appointed Clinical Lead for Oncology; and the lack of clinical protocols for every 6

115 19 radiotherapy procedure as required by IRMER Regulation 4. Other issues raised included the Clinical Lead s responsibility to manage the training records necessary for legal entitlement of Medical Staff as Duty Holders under the Regulations; and required to support appropriate cross-cover. The impact on the service caused by the significant continuing shortage of radiotherapy physics staff was also raised as a concern. It was noted that an Action Plan to address these issues has been developed by the Oncology IRMER Group, which was being taken forward by the Oncology Department and the Medical and Diagnostics Division. As in the last quarter, work was continuing on updating the Board s over-arching documentary framework for IRMER compliance in Radiology, Oncology, Nuclear Medicine and Dentistry. The programme of reviewing Employers Procedures was making progress and the Board s Radiation Safety Policy was being updated. The next meeting of the Board s Radiation Safety Committee (RSC) would be held on Friday 23 November 212. The Committee Noted the reports, the issues identified and the actions being taken. 7 TOPIC SPECIFIC ITEMS 7.1 Revised Role and Remit of Health & Safety Committee The revised Role and Remit of the Committee was circulated and members were requested to identify and submit any final changes to the Role and Remit to Anne Gent or Elspeth Caithness prior to ratification at the next meeting of the Committee. The Committee Agreed to finalise the Revised Role and Remit at the next meeting of the Committee to be held on 7 February Health & Safety Policy and Strategic Direction Speaking to his circulated report, Bob Summers advised that the existing policy which was ratified in 21 required to be amended to reflect the changes in structure following integration. He advised that this was ongoing work and partly predicted on the establishment of the new management roles and structures. In addition it was noted that the strategy required to be updated to reflect the new organisational structure and incoming integration risks associated with Adult Social Care and it was considered that an extension of the 3 year strategy to a 5 year strategy would be more realistic and achievable. The Committee: 7.3 Agreed to support the Policy and Strategic Direction as submitted. Agreed the integration of Health and Safety into Operational Delivery Plans. Revised Staff Governance Standard Anne Gent updated members on the revised Staff Governance Standard stressing that the Committee and the Board had a responsibility for providing a continuously improving and safe working environment, promoting the health and well-being of staff, patients and the wider community. 7

116 11 The Committee Noted the implications of the revised Staff Governance Standard and agreed to monitor implementation. 7.4 Lone Working Pilot Bob Summers reminded members that the lone working pilot had been agreed in February 212 for high risk groups. He advised that some lessons had been learned from the pilot and that staff generally felt safer with the device which used mobile phone technology. A paper would be presented to the May Committee meeting to propose a way forward. The Committee Agreed that the Lone Working Pilot be considered at the meeting of the Committee Meeting to be held on 13 May COSHH Draft COSHH Procedure Speaking to his circulated report, Bob Summers advised that this was a draft document the final version of which would be in two sections; a COSHH Procedure, which would outline NHS Highland s arrangements for managing and complying with the COSHH Regulations; and a Supporting Guidance Note, which would provide detailed technical guidance for those managers and COSHH Assessors with the responsibility to manage and undertake COSHH assessments. The Committee Agreed that comments on the draft be submitted to Bob Summers and that the final Procedure and Guidance Note would be considered at the next meeting of the Committee to be held on 7 February Skin Care programme Bob Summers updated the Committee on Operational Unit progress on the Skin Care Programme stressing that the challenge was one of identifying and nominating a responsible person and advised that Occupational Health had been made aware of this issue. The Committee Noted the update on the Skin Care Programme and undertook to remind Operational Units of the completion deadline of 1 January Workplace Hazards Sub-Group The minutes of the Workplace Hazards Sub-Group were noted. Bob Summers particularly stressed the fact that the SYPOL administration would be moved back to John Dewar building as a temporary measure and that appropriate central administration support for SYPOL required to be identified as a matter of urgency. The Committee Noted the update on the Workplace Hazards Sub-Group and agreed that progress should be reported to the next meeting of the Committee to be held on 7 February

117 Management of Contractors Policy and Site Rules Policy - Raigmore Pilot It was agreed that this matter had been covered in the Facilities Adviser s report. 7.7 Health and Safety Executive Update Speaking to his circulated report, Bob Summers advised that the HSE had asked NHS Highland to action three interventions as follows: Moving and Handling in Residential Care, It was noted that the workload required for this intervention was extensive but had been resourced appropriately to date. The deadline for completion of the works was noted as 1 February Infection Control in Residential Care Homes It was noted that the update and implementation of new arrangements for the management of infection control risks in Care Homes was on target with the delivery of an extensive training plan having been completed by 12 October Infection Control Training Lochaber Community Team It was noted that to comply with the Improvement Notice NHS Highland was required to deliver instruction and training on Standard Infection Control Precautions by 3 December 212 and that in addition arrangements for managing infection control risks in the community also required to be reviewed. It was further stressed that Notices received must be sent to Elspeth Caithness for circulation to Staff Representatives. The Committee Noted the Updates regarding Health and Safety Executive activity. 7.8 Mental Health and Wellbeing Speaking to her circulated report, Linda Rawlinson, Nurse Manager, Occupational Health advised on progress to date on Mental Health and Wellbeing, stressing that risk assessments should be included in local operational Health and Safety Groups, that the current policy should be reviewed and updated and that a Learnpro package would be discussed at the next meeting of the Mental Health at Work Steering Group. In addition it was stressed that Operational Units should identify Senior Managers to oversee the recommendations. The Committee Noted and Agreed the recommendations contained in the report. 7.9 The Health and Safety (Sharp Instruments in Healthcare) Regulations 213 Speaking to his circulated report Bob Summers advised that the Health and Safety Executive had issued a consultation document on new Regulations on sharp instruments with the aim of reducing the physical and psychological risks of needle stick injury. He highlighted the new requirements on employers as being the use of sharps that incorporate protection mechanisms, banning of recapping needles, placement of containers and instructions for the safe disposal of sharps close to the work area, regular review of procedures, provision of detail on the content of information and training and new requirements for measures to be taken following a sharps injury. He stressed that there may be cost implications and Anne 9

118 112 Gent advised that work was progressing on the Managing Health at Work PIN Policy and that a national policy would be produced. The Committee: Noted the content of the report and the commitment which would be required by the Committee, Operational Units and Clinical Leads. Agreed that this item be further considered at a future meeting of the Committee. 8 ANY OTHER COMPETENT BUSINESS 8.1 RIDDOR Bob Summers informed the Committee that the RIDDOR regulations were likely to change substantially with the removal of various categories and that there had been concern expressed over these changes by the various professional organisations. 9 DATES OF FUTURE MEETINGS The dates of future meetings of the Committee were noted. 1 DATE AND VENUE OF NEXT MEETING The next meeting of the Health and Safety Committee will be held on Thursday 7 February 213 at 1.3am in the Board room Assynt House. The meeting closed at 1. pm 1

119 113 Highland NHS Board 5 February 213 Item 3.9 The Highland Council Minutes of Meeting of the Adult and Children s Services Committee held in the Council Chamber, Council Headquarters, Glenurquhart Road, Inverness on Wednesday 7 November 212 at 1.5 am. Present: Highland Council: Dr D Alston Mrs I Campbell Mr A Christie (Chair) Mrs M Davidson Ms J Douglas Mr B Fernie Mr B Gormley Mr K Gowans Mr M Green(Substitute) Mr D Hendry Mr E Hunter Mrs L MacDonald (Vice Chair) Mrs D Mackay Mr G MacKenzie Mr T MacLennan Mrs B McAllister Mr D Millar(Substitute) Ms L Munro Mrs M Paterson Ms G Ross Mr G Ross Ms J Slater Ms K Stephen NHS Highland: Mr I Gibson Mrs G McCreath Dr M Somerville Religious Representatives: Rev C Mayo Ms M McCulloch Mr G Smith Non-Members also present: Mr B Clark Mr H Fraser Mr D Mackay Mr A MacLeod Mrs I McCallum Mr G Rimell Mr J Rosie Mr R Saxon Ms M Smith Mr J Stone In attendance: Mr H Fraser, Director of Education, Culture and Sport Mr B Alexander, Director of Health and Social Care Mr R MacKenzie, Head of Support Services, Education, Culture and Sport Service Mr C MacSween, Head of Education, Education, Culture and Sport Service Ms S MacLeod, Head of Health, Health and Social Care Service Ms F Palin, Head of Social Care, Health and Social Care Service Ms B Dunthorne, Finance Manager, Finance Service Mrs B Cairns, Principal Officer, Additional Support Needs, Education, Culture and Sport Service Mr P Finlayson, Quality Improvement Officer, Education, Culture and Sport Service Ms S Brogan, Resource Manager (Early Years), Health and Social Care Service

120 114 Ms A Brady, Care and Learning Alliance } Ms A Darlington, Action for Children }Third Sector Mr C Munro, Highland Children s Forum } Miss J Maclennan, Principal Administrator, Chief Executive s Office Miss M Murray, Committee Administrator, Chief Executive s Office Mrs R Daly, Committee Administrator, Chief Executive s Office Also in attendance: Dr S Zeedyk, Honorary Senior Lecturer in Developmental Psychology, University of Dundee Mr M Finnigan, Managing Director, Caledonian Economics Ltd Mr F Newall, Education Specialist, Caledonian Economics Ltd Ms K Laing, Grantown Grammar School An asterisk in the margin denotes a recommendation to the Council. All decisions with no marking in the margin are delegated to the Committee. Mr A Christie in the Chair Business Preliminaries The Chairman welcomed Ms K Laing, a pupil from Grantown Grammar School, who was shadowing Councillor J Douglas. He went on to inform the Committee that a Corporate Parenting Seminar would take place from 1.3 am to 12.3 pm on Friday 16 November 212 in the Council Chamber, Council Headquarters, Inverness. In addition, a Seminar on the Integrated Children s Plan, For Highland s Children 4 (FHC4), would be held from 2. pm to 4. pm on Wednesday 12 December in the Council Chamber, Dingwall. It was hoped that as many Members as possible would attend and it was highlighted that Third Sector representatives were also welcome. 1. Apologies for Absence Leisgeulan Apologies for absence were intimated on behalf of Mr W Mackay, Mr M Rattray and Mrs F Robertson. 2. Declarations of Interest Foillseachaidhean Com-pàirt The Committee NOTED the following declarations of interest:item 5ii - Mrs G McCreath (Financial) Item 7i - Ms J Douglas, Mr K Gowans and Mr D Millar (Non Financial) 3. Presentation on Early Years Brain Development Taisbeanadh mu LeasachadhEanchainnsnaTràth-bhliadhnaichean The Chairman welcomed Dr Suzanne Zeedyk, a leading researcher and presenter on early years development in the UK, to the meeting. Dr Zeedyk gained her BA in

121 115 Psychology at San Diego University followed by a PhD in Developmental Psychology at Yale University. In 1993 she took up an academic post as Developmental Psychologist at the University of Dundee, currently holding the post of Honorary Fellow. Her research programme focused on the interaction of parents and infants with the aim of revealing how sophisticated infant communication skills were from the earliest moments of life. She was influential with the Scottish Government and many other government and non-governmental organisations and was working closely with a number of local authorities. Dr Zeedyk then undertook a presentation during which detailed information was provided on early years brain development, including the neuroscience and psychology involved, and the economic benefits of early intervention. It was explained that humans were born social and babies brains didn t grow automatically but were shaped by how people treated them. Babies, and adults, suffered when they did not feel connected and this, in turn, led to society suffering. A CT scan of the brain of a normal three year old in comparison with a child of the same age who had suffered extreme neglect demonstrated the significant impact this had on brain development. Further slides showed how synaptic connections formed between the neurons in the brain at a rapid rate from birth to three years of age, after which the process slowed down. If these connections were based on negative experiences, difficulties were more likely later in life. The effects were not only emotional but physical, with children who experienced stress early in life being more prone to health issues as an adult. The issues surrounding Attachment Theory were explained and it was highlighted that Aberdeen City Council was allocating Change Fund monies to rolling out attachment training to 4 early years staff. A video of a three month old and his mother demonstrated the importance of quality interaction between a child and their carer and what happened when stimulation was withdrawn. In addition, examples were provided of studies which indicated that babies could hear what was going on in the world around them while they were still in the womb, to the point of being able to recognise vowel sounds. Furthermore, newborn babies could imitate facial expressions which meant that, contrary to popular belief, they could see. In relation to economics, graphs were presented which demonstrated that there was a higher return in terms of positive outcomes the earlier investment was made in a child's life. However, this was where the least money was currently being spent, with significantly more being invested in school age children and the majority post-school. Many people were of the view that the benefits of early intervention would not be evident until the children concerned had become teenagers but this was not the case and examples were provided of innovative schemes where investment in early intervention had resulted, very quickly, in outcomes such as enhanced language development, improved school readiness, increased birth weights and fewer injuries and hospital admissions. Savings could be achieved in as little as six months by thinking creatively and measuring the right outcomes. In summary, not only new money but new thinking was required. Growing brains needed human companions and, in delivering services, it was essential to understand babies emotional needs and how to serve them. Happiness was cheaper than unhappiness. A question and answer session then took place during which it was explained:-

122 116 in relation to "toxic stress", cortisol was a hormone designed to help in acute situations. However, if babies spent a lot of time with cortisol in their systems, it impacted on their behaviour and immune systems and led to stress-related diseases later in life. In places of poverty, there were "communities of cortisol" where children were growing up with toxic stress because their parents were struggling to cope. The country was not only in a financial recession but an emotional one and it was important to consider ways to reduce the stress in these communities; unless corporate parenting responsibilities helped give children companions the Council was not giving them what they needed; current practices often inadvertently led to problems. For example, the Bookbug programme, funded by the Scottish Government, encouraged parents to read to children to help their literacy and school readiness and this was often done by way of a bedtime story. However, this did not happen for foster children because foster carers were advised to engage in "safe touch" which often meant they were never alone with a child in their bedroom. A bedtime story told on the sofa or from a chair on the other side of the room did not produce the same feelings of safety or boost oxytocin levels and it was necessary to think creatively to address this sort of issue; nursery workers were currently often paid a minimum wage, with the least experienced people being put in charge of the baby room which implied that babies were not considered very important. There was also a gender issue as most nursery workers were women; studies could indicate, at three years of age, who was more likely to be a victim of abuse or an abuser, become pregnant as a teen or go to prison; simple measures could make a significant difference. For example, changing pickup routines at nurseries to focus on reuniting the child with their parent(s). Some nurseries had implemented "cuddle circles" whereby the children hugged each other three times a day. This increased oxytocin levels and, within two weeks, children cried and hit each other less; with regard to measuring success and savings, innovative thinking was required. For example, providing baby carriers to teenage mothers for a small cost, which would boost oxytocin levels, and linking that to the number of babies being admitted to A&E. One nursery invested in inward facing buggies, monitored children's behaviour over a two week period and compared it with data gathered when the buggies were facing outward. It was found that children were throwing dummies and losing hats less, not kicking and screaming as much and spending longer reading. The nursery was then able to demonstrate savings over a period of time by costing dummies, hats etc; Attachment issues were not confined to Looked After Children. Approximately 5% of people in the UK had secure attachments while the other 5% had more difficulty managing relationships, whether with parents, partners, children or colleagues. It was not always apparent as many people found a way to manage life. For others it would lead to difficulties such as repeatedly returning to prison because it was the first place they had felt safe and secure; and any targeted programmes put in place needed to address universal needs. The way children were cared for in the UK put them under additional stress. Nurseries separated them from what was familiar and it was therefore essential to change the way people thought about nursery care and to emphasise that it was not only about education. During further discussion, the following comments were made:-

123 117 the rewarding and thought provoking presentation was welcomed and it was important to encourage people to view the webcast and pass on the early years message; the issues raised went beyond the Adult and Children's Services Committee and it was necessary to shift resources, work in partnership with other agencies and fundamentally change practices and procedures to achieve better outcomes for young people in Highland; it was essential to have compassion and that Looked After Children felt that councillors, as corporate parents, were doing all they could for them; it was necessary to turn aspects of society on their head. For example, currently, many people instinctively allocated a higher status to lecturers in further and higher education than secondary or primary school teachers, with the lowest often being reserved for nursery workers; training nursery workers to detect conditions such as dyslexia at the earliest possible stage would reduce behavioural problems later in life; it was important to be clear about what it was hoped to achieve and the analogies in terms of measuring outcomes were welcomed; the information in the presentation should be incorporated in social education classes in secondary schools; parenting was the most difficult, yet rewarding, job in a person's life; and it was important not only to strive to leave a better nation for our children but better children to our nation. Thereafter, having expressed thanks to Dr Zeedyk, the Committee:i. NOTED the presentation; and ii. AGREED that consideration be given to how the issues raised during discussion could be taken forward. 4. Brain Development, Emotional Literacy and the Health and Wellbeing Strategy LeasachadhEanchainn, LitearrasFaireachdailagus RoinnleachdSlàinteagusMathais There had been circulated Report No ACS/4/12 dated 26 October 212 by the Director of Education, Culture and Sport which outlined some of the interventions and support structures used within Highland currently, that drew on the most up-to-date evidence based research and theoretical perspectives relating to child development and learning. These supports and interventions were appropriate to employ across all age ranges but it was critical that there was a specific focus on support to children in the early years with a focus on building positive relationships, supporting positive neural networks and enhancing positive attachments and emotional connections between children and their parents or carers. During discussion, the following comments were made: in terms of moving towards full integration, the importance of practitioners from different backgrounds swapping ideas and synergising was emphasised; the commitment and care exhibited by early years workers was commended; in relation to the Health and Wellbeing Strategy, the work which had been undertaken in partnership with NHS Highland s public health team was emphasised. It was essential that information on drugs and alcohol, for example,

124 118 was integrated fully into the curriculum so that children were able to assimilate the messages; District Partnerships had a key role in terms of disseminating the information in the report and previous presentation and it was important to consider other ways to spread the message, not only to practitioners but throughout society; and FHC4 presented an opportunity to reflect on current practices and where funding was being spent. In response to questions, it was explained that: in relation to staff training on emotional coaching, there were not the same opportunities to work with staff when children were placed out of authority. However, questions were asked at reviews and on visits to try to ensure that the development of emotional literacy was being addressed. In addition, there were sometimes opportunities to work with social workers and parents when children returned home on holiday; the implementation of Getting It Right For Every Child had led to an increased focus on ensuring it was understood that everybody had a responsibility to raise concerns about a child or family and that such concerns were followed up with appropriate services where necessary. Whilst there might be gaps in terms of individual cases, significant improvements had been made in identifying situations where services were required; the Roots of Empathy programme, piloted in 211/12, had been very well evaluated and was continuing in the current school year. The programme was run by Action for Children but Council support workers could be trained, thereby allowing it to be rolled out to a greater number of schools. It gave children, particularly those from difficult backgrounds, a sense of involvement and understanding. In addition, Head Teachers had reported that levels of bullying and fighting had reduced, not only in the class which was the subject of the programme but throughout the school, and it was hoped to carry out further research on this effect; with regard to measuring outcomes, some programmes had built in evaluative processes and some were used because they already had a strong evidence base in terms of positive outcomes. In addition, steps were taken to track the more anecdotal outcomes and there were a number of key improvement groups within the Council. For example, the Additional Support Needs Improvement Group examined the Positive Relationship Strategy and the outcomes relating to awareness raising in respect of emotional literacy. It was vital to ask children and young people for their experiences and whether, for example, they felt loved and nurtured. Furthermore, it was important to better train staff to carry out observation of those children who could not communicate or had not yet developed verbal communication so their input could also be taken into account; there were clear links between conditions such as ADHD (Attention Deficit Hyperactivity Disorder), dyslexia and dyspraxia and children who did not have the best start in life were more prone to these types of disorders. There were also secondary issues in terms of behaviour, relationships and self-esteem as a result of not being able to succeed in school. It was therefore essential that training on identifying such disorders was embedded into the more generic training for early years staff; and lectures on the developing brain were not mandatory and were run in the evenings so staff were giving up their own time. However, they had been extremely well attended. In addition, the Council's Educational Psychologists had delivered

125 119 presentations on the developing brain and the effects of trauma for a number of years. Thereafter, the Committee NOTED the contents of the report and the work that was already ongoing within Highland to support effective interventions within the Health and Wellbeing strand of Curriculum for Excellence. 5. Revenue Budget 212/13 Monitoring BuidseatTeachd-a-steach 212/13 Sgrùdadh i. Education, Culture and Sport Foghlam, CultaragusSpòrs There had been circulated Report No ACS/41/12 dated 3 October 212 by the Director of Education, Culture and Sport setting out the revenue budget monitoring position for the six months to 3 September 212. The current estimated year-end position was a projected underspend of.114m which was attributable to four main sectors, namely PPP; Management Team; Schools General; and Catering, Cleaning and Facilities Management. Further details were provided in the report together with information on other issues which might impact upon the final outturn. The Committee NOTED the current budget pressures and the ongoing management actions being taken to achieve a balanced budget by the end of the financial year. ii. Health and Social Care SlàinteagusCùramSòisealta Declaration of Interest: Mrs G McCreath declared a financial interest in this item as a foster carer and advised that if there was any specific discussion in relation to fostering she would leave the room. There had been circulated Report No ACS/42/12 dated 26 October 212 by the Director of Health and Social Care setting out the revenue monitoring statement for the Health and Social Care Service budget for the six months to 3 September 212. The current projected year-end outturn was an overspend of 1.937m, an increase of approximately.45m on the figure reported to the September Committee. As previously discussed, this was attributable to the significant pressures in relation to purchased placements for Looked After Children, both in residential schools and independent fostering agencies. The pressure had increased as a result of a number of placements in July and August and, although it was envisaged that some children would move on by the end of the financial year, that would not be reflected in the monitoring report until it took place. Work continued to identify compensatory savings with a view to achieving a balanced budget at the end of the financial year. As requested at the previous meeting of the Committee, further information on the management of vacancies

126 12 and any associated risks was provided in the report. In addition, approval was sought for the secondment of an officer to undertake dedicated work on identifying additional capacity for enhanced Looked After Children services in Highland. During discussion, the following comments were made: concern was expressed regarding the underspends on Early Years/Family Resources and Specialist Support for Learning, particularly given the earlier presentation and report on early years brain development; in relation to the shortage of Educational Psychologists and the proposed "grow your own" approach, it was suggested that links be made with the careers service and Skills Development Scotland, for example, with a view to promoting educational psychology to pupils as a potential career; it was essential to give Looked After Children the best possible substitute for a loving home and it was suggested that a budget bid be made in relation to providing specialist foster carers to keep Looked After Children out of residential units, both in and outwith Highland; and the importance of putting the needs of the child first was emphasised and it was highlighted that some children had exceptional needs that could not be met in Highland. In response to questions, it was explained that: high turnover of staff in children's services was a national issue. There tended to be a younger workforce and people often moved on to other things. In addition, child protection work was extremely demanding and something that people might not want to do for their entire career. However, children's services in Highland had a good reputation and it was usually possible to fill vacant posts; and with regard to the overspend on placements for Looked After Children and the compensatory underspends, officers only had authority to spend the budget allocated to them. Every effort was made to balance the budget whilst ensuring that individual children and families were not put at risk and it was the first item on every Management Team agenda. Thereafter, the Committee:i. NOTED the projected overspend of 1.937m; and ii. APPROVED the actions being taken, including the secondment of an officer to identify available capacity for enhanced looked after children services. 6. Capital Expenditure 212/13 Monitoring CaiteachasCalpa 212/13 - Sgrùdadh i. Education, Culture and Sport Foghlam, CultaragusSpòrs There had been circulated Report No ACS/43/12 dated 26 October 212 by the Director of Education, Culture and Sport which set out the net Capital expenditure position for the six months to 3 September 212, the related year-

127 121 end projections and progress on the major projects that would be completed within the next three financial years. The report also provided an update on several prioritised feasibility studies and the Sustainable School Estate Review and sought approval with regard to a proposed review of the determination of school capacity figures and issues related to the site selection process for the proposed Portree Gaelic Primary School. The current year-end projection was an underspend of 4.957m, an increase on the figure reported to the September Committee, which was mainly attributable to four projects, namely Thurso Swimming Pool; Raigmore Primary School; Smithton Primary School and Kingussie High School. Further details were provided in the report and it was confirmed that the position would be closely monitored during the remainder of the financial year and every effort made to improve the situation, particularly where construction work spanned this and the following financial year. In relation to Portree Gaelic Primary School, the work outlined in the report would be progressed in November/December 212 to allow fully costed proposals to be considered by the Committee in January 213. Any other accommodation implications arising from the proposals would also be addressed at that stage. During discussion, the following comments were made: the work undertaken in relation to Balnain and Beauly Primary Schools was welcomed. However, concern was expressed that local Members had not received feedback; the proposals in respect of Portee Gaelic Primary School were welcomed and an assurance was sought that there would be no further delays. The importance of identifying a site and maximising financial support from the Scottish Government was emphasised. In addition, the existing school residence buildings in Portree were not fit for purpose and it was essential this was addressed as soon as possible; and reference was made to the employability and training exercise being carried out by Michel Roux and it was suggested that refurbishing the kitchens at Charleston Academy would make a substantial difference to the school and the potential for employment in the local community. In response to questions, it was explained that: appropriate mechanisms would be put in place to ensure that Ward Members received feedback on local projects in future; in relation to concerns regarding the inefficient heating system at Plockton High School, discussions would take place between the Chair, local Members and officers with a view to understanding and addressing the issues; the costed proposals in relation to the Portree Gaelic Primary School site would be available for discussion at a stakeholders meeting in Portree in December prior to being submitted to the Committee in January 213; with regard to concerns about the single glazing and inefficient heating system at Nairn Academy, this would be picked up as part of the information gathering exercise being carried out in Inverness and Nairn Associated School Groups and which would be the subject of a future report to

128 122 Committee. However, the Chairman confirmed that he would meet with local Members to discuss specific issues; and the underspend in the current financial year would be rolled forward to the following year. With regard to future years, over-programming would take place to ensure there were schemes available which could be accelerated in the event of delays in other projects. Thereafter, the Committee:i. NOTED the current position with regard to expenditure to date and the projected expenditure for the current financial year as detailed in Appendix 1 of the report; ii. NOTED the status of the major capital projects as detailed in Appendix 2 of the report; iii. NOTED the status of the prioritised feasibility studies; iv. AGREED that the current methodology to determine school capacity figures be reviewed and proposals for both primary and secondary school sectors be brought to a future Committee for consideration; v. NOTED the current position with regard to the Sustainable School Estate Review and that an update report on the Wick schools project would be brought to the Finance, Housing and Resources Committee on 28 November 212; vi. AGREED that the campus configuration options for Portree Gaelic Primary School and the School Residence as outlined in paragraph 6.11 of the report be fully examined and costed and that a recommendation be considered at the next Adult and Children s Services Committee; vii. AGREED that the potential to develop a 3 to 18 model that would examine the future linkages between the existing Portree Primary School, the proposed Portree Gaelic Primary School and Portree High School be examined and recommendations be presented to the next Adult and Children s Services Committee; viii. AGREED that options for the strategic development of the existing Portree Primary School building be progressed and recommendations concerning the building and how it could be modified to support the innovative and effective implementation of Curriculum for Excellence be presented to the next Adult and Children s Services Committee; ix. AGREED that appropriate mechanisms be put in place to ensure that Ward Members received feedback on local projects; and x. AGREED that discussions take place between the Chair, Local Members and Officers on the issues surrounding the heating system at Plockton High School. ii. Health and Social Care SlàinteagusCùramSòisealta There had been circulated Report No ACS/44/12 dated 3 October 212 by the Director of Health and Social Care which provided an update on progress to date with the Health and Social Care Capital Programme and included a monitoring report on expenditure as at 3 September 212 which projected a year-end overspend of.81m.

129 123 The report also provided an update on a number of projects and fire safety and other health and safety capital works. The CommitteeAPPROVED the report and the budgetary position. 7. Service Plan Plana Seirbheis Fios as ùr i. Education, Culture and Sport Foghlam, CultaragusSpòrs Declarations of Interest: Ms J Douglas, Mr K Gowans and Mr D Millar declared non financial interests in this item as Directors of High Life Highland and advised that if there was any specific discussion in relation to the funding of High Life Highland they would leave the room. There had been circulated Report No ACS/45/12 dated 3 October 212 by the Director of Education, Culture and Sport which explained that the draft Service Plan for the Education, Culture and Sport Service outlined the enabling actions and key performance results which would deliver the Programme of the Highland Council Working together for the Highlands and core functions of the Service including the Single Outcome Agreement. The draft Service Plan had been circulated separately as Booklet A. The Chairman emphasised that both the Education, Culture and Sport and Health and Social Care Service Plans were interim Plans which would be updated to take account of the finalisation of FHC4 and re-presented to Committee. During discussion, the following comments were made: in relation to Enabling Action 2.3.1, it was emphasised that it was not simply a matter of maximising the number of children with additional support needs who were able to sustain full-time school attendance but of ensuring that those children had a full timetable suited to their needs; with regard to Enabling Action 2.6.1, it was important to make reference to the opportunities generated by the Olympics and the 214 Commonwealth Games and create links with the Physical Activity Plan; in relation to the commitment to roll out a single smart card to all young people, it was essential to ensure that the machines were maintained and there was a quick response when repairs were required; not all higher subjects were available in some schools and the commitment to use new technology to promote a wide choice of subjects for pupils was welcomed; and there should be a greater emphasis on partnership working throughout the Plan. In response to questions, it was explained that:-

130 124 regular updates would be presented to Committee to allow Members to monitor delivery of the Service Plan and the Council's Programme; there was no review date in respect of High Life Highland's programme of activity for young people as it was ongoing; the Youth Unemployment Strategy would be produced in partnership with other agencies; with regard to concerns that there was no reference to the Council's Dyslexia Policy, the preventative spend proposals to be considered later on the agenda sought support for earlier assessment of developmental delay and educational needs. It was hoped that the Council would approve the proposals at its meeting on 13 December 212 and they would then form a central part of FHC4 and the Service Plan. There were, however, already measures in place to support pupils with dyslexia and it was suggested that a Briefing Note be provided to Councillor T MacLennan in that regard; in relation to the commitment to ensure that all new school buildings would act as a community hub, regular discussions took place with partners in further and higher education and the possibility of using the domestic science facilities at Plockton High School could be discussed with Wester Ross College; with regard to Service ID 2.18 and concerns that the review dates were outwith the scope of the current Gaelic Language Plan, the dates related to the life of the Council's Programme. There would be review dates in the interim to ensure that targets were being met and reports would be presented to the Gaelic Implementation Group. More accurate review dates would be provided in the final version of the Service Plan; and Opposition Members would have the opportunity to contribute to the formulation of policies and strategies referred to in the Plan. Thereafter, the Committee:i. APPROVED the Education, Culture and Sport Service Plan subject to the points raised during discussion; ii. AGREED that regular updates be presented to Committee to allow Members to monitor delivery of the Service Plan and the Council s Programme; and iii. AGREED that a Briefing Note be provided to Councillor T MacLennan on the procedures in place in Highland schools in relation to pupils with dyslexia. ii. Health and Social Care SlàinteagusCùramSòisealta There had been circulated Report No ACS/46/12 dated 3 October 212 by the Director of Health and Social Care which explained that the draft Service Plan for the Health and Social Care Service outlined the enabling actions and key performance results which would deliver the Programme of the Highland Council Working together for the Highlands and core functions of the Service including the Single Outcome Agreement. The draft Service Plan had been circulated separately as Booklet B. The CommitteeAPPROVED the Health and Social Care Service Plan

131 Performance Report Children s Services AithisgDèanadais SeirbheiseanChloinne There had been circulated Report No ACS/47/12 dated 3 October 212 by the Director of Health and Social Care which introduced the quarterly performance report for Children s Services and provided a commentary on the measures where performance was not on target or better. During discussion, the following comments were made: in relation to Indicator 16, the importance of addressing the lack of continuity of health services for children in out of authority placements was emphasised; it was essential not to examine indicators in isolation and to make links, for example, between the number of children being looked after at home and educational outcomes; disappointment was expressed regarding the number of Looked After Children supported through the Family Firm scheme and the proposed dedicated report on this issue was welcomed; and with regard to the escalating costs in relation to Looked After Children, it was essential to target the root causes such as drug and alcohol misuse. In response to questions, it was explained that: Indicator 3 was a national HEAT target and the Council was performing well in that there were now no young people waiting longer than 26 weeks to see a Primary Mental Health Worker. However, there continued to be significant challenges across the range of mental health services, including Consultant Psychiatrists. There were ambitious plans in place to achieve the 26 week target across all mental health services and the HEAT target would reduce in 214. The relative Improvement Group, led by the Child Health Commissioner, was supported by the Council's Principal Officer, Additional Support Needs, as it was necessary to take a holistic approach across all tiers of service provision; moving Looked After Children into permanent settings was one of the key drivers and a report would be presented to a future meeting of the Committee on the issues surrounding children who were looked after at home and away from home, and about how permanency was supported; with regard to the Child Healthy Weight Programme, feedback from the initial rollout had been very positive, particularly in relation to the way in which it was becoming embedded in the curriculum. This would enable it to be delivered in a sustainable way and there was every confidence that targets would continue to be met, despite the steep trajectory; some of the issues around health and education outcomes could be addressed at the Corporate Parenting Seminar on 16 November 212; the review of the Child's Plan to ensure it was fit for purpose was now in the final stages. The new format would be trialled in all schools and with a small number of social workers and health visitors. It had been anticipated that it would be rolled out at the end of 212 but this would now take place in early 213, with a review of the impact of the new format also being undertaken in 213; and whilst recognising the importance of consulting service users, if respite provision was to be maximised, residential respite was the least cost effective option - fewer families could use it because it was more expensive. In addition, most families would choose respite on a personal basis. In relation to the group of younger

132 126 adults who were largely in the Inverness area, a series of meetings had taken place with NHS Highland regarding how respite facilities could be shaped to meet their needs. Thereafter, the Committee AGREED:i. the actions being taken to assess and improve performance; and ii. that a report be presented to a future meeting on the issues surrounding children who were looked after at home and away from home, and about how permanency was supported. 9. Preventative Spend: Early Years and Deprivation CosgCasgach: Tràth-bhliadhnaicheanagusBochdainn There had been circulated Report No ACS/48/12 dated 3 October 212 by the Director of Health and Social Care which provided an update on work to develop proposals for preventative spending on early years services and to address deprivation, prior to the final report being submitted to the Council on 13 December. During a summary of the report, it was confirmed that there had been on-going meetings with the Director of Public Health, led by the Chief Executive,in relation to preventative spend for deprivation. This had resulted in a Project Board having been established to ensure a full strategic approach to tackling deprivation. In addition to examining the proposals previously reported to the Committee, a further three measures had also been considered: dedicated support to address poverty and improve social inclusion, social prescribing (using leisure and exercise in a targeted way) and employment of looked after children. Regarding early years, further examination had taken place of the proposals presented to the last meeting of the Adult and Children s Committee. In particular, greater clarity could be afforded to the delivery model by referring to it as the Family Team rather than the Virtual Family Centre. The Family Team approach would coordinate all early years services around a geographical area which would have the benefit of local knowledge and familiarity with the client base and facilitate monitoring support and interventions from pre-birth to Primary 1. Some of this work would be directly managed by a Leader in the team and other aspects would form part of associated services e.g. nurseries and partner services. This formed the proposed delivery mechanism for parenting and other additional enhanced early years services including earlier assessment of developmental delay and additional need. The Committee was invited to comment on and approve the delivery model, following which officers would develop proposals based on this framework. During discussion, Members welcomed the progress and raised a range of issues, including: early years and families services had evolved over many years from the practices of a range of individual professions and it was accepted that there might be some resistance to the change in delivery model this would be a testing time for staff and they would need to be supported appropriately; in relation to on-going discussions with NHS Highland colleagues, it was suggested that this should be as far reaching as possible and be widened to involve GPs who played a critical role both in terms of the renewed GP contract and

133 127 specifically for any potential pilots for local enhanced service opportunities through the local GP contractual arrangements; with regard to the proposal to develop social prescribing using leisure and exercise in a co-ordinated and targeted way it had to be acknowledged that this would require specific packages of higher level support; earlier discussions had sought flexibility in the working practices of the Community Development Officer posts to address pockets of deprivationand it was hoped that that could be taken on board; the Family Team approach was particularly welcomed and it was hoped (a) that there could be co-location of staff in some areas, (b) that Family Team staff would engage with Parent Councils and community groups and (c) that appropriate flexibility be demonstrated by teams responsible for areas that included both rural and urban settings; in terms of deprivation, the measures proposed would create equality and it was hoped that the dedicated Community Development Officers could collate all relevant information presently available from the full range of individuals involved in this field to provide the most comprehensive service possible; it was recognised that there were areas of deprivation throughout the Highlands, in both rural and urban areas, and it was important to ensure that there were adequate measures in place to both identify and address deprivation in all geographical areas; it was clear that this new approach would represent a change in the way organisations behaved and it would be important to question whether spending levels were adequate in these crucial areas on a continual basis; and it would be helpful to indicate in the report that there would be significant risks associated with not engaging in preventative spend for both early years and deprivation. Responding to questions, it was confirmed that there would be a requirement for arrangements and support structures surrounding social prescribing. Regarding Community Development Officer posts, it had not been the intention that they would work to an exclusive geographic location but would work to wherever the needs and demands existed. The decision to spend preventatively was a first step in a far reaching and targeted approach and the Highland Council was at the forefront in targeting results in this way. It was hoped that preventative spending would become the norm for the Council s future activities. Following consideration of the proposals, recommendations to the full Council. the Committee APPROVED the The Committee adjourned for lunch at 1.2 p.m. and resumed at 1.5 p.m. 1. Support for Young People in Transition Taic do DhaoineÒga a thaageadar-ghluasad There had been circulated Report No ACS/49/12 dated 3 October 212 by the Director of Health and Social Care which provided an overview of recent approaches to better manage the transitions of young people into services for adults and which made proposals for a new strategic approach, including the appointment of a lead Elected Member.

134 128 It was confirmed that the report represented a starting point in terms of the work that was necessary to support young people in transition. By way of contextual background to the report, the Director of Health and Social Care quoted from a publication written by Elsie Normington entitled The Silent Doorbell referring to her own experiences raising her disabled sonin Inverness, lobbying for better services for disabled children and adults and striving for people from all social backgrounds to break through barriers and pursue their potential in life. Overall, the Council and NHS Highland were committed to improving services for transitions into adult services for young people who had care, health and support needs. Accordingly, the Chief Executives of both the Highland Council and NHS Highland would play a lead role in bringing these agencies together to identify both strength and challenges in the organisation of effective transitions management across Highland. This would lead to a Programme Management approach, led by both Chief Executives, which would involve the participation of all other agencies. Further, it was proposed that the Committee appoint a Lead Member for Transitions to engage with officers of the Council and NHS Highland on these matters and to liaise with young people and families to ensure that their issues were raised by the Council with the various local partners. During discussion, Members welcomed the report and raised a range of issues, including: it was recognised that the area of transitions was a risk area and that there was much work to be undertaken. The proposals were welcomed as a first step in a vast area of work that would never be straightforward; it would be important to consider how both the Council and NHS Highland would ensure that the high level involvement of both Chief Executives would filter down throughout each organisation; while recognising that there was a range of key agencies central to the success of transition for young people, it was essential not to overlook the central role of the young person in question and their family and that they be asked for feedback on arrangements put in place for their own transition; as this was a Highland-wide strategic approach it was not yet clear how this might be pursued at a district or local level and how Members could be involved in supporting this; regarding the Council s Employability Service, it would be important to address whether this extended to children coming out of services and it was hoped that it would incorporate some of the aspirations that would emerge from this exercise; it was hoped that this might increase connections between existing services and, in particular, facilitate directing funding to employers who might take on young people with profound disabilities; it had to be acknowledged that focussing outcomes on the aspirations of young people concerned could lead to agreed outcomes being redefined- for some individuals full-time work might not be the most appropriate outcome; existing transition policy had been drafted in consultation with young people themselves and was based on the document It s my Journey. Highland Children s Forum had submitted, to the Planning for Integration process, an interim review of young people s experience of transition. This review indicated that good transition experiences often depended on the member of staff

135 129 involved poor transition experiences had negative economic, health and emotional welfare impacts on both the young people concerned and their carers and the proposals were particularly welcomed by the third sector. Highland Children s Forum Management Committee wholeheartedly commended the report; and the approach proposed for better management would provide a unique opportunity to create an holistic joined-up response to a difficult area it was accepted that the report was not an answer in itself but represented a first step. Responding to these comments, it was confirmed that a clear mechanism to roll out the new arrangements throughout the organisations would be key to their success and the Chairman gave his assurance that this would be considered carefully. Surveying young people concerned would provide assistance and feedback on the success of transition arrangements. The report represented a first step and it was important to engage with as many individuals and organisations as necessary to enable the Council and NHS Highland to achieve the desired outcomes. The four specific areas of activity - employment, training, accommodation and personal support would widen activity to a more strategic approach than had traditionally been undertaken. It was recognised that transitions should be considered at District Partnership meetings and should be referred to at Ward Business meetings, this latter measure facilitating the involvement of all Members and building into the culture of the whole organisation. Co-ordinated effort across both organisations was necessary and the support and involvement of both Chief Executives would enable the process to embed throughout both the Council and NHS Highland. In terms of a Lead Member for Transition, Mr A Christie, seconded by Mrs L MacDonald, nominated Mr G MacKenzie. Mr T Maclennan, seconded by Mrs M Davidson, nominated Ms J Douglas. In a vote between the two candidates, Mr MacKenzie received 16 votes and Ms Douglas received 8 votes, with no abstentions, the votes having been cast as follows:votes for Mr MacKenzie Alston, D; Christie, A; Gormley, B; Gowans, K; Hendry, D; MacDonald, L; MacKay, D (W5); MacKenzie, G; McAllister, E; Millar, D; McCulloch M; Munro, L; Mayo, C; Ross, G (W3); Slater, J; Stephen, K. Votes for Ms Douglas Campbell, I; Davidson, M; Douglas, J; Fernie, B; Green, M; Hunter, E; MacLennan, T; Ross, G (W14). Thereafter, the Committee AGREED to:-

136 13 i. endorse the leadership of the Chief Executive of the Council in the strategic leadership of transitions management; and ii. appointmr G MacKenzie as Lead Member for Transitions from the Adult and Children s Services Committee. 11. Scotland s Schools for the Future Phase 3 Inverness Royal Academy SgoilteanairsonÀmRiTeachdna h-alba, Ceum 3 AcadamaidhRìoghailInbhir Nis There had been circulated Report No ACS/5/12 dated 15 October 212 by the Director of Education, Culture and Sport which confirmed that the Scottish Government was committed to supporting the delivery of a replacement for the existing Inverness Royal Academy school building and outlined a proposed timeline for the delivery of the project. The Committee AGREED that:i.the replacement Inverness Royal Academy Design, Build, Finance and Maintain contract be progressed and the appropriate approvals be sought at the key milestones in accordance with Scottish Futures Trust requirements; ii. the Council s in-house Wick High School and East Caithness community facilities project team be retained where possible and employed on the Inverness Royal Academy project; and iii. the initial Capital project costs be funded from the Capital budget already approved for the refurbishment of Inverness Royal Academy until such time that there was an approved budget for the school replacement. 12. Sustainable School Estate Review Tain Royal Academy Associated School Group Option Appraisal Report Ath-sgrùdadh air SeilbhSgoileSheasmhach AithisgMheasaidh air RoghainnBhuidhneanSgoilteanBuntainneachAcadamaidhRìoghailBhaileDhubht haich There had been circulated Report No ACS/51/12 dated 22 October 212 by the Director of Education, Culture and Sport which set out the recommendations contained within the option appraisal exercise carried out into future pre-school and primary school provision in the Tain Royal Academy Associated School Grouping. On the basis of the recommendations contained within the option appraisal report, Members were asked to agree that the following statutory consultation be progressed at a future date to be agreed by the Committee in accordance with the requirements of the Schools (Consultation) (Scotland) Act 21: That a 3 to 18 school should be constructed in Tain to replace the existing Tain Royal Academy, Craighill Primary School and Knockbreck Primary School The 3 to 18 campus would also include the appropriate community and Additional Support Needs facilities to serve the immediate area. A presentation was undertaken at the meeting by Caledonian Economics Limited setting out the methodology adopted in the Options Appraisal. Particular aspects that had been taken into account were detailed, namely the national context, processes, options, educational benefits, cost analysis and conclusions. The aim was to provide

137 131 a quantitative and qualitative view and, having considered all factors, the findings showed that a combined school had a higher value for money rating. During discussion, Members welcomed the options appraisal and, in particular, commended Caledonian Economics Limited for having involved both Elected Members and the community throughout the process. It was particularly welcome that the options appraisal had also included St Duthus Special School and that this process provided a solution to the long-term problems associated with the condition of St Duthus school building. In this regard, it was suggested that St Duthus could be formally included in the project. Responding to questions, it was clarified that new-builds would incorporate community rooms and that the new school in Tain would present the opportunity for community facilities to be incorporated such as a community library and swimming pool. It was also confirmed that the pupils themselves would be involved in stakeholder groups regarding design, as had taken place with similar projects in Wick and Inverness. Thereafter, the Committee AGREED:i.the recommendations contained within the outcome of the option appraisal exercise relating to future educational provision in Tain; ii. that an option appraisal exercise be carried out within 12 months to identify the appropriate site for the proposed 3 to 18 campus; iii. that, thereafter, at a date to be determined by the Committee, a statutory consultation be carried out on the proposal to create a 3 to 18 campus in Tain comprising the existing Tain Royal Academy, Craighill Primary School and Knockbreck Primary School; and iv. that the proposed new 3 to 18 campus include appropriate Additional Support Needs accommodation, including St Duthus Special School. 13. School Meal Uptake Na Tha a' GabhailBiadhSgoile There had been circulated Report No ACS/52/12 dated 3 October 212 by the Director of Education, Culture and Sport which set out an analysis of current school meal uptake and also an analysis of free school meal uptake as a percentage of entitlement. The report recommended that the way ahead was to form a stakeholders group, including Elected Members input, pupils and practitioners, to examine how school meal uptake could be improved. During discussion, Members raised a range of issues, including: young people themselves had commented on the size of dining halls as being a consideration around taking school meals and it was hoped that this could be taken into consideration when designing new builds; it was hoped that Head Teachers would be included on the stakeholders group; it would be helpful to expand on marketing and promotional activity on radio stations for areas outwith the Moray Firth Radio area; there was significant work to be undertaken in educating parents as to the importance of school meals in the physical and educational development of their child and it was suggested that perhaps the study group could consider

138 132 whether school meals should be made compulsory and seek to strengthen the school meals network; it was hoped that the stakeholder group would be furnished with previous reports on this subject, together with Committee minutes outlining the detailed debates that had previously taken place; it would be helpful and beneficial to engage with those pupils who elected not to take school meals these were no doubt hard to access groups but it was nonetheless necessary to reach out to these and other young people to hear their feedback rather than relying solely on the two young representatives on the group. Furthermore, it was unclear whether the High5 initiative had been ruled out; concerns were expressed that there was a significant proportion of secondary school children entitled to free school meals who did not take them. Nutrition was critical to their development and it was hoped that this could be addressed; it might be helpful to quantify the cost of providing free school meals to all Highland children as this would provide useful information on which further decisions could be made. The service was presently subsidised and it could at least be an option for consideration; and there were many other radical options that could be considered by the stakeholder group, such as opening up school meals to the community. Responding to these comments it was confirmed that Head Teachers would be involved in the stakeholders group which would consider a wide range of options connected to the uptake of school meals. The Committee AGREEDthat:i.a stakeholders group be formed, as detailed in paragraph 4.4 of the report, to examine how school meal uptake could be improved in consultation with the Chair and Vice Chair of the Adult and Children s Services Committee and Mr Bill Fernie; and ii. a further report be brought to Committee in May 213 with recommendations for improving uptake of schools meals generally and in particular free school meals. 14. Education Standards and Quality Report FoghlamAithisgInbheanagusMathais There had been circulated Report No ACS/53/12 dated 3 October 212 by the Director of Education, Culture and Sport which provided an overview of standards and quality in Highland primary and secondary schools and proposed detailed follow-up reports in areas that contributed to commitments across areas of Children and Families services. During a summary of the report, it was confirmed that during the school session , the Quality Improvement Team had developed and introduced a new School Improvement through Self-Evaluation (SISE) approach together with a standardised format for school Standards and Quality Reports which linked directly to the School Improvement Plan format.

139 133 The report provided a focussed summary of educational progress across the Service as a whole and recommended future work associated with the following three key headings: How well does the Service improve the quality of its work? How well do young people within Highland learn and achieve? How well does the Service support young people to develop and learn? During discussion, Members raised a range of issues, including: the attainment levels for the bottom 1-2% was not improving and it was hoped that a focussed report could be brought on this; regarding exclusions in Primary Schools, this seemed inappropriate and called into question why Head Teachers did not enlist the support of Children s Services for additional help. Reports at Ward level might be helpful on proposed exclusions in Primary Schools so that elected Members could offer assistance; it was acknowledged that the Curriculum for Excellence had been approached in a variety of different ways and it would be helpful if the Standards and Quality report could assess which approach had been the most effective method of implementing Curriculum for Excellence; it was unclear what current practical application had been achieved by the many excellent reports made to the previous Committee and Joint Committee on Children and Young People; regarding school leaver destinations, it might be helpful if more detailed contextual information could be provided. It was stated that 1% of children were not reaching positive destinations after leaving school and further information might have clarified what proportion of those children had special needs; the area of unofficial exclusion, for example pupils on a part-time timetable, was fraught and challenging and went unrecorded; if exclusion figures could indicate whether any of these children had additional needs, this might help direct effort to where it was needed; and the number of exclusions was still below the national average and set in the context of an increase in population, this was an overall good outcome. In response, it was confirmed that Head Teachers only ever considered exclusion as a last resort and, in 211,there had only been 9 incidences per 1 Primary pupils less than the national and family comparator authority averages - and effort was always made to reduce this number further. All performance, including exclusions, was contained in performance reports submitted to Area Committees. Assessment of the success of each school s application of the Curriculum for Excellence would form part of the on-going school improvement through selfevaluation. As Curriculum for Excellence became more embedded there would be much more information to bring back to Members for consideration regarding its implementation and application. The Committee NOTED the contents of the Education Standards and Quality Summary Report and AGREED to endorse the topics identified for more detailed follow-up reports. 15. Final Audit Report Nursery Payments AithisgSgrùdaidhDeireannach PàighidheanSgoil-àraich

140 134 There had been circulated Report No ACS/54/12 dated 3 October 212 by the Director of Health and Social Care which provided details of a report considered by the Audit and Scrutiny Committee on 2 September 212 and the actions agreed. The Committee NOTED the actions taken to address the issues identified in the Internal Audit Report. 16. Minutes Geàrr-chunntas The Committee NOTEDthe following Minutes of Meetings:i.Highland Alcohol and Drugs Partnership Strategy Group of 26 April 212; ii. Culture and Leisure Contracts Scrutiny Sub-Committee of 26 September 212, subject to a typographical error being corrected to refer to Wick High School rather than Academy; iii. Adult Services Development and Scrutiny Sub-Committee of 27 September 212; and iv. Criminal Justice Sub-Committee of 4 October 212. The Committee also AGREED in relation to the following:(a) (b) (c) (d) that agendas for all three Scrutiny Sub-Committees be ed to all ACS Members for information; Adult Services Development and Scrutiny Sub-Committee Minute of 27 September 212: Members of the Sub-Committee be provided with a copy of the report to NHS Highland s Health and Social Care Committee in relation to the number of people in Highland receiving a care at home service, as requested at the meeting; Members be provided with dates of future meetings of NHS Highland Health and Social Care Committees for information, together with a mechanism for accessing agendas, reports and minutes; that information relating to the reporting mechanism for the District Partnership minutes be provided; and a seminar outlining new developments in Adult Social Care be explored for early 213. The meeting concluded at 3.15 pm.

141 135 Highland NHS Board 5 February 213 Item 4.2 UPDATE REPORT THE HIGHLAND QUALITY APPROACH TO STRATEGIC COMMISSIONING Report by Simon Steer, Head of Strategic Commissioning on behalf of Deborah Jones, Chief Operating Officer The Board is asked to: Note Work being undertaken to take forward the Highland Quality Approach to Strategic Commissioning as described. Endorse the approach being taken whereby establishing a longer term culture that embeds strategic commissioning practice is underpinned by short and medium term initiatives to build skills and knowledge. 1 Background In June 212, the Board agreed that the Highland Quality Approach to Strategic Commissioning should be taken forward. This approach would seek to introduce and embed a shift from traditional service and investment planning, which could be described as The same as before, plus a bit more to meet demographic and other pressures, to a. Strategic Commissioning approach which would be used in Assessing and forecasting needs, agreeing desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place. The Highland Quality Approach to Commissioning would display the following characteristics: Understands the population needs by engaging with communities and representatives Engages provider organisations when setting priorities Outcomes are the heart of the process Maps and engages the fullest practical range of providers Considers investing in the provider base Ensures contract processes are transparent and fair Ensures long-term contracts and risk-sharing Seeks feedback to review effectiveness of the commissioning process For communities and representative groups, this means finding new ways to engage proportionately, so that the community s voice is present throughout, but the process is not disabled by consultations. Good Commissioning means that all sectors have to behave differently, with the focus shifting from consultation to engagement and innovation in line with agreed community priorities. This paper aims to provide assurance that the principles described above are being implemented, and that a pragmatic approach is being used to ensure that we do not delay implementation and the achievement of benefits by getting stuck in an over regimented process. This paper refers to North Highland only, due to the unique partnership arrangements in place. 2 Progress Progress is being made in the following areas:

142 136 Short Term Achievements: Development and Activities of the Adult Services Commissioning Group Good commissioning practice is about growing involvement, capacity and capability across all sectors. For the NHS, this means moving from a provider focus (i.e. commissioning from ourselves) to strategically commissioning and leading the development of an equitable, evidence based, transparent and engaged model for planning investment (and disinvestment) For other provider sectors, (such as voluntary and independent), this means a move from bidding and design in isolation; to a collaboration with the statutory sectors. In the short term, therefore, the Adult Services Commissioning Group has been set up to ensure cross sector involvement, and the development of collaborative planning approaches. The challenge for this group is to move from positive dialogue, to worked examples of commissioning for outcomes. The group has managed to achieve a shift in the approach taken towards use of the Change Fund, from bids to proposals for investment based on demonstrable outcomes and sustainability based on forecast return. A review of return on Change Fund investment has been initiated by this group and is due to report before the end of February 213. The group has also sought to support local (District) commissioning development by the establishment of a Winter Resilience initiative, allocating a relatively small amount of slippage ( 15k) across Districts to support greater local engagement whilst we establish a better understanding of the assets available in local areas. This is key to a proper commissioning approach, as the group has resisted the temptation to resource good ideas promoted by one or more organisations, until we better understand the map of partners (big and small) at a local level. Nevertheless, this limited funding will ensure that good, preventative ideas, e.g. path clearing etc, don t get delayed. This will be in place by end of January 213 Developmentally, this group will form the core for the Commissioning learning and development activities. The group has successfully attracted Scottish Government funding for an 18 month programme of work in Partnership with the University of Glasgow to develop Commissioning skills and, particularly, priority setting & option appraisal techniques for investment and disinvestment in services for Older People. An additional support programme is being developed with the Joint Improvement Team to support the development of local commissioning practice. Commences February 213 The group has also initiated a number of strands of work which will come together in an emerging Strategic Health Needs Analysis. This work will enable delivery of an initial Strategic Commissioning Plan to the Scottish Government in February 213, albeit that the more critical deadline for Partners is that of April 1st 213 for the review of the first year of the Partnership Agreement. An exercise has been undertaken specifically around acquired brain injury/challenging behaviour, to scope the population of patients currently within this care programme. The full list of patients has now been captured, and, alongside ongoing repatriation work, the Clinical Advisory Group is currently developing a Plan which: Scopes opportunities, resources, skills etc Scopes restrictions Develops commissioning approach Once needs understood, commissioning activity can be instituted. 2

143 137 Planned Medium Term Activity As noted above, whilst an initial Strategic Health Needs Analysis will be produced for April 1 st 213, this will be further refined and developed through 213/14 to inform service redesign. This means that managers, who are already armed with the stated outcomes that people want to achieve, will be able to develop a clear understanding of the volumes and depth of need involved. Complete April 214. The above work will also inform our understanding of population need as it relates to services like Care at Home, where a number of contracts are due for re negotiation. To enable the commissioning (not procurement) of these services to be fully informed by local redesign and understanding of local needs and assets, an interim arrangement is proposed to keep contracts in place pending a general redesign overseen by a new Older People s Improvement Group which reports in to the Adult Services Commissioning Group. Complete April 214 The Health Needs Analysis is, however, an emerging piece of work, and Senior Managers have been keen to take action on a known area where outcomes can be improved, and system benefits achieved. As such, the recently agreed commitment to aim for a zero tolerance of Delayed Discharge beyond 72hrs has been identified as a radical approach to commission for outcomes. Our approach is based on the following We know the quality/harm issue to be addressed, and it is evidenced We have quantified system benefits We have scoped the population concerned (both upstream and delayed) We have quantified days lost by reason, so we know what we may need to put in place We are addressing issues of practice and culture by means of local engagement in two workshops, then a road show approach We are working out the releasable benefit We are about to go to the provider base with all above. Managers recognise that achieving this standard means that careful planning is required to ensure that we not only commission the required capacity, so that it is in place throughout 213/14, but also that we commission new attitudes, practice and behaviours to support this. The second part of this commissioning exercise is how we ensure that we capture the benefits, which amount to an opportunity cost of approximately 13, hospital bed days used in accommodating patients delayed in their transfer to an appropriate care setting. Commences April 213, with redesign to sustain 72hr tolerance achieved April 214 Longer Term Looking towards 214/15, the challenge will be to bring together all of the above themes into a comprehensive Plan for the remaining period of the partnership agreement. Initial activities and objectives have already been outlined for this. 3

144 138 3 Contribution to Board Objectives As indicated above, a Highland Quality Approach towards Strategic Commissioning will impact on all board objectives by promoting optimal use of all available assets in the pursuit of optimal quality and outcomes, as per Board Objectives. 4 Governance Implications Staff Governance Patient and Public Involvement Clinical Governance As described above, Staff; Patient; Public; Clinical and other Sector engagement is a key component of the Highland Quality Approach to Strategic Commissioning. The implications for all of these areas are an increased engagement in the planning of investment and review of impact. Financial Impact Strategic commissioning is expected to have a positive financial impact, by providing a comprehensive framework for planning investment and use of assets, across all sectors, with a view to optimising outcomes. 5 Risk Assessment A commissioning approach will assist in reducing existing risks, but does not constitute a risk of itself. 6 Impact Assessment The details of structures and processes for implementing Strategic Commissioning will be risk assessed as development takes place. Simon Steer Head of Strategic Commissioning 25 January 213 4

145 139 Highland NHS Board 5 February 213 Item 5.1 SCHEME OF DELEGATION Report by Kenny Oliver, Board Secretary, on behalf of Elaine Mead, Chief Executive and Nick Kenton, Director of Finance The Board is asked to: Approve the attached Scheme of Delegation. 1 INTRODUCTION The Scheme of Delegation specifies the responsibilities delegated from the Board to specified Officers. There have been a number of changes since the Scheme of Delegation was last approved by the Board in 211. The attached draft amended Scheme of Delegation takes account of those changes. 2 CHANGES TO SCHEME OF DELEGATION The main changes to the Scheme of Delegation are summarised below: The Chief Executive has additional responsibilities in relation to the transfer of Adult Social Care services from Highland Council. Funding for Final Business Cases has been expanded to include all forms of funding. NHS Highland has reduced the number of CHP s from four to two. Hospital now forms part of Highland Health and Social Care. The CHP General Managers and Raigmore Hospital General Manager have been replaced by Directors of Operations. Raigmore 3. CONTRIBUTION TO BOARD OBJECTIVES A key Board Corporate Objective is to enhance Board governance. The Scheme of Delegation is a key tool which regulates the operation of the NHS Board and its Committees. 4 GOVERNANCE IMPLICATIONS The Scheme of Delegation is a key part of the Corporate Governance framework for NHS Highland. 5 IMPACT ASSESSMENT This paper describes a set of proposed revisions to the Scheme of Delegation which in themselves do not require an Equality and Diversity Impact Assessment 6 RISK ASSESSMENT No risk assessments have been undertaken in relation to this and it does not appear on the NHS Highland Risk Register. The absence of either document would constitute a risk to the organisation but this paper suggests only minor changes to the existing documents. Kenny Oliver Board Secretary 25 February 213

146 14 SCHEME OF DELEGATION Draft for consideration by the Board 5th February 213

147 141 CONTENTS Page No. 1 SCHEDULE OF MATTERS RESERVED FOR BOARD APPROVAL SCHEDULE OF MATTERS DELEGATED TO OFFICERS OF THE BOARD 2.1 INTERPRETATION CHIEF EXECUTIVE General Provisions Finance Legal Matters Procurement of Supplies and Services Human Resources Patients Property Chief Executive Responsibility for Clinical Governance Chief Executive Responsibility for Risk Management The Board s responsibilities Matters reserved for Board decisions and/or approval Board Responsibilities for Clinical Governance CHIEF OPERATING OFFICER, DIRECTORS OF OPERATIONS General Provisions Finance Legal Matters Procurement of Supplies and Services Human Resources Patients and Clients Valuables DIRECTOR OF FINANCE Accountable Officer Financial Statements Corporate Governance and Management Performance Management Banking Patients and Clients Valuables HEADS OF FINANCE Financial Statements Corporate Governance and Management Performance Management Patients and Clients Valuables Provisions Applicable To Other DIRECTORS General Provisions Human Resources Patients and Clients Valuables Provisions Applicable To CHP Chairs 17 APPENDICES Appendix A : Chief Operating Officer, Directors of Operations delegated operational responsibility for functions: 1. Argyll And Bute CHP 2. Highland Health and Social Care 1 18

148 SCHEDULE OF MATTERS RESERVED FOR BOARD APPROVAL 1.1 THE BOARD S RESPONSIBILITIES In accordance with Scottish Government guidance (NHS Circular HDL(23)11), the NHS Board is a board of governance. The Board has the delegated responsibilities for the provision of Adult Social Care Services from Highland Council through the Highland Partnership Agreement. This requires the Board to operate under the The Community Care (Joint Working etc.)(scotland) Regulations 22 and the conditions set out in the Highland Partnership Agreement. The Board has a corporate responsibility for ensuring that arrangements are in place for the conduct of its affairs and that of its component parts, including compliance with applicable guidance and legislation, and ensuring that public money is safeguarded, properly accounted for, and used economically, efficiently and effectively. The Board has an ongoing responsibility to ensure that it monitors the adequacy and effectiveness of these arrangements in practice. The Board is required to ensure that it conducts a review of its systems of internal control, including in particular its arrangements for risk management, at least annually. 1.2 MATTERS RESERVED FOR BOARD DECISIONS AND/OR APPROVAL The following matters shall be reserved for approval by the Board, as determined by Standing Orders: Strategic and Board Wide financial business plans and budgets, although detailed figures will be prepared by CHP s and Corporate Services within the targets agreed at Board level. Approval of Standing Orders and Standing Financial Instructions. Approval of Outline and Final Business cases for assets with a lifetime value over 1.5, All disposal or purchase of property/land. Local Delivery Plan including Financial Plan Appointment of Auditors Investment Strategy for Exchequer Funds and discharge of Trustee responsibilities in relation to Non Exchequer Funds will be a matter for the Trustees Approval of the Annual Report and Accounts. The establishment, terms of reference, and reporting arrangements for all Committees, and Sub Committees acting on behalf of the NHS Board. Policies, including arrangements remuneration of key staff. 2 for the appointment/removal and

149 The launch of the consultation process for Major Service Changes. The approval of Major Service Changes. Other duties prescribed in the Highland Partnership Agreement. Board Responsibility for Clinical Governance Clinical governance and risk management is the responsibility of the board of each NHS body. Each board must satisfy itself that the organisation for which it is responsible is pursuing clinical governance and risk management in an appropriate manner, i.e. that the activities which support the delivery of clinical governance and risk management are in place, and that information is flowing and action is being taken at appropriate levels, up to and including board level, on safety and quality of care issues both routinely and specifically when problems are identified. The Board discharges this responsibility through the appropriate governance committees. 3

150 144 2 SCHEDULE OF MATTERS DELEGATED TO OFFICERS OF THE BOARD 2.1 INTERPRETATION Any reference in this scheme to a statutory or other provision shall be interpreted as a reference to that provision as amended from time to time by any subsequent legislation. Any power delegated to a nominated or specified officer in terms of this scheme may be exercised by such an officer or officers of his or her department as the officer may authorise. This Scheme of Delegation should be read in conjunction with the Board Standing Orders, Standing Financial Instructions, and Delegated Levels of Authority. 2.2 CHIEF EXECUTIVE General Provisions In the context of the Board's principal role to protect and improve the health of Highland residents and social care provision for adults, the Chief Executive as Accountable Officer shall have delegated authority and responsibility to secure the economical, efficient and effective operation and management of Highland NHS Board and to safeguard its assets: in accordance with the statutory requirements and responsibilities laid upon the Chief Executive as Accountable Officer for Highland NHS Board; in accordance with direction from the Scottish Government Health Department; in accordance with the current policies of and decisions made by the Board; within the limits of the resources available, subject to the approval of the Board; and in accordance with Standing Orders and Standing Financial Instructions. The Chief Executive is authorised to take such measures as may be required in emergency situations, subject to advising, where possible, the Chairperson and the Vice-Chairperson of the Board, and the relevant Standing Committee Chairperson. Such measures, that might normally be outwith the scope of the authority delegated by the Board or its Standing Committees to the Chief Executive, shall be reported to the Board or appropriate Standing Committee as soon as possible thereafter. The Chief Executive is authorised to give a direction in special circumstances that any officer shall not exercise a delegated function subject to reporting on the terms of the direction to the next meeting of the appropriate Committee. The Chief Executive has personal statutory accountability for all Health and Safety matters within NHS Highland. 4

151 145 The Chief Executive is empowered to take all steps necessary to assist the Board to develop, promote and monitor compliance with Standing Orders and Standing Financial Instructions, and appropriate guidance on standards of business conduct Finance Resources shall be used only for the purpose for which they are allocated, unless otherwise approved by the Chief Executive, after taking account of the advice of the Director of Finance. The Chief Executive acting together with the Director of Finance has delegated authority to approve the transfer of funds between budget heads, including transfers from reserves and balances. The Chief Executive may, acting together with the Director of Finance, and having taken all reasonable action to pursue recovery, approve the writing-off of losses, subject to the financial limits and categorisation of losses laid down from time to time by the Scottish Government Health Department Legal Matters The Chief Executive is authorised to institute, defend or appear in any legal proceedings or any inquiry, including proceedings before any statutory tribunal, board or authority, and following consideration of the advice of the Central Legal Office of the National Services Division, to appoint or consult with Counsel where it is considered expedient to do so, for the promotion or protection of the Board's interests. In circumstances where a claim against the Board is settled by a decision of a Court, and the decision is not subject to appeal, the Chief Executive shall implement the decision of the relevant Court on behalf of the Board. In circumstances where the advice of the Central Legal Office is to reach an out-ofcourt settlement, the Chief Executive may, acting together with the Director of Finance, settle claims against the Board, and thereafter being noted by the Audit Committee as part of the year end accounts. The Chief Executive, acting together with the Director of Finance, may make exgratia payments subject to the limits laid down from time to time by the Scottish Government Health Department. The arrangements for signing of documents in respect of matters covered by the Property Transactions Handbook shall be in accordance with the direction of Scottish Ministers. The Chief Executive is currently authorised to sign such documentation on behalf of the Board and Scottish Ministers. 5

152 146 The Chief Executive shall have responsibility for the safe keeping of the Board's Seal, and together with the Chairperson or other nominated non-executive member of the Board, shall have responsibility for the application of the Seal on behalf of the Board Procurement of Supplies and Services The Chief Executive shall have responsibility for nominating officers or agents to act on behalf of the Board, for specifying, and issuing documentation associated with invitations to tender, and for receiving and opening of tenders. Where post tender negotiations are required, the Chief Executive shall nominate in writing, officers and/or agents to act on behalf of the Board. The Chief Executive, acting together with the Director of Finance, has authority to approve on behalf of the Board the acceptance of tenders, submitted in accordance with the Board's Standing Orders, up to a value of 5,,, within the limits of previously approved Revenue and Capital Budgets, where the most economically advantageous tender is to be accepted. The Chief Executive, through the Director of Finance, shall produce a listing, including specimen signatures, of those officers or agents to whom he has given delegated authority to sign official orders on behalf of the Board Human Resources The Chief Executive may appoint staff in accordance with the Board's Standing Orders, Human Resources Policies and Delegated Levels of Authority. The Chief Executive may, after consultation and agreement with the Director of Human Resources, and the relevant Director/ Officer, amend staffing establishments in respect of the number and grading of posts. In so doing, the Director of Finance must have been consulted, and have confirmed that the cost of the amended establishment can be contained within the relevant limit approved by the Board for the current and subsequent financial years. Any amendment must also be in accordance with the policies and arrangements relating to workforce planning, approved by the Board or Staff Governance Committee. The Chief Executive has delegated authority from Highland NHS Board to approve the establishment of salaried dentist posts within NHS Highland, within the systematic approach as laid down by the Scottish Government Circular No PCA(D)(25)3. The Chief Executive may attend and may authorise any member of staff to attend within and outwith the United Kingdom conferences, courses or meetings of relevant professional bodies and associations, provided that: 6

153 147 attendance is relevant to the duties or professional development of such member of staff; and appropriate allowance has been made within approved budgets; or external reimbursement of costs is to be made to the Board. The Chief Executive may, in accordance with the Board's agreed Employee Conduct Policy, take disciplinary action, in respect of members of staff, including dismissal where appropriate. The Chief Executive shall have overall responsibility for ensuring that the Board complies with Health and Safety legislation, and for ensuring the effective implementation of the Board's policies in this regard. The Chief Executive may, in consultation with the Director of Human Resources and Director of Finance, approve applications to leave the employment of the Board on grounds of redundancy and/or early retirement by any employee provided the terms and conditions relating to the redundancy and/or early retirement are in accordance with the relevant Board policy. All such applications and outcomes will be reported to the Remuneration Sub-Committee Patients & Clients Valuables The Chief Executive shall have overall responsibility for ensuring that the Board complies with legislation in respect of patients/clients valuables. The term valuables shall mean all assets other than land and buildings. (e.g. furniture, pictures, jewellery, bank accounts, shares, cash.) Chief Executive Responsibility for Clinical Governance The Chief Executive is responsible to the NHS Board for delivering clinical governance, and for ensuring that suitable local arrangements are in place and are integrated with existing structures such as clinical directorates. In this role, the Chief Executive has delegated overall responsibility for Clinical Governance to the Medical Director, working closely with the Director of Nursing. The Chief Executive remains responsible for reporting to the board, and for taking any action it decides Chief Executive Responsibility for Risk Management The Chief Executive has responsibility for maintaining a sound system of internal control that supports the achievement of the organisation s policies, aims and objectives, set by Scottish Ministers, whilst safeguarding the public funds. This is achieved by the reporting through the NHS Board of all relevant information, including performance against objectives. The performance management arrangements operate within an environment of active risk management. 7

154 CHIEF OPERATING OFFICER, DIRECTORS OF OPERATIONS General Provisions The Chief Operating Officer/ Directors of Operations/Directors of The Board shall have delegated authority and responsibility from the Board Chief Executive to secure the economical, efficient and effective operation and management of the Operational Units and Corporate Services and to safeguard their assets: in accordance with the current policies and decisions made by the Board; within the limits of the resources made available to the Operational Units/Corporate Services by the Board; in accordance with the Board s Standing Orders and Standing Financial Instructions; and in accordance with the relevant Scheme of Establishment. Note : Any reference throughout this document to Chief Operating Officer/Director of Operations in relation to Operational Units also applies to Directors of the Board in relation to Corporate Functions The functions of the 4 Operational Units, for which the Chief Operating Officer and the Directors of Operations have delegated operational responsibility are shown at Appendix A to this Scheme of Delegation. The Chief Operating Officer and the Directors of Operations have a general duty to assist the Chief Executive in fulfilling his/her responsibilities as the Accountable Officer of the Board. The Chief Operating Officer and the Directors of Operations are authorised to take such measures as may be required in emergency situations, subject to advising, where possible, the Chairperson or the Vice-Chairperson of the Board, the Chief Executive and where appropriate the relevant Standing Committee Chairperson. Such measures, that might normally be outwith the scope of the authority delegated by the Board or its Standing Committees to the Chief Executive and consequently the Chief Operating Officer/ Directors of Operations, shall be reported to the Board or appropriate Standing Committee as soon as possible thereafter. The Chief Operating Officer and Directors of Operations are authorised to give a direction in special circumstances that any officer within the Operational Units shall not exercise a delegated function subject to reporting on the terms of the direction to the next meeting of the CHP Governance Committees. 8

155 Finance Resources shall be used only for the purpose for which they are allocated, unless otherwise approved by the Chief Operating Officer or Director of Operations, after taking account of the advice of the Heads of Finance for Operational Units. The Chief Operating Officer/ Directors of Operations acting together with the designated Finance Officer have delegated authority to approve the transfer of funds between budget heads, including transfers from reserves and balances, up to a maximum of 5, (in the case of the Chief Operating Officer) or 2, (in the case of the Directors of Operations) in any one instance. The Chief Operating Officer/ Directors of Operations shall report to the CHP Governance Committees and to the Board Chief Executive those instances where this authority is exercised and/or the change in use of the funds relates to matters of public interest. The Chief Operating Officer/Directors of Operations may, acting together with the Director of Finance, and having taken all reasonable action to pursue recovery, approve the writing-off of losses in the Operational Units subject to the financial limits and categorisation of losses laid down from time to time by the Scottish Government Health Department Legal Matters The Chief Operating Officer/Directors of Operations are authorised to institute, defend or appear in any legal proceedings or any inquiry, (including proceedings before any statutory tribunal, board or authority) in respect of the Operational Units and following consideration of the advice of the Central Legal Office of the National Services Division and in consultation with the Chief Executive, to appoint or consult with Counsel where it is considered expedient to do so, for the promotion or protection of the Board's interests. In circumstances where a claim against the Board is settled by a decision of a Court, and the decision is not subject to appeal, the Chief Operating Officer/ Directors of Operations shall, following consultation with the Chief Executive, implement the decision of the relevant Court on behalf of the Board. The Chief Operating Officer/Directors of Operations acting together with the Heads of Finance must bring to the attention of the Chief Executive and Director of Finance any claim deemed to pose a significant risk to the Board s Revenue Resources. 9

156 Procurement of Supplies and Services The Chief Operating Officer shall have responsibility for nominating officers or agents to act on behalf of the Board, for specifying, and issuing documentation associated with invitations to tender, and for receiving and opening of tenders. The Chief Operating Officer/Directors of Operations, acting together with the Heads of Finance, have authority to approve on behalf of the Board the acceptance of tenders, in respect of the Operational Units submitted in accordance with the Board's Standing Orders, up to a value defined within the Delegated Levels of Authority and within the limits of previously approved Revenue and Capital Budgets. The Chief Operating Officer/Directors of Operations shall work with the designated Finance Officer and the Director of Finance to produce a listing, including specimen signatures, of those officers or agents to whom he has given delegated authority to sign official orders on behalf of the Board and the Operational Units Human Resources The Chief Operating Officer/Directors of Operations may appoint staff in accordance with the Board's Standing Orders, Human Resources Policies and Delegated Levels of Authority. The Chief Operating Officer/Directors of Operations may, after consultation and agreement with Human Resources and the relevant Director of Operations amend staffing establishments in respect of the number and grading of posts. In so doing, the Heads of Finance must have been consulted, and have confirmed that the cost of the amended establishment can be contained within the relevant limit approved by the CHP Committees for the current and subsequent financial years. Any amendment must also be in accordance with the policies and arrangements relating to workforce planning, approved by the Board or the Staff Governance Committee. The Chief Operating Officer/Directors of Operations may attend and may authorise any member of staff to attend within and outwith the United Kingdom conferences, courses or meetings of relevant professional bodies and associations, provided that: attendance is relevant to the duties or professional development of such member of staff; and appropriate allowance has been made within approved budgets; or external reimbursement of costs is to be made to the Board. The Chief Operating Officer/Directors of Operations may, in accordance with the Board's agreed Management of Employee Conduct Policy, take disciplinary action in respect of members of staff, including dismissal where appropriate. The Chief Operating Officer/Directors of Operations may, following consultation and agreement with the appropriate Senior Human Resources Officer and the Heads of 1

157 151 Finance and the Remuneration Sub Committee approve payment of honoraria to any employee within the Operational Units Patients & Clients Valuables The Chief Operating Officer/Directors of Operations shall have overall responsibility for ensuring that the Board s Operational Units comply with legislation in respect of patients and clients valuables and that effective and efficient management arrangements are in place. 11

158 DIRECTOR OF FINANCE Authority is delegated to the Director of Finance to take the necessary measures as undernoted, in order to assist the Board and the Chief Executive in fulfilling their corporate responsibilities: Accountable Officer The Director of Finance has a general duty to assist the Chief Executive in fulfilling his/her responsibilities as the Accountable Officer of the Board Financial Statements The Director of Finance is empowered to take all steps necessary to assist the Board to: Act within the law and ensure the regularity of transactions by putting in place systems of internal control to ensure that financial transactions are in accordance with the appropriate authority; Maintain proper accounting records; and Prepare and submit for External Audit timeous financial statements which give a true and fair view of the financial position of the Board and its income and expenditure for the period in question Corporate Governance and Management The Director of Finance is authorised to put in place proper arrangements to ensure that the financial position of the Board is soundly based by ensuring that the Board, its Committees, and supporting management groupings receive appropriate, accurate and timely information and advice with regard to: The development of financial plans, budgets and projections; Compliance with statutory financial requirements and achievement of financial targets; The impact of planned future policies and known or foreseeable developments on the Board's financial position. The Director of Finance is empowered to take steps to ensure that proper arrangements are in place for: Developing and implementing systems of internal control, including systems of financial, operational and compliance controls and risk management; Developing and implementing strategies for the prevention and detection of fraud and irregularity; 12

159 153 Internal Audit. Determine the level of expenses for patients travel and accommodation Determine the level of expenses for advisors to Board Committees Performance Management The Director of Finance is authorised to assist the Chief Executive to ensure that suitable arrangements are in place to secure economy, efficiency, and effectiveness in the use of resources and that they are working effectively. These arrangements include procedures: for planning, appraisal, authorisation and control, accountability and evaluation of the use of resources; to ensure that performance targets and required outcomes are met and achieved Banking The Director of Finance is authorised to oversee the Board's arrangements in respect of accounts held in the name of the Board with the Government Banking Service and the commercial bankers duly appointed by the Board. The Director of Finance will be responsible for ensuring that the Government Banking Service and the commercial bankers are advised in writing of amendments to the panel of nominated authorised signatories Patients and Clients Valuables The Director of Finance shall have delegated authority to ensure that detailed operating procedures in relation to the management of the valuables of patients and clients (including the opening of bank accounts where appropriate) are compiled for use by staff involved in the management of patients and clients valuables and financial affairs, in line with the terms of the Adults with Incapacity (Scotland) Act 2. 13

160 HEADS OF FINANCE The Finance Officer(s) designated as lead on financial matters for the Corporate Directorates and Operational Units have a general duty to assist the Chief Executive in fulfilling his/her responsibilities as the Accountable Officer of the Board. Authority is delegated to the Heads of Finance to take the necessary measures as undernoted, in order to assist the, Corporate Directorates and Operational Units, their respective Committees, and the Chief Operating Officer/Directors of Operations/Directors in fulfilling their corporate responsibilities. In exercising these delegated powers the designated Finance Officer is also acting as the Director of Finance s representative Financial Statements The designated Finance Officer is empowered to take all steps necessary for the Board to: Act within the law; Ensure the regularity of transactions by maintaining approved systems of internal control to ensure that financial transactions are in accordance with the appropriate authority; Maintain proper accounting records; and Ensure (by participation) the timeous completion of the Board s Annual Accounts Corporate Governance and Management The designated Finance Officers are authorised to put in place proper arrangements to ensure that the financial position of the Board s Operational Units/Corporate Directorates is soundly based by ensuring that the CHP Committees and supporting management groupings receive appropriate, accurate and timely information and advice with regard to: The development of financial plans, budgets and projections; Compliance with statutory financial requirements and achievement of financial targets; The impact of planned future policies and known or foreseeable developments on the Operational Units/Corporate Directorates financial position. The designated Finance Officer is empowered to take steps to ensure that proper arrangements are in place for: Monitoring compliance with the Board s Standing Orders and Standing Financial Instructions, and appropriate guidance on Standards of Business Conduct; 14

161 155 Contributing to the development and promotion of the Board s Standing Orders and Standing Financial Instructions; Developing and implementing systems of internal control, including systems of financial, operational and compliance controls and risk management; and Developing and implementing strategies for the prevention and detection of fraud and irregularity Performance Management The Heads of Finance is authorised to assist the Chief Operating Officer/Directors of Operations/Directors to ensure that suitable arrangements are in place to secure economy, efficiency, and effectiveness in the use of resources and that they are working effectively. These arrangements include procedures: for planning, appraisal, authorisation and control, accountability and evaluation of the use of resources; to ensure that performance targets and required outcomes are met and achieved Patients & Clients Valuables The Director of Finance shall have delegated authority to provide detailed operating procedures in relation to the management of the valuables of patients and clients (including the opening of bank accounts where appropriate) for use by staff involved in the management of patient s and clients valuables and financial affairs, in line with the terms of the Adults with Incapacity Act 2. 15

162 PROVISIONS APPLICABLE TO OTHER DIRECTORS General Provisions Directors shall have delegated authority, and responsibility in conjunction with the Board Chief Executive, Chief Operating Officer or appropriate Director of Operations for securing the economical, efficient and effective operation and management of their own Directorates/ Departments and for safeguarding the assets of the Board. Directors are authorised to take such measures as may be required in emergency situations, subject to advising, where possible, the Board Chief Executive, Chief Operating Officer/Director of Operations as appropriate, the Chairperson and the Vice-Chairperson of the Board or relevant Standing Committee Chairperson as appropriate. Such measures, that might normally be outwith the scope of the authority delegated by the Board or its Standing Committees to the relevant Director, shall be reported to the Board or appropriate Standing Committee as soon as possible thereafter Human Resources Directors may appoint staff in accordance with the Board's Standing orders, Human Resource policies and Delegated Levels of Authority. Designated Directors may, after consultation and agreement with the Director of Human Resources or appropriate Senior Human Resources Manager, amend staffing establishments in respect of the number and grading of posts, subject to the limits within the Delegated Levels of Authority. In so doing, the Director of Finance or his/her designated deputy as appropriate, must have been consulted, and have confirmed that the cost of the amended establishment can be contained within the relevant limit approved by the Board for the current and subsequent financial years. Any amendment must also be in accordance with the policies and arrangements relating to workforce planning, approved by the Board or Staff Governance Committee. Directors may attend and may authorise any member of staff to attend within and outwith the United Kingdom, conferences, courses or meetings of relevant professional bodies and associations, provided that: attendance is relevant to the duties or professional development of such member of staff; and appropriate allowance must also be contained within approved budgets; or external reimbursement of costs is to be made to the Board. Directors may, in accordance with the Board's agreed Employee Conduct Policy, take disciplinary action, in respect of members of staff, including dismissal where appropriate. 16

163 157 Directors shall have overall responsibility within their Directorates/Departments for ensuring compliance with Health and Safety legislation, and for ensuring the effective implementation of the Board's policies in this regard. 2.7 PROVISIONS APPLICABLE TO CHP CHAIRS CHP Chairs (Argyll and Bute CHP and Highland Health and Social Care) are appointed by the NHS Board and have delegated authority and responsibility, in conjunction with the Board Chair and appropriate Chief Operating Officer/Director of Operations, for ensuring the economical, efficient and effective governance of their CHP and for safeguarding the assets of the Board. The Chairs are accountable to the Board in this regard. 17

164 158 APPENDIX A CHIEF OPERATING OFFICER, DIRECTOR OF OPERATIONS DELEGATED OPERATIONAL RESPONSIBILITY FOR FUNCTIONS 1. ARGYLL AND BUTE CHP (a) Services managed or provided by the CHP for its local population are: 2. The full range of independent contractor services as per guidance (including primary care prescribing) All community related health services, including community and public health Nursing services and services provided by allied health professionals; Community based midwifery services School health services Community hospitals; Community assessment and rehabilitation; Health services for older people; Respite or short break services for all client groups; Services for people with sensory and/or physical disabilities; Acute and associated services at the Lorn & Islands DGH Acute and community mental health services provided from the Argyll & Bute hospital Community based integrated teams, including rapid response teams; Community child health services; Learning disability services; Community aspects of health improvement Drug and alcohol addiction services Sexual and reproductive health services Child and Adolescent Mental Health Services Community access to outpatient and diagnostic services Commissioning In and outreach clinical and non clinical services provided by partnership or SLAs from Glasgow HIGHLAND HEALTH AND SOCIAL CARE The Highland Health and Social Care Partnership is made up of three operational units which are responsible for providing a wide range of acute services, emergency care together with primary care and community based health and social care services including: accident and emergency acute hospital care acute mental health adult social work teams equipment stores 18

165 159 care at home care homes community hospitals community mental health teams community nurses day care dental services district general hospitals handyperson services health visitors learning disability midwifery services nutrition and dietetics occupational therapy pharmacy physiotherapy podiatry primary care services respite services rural general hospitals self-directed support speech and language therapy tele-care 19

166 16

167 161 Highland NHS Board 5 February 213 Item 5.2 AREA FINANCIAL POSITION AT 31 DECEMBER 212 Report by Nick Kenton, Director of Finance The Board is asked to: 1 Note: The current forecast remains break-even by the end of the financial year. Note: An improvement in the forecast operational position of 1.1m from the October position reported to the Board in December. Note: The need for further improvements within the financial position of 5.8m by the end of the year, split between; - NHS Care 3.8m - Adult Social Care 2.m INTRODUCTION This report is based on information as at the 31 December 212 and highlights a current forecast of break-even for the financial year. However, the underlying operational positions, including adult social care, indicate an in-year shortfall of 5.8m, an improvement of 1.1m on the position reported to the December Board. 2 FINANCIAL POSITION OVERVIEW As previously highlighted, the position at the end of December (Month 9) continues to show a forecast of financial breakeven, recognising that this depends on the further delivery of units savings targets, together with the appropriate management of emerging, in-year cost pressures and the application of any non-recurrent benefits as an improvement in the position. The operational position to date is detailed in Table 1 (attached) and the management of this forecast is being addressed through a range of management actions, local and Highlandwide, to deliver the projection of financial breakeven. At present, the current operational forecast can be broken down as follows; Breakdown of Month 9 Forecast Positions Heading Savings Operational Savings not yet achieved/identified Highland Wide Quality Initiatives In y ear non-recurrent benefits applied Pressures Adult Social Care In-year cost pressures Offsetting underspends/benefits Forecast Position N&W m S&M m Operational Unit Raigmore Tertiary Others HSCP A&B m m m m m (1.9) (1.1) (.7) (.1) (1.3) (1.3) (1.8) (2.7) (.6).7 (2.6) (3.2) Previous Month (1.4) (2.6) Change (.4). (2.).. Corp. m Quality Central m m (.3) Total m 5.6 (2.3) (4.5) 5.6 (4.5) (1.3) 1.8 (.6) (2.) (4.5) 1.2 (7.3) (.4).9.2 (.1).3.2 (4.5) 5.6 (2.) (5.) 2.4 (5.8) (3.4) (1.2) 1.4 (7.2)..1 (4.5) 4.7 (6.9).2 (.1).2 (.1) The usual financial tables are attached as follows;

168 162 Table 1 presents the overall income and expenditure position, inclusive of adult social care funding transferred in from Highland Council and excluding funding transferred out to Highland Council relating to children s services. The funding figures differ from the amounts in the Partnership Agreement primarily due to the fact that the position relating to overheads and baseline quantum are not yet fully resolved. Table 2 provides more detail on the overall expenditure position. The budgets for South & Mid Highland and North & West Highland operational units are now integrated budgets inclusive of adult social care relating to their areas. Table 3 shows the same information but excluding Adult Social Care. Table 4 shows the total position on adult social care alone. It should be recognised that the position shown in Table 4 needs to be treated with caution. The overall forecast is based on the Council s system and with intelligence from former Council employees and whilst this continues to improve, there are issues which need to be resolved and this will improve when all transactions finally move over to the NHSH financial system. Table 5 summarises the position against savings. This highlights the fact that there is still significant work required to identify sufficient savings to deliver the financial plan. Table 6 summarises the position with regards capital expenditure. 3 COST PRESSURES AND OPERATIONAL PERFORMANCE The 1.1m improvement is welcome and continues a trend of moving towards break-even however, the vast majority of this has come from fortuitous non-recurrent savings rather than planned savings initiatives. The main components of this are; Reduction in Raigmore deficit position Adverse movement in North & West Improvement in Argyll & Bute Improvement in Corporate Services Non-recurrent/allocation slippage.2m (.2m).2m.1m.9m The main issues which make up the bulk of the forecasted operational position remain broadly the same as reported to previous Board meetings: Raigmore position Tertiary (out of area) expenditure Adult Social Care System savings unidentified North & West (NHS element) In year non-recurrent benefits 3.2m 1.3m 2.m 4.5m.8m ( 5.6m) Specific issues within operational units are as follows (this excludes Adult Social Care, which is described separately): 3.1 Argyll & Bute CHP-.2m Underspend This represents a.2m improvement on the previous Board report and is primarily due to further reductions in prescribing costs due off-patent, generic price reductions. 3.2 North and West Unit -.8m NHS Overspend This is an adverse movement of.25m. Whilst N&W is expecting to meet its savings target, it is reporting financial pressures in medical vacancies, prescribing and the cost of 2

169 163 supporting vacant GP practices which are being managed. It is the very expensive locum costs associated with vacant practices which accounts for the majority of this increase. 3.3 South and Mid Unit NHS.1m NHS Underspend S&M continue to project a small underspend of.1m and this is unlikely to change significantly. Work is also progressing to convert a proportion of the non-recurrent savings to recurrent to reduce the burden carried into next year. 3.4 Raigmore Hospital - 3.2m Overspend The Raigmore Programme Board continues to oversee measures to further improve the position with the ultimate objective of returning to financial balance within an agreed timescale. As previously reported, the Programme Board set the Raigmore Management team an initial target of identifying a 1m improvement in the Raigmore forecast, to be identified by the end of the calendar year. To date the Raigmore position has improved by.75m since the Month 5 report, primarily due to a more robust review of budgets, costs and vacancies. 3.5 Tertiary - 1.3m Overspend The vast majority of the current estimated overspend relates to an increasing number of expensive forensic psychiatry placements. 3.6 Facilities -.1m Overspend The Facilities overspend is estimated at.1m and relates mainly to utility costs at Raigmore, where energy overspends are the subject of ongoing investigation. The proposed biomass installation will eventually make a significant impact on this. 3.7 Adult Social Care At the time of writing this report, the forecast overspend on Adult Social Care remains at 2m based on current figures. There is no change in this forecast from those previously reported to the Board. The Board continues to work very closely with Highland Council to find a resolution to this issue both organisations remain absolutely committed to achieving a break-even outturn. 4 Capital The funding in the capital plan has increased significantly since the report to the December Board. The vast majority of the increase is due to the approval of the Raigmore biomass project ( 1.4m) and Central Energy Efficiency Fund initiatives ( 2.4m). These are extremely positive developments, which will allow a step-change in the Board s carbon management plan. However, the receipt of this funding relatively late in the financial year does present significant challenges in terms of the procurement timetable. This position is being monitored very closely by the Asset Management Group on behalf of the Board any slippage will be pro-actively managed to ensure all funding is fully utilised. In addition,.6m funding is anticipated for enabling works in respect of the new Tain Health Centre development,.5m to facilitate the transfer of a leased property from a GP practice to the Board and.3m to allow relocation of Community Mental Health team bases in Argyll & Bute (which is part of the overall mental health re-design project). 5 Conclusion Once again, the improvement with the month 9 forecast position is very positive albeit mainly the result of fortuitous or non-recurrent items which help in delivering a break-even position in-year but this simply defers the requirement to deliver recurrent savings into future years. 3

170 164 It is likely that this trend will continue and further non-recurrent resources will be available during the remainder of the year to offset the position further. In addition, work is currently ongoing on a second phase of fixed asset accounting changes around asset lives and it is expected that this will be complete by the beginning of February when the exact amounts will be known and will be incorporated into the forecast. As well as this, further benefits as a result of impact of the off patent drug price reduction is expected and this should also be known within the next month. It is expected that the total for those items is likely to be in the region of 3m leaving a further.8m to be identified by the end of the year which, on a budget of almost 7million, is very much achievable. To facilitate this, there needs to continue to be a concerted effort to deliver further improvements at operational level. At the same time, it must be recognised that there remains an over-reliance on non-recurrent savings and the current projection (as set out in Table 7) shows an anticipated carry forward of unmet recurring savings of 7.1m. This must be reduced over the remainder of the financial year in order to reduce the scale of the challenge for 213/14 and also if the Board is to remain in course to eradicate its underlying deficit by the end of 214/15. 6 Governance Implications Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and Patient and Public Involvement. 7 Risk Assessment Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly. 8 Planning for Fairness A robust system of financial control is crucial to ensuring a planned approach to savings targets this allows time for impact assessments of key proposals impacting on any changes to services. 9 Engagement and Communication The majority of the Board s revenue budgets are devolved to operational units, which report into two governance committees that include staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public. The overall financial position was described in Health Check which was sent to every household in Highland. Nick Kenton Director of Finance 25 January 213 4

171 165 NHS Highland Income & Expenditure Report as at Annual Plan Initial Current Plan Plan 496,43 496,43 496,43 38,543 55,697 1,48 6,783 67,114 84,89 (3,42) 688,583 Summary Funding & Expenditure 496,157 SEHD -Baseline Funding 7,931 - Recurring Supplemental Allocations (11,172) - Non Recurring Supplemental Allocations 492,917 Sub total - SGHD Core RRL 24,643 - Non Core Funding 517,56 SGHD Funding as at July ,411 55,697 2,82 1,11 - FHS Non Discretionary - FHS GMS Allocation - Recurring Pending allocations - Non Recurring Pending allocations 616,598 TOTAL SGHD Funding 84,197 Add- Adult Social Care Funding (7,548) Less - Childrens services 693,247 Funding TABLE 1 DECEMBER 212 Plan to Date Position to Date Actual Variance to Date to Date Forecast Outturn Forecast Variance from Outturn Current Plan Prev month Forecast Movement Variance in month 351,249 5,948 (8,379) 348, ,249 5,948 (8,379) 348, ,157 7,931 (11,172) 492,917 18,482 18,482 24, ,31 367,31 517,56 29,558 41,773 2, ,558 41,773 2, ,411 55,697 2,82 1,11 441, , ,598 74,179 74,179 84,197 (7,548) 515, , ,598 86, ,629 8,98 99,723 14,683 3,723 5,212 13,19 1,81 88, ,687 9,224 12,58 14,736 3,735 5,198 13,9 1,777 (1,569) (57) (316) (2,336) (53) (12) 14 (791) , ,857 1, ,41 19,761 5,12 6,88 18,783 14,336 (1,81) (2,581) 1,774 (3,192) (134) (69) 5 (1,35) 2 (1,353) (2,612) 1,495 (3,48) (14) (37) (1,2) 19 (457) (32) 5 (15) 1 Health & Social Care Partnership 118, ,221 4, ,33 19,768 4,81 4,433 16,995 15, , ,276 3,32 133,848 19,627 4,943 6,885 17,478 14, , ,299 TOTAL H&SCP 369, ,712 (5,98) 491,592 (7,292) (7,236) (56) 172, ,382 Argyll & Bute CHP 129,33 129, , ,439 4,373 12,34 1, ,876 17,369 13, ,553 (4,5) 121 4,696 (4,5) , ,651 (1,893) 699,61 (5,814) (6,919) 1,15 (5,814) 5,814 6,919 (1,15) (1,893) 693,247 16,297 2,55 (4,5) 688,583 North & West Operational Unit South & Mid Operational Unit Adult Social Care - Central Raigmore Facilities Integrated Pharmacy e health Tertiary Other HCP Cental Services 17,594 Corporate Services 19,471 Central Costs & Reserves (4,5) Quality Agenda Savings 693,247 Total Expenditure Manangement Planned Actions Surplus/Deficit Mth 9 Finance - Monitoring 1, Area Finance Report-APPs.xlsx Total Summary 24/1/213 13:2

172 166 Income & Expenditure Report as at Annual Budget Initial Current Plan Plan Summary Health & Social Care Partnership 34,37 18,82 23,824 3,189 1, ,429 1, , ,123 34,468 19,94 22,768 3,4 9,22 115,95 1, ,94 117,854 North & West Operational Unit North Area - Caithness District - Sutherland District West Area - S,L, & WR District - Lochaber District North & West Area Mgt N & W Sub Total Sexual Health Services Highland Hub N & W Hosted Services Total North & West 24,814 3,153 27,163 16,485 19,596 24,723 3,882 27,79 16,684 2, ,31 126,552 18,145 1,217 1,669 18,693 39, ,276 South & Mid Operational Unit South Area - Inverness West District - Inverness East District - NABS district Mid Area - Easter Ross District - Mid Ross District South & Mid Midwifery Services South & Mid Unit Central S & M Sub Total Adult Mental Health Learning Disabilities Substance Misuse Dental Services Sub Total SE CHP Hosted services Total South & Mid 5,85 124,16 18,129 1,248 1,496 18,332 39,25 163,221 4,368 3,32 Adult Social Care - Central 49,399 73,671 4,367 3, ,33 48,826 72,237 4,192 4,249 4, ,848 19,768 4,81 4,433 16,995 15,854 61,851 19,627 4,943 6,885 17,478 14,356 63,289 Table 2 DECEMBER 212 Raigmore Operational Unit Surgical & Anaesth. Divison Medical & Diagnostics Division Raigmore Hotel Services Patient Support Division Raigmore Central Total Raigmore Other H&SCP Services Facilities Integrated Pharmacy e health Tertiary Other HCP Plan to Date YTD Position Actual to Date Variance to Date Forecast Outturn Prev month Forecast Var From Forecast Movement Outturn Current Plan Variance in month 25,885 14,259 17,32 23,35 4,917 85, ,43 86,828 26,85 14,292 18,463 23,435 4,533 86, ,588 88,397 (2) (33) (1,161) (399) 384 (1,41) (51) (17) (158) (1,569) 35,155 18,839 23,672 31,23 8,88 117,677 1, , ,664 (687) 255 (94) (83) 412 (1,727) (51) (32) (83) (1,81) (573) (1,252) 368 (1,274) (51) (28) (79) (1,353) (827) 212 (331) (453) (4) (4) (457) 19,414 24,25 2,53 12,68 15, ,673 97,59 13, ,193 13,949 29,57 126,629 19,585 24,38 19,991 12,794 16, ,959 97,398 13, ,133 13,886 29, ,687 (171) (186) (1,322) (53) 714 (339) (57) 25,291 31,167 27,172 17,52 21, , ,46 18,13 1,172 1,564 18,612 39, ,857 (568) (285) (93) (818) (1,743) (74) 728 (2,854) (2,581) (1,11) (765) 268 (962) (668) (52) 429 (2,851) (2,612) (361) 144 (1,75) (22) 299 (3) (6) ,98 9,224 (316) 1,258 1,774 1, ,68 53,821 3,114 3,157 2,949 99,723 39,61 53,795 3,237 3,397 2,21 12,58 (2,929) 27 (122) (239) 928 (2,336) 52,835 72,644 4,457 4,559 2, ,41 (4,9) (47) (265) (31) 1,799 (3,192) (4,395) (313) (261) (275) 1,836 (3,48) 386 (94) (4) (35) (37) ,683 3,723 5,212 13,19 1,81 47,527 14,736 3,735 5,198 13,9 1,777 48,345 (53) (12) 14 (791) 24 (818) 19,761 5,12 6,88 18,783 14,336 64,772 (134) (69) 5 (1,35) 2 (1,483) (14) (37) (1,2) 19 (1,358) 6 (32) 5 (15) 1 (125) 478, ,299 Total Health & Social Care Partnership 369, ,712 (5,96) 491,592 (7,292) (7,236) (56) 17,739 16,27 7,392 12,564 5,211 3,383 15,112 18,311 11,91 45,872 3,823 4,435 1, ,888 18,419 A & B CHP- Oban, Lorn & Isles 16,56 Mid Argyll, Kintyre & Islay 7,61 A&B MH In-patient Services 12,686 Cowal & Bute 4,915 Helensburgh & Lomond 4,847 Other clinical services 15,314 GMS 17,53 Prescribing 12,471 FHS Non Disc. Services 46,93 HCP - Glasgow & Clyde 3,88 HCP - Other 4,538 Resource Transfer 11,16 Central & Corporate 176,382 Total A&B CHP 13,722 12,382 5,585 9,471 3,636 3,178 11,59 12,773 8,496 35,28 2,911 3,44 7,55 129,33 13,826 12,398 5,585 9,538 3,575 3,21 11,611 12,337 8,496 35,28 2,959 3,44 6, ,136 (14) (16) () (67) 61 (23) (12) 436 () (47) ,62 16,669 7,535 12,786 4,815 4,876 15,414 16,393 12,471 46,93 4,49 4,538 11,87 176,182 (21) (19) 75 (1) 1 (29) (1) 66 (169) 73 2 (393) (124) (19) 125 (53) (15) 75 (269) (25) 24 5 (9) 1 (231) 2 16,297 25,5 (4,5) Central Services 17,594 Corporate Services 19,471 Central Costs/Reserves (4,5) Quality Agenda Savings 12,439 4,373 12,34 1, ,874 17,369 13, ,553 (4,5) 121 4,696 (4,5) , ,247 Total Net Expenditure 515, ,651 (1,893) 699,61 (5,814) (6,919) 1,15 Finance - Monitoring 5.2 Area Finance Report-APPs.xlsx Fin Position 24/1/213 13:2

173 DECEMBER Income & Expenditure Report as at Annual Budget Initial Current Plan Plan Summary Health excluding Adult Social Care Plan to Date Table 3 YTD Position Actual Variance to Date to Date Forecast Outturn Prev month Forecast Var From Forecast Movement Outturn Current Plan Variance in month North & West Operational Unit North Area - Caithness District - Sutherland District West Area - S,L, & WR District - Lochaber District - West Area Mgt N & W Sub Total Sexual Health Services Highland Hub N & W Hosted Services Total North & West 19,889 9,893 12,8 16,327 3,273 61, ,43 62,821 19,973 9,677 12,711 16,616 2,965 61, ,588 63,53 (84) 216 (72) (289) 38 (55) (51) (17) (158) (78) 26,688 13,69 16,395 22,118 6,899 85,169 1, ,986 87,155 (179) 196 (469) (61) 384 (669) (51) (31) (82) (751) (179) 163 (244) (573) 392 (44) (51) (28) (79) (519) 33 (225) (28) (8) (228) (3) (3) (231) 1,435 75,244 18,129 1,248 1,496 18,332 39,25 114,448 14,275 18,541 18,223 1,96 12, ,98 76,836 18,145 1,217 1,669 18,693 39, ,56 South & Mid Operational Unit South Area - Inverness West District - Inverness East District - NABS district Mid Area - Easter Ross District - Mid Ross District South & Mid Midwifery Services South & Mid Unit Central S & M Sub Total Adult Mental Health Learning Disabilities Substance Misuse Dental Services Sub Total SE CHP Hosted services Total South & Mid 1,743 13,986 13,691 8,281 9, ,61 57,323 13, ,193 13,949 29,57 86,893 1,813 13,82 13,82 8,259 9, ,31 13, ,133 13,886 29,289 86,599 (71) 165 (11) 21 (84) (53) ,365 18,393 18,378 11,3 12, ,787 76,975 18,13 1,172 1,564 18,612 39, ,426 (9) 148 (155) (7) (9) (74) 193 (139) (117) 143 (143) (116) (54) (52) 15 (188) (12) 46 (36) (22) (6) ,399 73,671 4,367 3, ,33 48,826 72,237 4,192 4,249 4, ,848 Raigmore Operational Unit Surgical & Anaesth. Divison Medical & Diagnostics Division Raigmore Hotel Services Patient Support Division Raigmore Central Total Raigmore 36,68 53,821 3,114 3,157 2,949 99,723 39,61 53,795 3,237 3,397 2,21 12,58 (2,929) 27 (122) (239) 928 (2,336) 52,835 72,644 4,457 4,559 2, ,41 (4,9) (47) (265) (31) 1,799 (3,192) (4,395) (313) (261) (275) 1,836 (3,48) 386 (94) (4) (35) (37) ,768 4,81 4,433 16,995 15,854 61,851 19,627 4,943 6,885 17,478 14,356 63,289 14,683 3,723 5,212 13,19 1,81 47,527 14,736 3,735 5,198 13,9 1,777 48,345 (53) (12) 14 (791) 24 (818) 19,761 5,12 6,88 18,783 14,336 64,772 (134) (69) 5 (1,35) 2 (1,483) (14) (37) (1,2) 19 (1,358) 6 (32) 5 (15) 1 (125) 26,2 12,265 16,698 21,15 8,366 84,679 1, ,695 86,374 26,59 13,265 15,926 21,517 7,283 84,51 1, ,94 86,45 14,368 17,86 18,437 11,338 11,87 Other H&SCP Services Facilities Integrated Pharmacy e health Tertiary Other HCP 394,3 4,12 Total Health & Social Care Partnership 296,964 3,532 (3,569) 45,394 (5,292) (5,234) (56) 17,739 16,27 7,392 12,564 5,211 3,383 15,112 18,311 11,91 45,872 3,823 4,435 1, ,888 18,419 A & B CHP- Oban, Lorn & Isles 16,56 Mid Argyll, Kintyre & Islay 7,61 A&B MH In-patient Services 12,686 Cowal & Bute 4,915 Helensburgh & Lomond 4,847 Other clinical services 15,314 GMS 17,53 Prescribing 12,471 FHS Non Disc. Services 46,93 HCP - Glasgow & Clyde 3,88 HCP - Other 4,538 Resource Transfer 11,16 Central & Corporate 176,382 Total A&B CHP 13,722 12,382 5,585 9,471 3,636 3,178 11,59 12,773 8,496 35,28 2,911 3,44 7,55 129,33 13,826 12,398 5,585 9,538 3,575 3,21 11,611 12,337 8,496 35,28 2,959 3,44 6, ,136 (14) (16) () (67) 61 (23) (12) 436 () (47) ,62 16,669 7,535 12,786 4,815 4,876 15,414 16,393 12,471 46,93 4,49 4,538 11,87 176,182 (21) (19) 75 (1) 1 (29) (1) 66 (169) 73 2 (393) (124) (19) 125 (53) (15) 75 (269) (25) 24 5 (9) 1 (231) 2 12,439 4,372 12,34 1, ,873 17,369 13, ,553 (4,5) 121 4,696 (4,5) ,16 443,472 (367) 612,863 (3,814) (4,917) 1,15 16,297 25,5 (4,5) 63,693 Central Services 17,594 Corporate Services 19,471 Central Costs/Reserves (4,5) Quality Agenda Savings 69,49 Total Net Expenditure Finance - Monitoring 5.2 Area Finance Report-APPs.xlsx Health 24/1/213 13:2

174 Income & Expenditure Report as at Annual Budget Initial Current Plan Plan Summary Adult Social Care DECEMBER Plan to Date YTD Position Actual to Date Table 4 Variance to Date Forecast Outturn Prev month Forecast Var From Forecast Movement Outturn Current Plan Variance in month 7,836 5,818 7,126 9,39 1,931 31,749 7,959 5,829 6,842 8,883 1,936 31,449 North & West Operational Unit North Area - Caithness - Sutherland District West Area - S,L, & WR District - Lochaber District North & West Unit Central Total North & West 5,996 4,366 5,294 6,78 1,644 24,8 6,112 4,615 5,753 6,818 1,568 24,868 (116) (249) (459) (11) 75 (859) 8,467 5,77 7,277 9,85 1,99 32,58 (58) 59 (435) (22) 27 (1,59) 318 (12) (328) (679) (26) (835) (826) 179 (17) (224) 1,447 12,293 8,726 5,148 7,79 4,37 48,773 1,447 12,342 8,856 5,724 8,17 4,33 49,716 South & Mid Operational Unit South Area - Inverness West District - Inverness East District - NABS district Mid Area - Easter Ross District - Mid Ross District South & Mid Unit - Central Total South & Mid 8,671 1,22 6,811 4,328 6,95 3,612 39,736 8,771 1,217 6,189 4,535 7,333 3,42 4,88 (1) (27) (1,238) 569 (351) 1,926 12,774 8,794 6,472 9,67 3,795 52,431 (479) (432) 62 (748) (1,653) 535 (2,715) (984) (98) 412 (845) (613) 278 (2,66) (35) 97 (1,4) 257 (55) 8,98 9,224 (316) 1,258 1,774 1, ,652 74,18 (1,526) 86,197 (2,) (2,) 4,368 84,89 3,32 Adult Social Care - Central 84,197 Total Net Expenditure Finance - Monitoring 5.2 Area Finance Report-APPs.xlsx Adult Social Care 24/1/213 13:2

175 NHS Highland Savings 212/13 Savings Target Rec Non Rec Target Target Total Position as at DECEMBER 212 Savings 169 Table 4 Position to Date Forecast to achieve Achieved YTD Forecast REC Non Rec REC Non Rec In Year Balance To Achieve Next Year Forecast FYE 213/14 Outstanding C/Fwd H&SC Partnership 1,53 1,658 4,366 4, ,266 1,53 1,658 4,366 4, ,266 2,828 3,347 2,828 Argyll & Bute CHP 3,347 Central Costs & Reserves 795 Corporate Services 3,347 19,236 Total Efficiency Savings ,889 4,5 2,389 North & West Operational Unit South & Mid Operational Unit Adult Social Care Raigmore Facilities Integrated Pharmacy e health Sub Total H&SC Partnership ,395 1, , , ,374 1, 568 5, , , , , (3,232) (1,8) 122 (854) 2,787 2,586 1, , ,838 () () 1,969 () 63 (4) 2,28 1,737 4,5 System Wide Quality Initiatives - Harm - Waste - Variation 3,347 23,736 Total CRS 179 1, ,5 9,573 7, ,737 3,646 4,5 2,787 7,86 TRUE Finance - Monitoring 5.2 Area Finance Report-APPs.xlsx CRS 24/1/213 13:2

176 Capital Income & Expenditure Report Annual Plan Position to Date Original Plan Current Plan Summary Funding & Expenditure 's 's 5, ,2 2,796 9,682 5, ,9 35 1,372 2,433 12,14 (564) 9,118 FUNDING NHS Highland Capital Allocation (Formula) Radiotherapy replacement Mull & Iona Oban Dental NOSCAN Funding Carbon Reduction Programme CEEF Funding Allocation Letter Dec ,329 8,329 12, (274) 24 (376) (125) (163) (23) (274) 24 (376) (125) (163) (23) (411) 24 (564) (187) (245) (345) ,843 Total SGHD Capital Funding 8,643 8,643 12,843 Expenditure/Commitments Mull & Iona Oban Dental Radiotherapy replacement Greater Inverness Masterplan Lifecycle Costs ERPCC Lifecycle Costs Mid Argyll Capital Salaries LinAcc Raigmore Hubco SubDebt Tain Enabling Works , (273) (32) 16 3 (33) (1) (545) 1, ,63 1,418 (645) 2,679 1, , (417) (27) (558) (826) 6, ,15 1,35 3,764 1,692 (2,72) 9, (278) (11) 53 (26) (36) 2 () (68) (41) (14) (78) (42) (5) (14) (18) 267 (176) (96) (235) 235 1,213 (136) (136) 6,785 3,163 (3,623) 13,214 (136) (235) 6,785 3,163 (3,623) 12,979 (136) (1,857) (5,48) (3,623) 136 (136) - Non Core Funding IFRS 12,385 SGHD Funding 5 (411) 24 (564) (187) (245) (345) Pending allocations Mull & Iona Oban Dental Revenue to Capital Virement Reversionary Interest - PFI's Radiotherapy replacement UK GAAP Capital Capital to Revenue Virement HFS Equipping Funding A&B CMH Bases Tain Enabling Riverbank GP Premises Surveillance Endoscopy Equipment 2,679 Commitments 2, , ,15 1,35 3,73 9,322 Rolling Programmes Other 5 Raigmore SSD washer/disinfectors 48 A&B 2 Washer/Disinfectors 35 NOSCAN Equipment 24 Revenue to Capital Virement 9 Community Jaundice Meters 55 Laundry Equipment Buy Out 18 Raigmore ION Replacement 78 Radiotherapy Equipment 56 Belford Hotel Services Equipment 5 Riverbank GP Premises 19 Ross Memorial Dental Chair 24 Surveillance Endoscopy Equipment (371) Contingency 235 NBV Disposals 1,77 Other Rolling Programmes Estates Backlog Main. Medical Equipment ehealth Replacement Radiology 13,78 Gross Capital Expenditure (235) NBV Disposals 9,118 Variance from Current Plan 5, ,9 35 1,372 2,433 12,14 4,341 9,118 Forecast Outturn 1, ,47 Forecast Outturn Actual to Variance Date to Date 3, , ,622 8,84 1,2 2, Plan to Date Table 1 3, , ,622 8, , Month 9-31st December ,843 Net Capital Expenditure SURPLUS/DEFICIT MONTH 9

177 171 Highland NHS Board 5 February 213 Item 5.3 INTERNAL AUDIT REVIEW OF WAITING TIMES Report by Nick Kenton, Director of Finance on behalf of Elaine Mead, Chief Executive The Board is asked to: 1 Consider the findings of the attached audit report. Note the management action plan. Remit the Audit Committee to monitor the implementation of the action plan. Background and Summary Internal audit undertook a review of waiting times at NHS Highland between September and November 212. The review was directed by the Scottish Government Health and Social Care Directorates (SGHSCD) in response to a request by the Cabinet Secretary for Health and Well-being for all relevant health boards in Scotland to audit local waiting times management arrangements. This report was considered by the Audit Committee on 4 December 212 and is required to be considered by the full Board. 2 Internal Audit Report The full internal audit report is attached. The report sets out the national context, background and the audit approach followed. The main findings are described on page 4. The key overall finding was that there was no indication of any systematic and deliberate mis-recording or mis-reporting of waiting times which would materially impact on achievement of waiting times targets. However, in a small number of cases tested internal audit identified inconsistencies in the implementation of the waiting times guidance which resulted in the avoidance of a breach against the 18 week RTT target, when correct implementation of the guidance would have resulted in a breach. From wider analysis performed and extended sample testing undertaken (including focussing on suspensions applied to journeys near to breaching) this would not appear to have a high risk of a material impact on reporting against waiting times targets. Audit also found that the Board takes the management of waiting times very seriously, with regular scrutiny at Board and Committee levels. A detailed management action plan is set out on pages 7 to 13 including timescales and responsible officers. 3 Contribution to Board Objectives The objective Our Vision and Strategy includes a commitment to deliver all HEAT (Health, Efficiency, Access & Treatment) targets. The delivery of waiting times targets is a key Access target. 4 Governance Implications The audit report provides independent assurance to the Board regarding the systems in place to manage waiting times in NHS Highland. The Board is asked to consider the report and to remit to the Audit Committee the oversight of the management action plan.

178 172 5 Risk Assessment The risk of failure to meet HEAT targets is on the Corporate Risk Register, under the ownership of the Chief Executive. Any risks relating to specific targets are monitored on the Board s behalf by the Improvement Committee at which officers are required to provide assurance and action plans as appropriate. 6 Planning for Fairness Waiting times management is an important aspect of ensuring patients are treated fairly in accordance with government policy on access. Nick Kenton Director of Finance 25 January 212 2

179 173 NHS Highland Internal Audit Report Waiting Times November 212

180 174 NHS Highland Internal Audit Report Waiting Times November Introduction Background Audit Approach Summary of Findings Executive Summary Management Action Plan... 6

181 175 1 Introduction Between September and November 212 we carried out a review of waiting times at NHS Highland. The review was directed by the Scottish Government Health and Social Care Directorates (SGHSCD) in response to a request by the Cabinet Secretary for Health and Well-being for all relevant health boards in Scotland to audit local waiting times management arrangements. 2 Background Patient waiting times is a key indicator of the accessibility of services and the quality of patient care. Reduced waiting times can result in earlier diagnosis and better outcomes for patients and can also improve the patient journey by reducing uncertainty and unnecessary worry. The Scottish Government introduced a HEAT target to reduce waiting times across NHS Scotland. The overall national target is that, from December 211, at least 9% of patients should receive treatment within 18 weeks of being referred (known at the Referral To Treatment time RTT). There are also related targets within this area, for example 12 week outpatient and 9 week admission "Stage of Treatment" targets. As at December 211, 92% of patients in Scotland whose journey could be fully measured were treated within 18 weeks, compared to 82% in January 211, an increase of around 12, patients. NHS Highland has exceeded the HEAT target and consistently performed around or above the national average in the nine months to June 212. Month Oct 211 Nov 211 Dec 211 Jan 212 Feb 212 Mar 212 Apr 212 May 212 June 212 Patient Journeys within RTT target (%) NHS Highland Patient Journeys within RTT target (%) Scotland To support consistency and fairness in managing and reporting on patient waiting times across NHS Scotland, SGHSCD introduced the New Ways approach in January 28. The waiting time clock was introduced which records the time between referral and treatment or outpatient admission, excluding periods when the patient is unavailable. To ensure that all patients are being managed in line with the guidance, health boards are required to record data clearly and accurately. All stages of the patient s journey must be recorded to calculate the waiting time, with NHS Highland using the isoft (North Highland area) and Helix (Argyll & Bute area) patient management systems for this purpose. The reason for having two different systems relates to the Board taking on responsibility in 26 for part of the area previous covered by Argyll and Clyde health board. Waiting times - national context The management of waiting times has come under national scrutiny following the publication of a report on waiting times in NHS Lothian. The main findings of the report include observations of: Excessive and inappropriate use of periods of patient unavailability; Manual adjustments to those patients who were breaching waiting times before reporting to more senior management levels; A practice of don t minute or record, which prevented full details of waiting times issues progressing up the operational framework where a more strategic and collective approach could have been NHS Highland Internal Audit Report Waiting Times November 212 Scott-Moncrieff 1

182 176 taken; and An encouragement to local operational staff to resolve issues through adjustments of waiting times figures rather than actually resolving delays. As a result of these observations the Cabinet Secretary for Health and Well-being requested all relevant NHS boards to commission an internal audit review of local waiting times arrangements. These findings are to be reported to SGHSCD. 3 Audit Approach The scope of this review was set by SGHSCD in a letter to NHS boards on 3 May 212 seeking audit assurance in relation to the specific objectives listed in Section 4 of this report. We have completed our work in accordance with those terms of reference. This review was supported by an analysis of waiting list information from the electronic patient management system and covered the two quarters ending March 212 and June 212. The extraction and analysis of this data was to be performed for all 14 territorial health boards and the National Waiting Times Centre Board by a single third party contractor appointed by SGHSCD, PwC. In line with the terms of that appointment, we used the output we received from the analysis to inform the nature and extent of our audit work and associated sample testing. However, the vast majority of the data analysis was unable to be performed in the originally planned way as relevant data was not extracted successfully from the North Highland patient management system, which covers the North Highland area. PwC spent time from the date of their appointment looking to understand and analyse the systems and data. They concluded that all data queries for the isoft system could not be run. Accordingly, in mid October 212, approximately 2% of the planned data queries were provided to us by PwC. Mindful of reporting deadlines, we developed and implemented our own contingency arrangements to deal with these data extraction issues in North Highland. This enabled us to analyse and select data for testing in an alternative way. This led to an extensive sample population being tested, including focussing on unavailability/suspensions, journey times around breach dates and review of entire patient journeys. This end-to-end approach gives greater insight into the entire patient journey compared to more aspect-specific queries which would have resulted if the data analysis had been successful in North Highland. However, this alternative approach could not initially be as directive and exception-based without the full PwC data. A similar data analysis and extraction problem was encountered at NHS Greater Glasgow and Clyde, which also uses the isoft patient management system. We liaised closely with the internal audit team responsible for that waiting times review to ensure consistency of approach and confirm a robust audit methodology was employed across both audits. We have also played an active part in national discussions involving NHS internal auditors across Scotland, including representation from SGHSCD and coordination with Audit Scotland, to promote a rigorous and consistent approach to this audit across all boards. The following is a summary of the waiting times key milestones since the publication of the initial internal report on NHS Lothian s waiting times arrangements, through to our final reporting to NHS Highland: Action Dates: Argyll & Bute 1. Publication of NHS Lothian internal report on waiting times 9 Jan Publication of PwC NHS Lothian Report 19 Mar Cabinet Secretary for Health and Well-being response to PwC report 31 Mar SGHSCD internal audit of Waiting Times Terms of Reference to NHS Boards 3 May 212 NHS Highland Internal Audit Report Waiting Times November 212 Dates: North Highland Scott-Moncrieff 2

183 Data analysis - tendering process completed by SGHSCD (PwC appointed) 16 July Start of fieldwork on governance, reporting and local guidance 5 Sept Data pack received from PwC 13 Sept Oct 212* 8. Selected sample information from data pack received 19 Sept Oct 212* 9. Data testing commenced 28 Sept Oct 212* 1. Data testing completed (fieldwork completed) 14 November Draft report issued for formal management responses 19 November Final report presented to NHS Highland Audit Committee 4 December Final report issued to Scottish Government 17 December 212 *The substantial delay to the North Highland data extraction and analysis explains the respective dates when we were able to undertake our work. Our detailed findings are discussed in the Management Action Plan (section 6) of this report. 4 Summary of Findings The table below summarises our assessment in relation to each of the audit objectives specified by SGHSCD. All control weaknesses identified are included in the Management Action Plan in section 6. No. Audit Objective Assessment Grading & no. of agreed actions Individual patient records are accurate and systems are in place to ensure that the patient administration system cannot be inappropriately changed. 2 Reporting on the target waiting times is accurate and consistent at every level of the organisation up to and including the Board. YELLOW 1 3 The local guidance is consistent with national guidance and its implementation is both valid and reliable (i.e. not open to different interpretation in use). YELLOW 1 TOTAL NUMBER OF AGREED ACTIONS Assessment RED Definition BLACK RED YELLOW GREEN Fundamental absence or failure of key control procedures - immediate action required. The control procedures in place are not effective - inadequate management of key risks. No major weaknesses in control but scope for improvement. Adequate and effective controls which are operating satisfactorily. NHS Highland Internal Audit Report Waiting Times November 212 Scott-Moncrieff 3

184 178 5 Executive Summary Conclusion Our findings do not indicate the existence of systematic and deliberate mis-recording or mis-reporting of waiting times which would materially impact on achievement of waiting times targets. However, in a small number of cases tested we identified inconsistencies in the implementation of the waiting times guidance which resulted in the avoidance of a breach against the 18 week RTT target, when correct implementation of the guidance would have resulted in a breach. From wider analysis we have performed and extended sample testing undertaken (including focussing on suspensions applied to journeys near to breaching) this would not appear to have a high risk of a material impact on reporting against waiting times targets. Main findings The Board takes the management of waiting times seriously, with regular reporting and scrutiny at Board and Committee levels. This is coupled with detailed analysis by senior management and operational groups to scrutinise the detail and trends within this complex area. We performed extensive testing over patient records and waiting times recording processes, in addition to reviewing the reporting and governance of those processes. This involved testing some 2 individual patient records, across both North Highland and Argyll & Bute. In North Highland we tested 133 patient journeys from referral to treatment (RTT), to ensure that the patient journey was recorded in line with the New Ways guidance and the Waiting Times Recording Manual. This testing identified 6 potential issues. These issues may relate to the extent and method of recording of these specific cases, within a system which management have advised is having to be used in a way not originally anticipated. We identified 4 cases where periods of social unavailability had been applied. However, in these 4 instances the narrative to support the period of unavailability did not support the dates that had been recorded on the patient management system, including one case where an additional 26 days of unavailability had been applied, apparently without sufficient justification. In all these cases, the unavailability avoided a breach against RTT target, although these were reported appropriately against stage of treatment targets. We also identified 2 instances where the patient had a period of unavailability applied because they had not responded to a patient-focussed booking (PFB) contact. In these cases a period of unavailability was applied for 14 days, providing 11 days more unavailability than we expected. This was because the unavailability was applied to the initial tranche of the PFB (ie between initial letter and the reminder letter) rather than from the date of the reminder letter until a response was received from the patient. In both these cases the unavailability avoided a breach against RTT target, although we identified no issues in relation to reporting against stage of treatment targets. Given our wider analysis and extended testing, these cases do not appear likely to have contributed to a material impact on reporting against waiting times targets. This is because we tested a large number of unavailabilities, including those which were applied around the RTT target time. This enabled us to assess the materiality of these issues in context. Our work included cross referencing unavailability against RTT times using computer analysis techniques, to help specifically target this extended testing. Our targeted patient record testing in Argyll and Bute did not lead to any reportable exceptions. In the Management Action Plan we have identified a number of further areas which, if addressed, would strengthen the organisation s waiting times processes. These include: When staff apply a period of patient unavailability (i.e. a patient is suspended from the waiting list) they often do not record any or sufficient detail of why the unavailability is being applied. The Waiting Times Recording Manual states that an explanation to support the period of unavailability should be recorded. This occurred in around one third of the sample tested, including cases where the RTT NHS Highland Internal Audit Report Waiting Times November 212 Scott-Moncrieff 4

185 179 target was nowhere near breached. Audit trail capabilities in place within the North Highland patient management system are not sufficiently robust. During testing we sought to analyse a sample of unavailability periods to establish when they were applied. However, we found that the audit trail within the system was often incomplete with the system regularly auto-erasing historic adjustments. We appreciate the need for pragmatism and costefficiency in dealing with systems, but sufficient audit trail is vital in such a high profile area. System access privileges should be reviewed to ensure that access is commensurate with user roles and responsibilities. The local access policy needs further review and update against revised national guidance and regulations. Patient and wider stakeholder input could support this process. These issues are discussed further in the Management Action Plan at Section 6 of this report. Basis of opinion In giving our opinion it should be noted that assurance can never be absolute. The most that the internal audit service can provide is reasonable assurance that there are no significant weaknesses in the areas within the scope of this review. In particular, the absence of clear and evidenced audit trails and issues with the specific cases highlighted above prevents us being able to provide fuller assurance. Acknowledgements We would like to thank all staff consulted during this review for their assistance and co-operation. NHS Highland Internal Audit Report Waiting Times November 212 Scott-Moncrieff 5

186 18 6 Management Action Plan Grading of recommendations Our grading structure helps management assess the significance of the issues raised and prioritise the action required to address them. The grading structure is as follows: Grade Definition 5 Very high risk exposure - Major concerns requiring immediate Board attention. 4 High risk exposure - Absence / failure of significant key controls. 3 Moderate risk exposure - Not all key control procedures are working effectively. 2 Limited risk exposure - Minor control procedures are not in place / not working effectively. 1 Efficiency / housekeeping point. NHS Highland Internal Audit Report Waiting Times November 212 Scott-Moncrieff 6

187 181 Management Action Plan 1 Key control objective: Individual patient records are accurate and systems are in place to ensure that the patient administration system cannot be inappropriately changed. Observation and Risk 1.1 Recommendation Whilst awaiting further national guidance we are taking a range of management actions: Waiting times In North Highland we tested 133 patient journeys to ensure they had been recorded in line with the New Ways guidance and Waiting Times Recording Manual. This identified 4 cases where a period of social unavailability was applied but the narrative to support the unavailability did not agree with the data recorded on the patient management system. The impact of this excess unavailability was that the patient journey did not breach the RTT deadline. We also identified 2 instances where the patient had a period of unavailability applied because they had not responded to a patient-focussed booking (PFB) contact. In these cases a period of unavailability was applied for 14 days, allowing 11 days more unavailability than we would otherwise expect. Given our wider analysis and extended testing (as explained further in the Executive Summary, above), there does not appear to be a high risk of a material impact on reporting against waiting times targets. However, these are still notable findings in themselves. We cannot give absolute assurance whether these specific cases were deliberate manipulations, due to the lack of a sufficient audit trail within the North Highland patient management system and related records. Management Response All staff should be clearly instructed to record waiting times accurately and with full reference to relevant back up. Further controls should also be put in place; for example, we suggest management should design an exception report to identify all cases which would have breached had a period of unavailability not been applied. These cases should be double checked and signed off by an independent officer in full in the short term, and potentially on a sample basis thereafter (dependent on the outcome of the checking in the more immediate term). The results of this work should be reported to relevant management for assurance. 1. Standard Operating Procedure has been developed across Northern NHS Highland to ensure that User IDs are recorded, start and end date to be agreed at PAS Users Group in December NHS Highland has a report on the Intranet detailing all patients who have a period of unavailability over 1 weeks which is reviewed at Operational Level. 3. NHS Highland has developed an Experienced Wait Report that identifies patients who would have breached had a period of unavailability not been st applied. The report will be tested from 1 December at Raigmore Hospital with the intention of implementing this report across the whole of Highland 4. A report will be developed to identify PFB non responders that highlights any patient with unavailability greater than 7 days. We will make any further changes required once we receive the awaited national guidance for management of nonresponders, along with refresher training for all PFB staff to confirm compliance with the policy. To be actioned by: Chief Operating Officer No later than: January 213 (impact of national guidance will depend on published date.) Grade NHS Highland Internal Audit Report Waiting Times November Scott-Moncrieff 7

188 182 Management Action Plan Observation and Risk 1.2 Recommendation Management Response Periods of unavailability (suspensions) Where a patient is unable to undergo treatment due to either medical or social reasons the patient should be recorded as unavailable (effectively suspended from the waiting list). This should only be applied if legitimate medical or social reasons are given, such as the patient going on holiday. The periods of unavailability are deducted from the patient s total waiting time to give a true reflection of the actual waiting time. Staff should be reminded that they should record sufficient and appropriate details of why the patient is unavailable, to support any recorded period of unavailability. Standard Operating Procedure has been developed across Northern NHS Highland to ensure that User IDs are recorded, start and end date to be agreed at PAS Users Group in December 212. In the meantime the operational staff will continue to be reminded of the need to record unavailability details through the regular waiting times management meetings. We performed detailed testing over the creation of periods of unavailability to ensure adequate evidence was in place to support the suspensions and they were in line with the New Ways guidance. This identified some one-third of cases where there was not sufficient evidence to explain why the period of unavailability had been created or amended. To be actioned by: Chief Operating Officer There is a risk that periods of unavailability are being created or amended without appropriate patient contact/audit trail. This is non-compliant with New Ways guidance. NHS Highland Internal Audit Report Waiting Times November 212 No later than: January 213 Grade 3 Scott-Moncrieff 8

189 183 Management Action Plan Observation and Risk 1.3 Recommendation Management Response The Board should liaise with the software provider to ascertain if the audit trails can be improved. Ideally the auto-erase of historic actions should be removed (or at least curtailed). This will allow management to conduct their own internal investigations, as and when appropriate, to satisfy themselves that patient journeys are being treated correctly. NHS Highland Board are considering a business case in December 212 for the introduction of the national PMS system. North Highland PMS audit trail/timestamps To gain further assurance on a number of patient journeys we sought to analyse the audit trail and timestamps within the North Highland patient management system to determine when each adjustment was made and by whom. However, in all but one case we found that the audit trails and timestamps were incomplete as the system autoerases historic adjustments, given the limitations of the system. There is a risk that inappropriate changes are made to the patient journey and these are not recorded appropriately. Management will not be able to identify, investigate and resolve any potential issues or misuse of the system. The existence of this trail would also act as a deterrent, to discourage anyone from amending records inappropriately. (This issue may be superseded, dependent on action taken and timing to address Action Plan Point 2.3, below) Discussions with Isoft confirmed the amendments could not be made within the timescales. Subjected to Board approval the implementation of the new PMS system will commence in April 213 To be actioned by: Head of ehealth st No later than: 1 April 213 Grade NHS Highland Internal Audit Report Waiting Times November Scott-Moncrieff 9

190 184 Management Action Plan Observation and Risk 1.4 Recommendation Management Response We recommend that management reviews the list of privileges to ensure that the list is current, relevant and access is commensurate with user roles and responsibilities. 1. A review of the Privileges in existence across NHS Highland has identified a significant piece of work to take forward the recommendation. Consideration is being given to whether this is beneficial given the likely timescale for the introduction of a new PMS System. System access Within the patient management systems there are multiple user access privileges that have been created over a number of years. These privileges are used to grant access to certain parts of the system and are generally granted based on the individual s job role. For example, if an existing Helix user has certain privileges, a new Helix user with the same job role will also be granted those privileges. The detail of access allowed by each privilege is not always clear and there is a risk that staff may be granted access to parts of the system that may not be aligned to their specific role or responsibility. 2. Work is underway to establish the SOPs that are required to be undertaken by each Job Profile, and then identify the PAS user profile that is required for each job family. To be actioned by: Head of ehealth No later than: October 213 Grade NHS Highland Internal Audit Report Waiting Times November Scott-Moncrieff 1

191 185 Management Action Plan 2 Key control objective: Reporting on waiting times is accurate and consistent at every level in the organisation up to and including the Board Observation and Risk 2.1 Recommendation Management Response Waiting times system integration NHS Highland operates two separate patient management systems: Helix in Argyll & Bute and isoft in North Highland. The reason for having two different systems relates to the Board taking on responsibility in 26 for part of the area previous covered by Argyll and Clyde health board. As well as presenting the Board with dual training/ recording/systems management costs, waiting times data for both areas needs to be merged in order to submit the Monthly Management Information (MMI) spreadsheet to SGHSCD and to inform Board-wide reporting. Whilst there are quality control checks in place over the the merging and publication process which help safeguard against errors, there remains an ongoing risk that the data may not be consolidated correctly and NHS Highland reports an inaccurate waiting times position. Further, there are wider cost/overhead and operational implications of continuing to run two separate systems. NHS Highland Internal Audit Report Waiting Times November 212 We are aware that initial work has been done to look at this area within NHS Highland. We believe the Board should take this initial work further and prepare a formal, detailed business case which looks at all qualitative and quantitative aspects of future patient management system provision. NHS Highland Board meeting in December 212 is considering a Business Case to replace the PAS systems across the Board. From our initial assessment, it would seem sensible to hold an initial preference for one, unified system for the whole Board area to resolve the current situation (which was the product of external circumstance). A unified approach would remove current duplication and reduce consolidation/data risks. System update/integration may also help resolve some of the issues the Board is experiencing with the North Highland patient management system. To be actioned by: Head of ehealth No later than: December 212 Grade 3 Scott-Moncrieff 11

192 186 Management Action Plan Observation and Risk 2.2 Recommendation Management Response Waiting times data available to consultants We interviewed consultants, including to discuss their interaction with the management on waiting times within their respective specialities. A common issue was that they felt patients could benefit from consultants getting earlier warning of potential breaches, including from access to more detailed reports on waiting times data. Consultants felt this could enable them to proactively plan additional capacity (if needed) and to review the reasons for referral and outcomes. Making information for consultants as tailored and user-friendly as possible could minimise reactive action and lead to a more responsive and integrated approach. We recognise that that NHS Highland is progressing with significant additional and improved reporting from their PMS system through the Highland Information Portal. The discussions within NHS Highland ehealth to better engage consultants and establish a forum to discuss, determine and agree the data needs of the clinicians should be taken further. It may also be useful to analyse the needs and wants of other key stakeholder groups to consider the cost/benefit (and appetite) for other, tailored reports. Consultants currently have ready access to patient level information via their individual service managers whose role it is to ensure service planning and delivery of waiting time targets through detailed discussions with clinicians. However to compliment this information and to respond to our discussions with consultants on how the information for each patient could be presented, work has commenced with the Urology specialty to design patient pathway information similar to the reports that have been designed for use by NHS Western Isles for patients treated in NHS Highland. To be actioned by: Head of ehealth st No later than: 1 April 213 Grade NHS Highland Internal Audit Report Waiting Times November Scott-Moncrieff 12

193 187 Management Action Plan 3 Key control objective: The local guidance is consistent with national guidance and its implementation is both valid and reliable (i.e. not open to different interpretation in use). Observation and Risk 3.1 Recommendation Management Response Managing Access for Patients policy At time of writing, the Managing Access for Patients policy was published in November 29 and has not been reviewed or updated since that time. This is the main, overarching policy NHS Highland has in place for managing patient waiting times. A paper was presented to NHS Highland s Board in April 211 that recommended updates to the policy. These do not appear to have been completed and approved. Without an up-to-date policy, staff and patients may not be fully aware of the processes in place and respective roles/responsibilities. In addition, an out-ofdate policy may result in NHS Highland not complying with the NHS Scotland National Access Policy and The Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 212. NHS Highland should review and update the Managing Access for Patients policy against updated NHS Scotland Treatment Time Guidance and the NHS Scotland National Access Policy. We agree with the Recommendation and NHS Scotland s Central Legal Office approval of the business processes will shape the NHS Highland Managing Access for Patients Policy. The existing policy is available on NHSH website In line with the recommendations in the National Access Policy, the Board s local policy should be developed with appropriate patient participation and published on the Board s website. Once published, a training and awareness programme for all staff involved in waiting times should be developed. To be auctioned by: Chief Operating Officer st No later than: 31 March 213 Grade NHS Highland Internal Audit Report Waiting Times November Scott-Moncrieff 13

194 188 Scott-Moncrieff ( one of Scotland s leading independent professional services firms, provides industry-focused audit, tax, business advisory and corporate consulting services for commercial, public, not-for-profit and private clients. Scott-Moncrieff Chartered Accountants 212. All rights reserved. Scott-Moncrieff refers to Scott-Moncrieff Chartered Accountants, a member of Moore Stephens International Limited, a worldwide network of independent firms. Scott-Moncrieff Chartered Accountants is registered to carry on audit work and regulated for a range of investment business activities by the Institute of Chartered Accountants of Scotland.

195 189 Highland NHS Board 5 February 213 Item 5.4 THE DEVELOPMENT OF PRIMARY CARE SERVICES IN TAIN FORRES, WOODSIDE, TAIN FWT BUNDLE PROJECT FULL BUSINESS CASE Report by John Bogle, Acting Head of Capital and Property Planning on behalf of Nick Kenton, Director of Finance The Board is asked to: Consider and approve the FWT Bundle Full Business Case (FBC). Acknowledge that the FWT Bundle FBC is based on a predicted maximum unitary charge based on the financial model developed at OBC (Outline Business Case) Addendum Stage. This sum will be regarded by the FWT Project Board as a not-to-beexceeded sum at the conclusion of Stage 2 and Financial Close. Agree that the FWT Bundle FBC is forwarded to the Scottish Government Capital Investment Group (SGCIG) with a recommendation for approval. 1 Background and Summary The NHS Highland Board approved the Tain Health Centre Outline OBC Addendum in November 212 and agreed that the Project Team should proceed to develop an FBC. As previously detailed, the Tain project is too small to achieve value for money in revenue financing terms and it was therefore bundled with 2 similar projects in NHS Grampian to achieve a critical mass for revenue funding. The 3 projects have now been brought together into one FBC for consideration by the 2 health boards and SGCIG. With the encouragement of Scottish Government the FWT Bundle Project has been working to an accelerated programme which pending approval by the Boards and SGCIG would see Financial Close in mid March 213, a start on site in mid April 213 and completion in mid April 214. This accelerated programme means that this FBC is based on the costs contained in the OBC Addendum and as such are a cap which will not be exceeded. The project will still be subject to the strict scrutiny of external advisors and a Key Stage Review by Scottish Futures Trust (SFT), this will be done later but before Financial Close. 2 Progress Since OBC Addendum Approval in November 212 Strategic Context The FBC includes the redevelopment of three health centres in Aberdeen, Forres and Tain. Planning of the proposed health centres has been taken forward in line with relevant national policy, local strategy and NHS guidance including e.g. NHSScotland Quality Strategy Delivering Quality in Primary Care Action Plan and NHS Highland s Quality Approach These strategies describe the need to provide appropriate community services so that care can be delivered as close as possible to people s homes. NHS Grampian and NHS Highland are committed to improving access to services for the public and therefore a need to provide investment in appropriate building infrastructure in the community to help achieve these objectives, with greater levels of need addressed in community settings and an increased emphasis on anticipatory care, self-care, re-enablement and health improvement.

196 19 Background The FBC seeks support for the proposed investment to develop new premises for a range of primary and community services in the Grampian and Highland Health Board areas. The FWT Bundle project includes three projects; the Forres Health and Care Centre, the Woodside Fountain Health Centre and the Tain Health Centre. Although there were three separate OBCs, there is a single FBC and a single SFT Contract (Project Agreement). The Forres project received Scottish Government Health & Social Care Directorates (SGHSC) OBC approval in April 211 and OBC Addendum approval in November 212. The Woodside project received SGHSC OBC approval in November 212 and the Tain project received SHGD OBC approval in July 211 and SGHSC OBC Addendum approval in November 212. All three projects were invited to submit a FBC on the basis that the projects will be developed as a Design, Build, Finance and Maintain (DBFM) project via the hub initiative. The three projects are to be delivered using a single DBFM bundled project with a single FBC and single SFT standard form Project Agreement covering two Health Board areas. This is the first hubco bundle project in Scotland using the hubco DBFM Service Concession Contract involving three projects over two health board areas. The SFT Standard Form Contract has been amended by SFT and their legal advisors to ensure that, from a governance and commercial perspective, both Boards and hubco are protected when they enter into a single Project Agreement covering two organisations (Health Boards). In addition to the Project Agreement an Interface Agreement between NHSG and NHSH will be developed to provide a joint framework within which each partner Board must operate to avoid any actions which may cause undue risk to either partner as a consequence. Progress Stage1 approval was confirmed by NHSG and NHSH on 29 November 212 following Key Stage Review (KSR) approval from SFT on 6 November 212. Stage 2 formally commenced on 22 October 212 and is scheduled to be completed on 4 March 213. The Tain site is in the ownership of Highland Council who have constructed an access road which will serve the health centre and adjacent care home. The purchase price for the site has been agreed and is expected to conclude mid February 213. Full planning consent for the development was granted in June 212. The FWT bundle of projects will be delivered by a Sub-hubCo (a non recourse vehicle funded from a combination of senior and subordinate debt underpinned by a 25 year service concession contract). The senior debt will be provided by a project funder (Aviva) and the subordinate debt by a combination of Private Sector (6%), Scottish Futures Trust (1%) and Participant investment (3%). The participant investment will include an agreed pro-rata contribution from both participating Boards (NHS Grampian and NHS Highland). SGHSC have recently agreed to pay this Participant sub-debt contribution if Financial Close occurs before 31 March 213. Programme Table 1 outlines the key programme dates to start on site and project completion for all three projects. 2

197 191 Table 1 Activity FBC Formal Consideration by NHS Boards FBC Formal Consideration by CIG SGHSC Stage 2 Submission SFT Stage 2 KSR Approval Stage 2 Acceptance Financial Close Start on Site FBC Addendum to NHSG Board and SGHSC Completion/Handover Asset 24 FM Service Commencement Bring into Operation (Clinical Services) Asset 24 FM Service Completion Timescale 5 February February March March March 213 w/c 18 March April 213 May April April April 214 (circa) 11 April 24 The NHS Governance process for the FWT project has been altered to allow Financial Close to occur in March 213. This means that the FBC approval process is happening in parallel with the Stage 2 process instead of at the end of the Stage 2 process. This means that FBC approval should be in place early in March based on a not to be exceeded Unitary Charge (UC). This will coincide with receipt of a Stage 2 submission from hubco which will be subject to internal and external scrutiny with the assistance of our technical and financial advisors and a formal Stage 2 KSR undertaken by SFT. Financial Close will then be planned for w/c 18 March 213 assuming a Stage 2 UC which is within the FBC approved sum and a Stage 2 KSR approval from SFT. Finance The capital cost for Tain is mainly unchanged from the approved OBC Addendum. Table 2 Tain Capital Costs Land and Fees Equipment Sub-debt Access Road External Advisor Costs OBC Preparation FBC m Totals 1.43 Included above is the OBC preparation cost which was incurred in a previous financial year. The equipment will be required in 213/14 and the Sub Debt payments will fall due on the date of Financial Close in 212/13. The recurring revenue costs for the project, inclusive of Unitary Charge, are given in Table 3 below. 3

198 192 Table 3 Tain Recurring Revenue Costs FBC m Costs Unitary Charge Additional Depreciation (Equipment) Dental Salaries & Supplies Other Scheme Costs (Net Additional) Total Additional Revenue Costs.737 Sources of Funding SGHSC Unitary Charge GDS Non Cash Limited GDS Cash Limited Third Parties (Practices) Total Sources of Funding Board Funded Additional Revenue Costs.57 At FBC stage there is no increase to the Unitary Charge. It remains consistent with the Predicted Maximum Unitary Charge (PMUC) of 1.852m (all 3 projects) contained in the OBC Addendum. The Board is asked to recognise the Unitary Charge as a not to be exceeded figure in the FBC. It is based on a Pricing Report and Financial Model from the hubco stage 1 submission which has the Coop bank as preferred funder. The Coop bank has however withdrawn from the project. Timing of events and complexity of work required to finalise an alternative deal means the details of a different funding solution could not be ready for FBC purposes. However, an alternative lender is available. Aviva, who were preferred funders for the Aberdeen Health Village project, have been engaged in discussions with hubco for some time. The Project Board for the FWT Project has agreed to progress with them to Financial Close as preferred funder. Work done by hubco to date suggests strongly that a significantly reduced Unitary Charge is achievable with Aviva. The Board s approval of the FBC will ratify the Project Board s decision to support Aviva as preferred lender. Further details of this complex situation are contained in Appendix 1 attached. The total additional annual revenue funding required from the Board is.57m. This is a reduction compared to OBC. The SGHSC contribution to the Unitary Charge at this stage remains at 9%. This may vary at Financial Close once the final financial modelling, reflecting the Aviva deal, is completed. Key financial assumptions and risks: General Practice Involvement: the development will incorporate two General Practices. The Practices will occupy a significant amount of space in the proposed building. In both cases the planned space is greater than at present and their costs will increase as a consequence. The practices have been informed of the additional costs that will apply to them and they have both signed Agreements in Principle to their uptake of the accommodation in the new building, in advance of the signing of the emerging Occupancy Agreement after Financial Close. 4

199 193 Dental Services: There will be an NHS Salaried Dental Practice in the Tain development occupying two of the four surgeries. It has been assumed their additional costs will be financed from Dental Non Cash Limited resources. Advertisements will be placed seeking a General Dental Practice to take over the other two surgeries. Affordability / Value for Money NHS Highland has shown its commitment to the project through approval of the OBC Addendum. To re-affirm this commitment it has incorporated the necessary funding increases for capital and revenue consequences in its financial plans and Local Development Plan for the coming years. The hubco Stage 1 submission, upon which the FBC is predicated, has been scrutinised by external advisors as part of their due diligence towards their validation of the cost representing value for money at Stage 1. The view of the Technical Advisor is that hubco have provided sufficient evidence for the purpose of a Stage 1 submission. The view of the Financial Advisor is that the quoted Unitary Charge is reflective of a value for money position at Stage 1. This scrutiny and diligence will also be applied to the Stage 2 submission, due on the 4 March. Stakeholder Involvement The stakeholder involvement for the Forres, Woodside and Tain Projects are summarised in appendix 2l, 2m and 2n of the FBC. The local communities, public and patient representatives have been involved in shaping all three projects at a number of key stages over recent years including e.g. site selection and concept design. There is strong stakeholder support for all three projects. Risks The FWT Bundle Project Risk Register is included as Appendix 2j of the FBC. The register outlines a number of FWT Bundle risks and also project specific risks. All risks are currently amber, yellow or green. There are currently no red (very high) risks. All risks have a mitigation strategy and are regularly reviewed by the joint project team. FWT Bundle Risks There are currently 31 risks identified within the FWT Bundle wide risk register that are open. Six of the risks are rated in the Amber category and mitigation strategies for each are in place. It is anticipated that the majority of these risks will be closed, or mitigated to acceptable reduced levels in the period leading up to Stage 2 submission and Financial Close. The risks carrying the greatest impact are: - The possibility that funding terms at financial close exceed the buffer identified at FBC and/or that the preferred lender withdraws its offer. In this scenario there will be no project. The market lending rates and lender commitment to the potential funding deal will be monitored during Stage 2 and up to financial close to identify such a situation as early as possible if it transpires. - The probability of the alternative funding deal from Aviva being selected as the preferred option means that an additional risk is introduced. The Project Agreement documents will require some alteration by the respective legal teams as a result of this and there is therefore a risk that this cannot be completed in time to allow 5

200 194 Financial Close. The legal teams and hubco have however given an assurance that this work will be completed according to the project programme in time for Financial Close prior to 31 March 213. The other risks in the Amber category relate to the programme not being achieved for the Stage 2 submission. Progress against the programme is monitored weekly at the joint project group and key issues are escalated to a principles meeting or the Project Board as appropriate. Also the BREEAM* Assessor has recently confirmed that BREEAM Excellent will not be possible for any of the FWT projects. Work to confirm how BREEAM Very Good will be achieved is underway. The Unitary Charge figure will be partially subject to the impact of inflation over the life of the contract with reference to the RPI. This is standard practice. The risk of movements in the Retail Price Index (RPI) remains with the Board for the duration of the Project. The Board will deal with this from its allocated resources and reserves set aside for inflationary purposes. Tain Project Specific Risks Should an independent Dental practitioner not be found for the additional space at Tain, then the running costs of that element of the building will fall to NHS Highland. Another risk is in relation to the purchase of the land. This has not yet been completed and the lender requires this to be completed in advance of financial close. Work to conclude by 15 February is well underway. The lender s legal advisors will require to satisfy themselves that the title is satisfactory and includes all necessary rights for access and services. Work to conclude by 15 February is well underway. * BREEAM (BRE Environmental Assessment Method) is an environmental assessment method and rating system for buildings. It sets the standard for best practice in sustainable building design, construction and operation and has become one of the most comprehensive and widely recognised measures of a building s environmental performance. 3 CONCLUSIONS The three general practice developments (including the Tain project) in the FWT Bundle Project continue to be strategic priorities for NHS Grampian and NHS Highland, with strong stakeholder support. The Woodside OBC and Forres and Tain OBC Addendums have been developed with full consideration of deliverability, strategic fit, economic appraisal, financial appraisal and risk analysis. A strong project management structure is in place to enable the project to be taken forward to Financial Close and onwards to a successful conclusion and to realise the benefits for the people of Forres, and Woodside and Tain. The total NHS Highland costs in relation to the two projects consist of: Capital costs of 1.43 million of which.277 million has already been incurred on the OBC. Additional recurring revenue costs of.57 million, including the Board s share of Unitary Charge. Cost increases are not expected post FBC. 6

201 195 The Unitary Charge component of recurring revenue is a predicted maximum sum and therefore not to be exceeded should the FBC be approved. As stated above and in the attached appendix the financing arrangements for the project will change for Financial Close. It is anticipated, from initial modelling, that there will be a substantial reduction in the overall Unitary Charge as a consequence. Final figures will not be known until the Stage 2 Pricing Report and final Financial Model are completed 4 March 213. The sub-debt contributions for the project are in part driven by the lending requirements. If these reduce as expected there will also be a reduction in the sub-debt investment which is to be funded by the SGHSC. 4 Contribution to Board Objectives This project will contribute to achievement of Better Health, Better Care, Better Value in the Tain area by providing the facilities to assist clinicians improve the health of the population. The new facilities will enhance the experience of care for individuals. The new building will be more energy efficient and cost effective to operate than the two buildings it will replace. 5 Governance Implications 6 Staff Governance Staff working in the current premises have been fully consulted and involved in the design of the new facility 7 Patient and Public Involvement The Head of Public Relations & Engagement is a member of the local project group and a communications plan is in place to keep stakeholders informed including the general public and their representatives. A patient representative is a member of the local project group. 8 Clinical Governance Local clinicians are members of the project group and have been involved in Benefits Realisation workshops. 9 Financial Impact The financial impact is detailed in the FBC; additional costs have been identified and will be funded by local savings. 1 Risk Assessment The project has its own Risk Register which is contained as Appendix 2j to the FBC. 11 Planning for Fairness An Equality and Impact Assessment was completed in early 29. 7

202 Engagement and Communication The project has an established governance structure with the Director of Finance as the Senior Responsible Officer. The local project group is chaired by the Director of Operations, South & Mid Operational Unit and includes representatives of Tain medical practices, community and dental staff as well as a patient representative. The Head of Public Relations & Engagement is also included and a communications plan is in place to inform stakeholders including the general public and their representatives. John Bogle Acting Head of Capital & Property Planning Corporate Services Finance - Capital Planning 25 January 213 8

203 197 NHS HIGHLAND 5 February 213 Appendix 1 Forres, Woodside, Tain - FWT Bundle Project Full Business Case Preferred Lender and hubco Financial Modelling at FBC 1 Hub North Scotland Ltd submitted financial model v85 as part of their overall Stage 1 submission for inclusion in the Woodside OBC and Forres/Tain OBC addendums. This model uses the capital cost of construction for the three preferred options to provide an indicative annual Unitary Charge cost, in advance of Financial Close. 2 The financial model proposed utilising funding for the projects from the Co-op Bank. This resulted in a total annual Unitary Charge for the three projects of 1.852m in 214/15, as the first year of operation. The estimated breakdown of the cost between the projects is; Forres.765m, Woodside.539m and Tain (NHS Highland).548m. 3 Indicative lending rates from Aviva, the lender for the NHS Grampian Health Village project were better than those offered from the Co-op. However, due to uncertainty surrounding the ability of Aviva to provide funding at the intended financial close (their lending for these types of projects is currently capped by the Financial Services Authority), it was deemed prudent to use the Co-op lending rates for Stage 1/OBC. 4 However, since the submission of the OBC and OBC addendums in October 212, the Co-op bank has withdrawn from the market for long term financing of projects of this type. It is therefore the preference of the FWT Bundle Project Board to proceed with Aviva as the preferred lender, utilising a different form of lending (the Capital Tax Variant model) from them, that was common in Public Sector revenue projects until 23. This form of lending is not subject to an FSA cap. PriceWaterhouseCoopers (PWC), as financial advisors, have provided assurance that the lending deals and rates being put forward by hubco in relation to Aviva are representative of what they are seeing in the market-place. 5 The Capital Tax Variant Model from Aviva is less tax efficient than the preferred method of lending (as provided by Aviva for the Village project) and hubco has indicated that the annual Unitary Charge resulting from this method will be higher as a result. Not withstanding this, hubco have also indicated that the Unitary Charge under this form of lending would still be significantly lower than the Co-op deal which was outlined in the OBC. 6 The only significant risk in using this form of lending was the potential for the accounting treatment of the contract to change. It has been confirmed by PWC that this funding route would have no impact on the accounting treatment of the contract under accounting standard IFRIC 12. SFT has also confirmed that it would have no impact on the accounting treatment under ESA 95. It therefore offers the projects a realistic and achievable alternative funding source, given the programmed Financial Close in March However, due to the shortened programme to submit the FBC and complete Financial Close prior to 31 March 213, the construction costs for the FWT Bundle Project are still under review at this time and will not be confirmed until the 4 March, as part of the Stage 2 submission by hubco. As a result of this, the financial model for the Capital 9

204 198 Tax Variant Model (using Aviva) has also not yet been finalised. Work will continue to finalise the model in advance of Financial Close, on the assumption that the FSA lending cap for the original lending method remains in place. 8 The FWT Project Board, in consultation with SFT, has therefore taken the decision to continue to use the Co-op lending terms for the FBC, as indicated by financial model v85. It is considered to be too high a risk to use the interim financial model for the alternative funding method from Aviva (which indicates a reduced annual cost compared to the OBC Co-op deal) for the FBC, due to the possibility of final costs at Financial Close exceeding those within this interim model. Such a scenario would prevent the signing of the contract, since the costs would exceed the approved limit. 9 The OBC Co-op lending terms, although no longer available, therefore become a cap, or not to be exceeded cost in the FBC submitted to the Board for approval. Hence, the deal ultimately agreed with Aviva at Financial Close must not exceed the original Co-op terms approved at OBC. The cap value is therefore a total Unitary Charge of 1.852m per annum for the three projects at 214/15 prices, as referred to in the attached covering paper and the FBC. 1

205 199 Highland NHS Board 5 February 213 Item 5.5 DRUMNADROCHIT HEALTHCARE CENTRE STANDARD BUSINESS CASE Report by Michael Waters, Capital Support and Project Manager on behalf of Nick Kenton, Director of Finance The Board is asked to: 1 Approve the attached Standard Business Case for the development of a replacement Drumnadrochit Healthcare Centre. Agree that the Standard Business Case can now be submitted to the Scottish Government Capital Investment Group for their approval. Background and Summary This Standard Business Case covers the provision of a replacement facility for the current Drumnadrochit Health Centre. The need to replace the current facility has been recognised for some time and is included in the Board s Property Asset Management Strategy, but due to the restricted availability of capital from within the Board s formula Capital allocation, it has not been possible to progress the project until now. The Scottish Government has agreed to an allocation of 1.5m subject to the submission of this Business Case. As NHS Boards are required to engage with the Scottish Futures Trust (SFT) hub programme for the provision of community facilities, hub North Scotland Ltd (hubco) were approached, but they felt that with the in-house background knowledge and expertise, a better value for money solution could, in this case, be achieved by retaining the project within the Board. 2 The Development of Primary Care Services in and around Drumnadrochit The Board has previously recognised the need to replace/upgrade the current Drumnadrochit Health Centre, which is no longer fit for purpose, with more appropriate facilities which will enable healthcare staff to deliver quality services to the people of Drumnadrochit and the surrounding area. A greenfield site, adjacent to the existing Health Centre, has been offered, at a token cost by a local landowner, and this allows for the provision of a modern, fit for purpose facility with the potential for extension to meet any future demand on service provision. The redesigned premises will improve co-operation between primary and secondary care services as well as extending collaboration with other agencies such as Social Work as part of the integrated working being promoted by NHS Highland and Highland Council. The provision of additional and/or enhanced services will be possible by utilising the existing pool of experienced staff. Patients will be seen more quickly and conveniently and this will lead to a reduction in the impact on Acute Services. As an alternative to hospitalisation, the extension of the scope of care within the community will be in keeping with national and local policies. There is also a proposal by Loch Ness Homes to provide residential housing and some commercial facilities nearby which may provide the opportunity to share some development costs, e.g. access from the A82 and site services. A joint major development application has been submitted to Planning and a joint public consultation exercise is in progress. A separate Full Planning Application will, however, be made in the summer for the Healthcare Centre.

206 2 3 Contribution to Board Objectives This project will contribute to achievement of Better Health, Better Care, Better Value and the Healthcare Quality Strategy for NHSScotland (21) and achieving Sustainable Quality in Scotland s Healthcare A 2:2 Vision (211) Helping people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care in the Drumnadrochit and surrounding areas by providing the facilities to assist healthcare professionals improve the health of the population. The new facility will enhance the experience of care for individuals and allow for integrated team working. The building will be more energy efficient and cost effective to operate than the present facility. 4 Governance Implications Staff Governance Staff working in the current premises have been fully consulted and involved in the design of the facility Patient and Public Involvement The Head of Public Relations & Engagement is a member of the local project group and a communications plan is in place to keep stakeholders informed including the general public and their representatives. A patient representative is a member of the local project group. Clinical Governance Local clinicians are members of the project group and have been involved in Benefits Realisation workshops. Financial Impact The financial impact is detailed in the attached document; additional costs have been identified and will be funded by local savings. 5 Risk Assessment The project has its own Risk Register which is contained as Appendix 3 of the Business Case. 6 Planning for Fairness An Equality and Impact Assessment meeting is being arranged. 7 Engagement and Communication The project has an established governance structure with the Director of Finance as the Senior Responsible Officer. The local project group is chaired by the Area Manager South Operational Unit and includes representatives of the Drumnadrochit Medical Practice and community as well as a patient representative. The Head of Public Relations & Engagement is also included and a communications plan is in place to inform stakeholders including the general public and their representatives. This included a community event which was held in January and had over 2 people participating. Michael Waters Capital Support and Project Manager Corporate Services Finance Capital & Property Planning 25 January 213 2

207 21 Highland NHS Board 5 February 213 Item 5.6 REPLACEMENT OF LABORATORY INFORMATION MANAGEMENT SYSTEM WITHIN NHS HIGHLAND Report by Alex Javed, Service Manager Laboratories and Radiology on behalf Deborah Jones, Chief Operating Officer The Board is asked to: 1 Agree the need for replacement of the current legacy Patient Administration Systems with a modern Laboratory Information System. Consider the more detailed content of the associated Business Case. Agree to the procurement of a new multi-laboratory LIMS to replace the GE Ultra product used in Pathology and LRS Medipath used in Blood Sciences and Microbiology. Agree immediate commencement of the procurement process associated with replacement of the LIMS to ensure implementation is achievable before the expiry of the GE Ultra Centricity system and associated loss of service provision for Pathology. Agree the required local funding to allow the implementation to commence in line with the schedule in the associated business case. BACKGROUND AND SUMMARY The business case supporting the replacement of the NHS Highland Laboratory Information Management Systems (LIMS) was presented at the December 212 Asset Management Group meeting, following its ratification by the ehealth Strategy Group on 3 October 212. The business case provides the rationale and benefits for replacing the current two LIMS with the preferred option of a unified system for all NHS Highland laboratory disciplines, this being one of the pillars of the ehealth strategy alongside replacement of the Patient Management and Radiology Information Systems in delivering an end to end IT solution for laboratory diagnostics. Cost savings related to reduction in WTE associated with booking in samples and delivering paper reports equate to 257K over the three year implementation timescale. The extensive product sourcing and procurement lead-in times coupled with the obsolescence of GE Ultra from 216 necessitates the approval of this business case within FY 12/13. NHS Highland is therefore requested to accept the above recommendation which will enable progress towards commencing the replacement of the LIMS before the expiry of the GE Ultra Centricity system and associated loss of service provision for Pathology. 2 REPLACEMENT OF THE CURRENT SYSTEMS WITH A MODERN, UNIFIED LIMS The Laboratory Services within NHS Highland consist of a number of specialised laboratories encompassing the disciplines of Blood Sciences (Biochemistry and Haematology), Blood Transfusion, Microbiology (culture, molecular, serology [including the Scottish Toxoplasma Reference Laboratory and Specialist Service for Lyme borreliosis]) and Pathology (Histology, Mortuary, Cytology and Cytogenetics). NHS Highland has, owing to its geography, a larger number of laboratories than would be normal in a more densely populated area. Accordingly, there are four physical locations, all of which are vital components of the organisation in which these laboratories are sited Raigmore, Belford, Caithness General and Lorn and Islands Hospitals in Inverness, Fort William, Wick and Oban respectively.

208 22 Blood transfusion is the responsibility of the respective laboratories on each of these sites with the exception of Raigmore Hospital and is therefore within the specification of the current and future LIMS. The associated business case considers the LIMS requirements of the first three sites, though is designed to accommodate the needs of the Lorn and Islands Hospital within Argyll and Bute, should that become a requirement. The existing LIMS within the three sites are: LRS Medipath (Blood Sciences Laboratory and Microbiology) GE Ultra Centricity Laboratory (Pathology) The Medipath system was procured nearly twenty years ago, is supported by an Australian based company (LRS) and the Western Isles Health Board is its only other Northern Hemisphere customer. There is no formal development programme for the version installed within NHSH, meaning that requirements of users have to be met by individual customised alterations to the software. This limits the extension of functionality to that required of a modern LIMS, and management information tools are limited in range and function data extraction is cumbersome, time-consuming and not sufficient to support the requirements of audit, workload analysis, quality management and demand management/control. Critically, Medipath does not fully support electronic ordering, which is a key requirement of requestors and laboratories, as well as being central to the benefits associated with the upcoming Patient Management System. Electronic resulting from Medipath is of a form that does not fully meet users needs. The GE Ultra Centricity system was implemented in February 29, but in July 21 GE announced that it would be undertaking no further development work on the Ultra product, and that its customers must withdraw the system from operational use by July However, because NHSH had signed a 7 year support contract support for NHSH only would be extended to February 216 with the rest of the World no longer being supported from July 213. Without a supported LIMS in place the Pathology service of NHS Highland would no longer be able to function and service would cease and it is essential that this situation be avoided. There is therefore an opportunity to redress the shortfall in functionality of the Medipath system used in Microbiology at Raigmore Hospital and Blood Sciences in Raigmore, Caithness General and Belford Hospitals at the same time as replacing the Pathology system and the recommendation is that a single supplier be commissioned to provide a multi-laboratory, multi-site solution. This would meet both the clinical requirements and additionally would enhance the management tools available (such as demand management and measurement of KPIs) and facilitate the implementation of associated critical systems, particularly order comms and electronic resulting to both internal and external users. Recurrent revenue savings associated with electronic requesting and electronic results transmission to users would arise from reduction in staff resource needed for booking in samples and printing out and despatching reports. Indicative costs for procurement and implementation are shown below, based NHS Lanarkshire s proposal. Although broadly equivalent in terms of laboratory services and multi-site delivery to a mix of primary and secondary care, it is not representative of the geography or specific operational requirements of NHS Highland and the costs are therefore provided for illustrative purposes only. Entering a joint procurement exercise with NHS Western Isles would reduce the capital and revenue commitment required from NHSH by approximately 1%, in line with the Partnership Agreement between the two organisations. Revenue savings associated with the implementation are shown below. These are predominantly comprised of reduction in headcount of Medical Laboratory Assistants (MLAs) and A&C staff, both in the laboratory and wider hospital setting (the latter involved in delivering paper reports to requesting clinicians), the exact amounts being dependent on 2

209 23 which laboratories go live first; Blood Sciences has a current establishment of 8.5WTE MLAs, Microbiology 1.29WTE, Pathology 2.6WTE therefore greater revenue savings will accrue if Medipath were to be replaced before Ultra. Non-pay savings associated with reduced printing costs are also included. Costs Procure new 213/14 214/15 215/16 216/17 LIMS System commitment commitment commitment commitment for all Laboratories Capital (excluding VAT) Purchase and interfacing of multi-lab system Interfacing to ehealth systems Hardware costs Capital charges Total Capital 5K 25K 5K 25K 5K 15K 42K 742K 1K 21K 371K 25K 2K 345K 25K 1K 26K 17K 6K 6K 5K 1K 6K 4K 1K 3K 2K 3K 2K 28K 7K 11K 1K TOTAL 122K 441K 455K 126K Revenue Savings (recurrent) Laboratory staff (MLAs) A&C staff (lab) A&C staff (Raigmore) Printing costs Total Revenue Savings Cumulative (4 years) 161K 27K 44K 25K 257K 23K 5K 11K 5K 44K 46K 11K 22K 1K 89K 92K 11K 22K 1K 135K Revenue Software, hardware support and licence Legal costs Implementation costs Data transfer from current systems Total Revenue Costs Additional to the revenue savings identified above, estimations presented in Appendix D of the business case shows that nearly 4 working days per year are spent within NHSH Primary Care simply transferring data from laboratory results into separate systems. This equates to 17.8 WTE involved in supporting the current inadequacies in the LIMS-Docman data transfer. Any savings in primary care associated with implementation of the LIMS project would not offset the associated capital and revenue commitments but would reduce the overall cost per reportable laboratory test. 3 CONTRIBUTION TO BOARD OBJECTIVES The laboratory systems are integral to the diagnostic process, which in turn is a key component of determining the direction of the patient pathway. As such, the results of investigations need to be communicated accurately, swiftly and efficiently to aid clinical decision-making and this replacement programme is integral to the Board objectives: Highland Quality Approach: the LIMS replacement programme supports a reduction in waste, harm and variation. 3

210 24 4 Improvement and Change: in conjunction with the forthcoming Patient Management System the LIMS will be a key enabler in promoting demonstrable quality improvements. Engaging Effectively: views and needs of service users are encompassed within the business case and the specification of the LIMS solution. Delivering Safe and Effective Services: removal of the reliance on manual transcription and paper reports will reduce errors and support clinicians in delivering the correct treatment in a timely manner. Delivering Efficient Services: cost savings associated with reducing manual involvement in multiple processes will reduce the overall, holistic cost of each diagnostic report, removing non value adding processes. GOVERNANCE IMPLICATIONS The business case impacts most notably on the following governance aspects: Clinical Governance: preventing errors and delays associated with manual transcription (both in the laboratory and in primary care) involves the use of a large amount of staff resource, which will be greatly reduced when a true end to end electronic service can be instigated within all laboratories Financial Impact: in addition to the resource savings noted above, an analysis of primary care processes showed that nearly 4 working days per year are spent transferring data from laboratory results into separate systems. The governance implications of this are both clinical and financial while the associated staff resource is unlikely to be dedicated solely to these tasks by removing them it would allow pressures on that resource to be reduced Staff Governance: There are significant implications for staff, both clinical and nonclinical. The implementation of a new LIMS, in conjunction with the new Patient Management System, will aid in the reconfiguration of service design and clinical work-flows. The formal project management process includes ensuring staff involvement in, and knowledge of, the streamlined processes which will result. 5 RISK ASSESSMENT The requirement for LIMS replacement is on the risk register and has been discussed at Asset Management Group in October and December 212 following on from its inclusion into the ehealth five year plan for capital investment, based on identified need. The implementation of the LIMS will be undertaken using formal Project Management techniques, based on Projects in a Controlled Environment (PRINCE2) and LEAN Principles. This approach ensures a continual process of risk assessment involving the maintenance of formal Risk Registers and audit trails around risk mitigation. 6 PLANNING FOR FAIRNESS No issues have been identified with this process, and none are anticipated. LIMS implementation will require reconfiguration of individual laboratory and secondary care delivery elements. This reconfiguration process will be subject to formal impact assessment as an inherent element of the project management process. 4

211 25 7 ENGAGEMENT AND COMMUNICATION Stakeholder engagement has taken place extensively within Primary Care (survey results included within the appendices of the business case) and with other service users, as well as internal stakeholders such as clinical leads and other end users. The business case has been presented at the ehealth Strategy Group and Asset Management Group and, following on from Board approval to commence the procurement process, all stakeholders will be invited to contribute to development of the operational specification of the LIMS. Approval of the Business Case will result in the establishment of a Procurement and Implementation Board which will include representatives of all stakeholders. Engagement and communication will be an inherent and formal element of this structure. In addition, communication with staff at all levels of the organisation will be through cascade from senior management, staff briefings and the joint staff governance approach along with the NHS Highland Communications Department. Alex Javed Service Manager Laboratories and Radiology Medicine and Diagnostics Division 25 January 213 5

212 26

213 27 Highland NHS Board 5 February 213 Item 5.7 INTEGRATING CARE IN ARGYLL AND BUTE Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive The Board is asked to: 1 Agree in principle to the development of an enhanced Strategic Partnership in Argyll & Bute. Agree the proposed phased approach to the development of this model including the proposed timescale. Background This report provides Board members with an update on work towards integrated services in Argyll and Bute and proposes a way forward for discussion and agreement. Discussions between Argyll and Bute Council and NHS Highland regarding the potential for integration of health and social care services have been ongoing since 29 and in the summer of 211 resulted in an in-principle agreement by both the Council and NHS Board leaders to progress a joint investigation into the business case that may be formed to take forward this proposal. In that agreement both partners agreed a statement of intent: The Argyll and Bute Partnership is committed to achieving the best possible outcomes for our population and service users through improving the quality and reducing the cost of services. This will be through the creation of new, simpler, organisational arrangements that are designed to maximise outcomes and through the streamlining of service delivery to ensure it is faster, more efficient and more effective. The partners also agreed a set of underlying principles that underpin service delivery and which guide the pathway to integration. The following headline statements are noted: The arrangements must make sense to our public and service users They will be outcomes focused They must be efficient and cost effective There must be sound leadership, governance and accountability The integrated service must be person centred and deliver the highest level of quality 2 Progress Update & Proposed Way Forward Progress Update: A number of meetings including facilitated workshops have been held with leaders from across the NHS and Argyll and Bute Council and significant progress has been made. The Partnership have agreed to progress the development of an Enhanced Strategic Partnership based on the following 1. To include from Argyll & Bute Council 36M adult care budget and approximately 16M children and families budget (early years to be extracted).

214 All current NHS budgets within the CHP including contracts with Greater Glasgow & Clyde. Joint management and governance structures from localities upwards to be developed including Jointly Accountable Officer (JAO) leading the partnership. Frontline practitioners and service providers to work within integrated teams in localities managed by JAOs but remaining employed within their original organisation. Clinical pathways not to be split as this would be detrimental to patients and carers. Integrated or pooled budgets required with performance management based on outcomes so allowing Health and Council resource to effectively lose its identity. Agreed first step will be to secure Board and Council approval in principle and to the development of a project management approach. Proposed Way Forward: A Project Management Approach is required to scope issues and risks and develop model. Two main phases have been identified with further discussion required with regard to a possible shadow period. Phase 1 Scope and identify risks and issues particularly in relation to Finance, HR and Legal to ensure this model can be developed within current legislation (including proposed Bill on Integration) and standing orders. Scope governance and management model recognising that this will involve significant organisational change and that accountability and decision-making processes must be explicit. Get agreement to progress the model, on the basis of the initial scoping and providing no show-stoppers are found, from Council and Health Board. Engage Trade Unions and other stakeholders especially staff groups. Phase 2 Develop Implementation Plan working to implementation in April 214 and including communication plan. Develop Strategic Partnership Agreement or Memorandum of Understanding that will be the legal agreement for the partnership working up all detail as required in relation to HR, Finance, IM&T, Legal, Governance, Management, Professional Leadership, Performance Monitoring and Assurance. It is envisaged that this arrangement may require a Memorandum of Understanding as has been established in Torbay with Southern Devon Council. Consider appointment of JAO to lead the organisational change and appointment of locality management. Summary: Following discussions between leaders in Argyll and Bute Council and NHS Highland, proposals are developing for an integrated model of care for services to adults and children across the area. Although at an early stage, agreement has been reached on a way forward and Board members are asked to agree the proposals in principle and the proposed phased approach. 3 Contribution to Board Objectives This proposal is in line with the Health Board Corporate objectives particularly in relation to developing integrated services and improving outcomes. 2

215 29 4 Governance Implications These developments will be progressed within the Governance framework of NHS Highland and all implications of the proposed model will be explored to ensure effective governance is retained. 5 Risk Assessment The proposed project management approach will include development and management of a full risk register. 6 Planning for Fairness All activity will be impact assessed in line with Health Board and Council requirements. 7 Engagement and Communication The proposed project management approach will include a comprehensive communication and engagement plan to ensure all stakeholders are involved. Jan Baird Director of Adult Care Corporate Services 25 January 213 3

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217 211 Highland NHS Board 5 February 213 Item 5.8 ADULT SUPPORT AND PROTECTION (ASP) SELF EVALUATION REPORT Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive The Board is asked to: 1 Note the approach taken to ensure learning from National reviews. Note the assurance route through the Adult Support and Protection route. Background and Summary Over the last few years going back as far as 28, there have been a number of deaths which have resulted in National and local reviews. Some of these have had a high public profile but all captured some learning that it is vital to disseminate across NHS Highland and their partners. A summary of the circumstances of the reviews is attached at Appendix 1. On behalf of the Adult Support and Protection Committee, the Quality Assurance subgroup undertook a self assessment against these reports in order to establish 1. What systems and processes were already in place across the Highland partners to prevent such abuse happening in Highland 2. What actions needed to be progressed to mitigate against any outstanding risks This piece of work involved the QA subgroup and members of the ASP Delivery group and progress reports were taken to the ASP committee. Summary: As part of the Quality assurance role of the Adult Support and Protection Committee a self-assessment against National reviews has been completed. Where actions have been identified they have been extracted and compiled into an action plan to be taken forward by the ASPC quality assurance sub-group. This activity will be monitored by the ASPC 2 Findings The initial draft of the self assessment found a number of recommendations that were aimed at the Care Inspectorate the Scottish equivalent of the Care Quality Commission in England. These have been extracted so that discussions directly with the Care Inspectorate can proceed. There was also some activity which related to English legislation and this is for the Scottish Government to consider. However a number of recommendations related to providers of care in the public and independent sectors. All of those recommendations where outstanding actions were identified have been extracted into an action plan with timescales and responsibilities now added. This activity has been captured in the overarching ASPC action plan with an expectation that the actions will be progressed in the main over the next 6 months. Monitoring of this activity will be through reporting to the ASPC.

218 212 The activity falls into a number of themes 3 Training the emphasis here is on the effectiveness of training in raising awareness of Adult support and protection but also ensuring that staff across the organisations and at all levels are aware of their duties and procedures to be followed. The Highland Partnership is in the process of developing further training and evaluation in relation to impact. New procedures reflecting the Lead Agency approach are also developing. Specialist training in challenging behaviour and agreed approaches is also being progressed. Communications and case files as so often found in CP reviews the importance of communication across and within organisations has been emphasised. Linked to this is the quality of case file and reporting. The NHSH Quality Improvement team are reviewing the current reporting of data within the Social Care system to improve efficacy. Partnership working Highland is well placed to ensure recommendations in relation to Partnership working are taken forward. Redesign and improvement plans for adult services will be able to capture this and the development of integrated teams will strengthen relationships and effectiveness of teams. Recruitment and contracts NHSH as part of the redesign of adult care will be undertaking a review of contact monitoring to ensure the quality of care provided by the independent sector continues to improve. This will ensure a number of recommendations are progressed and provides an opportunity for engagement of wider staff groups in the process of contract monitoring. Hospital admission and discharge- the roles of staff in admission and discharge and indentifying issues of abuse, neglect or potential abuse or neglect have been highlighted. The current admission transfer and discharge policy in NHSH is under review and will incorporate any learning. Procedures- this not only applies to the procedures to be followed when abuse is suspected but also the assurance that procedures are in place for staff to raise concerns within their, or a partner s organisation and that complaints procedures are robust and responsive. Primary, secondary and community care once again the need to ensure consistency across the person s journey is emphasised and this extends to all care providers. Quality- although some recommendations in relation to quality refer to the role of the Care Inspectorate, it is clear that all providers and commissioners have a responsibility to ensure a commitment to continuous quality improvement and this must be at the heart of the redesign process. Contribution to Board Objectives This piece of work meets the Board objectives in terms of reducing harm and waste and is at the heart of improving quality. 4 Governance Implications Activity identified as a result of this self assessment will be taken forward within the Governance framework of NHS Highland and the partnership arrangements of Safer Highland. Any financial implications will be discussed at the ASPC or with the Operational Units as appropriate. 2

219 213 5 Risk Assessment The Adults Support and Protection Committee monitors a risk register specific to this area of work and any risks arising out of the actions relating to this self assessment will be added to this register. The actions will also be captured within the 6 Planning for Fairness This activity will be impact assessed in line with requirements of Safer Highland. Jan Baird Director of Adult Care NHS Highland 25 January 213 3

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221 215 Highland NHS Board 5 February 213 Item 5.9 INFECTION PREVENTION & CONTROL REPORT Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Consultant Microbiologist on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: 1 Note the performance position for the Board. Note the progress to keep infection under control. Aim The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and infection control measures in NHS Highland. 2 Contribution to Board Objectives One of the Board key objectives is to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board. 3 Scaling factor used in reporting incidence rates To ensure consistency with wider UK and European Centre Disease Prevention & Control (ECDC) reporting and in light of decreases in the observed rates, Health Protection Scotland (HPS) have changed the scaling factor used in reporting incidence rates to per 1, bed days instead of the previously used per 1 bed days. The Clostridium difficile target for example, now shows as 39 rather than.39. It should be noted that NHS Highland figures for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile are provisional until validated by Health Protection Scotland (HPS) on a quarterly basis. Summary Table 1 NHS Highland infection prevention & control targets and performance data Clostridium difficile Group Target Age 65 and 39. over (1, OBDs) NHS Scotland 31.9 For period July Sept 12 Staphylococcus aureus bacteraemia Age 15 and 26. over (1,) OBDs Green For period July For period July Sept 12 Sept % 98% Green Hand Hygiene 95% NHS Highland 21.1 Green For period July Sept 12.

222 216 Cleaning 9% 96% Green Estates 9% 97% Green 95% AMAU 96% Green Antibacterial prescribing Hospitalbased Empiric prescribing Ward 95% Surgical Compliant antibiotic prophylaxis Primary Care Compliant empirical prescribing 4A Green Yes Green Yes Green Source: - Health Protection Scotland/ISD/Local data. 4 5 Challenges To deliver Infection Prevention & Control support and HAI education in care homes and adult social care settings. To involve all clinical staff in hospitals and in the community to put in place initiatives to reduce device/healthcare related infections. To resource appropriate pan Highland infection prevention doctor time 6 7 Achievements Surgical Site Infections (SSI) for orthopaedic procedures remains low. It has been 11 days since last Total Hip Replacement SSI and 249 days since last fractured neck of femur SSI up to 3/11/212. ICNet Infection Control Electronic Surveillance System is now live in North Highland.. Risks This season is tipped to be one of the worst for norovirus cases, many wards have been closed across Scotland. NHS Highland has had some ward closures and there is a risk of further closures given that norovirus is prevalent in the community. Forecast The Harm Reduction Work stream within the Highland Quality Approach will include infection control; this will enable a coordinated response to reducing HAI. An education sub group of the Infection Control Improvement Group is being convened in January 213 to standardise HAI education and training across NHS Highland. Emma Watson Consultant Microbiologist Liz McClurg Infection Control Manager 25 January 213 2

223 217 NHS Highland Healthcare Associated Infection Report November 212 Section 1 NHS Highland Board Wide Issues 1. Staphylococcus aureus (including MRSA) Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: Staphylococcus aureus : MRSA: NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: Trends National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate July September 212 was 29.3 per 1, acute occupied bed days (AOBDs). NHS Highland s rate was 12.8 per 1, AOBDs (8 SABs), this is a decrease on the previous quarters, (January March 212, 23.4 (15 SABs), April June 212, 3.3 (19 SABs). October December 212 (not yet validated by HPS) 21.4 per 1, AOBDs (13 SABs). The annual rate (not yet validated by HPS) for NHS Highland, January December 212 is 21.8 per 1, AOBDs (National target March 213, 26 per 1, AOBDs) A report prepared by Dr Adam Brown, Consultant Microbiologist for the December 212 Infection Control Improvement Group indicates there is no ongoing upward trend in SABs in quarters 2-4 line-related SABs constitute a small but significant and potentially preventable proportion of all SABs (19%, 6 SABs) Of the 6 line related SABs, 4 are associated with Peripherally Inserted Central Catheters (PICC lines) One third of all SABs for Q2 Q4 were community-associated with no prior healthcare involvement. 1.2 Current Initiatives A group will meet in January 213 to lead on the reliable implementation of the Central Line Insertion and Maintenance Bundle and the reliable implementation of a PICC Maintenance Bundle and to understand more around Midlines and Hickman lines and validate results around PVC insertion and maintenance. The Infection Control Improvement Group will monitor progress. 3

224 218 Figure 1 Staphylococcus aureus bacteraemia (MRSA and MSSA) cases per 1, occupied bed days, all ages, with 95% confidence interval (vertical lines), linear trend (Black line) and target (Red line) = 26, CI = Confidence Interval Figure 1 shows that SAB rates have remained stable at low levels since January 21. Figure 2 Funnel Plot of SAB rates for all NHS Boards against acute occupied bed days 1/7/212 3/9/212 HG = Highland Figure 2 shows that in the current reported quarter ending September 212 that the Highland SAB rate was significantly lower than that of other Scottish Boards. 1.3 MRSA Screening No change from last report. 4

225 219 2 Clostridium difficile Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: Trends Clostridium difficile in patients aged 65 and over National data published by Health Protection Scotland identifies that NHS Scotland Clostridium difficile rate July September 212 was 31.9 per 1, occupied bed days (OBDs). NHS Highland s rate was 21.1 per 1, OBDs (1 cases), this is a decrease on the previous quarters, January March 212, 44. (23 cases), April June 212, 32.8 (16 cases). October December 212 (not yet validated by HPS) per 1, OBDs (9 cases). The annual rate (not yet validated by HPS) for NHS Highland, January December 212 is 29.2 per 1, OBDs (National target March 213, 39 cases per 1, OBDs) which means the Board is well on track to meet the National HEAT Target. Please note that the numbers for Clostridium difficile in patients age 65 and over in the HAIRT differ from HPS July September 212 quarterly report. The reason being, that the HPS protocol for surveillance takes the number from the assigned laboratory which, in this quarter, was 1 from the Southern General and 2 from Inverclyde Hospitals. These are, however, included in the out of hospital infections report for Argyll & Bute CHP. Figure 3 Clostridium difficile cases per 1, occupied bed days, 65 years and over, with 95% confidence interval, linear trend and target = 39. The graph shows that NHS Highland has achieved a sustained downward trend in Clostridium difficile rates despite some variation quarterly. The Board is well on track to meet the HEAT target. 5

226 22 Figure 4 Funnel Plot of CDI incidence rates in patients aged 65 and over for all NHS Boards in Scotland, July September212. HG = Highland Clostridium difficile in patients aged years National data published by Health Protection Scotland identifies that NHS Scotland Clostridium difficile rate July September 212 was 41.6 per 1, occupied acute bed days (AOBDs). NHS Highland s rate was 6.8 per 1, AOBDs (1 cases), January March 212, 4. (7 cases), April June 212, 66.4 (12 cases). October December 212 (not yet validated by HPS) 6.8 per 1, AOBDs (1 cases). The annual rate (not yet validated by HPS) for NHS Highland, January December 212 is 57.1 per 1, AOBDs. There is no national HEAT target for Clostridium difficile in patients aged years. Despite NHS Highland having a slightly higher rate from the national average, the rate remains well within expected levels as demonstrated in Figure 6. Figure 6 Funnel Plot of CDI incidence rates in patients aged years for all NHS Boards in Scotland, July September 212 HG = Highland 6

227 Anti Microbial Prescribing Audits of Antimicrobial Prescribing Audits conducted in Raigmore Hospital, General Surgical and Orthopaedics wards show improvements in prescribing in accordance with guidelines. The Dental Clinical Governance Group in conjunction with the Antimicrobial Management Team are reviewing issues highlighted by an audit of antibiotic prescribing in the Dental Out of Hours and Emergency Dental Centre, around the completion of documentation of the indication for antibiotic use. European Antibiotic Awareness Day, November 212 This year, the focus for prescribers was to Start Smart and Then Focus using local prescribing guidelines, review with microbiology results and the clinical progress of the patient. Publicity for this event included an article in Public Health News, an all users and intranet announcement and a presentation in the Raigmore canteen. Information for the public in the form of posters and leaflets was distributed to all GP surgeries, community pharmacies, acute and community hospitals and NHS Highland Care Homes. Table 2 shows NHS Highland progress against the 3 national indicators. Antimicrobial Indicator NHS Highland progress Hospital-based empirical prescribing In acute admission areas, antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in above 95% of sampled cases. Ward AMAU - Compliant Data from April 211 to November 212 shows prescribers in AMAU have achieved the target as median compliance with antibiotic prescribing guidelines stands at 96%. Ward 4A - Compliant Data from April 211 to November 212 shows that, although still below the target, median compliance has increased to 93.5%, Data from April 212 to December 212 shows median compliance at 95%. Surgical antibiotic prophylaxis Duration of surgical antibiotic prophylaxis is less than 24 hours and compliant with local antimicrobial prescribing policy in above 95% of sampled elective colorectal surgical cases. Compliant. A review of prescribing in October 212 showed continuing compliance with guideline recommendations for elective colorectal surgery. Preliminary data collection for urological surgery commenced in December 212. Further reports will follow. Primary care empirical prescribing Compliant. Seasonal variation in Quinolone use Data to the end of March 212 indicates (summer months vs. winter months) is less continuing compliance with this measure. than 5%. NHS Highland is one of only two Boards in Scotland to demonstrate compliance with this quality indicator for every year since it was first measured in 28/9. 7

228 222 3 Hand Hygiene Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national hand hygiene monitoring can be found at: Trends NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 98% compliance for November and December 212. The November 212 National Hand Hygiene Audit report shows NHS Highland compliance as 98%, National compliance was 95%. 3.2 Initiatives Hand hygiene audits continue to be undertaken monthly by all clinical areas, the results displayed and any non compliance addressed. 4 Cleaning and the Healthcare Environment Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 9%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at: Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: Current Rates Domestic Service teams continue to carry out monthly cleaning and estates audits as per NHS Scotland National Cleaning Services Specification sustaining an average of 96% compliance in November and December 212 for Domestic monitoring; the average Estates compliance was 96% in November and 97% in December Current initiatives Two hospitals were below the target of 9% for Estates monitoring in November 212, County Community Hospital Invergordon 88.6% and Mid Argyll Hospital Lochgilphead 89.1%. Local action plans were implemented resulting in 96.1% and 98.5% respectively in December 212. In December 212 one hospital was below target for Domestic monitoring, St Vincent s Hospital Kingussie 89.7% and one for Estates monitoring in Argyll & Bute Hospital 89.1%.Local action plans have been implemented. 4.3 HEI Inspections An unannounced HEI inspection to Raigmore Hospital was undertaken on Wednesday 21 November 212 following the receipt of the updated 16-week action plan. They found evidence that NHS Highland has implemented a number of changes and taken positive action to address the 8

229 223 requirements made following the last inspection in June 212. The final report and action plan will be published on Monday 28 January Outbreaks/Incidents Norovirus Norovirus is prevalent in the community therefore there is a high risk of transmission to hospitals. In comparison with national figures since 29, NHS Highland ward closures are low. The Health Protection Team informs the Infection Prevention & Control Team of community outbreaks in hotels, care homes, ships etc. Between 1/9/212 31/12/212, there have been outbreaks in 9 care homes, 4 hotels and 1 small cruise ship. Hospital Staff are now familiar with following the norovirus protocols and are supported by the Infection Prevention & Control Team. Since the last report there has been one ward closure. Ward 3A Raigmore hospital reported the first case on 28/11/212. The ward was reopened following extensive cleaning on 17/12/212. A total of 9 patients and 21 staff were affected. By closing the ward to admissions and minimising movement of staff spread was prevented to other wards. Currently the samples to test for norovirus are sent out with Highland. We are investigating how this can be achieved locally in the future. Figure 7 shows the number of hospitals in Scotland with wards closed due to Norovirus from 9/1/212 31/12/212. Health & Safety Executive Visit The main education programme based on NES Preventing Infection in Care is being piloted in two Care Homes now managed by NHS Highland as a result of integration and will be progressed in all other homes following evaluation. The first quarterly update day for Infection Control Key Workers was held in December 212. All Care Homes are developing action plans. Integration and governance arrangements are being progressed with appropriate representation in the Control of infection Committee structure. The HSE confirmed in December 212 that NHS Highland have complied fully with the Improvement notice in respect to infection control in the community. 9

230 224 6 Surgical Site Infections (SSI) Colorectal Surgical Site Infection Colorectal surveillance shows that the overall the rate (18%) of elective colorectal surgical site infections has not changed since surveillance commenced in June 211. A detailed report will be submitted to the Infection Control Improvement Group in February 213. Orthopaedic Surgical Site Infections Orthopaedic surgical site infection rates remain low. January November 212, the Total Hip replacement SSI rate was 1.2% and the Fractured Neck of Femur SSI rate was 1%. Caesarean Section Infections The number of Caesarean section surgical site infections remains low (no elective SSIs and 1 emergency SSI in October/ November 212; the measures outlined in the action plan continue to be implemented. It will be at least 6 months before it can be determined if the practice of leaving the abdominal wound dressing in situ for 7 days post operatively is lowering the infection rate although initial findings are favourable. 7 Infection Prevention & Control Education A uniform approach to infection prevention & control training and the recording of training is being taken across Highland. An education sub group of the Infection Control Improvement Group is being convened in January 213 to ensure patient safety is achieved in relation to infection prevention & control by standardising HAI education and training, targeted at different staff groups across NHS Highland in hospitals, community, care homes, Adult Day Care Centres, Learning Disability and Bank and Social Care staff. 8 Highland Quality Approach To ensure that there is a co-ordinated approach to harm reduction; Infection Prevention & Control Team will participate in the Harm Reduction work stream within the Highland Quality Approach and the Scottish Patient Safety Programme. 9 ICNet Infection Control Electronic Surveillance System The ICNet Infection Control Electronic Surveillance System which will improve our ability to interrogate data and understand trends went live in North Highland in January 213. Because Argyll & Bute CHP interface with laboratories in NHS Greater Glasgow & Clyde, ICNet will not be live until later this year. 1

231 225 Healthcare Associated Infection Reporting Template (HAIRT) Section 2 Healthcare Associated Infection Report Cards The following section is a series of Report Cards which provide information for each acute hospital (Raigmore, Caithness General, Belford and Lorn & Islands), and the community hospitals within each Operational Unit/CHP. The information includes the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections as well as hand hygiene and cleaning and estates compliance. The out-of-hospital infections report card identifies infections as having been contracted from outwith hospital. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics. Understanding the Report Cards Infection Case Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital and the community hospitals within each CHP broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website: Clostridium difficile : Staphylococcus aureus : MRSA: For each acute hospital and community hospitals in each CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the out-of-hospital report card. Understanding the Report Cards Hand Hygiene Compliance Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland s national hand hygiene campaign website: Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/chp report card presents the percentage of hand hygiene compliance for all staff in table form. Understanding the Report Cards Cleaning Compliance Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: 11

232 226 The Report Cards show the hospitals cleaning compliance percentage in table form. Understanding the Report Cards Out of Hospital Infections Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries, care homes and the community itself. The final Report Card report in this section covers Out of Hospital Infections and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail. 12

233 227 Abbreviations ADTC Area Drugs & Therapeutics Committee AMT Antimicrobial Prescribing Team AMAU Acute Medical Admissions Unit CHP Community Health Partnership CDI Clostridium difficile Infection CNO Chief Nursing Officer CVC Central Venous Catheter ECDC European Centre for Disease Prevention & Control GDP General Dental Practitioner HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HEAT Health Improvement, Efficiency, Access, Treatment Hemi arthroplasty HPS HSE An operation used to treat fractured hip similar to a total hip replacement, but involves only half of the hip. Health Protection Scotland Health & Safety Executive ICU Intensive Care Unit JAG Joint Advisory Group MSSA Meticillin Sensitive Staphylococcus Aureus MRSA Meticillin Resistant Staphylococcus Aureus PICC Peripherally Inserted Central Catheter PPI Proton Pump Inhibitor PVC Peripheral Venous Catheter QUAD Quality Assurance Document RIDDOR Reporting of Injuries, Diseases and Dangerous Occupational Regulations 1995 SAB Staphylococcus aureus Bacteraemia SHPN Scottish Health Planning note SHTM 64 Scottish Health Technical Memoranda Sanitary assemblies. SPC Statistical Process Chart SAPG Scottish Antimicrobial Prescribing Group SICPs Standard Infection Control Precautions SPSP Scottish Patient Safety Programme VAP Ventilator Associated Pneumonia 13

234 228 Staphylococcus Aureus Bacteraemia (SAB) criteria Contaminated blood culture Hospital infection Staphylococcus aureus isolated from blood, and SAB diagnosis incompatible with clinical picture, i.e. no or minimal clinical signs and symptoms indicating SAB. Staphylococcus aureus isolated from blood cultures taken 48 hours after admission or within 48 hours of discharge, and, The presence of clinical signs and symptoms indicating SAB acquired Community onsethealthcare associated infection True community infection Staphylococcus aureus isolated from blood cultures taken <48 hours after admission, and The presence of clinical signs and symptoms indicating SAB, and At least one of the following within the past 12 months: Hospitalisation or invasive device management as an outpatient / community patient, or dialysis as an outpatient / community patient. Staphylococcus aureus isolated from blood, and No hospitalisation within the past 12 months No dialysis within the past 12 months No community or outpatient healthcare for invasive device management in the past 12 months 14

235 229 Quarterly rolling year Clostridium difficile Infection Cases per 1 total occupied bed days for HEAT Target Measurement Apr 1 Mar 11 Jul 1 Jun 11 Oct 1 Sept 11 Actual Performance Target Jan 11 Dec 11 Apr 11 Mar 12 Jul 11 Jun 12 Oct 11 Sept 12 Apr 1 Mar 11 Jul 1 Jun 11 Oct 1 Sept 11 Jan 11 Dec 11 Apr 11 Mar 12 Jul 11 Jun 12 Oct 11 Sept 12 Jan 12 Dec 12 Apr 12 Mar Jan 12 Dec 12 Apr 12 Mar 13 Quarterly rolling year Staphylococcus aureus Bacteraemia Rates per 1 Acute Occupied Bed Days for HEAT Target Measurement Apr 1 Mar 11 Jul 1 Jun 11 Oct 1 Sept 11 Actual Performance Target Jan 11 Dec 11 Apr 11 Mar 12 Jul 11 Jun 12 Oct 11 Sept 12 Jan 12 Dec 12 Apr 1 Mar 11 Jul 1 Jun 11 Oct 1 Sept 11 Jan 11 Dec 11 Apr 11 Mar 12 Jul 11 Jun 12 Oct 11 Sept 12 Jan 12 Dec 12 Apr 12 Mar Apr 12 Mar 13

236 23 Pan Highland Total Staphylococcus aureus Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 MRSA Bacteraemia Cases (all ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Jan-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 5 Feb-12 Feb-12 2 Mar-12 Mar-12 3 Apr-12 Apr-12 6 May-12 May-12 4 Jun-12 Jun-12 6 Jul-12 Aug-12 Jul-12 3 Sep-12 Aug-12 3 Oct-12 Sep-12 4 Nov-12 Dec-12 Oct

237 231 Raigmore Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages) Jan-12 Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Dec-12 MRSA Bacteraemia Cases - (All Ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 1 Sep-12 Oct-12 Clostridium difficile Cases (ages 15 and over) Dec-12 MSSA Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Jan-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Feb-12 Nov-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Dec-12

238 232 Caithness General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages) Jan-12 Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 MRSA Bacteraemia Cases - (All Ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Npv-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Npv-12 Dec-12 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Jan-12 Dec-12 Feb-12 Mar-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar Apr-12 Apr-12 May-12 May-12 Jun-12 Jun-12 Jul-12 Jul-12 Aug-12 Sep-12 Aug-12 Oct-12 Sep-12 Nov-12 Oct-12 Dec-12 Nov-12 Dec-12

239 233 Belford Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages) Jan-12 Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec MRSA Bacteraemia Cases - (All Ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar Apr-12 Apr-12 May-12 May-12 Jun-12 Jul-12 Jun-12 Aug-12 Jul-12 Sep-12 Aug-12 Oct-12 Sep-12 1 Nov-12 Oct-12 Dec-12 Nov-12 Dec-12

240 234 Lorn & Islands Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 MRSA Bacteraemia Cases (all ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) Jan-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12

241 235 Argyll & Bute CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages) 12 1 Argyll & Bute Community Hospitals include Argyll & Bute Hospital, Lochgilphead, Campbeltown Hospital, Cowal Community Hospital Dunoon, Dunaros Community Hospital, Isle of Mull, Islay Hospital, Mid Argyll Community Hospital & Integrated Care Centre Lochgilphead, Victoria Hospital & Annex Rothesay Jan-12 Hand Hygiene Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 MRSA Bacteraemia Cases (all ages) 12 1 Cleaning Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Estates Monitoring Compliance (%) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages) Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jun-12 Jul-12 Jul-12 Aug-12 Aug-12 Sep-12 Sep-12 Oct-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Jan-12 Mar-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 Apr-12 May-12 Feb-12 May-12 Jun-12 Jun-12 Jul-12 Jul-12 Aug-12 Mar-12 Aug-12 Sep-12 Sep-12 Oct-12 Nov-12 Apr-12 Oct-12 Dec-12 Nov-12 Dec-12

242 236 Out of Hospital Infections Clostridium difficile Infection Cases Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec MSSA Bacteraemia Cases MRSA Bacteraemia Cases Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar-12 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-12 Feb-12 Mar Apr-12 Apr-12 1 May-12 May-12 1 Jun-12 Jun-12 Jul-12 Jul-12 Aug-12 Aug-12 Sep-12 Sep-12 Oct-12 Nov-12 Oct-12 Dec-12 Nov-12 1 Dec-12 2

243 237 NW Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages) 12 1 The North West Operational Unit comprises Dunbar Hospital, Thurso; Town & County Wick; Lawson Memorial Hospital, Golspie; Migdale Hospital, Bonar Bridge, Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, MacKinnon memorial Hospital, Broadford & Portree Hospital Isle of Skye Apr-12 Hand Hygiene Monitoring Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-13 Feb-13 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Mar-13 Feb-13 Jan-13 Mar-13 Feb-13 Mar-13 MRSA Bacteraemia Cases (all ages) 12 1 Cleaning Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct Nov-12 Dec-12 Jan-13 Feb-13 Mar Estates Monitoring Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) Feb-13 Jan-13 Mar-13 Feb-13 Mar-13 MSSA Bacteraemia Cases (all ages) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 1 Jan-13 Feb-13 Jan-13 Mar-13 Feb-13 Apr-12 Mar-13 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Jan- Nov-12 Dec-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Jan-13 Mar-13 Feb-13 Mar-13

244 238 South Mid Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages) 12 1 The South Mid Operational Unit comprises Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, RNI Community Hospital Inverness, Town & County Hospital Nairn, Ian Charles Community Hospital Grantown on Spey, St. Vincents Hospital Kingussie. For the purposes of monitoring New Craigs Psychiatric Hospital is included in this report card Apr-12 Hand Hygiene Monitoring Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-13 Feb-13 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Mar-13 Feb-13 Jan-13 Mar-13 Feb-13 Mar-13 MRSA Bacteraemia Cases (all ages) 12 1 Cleaning Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct Nov-12 Dec-12 Jan-13 Feb-13 Mar Estates Monitoring Compliance (%) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Clostridium difficile Cases (ages 15 and over) Feb-13 Jan-13 Mar-13 Feb-13 Mar-13 MSSA Bacteraemia Cases (all ages) Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec Jan-13 Feb-13 Jan-13 Apr-12 Mar-13 Feb-13 Mar-13 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Jan- Nov-12 Dec-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Jan-13 Feb-13 Mar-13 Feb-13 Mar-13

245 239 Highland NHS Board 5 February 213 Item 5.1 NHS HIGHLAND ORGAN DONATION COMMITTEE ANNUAL REPORT Report by Kevin Holliday, Clinical Lead for Organ Donation; Deborah Gallagher, Specialist Nurse for Organ Donation & Gillian McCreath, Donation Committee Chair on behalf of Dr Ian Bashford, Board Medical Director/Executive Lead The Board is asked to: 1 Endorse the primary message of The Organ Donation Taskforce Report of 28, that the national organ donation programme is a core activity of NHS Highland. Background and Summary Transplant medicine both saves lives and restores quality of life. It frees people from burdens of healthcare, and reduces the burden on healthcare providers. However, potential benefits of organ transplantation are limited by the availability of organs transplant. This report outlines the developments within NHS Highland to contribute to supply of organs for donation. 2 the the for the NHS Highland Organ Donation Committee Annual Plan There is a long history of active recruitment to the organ donation Register within NHS Highland, aided by the Specialist Nurse in Organ Donation and a network of enthusiastic volunteers. Making organ donation usual rather than unusual across the area covered by NHS Highland is a principle of the report and guides the supporting actions. A copy of the Annual Plan is attached. Identification of potential organ donors, their referral and subsequent management within Raigmore Hospital will continue to be a priority in the coming year. 3 Contribution to Board Objectives By ensuring an effective contribution to the national transplant programme, this work will support NHS Highland contributing to the successful service provided to patients with organ failure throughout Scotland and their return to independent lives. Maximising the potential of patients within NHS Highland to benefit from organ transplants, will support better health of our population locally, and a better service by effective use of resources. 4 Governance Implications Staff Governance The report highlights a number of objectives which will support staff to deliver the service including education programme and recruitment of Lead Nurses.

246 24 Clinical Governance Work is ongoing to introduce a Policy on Organ Donation within Raigmore Hospital and is overseen by appropriate committees as highlighted in the Report. Monitoring is ongoing of National Audit Standards Financial Impact There are no financial implications associated with the Report 5 Planning for Fairness Organ retrieval activity occurs within acute care services and has an impact on these activities. Through this annual plan, it is our intention to ensure fairness to organ donors and recipients, in addition to all other patients requiring care to be provided acutely. Other areas of focus include looking at remote and rural issues and making contact with ethnic minorities within NHS Highland. 6 Engagement and Communication The Annual Plan has been composed in co-ordination with NHS Blood and Transplant and their plan for the national organ donation programme. Recruitment to the Organ Donation Register is co-ordinated nationally, supported by a publicity campaign and local recruitment drives, funded and facilitated by NHS Blood and Transplant. There is also significant work ongoing locally to raise the profile, including an article in NHS Highland s Newspaper (January 213). Kevin Holliday Clinical Lead for Organ Donation NHS Highland Deborah Gallager Specialist Nurse for Organ Donation NHS Highland 25 January Gillian McCreath Chair Organ Donation Committee NHS Highland

247 241 NHS Highland Annual Organ Donation Plan

248 242 Contents 1. Executive Summary Report from the Organ Donation Committee (ODC) Hospital Organ Donation Team Structure Organ Donation Rates / PDA Benchmarking 211/ Performance against 211/12 Objectives Strategic Direction and Issues to be addressed Objectives for 212/13 and Monitoring Arrangements

249 Executive Summary Organ Transplants- a triumph of modern medicine Organ transplants do more than save lives; organ transplants restore dependent patients to active and independent lives. Over the last fifty years the attention of both the public and health care professionals has been captured by developments in transplant medicine. Support for organ donation is widespread among healthcare professionals and the public. However, demographic conditions and disease prevalence contribute to an increasing gap between the demand for organs and their supply. This results in three patients a day dying while awaiting a transplant (UK figures.) While organ donation is widely accepted by society, there have been societal, ethical, professional and practical barriers which limit its benefits. The purpose of this document is to ensure the appropriate contribution of NHS Highland to the national need for organs to transplant. This aligns with support of the Scottish Government for the Organ Donation Taskforce Report of 28 and Working together to Save Lives ODTF Report 211. Organ retrieval activity places unusual demands on healthcare organisations. Opportunities for cadaveric organ donation occur infrequently and haphazardly. When opportunities arise they do so among the competing priorities of other acute healthcare activities, especially in emergency departments, theatre and critical care areas. When meeting the demands of the death of their patient, healthcare professionals can be additionally burdened by the complex ethical and organisational requirements of facilitating the process of organ retrieval. The ODTF reports recognise the difficult circumstances in which cadaveric organ donation occurs, and also that as individuals or as organisations, staff groups facilitating cadaveric organ donation are isolated from identifying the benefits of organ transplant both geographically and administratively (by the requirement of anonymous organ donation for the recipient.) These factors can combine to obstruct opportunities for organ retrieval. Consideration of organ donation should be a normal part of end of life care. An organ retrieval process should be viewed as a routine activity of acute care areas. Making Organ Donation Usual, Rather Than Unusual throughout NHS Highland is therefore the principal theme of this report. 3

250 Report from the Organ Donation Committee (ODC) The implementation of an effective organ donation programme within the Highlands is aided by a national network co-ordinated by NHS Blood and Transplant. NHSBT have co-ordinated the national plan for recruitment to the Organ Donation Register (ODR.) They have provided a programme and continuing resources for staff with responsibilities for organ donation within health boards. They have facilitated the introduction of a national Potential Donor Audit (PDA) which will assess the effectiveness of donation efforts at a local level. There is along history of active recruitment to the Organ Donation Register within NHS Highland, aided by the Specialist Nurse in Organ Donation and her network of enthusiastic volunteers. It is clear that activities to recruit to the ODR are now being centrally co-ordinated by NHSBT and that the emphasis of the NHS Highland Organ Donation Committee should adjust to ensure operational implementation of policies, by incorporating organ donation practice into clinical areas. This will be the main thrust of the Organ Donation Committee in 213 and constitutes a reassessment of priorities. Within Raigmore Hospital we have benefited from the presence of a nurse with organ donation responsibilities, a presence which predates the current national programme. We have an active organ donation programme centred on the Intensive Care Unit, where there has been successful introduction of new initiatives such as the donation of organs after circulatory death (DCD). Challenges remain in making organ donation a more regular consideration at the time of end of life decisions, particularly in the emergency department and surgical and medical directorates. These activities are monitored by a potential donor audit which is reported nationally. Evidence from this (see pages) indicates that the performance of our organ donation programme compares well with national data. The Rural District General Hospitals within NHS Highland show activity in the field of organ donation by referring patients to the Specialist Nurse in Organ Donation. This is encouraging. We need to address the difficulties of facilitating organ donation in patients in our RDGHs and ensure that appropriate management plans are in place. It is clear that there is a political will to ensure that patients in rural populations are included in the organ donation programme, however there are specific difficulties encountered in remote and smaller hospitals, which need to be appropriately explored and addressed. 4

251 NHS Board Organ Donation Team Structure NHS Highland NHSBT ASSISTANT DIRECTOR NHS BOARD Anthony Clarkson REGIONAL MANAGER HOSPITAL MANAGEMENT TEAM Lesley Logan REGIONAL CLINICAL LEADS CRITICAL CARE DIRECTOR TEAM MANAGER Dr Joyce Stuart Dr Stephen Cole Liz Waite Dr Charles Lee, Head of Service, Intensive Care DONATION COMMITTEE CHAIR CLINICAL LEAD (CLOD) Gillian McCreath Dr Kevin Holliday SPECIALIST NURSE (SNOD) SN Deborah Gallagher SN Louise Beattie NHS Highland DONATION COMMITTEE CRITICAL CARE EMERGENCY DEPARTMENT THEATRE END OF LIFE Facilitators LAY MEMBER Carol MacFarlane CN Gwen Calder CN Alison Fraser Dr Charles Lee Dr Andrew Rowlands SN Beverley MacLennan Kenny Clark, Theatre Manager Derek Brown, Hospital Chaplain MORTUARY REPRESENTATIVE David Scott COMMUNICATIONS REPRESENTATIVE Mamie Thompson 5

252 Organ Donation Rates / PDA Benchmarking 211/12 Donation after Brain Death 211/12 DBD (21/11 figs in brackets) Critical Care Patients with Suspected Neurological Death 3(3) Referred 3(3) BSDT Performed 3(3) Confirmed BSD and Medically Suitable 3(3) Family Approached 3(3) Authorisation Given 2(2) Donation Proceeded 2(2) Organs Retrieved 6 (8 ) Identification of Neurological Death (ND)% 1 (1) Neurological Death Testing (NDT) % 1 (1) Referral Rate of Patients Confirmed % 1 (1) Approach Rate% 1 (1) Authorisation Rate % 67 (67) Conversion Rate % 67 (67) 6

253 247 Donation after Circulatory Death 211/12 DCD (21/11 figs in brackets) Critical Care No. Patients for whom Imminent Death was Anticipated 13 (13) Referred to the SNOD 9 (4) No. Where Treatment was Withdrawn N/A No. Potential DCD Donors 3 (2) Family Approached 2 (1) Authorisation to Donation () Donation Proceeded () Organs Retrieved () Referral Rate of Patients Confirmed (ND) % 69 (31) Approach Rate 67 (5) Authorisation Rate % () Conversion Rate % () 7

254 248 PDA Benchmarking Rates Overall NHS Highland data compares very well to national levels of activity. There are areas worthy of attention, but these are relatively minor. Raigmore Hospital Raigmore Hospital has a strong tradition of retrieving organs from patients who have suffered a death of their brain stem. This is reflected in an excellent performance on the audit data for donation of brain death (DBD). Historically, the staff of the Intensive Care Unit have achieved a 1% authorisation rate from relatives when approached to consider organ donation. This has been a significant achievement which is still remarked upon nationally. There is evidence that Donation after Circulatory Death (DCD) is continuing to develop. Prospective donors by DCD are being identified and referred to the SNOD. It is notable that there have been no authorisations by relatives after DCD within the audited period, particularly in the light of such good figures for DBD. However, DCD has occurred in Raigmore prior to the audited period, and the audited numbers remain small (less than 5 opportunities.) When successful authorisations occur it will not take long for the figures to become more favourable. This aspect of the audit shall be kept under review by the ODC and ITU Head of Service. PDA has been initiated in Raigmore Emergency Department. Currently there are no significant returns, but from next year data will be available, using the same dataset as ITU. PDA Beyond Raigmore The Potential Donor Audit has begun in Raigmore Emergency Department but numbers overall (less than 2 patients) are not yet yielding significant information. Similarly, the PDA is in the process of being implemented in the RDGHs. 8

255 Performance against 211/12 Objectives Objectives for 211/12 Actions Required to Deliver Objective Measurable Outcome / Milestones Delivery Lead Completion Date Outcome Active recruitment to ODR within NHS Highland Maintain our position on the Scotland-wide register DG Ongoing. The population of NHS Highland has shown their support for the principle of Organ Donation by signing onto the Organ Donation Register. NHSH continues to have ODR rates which exceed the Scottish average. In Hospital development raising awareness in areas with greatest potential for donations (Raigmore). Including Liverpool Care Pathway. Education and awareness programme throughout the hospitals Local data gathered and entered into NHSBT National Potential Donor Audit. DG/KH Ongoing Both DG and KH have been active within departments and throughout the region promoting organ donation. Delivery of National Audit Standards Implementation of system to gather data for audit of potential donors Increase numbers of Highland residents on the Organ Donor Register Having Organ Donation lead nurses in each hospital department. Degree of completion of national dataset included in Annual Report of PDA from NHSBT. Continue an Education programme around the hospitals. DG/LB It remains ongoing in other acute areas within NHS Highland. DG/ LB Number of leads recruited December 213 Introduction of the NHSBT PDA has been implemented in the Belford Hospital and in Raigmore ITU and Emergency Department. Ongoing Recruitment of Lead nurses will follow the educational programme. 9

256 25 Objectives for 211/12 Promotion of Organ Donation throughout the acute care facilities within secondary care of NHS Highland Actions Required to Deliver Objective Discussions with Clinicians locally. Recruitment of local leads Measurable Outcome / Milestones Data from PDA Number of local leads Delivery Lead Paul Campbell, Completion Date Ongoing Outcome Ongoing development of Organ Donation Policy/ Care Pathway. KH DG/LB 1

257 Strategic Response to Issues to be addressed In the last year we have welcomed a new Chair onto NHS Highland ODC, Gillian McCreath. This gave us the opportunity to present an overview of activities to date and re-examine our priorities. Over the past four years recruitment to the Organ Donation Register has remained a significant priority of the NHS Highland Organ Donation Committee. Recruitment to the ODR is now being co-ordinated nationally, within a national publicity campaign and local recruitment drives funded and facilitated by NHSBT. We have been successful in making contact with groups composed largely of people form ethnic minorities within NHS Highland, such as the Pilipino Association and the local Muslim community. However, while local activities aimed at recruiting to the ODR will continue, these shall not be our primary priority for 213. In 21 NHSBT appointed a Clinical Lead for Organ donation within the remote and rural populations of Scotland. We have, therefore, welcomed Dr Paul Campbell onto our committee. The appointment of Dr Campbell gives recognition to the difficulties of facilitating organ retrieval in hospitals which are both small and geographically remote. However, the communities served by these hospitals give their support to organ donation, and reasonably expect to benefit from organ transplantation, which adds weight to the need to discuss organ donation capabilities within all the acute care areas within NHS Highland. Within NHS Highland most organ donation activity is centred around Raigmore Hospital, because of its larger acute care facilities. Optimisation of the process of identification of potential organ donors, their referral and subsequent management within Raigmore Hospital is, therefore, our first priority in

258 Objectives for 213 and Monitoring Arrangements Objectives for 212/13 Actions Required to Deliver Objective Introduce a Hospital Policy on Organ Donation within Raigmore Hospital Discussion and finalisation of policy with appropriate clinical groups Measurable Outcome / Milestones Delivery Lead Delivery Date PDA KH By August 213 ITU- Discussion on Minimum Notification Criteria for referral to SNOD PDA KH By August 213 ITU and theatres- Feedback after organ retrieval procedures. KH By August 213 PDA KH/DG/DB By August 213 Discussion on recommended logistical process to facilitate organ donation, particularly DCD Acute Care areas in Surgical Departments, Medical Unit and Emergency Departmentdiscussion to ensure organ donation becomes a usual part of end of life decisions Implementation of Care Pathway for Potential Organ Donors Monitoring Method 12

259 253 Objectives for 212/13 Establish a Network of Organ Donation Leads throughout Acute Care Areas Continue to support recruitment to ODR within NHS Highland Facilitate dialogue on the logistical difficulties in promoting organ retrieval in the smaller and more remote acute care areas within NHS Highland. Actions Required to Deliver Objective Raise awareness, Recruit as Leads, Regional Education Day June 213 Measurable Outcome / Milestones Monitoring Method Number of Leads Delivery Lead Delivery Date DG/KH Attendance at Educational Day National reporting of ODR rates National report DG/ NHSBT ongoing Likely to be addressed after Operational Policy implemented (after August 213) 13

260 254

261 255 Highland NHS Board 5 February 213 Item 5.11 ANNUAL LOCAL SUPERVISING AUTHORITY REPORT TO THE NURSING AND MIDWIFERY COUNCIL Report by Mary Vance, Local Supervising Authority Midwifery Officer (LSAMO) The Board is asked to: Note the LSAMO Annual Report to the Nursing and Midwifery Council. Support the implementation of the recommendations. 1 Background and Summary 1.1 The Nursing and Midwifery Council (NMC) has a duty to monitor the Local Supervising Authorities (LSA) in the UK to asses if they are meeting the standards specified in the Midwives rules and standards.1 The annual LSA report helps the NMC to do this, and it is one opportunity for a LSA to inform the NMC and the public on activities, key issues, good practice and trends affecting maternity services within its area. 1.2 The annual report was informed by the Annual LSA Audits for and the Supervisors of Midwives Annual Report to the Local Supervising Authority (see enclosed). 1.3 The NMC undertook a review of the North of Scotland LSAs between the 5th & 8th July 211. The Review Team determined that the LSAs met 53 out of the 54 standards for statutory supervision with standard 7.1 (reporting of serious incidents) being partially met. They also determined there were no public protection issues relating to statutory supervision of midwifery practice. 1.4 The purpose of this paper is to inform the board of the LSAMOs Annual Report to the NMC for the period 1 April March 212 and to highlight areas of good practice and the key areas for improvement for Highland LSA. 2 Executive Summary of LSAMO report to the NMC 2.1 Supervisors of Midwives (SoMs) throughout the North of Scotland have demonstrated a commitment to ensuring the profile of statutory supervision is raised within the maternity services and amongst the women and families of those accessing maternity services. They are to be commended for their tireless work to enhance the safety of the maternity services, which at times is undertaken in their own time. 2.2 Formal and informal LSA audits were carried out by the LSAMO in the Health Boards in the North of Scotland LSA Consortium to assess compliance with the NMC standards for the statutory supervision of midwives. There was clear evidence from the audits that SoMs support midwives in providing a safe environment for the practice of evidence based midwifery. Furthermore, it was evident that midwives value the support given to them by SoMs in their professional development. 1 NMC Midwives Rules and Standards

262 Overall, the ratio of supervisor to supervisee in the North of Scotland LSA Consortium was 1:13. This is well within the NMC standard of 1:15. However, with the real possibility that 45% of supervisors may retire in the next few years, there is a continued need to ensure the sustainability of the supervisory framework by increasing the numbers of midwives in training to be SoMs. 2.4 Across the LSA Consortium, there is clear evidence of full engagement with Higher Education Institutions (HEI) in relation to supervisory input into midwifery education. In addition, there are close working relationships between the LSAMO and Lead Midwives for Education (LME). 2.5 The numbers of deliveries in midwifery led units remains reasonably stable however; the number of planned home births has reduced significantly since however the numbers of babies born before arrival (BBA) of a midwife has increased again. In the past, the LSAMO established that data collated for BBAs was not consistent across the consortium. The LSAMO will discuss data collection with the Heads of Midwifery to ensure that comparable data is being provided. 2.6 The overall percentage of interventions to total numbers of deliveries appears to be stabilising, however there continues to be significantly more elective caesarean sections than emergency caesarean sections. The cause of this needs to be established to ensure that the principles of Keeping Childbirth Natural and Dynamic are being embedded in practice. 2.7 The LSAs are informed about serious untoward incidents (SUI) timeously with the SoMs undertaking an investigation following guidance from the LSAMO. These investigations are now undertaken in a timelier manner than in the past however there is still a need to ensure that the SoMs are given sufficient protected time and administrative support to enable them to carry out this important aspect of their role. 3 Areas of Good Practice in Highland LSA 3.1 SoMs in leadership roles have been able to influence policy and practice at a national level. They have actively participated and contributed to the following documents: Scottish Woman Held Maternity Record Vulnerable Families Pathways NHS Scotland Improving Maternal and Infant Nutrition: Framework for Action, SoMs have participated and been actively involved in local guideline development, these include: Maternity Services Strategy vulnerable women and families substance misuse perinatal mental health support for women with learning disabilities Healthy Weight in Pregnancy Genital Tract sepsis 3.3 The Raigmore Maternity Unit Dashboard, which has been viewed by other disciplines within Raigmore Surgical and Medical divisions as an excellent tool for the collation and dissemination of information. The Patient Safety and Quality committee receive frequent updates and reports on identified trends. 2

263 257 4 Challenges that face Highland LSA 4.1 The overall ratio of supervisor s to supervisees as at 31/3/212 was 1:13. This is well within the NMC ratio of 1:15 however; five SoM s had a ratio ranging from 1:16 1: The introduction of a training programme for Supervision of Midwives Robert Gordon University has encouraged two local staff to complete the has assisted in a reduction of ratios in the area, making caseloads more However, only one midwife has self-selected for forthcoming course for Supervisor of Midwives. 4.3 There is a possibility that supervisors may take a Leave of Absence or retire in the next few years, which could result in ratios rising again. We need to increase the numbers of midwives in training to be supervisors to ensure the sustainability of the supervisory framework. 4.4 The role of contact supervisor of midwives has not been implemented to date. NUMBERS OF SOMS 23 Taking time out 2 In post 31/3/212 2 APPOINTED 1 RESIGNED RETIRED REMOVED Suspended from role for any time during the period 1 In training 2 Nominated 1 (POSOM) at course. This manageable. training as a 5 Recommendations 5.1 Highland LSA should: Implement a robust recruitment and retention strategy Increase the number of midwives undertaking the preparation module Ensure the successful implementation of the role of the Contact Supervisor of Midwives 6 Contribution to Board Objectives The LSA ensures that the statutory supervision of midwives is undertaken according to the standards set by the Nursing and Midwifery Council (NMC) under article 43 of the Nursing and Midwifery Order 21. Supervisors of Midwives provide support, advice and guidance to individual midwives and encourage further development of skills and knowledge. They also provide professional leadership thereby enhancing the quality of midwifery practice. This supports the objectives of delivering high quality services to patients, clients and users within NHS Highland 3

264 258 7 Governance Implications The LSA function is a governance function which protects the public through supporting midwives to deliver safe and effective care through: continuous professional development the use of evidence based practice rigorous reflective practice. A fundamental principle of midwifery supervision is public involvement in the development and improvement of midwifery and maternity services. This plays a part in achieving equitable service provision. 8 Impact Assessment All new policies developed as a result of the LSAMO objectives for are impact assessed through the North of Scotland Nurse Directors Forum. Mary Vance LSA Midwifery Officer North of Scotland LSA Consortium 25 January 213 4

265 259 Highland NHS Board 5 February 213 Item 5.12 CHIEF EXECUTIVE S AND DIRECTORS REPORT EMERGING ISSUES AND UPDATES 1 CHILDREN AND ADOLESCENT MENTAL HEALTH BUSINESS CASE UPDATE The Board approved an Outline Business Case (OBC) in relation to Child & Adolescent Mental Health Services when it met in committee in December 211. This development is hosted by NHS Tayside on behalf of the North of Scotland. Since that date, an OBC Addendum has been developed by NHS Tayside. The North of Scotland Planning Group gave delegated authority to Directors of Finance to agree (on behalf of their respective Boards) that the OBC Addendum could go forward for formal consideration by the Board of NHS Tayside. The net revenue consequences of the OBC Addendum for NHS Highland are 44, compared with 373, identified in the OBC. The increase of 31, is due to revised baseline activity figures the overall revenue consequences of the OBC have reduced from 4,95, to 4,91,, but the change in baseline activity means that NHS Highland s share of the costs has increased. However, this increase is within the envelope agreed by the Board as part of the Five-Year Financial Plan approved in April 212. On that basis, the Director of Finance has agreed that the OBC Addendum can go forward to the NHS Tayside Board for consideration on 26 February 213 and to the Scottish Government Capital Investment Group on 28 February 213. Assuming approval is received, the next stage would be to produce a Full Business Case. The intention is that this would be considered by Directors of Finance in May 213, the NHS Tayside Board on 25 June 213 and the Scottish Government Capital Investment Group on 2 July 213. The intention would be to present the FBC to the Asset Management Group in May 213 for consideration on behalf of the Board. If the costs in the FBC remain within the envelope then the intention would be to present the FBC to the Board for ratification on 4 June 213. If the costs in the FBC are out-with the financial envelope previously agreed by the Board then consideration will need to be given in terms of an appropriate governance route. 2 MID YEAR REVIEW LETTER FROM SCOTTISH GOVERNMENT NHS Highland has now received the feedback letter from Scottish Government on NHS Highland s Mid-Year Review held on 2 November 212. A copy of the letter is circulated as Supplementary Paper 1 to this update. 3 NHS HIGHLAND NEWSPAPER ISSUE NO. 2 JANUARY 213 An in-depth opinion survey designed to give people an opportunity to shape services and communications provided by NHS Highland is just one of the features of a 12-page newspaper which has just been produced. NHS Highland News will be distributed to every household in the area covered by NHS Highland (157,551) and should start dropping through the doors by the end of the January. An electronic version of the Newspaper is also available on the website. It features a wide range of articles and updates including, the benefits of exercise, importance of power of attorney, oral health work in schools, organ donation, breastfeeding, dementia, and emergency planning. It also explains what the Highland Quality Approach is all about and how it will help NHS Highland to improve in the delivery of safe, high-quality health and adult social care.

266 26 The comprehensive survey can be sent in by Freepost or completed online The Newspaper has a section on how to Get in involved, get in touch, get support and get informed, and includes contact details for the Chair and Chief Executive. The cost of the newspaper was 1,125 to produce and 8,559 to distribute equating to just over 8p per household. More generally, NHS Highland has stepped up their efforts to provide more pro-active approach to promoting regular news updates through the local media, community newsletters and other outlets. During the period 1st October to 31st December, 1 media releases were issued on a wide range of topics. Our number of followers on social media sites has also doubled during the last six months. All NHS Highland media releases, social media sites are available on NHS Highland website 4 CANCER WAITING TIMES Performance against national cancer waiting times remains of concern both at Board level and at national level. Latest data for November 212 shows Highland to be an outlier in the delivery of the 31 day target for head and neck (74.1%), lung (83.3%) and urology (84.6%) and at risk in relation to breast cancer, all of which has had a detrimental impact on the overall position of 91.3% against a Scottish position of 98%. Current performance for the 62 day target is also poor in the same areas, due in part to small case numbers, 1/3 in head and neck and 1/2 in urology within target time, which has resulted in an increased level of scrutiny and significant event analysis for each breach case being requested. This issue was discussed at the improvement committee and these results are due in part due to increasing pressure in radiotherapy planning, resulting in an international recruitment process aimed at supporting and increasing capacity. Further detailed work is now ongoing to review the processes in place to oversee the delivery of cancer waiting times in line with agree milestones. 5 POLICE PARTNERSHIP AGREEMENT On 19 December 212 NHS Highland took over responsibility for the provision of Police Custody Health care services and Forensic services on behalf of the Northern Constabulary. Highland Hub will handle all requests from the police and covers North and West Operational Unit, South and Mid Operational Unit and Raigmore. The Service is based on four main police stations: Inverness, Wick, Fort William and Portree and will cover: Primary health care services to detained people Assessment to the Police on whether people are Fit to detain, interview or release Obtaining of forensic samples Examining alleged victims and suspects of sexual offences, serious assaults Intimate searches. A copy of the Partnership Agreement is circulated as Supplementary Paper 2 to this update. 2

267 261 6 EARLY YEARS COLLABORATIVE The Early Years Framework published in December 28, signified an important milestone in encouraging partnership working to deliver a shared commitment to giving children the best start in life and to improving the life chances of children, young people and families at risk. The Early Years Taskforce shares this commitment th January 213 saw the launch of the Early Years Collaborative (EYC) with Learning Session 1. The objective of the EYC is to accelerate the conversion of the High level principles set out in GIRFEC and the Early Years Framework into practical action. This must: Deliver tangible improvement in outcomes and reduce inequalities for Scotland s vulnerable children; Put Scotland squarely on course to shifting the balance of public services towards early intervention and prevention by 216; Sustain this change to 218 and beyond. A cross agency collaborative approach will be used to deliver on three stretch aims: To ensure that women experience positive pregnancies which result in the birth of more health babies as evidenced by a reduction of 15% in the rates of stillbirths and infant mortality. To ensure that 85% of all children have reached all of the expected developmental milestones at the times of the child s 27-3 month child health review, by end of 216. To ensure that 9% of all children have reached all of the expected developmental milestones at the time the child starts primary school, by end of 217. NHS Highland will work through the local Community Planning Partnerships in both Highland and Argyll and Bute to deliver on this vital agenda to ensure that we can ensure that every baby, child, mother, father and family in Highland has access to the best supports available. 7 PRESCRIBING IN GENERAL PRACTICE IN SCOTLAND AUDIT SCOTLAND REPORT Audit Scotland's report, Prescribing In General Practice In Scotland, has now been published and can be viewed at Overall, this presents a good picture of cost-efficiency, with costs reducing against a background of increasing healthcare costs. NHS Highland was identified as a relatively efficient prescribing area. According to Audit Scotland, Boards with higher levels of prescribing support staff tended to have lower prescribing costs, and the report emphasises the key role of prescribing support staff in working with prescribers. The key recommendations for NHS Boards are: continue to work with GPs to: 1. reduce unnecessary waste (e.g. unnecessary repeat prescriptions, over-ordering by patients); 2. reduce the use of drugs considered less suitable for prescribing (e.g. drugs with equivocal evidence of benefit, significant side effects, or where more effective drugs have superceded them); 3. increase generic prescribing; 4. only prescribe more expensive versions of drugs to those patients with a clinical need for that version; 3

268 262 8 consider the business case for employing prescribing support staff as part of an invest-to-save initiative; work with GPs to implement the national guidelines on prescribing multiple drugs (polypharmacy) and support GPs in reviewing the medication of patients taking multiple drugs. REGIONAL PLANNING WEST OF SCOTLAND PLANNING GROUP A copy of the Briefing for October 212 from the West of Scotland Planning Group is circulated as Supplementary Paper 3 to this update. There is no update this month from the North of Scotland Planning Group. Chief Executive s Office Assynt House 25 January 213 4

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