3.1 Tier 1 Report Out: Scottish Patient Safety Programme (SPSP) Falls Reduction Maryanne Gillies, Senior Quality Improvement Lead (SPSP) and Darrell S

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1 HIGHLAND NHS BOARD DRAFT MINUTE of BOARD MEETING Board Room, Assynt House, Beechwood Park, Inverness 1 Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel January am Highland NHS Board 30 March 2017 Item 3.2 Present Also present Dr David Alston, Chair Mr Robin Creelman Ms Jaci Douglas Ms Myra Duncan Dr Andrew Evennett Dr Michael Foxley Ms Melanie Newdick Mr Adam Palmer Ms Ann Pascoe Dr Gaener Rodger Ms Sarah Wedgwood Ms Elaine Wilkinson (VC) Prof Elaine Mead, Chief Executive Ms Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Nurse Director Ms Joanna MacDonald, Director of Adult Social Care Ms Maimie Thompson, Head of Public Relations & Engagement Prof. Hugo Van Woerden, Director of Public Health & Health Policy George McCaig, Head of Care Support Ms Gill McVicar, Director of Operations, North and West Highland Mr David Park, Director of Operations, Inner Moray Firth Ms Janet Spence, Head of Care Services Improvement Ms Ruth Daly, Board Secretary Ms MaryAnne Gillies, Senior Quality Improvement Lead (SPSP) Ms Darrell Sutherland Improvement Advisor SPSP Dr E Watson, Director of Medical Education Ms Donna Smith, Head of Planning and Performance Ms Fiona MacBain, Committee Administrator, Highland Council 1 Apologies Apologies were given on behalf of Cllr John McAlpine, Dr Rod Harvey, Mr Mike Evans and Mr Alistair Lawton. The Chair welcomed Mr David Park, who has recently been appointed as Director of Operations for Inner Moray Firth. 2 Declarations of Interest Ms Jaci Douglas, Dr David Alston and Dr Michael Foxley declared non-financial interests in Item 4.6 as members of the Board of Inverness College UHI.

2 3.1 Tier 1 Report Out: Scottish Patient Safety Programme (SPSP) Falls Reduction Maryanne Gillies, Senior Quality Improvement Lead (SPSP) and Darrell Sutherland Improvement Advisor SPSP Heidi May introduced the Report Out which summarised progress with Falls reduction following the introduction of SPSP methodology. Maryanne Gillies summarised the detail of the work that had been undertaken over the previous year, with the aim of reducing Falls with Harm by 20% and overall Falls by 25% by the end of Key points included the promotion of independent mobility and recovery, the use of the bundle approach and the roll out of the significant progress in reducing falls that had already been achieved. Four Quality Improvement Facilitators had been appointed and although the primary aim of the project was to reduce harm, it was also proving cost effective, with the significant costs of hospital stays and loss of independence as a result of Falls being highlighted. In addition to reducing the human cost of falls, behaviour change among staff, patients and families required to be promoted, for example, having appropriate footwear in hospital, visitors and staff leaving necessary equipment and supplies within reach of patients etc. Darrell Sutherland summarised the pilot that had taken place in the RNI hospital, demonstrating practices before and after the implementation of SPSP and the improvements that had been made, through staff, patient and family engagement along with supportive education. The next step was to spread the work across the organisation. During discussion, in response to questions, it was explained that:- A major challenge was to scale up and spread the lessons learnt during the pilot and the programme for this, with timeframes, would be taken to the Clinical Governance Committee. A public facing campaign, with the possibility of using the NHS Highland public newsletter, would be helpful to dispel misconceptions about safety and help carers understand how they could help to prevent falls. Efforts had been concentrated on analysing the reasons for the recorded peaks in Falls, with various reasons having been proposed, from increases in the numbers of patients to Falls prevention bundles not being applied in a methodical manner, for example during the night. A successful example was provided of additional night time staff being engaged to reduce Falls. It had been shown that Falls reduction, while primarily to reduce harm, also reduced costs, given the high cost of treating people who had fallen. The information would be taken to both inpatient and community Falls prevention groups. The Board noted the Tier 1 Report to the Board and the points made during discussion. 3.2 Minute of Meeting of 29 November and Action Plan In relation to Item 4.4, Finance, Ms Duncan pointed out that the sentence, Ms Duncan accepted and supported the decision of the board, however asked for her disagreement with it to be recorded was inaccurate and in fact she had disagreed with the recommendation and the decision of the Board and wished that her disagreement be recorded. The Board approved the minute, subject to the above amendment. 3.3 Matters Arising In relation to Item 4.1, Maternity, the following points were made: 2 Local discussion had been taking place amongst staff about changing the night-time midwifery model to make better use of midwives time. The move to a Community Midwife Unit (CMU) had slowed this process and the workforce model was being re-examined in light of the CMU decision, with a view to a final decision by 1 April 2017, the date having been moved at the request of the local staff. The Medical Director chaired the group that was overseeing implementation of the CMU and the national review would also be considered by that group. 2

3 3 Continued open dialogue was taking place with the public and partners in Caithness about specific issues being raised but it was emphasised that there had been some inaccurate reports in the press about the transition. The unanimous decision by the Board to move to a CMU was emphasised. It had been agreed that a report would be provided to the Board after the four-month transition period, and thereafter by exception. The transition report would include accommodation and transport issues and the Chief Executive was due to discuss the transportation of expectant mothers with the Chief Executive of the Scottish Ambulance Service later that day as part of continued open dialogue. Additional accommodation had been secured and work was ongoing to increase the speed at which mothers and families could be included in the system, including 24-hour access to accommodation. With regard to the difficulties experienced in recruiting midwives to remote and rural areas such as Caithness, the additional support being put in place was summarised, including the temporary allocation of senior midwives from other areas and the recruitment of midwives to Raigmore with a rolling allocation to Caithness. The recruitment issues were included on the Risk Register and were being closely monitored. The continuity of the mother-midwife relationship was highlighted as an issue for consideration. In relation to Item 5.9, Highland Council Children and Adult Services and the low uptake of 6-8 week Child Health Surveillance contacts and the percentage of statutory health assessments completed within 4 weeks of children becoming Looked After, the Chief Executive explained that she had written to the Council s Director of Care and Learning, and his response was awaited. Consideration was given to the need for this matter to be taken to the Highland Health and Social Care Committee but that the Board also be kept up to date. The Board noted the Matters Arising and the actions being taken. 4.1 Membership of the Board The Board was advised that Ms Sarah Wedgwood has tendered her resignation as a Non-Executive Director of the Board with effect from 31 March The Chair thanked her for her valuable work, particularly as Chair of the Clinical Governance Committee. As it was hoped that a replacement Non- Executive would be recruited relatively quickly, it was decided to defer the following appointments pending a new Non-Executive being appointed: Non Executive Member of Staff Governance Committee Chair of Mid Ross Local Community Planning Partnership 4.2 Local Delivery Plan Guidance Prof Elaine Mead, Chief Executive The Chief Executive presented the guidance for the new style Local Delivery Plan, which supported the Operational Delivery Plan for Health and Social Care. The first draft was required by 31 March 2017 and the final by September Attention was drawn to the following points: An update was being sought on work being undertaken by the Council on behalf of the NHS. The LDP was to include practical early steps towards regional planning across the North of Scotland and a meeting was planned the following week of the Chief Executives of the various Boards. The review of targets and indicators might not be completed by March 2017 and existing performance measurements might have to be used in the interim. The financial planning elements of the LDP were crucial and clarity was sought in the Plan on the shifting of resources from acute to community care. The Government was expected to produce a national workforce plan in late Spring 2017 attached to the Health and Social Care Delivery Plan and it was likely that Boards would be involved in this. The first draft would be presented to the Board in March 2017 prior to submission to the Scottish Government. During discussion the following points were made: 3

4 4 It was important that the outcomes from the Board Strategy financial planning session on 30 January 2017 were converted into actions that could be monitored. Engagement and consultation with the public was vital. It was emphasised that a first draft, and not a final version, was being submitted in March The Harry Burns review work on unscheduled care and returns was welcomed. In response to a query about the percentage of care that took place currently in the community, this was something that required to be established and a standard method of measurement developed. It was important the LDP and Community Planning Partnership (CPP) were joined up. The Chief Executive emphasised the importance of direction and clarity, coupled with local arrangements. Given the short timeframe for submission of the draft LDP, it was unclear what role the CPP could play in the compilation of the draft. Concern was expressed, given the tight deadline and the plan for different Executives to tackle different areas of the LDP, about how the overarching view of what to prioritise would be established. It was explained that the clear priority from the previous day s Strategy session was to try to keep frail older people out of hospital, with an immediate focus on where the biggest impact could be made, namely urban Inverness, and there were specific plans being drawn up to address this. Once the LDP was available it would be fed into the UHI network to ensure care training needs were taken into consideration. The process for change required to be made clear at the March board meeting, including the direction of travel, current situation and training requirements, with a firm emphasis on evidence for the case for change, for example how many patients were going into Raigmore who could be cared for elsewhere. In relation to the commissioning of Children s Services from the Council, it was important to establish clear outcomes from this for the LDP. Clarity on the strategic areas of focus was sought, with reference to the six areas of focus in Argyll & Bute, along with reporting mechanisms. The Chief Executive pointed out that information would be taken to the Highland Health and Social Care Committee that mirrored discussion that had taken place at the Argyll & Bute Integration Joint Board about priorities. The Chair explained that the timetable was government-driven and the way forward would be properly mapped out at the March 2017 meeting. The Board noted the guidance and the comments made. 4.3 Finance Mr Nick Kenton, Director of Finance Nick Kenton gave a comprehensive summary of the Month 9 financial position, as detailed in the report. He emphasised the importance of a final accelerated effort to minimise expenditure in the final months of the financial year to deliver the last 4.6m of the operational recovery plan, as well as converting nonrecurring savings into recurring savings for The risk that the Board might not meet its year-end target of breaking-even on revenue had been quantified in the region of 5.9m. Medical pay remained a considerable problem and savings were behind target but with some underspends to offset them. During discussion, the following points were considered: Stopping expenditure on locum doctors would pose huge clinical risks. Concern was expressed at the level of savings still required to break even in the timeframe required when so much daily management had already been put in place, in addition to other issues such as lowering staff morale, rising complaints and issues at Raigmore. Mr Kenton explained that with 600 cost centres, the required savings amounted to around 8k per cost centre over three months which was considered achievable although challenging. There was an artificiality about the end of year break-even point, with the NHS Board not being permitted to carry forward a surplus or a deficit. There were issues that could be delayed or postponed in the final two months of the year that would not be possible at other times in the year. 4

5 5 New and returning patients were treated in a similar manner and a paper on return patients was going to the Clinical Governance Committee on 7 February In the coming three months, a challenging tightening of budgets was required. Longer-term, culture change around models of care was required. The Chief Executive pointed out that 100% assurance on the budget could not be provided but that short term measures to delay expenditure could be put in place. Incremental changes to a model of care that was not sustainable were not the long-term solution but small changes could be made in the coming two months to achieve break even. Further concern was expressed about the risks of not breaking even, the need for more concrete plans and whether the Scottish Government had been notified of the high risk of not breaking even. The Chief Executive confirmed that the Government had not been so informed as the qualified position was that break even could be achieved if the proposed measures were put in place and tightly managed. The capital to revenue transfer was a one-off event, sanctioned by the Scottish Government and its impact had been discussed three times by the Asset Management Group. It was confirmed that the impact of the transfer was a slight increase in backlog maintenance but that this was preferable to not breaking even on the revenue budget. The Chair emphasised that the current models of care were not sustainable, that a sense of urgency was required for the coming two months to achieve break even and that longer term, plans to change the structure of care were being developed. It was explained that budget decisions had been made to have no or minimal impact on patient care, but there was now little leeway left in this regard, which was why service models required to be transformed. Some of the incremental changes had been the result of transformational projects and it was felt that, although concerns were raised about the lack of impact of the Highland Quality Approach on cost reductions, this approach was one of the reasons why Highland was in a better position now than many other Boards. However, the performance targets were disappointing, which suggested that patient care was being impacted. The recurring message about the need to change how services were delivered was being evidenced by the difficulties in constantly trying to cut back on incremental costs. It was suggested that an additional Board meeting before March might be beneficial. Following concern being expressed by Ms Wedgwood and Mr Creelman about the reactive manner in which break-even was being forecast and having confirmed the need to change for the future, the Board confirmed it was content with the accuracy of the financial position as set out in this report and the actions being taken to ensure the target of break-even was delivered on capital and revenue. 4.4 Budget for and beyond Mr Nick Kenton, Director of Finance Mr Kenton emphasised that the report was at this stage for information and discussion, with formal sign off anticipated in March He presented key points from the report including baseline uplifts, additional allocations, service development and pressures and inflationary cost pressures. The current estimate was that savings of around 50m would be required in order to deliver financial break-even in 2017/18; this compared to 28.8m in the current year. During discussion, the following points were made: Reference was made to the need to take the Community Empowerment Act and Equalities legislation fully into consideration in all such future reports. Clarity on decision making between the Board, the Highland Health and Social Care Committee and the Argyll & Bute Integration Joint Board was sought for the March Board meeting, as well as a firm conclusion on decisions for In relation to savings made when drugs became unpatented, it was important to ensure those savings were sustainable. Efforts were being made to monitor the market in this regard. The Chief Executive explained that a range of measures were to be put in place to change the models of care, particularly by avoiding debilitating frail older people by giving them acute care they 5

6 6 did not require. The Chair reminded the Board that the general direction of travel in this regard required to be fixed. In terms of staffing costs, variability was possible within the 15m spent on locums and the 18m on additional supplementary staffing. Lean accounting might help to restructure and allocate budgets. Multidisciplinary working was key to changing culture in the long term. Reference was made to a holistic management type and the Chief Executive offered to give a presentation on this to a future Board. Reference was made to the need to avoid financial jargon in reports to ensure they were understandable by all. It was suggested that budget holders be given a fixed budget rather than a budget with a savings target attached. It was important the direction of travel for was decided by the Board without further delay and full budget detail should be considered in March With regard to the transformational projects, it would be helpful to see them shown against the 50m gap. Staff required comprehensive communication and assurance that jobs were not being removed and of the range of changes that might affect them. The Chair emphasised the opportunities that would be created by the new model and the need for recruitment. The Board agreed that a presentation be provided to a future Board on lean accounting and noted: The financial settlement for 2017/18. The impact on NHS Highland s financial plan. The likely level of savings required to deliver financial break even. 4.5 North Coast (Sutherland) Redesign: Report on feed-back from public consultation (25 th July to 25 th October ) Report by Michelle Johnstone, Area Manager (Caithness & Sutherland), Christian Nicolson, Quality Improvement Lead (North & west) and Maimie Thompson, Head of PR and Engagement on behalf of Gill McVicar (Director of Operations, North & West) This report had already been to the Highland Health and Social Care Committee (HHSCC) where the move to one unit had been agreed. Further information was to be brought back to the Committee once there had been additional work done on location and staffing. Following a summary of the report, the Chair of the HHSCC clarified that the move to one unit had been supported subject to staffing being considered and decided to be achievable. Other points made included the following: It was clarified that it was the fabric of the building in Tongue that was of concern, and not the care being provided. In future reports further reference should be made to other forms of housing and community hubs etc that could be included in the project. Information was sought on what other services were due to be provided, to allow full consideration of the viability of the model. It was vital that individual residents were consulted, whenever possible, with full consideration of the extent to which their families could speak on their behalf. It was confirmed that all residents had been consulted, although there had been issues relating to powers of attorney for some. The My Home Life project was referenced. Staffing was a concern in the area and further work was being done on this. It was important that future long term demand for care in the area was taken into consideration. It was clarified that approval of the second bullet point in the recommendation was subject to the prior completion of the third bullet point, i.e. that further work was completed on the suitability of the staffing of Option 2, prior to approval of Option 2. The Board: Endorsed the process including the efforts made to raise awareness about the consultation, the amount of feed-back received and the level of analysis carried out. Approved the recommendation to move to a new model of service (Option 2) new build care home as part of a Hub facility in one location to replace two existing care homes in the area 6

7 7 (Caladh Sona in Melness and Melvich Community Care Unit), subject to the satisfactory consideration of the staffing model detailed below. Approved the recommendation that further work is required to consider that the preferred model and location will be suitable in terms of staffing (recruitment and retention). 4.6 Medical Education in NHS Highland Dr E Watson Director of Medical Education on behalf of Dr R Harvey, Medical Director Dr Watson summarised her report, highlighting in particular NHS Highland s involvement in the General Medical Council (GMC) s plans to visit Scotland in summer Further comments were made as follows: On the whole, NHS Highland compared favourably to other Boards in terms of medical education, with ragged reports being received based on student feedback. Actions plans were drawn up to tackle areas of poorer performance. In relation to the need for regular quarterly or annual reports, discussion took place on whether these should be primarily presented through the Staff Governance or the Clinical Governance Committees. Issues considered included the potential separation of medical staff from other staff, however it was pointed out that funding was being received specifically for medical education, therefor, on balance, it was considered that due to the need to triangulate evidence, regular reports should go to Clinical Governance, but with Staff Governance input, occasional reporting to the Board and consideration of links to the Educational Sub-group. In addition to the medical opportunities, the cultural benefits of the Highlands should also be emphasised in attracting medical students. Reference in the report to the boarding of patients should be looked at and was on the agenda for the Clinical Governance Committee on 7 February Joint working and recruitment measures with community partners could be considered, as should multi-disciplinary training. The Board: Noted the forthcoming GMC regional visit to Scotland and potentially to NHS Highland in the summer of Noted the GMC educational standards and the obligations placed on the Board. Understood NHS Highlands role as a Local Education Provider. Supported delivery of the medical education strategy and the Educational Governance Objectives. Recognised the contribution made by all staff groups to the educational environment for medical staff. Understood the risk to the delivery of high quality medical education delivery posed by operational service pressures. Accepted the requirement for the establishment of a formal reporting structure to the Board. 4.7 Performance against HEAT targets for NHS Highland Donna Smith, Head of Planning & Performance, on behalf of Elaine Mead, Chief Executive The report was summarised and it was explained that in future the Argyll and Bute Integration Joint Board and North Highland s performance would be reported at the same time. There was a lack of consistency in the At A Glance reports, with some standards reported nationally and others locally. On the whole the report reflected the significant challenges that lay ahead. During discussion, the Chair praised the transparency of the weekly accountability wall walk displaying progress against targets. Concern was expressed at the delay for reporting on cancer targets and information was sought on what action was being taken to address the red targets. It was explained that NHS Highland had to wait for national reports on Detect Cancer Early targets and there was an awareness that the ten month delay was too long. Local targets were considered on a daily basis, and behind them were the individual operational unit targets, with variation from unit to unit on areas of particular challenge. Raigmore was the biggest area of focus due to the numbers of patients going through the hospital. Improvement was being experienced on the Transforming Outpatients High Level Value Stream to change the models of care without committing additional resources. Nationally, many 7

8 8 Boards were struggling to meet the targets and were in discussion with the Scottish Government about them, specialty by specialty. It was vital that work continued to transform the models of care for outpatients and managing waiting lists. Regular meetings were held Information Services Division (ISD) to consider validation issues. It was clarified that differing performance measures in breast cancer versus urology were related to vacancies, with the detail on the targets being reported to the Highland Health and Social Care Committee. The Board noted the report. 4.8 Infection Prevention and Control Catherine Stokoe, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control The paper updated Board members of the current status of Healthcare Associated Infections (HAI) and Infection Control measures in NHS Highland. The report presented a comprehensive view of HAI data and activities for scrutiny and feedback from the Board. The decision to exclude NHS Highland bed occupancy data 2014/2015 and 2015/ from ISD publications remained in place and work was ongoing to resolve the situation. The case number target for Staphylococcus Aureus Bacteraemia had been breached and would not be met, although it was within predicted levels. Other key points from the report were highlighted, including good news in relation to reducing antibiotic prescribing in dentistry and this should be communicated to the relevant official to ensure this was maintained during the dental services rebalancing. The Board noted the position and the progress to reduce and manage healthcare associated infections. 4.9 Local Patient Access Policy Donna Smith, Head of Planning & Performance, on behalf of Elaine Mead, Chief Executive The Board deferred consideration of the Policy as it required to first be considered by the Area Clinical Forum Chief Executive s and Directors Report Emerging Issues and Updates Report by Elaine Mead, Chief Executive This month s report incorporated updates on: a. Health and Social Care Delivery Plan. b. Highland Alcohol & Drugs Partnership Annual Report for 2015/16 submitted to Scottish Government September (link in report). c. NoSPG (North of Scotland Planning Group) Annual Report 2015/16 from Jim Cannon, Director of Regional Planning (link in report). d. Hosted Study Tour. In response to a question about the governance arrangements for regional planning, the Chair explained that work was ongoing and that he was chairing the North of Scotland Chairs Group in the near future. Discussions were also underway with the Scottish Government in relation to governance, patient travel and accountability and more formality around this was anticipated in due course. The Board noted the Emerging Issues and Updates Report. 5.1 Highland Health & Social Care Governance Committee of 10 November and 5 January 2017 The Committee Chair explained that a single format would be used for the assurance reports in future. Discussions were underway with the Directors of Operation on staff governance reports going to the Committee. 8

9 9 There was some duplication of subject matter with the Clinical Governance Committee, for example radiology. It was pointed out that radiology was also raised at other groups, such as the Area Clinical Forum and the Area Medical Committee. The Committee Chair Group had been useful to avoid subject matter repetition at different meetings. The Board Vice Chair had drawn up a map of committees with the aim of avoiding duplication and identifying gaps and it was intended that this would be considered at a Board development session in February The rationale for noting the performance indicators was queried and the Chair of the HHSCC explained that discussion had been undertaken on how information was input into the scorecards and similar issues. The performance was discussed to a lesser extent and this was in part due to the structure of the current Committee. It was hoped that after March 2017, a performance scrutiny subgroup would be created. 5.2 Integration Joint Board of 28 September and special meeting of 2 November Robin Creelman explained that although the IJB had a combined budget, he would separate health from social care commentary. In relation to health, there was optimism around breaking even in -17, with less certainty about and in this regard he referred to anomalies in NRAC allocations that effectively penalised NHS Highland for the higher service delivery costs as a result of the geographic nature of the area. He updated on the special meeting of 2 November that the application to the local authority for the required 185k for the Service Redesigns in Struan Lodge and Thompson Court had been rejected, and other significant cost pressures had been identified. In relation to the MRI replacement at Raigmore from the capital budget, more information on the clinical implications of down time might be worth investigation. Mr Kenton pointed out that the lead from the radiology service was on the Asset Management Group. 5.3 Asset Management Group of 22 November & 20 December There were no additional comments. 5.4 Area Clinical Forum of 24 November The Chair of the ACF drew attention to the attendance of the Board s Vice Chair at the meeting and the useful discussion that had taken place on her role and on the Health and Social Care Delivery Plan. 5.5 Clinical Governance Committee of 6 December There were no additional comments. 5.6 Audit Committee of 13 December There were no additional comments. 5.7 Draft Staff Governance Committee of 15 November The Chair of the Committee referred to concern that had been raised about the requirement for the operational units to engage more with the staff governance agenda. 5.8 Adult Social Care Practice Forum There were no additional comments. The Board: Confirmed adequate assurance has been provided from the Governance Committees. Noted the Assurance Reports and agreed actions from the Staff Governance and Clinical Governance Committees. 6.1 Date of next meeting 9

10 10 The Board noted there would be a short meeting of the Endowment Fund Trustees immediately following the open Board meeting and that the next meeting of the Board would be held on 28 March 2017 in the Board Room, Assynt House, Inverness. The meeting ended at 12.25pm. 10

11 FOLLOW UP FROM BOARD ACTIONS AND GOVERNANCE REVIEW ACTIONS. 11 Meeting Item Action / Progress Lead Timeframe Highland NHS Board 28 March 2017 Item Board 31/1/17 36 Board 29/11/ Budget for and beyond 5.9 Highland Council/NHS Partnership A presentation be given on lean accounting/value Management to the Board Agreed that the Chief Executive discuss the matters raised with the Council s Director of Care and Learning. Elaine Mead/NK March 2017 Elaine Mead (Sally Amor to undertake) Raised with Council s Dir of C&L, 34 Board 29/11/ Mental Health Needs Assessment Agreed the future government strategy and linked action plan be brought to the Board in due course. Hugo Van Woerden Once document becomes available 33 Board 29/11/ Quarterly Performance Agreed that performance and exception reports be received by the Board on a quarterly basis in relation to: Donna Smith/Margaret Brown Ongoing Highland Health and Social Care Partnership. Argyll and Bute IJB Christina West 31 Board 29/11/ Community Planning Partnership Agreed that the use of non-executives for CPP representation be reviewed in a year. Ruth Daly/Cathy Steer/Jan Baird Board agenda Dec Board 29/11/ Maternity Services In addition to report recs, agreed the Board be given feedback at the end of the transition period and after a year postdecision, with exception reporting in the meantime and that consideration be given to childcare options as discussed. Rod Harvey Dec Board 29/11/ HQA Update Agreed to bring back information on lean accounting and on possible HVLS project management to the Board. Anne Gent TBC 28 Board 29/11/ Matters Arising: Action sheets Consider the Board action sheet at a Board Development Session Ruth Daly Future Board Dev Session 25 Board 27/9/ Finance Agreed to discuss future year budgeting issues at a separate meeting Nick Kenton March Board 26/7/ Health & Safety Committee of 12 May Report on Fire Safety Training Exercises to a future Board Eric Green/Anne Gent To be done as a Board briefing 21 Board 26/7/ Chief Executive Update Ms Wedgwood asked that the working group to consider the assurance framework should also take into consideration the statement that NHS Boards are expected to report progress against the LDP at their Board meetings Elaine Mead Donna Smith Ongoing

12 12 20 Board 26/7/ Highland Quality Approach Annual Objectives /17 Measuring Success Agreed to establish a short-life non-executive working group to assist with the refinement of the metrics and setting of appropriate targets. Ruth Daly/Anne Gent Group established Ongoing 18 Board 26/7/16 16 Board 26/7/ Towards the 2020 Vision - 10 Year Plan Summary of Progress to Date Governance Review action plan (from item 3.3 Matters Arising) Annual tracking of progress with the ten year plan should be undertaken, with timescales, to support long term objectives from -17 onwards with regular updates to the Board as appropriate. The actions resulting from the Recommendations from the Governance Review be added to the Board action sheet with timescales. Deborah Jones Donna Smith Ruth Daly Date tbc Appended 12 Board 5/4/16 Highland Quality Approach Update Formal mechanism to be investigated for the HQA Leadership Group to report to the Board Anne Gent to consider Date tbc 8 Board 5/4/16 7 In- Committ ee Board 5/4/16 5 Board 1/12/15 Item 3 of the Board minute of 26 January, Tier 1 Report out - Acute Medicine Ward 6A RPIW Tender Waiver Request FME services Improvement Committee Assurance Report of 2 November 2015 and Balanced Scorecard Ms Wedgwood asked that notional financial benefits of RPIWs be discussed Dr Foxley requested an update on FME service provision in Highland be provided at a future Board meeting To update the May Board meeting on discussions to facilitate generic referrals from GPs to any hospital in Highland Future Development Session Future Board agenda Christina West Future Board, Gill McVicar AG & NK Spring 2017 Being investigated Being investigated 3 Board 11/08/15 Financial Assistance for Patients Travelling to Hospital Undertake a full review of the Policy of Financial Assistance to Support Travel to and from Hospital Future Board, Maimie Thompson Target date before July Board 2/06/15 Inner Moray Firth Master Plan Hold an informal Board strategy day on the development of a holistic approach to developing future clinical services. Future Board Strategy, Nick Kenton and Deborah Jones Date tbc 1 Board 14/04/15 Infection Prevention and Control Agreed that infection prevention standards in care home settings were considered for future Board consideration Future Dev Session/ Board, HM and J MacD Date tbc 2

13 Jan Polley Recommendation Action & current Status Timeframe Leadership and Performance Scrutiny Roles Board to set aside time to undertake its leadership role of setting objectives, goals and milestones All board members and senior staff explain when and why the board move from performance scrutiny role to leadership Executive directors and other senior staff review the information they make available to the board and committees to flag up the need for leadership discussions in areas of repeated problems etc also to ensure appropriate information on causes, risks and implications is made available When leadership discussions are held in private sessions, no decisions should be made and when decisions are made in public forum, there is a clear and transparent audit trail of the reasoning. 2. Performance Framework Revised governance performance framework based on the High 5: o Quality and safety o Staff wellbeing o Finance o Performance/delivery o Person/patient centred Agreed by the Board 31 May Further work required around the Risk Register Annual Objectives Measuring Success WG work will inform the development of a Performance Framework Board needs to specify what the Framework should contain. Ongoing EM & DA AG/NK/DJ March 2017 Review existing indicators to ensure adequate coverage of key or critical aspects of the business. Where appropriate, framework should contain indicators of progress on high level projects and work streams of particular interest; Early consideration be given to the goals and indicators of progress required in areas with hybrid governance/management committees so that they can be replaced by appropriate performance oversight by the Still outstanding Still outstanding 3

14 14 board or one of its governance committees, The Audit Committee works with internal auditors to review the risk framework, including the strategic risk register used, to ensure that it reflects the revised performance framework; Review the audit programme in the light of the new risk register to ensure assurance to the board on significant areas of risk and that there is clear understanding of which committees are supporting the Audit Committee in its oversight of risk. 3. Roles and Responsibilities The board completes the governance compact so that the responsibilities, behaviours and contributions of all concerned are clear and agreed; Further work required around the Risk Register. Ongoing work through Audit Committee OU Risk Registers still need to be fleshed out. Issue if for the board to decide where it wants these risks to be reported to and managed by questions regarding whether this should go through Audit Committee or direct to the Board. Still outstanding Revised version to be worked-up for future discussion. Board discussed a working draft Compact with review in 6-9 months NK March 2017 NK March 2017 DA/AG/MT/RD Compact drafted and in operation for review in 6-9 months All board members, executive and non-executive, take stock as part of their annual appraisals of any skills, knowledge or behaviours they wish to develop in order to maximise their contribution to the board; Board and Committee Chairs devote adequate time to ensuring that their executive and non-executive members work as an effective team. Non Executive Annual Appraisals now largely complete Time at the end of each meeting for feedback on what went well and what didn t, engaging individually with members to ensure they are contributing as best they can and setting aside time, at least annually, for a formal collective self-evaluation of the performance of the board/committee. EM/DA/RD March 2017 DA Committee Chairs Ongoing 4

15 At least once a year, non-executive members of the board meet without executive members to review their own performance and their requirements of the organisation 4. Board and Committee remits and responsibilities Board agendas are split into items for Decision, Monitoring and Noting, in that order, so that matters for strategic decision making are given sufficient time and addressed early in the meeting; Committees raise issues with the board through the committee chair seeking the board chair s agreement to the topic s inclusion under the Decision part of the board agenda The Monitoring section of the agenda is used to review progress against performance measures that the board is responsible for scrutinising. Where performance is not on track the minutes record the remedial action being taken and the timeframe within which a revised target will be met The Noting section of the agenda contains any additional information that a committee or staff would like to make available to the board including committee minutes and assurance that the performance measures that they are overseeing are under control. 5. Changes to Main Committees The remits of the three main governance committees Staff Governance, Clinical Governance and Audit are reviewed to provide clarity of their governance roles and how they interact with the board 15 Board Agreed 31 May Ongoing Ongoing Ongoing Ongoing Work underway Staff Governance ToR agreed February 2017 Audit Committee ToR agreed March 2017 Clinical Governance ToR still being worked on and to be presented to next meeting of Committees DA DA/Board Secretary DA/Board Secretary DA/Board Secretary DA/Board Secretary Board Secretary/Chairs and Lead Executives The hybrid governance/management committees be abolished 31 May Board discontinued only the Improvement Committee 5

16 Hybrid staff/non-executive groups are used in future only as short term task groups to, for example, develop performance or assurance measures that can then be scrutinised by the board or a governance committee; The board clarifies the role it expects of the Area Clinical Forum, and its comparable body for social care, so that they become a source of professional advice to the board on key strategic developments as well as a means of identifying early warning signs of performance or risk weaknesses arising within the business. The remit of these bodies should be adjusted accordingly, including clarifying the mechanisms to be used for referring matters to the board. The board reviews other groups and committees to clarify their roles and ensure non-executive time is used appropriately. 6. Health and Social Care Integration NHS Highland board agrees with the Argyll and Bute IJB: The objectives, indicators and targets it will use to hold the IJB to account for the delivery of NHS Highland functions; The scrutiny mechanisms it will use to monitor progress against those targets; What role those individuals who are members of both boards will play in those mechanisms; What processes will be put in place to allow NHS Highland board and its audit committee to understand the risks to delivery of its services by the IJB and what sources of assurance they will use as evidence of adequate control of those risks; NHS Highland board clarifies with its own staff those services it remains responsible for delivering directly in Argyll and Bute and puts in place a 16 Board Agreed 31 May There is ongoing use of this model for a range of short-term tasks 31 May Board Noted that work was underway Topical issues to be highlighted for Advisory Committees to consider and feedback up to the Board. Ongoing Ongoing 6 Ongoing DA & ACF Chair In hand March 2017 DA/EM Committee Chairs March 2017 EM/DA Christina West EM/DA Christina West

17 17 clear performance framework for scrutinising progress; In North Highland, the NHS Highland board: Takes active responsibility for leadership and scrutiny of delivery of its main performance indicators; DA/EM/Gill McVicar/ Committee Chair Devotes sufficient time to understanding and fulfilling both its leadership and performance scrutiny roles with regard to children s services, recognising that it needs to have in place scrutiny arrangements that reflect the fact that the services are delivered through partnership with Highland Council; Replaces the existing HHSCC with a new governance Integration Committee which oversees on its behalf progress towards effective integration of services for both adults and children (including possibly the establishment of clear performance frameworks for adult social care services commissioned by Highland Council and the children s services delivered by the Council on behalf of NHSH) Reviews the continuing need for the Integration Committee after 2 years as the integrated services become more embedded in the day to day work of the organisation; Board established a Working Group to look into the governance arrangements of HHSCC Discussion held at Development Session 21 February 2017 Board paper for consideration 28 March 2017 Revisits in discussion with Highland Council the remit and membership of the new Joint Monitoring Committee so that it becomes an overarching forum through which senior councillors and board members can provide collective leadership of the whole integration vision in North Highland and can resolve any high level barriers to successful integration. It should not duplicate the existing leadership or performance scrutiny roles of the NHS Highland board or its new Integration Committee; Gives further consideration to the mechanisms (including the performance indicators and other information) that it uses to provide Highland Council with a satisfactory level of assurance on the delivery of adult social care. Jan Baird Jan Baird 7

18 18 7. Corporate Governance Support Each board member is given the opportunity to meet with the board chair to discuss their contribution to the board, their views on the board s governance and their individual training needs. The board secretary should then produce individual development plans for each board member that are supported by the organisation; Succession planning - updating the required skills matrix for nonexecutives and ensuring that board members build the necessary experience of all aspects of the governance role; The board agrees how it will ensure a more person centred focus to its meetings, perhaps exploring options such as holding meetings in different parts of the region and developing a staff/patient engagement plan. This governance review is taken forward through the development of an action plan with timescales and named individuals accountable for their own contributions, and that its delivery is overseen, on behalf of the board, by a short term working group of the board involving both executive and non-executive members. Annual Appraisals concluded Development Plans to be produced Development Plans to be produced Under consideration Under consideration DA/Board Secretary In Hand DA/Board Secretary In Hand DA/Board Secretary In hand DA/Board Secretary In hand 8

19 19 Highland NHS Board 28 March 2017 Item 4.2 Equality Outcomes and Mainstreaming Report Report prepared by Helen Sikora (and Hugo van Woerden for some areas) on behalf of Elaine Mead, Chief Executive The Board is asked to: Note the content of the report in relation to meeting the Scottish Specific Duties of the Equality Act 2010 Agree the equality outcomes proposed for Summary The Equality Outcomes and Mainstreaming Report collates the information that NHS Highland, as a listed public authority, is required to publish in April 2017 under the Scotland Specific Duties of the Equality Act This comprises of: Progress on equality outcomes set in 2013 Mainstreaming equality Refreshed equality outcomes for 2017 to 2021 Employee information Gender pay gap Succession planning a new requirement introduced in 2017 As well as meeting legislative requirements this report is an opportunity to highlight some of the work that NHS Highland is doing to promote equality and diversity within its functions and by working with partners. The report provides a number of examples of this in our role as an employer, in service improvement and quality of care and within our business functions. The report includes a refreshed set of equality outcomes which have been developed by drawing on reviews of outcomes set in 2013 and through engagement with stakeholders and partner organisations during. This partnership approach has led to the development of shared equality outcomes with the Highland Council and Highlands and Islands Enterprise. The equality outcomes proposed for are: 1. Increasing the diversity in leadership and workforce participation 2. Identified groups have improved experiences of accessing services and information 3. Identified groups of children and young people will benefit from improved access to mental health services and support 4. People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them 5. In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it 6. As a Community Planning Partnership, work towards addressing socio-economic disadvantage as set out in the Local Outcome Improvement Plan Annex 2 of the report includes employee data and information. A range of information about our employees is included however there is a need to improve the quality of data and our knowledge of the protected characteristics of our employees. A key action within the report to address this issue is to roll out Employee Self Service which will allow staff to update their own personal information.

20 20 Contribution to board objectives This report contributes to the organisation s missions, values and strategies set out in the Highland Quality Approach which captures the spirit of how NHS Highland is working to improve care and outcomes for people in Highland. The themes People, Quality and Care are used within the report to align the progress made in promoting equality and diversity with the Board s objectives. Planning for Fairness The focus of this report is entirely on equality and diversity and provides the information required to meet the duties of the Equality Act Communication and engagement The report sets out the how community representatives, colleagues and partners have been engaged in developing the proposed equality outcomes. This has included events attended by community representatives, discussions with community planning partners and the report has been discussed at a number of management meetings. The innovative approach of developing joint equality outcomes with community planning partners has also provided opportunities for joint engagement and a consistent approach to equality at a strategic level. Communication and engagement will continue as part of the delivery and ongoing review of the equality and diversity work programme and is embedded in a number of actions within the equality outcomes, for example, the Hate Free Highland Campaign and the Stonewall Diversity Champion programme.

21 21 EQUALITY OUTCOMES AND MAINSTREAMING REPORT April 2017

22 22 Contents FOREWORD BY ELAINE MEAD, CHIEF EXECUTIVE... 3 INTRODUCTION... 4 LOOKING BACK: ACHIEVING EQUALITY OUTCOMES PROGRESSING THE PUBLIC SECTOR EQUALITY DUTY... 7 LOOKING AHEAD: DEVELOPING EQUALITY OUTCOMES EQUALITY OUTCOMES ANNEX 1: EQUALITY OUTCOMES Equality Outcome 1: Increase diversity in leadership and workforce participation Equality Outcome 2: Identified groups have improved experiences of accessing services and information Equality Outcome 3: Identified groups of children and young people will benefit from improved access to mental health services and support Equality Outcome 4: People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them Equality Outcome 5: In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it Equality Outcome 6: As a Community Planning Partnership work towards addressing socio-economic disadvantage as set out in the Local Outcome Improvement Plan ANNEX 2: EMPLOYEE DATA AND INFORMATION Employee Protected Characteristics Data and Analysis Equal Pay Statement Gender Pay Gap ANNEX 3: SUCCESSION PLANNING

23 23 FOREWORD BY ELAINE MEAD, CHIEF EXECUTIVE I am pleased to introduce NHS Highland s Equality Outcomes and Mainstreaming Report for While the Report meets the Scottish Specific equalities duties, the work we are doing is driven by our relentless focus on providing person centred care and improving the health and wellbeing for the people of Highland. Equality is an issue for all of us but in terms of NHS Highland, it is something we take into account and consider as a provider of health and social care services, an employer and when we commission or procure goods and services. Since our last report published in 2015, the landscape has continued to change. We find ourselves with unprecedented demand, changing demographics, ageing workforce and a challenging financial position. It is clear we need to change our models of care and rapidly transform some of the services we provide. With change, however, comes opportunity and the chance to be more creative and innovative about the services we provide and the way we provide them and in a way that encompasses our values: listening and treating people with dignity and respect. The Community Empowerment Act, recently implemented, also brings positive opportunities for new ways of approaching things. The Act empowers communities by giving them new rights and greater control over services and assets. It has also strengthened NHS Highland s role in community planning. It offers clear possibilities to develop new relationships and ways of working with both communities and our partners to address inequality. Within this report you will see many examples which I hope you will agree demonstrate how we are progressing and promoting equality. It sets out some of the ways we are meeting the needs of our service users, their families and carers while also supporting our staff to embed equality in all that we do. I would like to express my thanks to our staff, partners and volunteers for their hard work and commitment to improving the way we work, and making NHS Highland a fair and just organisation. Elaine Mead Chief Executive 3

24 24 INTRODUCTION NHS Highland s view of equality is about what we can do to create a fairer society and recognises that: Equality is an issue for us all We don't all start from the same place To create a fairer society we need to recognise different needs We will focus effort where improvement is most needed to tackle inequalities within and between communities. This may include focusing on the particular needs of people who are disadvantaged or discriminated against because of who they are, or their protected characteristic, for example: age, disability, race, gender or transgender, religion or belief and sexual orientation. Equality Act 2010 The Equality Act 2010 became law on 1 October 2010 and replaced previous antidiscrimination laws with a single Act. It simplified the law into a single source and ensures that everyone who is protected under law from discrimination, harassment or victimisation is afforded the same level of protection. NHS Highland as a public body is required to ensure that equality and diversity are embedded into all our functions and activities in line with the Equality Act The Equality Act 2010 also introduced a new public sector equality duty (also known as the general equality duty). This requires Scottish public authorities to pay 'due regard' to the need to: Eliminate unlawful discrimination, victimisation, harassment or other unlawful conduct that is prohibited under the Equality Act 2010; Advance equality of opportunity between people who share a relevant protected characteristic and those who do not; and Foster good relations between people who share a relevant protected characteristic and those who do not Protected characteristics are: age; disability; gender reassignment; pregnancy and maternity; race; religion and belief; sex and sexual orientation; and marriage and civil partnership (only in relation to the requirement to have due regard to the need to eliminate discrimination). This report gathers the information that NHS Highland is required to publish under the Scotland Specific Duties of the Equality Act. This includes: - Progress on equality outcomes Mainstreaming equality - Refreshed equality outcomes Employee information - Gender pay gap 4

25 25 Argyll and Bute Integration Joint Board In 2015/16 Argyll and Bute formed an Integrated Joint Board (IJB). As a public authority the IJB published an Equality Outcomes and an Equality Mainstreaming Report as well as an equality impact assessment of the Argyll & Bute Health and Social Care Partnership Strategic Plan in April. These reports are available on the Argyll and Bute Health and Social Care Partnership website - The IJB does not directly employ staff therefore employee information and gender pay gap information is published by the employing organisations and not the IJB. This report includes the required information relating to staff working within the IJB, employed by NHS Highland. 5

26 26 LOOKING BACK: ACHIEVING EQUALITY OUTCOMES NHS Highland published its first set of equality outcomes in 2013 for the four year period to Progress against these outcomes was reported in 2015, at the midway point. The progress report is published and is available on the NHS Highland website aspx This progress report recommended that a review of the outcomes is undertaken to assess their relevance, alignment with Board priorities, and to ensure they were evidenced-based, measurable and achievable. This review was completed in April and is available on the NHS Highland website. 0Meeting%205%20April%20/5.2%20Equality%20Outcomes%20report.pdf The review summarises progress made for each outcome set in 2013 and also recommended that a number of the outcomes be amended. The review also suggested that new outcomes for be developed with a focus on the following themes: Developing an evidence base and improving data collection Celebrating difference within our workforce Person centred care The equality outcomes have now been refreshed for NHS Highland drawing on the review in April as well as consultation with a range of stakeholders within and outwith the organisation. The refreshed equality outcomes and information about how they have been developed are set out in Looking ahead: developing equality outcomes section of this report: 6

27 27 PROGRESSING THE PUBLIC SECTOR EQUALITY DUTY As well as the progress made on equality outcomes set out above, NHS Highland has continued to promote equality and diversity across the organisation in a range of settings and business functions. The following case studies demonstrate examples of this progress under the following themes: People attract and develop the best teams Quality relentlessly pursue the highest quality outcomes of care Care create a caring experience Participation and empowerment engaging and working with communities Embedding equality within business functions The first three themes, People, Quality and Care, reflect the strategies set out in the Highland Quality Approach which captures the spirit of how NHS Highland is working to improve care and outcomes for people in Highland. 1. People New Equality and diversity training opportunities Equality & Human Rights: a new mandatory training module was introduced in August. It is available to all NHS staff and focuses on the importance of equality, human rights and social justice to achieve fairness within health and social care and reduce health inequalities. Working with Interpreters: an important skill in ensuring that we provide quality person centred care to people whose first language is not English. This training session was introduced in May and will continue to run as part of NHS Highland s core training offer Equal Opportunities course: a new full day course developed in partnership with the Highland Council. This course is also part of NHS Highland s core training offer and is available to both NHS and council employees. Stonewall Diversity Champion In April NHS Highland signed up to become a Stonewall Diversity Champion. This demonstrates our commitment to celebrate diversity within our workforce and to promote equality, respect and dignity for people who identify as lesbian, gay, bisexual or transgender (LGBT). In September NHS Highland participated in the Stonewall Workplace Equality Index and the Stonewall staff survey where over 1,300 responses were received, over 10% of the workforce. 7

28 28 Partnership working to resettle Syrian families NHS Highland has been working with both Highland Council and Argyll and Bute Council following commitments to resettle a number of Syrian refugee families through the Government s Syrian Vulnerable Persons Relocation scheme (SVPR). The scheme prioritises people who cannot be supported effectively in their region of origin especially women and children at risk, people in severe need of medical care and survivors of torture and violence. There are clear equality, diversity and human rights elements to this work which has required detailed co-ordinated provision of a wide range of services. This includes providing support with interpretation, language skills and cultural understanding; the Scottish Refugee Council provided training to partners and agencies at an early stage. Key partners from statutory organisations and the third sector quickly developed and delivered a robust and effective resettlement plan to ensure that the families feel safe, secure and can integrate as smoothly and quickly as possible. Good communication amongst partners and with local community representatives helped to ensure a welcoming environment. NHS Highland will learn from the experiences of the refugee resettlement programme in Highland and Argyll and Bute so far and will continue to improve provision, particularly towards a trauma informed approach. Supporting carers in the workplace In the Carer Positive Award was given to NHS Highland to recognise working with the Scottish Government to support carers in the workplace. The Carer Positive scheme for staff supports any employee who may be in a caring role outwith their paid employment. A series of carer awareness events are also taking place for staff in January and February this year. The Scotland s Carers report in 2015 shows that 59% of carers are women and that working age women are much more likely to be carers than men. 2. Quality Responding to patients Access Support Needs Working with our operational unit managers, we have developed a programme of work to improve how NHS Highland identifies and responds to patients who have additional support needs. This important area of work will ensure that all our patients can access and benefit from NHS services equally. A complex area of work that looks across information systems, data collection, staff training and policy development, this work is vital in supporting person centred care. Representatives from NHS Highland are now working at a national level with other health boards to pursue opportunities to improve the identification of access support needs in primary care and the flow of this information through to secondary care. 8

29 29 Language Interpretation and Communication Support During 2015/16 NHS Highland provided interpretation for over 4,000 health, care and support appointments to ensure that people who do not have English as their first language, including British Sign Language, can access and benefit from our services: - Face to face language interpretation was provided for 1,598 appointments - Telephone language interpretation was provided for 2,089 appointments - British Sign Language interpretation was provided for 328 appointments Equality and inclusion for people with sight and hearing difficulties See Hear Highland Education & Learning Services (SHHELS), part of NHS Highland, are a professional training organisation for NHS staff at all levels and also help and advise people with sight and hearing difficulties. During Deaf Awareness Week a stand was held in Raigmore Hospital, Inverness to promote services and available to staff. This also included hearing screening and BSL taster sessions, as well as promoting equality and inclusion for people with sight and hearing difficulties. Fuel poverty The current definition of fuel poverty is that a household is in fuel poverty if, in order to maintain a satisfactory heating regime, it would be required to spend more than 10% of its income (including Housing Benefit or Income Support for Mortgage Interest) on all household fuel use. The area covered by NHS Highland experiences high levels of fuel poverty with pensioner households being at particular risk. Throughout NHS Highland has 9

30 30 worked with Home Energy Scotland to deliver a number of awareness-raising sessions throughout Highland to staff groups to highlight the impact on health and social wellbeing of living in a cold damp home. In November, a pilot project was established in two community hospitals in Sutherland. This pilot aims to include a referral to Home Energy Scotland s online referral portal as part of the hospital discharge process, and will be reviewed in early 2017 with a view to extending to other areas of Sutherland. Improving access to and experience of services for LGBT patients NHS Highland designed an online survey to gather the views of local lesbian and bisexual women about the cervical screening programme. Evidence suggests that barriers exist which may prevent or deter lesbian or bisexual women from attending screening. The data collected is to be used to improve services across Highland. NHS Highland is currently working with the Highland LGBT Forum to develop a toolkit to support primary care to send a clear message to people that their needs will be considered and a service will be delivered that is free from discrimination. A focus group is being held in February 2017 to progress this work. 3. Care Home Anorexia nervosa treatment for young patients NHS Highland has had remarkable success in treating young patients with an eating disorder because of an innovative project that saw them being cared for in their own homes. One of the challenges the board faces in treating anorexia nervosa in children and young people is its geographically large area. To meet this challenge, over the past two years NHS Highland s Child and Adolescent Mental Health Service (CAMHS) has combined family-based treatment (FBT) for anorexia nervosa with quick responses to referrals to treat far more children at home. As a result, CAMHS has seen in-patient bed use decrease dramatically. In March 2015, a revised care pathway was introduced to streamline its response to anorexia nervosa referrals and this was incorporated with family-based treatment (FBT) as its first line approach. New service at Raigmore Hospital reduces isolation for people with sight loss The Vision Support Service, established by RNIB Scotland in partnership with NHS Highland, is based in the Ophthalmology Outpatients Department in Raigmore. This new service offers emotional and practical support to people across Highland who have been diagnosed with sight loss. 10

31 31 Fostering good relations through new models of care NHS Highland is working towards more inclusive models of delivering care services. The Beachview Centre in Brora, a 'traditional' day/respite care centre for people with learning disability is being transformed into a community hub model which will include intergenerational activities. Moving from specialist service delivery to a more inclusive model breaks down barriers and brings together people with and without a disability and people of different ages. Dementia services in Caithness are also moving from a specialist provider dementia service to a more communityinclusive model. Adult social care Personal Outcomes Planning NHS Highland s adult social care services work with people, carers, families and other agencies (including user and carer groups) to ensure people are supported, and to ensure they retain their dignity and are free from stigma and discrimination. When people seek advice and support from adult social care services, an outcomes-focussed assessment can be offered. This Personal Outcome Planning process is carried out in partnership with people, their carers and families. The assessment documentation includes: the person s preferred method of communication; questions about experience of stigma or discrimination; the person s personal, cultural and social history; gender; ethnicity; religion. 11

32 32 4. Participation and empowerment Breastfeeding Awareness Week Breastfeeding provides a baby with the best start in life and also has health benefits for mothers. NHS Highland s approach to promoting breastfeeding has a specific focus on inequalities. Infant Feeding Support Workers: The UK-wide Infant Feeding Survey showed that women who were more likely to breastfeed were: those mums who were aged 30 or over (87%), those who left education over 18 years (91%), those in managerial positions (90%) and those living in the least deprived areas (89%). This made a clear focus to establish infant feeding support workers in areas of deprivation in order to target support in the antenatal period, and use face-to-face support in the early antenatal period. In collaboration with Highland Council, support workers were trained and established in Caithness, Dingwall, Alness/Invergordon, Raigmore Hospital, Inverness Merkinch/Raigmore and in Fort William. The postholders have demonstrated their impact through increased rates of breastfeeding. They have thought of new and exciting ways to engage local women encouraging a community empowerment model to increase breastfeeding rates and improve attendance at groups both before and after birth. Funding is being sought to extend these contracts beyond the 31 st March The Highland Health & Social Care Partnership area underwent reaccreditation from UNICEF Baby Friendly Initiative, resulting in an excellent pass and maintenance of the award. Breastfeeding Awareness Week: A range of events, including picnics and teaparties, were held across Highland to celebrate, raise awareness and break down barriers. Working with teenagers: NHS Highland worked with Eden Court to develop a film to encourage young people to talk about breastfeeding and influence their future choices in relation to infant feeding. Targeted at secondary school pupils, the film aimed to challenge common misconceptions around breastfeeding. Breastfeeding: How much do teenagers know? can be viewed on YouTube. 12

33 33 Hate Free Highland NHS Highland works closely with the Highland Council, Highlands and Islands Enterprise and Police Scotland to promote the Hate Free Highland campaign. During a new website has been launched to raise awareness of hate crime and hate incidents and provide information about how these can be reported. NHS Highland promoted the campaign with partners at the Community Celebration: Celebrating Diversity and Connecting Communities in May and at the LGBT Highland Forum open day in July. Argyll and Bute Health and Wellbeing Grant Fund NHS Highland continues to fund a wide range of community projects that promote equal opportunities, improve health and wellbeing for disadvantaged groups and foster good relations between groups of people. For example, during 2015/ community projects were supported, many of which were aimed at the strategic priorities: tackling health inequalities; mental health; early years; older people; and teenage transitions. More information is available at the Healthy Argyll and Bute website: content/uploads//06/healthwellbeing-in-argyll-bute-annual-report pdf Loneliness and Health NHS Highland s Director of Public Health s Annual report for focused on loneliness as a public health issue. This qualitative research focused on older peoples experiences and found that the prevalence of loneliness was greater for older people with a disability. The report also includes examples of how NHS Highland is working to address loneliness, including the Reach Out campaign. port%20%20(web%20version).pdf 13

34 34 5. Embedding equality within business functions Procurement strategy NHS Highland worked with community planning partners to host a procurement event Purchasing for Better Outcomes in April for public authorities in Highland. Chris Oswald from the Equality and Human Rights Commission presented to an audience of equality and procurement leads. Since this event the NHS Highland procurement team has confirmed that an equality impact assessment will be incorporated into all tender processes. This will help inform the procurement strategy, specification and evaluations of the project and allow for inclusion of appropriate equalities aspects as necessary throughout the tender process. Working with Waverley Care NHS Highland has a service level agreement with Waverley Care with two individual workplans (one for Argyll & Bute and one for North Highland). The overall objective of the service is to provide an easily accessible and locally delivered HIV Prevention/Sexual Health Promotion service aimed at limiting the spread of HIV within Highland and Argyll & Bute, to individuals likely to have the poorest sexual health/highest risk, including men who have sex with men and people of sub- Saharan origin. Actions and services include: Provision of rapid HIV testing services in non-hospital settings Social media. Waverley uses social media to establish contacts, particularly in rural areas A free condoms by post service. This is well used with an increasing number of clients. The service allows men who have sex with men, and young people in remote and rural communities to access free condoms Support for people living with HIV A range of training delivered to professionals across North NHS Highland Transgender awareness training delivered to staff at Oban High School and pupils in Tarbert Academy Outreach including a presence at festivals and college freshers weeks Peer group programme Educational Governance A new Equality and Diversity checklist has been introduced and embedded within the educational governance process to help support anyone designing new training opportunities to consider equality and diversity issues. The checklist uses a number of prompts across three key areas: planning the training; communication; delivery, monitoring and evaluation to help ensure training opportunities are inclusive. 14

35 35 Decision making A new Equality Impact Assessment framework has been introduced called Person Centred Planning. The new guidance aims to be more user-friendly, supporting managers to understand the benefits, how to carry one out, equality issues to consider and importantly actions to progress following the assessment. Recent Equality Impact Assessments are available to view on the NHS Highland website. 15

36 36 LOOKING AHEAD: DEVELOPING EQUALITY OUTCOMES To develop a refreshed set of outcomes NHS Highland has consulted with a range of stakeholders within the organisation and with community groups and representatives. Hate Crime Event October NHS Highland, Police Scotland, the Highland Council and Highlands and Islands Enterprise jointly planned the Tackling Hate Crime in Highland event on 31 st October. The purpose of the event was to increase knowledge and awareness of hate crime and hate incidents and to develop priorities and actions for a partnership hate crime action plan in Highland. Representatives from third party reporting organisations, community and equality groups and equality leads from public authorities attended. This consultation has led to a joint equality outcome with Police Scotland, the Highland Council and Highlands and Islands Enterprise focused on hate crime. Adult Health and Wellbeing Forum December NHS Highland led a discussion with leaders from a range of third sector health and wellbeing organisations which raised a number of issues to consider when developing a refreshed set of equality outcomes: - Communication: standard methods of communication are not always appropriate and may create anxiety if information is not understood - Communication: the needs of people with sensory difficulties, for example autistic adults, and the importance of the environment, greeting and lighting - Hate Crime: intimidation and lack of understanding and acceptance for people with mental health problems - LGBT: considering gender issues with autistic individuals and the impact on their mental health - Mental health meeting the physical health needs of people with mental illness and co-existing conditions e.g. diabetes or heart conditions. There is 16

37 37 also a prevalence of preventable infections/ diseases such as UTIs and pneumonia. - Mental health access to support for young people - Environment: the increase in flooding and other environmental issues affecting those already disadvantaged Many of the issues raised have been taken forward in the new equality outcomes and some of the issues raised may take longer to address and to understand what actions are required. NHS Highland will continue to consider the important issues raised and will continue to engage with the forum. Community Planning Partnership engagement NHS Highland, the Highland Council and Highlands and Islands Enterprise work very closely to review progress of the equality, diversity and human rights agenda across Highland. The equality and diversity leads from each organisation have worked together over the last few months to develop a set of high level equality outcomes that can be shared across the Highland area. Engagement with equality groups and relevant feedback has also been shared between the organisations to inform the new equality outcomes. This partnership approach has led to joint engagement and consultation with equality groups and other stakeholders, sharing of information and resources, and will allow a consistency in monitoring and reporting progress throughout Highland. NHS Highland internal engagement As well as having a number of discussions with community groups and representatives, a range of discussions have also taken place with managers and colleagues within NHS Highland. This is to ensure alignment between equality outcomes and strategic and operational priorities. It is important that equality outcomes are reflected throughout the organisation s plans and strategies, have senior level commitment and can be achieved and measured. The equality outcomes and mainstreaming reports have been recently discussed at the following meetings: - Argyll and Bute senior management team 25th November - Inner Moray Firth operational unit senior management team 21st December - North and West operational unit senior leadership team 11th January - Highland Partnership Forum 20 th January and 24 th February - Numerous meetings with key colleagues about relevant work programmes and service areas 17

38 38 EQUALITY OUTCOMES NHS Highland will work towards the following equality outcomes: 1. Increasing the diversity in leadership and workforce participation An amended outcome which addresses the poorer outcomes and opportunities experienced by some groups. This will benefit LGBT and disabled employees A joint outcome with the Highland Council (THC), Highlands and Islands Enterprise (HIE) 2. Identified groups have improved experiences of accessing services and information An amended outcome which addresses some of the barriers to providing person-centred care This will benefit people in care homes with sensory impairment and people with access support needs receiving secondary care A joint outcome with THC 3. Identified groups of children and young people will benefit from improved access to mental health services and support A new outcome which addresses the unequal access to mental health support for some children and young people A joint outcome with THC 4. People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them An amended outcome which focuses on the Hate Free Highland campaign A joint outcome with THC and HIE 5. In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it An amended outcome which focuses on the rights of women and the work of the Violence Against Women Partnership A joint outcome with THC 6. As a Community Planning Partnership, work towards addressing socioeconomic disadvantage as set out in the Local Outcome Improvement Plan A new outcome which recognises the focus on inequality within the new Community Planning Partnership arrangements A proposed joint outcome with THC, HIE and potential to be adopted by the wider partnership Each of the outcomes above has an accompanying action plan. The plans set out the justification for the equality outcome, the protected characteristics they will affect, the actions, measures and named lead person. These plans are included in Annex 1 of this report. 18

39 39 ANNEX 1: EQUALITY OUTCOMES Equality Outcome 1: Increase diversity in leadership and workforce participation What is the situation, problem or equality issue we want to address? This is a shared outcome with the Highland Council and Highlands and Islands Enterprise The Fairer Scotland Action Plan prioritises Fairer Working Lives as a key ambition. This recognises the importance of having a job that treats people fairly, the need to tackle discrimination in employment and provide flexible working with decent pay as well as equal citizenship and finding employment for disabled people. The Stonewall Unhealthy Attitudes report provides evidence of the scale of discrimination and harmful attitudes that some LGBT people experience working in health and social care. Local evidence also suggests an under reporting of protected characteristics (particularly disability and sexual orientation) and a gender pay gap in medical and dental and adult social care where female employees have a lower average hourly rate compared to males. NHS Highland is one of the largest employers in Highland, with around 10,000 employees. NHS Highland is committed to ensuring that all staff are treated with dignity and respect and will continue to promote fair working practices and address the inequalities that exist within the workforce. Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? Gender Eliminate unlawful discrimination Disability Advance equality of opportunity Sexual orientation Foster good relations Transgender How will this outcome be achieved? Example key activities Outputs Measures Leadership Continue to work as a Stonewall Diversity Champion to promote LGBT equality in the workplace Agree and implement action plan Improved Workplace Equality Index score Staff network established Stonewall improvement group Deputy Director of HR Principal Officer Health Inequalities Increase the number of staff completing Awareness raising Reduction in unknowns Deputy Director of HR 19

40 40 monitoring forms campaign and training materials for e:ess and Non-disclosure rates Carer Positive Award Policy review focused on HR policies, including work life balance policies Encourage staff to complete the Equality and Human Rights training module Progress to Disability Confident Leader Award Continue to gain the award and aim to improve level Policies reviewed and approved Internal communications to staff and managers Completion of assessments for award Achieve exemplary status Progress against the policy review programme Increase in completion rates: 80% by 2018 Achieve Award by April Deputy Director of HR HR Sub Group Highland Partnership Forum Highland Partnership Forum Deputy Director of HR Transfer Adult Social Care Staff to Agenda for Change terms and conditions Project Plan to transfer staff All staff, excluding Social Workers, transferred by April Deputy Director of HR 20

41 Equality Outcome 2: Identified groups have improved experiences of accessing services and information What is the situation, problem or equality issue we want to address? This is a shared outcome with the Highland Council There is extensive research to evidence that disabled people and people with translation, interpreting and communication support needs experience barriers in accessing services and information relating to their health and care (see Health Scotland website). Inaccessible communication means that some people miss their appointments and do not understand their condition or medical treatment. Disabled people and people with communication support needs have poorer experiences of services and experience poorer health outcomes. NHS Highland health and social care staff have also identified a lack of testing of vision and/or hearing in care homes which can lead to social isolation, possible mis-diagnosis, and can seriously impact on someone s ability to engage with the care home community. This issue has been highlighted in a Care England Report. Furthermore Stonewall s Unhealthy Attitudes report highlights stigma and discrimination that LGBT people have experienced when using health and social care services. NHS Highland is committed to improving the quality of care to every person every day, pursuing the highest outcomes and caring experiences and is therefore committed to addressing the inequalities that exist in accessing and benefitting from health and social care services. Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? Sexual orientation Eliminate unlawful discrimination Transgender Advance equality of opportunity Disability Foster good relations Race/ethnicity 41 21

42 42 How will this outcome be achieved? Example key activities Outputs Measures Leadership Responding to access support needs (ASN) Participate in national working group to develop READ codes to identify ASNs in primary care Use quality improvement methodology to develop the identification and response to specific ASNs Develop British Sign Language (BSL) Plan Provide communication support for people who are D/deaf or hard of hearing Provide interpretation to service users where appropriate Addressing sensory impairment in care homes Roll out sensory impairment assessment to all care home residents Improve identification of sensory impairment on admission to care homes A set of READ codes approved New guidance/protocol in place BSL plan published by 2018 New contract in place by 2018 Interpreters provided Working with Interpreters training provided to staff Screening programmes Improving the experience of care for LGBT service users Develop an inclusive communication toolkit for use in primary care Sensory icons on case notes and sensory information included in Personal Outcome Plans Focus group meetings to develop toolkit Toolkit published tbc tbc tbc Monitor use of service Annual survey of service users Monitor use of interpretation services Survey of staff/service user experience Increased number of care homes offering assessment and referral Number of people identified and supported on admission Survey service users on experience of care Head of Planning and Performance Principal Officer Health Inequalities Head of Planning and Performance Principal Officer Health Inequalities tbc Principal Officer Health Inequalities Principal Officer Health Inequalities Director of Adult Care See Hear Improvement Group Director of Adult Care See Hear Improvement Group Public Health, Health Improvement Specialists 22

43 Equality Outcome 3: Identified groups of children and young people will benefit from improved access to mental health services and support What is the situation, problem or equality issue we want to address? The Children and Young People in NHS Highland Health Needs Assessment provides a detailed account of the inequalities that exist for some children and young people with mental health difficulties: Across the UK one in ten children between the ages of 5 and 16 to have a clinically diagnosed mental health disorder Research suggests that 20% of children have a mental health problem in any given year, and about 10% at any one time Some groups of children and young people are particularly at greater risk of having mental health difficulties, notably Looked After Children and Young People, those with Learning Disabilities, young carers, those experiencing conflict at home, refugees and those from minority groups such as gypsy travellers. Nearly 40% of under 20 year olds live in remote or very remote and rural areas in NHS Highland; access to services and social and leisure activities is a major issue in these areas NHS Highland Children and Adolescent Mental Health Services (CAMHS) also recognise that not all children and young people benefit from equitable access to mental health services: Children and young people with learning disabilities (LD) and autistic spectrum disorder (ASD) often experience longer waiting times compared to those without Children and young people living in rural areas, outwith Inverness may also experience barriers in accessing services and support There is not a consistent pathway/ service for the assessment of children and young people with neurodevelopmental disorders NHS Highland is committed to addressing these issues and ensuring that access to mental health services is fair and equitable. 43 Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? Age Eliminate unlawful discrimination Disability Advance equality of opportunity Race and ethnicity 23

44 How will this outcome be achieved? Example key activities Outputs Measures Leadership Increased investment in services for children and young people with LD and ASD. Increased capacity and resources Reduced waiting times for children and young people with LD and ASD CAMHS Service Manager A new outreach team to deliver services in rural areas Staff recruited 44 Increased investment for services for children and young people with LD and ASD and for services in rural areas CAMHS Service Manager Use quality improvement methodology (RPIW) to develop a new pathway for CYP with neurodevelopmental disorders RPIW undertaken A new assessment service in place for children and young people with neurodevelopmental disorders CAMHS Service Manager 24

45 Equality Outcome 4: People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them What is the situation, problem or equality issue we want to address? This is a shared outcome with the Highland Council and Highlands and Islands Enterprise Hate Crime is motivated by hatred or prejudice on the grounds of race, religion, transgender identity, sexual orientation or disability. Hate crime is never acceptable and should not be tolerated. Everyone has the right to live safely and without fear. A recent independent report (September ) to the Scottish Government on hate crime highlights continued under-reporting, the need for joint working and the importance of the role of education. Highland Community Planning Partners (Police Scotland, Highland Council, NHS Highland, Highlands and Islands Enterprise) held a hate crime event in October in Inverness. This was well attended by partner agencies, Third Party Reporting Organisations (TPROs) and local equality groups in order to raise awareness of police Scotland s national approach and local activities. The issues raised reflect those highlighted above. Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? All protected characteristics Eliminate unlawful discrimination Advance equality of opportunity Foster good relations How will this outcome be achieved? Example key activities Outputs Measures Leadership Review and launch new Hate Free Highland website Hate Free Highland website Monitor use of website Identify and train Third Party Reporting Organisations (TPROs) Raise awareness of hate incidents and hate crime Organisations available for reporting, support and advice Participation in community events Stakeholder events 45 Number TPROs identified and fully trained Citizens Panel consultation question on awareness Principal Officer Health Inequalities (in partnership with equalities leads from Highland Council and Highlands and Islands Enterprise) Regular monitoring through Safer Highland Group Annual report to Community Safety, Public Engagement and Equalities Committee 25

46 Equality Outcome 5: In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it What is the situation, problem or equality issue we want to address? This is a shared outcome with the Highland Council and Police Scotland is a key partner Equally Safe is Scotland s strategy to take action on all forms of violence against women and girls. This is defined as the violent and abusive behaviour carried out predominantly by men directed at women and girls precisely because of their gender. Behaviour that stems from systemic, deep-rooted women s inequality, and which includes domestic abuse, rape, sexual assault, commercial sexual exploitation, and so called honour based violence and harmful traditional practices like female genital mutilation and forced marriage. Violence against women and girls can have both an immediate and long-lasting impact on the women, children and young people directly involved. Scotland s first National Action Plan (SNAP) for Human Rights explicitly recognises that taking action to address violence against women and girls is needed to ensure that we realise the human rights of everyone in Scotland. The Highland Violence Against Women Partnership (VAWP) works to ensure that Those affected by VAW receive services which meet their needs Perpetrators are tackled about their behaviour There is reduced acceptance of VAW Healthier gender relationships are promoted Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? Gender Eliminate unlawful discrimination Transgender Advance equality of opportunity Race/ethnicity Disability Age 46 26

47 How will this outcome be achieved? 47 Example key activities Outputs Measures Leadership Clear guidelines to support staff experiencing gender-based violence and tackle perpetrators Gender Based Violence Policy Incidents recorded on Datixtbc Deputy Director HR Refresh priorities and measures for VAW Delivering the VAW training programme and evidence the impact of VAW training Highland Violence Against Women Action Plan & Strategy VAW Educational governance framework See below local measures will also be confirmed No. of VAW training sessions delivered; no. of people attending VAW Partnership Chief Executive VAW Development & Training Manager Measures in the violence against women (VAW) performance framework include: Number of women and children identified by VAW Partnerships as being affected by violence against women and girls (VAWG) Number affected by VAWG who are referred to a specialist support service Average length of waiting time to access specialist support services Satisfaction with support services Number of men identified as being perpetrators of VAW Number and percentage of perpetrators of VAW referred to interventions Improvements in attitudes and understanding about VAW People are more likely to challenge examples of sexism 27

48 Equality Outcome 6: As a Community Planning Partnership work towards addressing socio-economic disadvantage as set out in the Local Outcome Improvement Plan What is the situation, problem or equality issue we want to address? This is a proposed shared outcome with the Highland Council, Highlands and Islands Enterprise with the potential to be adopted by the wider partnership. The Community Empowerment (Scotland) Act 2015 introduces new duties on public authorities and new rights for community bodies. The Act will promote and encourage community empowerment and participation and has a specific focus on tackling inequality. NHS Highland is a key partner in two Community Planning Partnerships (CPP); Highland and Argyll and Bute. Each CPP will work to understand the needs of the community and identify local priorities. They will be informed by information, knowledge and evidence from the public authorities and partners and importantly will take account of the views of local people or groups of people, for example young carers. This will enable each CPP to produce a Local Outcome Improvement Plan (LOIP). Each CPP will also produce a number of locality plans which will be focused on smaller geographical areas where the members of the community experience poorer outcomes compared to those who live elsewhere. Which protected characteristics will benefit? Which parts of the Public Sector Equality Duty apply? Potentially all protected characteristics Eliminate unlawful discrimination Advance equality of opportunity Foster good relations How will this outcome be achieved? This outcome is a proposed outcome, as the new arrangements for Community Planning Partnerships have not yet been fully implemented. This outcome aims to embed equality, diversity and human rights issues within the Local Outcome Improvement Plan and the locality plans. Each of the 24 areas identified in Highland (using the SEP Index) will develop a locality plan Argyll and Bute CPP will continue to develop locality plans in the geographical areas experiencing the poorest outcomes Although these plans are yet to be developed and we do not yet know the approaches that each CPP or smaller areas will take to address inequalities, activity may build on current partnership activity, for example: Fuel poverty the NHS Highland area has a higher rate of fuel poverty compared to Scotland as a whole. Pension aged people are particularly affected. Welfare reforms mitigating the impact of welfare reforms, of which women have been disproportionately affected

49 49 ANNEX 2: EMPLOYEE DATA AND INFORMATION Employee Protected Characteristics Data and Analysis Data Quality Issues and Actions NHS Highland employee data relating to protected characteristics is held in the electronic Employee Support System (e:ess). Although e:ess went live in 2013, the use of employee and manager self- service functionality within the system remains limited. This functionality is used by employees to update, amongst other things, their protected characteristic information. For most protected characteristics (notable exceptions being age and gender), somewhere in the region of 40-50% of the information is unknown because it has not been provided, either by declining to provide it or because they have not been asked. This figure has remained consistent over the last 3 years. The key action, therefore, in relation to our Equalities Duties in respect of employees, is to improve the quality of the employee equalities data we hold. To achieve this we will fully roll out across NHS Highland by March 2018, the elements of Employee Self Service that will allow staff to update their Equalities information. This will be combined with a communication campaign to encourage employees to enter or check and update their information. Linked to the above will be the introduction of leaver questionnaires. The current paper process is not used extensively and does not provide us with the opportunity to collect/update equalities information. Leaver questionnaires can be completed within e:ess and as part of the roll out of that process we will ask all leavers to update their Equalities information in e:ess at the same time. This will enable us to provide a robust analysis of the reasons why people leave the organisation and if there are reasons relating to protected characteristics that are perhaps not reported through other formal mechanisms. In addition, we will be able to report leaver information across all the protected characteristics, which we are currently unable to do with any confidence in the data. This will also be implemented by March Work is underway locally and nationally to enable us to report absence information through e:ess, which when combined with the above, will allow us to report and analyse absences across most of the protected characteristics. We are currently unable to do so. We anticipate the payroll interface, which will allow this information to be transferred into e:ess to be in place by the end of the financial year , allowing us to report absence information across the protected characteristics by the end of financial year Finally, in relation to recruitment, work has been undertaken to ensure we have robust equal opportunities monitoring information for the whole board area. This work was, however, only completed at the end of last year and although we do have quality information for most of the Board it will not be until the end of the next financial year that we will have confidence in board-wide information. The workforce profile information presented below covers 3 years from January 2014 to January Where there is no trend information, the data presented represents a 29

50 50 snapshot in time at 08 January Data relating to recruitment is only partial in that it does not include the Argyll and Bute Operational Unit and is for the financial year to date only. As noted above, work has been completed which will allow us to report more fully in future. Workforce Protected Characteristics Data Age Profile (headcount excluding Bank) The above graph shows the trend in age group profile over the last 3 years from January 2014 to January It clearly demonstrates a shift in the proportion of younger employees with increases in all but the two highest age ranges. 30

51 51 Table 1 below shows the number of applicants in each of the age bands along with the numbers appointed. This clearly shows a high proportion, over a third, of all applicants in the under 30 age bands. It also demonstrates that 30% of appointees are under the age of 30, the largest group by some margin. It should be noted, however, that the conversion rate (percentage of age group appointed) for this group is just 11.5% and for those under 20 it is just 5%. The best conversion rates are seen in the 35-39, and age bands. Table 1 Age Band Number of Applicants Number appointed Conversion Rates < % % % % % % % % % % % Work is ongoing in relation to attracting young people into careers in health and social care and providing them with the skills required through Modern Apprenticeships and a Care Academy. It is expected that these initiatives will improve the conversion rates above. Gender (Postholders Excluding Bank) Table 2 Employments by Gender Female Male Table 2 above shows the gender profile within NHS Highland. In common with other employers in the health and social care sectors, we have a significantly higher proportion of female employees (82.8%). The profile masks a high degree of vertical and occupational segregation of female employees across job families and pay bands as demonstrated in Table 3. 31

52 52 Table 3 Employments by Agenda for Change Band and Gender Agenda for Change Employees Female Male Grand Total Band Band Band Band Band Band Band Band 8A Band 8B Band 8C Band 8D Not assimilated Just under 90% of staff at Band 5, for example, are female, compared to 65% for Band 8B and 8C, significantly higher paid bands. The breakdown of gender across job families below demonstrates significant occupational segregation. Almost 100% of dental support staff are female, with very high proportions of women seen in nursing and midwifery, social care, allied health professions and administration. Higher paid occupations, such as medical and dental and senior management show an almost equal split between genders. Support services, which includes domestic services, portering and estates, and Health Care Sciences each have similar proportions of females, around 61%. This occupational segregation has a significant impact on the Gender Pay Gap reported later in this paper. Table 4 Employments by Gender and Job Family Gender Female Male Female Male ADMINISTRATIVE 88.1% 11.9% SERVICES ALLIED HEALTH 88.2% 11.8% PROFESSION DENTAL SUPPORT % 16.4% HEALTHCARE SCIENCES % 39.0% MEDICAL AND DENTAL % 51.2% MEDICAL SUPPORT % 50% NURSING/MIDWIFERY % 10.0% OTHER THERAPEUTIC % 13.7% PERSONAL AND SOCIAL 91.3% 8.65% CARE SENIOR MANAGERS % 46.8% SUPPORT SERVICES % 38.2% Unassimilated (TUPE) % 11.6% 32

53 53 In addition the proportion of part time workers who are female is significantly higher across all job families than their male counterparts, as demonstrated in Table 5 below, having a further effect on total earnings for female employees. Table 5 Part time and Whole Time Employments by Gender and Job Family Job Family Female Female Male Male % % Part Time Whole Time Part Time Whole Time Female P/T Male P/T ADMINISTRATIVE SERVICES ALLIED HEALTH PROFESSION DENTAL SUPPORT HEALTHCARE SCIENCES MEDICAL AND DENTAL MEDICAL SUPPORT NURSING/MIDWIFERY 1,959 1, OTHER THERAPEUTIC PERSONAL AND SOCIAL CARE SENIOR MANAGERS SUPPORT SERVICES Table 6 below highlights the recruitment conversion rates by Gender. It demonstrates that we continue to recruit more women than men with a male conversion rate of only 7.82% compared to 13.4% for women. Table 6 Applicants Appointees Total Applicants Conversion Rate Female % Male % Grand Total % However, as with the current workforce profile, there is significant variation in conversion rates across the different job families as illustrated in the table below. Conversion rates are significantly higher for females in the Allied Health Professions, Health Care Sciences, Social Care and Nursing. 33

54 54 Table 7 Female Conversion Rate Male Conversion Rate Job Family Administrative Services 7.00% 6.53% Allied Health Profession 16.97% 10.09% Dental 0.00% 50.00% Dental Support 15.38% 15.38% Healthcare Sciences 11.46% 5.26% Medical 51.16% 29.58% Nursing/Midwifery (Qual) 22.22% 12.99% Nursing/Midwifery (Unqual) 9.01% 8.84% Other 0.55% 0.00% Other Therapeutic 9.83% 5.83% Personal and Social Care 27.30% 17.39% Senior Management 11.11% 10.53% Support Services 10.02% 4.48% Disability Table 8 below highlights the reporting issues mentioned at the start of this appendix. As at 8 January 2017, the disability status of 46% of our employees is unknown. More concerning is the trend in those describing themselves as disabled, which is reduced as a percentage of the workforce each year. As well as the data quality work mentioned above, we will work with colleagues in Occupational Health to promote reporting in relation to disability by employees following new diagnoses. Table Disabled 1.10% 0.95% 0.90% 0.79% Non-Disabled 56.10% 52.40% 53% 53.20% Not Declared 30.60% 28.30% 26.60% 26% Don't Know 12.20% 18.30% 19.50% 20% The application rate from disabled candidates is low at just 2.4% of all applicants, compared to the 23% of adults living with a limiting condition within NHS Highland board area. 34

55 55 As seen in table 9 below, the applicant to successful candidate conversion rate is 5.26% for disabled candidates, significantly lower than that for those stating they do not have a disability (12.32%) Further qualitative work is required to understand both the low application rate and the poor conversion rate. NHS Highland has recently been awarded the Disability Confident Employer award and is committed to achieving the core actions required to be a Disability Confident Leader. We expect these actions to have a positive effect on the number of applications from disabled candidates and improve the conversion rate. Table 9 Disability Unsuccessful Applicants Successful Applicants Conversion Rate No % Prefer not to say % Yes % Transgender Table 10 outlines the percentage of employees identifying as Transgender or Transsexual. Table Transgender or transsexual 0.16% 0.10% 0.10% 0.10% Not Transgender or transsexual 50.24% 47.20% 48.20% 47.10% Not Declared 36.50% 34.50% 32.20% 34.40% Don't know 13.10% 18.20% 19.50% 18.40% Sexual Orientation Table 11 outlines the percentage of employees identifying as gay, lesbian, bi-sexual or heterosexual. Table Gay/Lesbian/Bi-Sexual 1.30% 1.21% 1.34% 1.32% Heterosexual 52.30% 48.90% 49.50% 50.00% Not Declared 27.10% 25.30% 23.80% 22.70% Don't Know 19.30% 24.60% 25.40% 25.90% Although the numbers are very small and again highlight the data quality issues faced, the figures reported have remained steady over the last 3 years for employees identifying in each category. The key priority is to encourage full reporting. 35

56 56 Table 12 below provides numbers and conversion rates of applicants identifying as gay/lesbian/bi-sexual. Compared to the heterosexual conversion rate, gay/lesbian/bisexual applicants are less successful at securing an appointment. Table 12 Successful candidate Conversion rate Applicant Gay/Lesbian/Bi- Sexual % Heterosexual % Not known % Other % Prefer not to answer % The numbers relating to Transgender applicants are too small to provide any meaningful data to analyse. Ethnicity Table 13 below outlines the percentage of employees identifying themselves as members of an ethnic group. Due to the small numbers involved, and following the Equalities and Human Rights Commission approach, Black and Ethnic minority groups have been aggregated. Table Black and Ethnic Minority 0.94% 0.88% 0.99% 1.09% White British 60.50% 56.40% 55.80% 55.20% White Irish 0.71% 0.63% 0.75% 0.77% White Other 1.99% 1.92% 2.00% 1.99% Not Declared 17.40% 16.03% 15.20% 14.60% Don't Know 18.60% 24.30% 25.30% 26.50% As can be seen from the data above employees identifying with non-white ethnic groups has increased as a proportion of the workforce over the last 3 years. Over the same period the percentage of White Other employees has remained steady, despite fears that employees from the European Union may leave due to fears over Brexit. These figures mask, however, a clear occupational segregation within and across ethnic groups. For example, 31% of Asian Others are employed within Support Services, compared to 16.8% of White- Other and just 10.6% of White British employees. Medical and Dental employees make up 11% of our Asian Other workforce, compared to 6.8% of the British White Workforce and 21.9% of White Other employees. 36

57 57 Table 14 shows numbers and conversion rates of applicants and successful candidates for a range of ethnic minority groups. The groups have been aggregated to show meaningful data, due to small numbers in the individual BME groups. The conversion rate for White Irish is skewed by the small numbers involved. It is clear that other ethnic groups, including BME show lower conversion rates than White British applicants. Table 14 BME White British White Irish White Other Successful Conversion Applicants Candidates Rates % % % % Religion The data below shows the proportions of employees who claimed to identify with a particular religion or belief. Table 15 shows a steady decline in employees identifying with a religion or belief over the last 3 years, but there has been a corresponding increase in the number of employees whose religious beliefs are unknown. One would expect a large and complex workforce such as NHS Highland to follow national trends. The Scottish Government reports that in 2014, 44.5% of the Scottish Population did not identify with a religion or belief.1 In 2017 we are reporting only 18% which has fallen from 19.9% in Table 15 Religion or Belief No Religion or Belief Not Declared Not Known % 19.90% 20.70% 19.80% % 19.00% 19.10% 25.20% 34.60% 17.80% 17.70% 29.90% % 18.00% 16.90% 31.50% Again the figures above mask occupational segregation within and across religious groups. 25% of those identifying with a non-christian religion or belief work within the Medical and Dental Job family, compared to just 6.9% of those identifying with a Christian religion. This contrasts with just 4% of Nurses and Midwives identifying with a non-christian religion or belief and 12% in Administrative Services

58 58 The table below highlights the number of applicants and successful candidates along with the conversion rate for those identifying with a religion or belief and those who do not. Again the data has been aggregated to provide meaningful data due to small numbers in some of the religious groups on which we collect data. The data shows an overall trend rate for those identifying with a religion/belief slightly higher than those who do not identify. However, this overall rate masks the very low conversion rates (even when the small numbers are considered) for applicants identifying with Judaism, Sikhism and Buddhism where conversion rates are between 0% and 6%. Table 16 Applicants Successful Candidates Conversion Rate Religion/Belief % No Religion/Belief % Not Known % Prefer not to Answer % 38

59 59 Equal Pay Statement This statement has been agreed in partnership and will be reviewed on a regular basis by the NHS Highland Partnership Forum and the Staff Governance Committee. NHS Highland is committed to the principles of equality of opportunity in employment and believes that staff should receive equal pay for the same or broadly similar work, or work rated as equivalent and for work of equal value, regardless of their age, disability, ethnicity or race, gender reassignment, marital or civil partnership status, pregnancy, political beliefs, religion or belief, sex or sexual orientation. NHS Highland understands that the right to equal pay between women and men is a legal right under both domestic and European Law. In addition, the Equality Act 2010 (Specific Duties) (Scotland) Regulations require NHS Highland to taking the following steps: Publish gender pay gap information by 30 April 2013 Publish a statement on equal pay between men and women by 30 April 2013, and to include the protected characteristics of race and disability in the second and subsequent statements from 2017 onwards. It is good practice and reflects the values of NHS Highland that pay is awarded fairly and equitably. NHS Highland recognises that in order to achieve equal pay for employees doing the same or broadly similar work, work rated as equivalent, or work of equal value, it should operate pay systems which are transparent, based on objective criteria and free from unlawful bias. In line with the General Duty of the Equality Act 2010, our objectives are to: Eliminate unfair, unjust or unlawful practices and other discrimination that impact on pay equality Promote equality of opportunity and the principles of equal pay throughout the workforce. Promote good relations between people sharing different protected characteristics in the implementation of equal pay We will: Review this policy, statement and action points with trade unions and professional organisations as appropriate, every 2 years and provide a formal report within 4 years; Inform employees as to how pay practices work and how their own pay is determined; Provide training and guidance for managers and for those involved in making decisions about pay and benefits and grading decisions; 39

60 60 Examine our existing and future pay practices for all our employees, including parttime workers, those on fixed term contracts or contracts of unspecified duration, and those on pregnancy, maternity or other authorised leave; Undertake regular monitoring of the impact of our practices in line with the requirements of the Equality Act 2010; Consider, and where appropriate, undertake a planned programme of equal pay reviews in line with guidance to be developed in partnership with the workforce. Responsibility for implementing this policy is held by the NHS Highland Chief Executive. If a member of staff wishes to raise a concern at a formal level within NHS Highland relating to equal pay, the Grievance Procedure is available for their use. 40

61 61 Gender Pay Gap The tables below outline the Gender Pay Gap for the Board as a whole and then further broken down across the different terms and conditions in use across the board. The information is presented in three different formats, each defined below. Mean Pay is a sum of hourly rates divided by the number of hourly rates. Median Pay is the hourly rate in the middle of all hourly rates in ascending order. For example, 3 is the median of the range 1,2,3,4,5. Mode Pay is the most common hourly rate. Gender Pay Gap Gender Percentage Male Female Whole Board Pay Gap Difference Mean Pay % Median Pay % Mode Pay Gender Percentage Male Female Agenda for Change Pay Gap Difference Mean Pay % Median Pay % Mode Pay Adult Social Care Gender Percentage Male Female (TUPE) Pay Gap Difference Mean Pay % Median Pay % Mode Pay Gender Percentage Male Female Medical And Dental Pay Gap Difference Mean Pay % Median Pay % Mode Pay Gender Percentage Male Female Senior Management Pay Gap Difference Mean Pay % Median Pay % Mode Pay

62 62 The gender pay gap for the board as a whole is significant at negative 5.27 or 28.16%. This is higher than the national average reported in 2015 of 14.8%. 2 The positive Mode pay gap illustrates the relatively high proportion of men in lower paid job families, such as support services. The negative median pay gap of 2.53, when read in conjunction with the Mean pay and Mode pay, effectively shows there are a relatively small number of men in NHS Highland with high levels of pay compared to the rest of the workforce. This can be seen when we look at the Medical and Dental pay gaps. NHS Highland is committed to moving Adult Social Care staff from their current terms and conditions to Agenda for Change. Opportunities to move other groups of staff will be explored where appropriate. Pay Gap for Full Time and Part time Employees The pay gap for full time employees only and part time employees only are noted below. The median pay gaps are relatively small, indeed non-existent for part time employees. However, it should as noted in the workforce analysis above, the higher proportion of part time women in lower paid job roles has a significant impact on the mean Gender pay gap for female employees with a negative pay gap of 5.64, or 31%. The gap is even higher if the mean pay for part time women is compared with the mean pay for full time men, producing a negative pay gap of Full Time Pay Gap Whole Board Mean Pay Median Pay Mode Pay Male Female Male Female Gender Pay Gap Percentage Difference 20.75% 3.88% Part Time Pay Gap Whole Board Mean Pay Median Pay Mode Pay 2 Gender Percentage Pay Gap Difference % % 42

63 63 ANNEX 3: SUCCESSION PLANNING NHS Highland is keen to ensure that the composition of its Board properly covers the full range of interests of its stakeholders, and that membership is open to a true cross section of society. Currently the Board comprises of 20 members and the gender balance is 50:50. NHS Highland is committed to ensuring that the national challenge for the Boards of all public sector organisations to have a gender balance of 50:50 is maintained. In order to progress towards a successful strategy in relation to succession planning we will: Continue to work to assess and define the desired skills, experience and attributes required to promote member diversity Identify any gaps and design engagement and outreach activity to attract people from a diverse range of groups to the work of the Board Consider how to nurture those with no previous Board experience to develop the skills required to become a Board member Engage with some target groups on an on-going basis to develop awareness and understanding of the Board s work Deliver development sessions to build capacity for existing Board members to take on leadership roles within the Board s structure Work with the Public Appointments Team in Scottish Government to extend the reach of our recruitment to Board positions, using a variety of channels to promote vacancies 43

64 64 Report prepared by: Helen Sikora, Public Health and Policy Directorate Employee data and information prepared by: Kevin Colclough, Human Resources Directorate 44

65 65 NHS Highland Board 28 March 2017 Item 4.3 FUTURE GOVERNANCE ARRANGEMENTS FOR HIGHLAND HEALTH AND SOCIAL CARE PARTNERSHIP Report by Ruth Daly, Board Secretary, on behalf of David Alston, Chair NHS Highland The Board is asked to: consider options detailed in this report in relation to the future governance of the Highland Health and Social Care Partnership, and agree to determine the way forward for the future governance arrangements for the Highland Health and Social Care Partnership and adopt Option four as detailed. 1. Summary This paper describes possible options for the future of the Highland Health and Social Care Committee (HHSCC) as requested by the Board and invites the Board to take a decision on the options available. 2. Background The HHSCC was developed under the Community Care and Health (Scotland) Act In 2012, NHS Highland and Highland Council entered into a Partnership Agreement which heralded the beginning of service integration through the Lead Agency model. The Public Bodies (Joint Working) (Scotland) Act 2014 came into force in April 2015 with the disestablishment of Community Health Partnerships and the repealing of the Community Care and Health (Scotland) Act The integration of health and social care is governed by one of two models as detailed in the new legislation: the Lead Agency model as entered into in north Highland and the Body Corporate (Integration Joint Board) which was adopted for the Argyll and Bute Health and Social Care Partnership by the Board on 1st April Governance Considerations In May the Board gave careful consideration to the recommendations of the Jan Polley Governance Review. In relation to provision of health and social care in north Highland the Polley recommendation to replace HHSCC with an intermediate stage Integration Committee represented a significant change to the current arrangements. This option was not fully fleshed out in the Polley Governance Review and focussed on the Lead Agency model while excluding other contractual areas of business. Consequently the Board agreed to carry out further work on its implications through a short-life Working Group. Determination of this recommendation from the Polley Governance Review is still outstanding. The short-life Working Group met on three occasions to consider the implications for Health and Social Care in North Highland and aimed to present a preferred option for future governance to the Board by the end of. The Working Group also considered wider issues relating to health and social care integration across the whole of the Board area. In November the Board was informed that, since there was continuing division of opinion, a united recommendation could not be proposed by the Working Group to the

66 66 Board. Instead, a report covering the scope of deliberations undertaken by the Working Group was presented and it was agreed that further detailed consideration be undertaken by the Board, at a Development Session, prior to determining any changes to the governance arrangements for HHSCC. 4. Options for Board Consideration Option one: to maintain the status quo Option two: to replace HHSCC with an intermediate stage Governance Integration Committee (with a review after 2 years) Option three: to dissolve the current HHSCC and remit its responsibilities back to the Board Option four: to increase delegation of responsibility to HHSCC. 5. Assessment of Options Option one: to maintain the status quo. The HHSCC was developed to replace the original Community Health Partnerships and operates formally as a Sub-Committee of the Board. This arrangement has been in place since April 2012 and the Committee covers the business of all health and social care across the north of the NHS Highland Board area. The overall Committee remit is To co-ordinate for the Highland Health and Social Care area the planning, development and provision of services which it is the function of NHS Highland to provide with a view to improving these services. To provide quality, safe and effective care as close to home as possible and to ensure frontline staff have the opportunity and resources to achieve that objective. To be closely involved in community planning with emphasis on Health & Quality Improvement. To play a key role in the modernisation of healthcare services along with a vital participation in partnerships, integration and re-design. Pros: The existing Lead Agency model has a relationship with the Board that is unique in Scotland and which has never sought to operate in parallel with IJBs. The structure provides a forum for the Board s core business of governance, leadership and performance management around health and social care services in north Highland. This reflects the day to day business of what Executives, Non-Executives and the Board are accountable for. Cons: while recognising that accountability rests with the Board for both HHSCC and the IJB, the power vested in the Committee to take full responsibility for operational delivery in north Highland does not match the delegation of responsibility to the IJB. The strength of scrutiny of delivery is also unevenly matched. This creates an imbalance of attention at Board level and reflects HHSCC s culture of referral of significant decisions back up to the Board. This leads to a degree of duplication with some business being considered at both HHSCC and the Board, e.g. Out of Hours, North Coast Redesign. The current working arrangement also impacts on the Board s aspirations to devote more time to strategic matters and forward thinking items. Option two: to replace HHSCC with an intermediate stage Governance Integration Committee (with a review after 2 years). It is understood that, implicit within this recommendation from the Polley Governance Review, that the work of HHSCC would ultimately be subsumed into the Board and other Committees.

67 67 Pros: the option enables the Board to continue to take active responsibility for leadership and scrutiny of delivery of its main performance indicators and has the option to review the Integration Committee after 2 years. Any such review could provide flexibility of choice for alternative governance options. The Polley Report suggested that this period of time would enable a fuller understanding and fulfilment of leadership and performance scrutiny roles with regard to childrens services as delivered by Highland Council. Cons: this option does not clarify what the HHSCC would ultimately transform into. It recommends replacing it with a Committee that would oversee progress towards effective integration of services for both adults and children by subsuming the work of the Committee into the Board after a two year period. Option three: to dissolve the current HHSCC and remit its responsibilities back to the Board Pros: the option enables the Board to continue to take active responsibility for leadership and scrutiny of delivery of its main performance indicators and would involve all Board Directors in the delivery of health and social care in north Highland. Cons: subsuming the work of the Committee into the Board and existing Governance Committees would be impractical and over-burdensome. This would draw the Board s attention away from its aim to focus on strategic matters 75% of the time by involving it in operational details and would not be an efficient use of Directors time. In addition, there would be a need to hold more frequent or longer meetings of the Board and this would create a significant disproportion of Board attention towards services in north Highland. There would also be a need for very clear differentiation during meetings when Directors are expected to operate in leadership, scrutiny and performance management modes. Option four: increase delegation to HHSCC and review its terms of reference to create parallels with the responsibilities invested in the Integration Joint Board (albeit with a different legal status) which would include responsibility for governance of all elements of the business in north Highland. Under this model the overall remit of HHSCC could be revised to read as follows (revisions highlighted) To take responsibility for and discharge NHS Highland s function to provide services for the Highland Health and Social Care area which will include coordination of the planning, development and provision of services with a view to their continual improvement. To provide quality, safe and effective care as close to home as possible and to ensure frontline staff have the opportunity and resources to achieve that objective. To be closely involved in community planning with emphasis on Health & Quality Improvement. To play a lead role in the modernisation of healthcare services along with a vital participation in partnerships, integration and re-design. For illustrative purposes, the consequence of increased delegation would mean that the following recent items of business would no longer be addressed by the Board but would be under the full aegis of HHSCC: Integrated Children and Young Peoples Plans in NHS Highland Local Delivery Plan Workforce Development Plans North of Scotland Planning Group annual reports Nursing and midwifery issues e.g. revalidation Infection prevention and control

68 68 Financial reporting both capital and revenue Joint Health Protection Plan Inner Moray Firth Masterplan Adult strategic commissioning intentions Quality and Finance report Out of Hours The Board might wish to retain responsibility for all HQA matters including Tier 1 report outs and would have a final say on matters such as major service redesign, asset management and property matters albeit HHSCC would clearly be involved in planning/recommendations to the Board. Pros: increasing delegation would redress the imbalance of attention of health and social care at the Board between north Highland and Argyll and Bute. Amplifying the remit of the Committee would free the Committee to take responsibility which it has hitherto been unable to take and the Board would seek to gain assurance. While it would still be a legal responsibility for the Board to sanction major service change, other changes to service provision and delivery would rest with HHSCC. This option would serve to protect services for the future and would maximise on the whole system approach that had been taken. This would also apply to protecting the quality work that was now fully embedded in the organisation. This option introduces changes to the functions and responsibilities of both HHSCC and the Board and would permit the Board to operate more strategically which was one of the recommendations of the Polley review. Increased delegation would naturally bring with it wider and onerous duties which would more effectively be discharged through a sub-committee structure reporting back to HHSCC for good governance. Revisions to the HHSCC terms of reference would need to include provision for Sub-Committees to facilitate the core business being discharged. This could lead to Sub-Committees being established for a range of areas such as, though not limited to, clinical governance and audit. For example, a clinical governance sub-committee could receive accounts on the application of clinical governance standards and interrogate areas of concern. This would lead to a re-shape of the roles of for existing Board Governance Committees taking place to create a move away from operational considerations. Such governance committees would thereafter require to take an overseeing/assurance role in relation to governance priorities for both north Highland and Argyll and Bute. Existing Governance Committees would therefore operate at a higher level and focus on areas such as: Cascading information from Scottish Government Assessing commonality/overarching issues covering both north Highland and Argyll and Bute Overseeing the governance of HHSCC sub-committees. Cons: this would change the Board s responsibilities and there would be a need for a cultural shift to actively delegate responsibility to HHSCC and not expect referral back to the Board for the vast majority of its business. Accepting that the Board wishes to adopt a more strategic role, it would still need to carry out its performance management and scrutiny responsibilities. Recognising it would take time to adjust to delegating more responsibility and to allow the scrutiny role to develop, a formal mechanism to escalate business to the Board might help with this transition. There would be a need for vigilance to ensure there was no duplication if the HHSCC substructure replicated that of the Board and this might influence the work of existing

69 69 Governance Committees. For example, the Clinical Governance Committee currently undertakes detailed consideration of activity in north Highland with a lighter touch in Argyll and Bute. There are inherent risks associated with increasing delegation. Committee members would require to be fully cognisant of their responsibility for decisions on finance and quality that would be delegated to them. A change in culture and approach on behalf of both HHSCC and the Board would be necessary which would require additional training/development and a period of adjustment to the new governance relationship to allow the scrutiny role to develop. It is possible that increasing delegation to the Committee would also increase the burden of work to service a new structure. It can also be argued that the desire for the Board s attention to be split equally between north Highland and Argyll and Bute does not recognise the different legal relationships governing health and social care delivery. 6. Governance Working Group Position The Governance Working Group did reach consensus on some areas: the Board was not legislatively constrained and could choose its own governance system for health and social care in north Highland. In the event of increased delegation to HHSCC there was a need for clarity on: what business would remain with the Board if it were to operate in a uniquely strategic way what business and responsibility it would delegate to the HHSCC the Committee s and the Board s accountabilities There is a need, whatever the governance arrangements for north Highland, for greater clarity around the Board s role in overseeing the IJB and around how this should be managed for the future. Recommendation The Board is invited to: consider options detailed in this report in relation to the future governance of the Highland Health and Social Care Partnership, and agree to determine the way forward for the future governance arrangements for the Highland Health and Social Care Partnership and adopt Option four as detailed. 7. Contribution to Board objectives Governance implications Staff governance The future arrangements will move to provide assurance around the staff governance for all staff in the HHSCC area. Clinical governance The future arrangements will move to provide assurance around the clinical governance for all clinical and care services in the HHSCC area.

70 70 Financial impact The future arrangements will move to provide assurance around the financial governance for all operations the HHSCC area. 8. Risk assessment The future arrangements will move to manage the risks identified arising from within the operational areas of the HHSCC in line with the NHS Highland Board criteria and escalating as necessary. 9. Planning for Fairness The integration of adult health and social care was subject to a full impact assessment. As appropriate all work programmes should have Impact assessment and it will be the responsibility of the committee to ensue this takes place and is monitored. 10. Engagement and Communication The integration of adult health and social care was subject to comprehensive communications and engagement and this is ongoing. Any changes to the governance arrangements will also require to be communicated including to seek appropriate representation onto the committee. Ruth Daly, Board Secretary March 2017

71 71 NHS Highland Board 28 March 2017 Item 4.4 FINANCE REPORT to February 2017 Report by Nick Kenton, Director of Finance The Board is asked to: Confirm it is content with the accuracy of the financial position as set out in this report and the actions being taken to ensure the target of break-even is delivered on capital and revenue. Executive Summary The Board s two key financial targets are to break-even on revenue and capital The Board is not able to move funding between revenue and capital both targets must be met independently For the 11 month period April to January 2017, the Board has overspent its revenue budgets by 0.6m There is a risk that the Board may not meet its year-end target of breaking-even on revenue but as at month 11 current projected figure is a small surplus of 0.07m so on target to achieve breakeven. In addition, there are around 0.08m of further financial risks that may crystallise in the remainder of the financial year. My view is that the Board is on course to break-even, but that this is dependent on continued efforts in the last month to hold this position in order to deliver this. For the 11 month period April to February 2017, the Board has underspent its capital budgets by 0.02m The Board is on course to meet its target of breaking even on capital Detailed Report Background In April the Board approved a Revenue Plan and Capital Plan for the financial year /17. Revenue generally relates to day-to-day expenditure such as staff salaries, drugs, surgical dressings etc and this represents the vast majority of expenditure. The plan agreed in April was based on an assumed Revenue budget of 819.7m, before savings and before the transfer of resources to Highland Council in respect of the lead agency arrangements relating to children s services. When adjusted for these two elements, the relevant figure is 781.9m. The majority of the Board s revenue funding comes from the Scottish Government (SG) in the form of a Revenue Resource Limit (RRL). The assumed level of RRL funding in the plan was 695.2m, which included an additional 15.3m of funding relating to Social Care (of which 4.1m was passed to The Highland Council) and 1m in terms of movement towards Highland s NRAC target. In addition, the plan assumed income from Highland Council of 91.6m (net of the 4.1m Social care funding) regarding Adult Social Care and a transfer out of funding of 9m to Highland Council relating to children s services.

72 The Revenue Plan was predicated on a number of key assumptions these are shown in Appendix A, together with a brief assessment of the current position against each of these assumptions. Any potentially significant exceptions to these assumptions are explained in more detail in the report. Capital generally relates to one-off expenditure on individual items costing in excess of 5,000 and with an anticipated life exceeding one year. Examples can range from pieces of IT equipment or medical equipment, through to a new health centre or new hospital. The vast majority of the Board s capital funding comes from SG in the form of a Capital Resource Limit (CRL). The Capital Plan for /17 was based on assumed SG funding of 21.5m which included proposed schemes not yet agreed. It is important to note that the Board is not allowed to transfer resources between capital and revenue except in very specific circumstances and with permission from SG. A break-even must therefore be achieved on both RRL and CRL it is not acceptable to underspend on one to compensate for an overspend on the other. This report will deal with RRL and CRL separately. Contribution to Board s Objectives Meeting financial targets is a key objective of the Board. The Board aims to align its resources with its clinical and care objectives. In /17 there are two sources of revenue funding that are worthy of particular note: Social Care In addition to the baseline uplift, the Board received 15.3m as its share of a national allocation of 250m in respect of Adult Social Care (ASC). Of this, 4.6m relates to Argyll & Bute and forms part of the initial payment offer to the IJB. The remaining 10.7m relates to Northern Highland and an agreement for utilising this has been reached with The Highland Council (THC), which must be seen in the context of /17 being the fifth year of the Lead Agency agreement and the third year of the three year financial agreement. NRAC For /17, an initial 30.5m was targeted towards Boards below their NRAC share and the Board s share of this funding is 1m. For an explanation of NRAC please refer to the glossary in Appendix G. In order to move further towards parity, those Boards targeted with this resource need to receive more than their NRAC share of the total amount - for NHS Highland this would be circa 2m the impact of this is that despite an additional 1m of funding, NHS Highland moved 1m further from parity and is now 8.5m (1.53%) below target share. Lead Agency Commissions 72 In North Highland, NHS Highland is the Lead Agency for Adult Social Care (ASC) and Highland Council is the Lead Agency for Children s Community Care. In /17 the total budget for ASC and associated costs such as care home property maintenance is 115.6m of which 91.6m is funded by Highland Council and 24m is funded by NHS Highland (of which 11.7m is from Resource Transfer funding that would have been passed to Highland Council prior to integration). ASC budgets face significant cost pressures in /17 including packages of care and the living wage for care homes and care at home. Highland Council has contributed 1.4m towards these (in line with the agreed three-year funding package) and NHS Highland has contributed 6.6m.

73 NHS Highland has contributed 9.1m to children s services managed by Highland Council in /17, which includes an uplift of 0.1m. Revenue Position Financial Position (April to February 2017) Funding Position As at January, the SG had confirmed funding of 686m for /17. Total anticipated funding from SG for the financial year stands as 715m (this matches the normal pattern of announcements throughout the year). The anticipated funding is re-confirmed with SG on a monthly basis, and this is not considered to be a risk Position Against Budget 73 The year-to-date revenue position for the first 11 months of the financial year (April to February 2017) is an overspend against budgets of 0.6m. Based on this trend, there is a small risk that a breakeven on the revenue budget might not be achieved by year-end. The table below demonstrates the overspend to date and the potential position for year-end, based on the current forecasts from each part of the organisation which is showing a small surplus of 0.1m. In addition to the figures set out below, there are other financial risks that are being managed across the organisation. These are not currently considered a high enough risk to include in the forecast position. This is discussed further in the risk section below. Position to date and Potential Forecast Position - by Management Unit Analysis The table above represents the position by management unit within the organisation (which historically has been the way of managing and reporting the financial position in NHS Highland).

74 74 There is a more detailed version of this table in Appendix B. This table shows that there is a year to date overspend in Inner Moray Firth Operational unit of 9.7m and year end projected overspend of 9.9m, this overspend is entirely due to overspends within Raigmore Hospital and is made up of 6.2m of recovery plan actions that did not materialise recurrently in previous years, and other pressures, mainly within the surgical directorate, including a net spend of 2m on waiting times. North & West Highland is showing a year to date overspend of 5.2m and a projected year end overspend of 6m primarily due to Out of Hours ( 1m) medical locums ( 1.7m) unachieved savings ( 1.9m) ASC pressures including care packages ( 2.2m) and vacant practice costs. Argyll & Bute is showing an underspend to date of 0.5m. An underspend of 0.7m is forecast, but this is not reflected in the table above due to the fact that the IJB needs to take a view on this forecast underspend (i.e. on the health elements of its budgets) in light of the fact that its overall forecast is currently an overspend of 1.2m. In addition to the analysis by unit shown above, it is also helpful to consider the position by type of spend, as this indicates key themes that cut across the organisation which may be relevant when seeking efficiencies. The table below presents information by type of expenditure. Position to Date and Potential Forecast Position by Type of Spend Pay Budgets The effective management of pay budgets in delivering our services remains a key challenge. There remain a number of hard-to-fill posts critical to service delivery (particularly in relation to medical staff

75 but also in other disciplines) where vacancies may exist for an extended period of time. Many of these are filled with locum or agency staff whose costs tend to exceed the salary budget available to cover the cost (often by a significant amount). These excessive costs for key medical posts have still to be met within the overall pay budget so savings have to be generated elsewhere. This is done mostly through the turnover of staff or vacancies being carried for a period of time. In a large organisation, a level of staff turnover is inevitable. NHS Highland s turnover historically tends to run at around 9-10% per rolling year although this is now increasing and currently sits at 11%. There is generally a gap between a member of staff leaving and a new member of staff starting this generates a non-recurring savings usually referred to as a vacancy factor. Most pay budgets are set based on an expected level of natural vacancy factor. Pay is overspending to date by 3.5m and 3.5m projected for year end. Non Pay A key pressure on non-pay is clinical non-pay budgets, which have a year-to-date overspend of 1.3m (mainly at Raigmore). This is offset by an underspend of 1.3m on a range of general non-pay budgets ( 0.5m) and property costs ( 0.8m) and an underspend on Family Health Services (FHS budgets) of 0.6m. The other pressures on non-pay are 3.1m on social care and 0.3m on out of area placements this mainly relates to individual high cost cases for Argyll & Bute patients. Additional Actions 75 At month 3, a forecast of potential overspend of 16.5m was reported to the Board, along with a range of contingencies totalling 9.5m. If these contingencies were delivered then there would be a residual gap of around 7m to close - by pursuing changes to footprint, service redesigns and improvement opportunities. For month 5, there was some progress on implementing these contingencies with 3.6m identified with confidence and played into the forecast reducing the operational forecast to 12.6m. Discussions with the Board at its development session on 26 September, and at the Board meeting on 27 September, led to a further operational recovery plan being put in place to address the forecasted gap, resulting in a revised month 5 position bringing the residual gap down to 2.1m. Further progress was made in month 6, with the residual gap reducing to 1.6m. Progress continues with the residual gap being closed subject to a number of deliverables. The position at month 11 shown in the table below, which summarises the progress since month 5. The capital to revenue transfer previously agreed by the Board has now been actioned and is reflected in the operational forecast. As set out below, there was a requirement of 2.9m still to be delivered at month 10 and a further revision to the recovery plan was agreed to bring down the target for the operational units to 2m and a target for central/allocations to find a further 0.9m, In total the recovery plan has been achieved and the current position is shown in the table below

76 76 Summary Position Month 5 to Month 11 The contingency plan has delivered in full and progress can be seen in the table below. Progress Against Contingency Plan Capital to Revenue Flexibility This has now been actioned at a value of 2.5m as agreed by the Board in November.

77 77 Savings The financial plan agreed by the Board in April was dependent on delivery of a savings target of 28.8m, with 25.8m of that required recurrently. At month 11, 21.9m has been identified and removed from budgets, with a further 0.4m forecast to achieve leaving a shortfall of 6.5m still to be identified - this shortfall is included in the operational forecast. Further details are shown in Appendix C. Assumptions The key assumptions made when setting the financial plan are summarised in Appendix A. Trajectories As part of the Local Delivery Plan (LDP), the Board agreed financial trajectories with the SG relating to year-to-date overspends and savings delivery. The position against these trajectories is shown in the tables below. The first table shows year-to-date estimated overspend by month. The anticipated trajectory from the LDP is shown in dark grey and the actual year-to-date position is light grey. At month 11 the trajectory is 1.5m (overspend) and the actual is 0.6m overspend. The second table shows the trajectory for achieving the 28.8m of savings required in the financial plan. The trajectory is in dark grey and the achieved position is in light grey. At month 11 the trajectory was to have achieved 25.5m and the actual achieved is below that at 21.9m including identified savings removed from budgets in month 12. Performance Against LDP Trajectories

78 78 Risks As set out in the narrative above, there are risks totalling 0.7m that are being managed across the organisation - at this stage it is not considered necessary to include them in the forecast, but they are summarised below (risk table 1) for visibility. The high risks category has been quantified at around 0.1m which represents continued good progress compared with previous reports as detailed below (risk table 2). There is ongoing detailed discussion with operational units regarding these risks every month. Based on these discussions, I am content that these high risks can be held out-with the forecast for now.

79 79 Overall Trajectory - Forecast At the Board meeting in September a trajectory was discussed, which considered both the operational forecast potential overspend and high risks. The aim of the trajectory is to set out a planned reduction in these combined figures over the remainder of the financial year (aiming for break-even in March). For month 11, the target figure was a forecast of 6m. The actual at month 11 is break-even which means the Board is ahead of the trajectory heading into month 12. Summary Forecast and High Risk Trajectory to Break-even

80 80 Underlying Position The Board will be aware that it has been carrying an underlying financial deficit for a number of years. This means that ongoing expenditure exceeds ongoing income and in recent years a break-even has only been delivered in-year by non-recurring (one-off) methods that may not be sustainable going forward. The target for /17 is to hold this underlying deficit at 3m as achieved at the end of 2015/16 a break-even would then be achieved via non-recurring savings of 3m. At month 11 this now stands at around 13m. The working assumption is that this can be reduced down to 6m in advance of next financial year. However, this requires significant effort in the final quarter to convert non-recurrent savings into recurrent. This underlying position does not include underlying cost pressures, as the Board s position has always been that these need to be managed by units. This is becoming increasingly difficult and has been reviewed as part of the planning for 2017/18. Conclusion Revenue In summary: The month 11 year to date position continues to show a steady improvement The position against the overall combined forecast trajectory is ahead of plan, and is now showing break-even, efforts must be maintained to hold that position in the final month My overall view is that the Board is now firmly on course to deliver break-even. In addition there needs to be a concerted effort to convert savings currently identified as non-recurrent into recurrent in order to alleviate some of the pressure on the 2017/18 financial year. Next year will be significantly more challenging than /17. Capital Position Final Position (April to February 2017) As at February, the SG had confirmed capital funding of 12.9m for /17. Position Against Budget The funding position for the year (April to February) is as expected in the financial plan, and now reflects the 2m slippage on Raigmore Critical care that is being brokered to 2018/19, and the 2.5m transfer from Capital to Revenue as discussed above The capital position for the -17 financial year (April to March 2017) is a breakeven against budgets. The year to date capital position for the first eleven months of the financial year (April to February 2017) is also showing breakeven against the phased target. The cashflow position is monitored monthly by the Asset Management Group and assurance is continually sought from capital budget holders that allocations will be spent as planned. At month 11 (when orders placed are taken into account) there is less that 0.9m to be actioned in month 12 as per the table below

81 81 The table below gives a brief overview of the key capital projects and their current status and a more detailed financial position is shown in Appendix D. Conclusion Capital At this stage my view is that the Board is on course to meet its target of breaking-even on capital by year-end. The 2.5m of resources transferred to revenue will create additional pressure on the 2017/18 plan but this is manageable. The Asset Management Group is firmly sighted on this and the consequences have already been risk-assessed.

82 82 Governance Implications Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and Patient and Public Involvement. The financial position is scrutinised in a wide variety of governance settings in NHS Highland (see Appendix E for details). Risk Assessment Risks to the financial position are set out in a specific risk section above. There is an over-arching entry in the Strategic Risk Register. Planning for Fairness A robust system of financial control is crucial to ensuring a planned approach to savings targets this allows time for impact assessments of key proposals impacting on services. Engagement and Communication The majority of the Board s revenue budgets are devolved to operational units, which report into two governance committees that include staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public and are webcast. It is recognised that NHS finances are complex and often jargon is used. The Executive Summary aims to convey the key messages in non-technical language. There is also a glossary of key terms used in Appendix F. Nick Kenton Director of Finance 17 March 2017

83 83 Current Position Against Key Assumptions Appendix A What did was assumed in the financial plan? To hold the underlying deficit carried forward from 2015/16 to 3.0m Continued funding from New Medicines Fund for IPTRs. New Scottish Medicines Consortium (SMC) approvals for drugs assumed as orphan, ultra orphan or end of life care are also funded from new medicines fund at NRAC share as per guidance. No increase in the national target for the treatment of Hepatitis C and therefore 45 new drug treatments in Northern Highland and 11 in Argyll & Bute are factored into the plan. Salaried Dental Services reduction in allocation of 5% Funding is received to support the achievement of TTG targets Raigmore Hospital (IMFOU) to reduce underlying deficit by implementing cost reduction plan. Additional 1.6m AME funding What is the current position? Will increase target now 6m but a challenge to reach this Allocation received of 2.8m which was less than anticipated in the plan Funding now confirmed and reflected in plans Unchanged for -17 Unchanged Allocation Received Indications are that insufficient funding will be provided to meet this target Being progressed with additional actions but risk that the target will not be met. Unchanged. Allocation received.

84 84 Revenue position Month 11 February 2017 Appendix C

85 85 Savings Appendix D

86 86 Capital Position to January 2017 Appendix D

87 87 Forums for Scrutinising the Financial Position Appendix E Board overall responsibility for scrutinising and approving financial plans and achieving financial targets Delivering Financial Balance Programme Board - includes two non-executive Board members who carry out detailed scrutiny of the financial position on behalf of the Board Highland Health & Social Care Committee chaired by a Non Executive Director and provides assurance to the Board regarding progress against a number of key areas including achieving financial balance Argyll & Bute Governance Committee (formerly A&B CHP) - chaired by a Non Executive Director and provides assurance to the Board regarding progress against a number of key areas including achieving financial balance Senior Management Team this forum brings together the senior leadership from across the organisation, the current financial position is discussed and provides an opportunity to agree any actions which cut across the organisation Highland Partnership Forum (and local partnership forums in each unit) chaired by a Non Executive Director, is an opportunity to share the current financial position with staff side representatives Raigmore Senior Management Team an operational meeting where the financial position is discussed and any requirement for local remedial actions are agreed North & West Highland Senior Management Team (also District and Area Management Teams) - an operational meeting where the financial position is discussed and any requirement for local remedial actions are agreed South & Mid Highland Senior Management Team (also District and Area Management Teams) - an operational meeting where the financial position is discussed and any requirement for local remedial actions are agreed Argyll & Bute Core Management Team (also Management Team and Localities Management) - an operational meeting where the financial position is discussed and any requirement for local remedial actions are agreed Asset Management Group chaired by a Non Executive Director, provides oversight and scrutiny of the capital budget and provides assurance to the Board. Scottish Government mid-year and annual reviews - formal Scottish Government Reviews where the financial position is outlined and plans discussed with senior officials from the Scottish Government. Feedback from these reviews is shared with the Board Adult Services Resources & Commissioning Group attended by officials from both Highland Council and NHS Highland and reviews the financial position on Adult Social Care budgets including consideration of operational impact of any potential corrective action Children s Services Resources & Commissioning Group - attended by officials from both Highland Council and NHS Highland and reviews the financial position on Adult Social Care budgets including consideration of operational impact of any potential corrective action

88 88 Highland Strategic Commissioning Group formal governance group comprising senior councillors and officials from Highland Council and senior non executives and officials from NHS Highland. The Group considers finance (amongst other matters) in the context of the Strategic Plan. Argyll & Bute Integrated Joint Board will be legally established on 16 August However, it has no operational responsibility or accountability role until the 1 April. The current Shadow IJB has received some assurance on the financial framework and the process for agreeing opening budgets for the IJB. In the transition period it will be agreeing and establishing the financial governance arrangement and ensuring due financial diligence to inform its formal acceptance of the opening budget from 1 April.

89 89 Glossary of Key Terms Appendix F RRL Core Revenue Resource Limit. The majority of the Board s revenue income comes in the form or Core RRL from the Scottish Government. The Board has a duty to break-even on RRL each and every financial year. CRL - Core Capital Resource Limit. The overwhelming majority of the Board s capital income comes in the form or Core CRL from the Scottish Government. The Board has a duty to break-even on CRL each and every financial year. Revenue - generally relates to day-to-day expenditure such as staff salaries, drugs, surgical dressings etc and this represents the vast majority of expenditure. Capital - generally relates to one-off expenditure on individual items costing in excess of 5,000 and with an anticipated life exceeding one year. Examples can range from pieces of IT equipment or medical equipment through to a new health centre or new hospital. Recurring ongoing (i.e. income or expenditure that is expected to continue for the foreseeable future). Non-recurring one-off (i.e. income or expenditure that is one-off in nature and is only expected in a single financial year). However, it is the case that there is always a level of non-recurring income or expenditure every year. Therefore, whilst individual items might be viewed as non-recurrent, as a general assumption there will always be some level of non-recurrent activity in any given year. Underlying deficit this is the difference between recurrent resources and recurrent commitments. It is common in the NHS for recurrent commitments to exceed recurrent resources, with the shortfall being made up of non-recurrent income and / or non-recurrent expenditure reductions. Saving a reduction to a budget to reflect a firm plan for delivering a saving. The savings will be expected to reduce expenditure, therefore allowing the budget to be reduced without generating an overspend. Cost reduction a reduction in expenditure. Generally, the difference between this and a saving is that a cost reduction usually refers to a reduction in an overspend against a budget. In order to deliver a saving, further reductions usually have to be made so that the budget can be reduced. Cost pressure usually refers to expenditure that cannot be contained within an existing budget. Lead Agency Model In North Highland, NHS Highland and Highland Council have had a Lead Agency model in place since This model involves single lead agency arrangements, and leaves both organisations jointly accountable for determining outcomes and the resources to be committed. The lead agency assumes responsibility for all aspects of business delivery strategy, internal governance and operational delivery or commissioning of services and is fully accountable for the delivery of agreed outcomes. Under this model, NHS Highland is the Lead Agency for adult services (including adult social care) and Highland Council is the Lead Agency for children s community services. In order to facilitate this, Highland Council has transferred resources to NHS Highland in respect of Adult Social Care. This included the transfer of a significant number of staff from the Council to NHS Highland. This means that NHS Highland is now in direct control of the majority of the resources for adult health and care services in north Highland. Similarly, NHS Highland has transferred resources (including staff) to Highland Council in respect of children s community services. Integrated Joint Board Model - the Scottish Government requires all NHS boards to move towards integrated services, working closely with their partners. A Health & Social Care Partnership must be set up for each local authority area. The Scottish Government s legislation allows partners to utilise either a Lead Agency model or an Integrated Joint Board model. In Argyll & Bute, NHS Highland and

90 90 Argyll & Bute Council have agreed to move forward under the Integrated Joint Board model. Under this model, an Integrated Joint Board is established as a separate legal entity. Resources are then transferred from the two parent bodies (NHS Highland and Argyll & Bute Council) to the Joint Board, which then transfers resource back to the two parent bodies in order to provide them with funding for delivering operational services. Vacancy factor usually refers to a reduction in a pay budget in anticipation of savings arising from vacancies. A level of turnover of staff is inevitable in a large organisation. The gap between a member of staff leaving and their replacement starting often generates a non-recurring saving. Most pay budgets are set with an in-built shortfall to reflect this fact known as the vacancy factor. All units begin the year with an assumption that this vacancy factor will be achieved so it is generally just noted in their financial risks (and monitored monthly) rather than featuring as a forecast overspend. There is a solid history of achieving vacancy factor targets. SLA - Service Level Agreement an agreement between NHS organisations to provide services for the other s patients. Forecast the financial forecast represents the best estimate of the year-end position based on current known facts and the anticipated impact of actions being taken or planned. It is crucial to appreciate that the forecast is only an estimate and reflects how the position might be at year-end. The forecast is not a mechanical calculation there is considerable uncertainty and hundreds of variables are involved - so it requires professional judgement. Clearly, the level of uncertainty reduces as the financial year progresses. Risk in the context of this report, risk relates mainly to financial risk (i.e. the possibility of an overspend materialising which is not currently built into a forecast). Risks are generally managed at unit level and it is the unit that will judge whether a risk can be held outside the forecast or not. Usually this requires a mitigation plan. Another related risk factor is the operational risks associated with achieving financial targets (e.g. a savings plan may be low risk in financial terms i.e. there is high degree of confidence in delivering a cash saving but might be high risk in terms of an operational impact). Unless otherwise stated, the risks (and risk ratings) referred to in this report relate to the risk of an adverse financial impact (rather than any other risks such as operational or reputational). Public dental services generally relates to dental services provided directly by the Board via directlyemployed staff. FHS - Family Health Services - refers to independent primary care contractors comprising General Medical (i.e. GPs), Ophthalmic, Pharmaceutical and Dental General dental practitioner services generally relates to dental services delivered by independent contractors. TTG Treatment Time Guarantee. This is a statutory SG target, which requires Boards to treat patients within 12 weeks of them being diagnosed and agreeing to inpatient or day case treatment. NRAC NHSScotland Resources Allocation Committee. In 2007 the Committee made recommendations regarding the formula for funding NHSScotland territorial boards. These recommendations were accepted by the then Cabinet Secretary and the formula has been refined and improved in subsequent years. Around 70% of NHSScotland s resources are within the scope of the funding formula defined by the Committee. The formula sets a target percentage share of overall NHSScotland baseline funding for each territorial board. It does not set the overall funding level for NHSScotland nor for individual boards it simply defines each board s fair share percentage of whatever baseline funding is available.

91 91 Distance from target this is the difference between a territorial board s fair share of the total NHSScotland baseline funding and its actual baseline funding. A board that is receiving more than its fair share is described as being above parity and vice versa. Hubco model The hub initiative is a long-term partnering relationship between the private and public sector. hub North provide or procure, across the North Territory as a whole, the provision of appropriate accommodation and related services to the public sector participants with the aim of: a) Improving the efficiency of delivery of community-based facilities; b) Delivering economies of scale through shared facilities; c) Making the best use of public resources; and d) Providing continuous improvement in both cost and quality in public procurement These costs are financed via revenue rather than capital. The up-front cost of a new build procured under the hubco model is funded by lenders providing funding to hubco. The costs of this funding is then recovered as part of the Unitary Charge made by hubco to the public sector. IPTR Individual Patient Treatment Request for specialist medicines

92 92

93 93 NHS Highland Board 28 March 2017 Item 4.5 NHS Highland Strategic Quality and Sustainability Plan: 2017/18 to 2019/20 Report by Elaine Mead, Chief Executive NHS Highland The Board is asked to endorse the strategic direction set out in the plan Note the efficiencies identified to date and the process for addressing the unidentified savings Approve the proposed rolling planning cycle Note detailed papers to follow for 2017/18 annual plan and rolling three year plan 1. Summary and Background Our Quality and Sustainability Plan describes the national and local strategic context, and sets out a compelling case for change as well as NHS Highland s approach to addressing some of the challenges. Increasing costs and demands, staffing pressures and unprecedented savings targets mean that the current model of health and social care delivery is not sustainable in Highland. Over the next three years it is estimated that NHS Highland will need to deliver efficiencies of around 100 million with around 47million in 2017/18 (around 7% of the annual budget). On top of this the board has struggled to meet some of the national waiting time targets and to sustain some services. When taken all together it is clear that a more of the same approach will not be sufficient to provide sustainable and affordable services. There is an overreliance on costly hospital and institutional care which needs to change in order to invest in community based services to meet future needs. While in 2015 about one in twenty people in Highland are aged over 80 years old, by 2035 this figure will be over one in ten. Initiatives identified for 2017/18 are themed under seven main headings: Adult care, Flow, New models of care, Realistic medicine, Drug costs, Remodelling assets and Continuous quality improvement / local initiatives Our approach to delivering the changs is described including embedding continuous quality improvement and engagement to improve care. Service re-design work is ongoing across many districts and for a range of services including outpatients, out of hours and Rural General Hospitals. Local regional and national collaboration will be required to develop solutions for some services. As the changes become embedded it will see a reduction in our footprint as well as the workforce over the next three to five years. Although NHS Highland is well placed to deliver the new approaches this will be challenging. The biggest hurdle is how best to speed up the pace of change while at the same time taking staff, communities and partners with us.

94 94 NHS Highland Board 28 March 2017 Item 4.5 Background The Health and Social Care Delivery Plan by the Cabinet Secretary for Health and Sport published in December brings into sharp focus the urgent need to address the rising demands and other challenges facing the NHS in Scotland (which had been summarised in a report entitled NHS in Scotland - published by the Auditor General in October ). The combined impacts of our ageing population, reduced workforce, problems with recruitment, unsustainable models of care and financial pressures mean that the way we provide health and social care services has to change. While there is a clear need to speed up the pace of change it is also important to recognise that there is already momentum and we are not working from a standing-start.. As set out in our 10 year operational plan published in February 2015, work has been ongoing for some time to transform models of care and services. The changes are supported by a number of underpinning principles and measures, including: Support for people to stay at home for longer Supporting people and communities to be more independent and resilient Increase choice for end of life care and more realistic medicine Greater integration, co-location and co-ordination of care Greater Regional collaboration and solutions Greater use of technology Reduction the length of time people spend in instructional care Reduction unnecessary attendances and appointments Reduction waste, harm and unwarranted variation As services and models of care are transformed it will see a changing workforce requirement, with new roles, and in turn, a reduction in use of locums and agency staff in relation to those and health and social care professions which cannot be easily recruited to. The changes flowing from implementing our clinical and care strategy will therefore require us to remodel our workforce and our assets. Overtime this will bring a reduction in the number of staff, and in our foot-print, with fewer but better hospitals, care homes, facilities, offices and other assets. Our Quality and Sustainability Plan describes the national and local strategic context, and sets out a compelling case for change as well as NHS Highland s approach to addressing some of the challenges. Initiatives identified for 2017/18 are themed under seven main headings: Adult care, Flow, New models of care, Realistic medicine, Drug costs, Remodelling assets and Continuous quality improvement / local initiatives In reality trying to summarise these iniativies and actions in a linear way is inevitably artificial as the various themes are inter-linked and inter-dependent. However, there are distinct elements in each initiative and describing them illustrates how the complex jigsaw of health and social care starts to fit together. Inter-dependencies willl be managed in detail by the opertaional units to ensure that the changes are delivered in a balanced way to support overall improvements and gains. Significant redesign on models of care are ongoing from previous years such as Out of Hours, Transforming Outpatients, Office Redesign and major service redesign and elememts of these will be completed during 2017/18. NHS Highland also has a

95 95 NHS Highland Board 28 March 2017 Item 4.5 good track record of realsing savings through initiatives related to procurement, presrcribing and quality improvement. The plan is underpinned by our various strategies including Workforce, Asset Management and ehealth as well by more detailed operational plans for both Health and Social Care Partnerships and Corporate Services. The work programmes all sit within our framework of the Highland Quality Approach and ten year operational plan. 2. Contribution to Board Objectives The Quality and Sustainability Plan sets out the vision and strategy through which to deliver the board s corporate objectives. The seven initiatives relate back to People, Quality and Care and will support the reduction of waste, harm and unwarranted variation, allow new models of care to be introduced and in turn will reduce costs. It builds on our ten year operational plan published in The vision and strategy have not substantially changed since then, however, there is an even more urgent need to deliver some of the changes and improved ways of working. 3. Governance Implications Staff In many areas there are now significant staffing challenges and its clear the the shape of the work-force will have to change. This will have implications for all staff of all grades and all professionals. Over time this should have far-reaching impacts on how people practice their clinical care, the different conversations they will need to have with patients and services users and the new locations they will work from. These changes will need to be led and managed in a supportive way with appropriate training and inductions as required. As reducing costs by continuous quality improvement is a key element of the plan staff will be further supported to learn and use various tools and techniques. As new models of care are brought in it will be important to have workforce and transitions plans in place. Therefore while there are clear implications for staff as we roll out new arrangements and ways of working, doing nothing is not an option and already has some governance implications which this plan seeks to address. There is clear guidance through Staff Guidance Standard and Organisational Change Policy to support any changes. There will be a clear role for Staff-side representatives, the Highland Partnership Forum and Staff Governance Committee to oversee, lead and guide any implications for the workforce. The 2017/18 and three year plan will be subject to wider engagement with Highland Partnership Forum and Senior Management. Clinical As described in the Plan many of the current clinical models are not sustainable and therefore pose risks for some services including clinical. The delivery of realistic medicine, new models of care and greater local, regional and collaborative working are designed to reduce clinical risks as well as making models of care safer and more sustainable. Overall reducing waste, harm and unwarranted variation will improve clinical governance. Monitoring will be through the Clinical Governance Committee. The 2017/18 and three year plan will be subject to wider engagement with the Area Clinical Forum. Financial

96 96 NHS Highland Board 28 March 2017 Item 4.5 Over the next three years it is estimated that NHS Highland will need to deliver efficiencies of around 100 million with around 47million in 2017/18 (around 7% of the baseline budget). The plans sets out the governance arrangements including actions that will be taken to deliver a break-even position and the associated monitoring. The regular financial monitoring reports that the Director of Finance presents to each Board meeting sets out the financial governance arrangements in more detail and in particular the various forums for scrutiny. It is proposed that the Delivering Financial Balance Programme Board will continue to play a key role in terms of oversight and that it will take a more programme-based approach than previously. On 28 February 2017, a draft financial Local Delivery Plan template was submitted to the Scottish Government. This presented a balanced plan however this was dependent on savings of 47m, of which 15.5m were flagged as unidentified. Further progress has been made and as at the date of this report, 33.2m had been identified with 13.8m unidentified. Work is continuing on closing this gap and a verbal update will be given at the Board meeting. It is likely that a substantial part of this gap will need to come from a significant ramping up of the implementation of continuous improvement methodology at scale. 4. Risk Assessment The board will consider a paper on Risk Appetite as its meeting in March 2017 and depending on the outcome of the discussion some of the plans may need to be altered or addittional proposals brought forward. The major risk to delivery is believed to be the pace with which we will be able to intitiate the necessary change and capacity to deliver, whilst coping with the inevitable impact of meeting current needs within resources. Despite signifiant engagement in all areas about the need to change over the years the pace of change has been slow. There has been some resistance and further can be anticpated. However there are greater risks of not changing. If the current ways of working continue then sooner or later they will fall over in an unplanned way which is inherently more risky. As appropriate specific work programmes already have risks registers. 5. Planning for Fairness Our high-level strategic plan sets out the future direction of how services will be redesigned. Impact assessments will be carried out before any changes are implemented. Assessments are already in place for many of the service redesigns underway or planned. 6. Engagement and Communication Increasing costs and demands, staffing pressures and unprecedented savings targets mean that the current model of health and social care delivery is not sustainable in Highland. These are stark messages which can t reasonably be refuted yet are still not necessarily believed, taken seriously or being owned by staff and or communities. Relationships and leadership are therefore key to getting these messages to be believed, accepted and acted upon. A key enabler to support Realistic Medicine must be to get better shared decision making. To achieve this needs clinicians to be supported to have the time to have the necessary conversations with patients, carers and families. Overall, more work needs to be done to raise awareness with the public about their choices.

97 97 NHS Highland Board 28 March 2017 Item 4.5 Delivering continuous quality improvement will drive down costs and forms a significant element of delivering savings and improving quality of care. Critically this does not require consultation, is already underway and with more support will be rolled out at scale. Nevertheless it is clear that some difficult decisions and choices need to be made. Understandably, this will create concerns if people don t understand or accept that there is a fundamental problem and credible alternatives are in place. The challenges described are not new. Issues around needing to change models of care were described in our first NHS Highland Newspaper published in August 2011 and delivered to every home in our area. It described why we need to change and shaping the future. What is new is the scale of change now required and the pace at which we need to reform. Therefore we will need to work together with staff, service users, communities and influential leaders to support the move to new and improved models of care across our wide geographic area. Key work programmes will be underpinned by communications and engagement plans as well as impact assessments where appropriate. The different stages of engagement to date are summarised in the plan. The detailed plans including the approach to communications and engagment will be revised following ongoing feed-back with various staff groups, communities, Sottish Health Council and board committees. Elaine Mead Chief Executive 15 March 2017 Appendix 1 - NHS Highland Quality and Sustainability Plan: 2017/18 to 2019/20

98 98

99 99 ` DRAFT NHS Highland Strategic Quality & Sustainability Plan 2017/18 to 2019/20 Better health, better care, better value March 2017

100 100 Contents Foreword ExecutiveSummary 1. Introduction to the Plan 2. Strategic Context 3. Case for Change 4. Our Approach 5. Analysis of Spend and Costs 6. Developing our three year Quality and Sustainability Plan 7. Supporting Strategies 8. Communications and Engagement 9. Assurance, Performance, Risk and Planning Cycle Annexes I) Annual Quality and Sustainability Plan II) Communications and Engagement Tracker III) Monitoring Framework Draft V4.1 updated 17 MAR

101 101 Foreword The current models to deliver health and social care across our complex and changing environment in Highland is no longer sustainable. Meeting the needs of the population has become increasingly difficult and now requires fundamental change to ensure sustainable models are in place for future generations. Challenges are being experienced across the country and include the shortage of some professionals, an ageing workforce, rising costs and demands. These challenges were set out in our 10 year plan published in February 2015 and our strategic case for changes is supported by the Operational and Delivery Plan for Health and Social Care in Scotland published in December. While NHS Highland is on-track to breakeven financially this financial year (/17) - with savings totalling 28 million - this was to the detriment of some access waiting times with patients waiting for new out-patient appointments and surgery in excess of the specified government-defined waiting time guarantees. This position was largely replicated across Scotland as the whole service came under significant pressure. NHS Highland sought to prioritise and maintain treatment times for emergency and urgent care which included A&E waits and cancer treatment times. Going into 2017/18, it is anticipated that there will be a need to deliver at least seven per cent of savings in order to breakeven. On the current budget and allocations this amounts to around 47 million to be delivered from a budget of 800 million. Over a three period it is estimated we will need to save around 100 million. Therefore, is it is clear that a more of the same approach will not deliver sustainable solutions, here in Highland, across the North of Scotland or nationally. Over the past five years, in particular, NHS Highland has put in place a number of arrangements which mean we should be well placed to respond to these challenges. The Highland Quality Approach encompasses both the aspiration and techniques to deliver the changes in a planned and timely way. However, it will only be an operational reality if there is a willingness to change (and to change quickly). To achieve that, we need to persuade people that the problems are real and pressing, and that we have credible plans to deliver better alternatives. We must move with pace to lead, engage and describe with enthusiasm the benefits of the new models and how everyday improvements can scale up to make significant gains. Draft V4.1 updated 17 MAR

102 102 Executive Summary Our Quality and Sustainability Plan describes the national and local strategic context, and sets out a compelling case for change as well as NHS Highland s approach to addressing some of the challenges. Increasing costs and demands, staffing pressures and unprecedented savings targets mean that the current model of health and social care delivery is not sustainable in Highland. Over the next three years it is estimated that NHS Highland will need to reduce costs by 100 million with around 47million in 2017/18 (around 7% of the annual budget). On top of this the board has struggled to meet some of the national waiting time targets and to taken all together it is clear that a more of the same approach will not be sufficient. sustain some services. When There is an overreliance on costly hospital and institutional care which needs to change in orderr to invest in community based services to meet future needs. While in 2015 about one in twenty people in Highland are aged over 80 years old, by 2035 this figure will be over one in ten. Initiatives identified for 2017/18 are themed under seven main headings: Adult care, Flow, New models of care, Realistic medicine, Drug costs, Remodelling assets and Continuous quality improvement and local initiatives and opportunities. Our approach to delivering the changs improve care. is described including embedding continuous quality improvement and engagement to Service re-design work is ongoing across many districts and for a range of services including outpatients, out of hours and Rural General Hospitals. Local regional and national collaboration will be required to develop solutions for some services. As the changes become embedded the number of facilities we require will reduce as well as the workforce Although NHS Highland is well placed to deliver the new approaches this will be challenging. The biggest hurdle is how best to speed up the pace of change while at the same time taking staff, communities and partners with us. Key points underpinning tje case for change are summarised (Box1). Draft V4.1 updated 17 MAR

103 103 Box 1 Summary of key points underpinning the case for change 1. People are living longer and will require more support from the health and care systems per cent of the population are living with one or more long term conditions 3. Two per cent of the population use 50% of the total resource and spend per person differs markedly between areas 4. There is a difference of 15 years in life expectancy across parts of Highland highlighting current inequalities 5. There is an overreliance in hospital bed-based care. Every day xx patients are medically fit to leave hospital in-patient care but there are currently 135 delayed transfers of care (March ) 6. Our models for Rural General Hospitals, Community Hospitals, Out-of-Hours, Out-patients are not as clinically safe as they could be nor are sustainable without marked changes 7. The care home sector is struggling to meet increasing demand and complexity of need 8. Many of our services are very fragile due to workforce issues linked to recruitment and retention including GPs, general surgeons, some consultant specialists, Allied Health Professionals, midwives and care at home workers 9. Local health and social care services (as well as local authorities) are under severe financial pressures and will not be able to deliver statutory requirements unless there are significant and rapid changes. 10.Over the next three years it is estimated that NHS Highland will need to reduce costs by 100 million with around 47million in 2017/18 (around 7% of the annual budget). Draft V4.1 updated 17 MAR

104 Introduction to our Plan Across the country - and beyond- the challenges to bring in better ways of working and new models of care that are sustainable from both a staffing and financial viewpoints are significant. Here in Highland we also face some additional pressures due to the remoteness and ruraility of some of our communities, plus we have a higher proportion of older people. Many of our communities are, therefore, fragile. As an important partner in maintaining the social and economic vibrancy, concerns around health service quality or service changes can, and do, generate considerable attention from communities, local and national politicians as well as staff. While there appears to be a general understanding and acceptance that the models of care have to change, there are differing views on what and where these changes should be. In addition it is clear that significant gains across a 800 million budget can be achieved through continuous quality improvement. The biggest challenge is how best to speed up the pace of change while at the same time taking staff, communities and partners with us. This plan sets out our committment to continue to transform care and the ways we manage our business to deliver the best possible outcomes for the people of Highland and Argyll & Bute. Our transformational journey includes working in ways which deliver continuous quality improvement. In terms of models of care we continue to move towards more people being cared for at home which will be delivered through a combination of prevention and anticipatory care, better use of technology and developing and embedding more community capacity. It will also need to be a collaborative approach, working with our statutory partners, voluntary and third sectors as well as our staff and local communities. Clearly, wider work delivered through Public Health, Primary Care, Dental and Children s services are ongoing, and will further shape improved outcomes in the longer term. The vision to deliver better health, better care and better value was adopted by the board on 3rd February 2015 and has not substantially changed. This three year approach and plan, therefore, builds on progress to date and further describes actions to deliver safe, sustainable, integrated and affordable care. Our strategic direction of travel is underpinned by seven initiatives which will direct the necessary changes and reform required over the next three financial years (Figure 1 ). Draft V4.1 updated 17 MAR

105 105 Figure 1 Summary of seven strategic high level initiatives and associated spend and savings requirement in 2017/18 Draft V4.1 updated 17 MAR

106 Strategic Context National Context The Scottish Government s 2020 vision, published in 2010, articulated the ambition of Safe, effectivee and person-centred care which supports people to live as long as possible at home or in a homely setting. This vision was supported by the Healthcaree Quality Strategy 2012, which called for accelerated quality improvement to ensure that care is person-centred, safe and effective. While these strategy documents remain the central vision for the Health Service in Scotland, four reports published in further strengthen the strategic direction and describe a compelling case for change: Realistic Medicine - The Chief Medical Officer for Scotland s Annual Report for 2014/15, published in January; The National Clinical Strategy for Scotland published in February; Audit Scotland NHS in Scotland (October ).and most recently the Health and Social Care Delivery Plan by the Cabinet Secretary for Health and Sport published in December. In particular, the Health and Social Care Delivery Plan sets out the transformation required for health and social care to make care and services sustainable for the future. The plan is designed to help address the combination of rising demand being faced by health and care services, the changing needs of an ageing population, increasing costs, staffing pressures and unprecedented financial challenges. The new GP contract due in April 2017 is also proposing significant change. The strategic direction is all around increasing more resources to primary and community care. Overview of Highland Context NHS Highland is committed to providing highh quality, effective care to the population of the Highlands in a safe, efficient and person centred way. This was initially set out in August 2014, when the board endorsed The Highland Care Strategy: NHS Highland s Improvement and Co-production Plan. The Care Strategy outlines NHS Highland s vision for the future delivery of health and social care services for the people of Highland over a ten year period and set out a number of goals including: Draft V4.1 updated 17 MAR

107 107 o o o o Provide services and facilities which meet 21 st century health and social care needs and are acceptable to both staff and patients; Provide high quality, integrated and cost-effective services; Reduce waste and inefficiency acrosss services; and Ensure services are sustainable. The requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 ( the Act ), which puts in place the framework for integrating health and social care, places a duty on Integration Authorities to develop a strategic plan for integrated functions and budgets under their control. Since April services are planned through two health and social care partnerships, working with two local authorities (Highland Council 1 and Argyll and Bute Council 2 ) see further in Section four. Profile NHS Highland is the largest and most sparsely populated Scottish Health Board area, covering 41 per cent of the country s landmass. We provide health and social care services to our resident population of 320,000. Our diverse area includes Inverness, one of the fastest growing cities in Western Europe and 36 populated islands - 23 in Argyll & Bute in 2011 and 13 in Highland (excluding Skye connected to the mainland by a road bridge). The shape of our changing population, age, distribution and deprivation was described in our 10 year plan (under section 4 of that report). The number of people aged 65 years or over is expected to increase by 17,000 in NHS Highland area between 2014 and 2025 to 26 per cent of the total population (Figure 2). 1 Since 1st April 2012, health and social care in the Highland region has been formally integrated with NHS Highland the lead agent for the delivery of adult services across health and social care and the Highland Council the lead agency for children's services 2 In Argyll & Bute an Integrated Joint Board between NHS Highland and Argyll and Bute Council was established on 1 st April Draft V4.1 updated 17 MAR

108 108 Figure 2: Estimated and projected populationon of NHS Highland aged 65 years and over In 2015 about one in twenty people in Highland are aged over 80 years old, but by 2035 this figure will be over one in ten Data source: National Records of Scotland Sub National Population Estimates and Population Projection (2014 based principal projection) Draft V4.1 updated 17 MAR

109 109 Figure 3: Population of NHS Highland and Scotland percentage of total population by ageband The general epidemiological picture in NHS Highland is similar to that nationally and is one in which adult mortality predominates and chronic and degenerative diseases are the most common form of morbidity (Figure 3). Multi-morbidity is already very common and continued population ageing will mean that there will be a rising demand for the prevention and management of multi-morbidity rather than of single diseases. Data source: National Records of Scotland (NRS) Mid-year estimate population 2015 Available online: k/statistics-and-data/statistics/statistics-by-theme/population/population-es stimates/mid-year-populationestimates/mid Draft V4.1 updated 17 MAR

110 110 Figure 4: Number of chronic disorders by age group in patients registered with 314 Scottish General Practices Figure 4 highlights that the majority of patients over 65 have two or more conditions and the majority of over 75s have three or more conditions. More people have two or more conditions than only have one. Data source: Scottish School of Primary Care s Multi-morbidity Research Programme Slide Pack. Draft V4.1 updated 17 MAR

111 111 In our ten year plan we also described diffuse settlement patterns emphasising the challenges in delivering health and social care to a widely spread out and in some cases low population density. Despite the often popular image of a rural idyll, deprivation, fuel poverty and inequalities also affect many parts of the population of the area. As shown in Figure 5 some people living in the most deprived areas of NHS Highland will experience life limiting health problems 20 years earlier than people living in the least deprived areas. Figure 5: NHS Highland population with day to day activity limited a lot by longstanding health problem or disability by age in the most and least deprived deciles of multiple deprivations Draft V4.1 updated 17 MAR

112 112 Figure 6: Highland and Island Enterprise Map of Fragile Areas In many parts of Highland, the NHS and other public sector agencies are major employers, and changes to services can impact on socially and economically fragile areas (Figure 6). As an important partner in maintaining the social and economic vibrancy of the areas, concerns around health service quality or reduction in service changes can generate considerable attention from communities, local and national politicians as well as staff. Any such change therefore needs to be carefully thought through and managed.it will be important to demonstrate what safe and sustainable options were considered prior to making changes. Draft V4.1 updated 17 MAR

113 113 End of Life and Place of Care Another key piece of contextual informationn relates to end of life care and place of care. Providing greater choice including more people to be supported at home has been a theme that has been debated through our various consultations on redesigns. It is clear however, that we are not meeting the needs of may people with 71% people dieing in instutional care (hospital, care home or hospice) vs 29% dieing at home. Yet almost two thirds (63%) said they wished to die in their own home (Figure 7). Figure 7 End of life care - place of death in NHS Highland Where peoplee die in NHS Highland and end of life care choice 2 want to die* Hospice Draft V4.1 updated 17 MAR

114 114 The historical trend in Highland is for the majority of people to die in hospital and with deaths in care homes steadily rising (Figure 8). Figure 8 End of life care - place of death in NHS Highland Number of deaths by place, NHS Highland residents Number of deaths Care Home Hospital OwnHome Hospice Draft V4.1 updated 17 MAR

115 115 Financial context Whilst NHS Highland is anticipating a small cash uplift to its baseline in 2017/18 equivalent to 1.5% (of which 1.1% is for social care and 0.4% is for health). Cost pressures such as the Living Wage in the social care sector and the increasing cost of acute medicines plus inflation far outweigh the uplift. In addition there are underlying cost pressures (most notably in North West Highland and Raigmore Hospital) that largely reflect the difficulty in sustaining the current models of care (see below). These challenges have necessitated a requirement to carry over, from /17 an estimated at 13 million of savings, made through non- to reduce that will have a recurring initiatives. Clearly this has further exacerbated the financial challenges for 2017/18. Anything benfit going forward. Therefore, a savings target of 47 million is required in order to deliver breakeven this financial year (2017/18) (7.9 per cent of NHS baseline or 7 per cent if the funding for Adult Social Care from Highland Council is included as effectively part of the baseline). Of this it is estimated that 43.5 million is a recurrent target and 3.5 million non-recurrent. This target is considerably higher than /17 which has been our most challenging year (Table 1) ). Moreover, some of the 28 million savings achieved in /17 to deliver financial breakeven resulted in some patients waiting for new out-patient appointments and surgery in excess of the specified government-defined waiting time guarantees. This position was largely replicated across Scotland. NHS Highland sought to prioritise and maintain treatment times for emergency and urgent care which included A&E waits and cancer treatment times. Maintaining waiting times for some specialities has been a challenge for a number of years Historically, we addressed this by costly waiting times initiatives which did not address the root cause of the problem which is partly due to shortage of consultants in some specialities, and growing demands. Table1 Summary of savings delivered/forecast by financial years: 2014/15 to 2019/20 Savings delivered/forecast Financial Years 2014/ /16 / / / /20 22m 16m 28m 47m 30m 29m Draft V4.1 updated 17 MAR

116 116 Over the course of the next three financial years an estimate of 100milion will be required to be reduced from our overall expenditure. 3. The Case for Change: Why our health and care model is unsustainable? The Health and Social Care Delivery Plan by the Cabinet Secretary for Health and Sport published in December highlights the urgent need to address the rising demand being faced by health and care services, and the changing needs of an ageing population across Scotland. As described in our The Highland Care Strategy: NHS Highland s Improvement and Co-production Plan (2014) and ten year plan (2015) this is not a new situation for Highland. However, what is different is that the scale of the financial pressures and the pace of change now required is unprecedented. The combined impacts of our ageing population, reduced workforce, problems with recruitment, financial pressures mean that the way we provide health and social care has to urgently change. Despite the best efforts of staff the current ways of working are not matched to future requirements and the way our systems are organised are very inefficient and historic (Box 1). Box 1 Summary of the Case for Change 1. People are living longer and will require more support from the health and care systems per cent of the population are living with one or more long term conditions 3. Two per cent of the population use 50% of the total resource and spend per person differs markedly between areas 4. There is a difference of 15 years in life expectancy across parts of Highland highlighting current inequalities 5. There is an overreliance in hospital bed-based care. Every day xx patients are medically fit to leave hospital in-patient care but there are currently 135 delayed transfers of care. 6. Our models for Rural General Hospitals, Community Hospitals, Out-of-Hours, Out-patients are not as clinically safe as they could be nor are sustainable without marked changes 7. The care home sector is struggling to meet increasing demand and complexity of need 8. Many of our services are very fragile due to workforce issues linked to recruitment and retention including GPs, general surgeons, some consultant specialists, Allied Health Professionals, midwives and care at home workers 9. Local health and social care services (as well as local authorities) are under severe financial pressures and will not be able Draft V4.1 updated 17 MAR

117 117 to deliver statutory requirements unless there are significant and rapid changes. 10.Over the next three years it is estimated that NHS Highland will need to reduce costs by 100 million with around 47million in 2017/18 (around 7% of the annual budget). While in many cases the money is not the primary driver, it is now an increasingly critical factor. The Revenue position for 2017/18 and beyond requires a cash releasing target that is unprecedented for NHS Highland. Moreover, Raigmore Hospital and the North & West Operational Unit overspent their budgets in /17 highlighting that the current clinical and financial models are not sustainable..the pressures facing Raigmore Hospital have been long-standing. They are numerous and complex and reflect the position across the country in terms of acute hospital pressures, rising demand, waiting times, increased specialisation and rising drug costs. The hospital also at times struggles to discharge patients in a timely manner resulting in an overreliance of expensive acute hospital beds and services, and delays for patients. Changing this requires taking actions both in the hospital and across community services to make sure patients are better able to flow through the system by getting rid of any delays. In North and West there are extreme pressures including due to the inability to recruit to, sustain or afford historical models of care for Rural General Hospitals, Out of Hours and, in some parts, Primary Care resulting in exorbitant locum costs. There are also a number of small care home units which are not viable. While most keenly felt in North and West, these are challenges increasingly being felt in Argyll and Bute, as well as elsewhere across the country NHS Highland also faces the additional challenges of how to best provide specialist support to all of our communities. While outreach models support our desire to deliver as much care as close to home as possible, our current reliance on face-to-face consultations make either this expensive to deliver or delivered via unpopular centralised models. In some cases centralisation is necessary for safety considerations. It is clear that some difficult decisions and choices need to be made and understandably this will cause concerns if people don t understand or accept the case for change. It is within this context that the 100 million reduction in costs over the next three years must be considered. Draft V4.1 updated 17 MAR

118 Our Approach In considering these challenges the board has had to consider how to re-design care, services and ways of working to ensure we deliver safe, quality care services that are also sustainable and affordable. It is clear from the scale of the financial challenges faced in 2017/18, and beyond, that the current models of care are unsustainable. This will be a major challenge and a more of the same approach will not deliver the scale of change required. There needs to be a radical shift to embedding more permanent cost effective models of care. One example the Health and Social Care Delivery Plan outlines is the requirement for more investment in the community services to allow more people to stay at home, whilst not continuing to grow the acute sector. This remains a fundamental goal of our strategic plans. The lack of bridging funds to double-run to can present a difficulties for some of the changes required and so it will be important to have effective and credible transitions plans in place. Remodelling of Assets including Major Service Change The reconfiguration of the footprint and associated staffing models is ongoing. Where the changes were considered to be major, formal public consultation has been required. The main drivers for these major change are that our current dispersed models of care, significant back-log maintenance, andworkforce challenges are not sustainable. Many of our assets are also not strategically located and this also needs to be addressed. Guidance on what is deemed major service change has been provided by the Scottish Health Council and is also discussed with Scottish Government and the Board. Changes required on grounds of safety do not require formal public consultation. Quality Improvement and Marginal Gains: Reducing Waste and Inefficiencies It is easy to overestimate the importance of making big decisions yet underestimate the value of making better decisions on a daily basis. A one per cent improvement on everything aggregates up to important gains and equally one per cent deterioration leads to significant increases on demand, harm and so on. So a daily focus on high volume, every day activities is critical and forms a key part of our approach. The key benefit is these are within our control and don t require lengthy consultation Draft V4.1 updated 17 MAR

119 119 processes. As we go on to illustrate later, a closer look at how we manage service users who require significant levels of care will impact significantly on spend and fits within the wider context of realistic medicine. Our partnership with the Virginia Mason Medical Centre since 2012 has been productive and has helped us to shape our approach. They are a world leader in delivering safe, high-quality health care. Their experience is that, on average, there can be in the region of up to 30 per cent waste in healthcare systems (Berwick and Hackbarth, 2012). They began implementing their system in 2002 and since then they have been able to deliver higher quality healthcare with significant cost savings in particular services. NHS Highland has steadily built capability and capacity (and this is ongoing) to deliver effective solutions for the removal of waste, harm and unwanted variation in practice. We now have many of our own examples of areas of improvement to increase capacity, to improve flow and reduce costs and this offers significant potential for making recurring savings, year on year. While Lean and quality improvement tools, including through the Scottish Patient Safety Programme, have been effective, it is the spread of these initiatives across the organisation which will have maximum impact and influence the marginal gains. To create sustainable improvements the challenge is how best to integrate work on quality improvement into the organisation s daily work, while keeping the service functioning. The move to daily management with the support for the implementation of daily huddles, production boards, visual control and 5S to reduce, for instance, unnecessary stock levels and the application of standard work will further embed this approach acrosss all of the business. High Level Value Streams The development of high level value streams has allowed the co-ordination of work across key organisational objectives to transform adult flow, out-of-hours and out-patients. All three value streams have pursued initiatives which will result in new models of care improve reliability and reduce costs. Thye will continue to form part of our ongoing delivery plans. Regional Working and Wider Collaborations The Health and Social Care Delivery Plan sets out a clear expectation that Boards will collaborate across regional areas in an attempt to deliver care more safely, effectively and sustainably. Our three year plan will take full cognisance of the North of Scotland Regional Clinical Strategy which is due to be signed off by Boards between June to September Draft V4.1 updated 17 MAR

120 120 The case for change to regional working was considered by the Board in May last year. There are a number of services across the North of Scotland area where more effectivee services could be delivered through a regional approach including Radiology, Urology, Oncology, Maxillofacial services, Upper GI and Diabetic Foot Network. Collaboration will also be required across elective centres and out-of- hours and will be underpinned by appropriate ehealth and workforce strategies and plans. We will also need to develop, with the Scottish Ambulance Service and others, plans to deliver robust infrastructure for the transportt of patients to the most appropriate points of care. This will need to also consider any support for people who need to travel for more specialist care. National working in line with the Once for Scotland shared service models will also need to be considered. Within Highland it will be important to sustain core services at Raigmore District General Hospital in Inverness, as well as the strategic clinical necessity to provide services from our three rural general hospitals located in Wick, Fort William and Oban. It will be increasingly important to ensure that clinical services are planned and delivered across the wider Highland and Island area in order to make the training and jobs attractive. This will require close working both with other providers and local universities. Close working with Scottish Ambulance Services is also required for planning, redesign and delivering services Working with local authorities and our other partners NHS Highland has been fully integrated in the North Highland area for five years through the creation of the Highland Health and Social Care Partnership in April In Argyll and Bute, the Integrated Joint Board was established in April. Our approach has been to have the whole of the care system to be within one finance, management and governance arrangement, thus allowing the maximum opportunity to vire resources from one sector to another to meet needs. In North Highland we have taken this a step further and integrated health services through the creation of the Inner Moray Firth Operational Unit which includes all health and social care services (eg Acute, Community, Primary Care and Adult Social Care under one Director of Operations. The different partnership arrangments mean that children s service are managed differently in Highland and Argyll and Bute.However under both model the board seeks to ensure that children and young people to have the best experience of growing up and have a good experience of health and well being into adulthood and through to the older years. Investment in the early years has demonstrable benefit across the life course, with growing awareness of the window of opportunity presented in adolescence to take stock of life experiences to date, and further enhance health and well being. Draft V4.1 updated 17 MAR

121 121 The Lead Agency Model for integrated services in North Highland involves Care and Learning Highland Council delivering a range of commissioned health services on behalf of NHS Highland. Medical and community paediatrics, inpatient paediatrics and Tier 3 and 4 Child and Adolescent Mental Health Services are provided by the Highland Health and Social Care Partnership. Within Argyll and Bute, a similar range of health services for children and young people are provided through the Integrated Joint Board. Greater Glasgow and Clyde provide in patient care and acute/community paediatrics. NHS Highland spends a minimum of 65 million on children and young people. In the last few years year additional funding has supported increases in Health Visitor numbers the Family Nurse Partnership and Child and Adolescent Mental Health Services. There are also notable cost pressures with regard to an increase in need for home ventilation, peg feeding/ home parenteral nutrition. Work streams are orientated around the well being indicators that children and young people are safe, healthy, active, nurtured, achieving, respected and included. Cross cutting themes include consideration of age and stage, workforce, training and skills development, improvement and quality and engagement and consultation with children, young peoplee and their families. As reflected throughout this report both Local Authorities and NHS Highland face financial pressures and priorities for the years ahead will require consideration of savings and new ways of working. Within integrated models there are opportunities to align services, create different service models and add value to journeys of care. Integrated Service Planning in Highland and Argyll and Bute brings the key services together. Argyll and Bute are in the process of developing a new integrated plan ( ) and in Highland planning for the next plan (2018/21) will take place over the next year. NHS Highland fully supports the developments in Community Planning that bring together the Public Bodies (Joint Working) (Scotland) Act 2014 with the Community Empowerment (Scotland) Act and the 2013 guidance on Community Learning and Development. The strategic partners acrosss the area Highland Council, Argyll and Bute Council, NHS Highland, Police Scotland, Fire and Rescue Scotland and Highlands and Islands Enterprise - have in place a practical planning framework with colleagues across the third and independent sectors to develop community partnerships where community engagement and coproduction can happen more effectively. Draft V4.1 updated 17 MAR

122 122 The revised arrangements are focussed on developing plans and effective priority setting to improve outcomes for communities. They should also enhance resilience, sustainability, and efficiencies across public sector services. We are work closely with a wide range of partners including The Highland Hospice, Marie Curie, Macmillan, Alzheimer Scotland and others, We also believe we have also enjoyed much closer working with third and independent sectors. One example is the introduction of the Living Wage for the independent care-at-home sector which has supported a transformation of the delivery of care at home. This is one example of how innovative thinking and collaboration can delivery both better quality care but at lower cost. Similarly, our collaboration with Albyn Housing Society and Carbon Dynamic in the Fit Homes project is also bringing new solutions to long standing problems which will further help to support our new models of care. Draft V4.1 updated 17 MAR

123 Analysis of Spend and Costs A high-level summary of how NHS Highland spends 800milion by category (Figure 9) and Unit (Figure 10) is set out below. Figure 9 Analysiss of 800m Spend by Category m's Pay - Staff Pay Locums Agency Drugs Clinical Non Pay Non Pay Property costs FHS Social Care SLA's & Out of Area Draft V4.1 updated 17 MAR

124 124 Figure 10 Analysis of 800m spend by Unit m's Raigmore S&M N& &W A&B Corporate Facilities Tertiary Others Draft V4.1 updated 17 MAR

125 125 The costs in Table 2 also illustrates indicative costs in different settings. The key point to note is it neither makes sense from a care point of view or costs to have someone being looked after in a higher level of care than they require. Table 2 Indicative costs associated with places of care Place of care Cost per week District General Hospital 3,500 Rural General Hospital 4,200 Community Hospital 2,500 NHS Highland Care Home 1,000 Private Care Home 649 Care at Home 200 The costs per cases also varies enormously across our health and social care systems such as for out of hours (EXAMPLE), Care Homes (Example) and Primary Care (Example). High Resource Individuals Health and social care resources are not utilised evenly across the population and by understanding more about the cohort of individuals who account for any disproportionate spread of resource could allow for more effective planning and delivery of services and an improved service user experience. Information Services Division (ISD) has undertaken cost per patient analysis on various inpatient and day-case hospital admissions to support Health and Social Care Partnerships in deepening their knowledge of High Resource Individuals. High Resource Individuals are classified by calculating the total expenditure for an individual service user during a financial year. Health costs incurred across a range of services are all taken into account when identifying a high resource individuals including: acute inpatient and day case activities; geriatric long stay; mental health; maternity activity; new consultant-led outpatient attendances; accident & emergency and community prescribing. The total costs for individuals are ranked in order of total resource consumption and those who have the highest individual costs and make up the top 50% of total expenditure have been defined as High Resource Individuals. Draft V4.1 updated 17 MAR

126 126 During the financial year, 2013/14, Highland Health & Social Care partnership (H&SCP) provided health care for 4,121 HRIs which equates to 2.2% of Highland s overall population. The accumulated expenditure for HRIs was 112.6M over the same time period equating to 50% of the total health care costs for Highland H&SCP (Table 3). Costss per person for HRIs ranged from 10,590 to a maximum of 394,766 with an average cost of an HRI was 27,329 compared to an average cost of 89 for a lower cost individual. This is pattern of spend is not specific to Highland Table 3 Highland H&SCP: HRIs breakdown by Population and Expenditure, 2013/14 H&SC Partnership Number of HRIs % of Population Total HRI Cost ( ) % of Total Expenditure Highland 4, M 50% Draft V4.1 updated 17 MAR

127 Developing Our Three Year Quality and Sustainability Plan Overview NHS Highland has embarked on a high profile and impactful transformational programme which has maximised a wide range of quality improvement, service redesign and staff engagement tools and techniques. In this section of the document, initiatives identified for 2017/18 are themed under seven main headings: Adult Care; Flow; New Models of Care; Realistic medicine; Drug Costs; Remodelling Assets and Continuous Quality Improvement, Local Initiatives and Opportunities. In reality, trying to summarise the initiatives and actions in a linear way is inevitably artificial as the various themes are inter-linked. However, there are distinct elements in each of the initiatives and describing these should help to illustate how the complex jigsaw of health and social care starts to fit together. Inter-dependencies are considered in detail by the operational units to ensure that the changes are delivered in a balanced way to support overall improvements and efficiencies. These initiatives reflect the board s strategic direction as set out in our 10 year operational plan. Detailed Actions Plans for each Initiative are being prepared and the underpinning workstreams are briefly described in this section: Adult Care One of the fundamental decisions underpinning the plan is predicated on further implementing an integrated care model that is is significantly less reliant on hospital and institutional bed-based care. The changes we are proposing will result in further reduction of acute, community hospital and care home beds across Highland and Argyll and Bute. Actions will be taken to invest in greater 24/7 provision in community and home-based settings and associated technologies resulting in beds no longer being required. Work will also be required to enhance support and empower people, their carers and local communities to take a more pro-active role to support people to be more independent and keep people well. It will see a focus on delivering high quality end of life care. Two key metrics for this workstream are to support a reduction in emergency hospital admissions and an increase in the percentage of people who chose to die at home. Draft V4.1 updated 17 MAR

128 128 Adult Flow Improving patient flow through our hospitalss will support safer and more effective care. Actions will include a move to more senior decision support, new triage and ambulatory care approaches and more effective discharge planning. These actions will support reduction in length of stay and shorter waits in Emergency Departments. The combination of this workstream and adult care will support much more efficient ways of working in hospital settings and reduce many of the current defects in our systems across both elective and emergency care pathways. A key measure will be a reduction in length of stay. New Models of Care New clinical models of care are underway and include transforming out-of-hours, out-patients, maternity services, Rural General Hospitals, Primary Care and Cardiac Rehabilitation. Adult care and flow will also be supported by some new models. Many of the new models will see less reliance on doctors, fewer face-to-face interventions and less hospital-based care. Key measures will be less reliance on locums, fewer return hospital out-patient appointments, better use of the clinical estate supporting a reduction in the the number of buildings we require. Realistic Medicine This workstream perhaps offers the greatestt challenges but biggest benefits in terms of delivering more person-centred care. The Chief Medical Officers Annual Report on Realistic Medicine (published in February ), followed up with Realising Realistic Medicine (February 2017), clearly set out the need to reduce the burden and harm that patients experience from over-investigation and overtreatment. The importance of the need to reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients and how to prevent waste is highlighted. As more realistic medicine is delivered it will bring a move towards more shared decision making and that will require more realistic conversations. Realistic Medicine captures all elements of our Highland Quality Approach. Actions will include implementing new models for consent and creating time to discuss choices with patients and their families. The sole driver for this initiative is to improve quality albeit there will be potential implications for costs by reducing waste, harm and unwanted variation. This part of the plan, however, will not have financial costs attributed to any actions. Draft V4.1 updated 17 MAR

129 129 Drug Costs Investment in medicines represents one of the most costly outlays in health care, often second only to staff costs. Over 10 per cent of NHS Highland s expenditure is on medicines. Medicines, of course, also bring significant benefit to patients and to society at large. For instance, NHS Highland allocates a significant resource to paying for drugs to prevent or delay blindness in patients with macular degeneration. Early work in Edinburgh showed that the number of individuals being registered as blind had fallen by over 50 per cent in an early treatment cohort. Alongside this it is important to set the overall cost of access to new and existing medicines. It is Scottish Government policy to increase access to new medicines. A proportion of the cost of these new medicines has been offset by the New Medicines Fund (NMF). It is estimated that across Scotland the NMF meets about half the cost of the new medicines covered by the policy. The new access to medicines policy requires the Scottish Medicines Consortium (SMC) to apply new acceptance criteria to medicines for rare and end of life conditions. Health Boards are also required to make available medicines if a clinician believes the patient will benefit, even where the SMC has not accepted the medicine for routine use in Scotland. This places significant pressure on the Secondary Care drugs budget. NHS Highland in common with other Health Boards has seen an average rise in costs of around 15 per cent per annum for the last five years. Primary Care drug costs are also on the rise albeit at a lower rate. Whilst the individual medicines prescribed are cheaper than in Secondary Care they are prescribed in significantly greater volume. The cost pressures associated with Primary Care drug costs are mainly around an aging population that requires more medicines and fluctuation in market prices that affect the cost of medicines on the Scottish Drug Tariff. The number of items prescribed per patient is levelling off thanks in part to initiatives like polypharmacy. The cost of some routine and long established medicines, e.g. metformin and co-codamol, can rise steeply with little warning. Few medicines are made in the UK and, therefore, medicine supply and costs are subject to influence by international factors including fluctuations in exchange rates and changes in demand. The UK Government has announced plans to tackle excessive profit-making from companies that buy up the rights to old medicines and then increase the price significantly. The impact on medicine prices of a weakened Sterling is hard to predict with any accuracy. However, it is reasonable to assume that it won t lead to a fall in the prices of medicines. There are a large number of ongoing initiatives in NHS Highland that aim to reduce unnecessary costss associated with medicines. In Primary Care this includes reducing waste, increasing the number of polypharmacy reviews in General Practice, reviewing the Draft V4.1 updated 17 MAR

130 130 prescribing of high cost medicines and patients whose medicine costs are high, reviewing the prescribing of oral nutrition supplements, arranging for some high cost medicines to be dispensed via community pharmacies, increasing the rate of generic prescribing and reviewing the prescribing of medicines to patients in nursing homes. Board leadership will be required around some of these initiatives especially where there might be a requirement to stop the prescribing of medicines of no, or very, low value. Where they are available these changes willl be led by advanced pharmacists in General Practice in line with Scottish Government Policy Prescription for Excellence. Where available these staff will generate medicines efficiencies in a similar manner to those identified in the Carter Report, Productivity in NHS Hospitals (). In Secondary Care, ongoing work will focus on efficient distribution and recycling of medicines, increased use of patients own medicines, reducing inventory, and greater pace of switch from originator to biosimilar products. This work is all in line with recommendations in the Carter Report. These initiatives will be led by the clinical pharmacists in Raigmore Hospital. Nationally, Highland plays a lead role in the Effective Prescribing Programme and new initiatives from that programme have, and will be, introduced as they arise. As an example, work is almost complete on an initiative that will save NHS Highland around 200K per annum on melatonin prescribing in sleep disorders. Remodelling Assets With new models of care becoming embedded, attendance at out-patients, admissions and length of stay will reduce in both hospitals and care homes and so the need for beds will also reduce. This provides opportunities to enhance community and home based services. In turn this will allow us to remodel our assets to reflect the reduced need for number of beds required as well as hospitals or in-patient facilities. It will also be important to make sure that we make best use of all of our clinical space and align it to best fit patient flow and clinical requirements. The board has already approved major service redesigns in Badenoch and Strathspey, Skye, Lochalsh and South West Ross, the North Coast (Sutherland), and the development of the elective centre and critical care upgrade in Raigmore Hospital. All these have implications for remodelling our assets. Work is also ongoing to remodel office space and space in Rural General Hospitals, Mental Health Units, Care Homes, and Day Care Services to ensure only medical care is delivered from our hospitals. Many of these projects are well advanced and will come to conclusion during this three year plan. Opportunities to accelerate some of the changes may also need to be considered. Key Draft V4.1 updated 17 MAR

131 131 measures will be a reduction in our foot-print and clinical space being used for clinical services. As mentioned earlier, many of our assets are also not strategically located and there are overall benefits of making sure our assets are aligned to reflect the current and future transport networks; IT and changing settlement patterns. Continuous Quality Improvement, Local Initiatives and Opportunities NHS Highland also has a good track record of delivering significant financial savings and reducing costs from continuous quality improvement and local initiatives and opportunities. This will include everyday improvements linked to daily management and Rapid Process Improvement Workshops to specificc initiatives around procurement, vacancy management and a move to more shared services. Plans are also being prepared to support a significant scaling up of the implementation of continuous improvement methodologies across the organisation. This will build on our examples of successful improvements including, for instance on the reduction in falls in hospital and the new approach being tested through Lean accounting at ward level. Draft V4.1 updated 17 MAR

132 Supporting Strategies Workforce People strategy is a key element of the Highland Quality Approach. The workforce challenges alone are significant drivers requiring us to urgently remodel our care, create new roles and new ways of working. Some of the solutions will require regional and national approaches, as well as local innovations. Although our worforce is ageing we have seen over the last three years an increase in the number of employyes in the lower age bands. For the past two years or so sickness absences has been around 5 per cent and consistently slightly lower than the Scottish Average (5.15 vs 5.23). Annual turnover as at 31 December was 10.7 per cent but showing significant variation, ranging from 24 per cent (medical support) and 23 per cent (medical) to less than 10 per cent for Administrative Services, Dental, Nursing and Senior Management. Our overall turnover rate is higher than the national average (6.2 per cent). In terms of vacancies there were just over 500 posts vacant equates to 6.2% of our filled posst) at December again with significant variation. There are particular challenges for some staff groups including GPs, midwives, care at home, radiologists, health care scientists, sonographers and some allied health professionals. Our latest workforce strategy was endorsed by the Board in August and annual updates are provided as part of Local Delivery Planning Process. A range of workforce plans are in place or being developed including: Increased flexibility in the workforce Work towards seven day working for some clinical staff to enhance senior decision making at week-ends Develop and strengthen new roles such as Health and Social Care Support workers Expansion Advanced Practitioners including Nurse Practitioners and Pharmacists working in GP Practice Consideration of adopting shared services Alignments of workforce to new models of care Development of new employment routes such as apprentice roles and developing the young workforce Draft V4.1 updated 17 MAR

133 133 Development of a Care Academy Collaboration with partner organisations, locally, regionally and nationally Developing community resilience approaches and providing support to develop support for First Responders will also impact on the workforce. Through our Research, Development and Innovation Department opportunities for recruitment and retention of all levels of staff will be created. Asset Management Strategy Many of our assets are not strategically located or aligned to new models of care, infrastructure (roads, technology, changes in clinical models and practice and so on). We, therefore, need to look at many things afresh and consider whether the location of our assets (people, buildings, equipment) make sense today and are right for the future. Our rolling five year Asset Management Strategy published in August 2015 is ambitious and will transform the assets we deliver health and social care from right across Highland and Argyll & Bute. Our assets are being re-shaped to underpin our new models of care. We continue to drive forward the work to deal with backlog maintenance and to renew our infrastructure, equipment and other assets. There has been, and continues to be, significant community and staff engagement about any changes and in particular around any changes to location of buildings. Notably while there is strong consensus for the new models of care to look after more people at home there remains strong association with buildings and even space within buildings. This is an important consideration because it can be a significant factor dictating the pace of change and the capacity to deliver and execute changes. The Integrated Joint Board does not have a budget for capital and so any capital requirements need to be considered by the Board. While NHS Highland run adult social care services, in the Highland Council area, the Council own the buildings and are responsible for the upkeep and replacement as required. e-health Our ehealth Strategy is aligned with NHS Highland s corporate objectives and the National Strategy. Key aims are: Draft V4.1 updated 17 MAR

134 134 enhance the availability of appropriate information for healthcare workers to communicate information effectively to improve quality. support people to communicate with NHS Highland to manage their own health and wellbeing, and to become more active participants in the care and services they receive. support people with long term conditions. Iimprove the safety of people taking medicines and their effective use. provide clinical and other managers across the health and social care spectrum with the timely management information they need to inform their decisions on service quality, performance and delivery. maximise efficient working practices, minimise wasteful variation, bring about measurable savings and ensure value for money. contribute to innovation occurring through the Health Innovation Partnerships, the research community and suppliers A Regional ehealth Strategy is also being developed by the North of Scotland Planning Group which will reflect the need to better integrate services. Areas will be mapped to identify where technology can better support remote decision making for clinicians and where remote contact with patients and service users can add value for individuals and communities. There will need to be an ongoing programme to prioritise investment in technology. Immediate priorities for NHS Highland are to fully develop an integrated Electronic Patient/Person Record to replace existing paper records and to provide Equity of Access to Systems and Services including to ensure NHS Highland users have access to modern technology to support care to patients/persons. Research, Development and Innovation Our principal aims are to bring equity of access to Research, Development and Innovation (RD&I) activity to the entire population of the Highlands and Islands. The RD&I department supports a variety of studies which range from cancer drug trials to the deployment of new technological innovations in health and social care. They support core NHS activity by seeking to solve some of the major challenges that the organisation faces on a daily basis. They offer expertise to solve problems and are the key link between the NHS, the academic sector and commercial partners. Increasingly the RD&I team will engage with small and medium-sized enterprises (SMEs) to form partnerships with the NHS which Draft V4.1 updated 17 MAR

135 135 help create new solutions for our challenges. Staff support the health department with a pipeline of innovations and products that could be helpful to the organisation. One of the main pillars of our current strategy is to support the health and social care service by developing innovative models of efficient and sustainable care for our citizens. Specifically, we are supporting projects that encompass remote clinical decision support and home consultation. Another of our principal aims is to ensure that our RD&I activity is distributed across all sectors of our workforce and geography. Draft V4.1 updated 17 MAR

136 Communication and Engagement A key enabler to support Realistic Medicine must be to get better shared decision making. To achievee this needs clinicians to be supported to have the time to have the necessary conversations with patients, carers and families. Overall, more work needs to be done to raise awareness with the public about their choices. The Chief Medical Officer s latest Annuall Report (2015/16) Realising Realistic Medicine published in February 2017 offers some thoughts and case-studies to guide these conversations and practical actions. The report also sets out the involvement of the Scottish Health Council to support wider public engagement. Work needs to continue to prevent ill health and greater support for self management especially through public healthh and primary care routes. Scaling up the benefits from continuous quality improvement is particularly attractive as this is designed to drive out waste while delivering better care and value. The impacts can be significant and do not require long lead in times or public consultation. It will require skilled leadership and more buy-in from staff and local examples promoted to share learning and provide encouragement. CEL 4 (2010) 3 provides guidance on informing, engaging and consulting people in developing health and community care services including requirements for a public consultation. The critical point to note from the CEL is the ongoing need to engage with local communities, partner agencies, politicians and staff not just at the point of change becoming a necessity. Across Highland and Argyll and Bute considerable work is ongoing around all of the workstreams. The guidance also clarifies the role of the Scottish Health Council during service change which is to quality assure the engagement process and produce a report on their findings for the Board to submit to the minister, alongside the final proposals. NHS Highland works very closely with the Scottish Health Council on the communications. The Board is not required to consult on any changes required on the grounds of safety though appropriate communications and engagement is, of course, necessary. Over the last four years, officers have initiated formal and informal processes to support the changes outlined in the 10 year plan (Annex). All of the change programme being delivered are underpinned by local communication and engagement plans and local groups which are proportionate to the changes under consideration. There will be further opportunities to engage with Community Partnerships (Highland Council) and Locality Planning Groups (Argyll & Bute) across the whole area, where detailed priorities will be identified for both Adults and Childrens services. A communications and engagement tracker (Annex II) and a monitoring framework of key metrics is also being prepared (Annex III). 3 Draft V4.1 updated 17 MAR

137 Assurance, Performance, Risk and Planning Assurance The Board will continue to receive monthly updates on progress with more formal presentations to the board meetings held in public every other month. The content of these reports and presentations will be derived from the governance reports provided to both the Argyll and Bute Integrated Joint Board and and the Highland Health and Social Care Partnership Committee. The regular financial monitoring reports that the Director of Finance presents to each Board meeting sets out the financial governance arrangements in more detail and in particular the various forums for scrutiny. It is proposed that the Delivering Financial Balance Programme Board will continue to play a key role in terms of oversight and that it will take a more programme- based approach than previously. Performance The Delivering Financial Balance meeting, chaired by the CEO, will coordinate the programme of work and oversee the delivery plans, navigating the continued progress towards breakeven throughout the year. Additional remedial action to ensure delivery will be initiated and reported to the Board. Monthly reports will continue to be provided to the Scottish Government with a forecast against delivery. NHS Highland has restructured to create a Business Support Services Directorate with a specific planning and performamce remit. A performance management framework is being developed to underpin the annual and longer term plans. This will include looking at benchmarking data to look at areas for potential improvements such as costs per case across theatres, out-patients, in-patients, theatres and so on. For each initiative, performance measures have been identified so progress can be tracked. This will be further refined and developed (Annex 3). It will be important to monitor progress in terms of delivering both the new models and the savings targets. One of the key drivers is sustainability and some of those challenges can not be addressed simply by investing more resource. Draft V4.1 updated 17 MAR

138 138 Risk The Board will consider a paper on Risk Appetite as its meeting in March 2017 and depending on the outcome of the discussions and decisions, some of the plans may need to be altered or addittional proposals brought forward. One risk to delivery is believed to be the pace with which we are able to intitiate the necessary change and capacity to deliver, whilst coping with the inevitable impact of meeting current needs, targets within resources. Despite significant engagement in all areas about the need to change over the years, some ongoing resistance is experienced and further can be anticipated. However, if the current ways of working continue then, sooner or later, more services will fall over in an unplanned way which is inherently more risky. Recent examples of staffing challenges in out of hours/ Minor Injuty Units (Dunbar, Ross Memorial/Invergordon/ Nairn), inpatients (Dunbar, Portree, St Vincent s, Ross Memorial) have seen short-term disruptive to services, either through reduced hours or temporary bed closures. These all serve to illusrate why these services need to be redesigned to have safe and sustainable staffing models. Therefore, we will need to work together with staff, service users, communities and influencial leaders to support the move to new and improved models of care across our wide geographic area. Whilst the Public Bodies(Joint Working)(Scotland) Act 2014 supported the principle of integration, the reality continues to be pressures between NHS Highland and both partner local authorities in attempting to agree a quantum for delivery in advance of each financial year This poses further risks for all organisations and a more satisfactory approach should be sought that gives the public more confidence in planning process and appropriate allocation of resource, based on need. Planning Cycle If the board endorses the strategic direction in March further work will be brought back to the board in May including a detailed annual plan (2017/18) and three year plan. They will be underpinned by more detailed operational and corporate plans which will be overseen by Health and Social Care Partnerships. Going forward the annual planning process will get underway in September with draft plans ready for consideration ideally at the November Board Meeting. Once the Board approve the plan, the operational units and corporate services will prepare their local plans for consideration by their Health and Social Care Partnership Committees in Highland and Argyll and Bute. They would also be required to update longer term plans (Table below). Draft V4.1 updated 17 MAR

139 139 Proposed Time-Line for developing and appropving Annual and three year plan Time-frame Description of document Requirement Board or Committee Mar 17 Development of annual three year plan Discussion on NHS Highland Board prioritisation, monitoring Development and risks Mar 17 NHS Highland Strategic Quality and Sustainability Plan Approval of Plan NHS Highland Board Mar May 17 NHS Highland Strategic Quality and Sustainability plan and developing action plans Engagement Highland Partmership Forum Area Clinical Forum Clinical Governance Staff Governance Asset Management Senior Managment Teams Opertaional Units Mar 17 Argyll & Bute Strategic Plan Update of Strategic Plan to Argyll & Bute Integrated Joint reflect board Quality and Board Sustainability Paln May 17 North Highland Action Plan Approval of Plan Highland Health and Social Care Committee May 17 NHS Highland Strategic Quality and Sustainability detailed plan (2017/18) Approval of Plan NHS Highland Board Sep Nov 17 Development of Annual (2018/19) and rolling three year plan Discussion on prioritisation, monitoring NHS Highland Board and risks Dec17- Mar 18 NHS Highland Strategic Quality and Sustainability Plan and update on strategy Approval of Plan and any refresh to strategy NHS Highland Board Highland Health and Social Care Committee Argyll & Bute Integrated Joint Board Draft V4.1 updated 17 MAR

140 140. Annexes These have been draftedd and will be available for comment in April 2017 I) Annual Quality and Sustainability Plan II) Communications and Engagement Tracker III) Monitoring Framework IV) Gant Chart Draft V4.1 updated 17 MAR

141 141 NHS Highland Board 28 March 2017 Item 4.6 DRAFT LOCAL DELIVERY PLAN 2017/18 Report by Margaret Brown, Business Support Directorate, on behalf of Elaine Mead, Chief Executive. The Board is asked to: Approve this Draft Local Delivery Plan 2017/18 for submission to the Scottish Government by the national deadline of 31 st March. 1. Summary The attached Draft Local Delivery Plan 2017/18 is NHS Highland s proposed response to DL (2017)1: Local Delivery Plan (LDP) Guidance 2017/18. This will be the first submission of the document with the final version due to be submitted by 30 th September Background The Scottish Government issued DL (2017)1: Local Delivery Plan (LDP) Guidance 2017/18 on 16 th January This sets out the Scottish Government planning priorities for NHS Boards and was shared with the Board at its meeting on 31 st January The guidance requires the submission of a new style LDP from those of the last few years, and although it does not require the document to be in any particular format it does specify the requirement for 5 key sections in our response. 1. Increasing healthy life expectancy. 2. Health and Social Care Delivery Plan. 3. National review of targets and indicators for health and social care. 4. Financial Planning. 5. Workforce Planning. The guidance also requires that our response to the national Health and Social Care Delivery Plan needs to identify how our actions will impact on outcomes and how we will monitor our progress. It acknowledges that this new LDP process will evolve over the coming months particularly in relation to The pending recommendations from the national review of the targets and indicators for health and social care, being led by Sir Harry Burns. These are not due to be published until Spring 2017 and will therefore not be reflected in the LDP until the final version. The new arrangements for regional planning and delivery of services. An initial submission of the Financial Plan was required to be made on the 28 th February. This was done and the feedback received will be reflected in the submission made on the 31 st March. The Financial Plan is underpinned by the Quality and Sustainability 3 year Plan 2017/18 to 2019/20.

142 Issues for consideration The guidance stipulates that NHS Boards must engage with Health & Social Care Partnerships in the preparation of the LDP with a relationship based on collaboration. The development of this document has been based on the contribution and responses from a wide range of staff across NHS Highland, including both Partnerships and Corporate Services. However, due to the late issue of the guidance and the national deadline of 31 st March 2017, there has been limited time for the circulation of the draft document and this will form a key part of its ongoing development from April through to its final submission in September. It is important to note that it has not yet been to the Highland Health and Social Care Partnership Committee or the Argyll and Bute Integrated Joint Board. It is scheduled on the agenda for the Senior Management Team meeting on 23 rd March 2017 and therefore does not reflect any comments/changes that may arise from that meeting. 4. Recommendation The Board is invited to approve this document for submission to the Scottish Government by the national deadline of 31 st March, while acknowledging that further development of the LDP will be taken in response to Feedback from the organisation on this initial draft Feedback from the Scottish Government on this initial draft Issue of further national guidance and recommendations. The proposed final version of the LDP 2017/18 will be presented to the Board in September prior to its submission to the Scottish Government on 30 th September Contribution to Board objectives The planned actions contained within the LDP details a significant proportion of the objectives that the Board will be required to deliver in 2017/18 and the following years, and forms the basis on which the Board will be held accountable for its performance at the Annual Review. The Governance Committees will need to be assured that NHS Highland performance meets the milestones and targets detailed in this paper. 6. Governance implications Staff governance One of the Key sections of the Draft LDP 2017/18 is the Workforce Plan (Section5). There are also a number of actions related to workforce development contained within our response to the national Health & Social Care Delivery Plan (Section 2). Clinical governance There are a range of clinical governance implications in the detailed actions throughout the document. Financial impact Section 4: Financial Planning and its supporting tables contain NHS Highland s financial plans for the next 3 years.

143 Risk assessment Risk assessment will be undertaken and addressed by the relevant teams and committees for the individual actions identified. 8. Planning for Fairness The individual national standards have been impacted assessed at national level. The equality impact assessment for each of the actions at local level can be requested from the lead staff member. 9. Engagement and Communication The final Local Delivery Plan is published on the NHS Highland website. Each year, through the Annual Review process, the Board is held accountable for delivery against the key elements of the Local Delivery Plan. This is carried out in public with the opportunity for the public to question the Board on its performance over the year. Report Author: Margaret Brown Date: 15 th March 2017

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145 145 DRAFT NHS HIGHLAND LOCAL DELIVERY PLAN 2017/18 Better Health, Better care, Better value March P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

146 146 CONTENTS Section 1: Increasing Healthy Life Expectancy 1.1 Supporting more individuals and their families to make choices about their health and care 1.2 Providing timely access to clinically appropriate care 1.3 Making NHS Highland the employer of choice 1.4 Argyll & Bute IJB Section 2: The Health & Social Care Delivery Plan 2.1. Health and Social Care Integrationn 2.2 The National Clinical Strategy 2.3 Public Health Improvement 2.4 NHS Board Reform Section 3: National Standards 3.1 Standards 3.2 Patient Safety 3.3 Patient Centeredness 2 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

147 147 Section 4: Financial Planning 4.1 Headlines 4.2 Revenue Core RRL 4.3 Revenue Non Core RRL 4.4 Capital 4.5 Efficiency Savings 4.6 Assumptions Appendices: Financial Tables Section 5: Workforce Planning 5.1 Healthy Organisational Culture 5.2 Sustainable Workforce 5.3 Capable Workforce 5.4 Workforce to Deliver Integrated Services 5.5 Effective Leadership and Management 3 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

148 148 SECTION 1: INCREASING HEALTHY LIFE EXPECTANCY NHS Highland recognises the contribution that increasing healthy life expectancy makes to people living longerl in good health, increasing their capacity for productive activity and reducing the burden of ill health and long term conditions on people, their families and communities, public services and the economy in general. This section details our action plans for the following focus areas. Supporting more individuals and their families to make choices about their health and care Providing timely access to clinically appropriate care Making NHS Highland the employer of choice Specific Argyll & Bute IJB actions. 1.1 SUPPORTING MORE INDIVIDUALS AND THEIR FAMILIES TO MAKE CHOICES ABOUT THEIR HEALTH AND CARE Improvement Aim 1 Supporting more individuals and families to make informed choices about food and health Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Support, promote and encourage breastfeeding with young people. Implement through the 3 18 curriculum programme available on GLOW. Monitoring of breastfeeding rates Support NHS Highland to maintain UNICEF BFI award including peer support and intensive interventions through infant feeding support workers. Appropriate staff will be trained to ensure standards are met. Standards will be built into NHS Highland policies and procedures for ante natal and post natal care and support. On-going audit and monitoring of standards by the Maternal and Infant Nutrition Improvement group. Deliver food skills courses in our most deprived communities. By building capacity in staff and volunteers within communities 4 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

149 149 Monitoring progress Activities Embedding into practice Monitoring progress Quantitative evaluation of numbers trained and course delivered. Qualitative evaluation of experiences. Pilot 1 year Food Friends, using food and meals to decrease social isolation in rural areas Partnership work with the third and voluntary sector 6 and 12 monthly review numbers, cost, and outcomes evaluation Improvement Aim 2 Support individuals and families to jointly agree priorities and approaches for health improvement and wellbeing Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Support, promote and encourage breastfeeding with young people Implement through the 3 18 curriculum programme available on GLOW Monitoring of breastfeeding rates Support NHS Highland to maintain UNICEF BFI award including peer support and intensive interventions through infant feeding support workers. Appropriate staff will be trained to ensure standards are met. Standards will be built into NHS Highland policies and procedures for ante natal and post natal care and support. On-going audit and monitoring of standards by the Maternal and Infant Nutrition Improvement group. Improving access to Maternal and Children s vitamins. Facilitate the provision of universal vitamins for the duration of pregnancy. Use LEAN methodology to pilot distribution of vitamins to beneficiaries by Health Visitors. Number of vitamins distributed 5 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

150 150 Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Support childcare providers to take a preventative approach to toddler nutrition, eating and body confidence. Disseminate and implement the new NHSH toddler guidance; Food, Mood and Health. Number of staff groups trained. Support children and families to manage their weight and well being. Develop child healthy weight interventions for delivery by Primary care staff based on scoping/ needs assessment. Toolkit developed and disseminated. Reporting framework developed. Improvement Aim 3 Widen delivery of ABIs in non-priority settings, support those trained to deliver, and target delivery toward tackling health inequalities Activities Embedding into practice Monitoring progress Deliver the target of 3,688 ABIs..for NHS Highland, set by the Scottish Government acrosss the Operational Units. New areas Criminal Justice; via Unison. Ongoing support scheduled for Police Custody Suite and Inverness Response Team and Housing Officers, who were trained earlier in 21016/17. Work with local agencies to deliver Discussing Drugs and Alcohol with Young People training, encouraging conversations with young people about alcohol and substance use. Maximise effective delivery by training and supporting staff to deliver ABI s. Delivery of Training for Trainers in areas where decreased delivery was causing concern. Include in the training of health and social care students attending Highland colleges and University. Number of ABI s delivered by Operational Units. Numbers of trainers trained and delivering courses. Numbers attending training. 6 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

151 151 Improvement Aim 4 Integrating prevention into clinical care and improve health outcomes through implementing the Health Promoting Health Service framework. Activities Embedding into practice Monitoring progress Progress the key areas of improvement recommended from NHS Health Scotland from NHS Highland 1 st year report of CMO (2015) 19 letter. These are Build in the measurement of impact of HPHS within any relevant strategic, or commissioning and implementation plans. Explore ways of increasing health improvement staff training with hospital staff including raising the awareness of the Smokefree Policy to reduce the number of incidences of patients and visitors smoking on hospital grounds. Consider a prevention approach to health and wellbeing, including effective interventions and impact. The collection of data for a range of measures/ indicators, including wellbeing indicators and not just staff sickness absence rates, may be helpful. Progress with Healthy Working Lives Award, ensuring that all hospital sites maintain or attain gold. Continue to support and develop Health Promoting Health Service leads within each hospital with clear communication links to and between all staff and networks Implement through NHS Highland policies where appropriate Quantitative and qualitative reporting annually to Scottish Government, Health Scotland and NHS Highland Board. 1.2 PROVIDING TIMELY ACCESS TO CLINICALLY APPROPRIATE CARE Improvement Aim 1 Improve the reach of healthy weight interventions. Activities Embedding into practice Increase the delivery of Well Now groups in new areas. Use LEAN methodology in: Recruiting and training new facilitators Programme delivery Reviewing and updating referral pathway 7 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

152 152 Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Numbers of participants completing the course. Achievement of course objectives. Improve the delivery of High5 primary school interventions. Use LEAN methodology in training teachers, Disseminating resources including website. Number of programmes delivered, number of website hits. Supporting individuals to manage their weight and wellbeing Develop and pilot a 1-1 weight inclusive intervention for delivery in community. Pilot evaluation Improvement Aim 2 Improve the accessibility to services for people whose first language is not English (foreign language and BSL). Activities Disseminate new guidance and materials about interpretation services to all relevant Managers. Run three Working With Interpreters training courses for NHSH staff Communication support servicee agreement extended to March 2018 via a contract variation. Embedding Seek to embed access to interpretation within existing work programmes, e.g. out of hours and Patient Management into practice System improvement. This is ongoing and relies on national systems. NHSH is part of a new national short life working group set up to better identify access support needs within NHS Scotland Monitoring Numbers of NHS staff attending Working With Interpreters training. progress Monitor patient feedback about interpretation services and access to them. Monitoring meetings with providers of interpretation every 6 months. Regular monitoring meetings with providers. 8 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

153 153 Improvement Aim 3 Improving the reach of smoking cessation services Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Further develop and embed a smoking cessation service to inpatients within acute settings. Train hospital ward staff. Monitor nicotine replace therapy (NRT) prescribed within the hospital setting. Further develop and support a smoking cessation service within outpatients. Include within existing quality improvement work. Monitor referrals to service and successful quits through the ISD database. Train and support key workers in mental health inpatient facilities to support patients to cut down or quit smoking. Include in existing job roles. Monitor activity through ISD database and NRT prescribing. Provide support to Inverness prison to support smoke free prisons. Provide support by means of training and adviser time pilot time of 6 months initially. Monitor activity through ISD database. 9 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

154 154 Improvement Aim 4 Improve our response to survivors of gender based violence Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Development of training for clinical interventions for women affected by female genital mutilation. Supports the updated FGM Protocol. Monitor ISD recordings for FGM. NHSH become a trauma informed service. Trauma training is mandatory for mental health staff. Staff/survivor feedback. Agreed set of actions that NHSHH can contribute to MARAC cases. Implementation of organisational MARAC Protocols. Numbers of actions attributed to NHSH by MARAC. 10 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

155 MAKING NHS HIGHLAND THE EMPLOYER OF CHOICE Improvement Aim 1 Improve the health and wellbeing of our staff Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Review and update our staff health and wellbeing framework and identify priorities for Guidance contained within PIN Policies, department briefings etc. Progress monitored through HR and partnership forum. Develop activities aimed at helping staff and managers to recognise and manage stress. Online support available to all staff. Information included within staff induction policy. Monitoring of sickness absence Number of accredited sites. Develop and promote an active travel initiative. Identification of policies and guidance to embed practice will be part of the initiative. To be confirmed but likely to include awareness and participation in active travel determined through staff surveys. Support development of LGBT staff network. Through HR policy and Equalities outcomes. where stress is given as the reason for absence Progress monitored through Stonewall Diversity Champion index. 11 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

156 156 Improvement Aim 2 Activities Embedding into practice Monitoring progress Making NHS Highland a fairer place to work Develop Diversity Champion Improvement Plan by May Assessment of the organisation - submit Workplace Equality Index to Stonewall in September Establish a staff network for LGBT staff and allies. Develop communications plan for the Stonewall work programme. Improved score from the Workplace Equality Index. Feedback from Stonewall staff survey. Monitoring via Highland Partnership Forum. Improvement Aim 3 Continuously develop our staff s knowledge and skills Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Deliver mandatory Violence Against Women training to our staff. Included within NHS Highland policy for statutory and mandatory training and Educational Governance Framework. Numbers attending training. Development and delivery of health improvement statutory and mandatory, core and topic specific training offered to staff and partners. Development of blended learning with e-learning modules linked to KSF and PDP development. Equality and diversity and tackling health inequalities embedded in current stat and man courses. Number of courses delivered. Number of staff attending training. Evaluation on impact of training. 1.4 ARGYLL AND BUTE IJB Improvement Aim 1 To support staff to support the most vulnerable people and communities. 12 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

157 157 Activities Embedding into practice Monitoring progress Implementation of A&B HSCP Organisational Development Plan. Roll out of Caring Connections within the context of an overall Organisational Development Plan. (a copy of this plan is available on request) Review of the Organisational Development Plan. 13 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

158 158 Improvement Aim 2 To promote healthy living and better mental health. Activities Implementation of multi-agency Joint Health Improvement Plan: ( and the A&B Health Improvement Team Plan. (a copy of this plan is available on request) Embedding Implementation of both plans. Work has started to consider the health and wellbeing plan beyond. This will take into practice cognizance of the national Health and Social Care Delivery Plan Monitoring progress Activities Embedding into practice Monitoring progress Activities Embedding into practice Monitoring progress Performance measures within the plans. Use of the Integrated Care Fund (ICF) on prevention and health improvement. ICF spent on preventative and anticipatory care programmes including: management and preventionn of falls self management reablement preventative physical activity programmes programmes improving mental health and wellbeing. Performance measures within the plans. The A&B HSCP Strategic Plan also incorporates within its aims the need for greater prevention and early intervention Following local evaluation mainstream finance has also been provided following the pilot of increased funding to improve public health capacity within health and wellbeing networks. This increase in capacity has been focussing on helping localities direct more attention to prevention and early intervention. Local evaluation continues. 14 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

159 159 SECTION 2: HEALTH & SOCIAL CARE DELIVERY PLAN The following section sets out our local actions being progressed in 2017/18 to deliver the actions and milestones set out in the national Health & Social Care Delivery Plan. The section is structured around the 4 Programmes of Activity and their Key Areas. Programme of activity HEALTH AND SOCIAL CARE INTEGRATION THE NATIONAL CLINICAL STRATEGY Strengthen primary and community care Improve secondary and acute care Focus on realistic medicine PUBLIC HEALTH IMPROVEMENT NHS BOARD REFORM Key Areas Reducing inappropriate use of hospital services Shifting resources to the community Supporting the capacity of community care Building up capacity in primary and community care Supporting new models of care Reducing unscheduled care Improving scheduled care Improving outpatients Strengthening relationships between professionals and individuals Reducing the unnecessary cost of medical action Supporting national priorities Supporting key public health issues Supporting mental health Supporting a More Active Scotland Delivery of national services Once for Scotland approach Leadership and talent management 15 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

160 HEALTH & SOCIAL CARE INTEGRATION Key Area REDUCING INAPPROPRIATE USE OF HOSPITAL SERVICES HSC Delivery Plan Action/Milestone: Ensure Health and Social Care Partnershipspowers and responsibilities to shift investment into community provision by reducing inappropriate use of hospital care and with NHS Boards, local authorities and other care providers make full use of their new redesigning the shape of service provision across hospital, care home and community settings. This will be a key lever in shifting the focus of care across health and social care services. NHS Highland Local Action(s) Submission by: IMFOU Introduction of overnight scheduled and unscheduled care service in people s own homes Co-location of Inverness Integrated Teams Redesign of model of integrated care in Inverness Introduction of flexible use of care home beds Redesign and relocation to Raigmore Hospital of day assessment and treatment units for older adults Redesign of day care centres to community resource centres Redesign of community equipment stores to provide a move effective and responsive service Use of frailty assessment tool to reducee length of stay in hospital and prevent admission. Impact on outcomes Reduction in length of stay in hospitals Reduction in people 75+ admitted to hospital Increased planned activity Progress monitoring Senior Management Team Health & Social Care Committee Adult Social Care Group 16 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

161 161 HSC Delivery Plan Action/Milestone: Ensure that everyone who needs palliative care will get hospice, palliative or end of life care. All who would benefit from a Key Information Summary will receive one. More people will have the opportunity to develop their own personalised care and support plan. The availability of care options will be improved by doubling the palliative and end of life provision in the community, which will result in fewer people dying in a hospital setting. NHS Highland Local Action(s) Submission by: Pat Tyrrell Develop clear framework which includes principles and standards for palliative end of life care in all settings. Identify the required workforce across statutory, independent and third sectors at neighbourhood and locality levels. Develop ongoing training and education programme to support workforce development. Develop community based neighbourhood teams that work across 24/7. Ensure that KIS is available as part of anticipatory care planning for all appropriate patients. Work with UHI to develop research proposal to identify how well anticipatory care predicts and supports good palliative and end of life care delivery. Impact on outcomes More people will die in their preferred place of care in Highland. Fewer people will be admitted in emergency situations to hospitals and care homes during the last 6-12 months of life. Families and carers will report improved experience of care services. Progress monitoring Progress with the implementation plan will be reviewed through the Highland Palliative End of Life Care partnership. Progress towards outcomes will also be monitored through the Highland and Argyll and Bute Health and Social Care partnerships and through this route by NHS Highland Board Key Area SHIFTING RESOURCES TO THE COMMUNITY HSC Delivery Plan Action/Milestone: Ensure Health and Social Care Partnerships increase spending on Primary Care Services to 11 per cent of the frontline NHS Scotland budget. 17 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

162 162 NHS Highland Local Action(s) Submission by: Dr Paul Davidson Development of: Investigation Treatment Rooms General Practice Clusters Immunisation Teams Wider clinical teams in General Practice (ANP s, Pharmacists) Evaluation of caring, AHP, district nurse, health visitor and school nurse roles Investigation Treatment Rooms In response to transferring care from a secondary care setting to primary care we have created new investigation treatment rooms allowing for activities such as follow up blood testing, basic investigations and dressings to be undertaken by a new nursing team. There will be several centres developed over the coming year and impact fully assessed. General Practice Clusters Following Scottish Government and BMA guidance we have developed GP clusters across NHSH based on relationships between practices and focused on quality improvement. This has been supported by the Transformation Fund and government funding and will mature into joint working across wider areas on clinical, quality and later organisational issues. Immunisation Teams In light of changing professional duties affecting GP s, Health Visitor s and School Nursing teams and reflecting in particular the increased pressure on general practice and district nursing we are exploring dedicated immunisation teams. 2 pilot areas have been selected which will inform this wider work and will commence this year. Wider Clinical teams in GP GP recruitment and retention continues to be a significant challenge. A substantial number of practices are now 2C allowing NHSH to directly introduce advanced nurse practitioners and pharmacy practitioners to new general practice roles. GMS practices in several areas are following this lead and the role mix in general practice is thus changing. Evaluation of community roles All community teams are subject to review and change. The development of integrated teams and single point of access is complete in some areas and this will continue through to Such integrated teams include all previous community staff combined to allow 18 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

163 163 excellent sharing of patient care issues and in time, the development of pull from hospitals and more opportunity to provide traditional hospital level care in the community. Impact on outcomes We are on a journey from heavy traditional hospital based investment to more community level capability. This will require ongoing transfer of resource from hospital beds to community capability. A staged and considered approach is required alongside significant community engagement and advocating of personal responsibility for health for success to be achieved. Progress monitoring NHSH has reduced substantially the number of acute and community beds in hospitals that it supports. This will continue and can be easily monitored. Staff levels and capabilities in communities can also be monitored with impact on patients ascertained by both clinical outcomes and patient satisfaction surveys. Such change is not without difficulty in a climate of a reduction of available finance and the need to transfer resource from secondary care to community care to allow change but we are committed to this journey. Key Area SUPPORTING THE CAPACITY OF COMMUNITY CARE HSC Delivery Plan Action/Milestone: Continue to take forward a programme of work to deliver change in the adult social care sector, together with COSLA and other partners. This has begun with work to reform The National Care Home Contract whichh will maintain the continuity, stability and sustainability of residential care provision while embedding greater local flexibility, maximising efficiency, improving quality, enhancing personalisation and promoting innovation. Social care workforce issues and New models of care and support in home care. NHS Highland Local Action(s) Submission by: IMFOU /Simon Steer Implement the National Care Home Contract if settled; or find alternative negotiating mechanismss built on the collaborative commissioning approaches that have been developed in Highland. 19 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

164 164 Support residential care sectors focus on complex care and nursing care needs and ensure resources are in place to support more home based care. Continue redesign of care at home service which commenced In-house reablement servicee will be fully operational with the transfer of mainstream care at home to the independent sector completed during Continue to work collaboratively with independent; voluntary and community providers to develop new models of provision which address the challenges of delivering care in remote and rural settings. Develop new models of supported housing, taking full advantage of technology, to maintain people in their communities. Increase collaboration across care home and care at home sectors to develop new types of support services. Develop short break services in collaboration with carers. Increase support for carers via increased carers support plan uptake. Impact on outcomes Increased mainstream care at home capacity keeping people in their homes. Increased community based/community run provision keeping people in their communities. Increased levels of independence following receipt of reablement service. Increased night provision to keep people at home. Increase in available home care allowing people to be assured that care is available when they need it. Carers will be better supported. Reduced delayed transfers of care related to care at home availability. Reduced transfers of care related to care home capacity. Progress monitoring Senior Management Team Health & Social Care Committee Adult Social Care Group 20 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

165 THE NATIONAL CLINICAL STRATEGY STRENGTHEN PRIMARY AND COMMUNITY CARE Key Area BUILDING UP CAPACITY IN PRIMARY AND COMMUNITY CARE HSC Delivery Plan Action/Milestone: Continue the investment in recruitment and expansion of the primary care workforce which will mean that by 2022, there will be more GP s and every GP practice will have access to a pharmacist with advanced clinical skills. NHS Highland Local Action(s) Development of: Submission by: Dr Paul Davidson /IMFOU Pharmacy support to General Practice Immunisation Teams Development of Advanced Nurse Practitioner role in Primary care Evaluation of caring, AHP, district nurse, health visitor and school nurse roles Pharmacy Support to General Practice For a number of years we have provided pharmacy support to GP practices to support medicines management projects, medication review, prescribing efficiencies, efficient and effective prescribing systems and processes, and medicines information. In recent years and in line with Prescription for Excellence our pharmacy team has developed new and innovative models of care, particularly to be more clinically focused and patient-facing, whilst developing the roles and responsibilities of pharmacy staff, both pharmacists and pharmacy technicians. Changes to the GMS Contract provided the pharmacy team with the opportunity to work differently and more responsively, developing services and support that better meet the needs of patients and individual GP practices with all aspects of prescribing, medicines management and clinical care. We aim to continue with this approach and work with our GP practices on more significant areas medicines management e.g. medicines waste, adherence to medicines and repeat prescribing. Additionally, we will continue to develop individuals in the pharmacy team in line with national competency and capability frameworks, both for pharmacists and pharmacy technicians. All of this is in tandem with the gradual broadening of the role of the community pharmacist to provide advice and treatment for minor illness and pharmaceutical care more formally. 21 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

166 166 Immunisation Teams In light of changing professional duties affecting GP s, Health Visitor s and School Nursing teams and reflecting in particular the increased pressure on general practice and district nursing we are exploring dedicated immunisation teams. 2 pilot areas have been selected which will inform this wider work and will commence this year. Development of ANP role in Primary Care We have a tradition of growing our own staff and in secondary care we have long developed advanced nurse practitioners for a variety of roles. We noted that such staff often ended in primary care and as such we have encouraged joint training and ANP development for both secondary care and primary care. In several areas we are thus advocating for and training for wider use of ANP s in primary care. This will continue. Several salaried practices and GMS practices now have ANP s as key team members with others also utilising paramedic practitioners in acute roles. Evaluation of community roles All community teams are subject to review and change. The development of integrated teams and single point of access is complete in some areas and this will continue through to Such integrated teams include all previous community staff combined to allow excellent sharing of patient care issues and in time, the development of pull from hospitals and more opportunity to provide traditional hospital level care in the community Impact on outcomes It is challenging to directly provide more funding for community care without new money being available. However NHSH has a clear policy of enhancing community care by disinvesting in community and secondary care hospitals when the opportunity arises. Developments on Skye and in Badenoch and Strathspey are headline in this but more widely our steps towards cluster working, immunisation teams and community treatment centres alongside integrated teams with single point of access are all aligned. Making better use of the knowledge and skills of the pharmacy team in GP practices will better support GP practices around areas such as medicines management and repeat prescribing. Overall, the outcomes from this work are to reduce harm, waste/inefficiencies and clinical variation in prescribing and medicines management at levels ranging from that of the organisation right through to individuals. We aim to make systems and processes more efficient. Having pharmacy staff focus on medicines and medication review will improve the quality and safety of prescribing and will introduce better skill mix into GP practices, in particular freeing up GP time. The work being done to broaden and develop the role of community pharmacy aims to: 22 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

167 167 Improve patients access to medicines. Advance the provision of care through community pharmacies. Transfer appropriate care from GPs/OOH to community pharmacies. Progress monitoring Areas of work being done by the pharmacy team in GP practices is being collated and reported to Scottish Government in order to demonstrate the use of primary care monies. At a local level more detailed information is being collated about the outcomes of work being undertakenn e.g. changes made to individuals medication as a result of review by pharmacy staff. Financial measures are available to monitor gross spend across the sectors and this would allow monitoring against national strategies. Total bed estate, employed staff, and activity could also be monitored but we do not report on this routinely. HSC Delivery Plan Action/Milestone: Have increased health visitor numbers with a continued focus on early intervention for children through addressing needs identified through the Universal Health Visiting Pathway. As a result of this, every family will be offered a minimumm of 11 home visits including three child health reviews by 2020, ensuring that children and their families are given the support they need for a healthier start in life. NHS Highland Local Action(s) Submission by: Sally Amor Ongoing recruitment to Health Visitor Training posts. Development of Preceptorships for newly qualified Health Visitors. Work will continue to develop and implement the Universal Health Visiting Pathway. Resources will be developed and shared through the Bumps to Bairns website. Health Visitors will be trained in the use of the ASQ assessment tool which will be used as part of the Universal Pathway. The Health Visitor Record will be reviewed and revised in light of the Universal Pathway. 23 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

168 168 Impact on outcomes Children s needs will be assessed across the Universal Pathway with referral on for additional support and services as indicated. Parents and families will be supported and enabled in their parenting role. Mums with vulnerable mental health/low mood will be supported. Progress monitoring Uptake of the 6-8 week surveillance contact. Uptake of the month surveillance contact. Feedback from staff. Feedback from parents Hits on Bumps to Bairns website. Early Years Improvement Group. Education Children and Adults Committee Highland Council. Highland Health and Social Care Committee NHS Highland. HSC Delivery Plan Action/Milestone: Have commenced Scotland s first graduate entry programme for medicine. This will focus on increasing the supply of doctors to rural areas and general practices more generally. NHS Highland Local Action(s) Submission by: Emma Watson NHS Highland has committed to support Scotland s first graduate entry program for Medicine whose focus is on increasing the supply of doctors who have a positive experience and increased exposure to General Practice. Our action plans include:- Working in partnership with St Andrews, Dundee University, University of Highlands and Islands, NHS Tayside, NHS Fife, NHS Dumfries and Galloway, NHS Highland have contributed to and commented on the curriculum design and delivery plans, we are building a new UHI / NHS Highland clinical faculty to support the delivery of the ScotGEM project. Working with colleagues in the operational units to identify new capacity for undergraduates in the community e.g. new General Practices, Community Hospitals, and Nursing Homes. Reviewing our accommodation stock to ensure no Medical Student will be disadvantaged by a placement in NHS Highland. Developing a communications plan for the region so that new Science graduates are aware that this programme will be coming on stream in P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

169 169 Impact on outcomes Supporting delivery of the graduate entry medical school in region should translate to increased doctors working in the region in the future. Progress monitoring We will have a map of current capacity. We will identify an action plan to grow new educational capacity in primary care. We will understand what the current possibilities are to support medical student accommodation out with Inverness. We will support a communication strategy in local press to ensure local families are aware. that the graduate medical school will be recruiting in October of this year. HSC Delivery Plan Action/Milestone: Have implemented the recommendations of: The improving practice sustainability group The GP premises short life working group The GP cluster advisory group NHS Highland Local Action(s) Submission by: Dr Paul Davidson The improving practice sustainability group NHS Highland was a member on this group and contributed directly to the recommendations developed. We have also offered to be part of the ongoing delivery group but have had no feedback from the primary care division on this offer. Locally we are currently undertaking a gap analysis of the recommendations with a particular focus on our at risk areas, particularly rural. The GP premises short life working group The recommendations of this group have as yet not been made available to us due, we believe, to issues of commercial impact. However we have engaged in the request from the group to inform the primary care division of the kind of premises difficulties experienced in Highland and have split this into: Lease issues affordability, renovations, maintenance, exit criteria Development not able to enlarge consulting space, new/re-builds, property prices negative equity Shared space issues with board or other partners agreements 25 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

170 170 Recruitment mainly new partners not agreeing to buy in / take risk Legislation difficulty complying / cost of such The GP cluster advisory group NHSH has followed the advice of the primary care division and the BMA and has supported the formation of GP clusters across all of our practices. This is complete with all practice quality leads, cluster quality leads now in place. Quality improvement activity has begun, led by the cluster quality leads. We have also held two CQL development days and are progressing on leadership and quality improvement skill training for this group. All national guidance and the Scottish School of Primary Care briefing notes has been shared via a dedicated mailing list for CQL s and we are developing an intranet site for collation of advice and output from clusters for sharing. Impact on outcomes All 3 groups noted have a significant impact on general practice and we welcome the advice developed. It is yet to be seen what tangible change will be engendered but we are encouraged by the joint working and enthusiasm seen in the cluster approach. Progress monitoring For each group we will analyse and monitor in our GP technical group and share with the wider GP community via our committee structure and less formal networks. Cluster development is complete but ongoing change and development is expected with amalgamations possible. We will test ourselvess against the advice on resilience and await the output of the premises group and indeed the GMS contract negotiations. HSC Delivery Plan Action/Milestone: Have strengthened the multi-disciplinary workforce across health services. We will Agree a refreshed role for district nursess by 2017 Train an additional 500 advanced nurse practitioners by 2021 and Create an additional 1,000 training places for nurses and midwives by NHS Highland Local Action(s) Submission by: Pat Tyrrell Review of District Nursing Workload and Workforce will be completed by May Recommendations will be included within an implementation plan which will cover both Highland and Argyll and Bute HSC Partnerships. New models of Neighbourhood Care are being developed which will have district nursing at the centre. 26 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

171 171 Framework for Advanced Practice has been developed which include skills, education and supervision frameworks. Workforce planning is underway to identify the future number and type of Advanced Practice roles required in nursing, midwifery and allied health professions. Transition of undergraduate nursing programme from the University of Stirling to the University of Highlands and Islands first student cohort of 130 students due to begin in September Impact on outcomes More people able to live independently at home for longer. Improved experience of care. Fit for purpose district nursing workforce as part of wider integrated multi disciplinary community based teams. 24/7 community based neighbourhood teams. Increase in number and type of AP roles. Sustainable workforce. Progress monitoring NMAHP Workforce Planning and Development Group NHS Highland NMAHP Leadership Committee. HSC Delivery Plan Action/Milestone: Have increased the number of undergraduates studying medicine by 250 as a result of the 50 additional places in Scotland s medical schools introduced in. NHS Highland Local Action(s) Submission by: Emma Watson NHS Highland currently works with Highland Council, the Western Isles and Orkney Council education bodies to provide exposure to careers in health and care. We offer interest days building up to week long opportunities for senior school pupils across the region to gain work experience necessary for application to Medical School. School pupils are encouraged to make competitive applications. If they gain a place they are supported with personal statement and interview practice as well as input from all universities on their application process and what is particular to their course. This work aims to support fair access to medical school and free accommodation is provided to any school pupil who has to travel for more than 45minutes to reach Inverness. NHS Highland is working in partnership with Dundee University to support awareness of the A104 Gateway to Medicine course, where 27 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

172 172 S5 school pupils with a desire and the value set to become doctors, but perhaps not the grades due to opportunities available in their region, are given a place and if they pass the necessary academic standards in the end of A104 first year, they transfer directly in Medicine at Dundee University. In the coming year NHS Highland working in partnership with Skills Academy will be supporting sessionss in the Newton Rooms to P6 to S2 pupils to support them aspire to careers in Health and Care, again this will be part of our fair access work and link with our social responsibility employer status. Impact on outcomes This work has already proven effective at increasing the number of successful applicants to Scottish medical schools from the Highland region. Progress monitoring We will continue to monitor the progress of pupils who participate in Doctors at work. HSC Delivery Plan Action/Milestone: Have increased spending on primary care and GP services by 500 million by the end of the current parliament so that it represents 11 percent of the frontline budget. NHS Highland Local Action(s) Submission by: Gill McVicar Develop community infrastructure to enable more care in the community. Reconfigure day care centres and encourage community ownership. Review all care homes with a view to reducing the footprint and closure of small facilities. Review all hospital beds with a view to reducing both the number and footprint. Review use of RGHs including bed numbers and staffing models Continue business case development for SLSWR Continue work towards Initial Agreement in Fort William Co locate North teams on Dunbar site to reduce footprint and improve working environment. Explore co location for independent care at home providers in Thurso. Larachan House reprovisioning 28 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

173 173 Impact on outcomes Investment in community services to assist delivery on all key targets Improved estate and environment Ability to make cost savings Progress monitoring Area Management teams Senior Leadership Team Highland Health & Social Care Partnership Committee Key Area SUPPORTING NEW MODELS OF CARE HSC Delivery Plan Action/Milestone: Negotiate a new landmark GMS contract, as a foundation for developing multi-disciplinary teams and a clearer leadership role for GP s. NHS Highland Local Action(s) Submission by: Dr Paul Davidson NHSH do not have a formal role in the contractt negotiations between the primary care division and the BMA. We have also not been asked to contribute to any of the topics being discussed within that negotiation; we expect that to occur as the process matures. Impact on outcomes We expect significant impact from the negotiations on our GMS practices but cannot judge that at this stage. Progress monitoring The contract negotiations are continuing and are likely to set a stage for transformation rather than be a big bang change. We await the outputs of the negotiating group later in HSC Delivery Plan Action/Milestone: Test and evaluate the new models of primary care in every NHS Board, which will be funded by 23 million, and disseminate good practice with support from the Scottish School of Primary Care. These new models of care will include developing new, effective approaches to out-of-hours services and mental health support, and are essential for moving to a more person- and relationship- 29 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

174 174 centred approach to individual care across the whole of Scotland NHS Highland Local Action(s) Submission by: Dr Paul Davidson Across NHS Highland NHS Highland has a close working relationship with both GMS practices and our significant salaried practice sector. Traditionally our GP s have led and contributed to practice functions as well as wider community team tasks. That community role has been eroded by the 2004 contract. In recent years we have moved to integrated community teams with a single point of access and this structure again needs to include our general practitioners more fully. This is an ambition for the coming years and we will utilise our cluster development work and leadership role of our CQL s to enable this. We hope finally to reach a point where the integrated teams include all primary care clinicians and our GP s have an opportunity to lead alongside other senior staff. The advice from the Scottish School of Primary Care has been disseminated via our cluster network and we would welcome any additional funding to further implement such advice. We are in the process of redesigning our geographically challenging OOH s service and moving to a multidisciplinary model, community resilience and distal senior clinical support. We have adopted recommendations from the Being Here project and other healthcare systems such as Nuka in Alaska. Such work requires significant community engagement and is on-going. Impact on outcomes Through a fully integrated community team that includes general practice we hope to improve outcomes for patients and allow many more people to be treated at or near home in the future. By redesigning our OOH s service we aim to continue to meet our population need while also improving our resilience and addressing our financial and recruitment issues. Progress monitoring There is close monitoring of the progress of the OOH s project. Recent visits by Sir Lewis Ritchie and close operational unit and Board oversight should ensure targets are achieved and solutions found. The new GMS contract will, we hope, allow more clearly the leadership role of GP s as expert generalists to develop and integrate with our community teams. 30 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

175 175 NHS Highland Local Action(s) Submission by: IMFOU (Ros Philip) Within Inner Moray Firth Operational Unit Continue links to national Improving Practice Sustainability SLWG. Locally continue to develop our knowledge of the underlying issues that lead to practices experiencing difficulties. Promote signposting of patients to the most appropriate Primary Care services using tools such as Know Who to Turn To. Assist Practices in managing workload by review of Practice boundaries. Support Practices with informal patient list arrangements to manage workload and ensure patientt safety where recruitment difficulties dictate. Continue to share learning on benefits of multi-disciplinary Practice teams across Practices. Develop a Premises strategy to: - Improve access to a range of services and therapies linked to primary care in fit for purpose accommodation in an integrated facility. - Enhance GP recruitment. - Allow ongoing training of doctors. - Improve patient facilities. - Improve palliative and end of life care. - Improve joint use of resources (revenue and capital). Roll out of secondary/primary care interface work to reduce unnecessary GP involvement. Impact on outcomes The above should not only impact on workload in General Practice but also improve on local GP recruitment. By tackling the workload through patient direction, dealing with Practice boundary issues, flexibly addressing short term vacancies, interface working and working towards negating the need for capital input by GPs, we would expect to see a positive impact on the overall General Practice workforce. Progress monitoring No. of GP vacancies. No of other clinicians engaged in General Practice. Data collated on any boundary or informal list arrangements put into place and where benefits have been felt by Practices. Secondary/primary care interface activity data. Premises strategy progress. 31 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

176 176 NHS Highland Local Action(s) Submission by: Gill McVicar Within North & West Highland Operational Unit Implementation of NHS Highland Transforming Outpatients Programme particularly further exploration on virtual clinics. Review of ambulatory care at Belford Hospital Implementation of Out of Hours review fewer sites, multi professional approach. Community resilience approaches, support for First Responders and Rural Health and Social Care Support Workers Encourage community enterprise e.g. Care at Home, Day care. Consolidate GP Practices and link where possible to prevent professional isolation. Increased use of technology. Fit Homes clusters to be further explored. Increase capacity in care at home, expand working day for Integrated Teams, 7 day working for AHPs. Expansion of new roles such as Advanced Practitioners. Professional triage in Primary Care e.g. Advanced Nurse Practitioner. Implementation of the new Community Maternity Unit in Caithness. Impact on outcomes More people enabled to be at home Greater investment in primary and community services Leaner more productive organisation Progress monitoring Teams Local Management Senior Leadership Highland Health & Social Care Partnership Committee 32 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

177 177 HSC Delivery Plan Action/Milestone: Take forward the recommendations from the Review of Maternity and Neonatal Services and progress actions across all aspects of maternity and neonatal care. NHS Highland Local Action(s) Submission by: Helen Bryers for Heidi May The Best Start - A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland was published in January The policy recommends continuity of care and carer; multidisciplinary team work and integrated care; additional tailored support for vulnerable women; and a skilled and flexible workforce, with an emphasis on skills and competencies for remote and rural maternity care. The main areas for action are: 1. Redesign of maternity & neonatal services within a Hub and Spoke Highland model- this will include: Continuity of care from a primary midwife, midwifery and obstetric teams aligned and choice of birthplace. Multidisciplinary team working and integration with community hubs (Family teams). OOH maternity care and integration with OOH teams and collaborative working with RGH and community hospital emergency response teams. 2. Development and implementation of an electronic maternity record and use of technology to support practice. 3. Use of improvement collaborative work (MCQIC) and clinical governance processes to ensure the maternity & neonatal care is high quality, safe and effective. 4. Focus on services for vulnerable women and perinatal mental health. 5. Review of skills and competencies for staff working in remote and rural areas. Impact on outcomes These areas for action have yet to be approved by the Maternity & Neonatal Services Strategy & Co-ordination Committee (MNSSCC) and the work to take them forward has yet to be undertaken. Progress monitoring The Implementation Plan and progress will be monitored through the Maternity & Neonatal Services Strategy & Co-ordination Committee (responsible to the Clinical Governance Committee). 33 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

178 178 HSC Delivery Plan Action/Milestone: Launch Scotland s Oral Health Plan, following consultation, as part of a comprehensive approach to modernise dentistry and improve the oral health of the population through a prevention and early intervention approach NHS Highland Local Action(s) Submission by: J Lyon (Clinical Dental Director) Detail of Scotland s Oral Health Plan is yet to be shared with NHS Highland however the local implementation plan will involve engagement with dental professionals, other healthcare staff /agencies and local communities. It is difficult to provide further detail until the vision for Scotland s Oral Health plan is available however partnership working between dental professions is key to successful delivery of this plan. Ongoing engagement with General Dental Practitioners (GDP) as the NHSH rebalancing primary care dental services project progresses, gives a foundation for future engagement with General Dental Service providers. The role of the NHSH GDP lead is important in this process. Ongoing Public Dental Service (PDS) provision throughout the area to reduce inequalities and move forward the oral health improvement agenda should be significant; the current 2020 vision for the NHSH PDS gives a firm starting point for taking this forward. Impact on outcomes Successful engagement and delivery of the Oral Health Plan, should deliver sustainable General Dental Services, with professional quality leadership, with appropriately trained workforce. Oral Health inequalities should be reduced, patients will be provided with Oral Health Risk Assessments on an ongoing basis. New Technologies and Techniques will be incorporated in the NHS Dental Services framework. Potential for enhanced dental service provision is anticipated. Progress monitoring Engagement of the NHS Highland Area Dental Committee will deliver local scrutiny of Oral Health Plan delivery, this committee meets regularly and membership is now wide-ranging. Monitoring via the current NHSH Dental Governance model on an ongoing basis is recommended along with Involvement of the Area Dental Committee. Monitoring engagement with all dental professionals is fundamental. Building on the existing local dental structures and reporting structure is a suitable structure to monitor delivery of the Oral Health Plan locally. 34 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

179 179 HSC Delivery Plan Action/Milestone: Have rolled out the Family Nurse Partnership mothers. NHS Highland Local Action(s) Submission by: Sally Amor FNP in the Highland Health and Social Care Partnership is funded by the Scottish Government and delivered through the Care and Learning Service, Highland Council. Conclude funding discussions with Scottish Government with regard to funding for 2017/18 for the Highland Health and Social Care Partnership. Recruit to posts to ensure rolling programme of FNP within the current geography. (FNP) programme to provide targeted support for all eligible first-time teenage Work with Scottish Government to look at funding options and service models to achieve the full reach across the Highland Health and Social Care Partnership. Begin a dialogue with Scottish Government for the delivery of FNP in Argyll and Bute Health and Social Care Partnership. Share learning from FNP programme with universal health visiting services, namely motivational interviewing and strengths based approaches. Impact on outcomes Sustained delivery of the current FNP service through Care and Learning, Highland Council. Improved outcomes for children and parents participating in the current programme. Progress monitoring Fidelity outcomes as per the FNP programme. FNP Local Project Board. Education Children and Adults Committee. NHS Highland Board. 35 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

180 IMPROVE SECONDARY AND ACUTE CARE Key Area REDUCING UNSCHEDULED CARE HSC Delivery Plan Action/Milestone: Complete the roll out of the Unscheduled Care Six Essential Actions9 across the whole of acute care. Through improving the time-of- in hospitals, we will day of discharge, increasing weekend emergency discharges and a more effective use of electronic information enhance a patient s journey at each stage through the hospital system and back into the community without delay. Undertake a survey on admission and referral avoidance opportunities. This will give a strong evidence base to target modelling for how to reduce unscheduled care through integrated primary and secondary care services. NHS Highland Local Action(s) Submission by: Gill McVicar Patient Flow Continue development of Integrated Community Teams with delegated budgetary responsibility to avoid hospital admission and support early discharge. Continue to co-locate where possible and ensure good communication tools where this is not possible to facilitate daily huddles. Daily management and standard work further developed. Continue development of the role of Health and Social Care Support Worker. Strengthen the role of Health and Social Care Coordinator and Single Point of Access. Embed in-house Care at Home servicess in integrated teams, expand capacity. Teams using Enablement approach in all cases to embed discharge to assess. Development and support for GP Clusters, to enable and support more options for maintaining people in their own homes. Intensive work on anticipatory care planning for those most at risk of admission, further development of the role of advanced Practitioners Social Workers, AHPs, Nurses, Pharmacists, working across professional boundaries. Continued development of Personal Outcome Plans. Continued flexible and creative use of SDS. Work to increase the hours covered by the integrated team to 24/7 to allow for care in the home on both scheduled and unscheduled basis. Explore possibility of Hospital at Home level care. Continued development and standard work for community virtual ward. 36 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

181 181 Continue to seek to commission Care at Home from third and independent sectors. Develop the range of options for end of life care, to enable people to die at home if that is their wish. Continue to develop flexible use of care homes, step up and step down beds for intermediate care. Assessment Units development for ambulatory care to avoid admission. Clinical decision support for Primary Care Teams. Promotion of and support for self management, working closely with Let s get on with it together. Expand use of technology to support those living with long term conditions. Review use of all day centres with a view to more flexible, imaginative and community run facilities. Review all packages of care for people with a learning disability Review and develop potential opportunities for different models of sleep over support in line with Neighbourhood care. Explore more supported extra care and Fit housing clusters. Explore better use of vacant local housing as adapted facilities for rehabilitation. Use of frailty tool in all hospitals. Daily dynamic discharge. Criteria led discharge. Home bundle roll out and support for use. Improve communication by use of voice recognition software for immediate reports to GPs. Continued focus on SPSP in hospitals to prevent harm. Impact on outcomes Reduction in emergency admissions Reduction in occupied bed days Discharge within 72 hours of being medically fit Reduction in falls with harm Reduction in hospital acquired infection Prevention of avoidable admission Early supported discharge Reduced delayed discharge 37 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

182 182 Progress monitoring Daily team huddles Run charts Daily management and Leader standard work Weekly Senior Leadership Team Wall Walk Weekly NHS Highland Senior Leadership Walll Walk Highland Health and Social Care Partnership Committee NHS Highland Local Action(s) Submission by: Donna Smith, Head of Planning & Performance Effective use of electronic information in hospitals a) Roll out Ward View across all hospitals (excl. Mental Health) in NHS Highland to allow visual control of patients. b) Roll out Info View across all hospitals (excl. Mental Health) in NHS Highland to provide a NHS Highland holistic of patient flow. c) Seed the Social Care system with CHI Numbers to allow the integration of social care data with health data via a client portal solution. d) Consolidate disparate GP information into a GP repository, and with agreement of GPs via an information sharing agreement, incorporate this data into the client portal. e) Introduce a community solution to integrated teams based within Inverness to improve the flow of information across the health sectors. f) Examine options for the introduction of electronic forms to replace paper records across secondary care and investigate options for the scanning of physical case records to make them available via the client portal. g) Examine ways of early identification of the Frail Elderly to ensure that they are identified prior to admission and then clearly on Ward View to allow appropriate measures to be taken to avoid unscheduled activity. h) ROTT rate (removal other than Treatment) information is currently available to the Operational Units and can form the basis for a survey of referral avoidance opportunities. The Clinical Dialogue module of SCI Gateway provides support to integrate primary care and secondary care services to avoid referrals. i) Investigate options with the suppliers on how we can provide information on activity flowing through the Acute Assessment Units and the avoidance of admission. 38 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

183 183 Impact on outcomes Increasing efficiency and effectiveness of clinical time. Improved availability of information to improve clinical decision making. Reduction of inappropriate admissions particularly for the frail elderly pathway. Progress towards the achievement of a fully electronic patient record. Progress monitoring Actions a g above will be monitored through the ehealth Delivery Group and via an annual update to the Board. Actions h and i form part of the High Level Value Stream (HLVS) work of the Unscheduled Care Project and will be monitored through that project. Frail Elderly Audit this information will be monitored through the HLVS for Adult Social Care and actions taken and developed through this project. All of the actions will be evaluated by the Senior Management Team for the benefits being achieved within NHS Highland. Key Area IMPROVING SCHEDULED CARE HSC Delivery Plan Action/Milestone: Put in place new arrangements for the regional planning of services. The National Clinical Strategy setss out an initial analysis of which clinical services might best be planned and delivered nationally and regionally, based on evidencee supporting best outcomes for the populations those services will serve. This is a critical first step towards strengthening population-based planning arrangements for hospital services, working across Scotland. NHS boards will work together through three regional groups. In 2018, the appropriate national and regional groups will set out how services will evolve over the next 15 to 20 years, in line with the National Clinical Strategy. NHS Highland Local Action(s) Submission by: Rod Harvey NHS Highland will work through the North of Scotland Planning Group in collaboration with other regional Health Boards to address vulnerable services with either low volume but high impact activity or core high volume services that as a result of recruitment and retention difficulties are difficult to sustain. The initial area of focus for 2017/18 will be the development of regional radiology services with the aim of sharing out of hours emergency work an in-reach service for oral and maxillofacial surgery upper GI cancer surgery 39 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

184 184 Urology services. Impact on outcomes These developments will lead to more reliable, timely and equitable service provision and for the low volume activity should provide better outcomes. There should be a reduction in spend on outsourcing work for radiology. Progress monitoring Monitored through NOS Planning Group and in terms of outcome through current access waiting time targets and radiology reporting performance. HSC Delivery Plan Action/Milestone: Reduce cancellations and private care spend in scheduled care by rolling out the Patient Flow Programme from the current pilots across all NHS Boards. The Programme builds on the success of previous programmes such as Day Surgery, Enhanced Recovery for Orthopaedics and Fracture Redesign by increasing national and local capacity to use operations management techniques to improve care for patients. Four pilot boards are implementing improvement projects covering emergency and elective theatre operations, elective surgery planning and emergency medical patient flow. As this is expanded, it will introduce more responsive and efficient secondary care and reduce wastage and the unnecessary use of resources. NHS Highland Local Action(s) Submission by: IMFOU (Katherine Sutton) Raigmore Hospital Operational Division within the Inner Moray Firth Operational unit is fully engaged with the Scottish Government to support improved performance relating to the delivery of Scheduled Care and the Treatment Time Guarantee. To support improving patient journeys through secondary care the following actions will be progressed as a part of the Raigmore Hospital Transformational Change Delivery Plan 2017/18 as follows: Continued provision of the Elective Orthopaedic Ring Fenced Ward. Introduction of Short Stay Ring Fenced Ward for a range of medical and surgical specialities. Introduction of an administration system to enhance elective scheduling and ensure best use of all available capacity. Development of high quality patient information for elective patients. Training and development for nursing staff to ensure a wider range of generic skills can be supported. Continued progression of improving theatre efficiency programme by the following areas of focus. 40 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

185 185 - Reducing cancellations due to clinical, patient related, bed related and equipment related reasons. - Reducing late theatre starts and over runs. Continued Enhanced recovery programme. Continuing to enhance Fracture re-design pathways. Impact on outcomes Continuing improvement in TTG performance working towards compliance with TTG. Reduction in theatre cancellations for non-clinical reasons. Progress monitoring The Actions above will be reviewed through the Raigmore Hospital Formal Senior Management Team. Highland Health and Social Care Committee HSC Delivery Plan Action/Milestone: Complete investment of 200 million in new elective treatment capacity and expanding the Golden Jubilee National Hospital. Overall, this investment will ensure that there is high-quality and adequate provision of elective care services to meet the needs of an ageing population. NHS Highland Local Action(s) Submission by: Donna Smith, Head of Planning & Performance Develop the Business Case for our agreed Elective Care Centre to deliver elective Ophthalmology and Orthopaedic services in a safe, effective and efficient way, working in collaboration with the University of the Highlands & Islands, the Highland & Islands Enterprise, and our regional partners. Impact on outcomes Improved access times for both specialities for relevant activity. More NHS Highland residents able to be treated within the Board area. Improved recruitment and retention of staff. Integration and collaboration with enterprise and education. Progress monitoring Highland Elective Care Centre Project Board North of Scotland Regional Planning Group 41 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

186 186 HSC Delivery Plan Action/Milestone: Complete investment of 100 million in cancer care to ensure: earlier detection with more rapid diagnosis and treatment; more and better care during and after treatment, taking account of what matters most to people with cancer; increased entry to clinical trials/research; and an evidence driven cancer intelligence system for clinicians and patients with accesss to near-to-real time information through care pathways. Addressing cancer in such a comprehensive way will target one of the critical health issues facing the population. NHS Highland Local Action(s) Submission by: Rod Harvey NHS Highland will promote public uptake of the established cancer screening programmes for breast, bowel and cervical cancer and raise awareness to encourage early self referral for other cancers presenting symptomatically. During 2017 we will provide direct access for general practitioners to selected cross-sectional imaging according to clinical guidelines to facilitate more rapid diagnosis of suspected cancer by avoiding the delay of waiting for an outpatient attendance where the diagnostic pathway is well defined. See also Section 3: National Standards for more detailed activities. Impact on outcomes Improved overall cancer detection rates at an early stage where treatment may be possible or simpler. Better access to specialist services as patients who test negative in primary care will not require a secondary care appointment. Improved performance against 30 day diagnostic and 60 day treatment targets Progress monitoring Screening performance will be monitored through regular reports to the Clinical Governance Committee. 30 and 60 day diagnosis and treatment cancer performance monitored through senior leadership team. Key Area IMPROVING OUTPATIENTS HSC Delivery Plan Action/Milestone: Have reduced unnecessary attendances and referrals to outpatient services through the recently-published Modern Outpatient Programme, drawing on the existing Delivering Outpatient Integration Together (DOIT) Programme and other activities such as the Technology Enabled Care Programme to give GPs greater access to specialist advice to reduce the time people wait to get appropriate treatment use clinical decision support tools to reduce the amount of time people wait to get the right treatment; 42 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

187 187 reduce the number of attendances for people with multiple issues through a holistic approach to their support and care; enable GPs to have more access to hospital-based tests so that people can be referred to the right clinician first time; and facilitate more return or follow-up appointments in non-hospital settings through virtual consultation from their own home. NHS Highland Local Action(s) Submission by: Rod Harvey Across NHS Highland By August Provide direct access for GPs to appropriate cross sectional imaging. By September Encourage the uptake of telephone/vc consultations: we intend to expand the existing use of telephone consultations as well as VC consultations. By December Identify and prioritise new areas for guideline development. By March Develop an Advice and Guidance portal in SCI gateway enabling type communication between GP. The conversation will automatically be uploaded to the patient s record. By March Review existing Shared Clinical Guidelines increasing guidance on definitive treatment. By March Develop Therapeutic Portal. Impact on outcomes Access to cross sectional imaging: GPs currently have access to a number of radiological investigations however do not have access to CT or MRI. We intend to develop referral guidelines and pathways, initially to access cross sectional imaging for patients with chronic headache. Telephone / v.c. consultations: Increased uptake of this established service will reduce the need for personal attendance in hospital and allow a more equitable service to be provided directly to the patient irrespective of location. The use of these consultations will slightly reduce demand on medical staff time and substantially reduce the resource required for the overall clinic overhead and administrative support. New areas for guideline development: there has been a variation in development in clinical guidelines between specialities. These guidelines are hosted on the NHS Highland intranet. We intend to develop more clinical guidelines whichh support GPs managing patients in the community. Advice and Guidance : this will reduce the need for patients to travel to an outpatient department if a GP and consultant can have a documented dialogue and establish a treatment plan for the patient without the need for the patient to be seen at an out-patient clinic. Review existing Shared Clinical Guidelines : many of the existing guidelines culminate in a point when the patient is then referred on to secondary care. Through guideline review, we would anticipate definitive treatment being the outcome rather than referral to 43 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

188 188 outpatient clinic. This may be through provision of increased access to investigations (see later). Therapeutic Portal: The Highland Therapeutic Portal aims to provide access to information for patients, suitable therapeutics guidance for health care staff and allow public view of NHS Highland processes around choice of medicines. The Therapeutic Portal will host the NHS Highland Formulary, clinical policies, procedures and guidelines, Junior Doctors Handbooks and locally developed patient information. It will also provide links to appropriate outside websites and access to specific clinical information, for example for staff in remote and rural areas and for inductionn training. This electronic platform, accessible by the public and by NHS staff on various devices, will be hosted by NHS Education for Scotland (NES) as part of the development of their NES Handbook thus leaning towards uniformity of design across Scotland. Progress monitoring Outcome: a reduction in demand for new consultant outpatient clinic consultations. Advice and Guidance : record activity on portal. Telephone / v.c. consultations: develop a means of accurately recording telephone and v.c. consultation activity on Trakcare PMS. NHS Highland Local Action(s) Submission by: IMFOU (Katherine Sutton) Within Raigmore Hospital Raigmore Hospital Operational Division within the Inner Moray Firth Operational unit is fully engaged with the Scottish Government to support the delivery of Out-Patient Services and performance against Out-Patient Waiting Times To support improving patient journeys through secondary care the following actions will be progressed as a part of the Raigmore Hospital Transformational Change Delivery Plan 2017/18 as follows: Raigmore Hospital is engaging with the national Access Support Team to improve delivery of timely access to services and with the Modernising Out-Patients programme during 2017/18. Services are already engaging with the DOIT programme and this transformational programme will continue to be progressed. Key areas of focus will be Enhancing access to GP specialist advice. Introduction of Clinical Decision Support access for GPs. Redesign of pathways for patients with multiple issues. 44 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

189 189 Increasing access for GPs to hospital based tests. Increasing the number of review appointments delivered by non face to face routes. Making best use of technology in delivering out-patient services. Reducing the amount of clinical time wasted as a result of travel. Ensuring clinical capacity is maximised by reducing DNAs, CNAs and lost slots. Ensuring efficient information flow pathways within the out-patient setting. Reviewing booking and scheduling practices. Reducing review appointments to ensure timely access for patients with on-going chronic conditions. Ensuring robust waiting list management and information governance for out-patients. Impact on outcomes Continuing improvement in OP performance working towards compliance with Out-Patient waiting times across all speciality areas. Reductions in the number of follow-up appointments per patient. Increases in the number of telephone and video-conference consultations proportionately. Reductions in the number of overall new referrals. Reduction in cost per patient episode. Progress monitoring The Actions above will be reviewed through the Raigmore Hospital Formal Senior Management Team NHS Highland Local Action(s) Submission by: A & B HSC Partnership Within Argyll & Bute Mental Health 24/7 access by telephone or VC to Consultant Psychiatrist or Trainee. Generic Community Mental Health trained nurses who can deliver multiple therapies ensuring person centred care. Home visits offered to patients with memory difficulties. VC consultations offered especially to those living on Islands. On Line CBT via Primary care setting (GP surgeries) to be introduced and tested. Medical & Surgical Specialties One stop Stroke clinic. Direct access for Primary care. One stop Chest pain clinic. Heart Failure pathway Introduction of BNP testing as a pilot within Oban & Lorn, for GP s. 45 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

190 190 Self management of chronic Diseases. Diabetes introduction of Bertie courses, introduction of technology Florence to assist with Glycaemic control & reduce DNA s to reviews. Direct access for GP s to Endoscopy Upper GI & Flexible Sigmoidoscopy. Direct access for Radiology services. Introduction of NHS 24 MATS service for musculoskeletal problems Introduction of a Physiotherapist clinic within primary care setting. Development of Advanced Nurse practitioners, working alongside GP s to prevent unnecessary hospital admission. Supported by ICF funding, pilot within Lorn Medical Centre. The majority of secondary care outpatient appointments for residents of Argyll & Bute are undertaken in NHSGG&C or at local outreach clinics. Work is underway to scope the number of return attendances within NHSGG&C to develop plans for specialties most under pressure including Obstetrics & Gynaecology - A redesign to ensure patients are directed to the appropriate services to reduce the number of appointments required. Test models of triage to reduce level of internal referrals due to increasing subspecialisation. Utilise existing local sexual health services to prevent unnecessary referrals for basic procedures and establishing a local obstetric scanning service. Dermatology - Tele-vetting has been established in one locality and a standardised process will be rolled out across existing outreach services within Argyll & Bute. GP s have been provided with cameras to enable them to send pictures for advice only or to accompany the referral to allow for better vetting and more cases able to be managed within primary care with consultant advice. Ophthalmology - Opportunities for shared care with local optometrists are being explored to address increasing an referral rate and a low discharge rate. Orthopaedics/MSK Triage Continued work in MSK Triage service to ensure the Extended Scope Physiotherapists have access to refer for MRI and training for injection therapy. Oncology - An attend anywhere test of change pilot is being undertaken in one locality jointly with GGC for oncology patients to enable them to link in with their consultant remotely from their own home, reducing travel for patients. Impact on outcomes Increased multi disciplinary management, particularly within primary care with consultant decision support. Increased self management. Reduced referrals into secondary care. 46 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

191 191 Faster access to services where required through appropriate triage. Reduced travel for patients. Optimal clinical outcomes. Progress monitoring Monitor the use of technology and reports available for technology lead Lorn & Islands Hospital planning for the future group. Care & governance meetings Locality management teams. Locality planning groups Clinical groups PMS Trakcare Number of referrals/reductions Number of return attendances & DNAs Reductions in onward referrals Waiting lists Patient experience & outcomes FOCUS ON REALISTIC MEDICINE Key Area STRENGTHENING RELATIONSHIPS BETWEEN PROFESSIONALS AND INDIVIDUALS HSC Delivery Plan Action/Milestone: Refresh our Health Literacy Plan, Making It Easy, to support everyone in Scotland to have the confidence, knowledge, understanding and skills we need to live well with any health condition we have. NHS Highland Local Action(s) Submission by: Hugo van Woerden The Highland Health Sciences Library service has recently been involved with the Health Literacy Plan. This process involved a meeting with members of the local NHS clinical and library staff (Highland and Grampian) and the NES Knowledge Services team implementing the strategy. The document is available electronically via the following link: 47 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

192 192 Impact on outcomes Support and give people confidence and better understanding to being able to look after and improve their own health and wellbeing and live in better health for longer. Contribute to reducing health inequalities. More equitable access to services. Support the national agenda on Realistic Medicine. Progress monitoring Feedback from professionals and service userss Future reviews of the Highland Health Sciences Library service HSC Delivery Plan Action/Milestone: Review the consent process for patients in Scotland with the General Medical Council and Academy of Medical Royal Colleges and make recommendations for implementation from 2018 onwards. NHS Highland Local Action(s) Submission by: Clinical Governance Consent policy has undergone review over recent years and will continue to be reviewed in line with national guidance and best practice. Current consent processes are being reviewed within NHS Highland to inform best practice in implementation of standardised procedures in 2017/18 A review of current provision of written patient information was undertaken /2017 An RPIW for the Consent Process to provide a new consent form and provision of written patient information is planned during 2017 with a view to rolling out new consent process from April Impact on outcomes Implementation of revised consent policy, procedures and processes will enable improvements to be made around consent, enhancing information provision and engagement with patients and ensuring compliance with relevant guidance and legislation. Progress monitoring Patient surveys will be undertaken to ascertain improvements in the consent process and information provision. Complaints and litigation with consent issues at the centre will decrease. Audit of consent process across specialities to be developed. 48 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

193 193 HSC Delivery Plan Action/Milestone: Refresh the Professionalism and Excellence in Medicine Action Plan and align high-impact actions to realistic medicine. NHS Highland Local Action(s) Submission by: Rod Harvey NHS Highland supports clinicians in new leadership roles to undertake the Leading with Purpose programme, which enables them to further develop their knowledge and skills as NHS Leaders and Managers. NHS Highland delivers a Mentoring Training Programme and has a mentor programme to support trained medical staff at choice points in their career. NHS Highland delivers high quality Faculty Development Courses to all clinical educators across the region. NHS Highland delivers bi-annual medical education conferences, this year an international conference, examining how strengthening excellence in medical education supports multidisciplinary workforce to remains in rural area. NHS Highland brings together all those in a clinical leadership role to an informal breakfast meeting every eight weeks or so, where there is an opportunity to support each other on challenging issues and to learn or revisit useful skills. NHS Clinical Directors meet on a monthly basis, providing support to and gaining support from the Board Medical Director where challenging service pressure issues are discussed alongside professionalism. Impact on outcomes By strengthening clinician s awareness of NHS management roles and giving them the tools to deliver in roles we will provide an enabling environment where clinicians can be involved in making changes to service delivery. Progress monitoring Currently attendance at meetings is recorded. A survey of those participating could be undertaken to evaluate impact on the individual. Rolling out changes discussed at sessions- e.g. reducing OP attendance. Identify how many individuals have taken up mentoring. 49 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

194 194 Key Area REDUCING THE UNNECESSARY COST OF MEDICAL ACTION HSC Delivery Plan Action/Milestone: Incorporate the principles of realistic medicinee as a core component of lifelong learning in medical education and mainstream the principles of realistic medicine into medical professionals working lives at an early stage. NHS Highland Local Action(s) Submission by: Rod Harvey/ Gill McVicar NHS Highland has a significant history in incorporating LEAN principles in the delivery of high quality care. Clinicians are invited to participate in Rapid Process Improvement Weeks gaining new skills to enable them to effect change by removing waste form the system in which they work. Other ongoing work includes:- Review of existing end of life care - carry out Rapid Process Improvement Workshop Development of 24/7 Integrated teams Development of Virtual community wards Develop work with Marie Curie, review Service Level Agreement. Develop work with Highland Hospice on virtual hospice, clinical decision support and support for care homes GP Clusters Prescribing examples Public awareness raising events NHS Highland clinical compact supports clinicians to deliver evidence based care aligned to realistic medicine. Impact on outcomes By engaging more clinicians in RPIW we will empower clinicians to make changes. By implementing the NHS highland clinicians compact we will support clinicians to deliver realistic medicine. More people involved in choices about their own care. More people understanding the implications and potential impact of treatments. Improved quality of life for people at end of life. 50 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

195 195 Progress monitoring We will build in to the RPIW planning process a question could a junior doctor contribute to this process, if the answer is yes a doctor in training or CDF will be allocated to the RPIW and supported to attend. In clinical RPIW we will continue to ensure a senior doctors is part of the away team The RPIW team will keep a run chart of clinician engagement. We are in the process of rolling out the cliniciann compact starting with senior clinicians feeling comfortable using it together in meetings. In our implementation plan once CDs feel confident using the compact we will start using it to inform agendas for meetings and then in 121s. We will record at clinical directors meeting who is using the compact. Daily at team level Weekly by managers Weekly by SLT Highland Health & Social Care Partnership Committee HSC Delivery Plan Action/Milestone: Develop a Single National Formulary to further tackle health inequalities by reducing inappropriate variation in medicine use and cost and reduce the overall cost of medicine. NHS Highland Local Action(s) Submission by: Ian Rudd, Director of Pharmacy The NHS Highland Formulary Pharmacist is working with Scottish Formulary Network colleagues in other health boards under the auspices of the Area Drug and Therapeutic Committee Collaborative of Health Improvement Scotland (ADTCC HIS) to deliver a single national formulary. Argyll and Bute HSCP will be included within work being done by the pharmacist in NHS GG&C as A&B HSCP adheres to the NHS GG&C formulary. 51 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

196 196 Impact on outcomes The Scottish Government anticipates that a national formulary will reduce the cost of medicines in NHS Scotland. Progress monitoring At this time ADTCC HIS is responsible for reporting on this national initiative. NHS Highland will begin reporting on progress once the project has reached a point where it impacts on practice in the board. NHS Highland Local Action(s) Submission by: Gill McVicar Cost benefit analysis on introduction of new drugs (mainly carried out at Board level, implementation locally) Review use of biologics (mainly hospital, but relevant to RGHs) Continued development of role of Advancedd Pharmacist Practitioners to improve quality of medication review in GP practices (in line with Prescription for Excellence and Primary Care Development) Continued role expansion of Primary Care Clinical Pharmacists with a focus on polypharmacy reviews in frail older population (in line with Prescription for Excellence) Medication reviews (levels 1, 2 and 3) Continuation of work on polypharmacy and implementation in line with revised national guidance (early summer ) and strategy of Effective Prescribing Programme overlap with Realistic Medicine Medicines for HIV treatment regimen rationalisation, use of generics (when available), move to Homecare if appropriate and acceptable to patient Specific projects in collaboration with GP Clusters and GP/Community Pharmacy contractors, for example - Cost saving switches (to Formulary choices) being delivered by GP practices - Maximise generic realisation (especially pregabalin and rosuvastatin), potentially through a community pharmacy scheme (in development) - Review first-line prescribing in asthma and COPD to increase the proportion of prescriptions accounted for by Formulary first choices - Peer review in clusters of National Therapeutic Indicators (NTIs) and Additional Prescribing Measures (APMs) - Antimicrobial husbandry (also covered by NTIs) - Cholinergic load - overlap with Realistic Medicine - Reducing variation (Intermountain) project initially testing for polypharmacy reviews and antibiotic prescribing, with plans to expand to other areas - Tele-health project to deliver improved quality of medication reviews in dispensing GP practices 52 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

197 197 Impact on outcomes Decrease in iatrogenic illness as a result of polypharmacy and other medication reviews. A reduction in falls consequent to reviews of patients who have had falls or who are at risk of falls, e.g. due to cholinergic load. Reduction in admissions due to contribution to improved management of difficult clinical conditions and patients with multiple morbidities. Greater cost-efficiency as a result of consistent implementation of Board prescribing policies. Savings as a result of targeted and fully implemented prescribing projects in GP Clusters. Reduced risk of health acquired infections as a result of improved appropriate use of PPIs and antibacterials. Improved antimicrobial husbandry. Progress monitoring Many measurements are retrospective and most appropriately measure quarterly. Those with a high cost value (e.g. generic changes) will be reported monthly. Monitoring cost per 1,000 patients (including cost per 1,000 treated patients as new data become available) by practice, Cluster and Operational Unit, with reference to NHS Highland & national rates as appropriate. Medication reviews, all levels (1, 2 and 3) ncluding polypharmacy record number of reviews and type quality to be assured by standardised processes through reducing variation (Intermountain) project. Generic prescribing monitor realisation of savings against for newly available generic medicines and identified target medicines using PRISMS. HIV medicines continued monitoring of overall costs and cost per patient treated. Antimicrobial husbandry prescribing rates of antibacterials and antibacterials associated with CDI at practice level (aiming to reduce mean to lowest quartile for NHS Highland), number of CDIs. Reduction in cholinergic load. On-going monitoring of NTIs and APMs. Review of SPARRA data. 53 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

198 PUBLIC HEALTH IMPROVEMENT Key Area SUPPORTING NATIONAL PRIORITIES HSC Delivery Plan Action/Milestone: Set national public health priorities with SOLACE and COSLA that will direct public health improvement across the whole of Scotland. This will establish the national consensus around public health direction that will inform local, regional and national action. NHS Highland Local Action(s) Submission by: Hugo van Woerden We will fully participate in the consultation and agenda setting process for establishing the national Public Health priorities. We will also continue to establish strong and effective population based regional planning and delivery of services during 2017/18. These aspects will be more fully developed as furtherr national guidance is published. Impact on outcomes Increased awareness by public health teams of the necessitation to meet the increased need for regional/national working and involvement in regional services. People will be able to look after and improve their own health and wellbeing and live in better health for longer Contribute to reducing health inequalities Support the national agenda around Realistic Medicine Progress monitoring Adhering to the timescales outlined in the consultation. Through national, regional and local meetings. During meetings and within job plans. Key Area SUPPORTING KEY PUBLIC HEALTH ISSUES HSC Delivery Plan Action/Milestone: Continue delivery of the ambitious targets set out in our 2013 Strategy, Creating a Tobacco Free Generation, including reducing smoking rates to less than 5 percent by We will implement legislation to protect more children from second-hand smoke and reduce smoking in hospital grounds. 54 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

199 199 NHS Highland Local Action(s) Submission by: Susan Birse Roll out and monitor the Florence text messaging service within the Community Pharmacy smoking cessation programme throughout NHS Highland. Deliver refresher training to all Community Midwives in smoking cessation brief advice and CO monitoring to all pregnant women at all visits. Continue and develop the Highland Smokefree Service ensuring advisers deliver a whole centred approach in all areas but particularly areas of deprivation. Implement and develop a robust smoking cessation service in HMP Inverness providing adviser time, training for prison staff and consider prisoner peer support. Continue to work with responsible e-cigarette retailers to ensure smokers receive appropriate advice and the option of referral to the Highland Smokefree Service. Continue to develop an e-cigarette friendly Smokefree Highland service. Deliver 1:1 smoking cessation training to named mental health staff. Refresher smoking cessation brief advice training to mental health hospital staff. Develop and embed a more robust 24/7 service to inpatients within acute setting. Develop and support a smoking cessation service within outpatients. Roll out the Highland Smokefree Sport initiative throughout the Highland area and throughout other sports. Review the lesson plans relating to tobacco within the GLOW site used in all schools in Highland... Work with University of Highlands and Islands to establish a programme for smoking prevention. Explore the possible roll out of ASSIST in secondary schools in Highland. Continue to develop and promote the Highland Smokefree Homes and Cars project ensuring the protection of second-hand smoke in children, including pregnant women. Continue training and updating Community Midwives to provide them with the confidence and tools to speak to pregnant women on the dangers of second hand smoke. Support HMP Inverness to work towards a smoke free environment. Impact on outcomes Improved access to smoke free service ensuring all smokers have the opportunity to receive the support to stop. This supports the National Tobacco Strategy Creating a Tobacco Free Generation. Reduced uptake of smoking in young people i..e. age P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

200 200 Prevent the dangers of second hand smoke. Progress monitoring Monitor referral, successful 1 month, 3 month and 12 month quits through the ISD database. Monitor NRT prescribing. National publications such as SALSUS. Monitor numbers of smokefree pledges along with numbers of children within the household. Number of referrals from community midwives. Smokefree prison. HSC Delivery Plan Action/Milestone: Refresh the Alcohol Framework building on the progress made so far across the key areas of Reducing the harms of consumption Supporting families and communities Encouraging positive attitudes and choices Supporting effective treatment. NHS Highland Local Action(s) Submission by: HADP Reduce harm related to alcohol consumption Influence licensing practice to reduce the availability of alcohol. Extend delivery of ABI s to deprived communities and harder to reach groups. Promote whole population approaches including minimum unit pricing. The public health agenda will continue to be assertively driven through a refreshed overprovision policy and collaboration with members of the licensing forum to offer low and no alcohol options in a range of premises. A work programme will be developed to target deprived communities and harder to reach groups. Whole population approaches will be proactively and consistently promoted in all presentations, collaborations and alcohol related training delivery. Support Families and Communities Embed GIRFEC and implement the universal health visiting pathway. Extend peer support / mutual aid/ advocacy for children and families. 56 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

201 201 Highland Getting Our Priorities Right (GOPR) practitioner guidance will be reviewed to support embedding of GIRFEC and ABI training targeted at Health Visitors to support implementation on the universal pathway. Relevant training will be targeted at early years workers to aid early identification of children affected by parental substance misuse (CAPSM). Partnership working will be developed with SMART Recovery U.K. to develop mutual aid groups for families to support recovery and tackle loneliness and isolation. Support will be provided to innovative community asset building initiatives that give children and young people a voice in recovery processes e.g. Catalyst Project. Encourage Positive Attitudes and Choices Embed prevention in holistic strategies promoting healthy development and wellbeing across the life course. Support generic and targeted diversionary / positive activities. Deliver prevention activities that are family-inclusive and span the life course. The Highland Substance Misuse Framework for Schools will be reviewed and further aligned with the on-line Substance Awareness Toolkit that provides prevention resources for pupils, parents, professionals including teachers. A peer education approach will be utilised to raise alcohol awareness among older people. Numbers of children, young people and schoolss participating in J Rock and Rock Challenge diversionary initiatives will be increased with inclusion of boys prioritised alongside promotion of family based and generic activities. Support Effective Treatment Develop recovery communities and reduce loneliness and isolation. Implement the Quality Principles and systematic quality improvement procedures. Mutual aid provision and peer support opportunities will be strengthened with reach extended in remote and rural communities. The Drug and Alcohol Recovery Service will drive a programme of improvement work led by the Service Improvement Group (SIG) that includes implementation of the Quality Principles, preparation for DAISy and roll out of the RO Tool to enable recovery outcomes to be evidenced. Impact on outcomes Progress in achieving outcomes is currently measured in north Highland against 64 national core and local indicators: Indicators demonstrate a far more positive than negative impact on outcomes for North Highland. 39% - Show an improving picture in Health, Community Safety and the Local Environment. 39% - Insufficient trend data available. Although qualitative data provides insight. 57 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

202 202 8% - Show a worsening picture. May also indicate improvements in collecting certain data. 14% - Insufficient data. DAISy and Recovery Outcomes (RO) Tool to be implemented in 2017 providing data on Recovery and Service outcomes. Progress monitoring The Alcohol and Drug Partnerships produce a three year Local Delivery Plan (LDP) with progress accounted for via annual reports. The annual reporting process is a self-assessment exercise where the Highland performance is evaluated against national core outcome and local indicators which are benchmarked against the Scottish average and other areas. Trends are reported as worsening or improving where robust data is available, and targets from which to measure performance have been set that are SMART. Introduction of DAISy in Autumn 2017 and the Recovery Outcomes (RO) Tool in Spring 2017 will enablee improved reporting of service user outcomes. Once embedded in local service delivery, indicators will be generated that will allow reporting on the recovery outcomes being achieved by service users engaged with local services. In 2017, Drug and Alcohol Recovery Services will continue with an amended version of the Care Inspectorate validated self-evaluation process for implementation of the Quality Principles that was initiated in. Participation in the process is for the purposes of quality improvement as well as performance management. HSC Delivery Plan Action/Milestone: Consult on a new strategy on diet and obesity. NHS Highland Local Action(s) Submission by: Fiona Clarke We will contribute to the national consultation on the new strategy for diet and obesity. Impact on outcomes Increased awareness of: Weight inclusive approaches Size discrimination and the impact of this on health. Progress monitoring Working to the timescales outlined in the consultation. Monitor and collate the engagement in the consultation by organisations in the NHSH area. 58 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

203 203 HSC Delivery Plan Action/Milestone: Introduce the Active and Independent Living Improvement Programme which will support people of all ages and abilities to live well, be physically active, manage their own health conditions, remain in or return to employment, and live independently at home or in a homely setting. NHS Highland Local Action(s) Submission by: Lynn Bauermeister & Dan Jenkins NHSH and High Life Highland are working in partnership to support individuals and families with self-management through engagement with leisure centres, libraries and archives, including specific programmes such as: Active Living With and Beyond Cancer Cardiac Rehabilitation Exercise in care settings Additionally Connecting Carers and High Life Highland have worked together to enable people who care for a loved one for more than 35-hours per week to access leisure facilities for 50p a time. Impact on outcomes The actions above support the national health and wellbeing outcomes: Outcome 1: People are able to look after and improve their own health and wellbeing and live in good health for longer Outcome 2: People, including those with disabilities or long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community Outcome 3. People who use health and social care services have positive experiences of those services, and have their dignity respected Outcome 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services Outcome 5. Health and social care services contribute to reducing health inequalities Outcome 6. People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and well-being Outcome 7. People using health and social care services are safe from harm Progress monitoring Reporting from High Life Highland and NHSH Operational Units on participation and feedback from clients. 59 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

204 204 HSC Delivery Plan Action/Milestone: Deliver the Maternal and Infant Nutrition Framework with a focus on improving early diet choices and driving improvements in the health of children from the earliest years. This will include: by 2017, rolling out universal vitamins to all pregnant women; by 2019, consolidating best practice and evidence on nutritional guidance for pregnancy up to when children are aged 3, and developing a competency framework to promote and support breastfeeding; and by 2020, have integrated material into training packages for core education and continuing professional development. NHS Highland Local Action(s) Submission by: Public Health See Section 1.1, Improvement Aim 2 - Support individuals and families to jointly agree priorities and approaches for health improvement and wellbeing Key Area SUPPORTING MENTAL HEALTHH HSC Delivery Plan Action/Milestone: Improve access to mental health support by rolling out computerised cognitive behavioural therapy services nationally. NHS Highland Local Action(s) Submission by: Boyd Peters NHS Highland has significant geographical challenge with travel being a major limiting factor for patients and clinicians. There is increasing use of online resources by patients and clinicians for example BreathingSpace (NHS), MoodJuice (NHS) and from the voluntary sector Mikeysline which offers a text line and also a smartphone app for young people who have mental health issues. A national computerised CBT resource will be welcomed here as an addition to our growing raft of remote & rural solutions. Once available we will raise awareness of the resource to GPs, CMHTs and other relevant professionals. we will introduce the Mastermind Project to North Highland and Argyll and Bute during 2017 Impact on outcomes We will seek feedback from users and referrers to ascertain the uptake and effect of the new service. Progress monitoring The Mental Health Strategy, Improvement and Performance Group and the Psychological Therapies Steering Group will table updates about the service once it is available. 60 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

205 205 HSC Delivery Plan Action/Milestone: Have improved access to mental health services across Scotland, increased capacity and reduced waiting times by improving support for greater efficiency and effectivenesss of services, including Child and Adolescent Mental Health Services and psychological therapies. This will be accompanied by a workforce development programme and direct investment to increase capacity of local services. NHS Highland Local Action(s) Submission by: Boyd Peters/IMFOU NHS Highland has a Needs Assessment document which will be used in conjunction with the new National Mental Health Strategy to form a local plan. This will be carried forward via the MH Strategy Improvement and Performance group. In particular Child and Adolescent Mental Health Services will recruit a Psychotherapist, and a Learning Disabilities/Autistic Spectrum Disorder nurse practitioner together with administrative and secretarial support for these staff. This will increase service capacity and further reduce waiting times. The Adult Service will recruit a Clinical Psychologist to increase service provision. This would increase the capacity of the service to - Deliver psychological assessment and intervention to older people and offer supervision and training to others providing psychological therapies and/or techniques (eg Stress & Distress, psychological therapies for emotional disorder, cognitive rehab). - Contribute expertise to service developments such as case formulation within older adult Community Mental Health and Integrated Community Care Teams (and also in-patient assessment and treatment wards). - Help with the development of a challenging behaviour team with identified individuals (suitably skilled, trained) but also a tiered network of expertise and supervision. Increase resource to improve access to psychological interventions for patients with Personality Disorder, Depression, and Trauma. Recruit 1.4 wte to offer STEPPS supervision, while freeing up clinical psychology time to help meet the 18 week standard. In addition to the STEPPS program being made available widely across the Health Board area, NHS Highland will deliver training to staff in Decider Skills (a brief intervention approach which teaches mood regulation techniques which come from CBT and DBT.) 61 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

206 206 Increasing capacity in DBT and DBT-PE means that the likelihood of high costs of lengthy inpatient stays and out-of-area placements for severe borderline patients will be reduced. This effect can be demonstrated with existing local data. If more resources are made available to engage and treat high risk patients with complex and severe conditions, then these benefits are also likely to be scaled up. Impact on outcomes Provision of STEPPS, Decider Skills, Survive and Thrive and Behavioural Activation Groups across North Highland during 2017/18. Progress monitoring NHS Highland Psychological Therapies Operational Group who will lead on the project and report to the Board Psychological Therapies Steering Group chaired by Associate Medical Director. HSC Delivery Plan Action/Milestone: Have invested 150 million to improve services supporting mental health through the actions set out in the 10-year strategy. NHS Highland Local Action(s) Submission by: Boyd Peters NHS Highland in commissioned a Needs Assessment document. This gives a detailed overview of what services we have in the health board area. The report was compiled by Public Health and as well as available healthcare data and feedback from professionals, there is also significant contribution from service users, voluntary groups and others. Once the national Mental Health strategy is published we will begin consultationn locally to decide how to amalgamate the needs assessment with the national strategy in order to shape our local delivery plan. The Scottish Government s 2020 Vision principles will also be incorporated into our way forward and is particularly important (and challenging) given the remote and rural nature of the health board area. Monies from Scottish Government to improve mental health services will be used strategically and particularly to support innovative projects which may offer future solutions. Impact on outcomes We will look for impact in terms of equitable service delivery within the context of a very remote and rural health board area, and the development of innovative approaches which need to be acceptable to patients, achievable, sustainable and effective. Progress monitoring The Mental Health Strategy, Improvement and Performance group will monitor progress. 62 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

207 NHS BOARD REFORM Key Area DELIVERY OF NATIONAL SERVICES HSC Delivery Plan Action/Milestone: Review the functions of existing national NHS Boards to explore the scope for more effective and consistent delivery of national services and the support provided to local health and social care system for service delivery at regional level. As part of this, clear guidance will be put in place to NHS Boards that their Local Delivery Plans for 2017/18 must show their contributions to driving the work of this delivery plan, not least their contributions in support of the regional planning of clinicall services. NHS Highland Local Action(s) Submission by: Head of Planning & Performance NHS Highland have restructured to create a Business Support Services Directorate with a specific Planning and Performance remit to allow direct focus on National and Regional Planning. NHS Highland contributes to the work of the National Planning Forum, National Specialist Services and the Directors of Planning to ensure the development of a National, Regional, Local and Collaborative Framework for the new planning approach across NHS Scotland. This work will initially focus on national planning for Burns, Neurosurgery, Cardiac and national oncology services. The planned actions are to:- Produce a series of maps for NHS Highland indicating the sites, service, and population needs assessment by specialty and sustainability of service to allow identification of where services can be provided from. E.g. Unscheduled Care, Elective Care by specialty, Major Trauma, Radiology, Eye Care, OMFS etc. Continue to work collaboratively with NHS Grampian and NHS Tayside and the North of Scotland Planning Team to look at opportunities to deliver more effective services across the Region specifically in the delivery of Radiology Services, OMFS services, and Urology. Link in with the North of Scotland Planning Group to review the contributions of the Managed Clinical Networks and ensure the most cost effective delivery of services across the networks. Develop the Business Case for our agreed Elective Care Centre to deliver elective Ophthalmology and Orthopaedic services in a safe, effective and efficient way working in collaboration with the University of the Highlands & Islands, and the Highland & Islands 63 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

208 208 Enterprise. Develop regional plans to deliver low volume surgery on a regional basis improving the outcomes for our patients e.g. Upper GI Surgery being centralised on the Aberdeen Royal Infirmary site Develop and implement plans to enhance the Major Trauma Network across the North of Scotland in line with the National Strategy with the appointment of a Project Manager for the Trauma Unit and Local Emergency Hospitals within NHS Highland to maximise service improvements in the delivery of trauma care Impact on outcomes Contribute to the remodelling of our assets. Increased regional collaboration to ensure sustainability of vulnerable services, availability of specialist services, and delivery of national access standards. Delivery of the national trauma network. Progress monitoring The Actions above will be reviewed through the Business Support Directorate and on to the Senior Management Team in NHS Highland. 64 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

209 209 SECTION 3: NATIONAL STANDARDS Pending the formal national review of targets and indicators for health and social care, NHS Highland continues to ensure that clinical priority is given to patients. This section focusess on the ongoing improvement work in unscheduled care, cancer and other patients referred with urgent status. It also provides plans for our continued focus on patient safety and person-centeredness. 3.1 STANDARDS Target Detect Cancer Early To increase the proportion of people diagnosedd and treated in the first stage of breast, colorectal and lung cancer. 29% Early Access to Antenatal Services Pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation. 80% Smoking Cessation Annual successful quits at 12 weeks post quit in the 40% most deprived board SIMD areas (the bottom two local SIMD quintiles). 430 Alcohol Brief Interventions Annual brief interventions in the 3 priority areas of primary care, A&E and antenatal Financial Performance Operate within agreed revenue resource and capital resource limits, and meet cash requirement. 0 Cash Efficiencies Deliver a 3% efficiency saving to reinvest in frontline services 100% Sickness Absence Maximum sickness absence rate every 12 month period 4% All Cancer Treatment (31 days) For patients diagnosed with cancer, the maximum wait from first decision to treat will be 31 days. 95% Suspicion of cancer referrals (62 days) For patients referred urgently with a suspicion of cancer, maximum wait from referral to treatment will be 62 days. 95% 18 Weeks Referral to Treatment Elective/planned patients to commence treatment within 18 weeks of referral. 90% New Outpatient Waiting Times No patient should wait longer than 12 weeks for a first outpatient appointment P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

210 210 Treatment Time Guarantee No patient should wait longer than 12 weeks for elective treatment from the date the agreement to treatment is made. 0 Drug & Alcohol Treatment: Referral to Treatment Clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery. 90% Faster access to Specialist Child & Adolescent Mental Health Services (CAMHS) Patients will wait no longer than 18 weeks from referral to start of treatment. 90% Faster access to Psychological Therapies Patients will wait no longer than 18 weeks from referral to start of treatment. 90% IVF Treatment Eligible patients will commence IVF treatment within 12 Months of referral. 100% 4hr A&E Patients will wait no longer than 4 hours from arrival in A&E to admission, discharge or transfer. 95% MRSA/MSSA Bacterium: Maximum Staphylococcus aureus bacteriamia (including MRSA) cases per 1000 acute occupied bed days Clostridium Difficile Infections (CDI) Maximum rate of CDI in patients aged 15 and over per 1000 total occupied bed days Detect Cancer Early During 2017 / 2018, NHS Highland will continue in its efforts to encourage eligible individuals to participate in the Scottish Bowel and Breast Screening Programmes, both of which aim to diagnose cancer at an early stage. Following a successful pilot of an initiative to increase uptake of bowel screening, carried out in partnership with a local GP Practice, means of rolling this out to other Practices will be explored. Activity will focus on development of a locally derived evidence based toolkit to support practices increase acceptance of Bowel screening test and Primary care engagement activity. NHS Highland will continue to work in collaboration with Bowel Cancer UK to deliver bowel health and bowel screening awareness raising sessions to NHS, third sector and voluntary staff working in support roles and likely to be best placed cascade the message amongst service users and the wider community. A project to recruit and train community screening engagement volunteers will be piloted. A project objective will be to increase local 66 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

211 211 capacity to deliver face to face awareness raising initiatives to increase acceptance of national screening programmes and knowledge of the associated cancer signs and symptoms. This project will focus its attention on an area of deprivation known to have lower than average uptake to all national screening programmes (including Breast, Cervical and Bowel screening). Particular efforts will be made to highlight the bowel and breast screening programmes during bowel and breast cancer awareness months in April and October respectively, building on any publicity generated by statutory and third sector bodies. Similarly, during lung cancer awareness month in November, a distinct effort will be made to raise the public s knowledgee of this tumour s symptoms and encourage individuals experiencing these to consult their GP as soon as possible. A survey circulated in to capture the perceptions and opinions of lesbian and bisexual women about cervical screening revealed the need to progress a broader piece of work to ascertain how the needs of local LGBT could be better met by NHS Highland. This project will focus on further stakeholder engagement and consultation which will result in the production of local guidance and resources aimed at improving equitable accesss to services. NHS Highland has commenced discussions with Cancer Research UK regarding the introduction of its Primary Care Facilitator Programme within the Board. This aims to support GP Practices to engage in measures to promote participation in the national cancer screening programmes and to encourage them to consider what steps they can take to enable early identification of patients with suspected cancer to facilitate swift referral for further assessment and investigation. It is understood that the Scottish Government aims to introduce faecal immunochemical testing as a means of triaging symptomatic referrals for colonoscopy. This will help ensuree that scarce colonoscopy capacity is used to promptly investigate those at highest risk of having significant colorectal pathology. NHS Highland is keen to work with the Government to implement this within the Board. Early Access to Antenatal Services NHS Highland Maternity & Neonatal services will continue to ensure that adequate information about how to access maternity services & direct access to a midwife is widely available in NHS Highland communities, GP surgeries, pharmacies, childcare facilities and relevant internet sites. Policy alignment through local implementation of The Best Start, The National Review of Maternity & Neonatal services (SG, 2017), and NHS Highland Maternity & Neonatal Services Strategy ( ) will help to support improvements around the early access target. 67 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

212 212 Smoking Cessation See Section 1 Increasing Healthy Life Expectancy Alcohol Brief Interventions See Section 1 Increasing Healthy Life Expectancy Financial Performance and Cash Efficiencies See Section 4: Financial Planning Cancer Performance against national cancer waiting times remains of concern both at Board level and at national level. These results have been for a large part due to national staffing shortages in cancer specialties. Within Oncology until quite recently but continued shortages within Urology against a background of increasing demand is a major concern. The Board is engaged in a number of approaches to increase capacity; working closely with colleagues in NOSCAN and the other Cancer Centres with the aim of creating and sustaining a robust, sustainable service; and engaged in diagnostic and small professional workforce planning groups on a regional and national basis, to address workforce supply issues. The additional monies made available as a result of Beating Cancer :Ambition and Action will be utilised to address the key themes of this new National Cancer Strategy of Prevention, Improving Survival, Early Detection and Diagnosis, Improving Treatment, Workforce, Living With and Beyond Cancer, Quality Improvement and Research. The Board s Cancer Action Plan is being updated to reflect these key themes. An emphasis will be placed upon the regional co- ordination of our activities in order maximise the economies of scale and improve the sustainability of service provision. Outpatients & TTG See Section Improving Scheduled Care and Improving Outpatients 68 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

213 213 Drug & Alcohol Treatment: Referral to Treatment The priority to ensure that service change was sustainable and avoided the risk of seeking short term gains was determined in discussion with partners within the Alcohol & Drugs Partnerships across NHS Highland area, Argyll & Bute ADP and Highland ADP. This ensures that activity matches the overall recovery strategy in both areas. Key challenges are the geography of Highland, which dictates that teams are often small in number and are vulnerable to sickness or vacancies, and recruitment. The north Highland area has established a Service Improvement Group with the HEAT standard as a standing agenda. This group seeks opportunities to review service provision, increase access times and learn from teams across the area. The challenges faced are relating to recruitment, capacity, team absence and referral management. The geographical area creates challenges in ensuring rapid access where there is limited service provision. Primary Care partners are involved in opiate replacement therapy in line with enhanced service and as a result, not all practices are engaged in this work. For those who are, theree are issues in transferring full care when stability is achieved. An RPIW event is scheduled for June 2017 and will focus on access and throughput for servicess within the Inner Moray Firth Operational Unit. There is an agreed management restructure within the unit that is anticipated to be implemented by May This will drive forward a more flexible response to need and as this is the area with the highest referral rates, it will impact on improvement steps towards the HEAT standard. There are discussions taking place regarding the restructure of the management of addiction servicess within Argyll & Bute. This is aimed at improving integration and service pathways; driving forward a more flexible response to need ensuring a continued focus on meeting the HEAT standard. Both commissioned organisations are in consultation regarding the implementation of the Recovery Outcome Tool (ROW). The implementation of the Drug & Alcohol Information System (DAISy) has been moved back to April requested that both ADP areas be involved in the pilot from October NHS Highland has In response to the Care Inspectorate Alcohol & Drug Partnership self evaluation exercise on the embedding of the national Quality Principles, a local group has been established in North highland to monitor the adherence to these to ensure services are of a high standard. In Argyll & Bute there has been a marked increase in the coordinated activities between the commissioned services. The 69 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

214 214 management teams of these services are committed to providing a governance framework using this report and these principles which can be replicated across Argyll & Bute. This will ensure faster, smoother and better planned pathways are in place in all Argyll & Bute communities. CAMHS & Psychological Therapies See Section 2.3 Supporting Mental Health 4hr A&E See Section Reducing Unscheduled Care MRSA/MSSA bacteraemia Focus will be ongoing on reducing the number Blood culture contaminants Vascular access device infections Surgical site infections of: Clostridium difficile infection (CDI) Cases of infection are reviewed by a multi disciplinary root cause analysis process. Information from these reviews is utilised to inform future practice. Focus will be ongoing on monitoring of : Environmental cleanliness Antibiotic prescribing Compliance with Standard Infection Control Precautions 70 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

215 PATIENT SAFETY Patient safety infrastructure A SPSP Senior Leadership Team meeting takes place monthly to monitor progress against aims of all the improvement programmes. This meeting is chaired by the CEO or the Medical Director. Our SPSP Executive Sponsor is our Chief Executive. The work streams for Acute Adult report 2 monthly, in- patient raw mortality across the four acute hospitals is monitored monthly and latest HSMR results when available quarterly. Reports are also sent to the clinical governance committee and Board on request. Submission by: Dr Rod Harvey Medical Director / Maryanne Gillies SPSP NHS Highland Local Action(s) Implementation of the HSMR Quality Improvement plans. Full scale implementation of the 10 safety essentials. Scale up and spread of point of care priorities when improvement noted at pilot site. HSMR Raigmore Hospital & Belford Hospital Raigmore, Belford, Lorne & the Isles General and Caithness General Hospitals HSMR have triggered a review by Healthcare improvement Scotland. A high level Driver Diagram has been created and each hospital site is pro-actively implementing improvements across a range of 5 Primary Drivers within their Quality Improvement Plans: Comprehensive implementation of the 10 patient safety essentials. Implementation of the 9 point of care priorities. Implementation of reliable structured review. Implementation of reliable administrative recording processes. QI Infrastructure and Communication. An HSMR short life working group has been formed to include all hospital sites. The Acute Adult 10 patient safety essentials are monitored for reliability and sustainability using Horizon plots. They are hosted on line and can be filtered at each level from NHSH wide to hospital wide and individual ward run chart. Local operational units are responsible for achieving and sustaining 95% or > reliability. 71 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

216 216 NHS Highland has prioritised the following work streams within Acute Adult. Deteriorating Patient Sepsis VTE Falls AUTI Medicines Management Colorectal SSI reduction The focus for will be to scale up and spread to all applicable areas where improvements have been noted at pilot site level and supporting wider system improvements as detailed in HSMR QI plan. Deteriorating Patients/Cardiac Arrests Aim: 95% of people with physiological deterioration in acute care will have a structured response and plan and 50% reduction in CPR attempts in general ward setting by December Structured ward round document implemented and spreading to other surgical and medical wards. The Scottish Structured Response roll-out to all Raigmore wards supported by the Nurse Practitioner teams. Principles of treatment escalation planning (TEP) supported in surgery and throughout medical wards and being spread to the 3 RGH s. Sepsis NHSH currently reviewing the Sepsis 6 record and testing further versions. Spread has taken place to all admitting units across the four acute hospitals and further spread planned for the coming year. National outcome data demonstrated a reduction in mortality after sepsis diagnosis at Raigmore hospital. NHSH were successful in their bid to be part of the sepsis PC collaborative and will harness this opportunity to integrate teams across the interface. VTE NHSH have a single cross specialty VTE risk assessment and treatment protocol which is embedded within the Common Admissions Document in the four acute hospitals. Process measures continue to demonstrate variable reliability. The team are currently testing innovative ways to achieve patient self administration of chemical thromboprophylaxis night before surgery and extended thromboprophylaxis. NHSH are developing a system to provide outcome measures in terms of DVT and PE which may have occurred within 12 weeks of an acute hospital admission. A case note review has also taken place to understand if there is any correlation between admissions and events. 72 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

217 217 Falls Reduction Aim: 25% reduction in all falls and 20% reduction falls with harm The current falls bundles have been reviewed and re-designed. Work in 9 pilot ward is focussing on Safety briefs and huddles, Multi- progress with significant falls disciplianry team review of MDT bundle, care & comfort rounding and cohorting. We have seen excellent redcution across NHSH. One pilot ward noted a 47% reduction from 2015 to. Note data above in outcomes. Catheter Associated Urinary Tract Infectionn (CAUTI) Aim: 95% or > insertion and maintenance bundles and 30% reduction in CAUTI The CAUTI insertion and maintenance bundles were rigorously tested in pilot ward which is now demonstrating high reliability in insertion and maintenance. Spread and full scale implementation is now taking place for the CAUTI prevention bundles has now taken place to all wards and applicable areas Medicines NHS Highland has brought together all the medicines management teams across the SPSP programmers under the the ADTC Medicines Safety Sub Group. This allows for cross-programme discussion, e.g. primary and secondary care, mental health and primary care, community pharmacy and primary care. Many of the safety issues with medicines relate to the handover from one service to another and this new grouping allows for sharing and co-ordination of activity across NHS Highland. Surgical Site Infections: Colorectal SSI reduction Aim: 95% or > with 3 SSI reduction bundles and less than 10% elective colorectal SSI by end December. The team have produced a ward, theatre and intra operative technical bundle and are now achieving high reliability across many measures. The team have achieved their ambitious aim of < 10% Colorectal SSI at 9.1%. Efforts to maintain outcome and continue to focus on Normothermia, normoglycaemia, on-time and repeat antibiotics continue. Impact on outcomes 47% reduction of falls in pilot ward. < 10% colorectal surgical site infection. 155 days between Catheter associated infections in pilot ward. > 95% reliability across the majority of patient safety essentials, > 1000 days between VAP's and >1400days since last CVC infection in critical care. 73 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

218 218 Progress monitoring Progress is monitored using data over time displayed at ward and management level for continued improvement and correlated for onward reporting to Governance committees. A SPSP Senior Leadership Team meeting takes place monthly to monitor progress against aims of all the improvement programmes. This meeting is chaired by the CEO or the Medical Director. A HSMR short life working group had been formed to monitor progress against the HSMR reduction Driver Diagram and associated Quality Improvement Plans NHS Highland Local Action(s) Implementation and spread of the Mental Health, Primary Care, Maternity, Paediatric, Neonatal and Pharmacy programmes Primary Care - Local Enhanced Service Agreements In Primary Care agreement is in place for the continuation of the Warfarin and the Medicines Reconciliation bundles in and/or other QI activity, as part of the Local Enhanced Service Agreement. During SPSP plans to align with the Cluster Quality Leads for each Cluster. The main aims being: To establish QI activity linking with SPSS with each Cluster Quality lead. To provide visible resource in Quality Improvement Methodology. Mental Health - Focus on achieving sustained improvements across a number of measures in Phase 1 & 2 of programme and start early testing and engagement within phase 3 Maternity Reduce the number of avoidable adverse events in women and babies by 30% National reporting of stillbirths and PPH In plan to focus on VTE, CTG, PPH, Smoking Cessation referral to smoking cessation services. Neonates - Continue to focus on: PVC insertion & maintenance bundle. Observation recording and monitoring system. 74 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

219 219 Infants discharged on breast milk. New born screening bundle. Daily safety brief. Consultation with parents within 24 hours of admission. Gentamicin bundle compliance. Gentamicin dose/frequency. Paediatrics - Continue with focus on: PEWS Bundle Compliance PVC Insertion Sepsis 6 Bundle Compliance Medicines Reconciliation Use of SBAR Pharmacy in primary care - Continue in with: NSAIDs spread Warfarin testing Medicines reconciliation redesign/testing Medicines wallet testing Impact on outcomes Primary care NHS Highland SPSP is a Pilot Board for the sepsis in primary care collaborative To achieve prompt, reliable recognition and response to sepsis in Primary Care. Currently identifying a cluster lead for early testing. Primary care team will continue with Warfarin and Medicines Reconciliation Bundle in and are offered support to continue with safety climate tool and trigger tool. Mental Health Communication at Transition Guidelines on completion of Immediate 75 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8 Discharge Letter/Community Care Plan completed and work to continue

220 220 Identifying barriers e-health to IDL being sent in a timely manner Medicines Management Pilot on alternatives to as required medication continuing, lifeskills and decider training delivered to staff to enable support to patients Green sticker to record intervention and effectiveness has been developed by pilot ward and is currently being tested with patients under care of 2 of the consultants Medicines reconciliation is rolled out across all wards in the hospital, carried out by medical staff with quality assurance by pharmacy Leadership & Culture Chief executive and director of HR have started the leadership walk around within hospital plan to continue with this process Huddles active & developing Maternity Women are offered CO monitoring at booking and referred to smoking cessation services. Maternity & Neonatal team Huddle weekly Daily morning clinical safety briefs Continue with early testing of all new measures Neonates Continue to work towards sustained improvement in all areas for improvement identified. Parental questionnaire being tested Breast feeding group established (purchasing new chairs and freezer) NEWS charts currently being developed (initially for post-natal) January 2017 measure CVC insertion bundle (collecting data but not inputting) Paediatrics PEWS Bundle Compliance Local practices are now fully embedded into standards of care. Sepsis 6 Bundle Compliance demonstrating good progress Medicines Reconciliation/PVC and SBAR : continuing with improvement efforts 76 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

221 221 Pharmacy in Primary Care Medicines reconciliation: 95% of patients recently discharged from hospital have their medicines accurately reconciled in community pharmacy by September ; 95% of patients have discussed changes to their medication with their community pharmacy team by September. National spread of SPSP Pharmacy programme continues. All community pharmacy contractors are completing online modules in quality improvement, participating in one improvement activity and carrying out a safety climate survey. Progress monitoring Progress is monitored at local ward and hospital level with data displayed on Quality Improvement Boards. Data and progress is also reviewed 2 monthly at SPSP senior leadership meeting 3.3 PERSON-CENTEREDNESS NHS Highland Local Action(s) - Launch of Board-wide person centred assessment and care planning documentation across all hospitals in NHS Highland, accompanied by on site improvement support for staff. This includes 5 Must Dos with Me. - Adoption of John s Campaign across alll NHS Highland Hospitals. - Revision of Guidance for Carers and Visitors to NHS Highland Hospitals. - Development of written information leaflet for all patients and visitors to NHS Highland hospitals. Participation in What Matters to You day on 6/6/17. Measuring people s experience: Launch of Care Opinion May 2017, we will work with the national team to ensure awareness and publicity is shared across Highland. Refining structures to ensure responders and subscribers for Care Opinion across Operational Units. Methods in place to capture feedback will continue to be refined. 77 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

222 222 Increased focus on ensuring action taken and improvements made in response to feedback. Patients and service users involved in RPIWs. New National Model Complaints Handling Procedure Implementation of new arrangements from 1/4/17. Developing one model scheme to cover health and adult social care. Awareness raising and training being rolled out, procedures being updated to reflect new requirements. Refine and roll-out process for seeking feedback from complainants. Impact on outcomes Implement more person-centred and timely approach with increased frontline resolution of complaints and seek feedback to ascertain satisfaction with complaints handling. Increased use of complaint outputs to inform themes for improvement which will be actioned within OUs or across the Board. Increased uptake of Care Opinion and also postings which result in evidence of action taken. Progress monitoring Monitoring of actions will be via OU Quality and Patient Safety Groups/Clinical and Care Governance Committee; Board-wide Clinical Governance Committee and Board-wide Care and Experience Group. 78 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

223 223 SECTION 4: FINANCIAL PLANNING NARRATIVE TO SUPPORT FINANCIAL TABLES 4.1 HEADLINES Break-even position over the period of the plan with significant risks and dependencies o Savings targets for 2017/18 total 47m with 15m currently unidentified o Compares to 29m in /17 Non-recurrent savings carried forward to 2017/18 currently planned to be 6m, an increase on the c/fwd to -17 Capital in balance but extremely challengingg Cost pressures continue to grow and will need to be contained. 4.2 REVENUE - CORE RRL NHS Highland s LDP assumes financial break-even over the three years of the plan. The underlying deficit heading into 2017/18 is currently 13m although we continue to work to reduce this. We would aim to reduce the underlying deficit over the course of the three year in order to reach 6m by 2019/20. Assumptions and risks within the RRL are discussed below. Movements in core RRL expenditure are consistent year on year to take account of inflation and planned achieved savings. 2017/18 includes uplifts as announced by SG including 1.5% general uplift 8.7m. Future years assume 1.5% health uplift going forward, with ADP s and Police custody added to baseline. Included within the 1.5% is an amount of 7m which is effectively ring fenced ( 100m nationally) to be transferred from NHS Boards to Integration Authorities to support continued delivery of the Living Wage and sustainability in the care sector. 79 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

224 224 Allocations are assumed in line with recent SG guidance on Outcomes Framework, New Medicines, PCF, Mental Health etc, and other expenditure and allocations have been incorporated in line with previous year 0.75m of NRAC parity adjustment has been included. Argyll & Bute Integrated Joint Board An Integrated Joint Board (IJB) for Argyll & Bute was formally established on 18 August Its notional share of the NHSH uplift of 1.5% detailed above is 2.5m. Social Care Funding North Highland is now approaching the sixth year of the Lead agency model and the significant additional costs of social care are already contained within the plan, adding a considerable financial burden. The transfer of the North Highland share of the 100m to social care amounts to around 4.4m and agreement has been reached with Highland Council of a flat cash proposal for the quantum which leaves savings of around 5m equired to breakeven in Social care. 4.3 REVENUE - NON CORE RRL Depreciation for 2017/18 is calculated on expected spend in year, with uplifts in future years based on proposed expenditure as per the NHS Highland Capital plan. No indications at this point have been identifiedd of AME impairments required for but this is subject to change for future years as the timing of the redesigns for Badenoch & Strathspey and Skye, Lochalsh and South West Ross are finalised. AME provisions have been estimated using the information available to date provided from SPPA around pensions and injury benefits provisions. This is subject to change based on changes to life tables and discount rate. 80 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

225 CAPITAL Expected funding for Core Capital for is 19.5m, this includes 6.6m of formula funding, 8..6m of continued investment in Raigmore Critical Care, 0.6m for the purchase of land for the proposed Badenoch and Strathspey development and 1.8m as the first year s cost of the development bundle, and 0.84m as the final 70% of the smarter offices funding After legally committed schemes, there is a considerable focus on statutory compliance and backlog maintenance expenditure, which is required to comply with regulations across a number of sites and despite in excess of 2m being earmarked for this purpose each year, the amount is considerably less than has been assessed as needed - however we endeavour to remain on track to eliminate all high risk backlog maintenance according to the timetablee shown in the asset management strategy. For a further year and for the foreseeable future, equipment and service replacement programmes have had to be curtailed to live within the CRL and this applies to IM&T, Medical Equipment and Radiography. Any major equipment failures in year will present a considerable risk, and the backlog is increasing each year. The funding available has been put against these replacement programmes though this only covers the risk prioritised as red. There are a number of schemes currently under discussion with SG and these have been included in the table as aspirational funding, and listed in the table below. Efforts will be required to deliver the Capital programme over a number of years and work to progress this will continue throughout the year. 81 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

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227 EFFICIENCY SAVINGS A savings target of 47m is required in order to deliver breakeven (7.9% of NHS baseline or 7% if the funding for Adult Social Care from Highland Council is included as effectively part of the baseline). Of this 43.5m is a recurrent target and 3.5m non-recurrent this relates specifically to general local initiatives savings which tend to be non recurrent. This target is considerably higher than /17 and previous years, mainly as a result of continued pressures on both primary and secondary care drugs, cost pressures within the operational units and significant costs pressures as a result of the implementation of the living wage especially in Independent Sector care homes and care at home providers as well as the FYE of Adult Social Care packages of care. 4.6 ASSUMPTIONS A number of assumptions underpin the plan; Funding of 2.25m for New Medicines Fund which will be insufficient to cover costs An increase in the national target for the treatment of Hepatitis C and therefore 54 new drug treatments in Northern Highland and 14 in Argyll & Bute are factored into the plan. Appropriate funding is received to support the achievement of TTG Raigmore Hospital (now part of the Inner Moray Firth Operational Unit) and North & West Units are estimated to have significant levels of overspend by the end of the financial year. Whilst the plan assumes funding for part of the recurrent overspend, both Units are required to reduce their cost base during the course of the financial year. Pay uplifts of 1.7%. This figure includes pay awards for staff of 1% as per current guidelines and incremental increases which have been estimated using our usual method of person by person calculations along with the implementation of living wage and these have resulted in an uplift of over 11m. Prices include uplifts in non pay, Hospital drugs of 16% (this takes account of estimated impact of drugs relating to Rare Conditions, Very Rare Conditions and Orphan Drugs and is offset with guidance on NMF). Primary care prescribing of 4% and inflationary uplifts for service contracts, SLA s and PFI s. Future years assumptions for uplifts and inflation for pay uplifts are based on current information as supplied by SG colleagues. 83 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

228 RISKS Broadly there are two risks areas facing the Board in 20171/8: Ability to manage underlying cost pressures Ability to deliver a very challenging savings target Underlying Cost Pressures As highlighted previously both Raigmore and North & West Operational Units have overspent their budgets in /17 due to a range of issues. In N&W, this is primarily due the recruitment and service model issues around Caithness General Hospital and primary care resulting in exorbitant locum costs to maintain the level of service. Work is ongoing to develop a new sustainable model of care in CGH as part of the wider Caithness review. In terms of Raigmore, the pressures there are numerous and complicated and reflect the position across the country in terms of acute hospital pressures. The hospital has had a period of sustained pressure on beds and has been running on red alert on a regular basis which cannot be sustained. This has resulted in a number of service pressures such as cancellations of admissions, which impacts the TTG target. There are continued challenges with delayed transfers of care although this is currently improving. Savings Target In terms of the savings target, 47m far exceeds any level of savings target in previous years and will be extremely challenging to deliver, at this point 32m has been identified in principle in the planning process with 15m still unidentified in the plans. In terms of local initiatives, corporate savings and central benefits, NHSH has a track history in delivering in those areas and there is a relatively high degree of confidence that the level set is challenging but deliverable. 84 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

229 229 It is clear from the scale of financial challenge in 2017/18 and beyond that the current models of care are unsustainable. NHS Highland is developing a Quality and Sustainability Plan as a response to this. We believe we are well placed to respond to this challenge with the Highland Quality Approach now becoming embedded. The recently publish Operational Delivery Plan for Health & Social Care in Scotland (in tandem with the National Clinical Strategy and the Report on Realistic Medicine) provide us with the necessary strategic context to make the changes required to provide more cost effective care. 4.8 CONCLUSION The Revenue position for 2017/18 and beyond requires a cash releasing target that is unprecedented for NHSH. This will be a major challenge and it is clear that a more of the same approach will not deliver the degree of change required. There needs to be a radical shift to more cost effective models are care we believe this is possible without compromising safety or quality but only if there is a willingness to change (and change quickly). 85 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

230 230 SECTION 5: WORKFORCE PLANNING Everyone Matters: 2020 Workforce Vision remains the workforce policy for Scotland. This section provides a short outline of our local Everyone Matters Action Plan to deliver the 5 priorities; Healthy Organisational Culture Sustainable Workforce Capable Workforce Workforce to Deliver Integrated Services Effective Leadership and Management. Delivery against the 5 priorities are overseen by the Highland Partnership Forum and monitored by the Staff Governance Committee, thus providing assurance to the NHS Board of progress against implementation of the work streams. 5.1 PRIORITY: Healthy Organisational Culture Creating a healthy organisational culture in which our NHS Scotland values are embedded in everything we do, enabling a healthy, engaged and empowered workforce. The focus this year is on ensuring behaviours consistently live up to expectations. NHS Highland recognises that a healthy, engaged and empowered workforce is key to recruitment and retention and the sustainability of service delivery. NHS Highland values have been developed as part of the Highland Quality Approach. A number of work streams have been progressed: People Strategy is a key element of the Highland Quality Approach (HQA). A Catchball exercise was undertaken between January and March to develop and agree the organisation s Annual Objectives for This has shared the clear connection between the vision for NHS Highland and where teams and individuals need to focus 86 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

231 231 their effort. Engaging staff in the development of the objectives has sighted them on the focus for change of care models and their contribution to achieving these going forward. Current recruitment practices are based upon a Competency Based Application Process. Development of a Values Based Recruitment model is in place and will be taken forward throughout Staff Experience: imatter implementation is progressing well and inclusive of health and social care staff ini North Highland and Argyll and Bute Integrated Joint Board. In NHS Highland Response Rate was 63% and Employee Engagement Index was 74. NHS Highland expect to improve these figures in The Board will meet national imatter implementation timescales in that its entire workforce will be surveyed at least once by the end of Several pulse surveys have also been undertaken to understand staff experience and respond to feedback. The Board also participated in the Stonewall survey to understand its approach to LBGT and those with protected characteristics in the workforce and those who use services. Survey findings and areas for improvement will be taken forward in The Board also has a staff award scheme in place and nominations can be made by staff and members of the public to recognise contribution in one of the three Highland Quality Approach Strategy categories: People, Quality and Care. Awards happen monthly. The Board has also engaged in IHI Joy in Work prototyping and has plans to implement the learning in the Board in A successful aspect has been staff exposure to quality improvement in their service and this has led to engagement in change and empowerment to make the changes in their service their involvement and engagement has led to joy in work outputs streamlined processes, increased productivity, good engagement with imatter and the development of team values. The principles of Daily Management, Leader Standard Work, Leadership Development and investment in Continuous Quality Improvement; underpinned by Lean Improvement Methodology are being rolled out and include staff Daily Huddles, Production Boards, investment in supervisor support to the front line; and ensuring staff are valued, supported and thanked for their contribution. This has involved the creation of standard work for HQA Team Boards for Teams to focus on People Issues e.g. - Celebration of success - Team Objectives - imatter Action Plans - PDP&R status - Statutory and Mandatory Training status 87 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

232 232 - Sickness Absence - Improvement Ideas 5.2 PRIORITY: Sustainable Workforce Ensuring that the right people are available to deliver the right care, in the right place, at the right time. Strengthening workforce planning continues to be the focus this year. NHS Highland monitors its workforce planning requirements on a monthly basis. There is a workforce plan rolling action plan that is overseen by the Highland Partnership Forum and monitored by the Staff Governance Committee on a quarterly basis, this providing assurance to the NHS Board of progress against workforce plans. A National Health and Social Care Workforce Plan is planned for publication in Spring The Plan will present an opportunity to refresh guidance for the production of NHS workforce plans; and introduce workforce planning which provides an overall picture for health and social care staff. NHS Highland is engaging with this process and are in the process of collating feedback to The Scottish Government on their National Discussion Document. In the meantime, NHS Highland will develop its workforce projections by the end of June 2017, in line with Scottish Government requirements. These projections will be informed by validated workload and workforce planning tools, where available. Work is being taken forward to identify workforce planning requirements in line with NHS Scotland Health and Social Care Delivery Plan; and National Clinical Strategy. A range of workforce planning and development plans are in place or being scoped or developed: Increase flexibility in the workforce by encouraging horizontal integration of roles Facilitate a move towards realistic medicine by developing staff in the concept and practice Consider shared services in partnership with Boards and Regions Increase regulation in the workforce to provide protection and assurance to the public employer led health care support workforce Develop employment routes into health and social care Apprentice Roles. 88 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

233 233 The Board continually reviews service delivery and sustainability risks arising from recruitment and succession planning for small specialties and is engaged with Regions and NHS Scotland to address these for: Radiologists Psychiatry Consultants GPs Health Care Science Roles Radiotherapy Physics Sonographers Workforce plans have also been developed to support major service redesign that will take place in 2017/ /18. Workforce Plan developed to support Badenoch and Strathspey Service Redesign. Workforce Plan to support Skye, Lochalsh and West Ross will be developed in due course (in line with business planning timescales). Broader developments across health and social care will: Align workforce to new models of care Develop a Care Academy for Highland to signpost the diversity of health and social care career entry and career routes Address Care at Home workforce sustainability with sector partners (currently scoped and being implemented) Further develop Out of Hours and Unscheduled Care workforce to maintain service delivery Workforce Development initiatives to ensure staff are working to the top of their sphere of practice and role Develop new roles and new employment routes into health and social care for future sustainability including developing young workforce. Consultant recruitment and the sustainability of Rural General hospitals remains a risk for NHS Highland with continuing spend on locum doctors to support service delivery. A quality improvement project has been undertaken and the locum recruitment process is currently being reviewed with new processes being tested to improve how we recruit locum doctors. Work has also been taken forward to reduce the cost base in medical locums and agenda for change supplementary staffing bank, agency, overtime and excess part time hours reduction and reducing premium payments. 89 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

234 PRIORITY: Capable Workforce Ensuring that everyone has the skills needed to deliver safe, effective, person-centred care. The focus this year is on developing a more consistent, Scotland-wide approach to learning and development. NHS Highland is committed to the development of staff and continues to train and support managers and staff in eksf PDP&R process. Oracle Performance Management (OPM) system, the electronic system developed to replace e-ksf (the contract for the provision of e- KSF is due to end on 31 March 2018) was scheduled to be introduced from April as part of the implementation of the national electronic Employee Support System (eess). In preparation for the introduction of OPM Boards were requested to consider undertaking a rationalisation of the KSF Post Outlines in use in each Board. Within NHS Highland this process was applied to the >5500 KSF post outlines in use. A suite of revised post outlines was developed and agreed resulting in the creation of post outlines containing just the six core dimensions. This has enabled the eksf process to be simplified and further improvement work is underway. Opportunities have been taken to link the details of actions created in imatter Action Plans to individuals PDP s. This has the potential for managers to recognise how the elements of the HQA Strategies and Quality Objectives can be achieved through supporting staff development and increasing staff engagement leading to improved staff and patient satisfaction. PDP and imatter participation also support evidence for revalidation for nurses and midwives. A range of Education Frameworks have been developed following consultation with service managers and team / professional leads. The frameworks describe the Statutory/Mandatory and Core education and development required for the key roles within the individual service or department. It is anticipated that the frameworks will support managers and staff to continue to provide services of the highest quality; this ultimately inspires confidence in patients and visitors, as well as staff. It is intended that managers and reviewers will use the frameworks as part of the PDP&R process to identify, discuss and confirm that staff are aware of and have either undertaken or plan to undertake the training required for their post. Improvement work has been undertaken to increase participation in statutory and mandatory training. A tool has been developed to support managers to identify which training their staff has had. Baseline statistics on compliance have been established and trajectories on performance are being agreed. 90 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

235 235 As part of the delivery of the Highland Quality Approach the Board has invested in improving the confidence, capability and capacity of everyone involved in leading and practising quality improvement. The Board has over 30 Certified Lean Leaders. An additional 19 people have undertaken Certified Lean Leader Training and are currently undertaking their practical training. 3,000+ staff have attended a Lean Introductory course. 3 Cohorts of Intermediate Lean Training have been undertaken (30 Leaders) Many staff involved in Lean Projects and have received QI modules. Many staff, particularly nurses, with PDSA experience. We have a team of experts in SPSP. Increasing capacity in Lean Coaching: Two qualified coaches and there are a further 3 in training who will qualify by the end of PRIORITY: Workforce to Deliver Integrated Services Developing an integrated health and social care workforce across NHS Boards, local authorities and third party providers. The focus this year is on working with colleagues and partner organisations to implement integrated health and social care workforce arrangements. North Highland area which is co-terminus with Highland Council has had integrated health and social care services since April Integrated working is well established and theree have been outcomes in leadership structures and co-location of staff to ensure a truly integrated team approach to care, including primary care. There are recruitment and retention challenges address these aspects. in Care at Home Services and the Board is working with independent sector partners to In Argyll and Bute services are integrated under the Integrated Joint Board. The IJB has a comprehensivee workforce plan and organisation development plan to support the workforce integration and change agenda. These work streams will be progressed in 2017 and beyond. 91 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

236 PRIORITY: Effective Leadership and Management Leaders and managers lead by example and empower teams and individuals to deliver the 2020 vision. This year the focus is on ensuring effective leadership for change and quality improvement. The Board continues to deliver the following bespoke courses across NHS, Highland Council, Argyll and Bute Council and public sector partners (e.g. Highlands and Islands Enterprise) Leading for the Future Leading with Purpose Leading for Integration The Board also has in house programmes validated by Institute of Leadership and Management and Scottish Vocational Qualifications delivered through its in-house SVQ Centre. 92 P a g e D R A F T L O C A L D E L I V E R Y P L A N / 1 8

237 Form 1 - Core RRL 237 NHS HIGHLAND INITIAL LDP SUBMISSION Core Revenue Outturn Statement -17 Line no Total Rec 000s Non-Rec Non-Rec Non-Rec 000s TOTAL Rec 000s 000s TOTAL Rec 000s 000s TOTAL Core RRL: ,578 Gross Expenditure - Clinical & Non-clinical 822,597 32, , ,007 29, , ,104 29, , ,596 Less: Gross Income 140,127 5, , ,664 5, , ,206 5, , ,982 Total Expenditure 682,470 27, , ,343 24, , ,898 24, , ,385 Less: Total Non-Core RRL Expenditure 14,523 14,523 14,698 14,698 14,898 14, ,873 Less: FHS Non Discretionary Net Expenditure 28,430 28,430 28,999 28,999 29,579 29, ,724 Core Revenue Resource Outturn 654,040 13, , ,344 9, , ,319 9, , ,613 Baseline Allocation 591, , , , , , NRAC parity funding uplift ,111 Anticipated Allocations: Rec/ Non-rec/ Earmarked 70,990 3,848 74,838 70,990 3,848 74,838 70,990 3,848 74, ,724 Core Revenue Resource Limit (RRL) 663,540 3, , ,344 3, , ,319 3, , Saving / (Excess) against Core RRL 9,500 (9,500) 0 6,000 (6,000) (0) 6,000 (6,000) (0) Memorandum s Expenditure detail: s s s s s 1.12 Contribution to Integration Authority 1.13 Primary Care 1.14 Mental Health Total Main contact name Carol Marlin Version number address carol.marlin@nhs.net Date of submission Phone number Board Approval Date

238 238 Line no Efficiency Savings Programme Details Rec 000s NHS HIGHLAND INITIAL LDP SUBMISSION Efficiency Savings Risk rating Risk rating Non-Rec Unidenti Rec Non-Rec Unidenti Rec Non-Rec Unidenti High Med Low High Med Low 000s Total 000s fied 000s 000s Total 000s fied 000s 000s Total 000s fied High Med Low Efficiency & Productivity Workstreams: % % % % % % % % % % % % 2.01 Service productivity 14,500 14,500 n/a 20% 40% 40% 7,000 7,000 n/a 20% 40% 40% 6,000 6,000 n/a 20% 40% 40% 2.02 Drugs & Prescribing 3,000 3,000 n/a 0% 50% 50% 1,500 1,500 n/a 25% 50% 25% 1,250 1,250 n/a 25% 50% 25% 2.03 Procurement 0 n/a 100% 0 n/a 100% 0 n/a 100% 2.04 Workforce 5,000 5,000 n/a 24% 26% 50% 2,000 2,000 n/a 25% 25% 50% 2,000 2,000 n/a 25% 25% 50% 2.05 Support Services (Non-Clinical) 1,000 3,500 4,500 n/a 0% 11% 89% 2,000 2,000 n/a 25% 75% 1,500 1,500 n/a 25% 75% 2.06 Estates & facilities n/a 0% 0% 100% n/a 100% n/a 100% 2.07 Shared Services 0 n/a 100% 0 n/a 100% 0 n/a 100% 2.08 Other 4,000 4,000 n/a 0% 30% 70% 2,000 2,000 n/a 50% 50% 2,000 2,000 n/a 50% 50% 2.09 Unidentified Savings 15,500 15, % n/a n/a n/a 15,000 15, % n/a n/a n/a 15,000 15, % n/a n/a n/a 2.10 Total In-Year Efficiency Savings 43,500 3,500 47,000 15,500 4,050 10,345 17,105 30, ,000 15,000 2,275 5,550 7,175 28, ,000 15,000 2,013 4,900 6, Cash-releasing Savings 43,500 3,500 47,000 Savings % of 30,000 30,000 Savings % of 28,000 28,000 Savings % of Baseline '000 Baseline '000 Baseline ' Productivity Savings (non-cash) 0 Baseline 0 Baseline 0 Baseline 2.13 Total In-Year Efficiency Savings (must match line 2.10) 43,500 3,500 47, , % 30, , , % 28, , , % Risk rating Form 2 - Efficiencies

239 239 NHS HIGHLAND INITIAL LDP SUBMISSION Non-Core RRL Expenditure Total Total Total Line no Total 000s Non-Rec 000s Non-Rec 000s Non-Rec 000s ,471 Capital Grants ,609 Depreciation / Amortisation 12,750 12,900 13,000 ODEL - IFRS PFI Expenditure PFI/PPP/Hub - Depreciation PFI/PPP/Hub - Impairment 3.05 PFI/PPP/Hub - Notional Costs Total IFRS PFI Expenditure Anually Managed Expenditure ,000 AME - Impairments ,407 AME - Provisions , AME - Donated Assets Depreciation AME - Movement in Pension Valuation ,561 Total AME Expenditure 1,029 1,054 1, ,385 Total Non-Core RRL Expenditure 14,523 14,698 14,898 Form 3 - Non-Core RRL

240 240 Line No s NHS HIGHLAND INITIAL LDP SUBMISSION Infrastructure Investment Programme s s s s s ,788 Capital Resource Limit (CRL) 26,923 49,880 42,870 42,569 51, ,616 SGHSCD formula allocation 6,616 6,616 6,616 6,616 6, (100) Asset sale proceeds reapplied (net book value, from line 4.28 below) 0 0 (1,150) ,612 Project specific funding (from line 4.19 below) 19,105 38,305 36,654 35,300 42, Radiotherapy funding 1,202 4, , Hub/ NPD enabling funding Other centrally provided capital funding 4.08 (2,500) Revenue to capital transfers ,788 Total Capital Resource Limit 26,923 49,880 42,870 42,569 51, Saving / (Excess) against CRL s Project Specific Funding: s s s s s 4.11 Bandenoch & Strathspey Land Purchase ,612 Raigmore Critical Care & Theatres 8,500 6, Prior Year Brokerage - Raigmore CC&T 2, Smarter Offices final 70% Badenoch, Strathspey and Skye Bundle 1,800 12,000 16, MRI replacement 1, *** Asperational funding - list in narrative 7,365 16,505 20,654 35,300 42, ,612 Total (copies to line 4.04 above) 19,105 38,305 36,654 35,300 42, s Source of capital receipts (please enter NBV figures as negative): s s s 4.20 St Vincents Hospital (500) 4.21 Ian Charles Hospital (400) 4.22 Aviemore HC (250) 4.23 (100) Drumnadrochit HC Memoranda s 4.28 (100) Total Asset Sale proceeds (at NBV) (copies to line 4.03 above) 0 0 (1,150) s Form 4 - Capital Investment

241 241 NHS HIGHLAND INITIAL LDP SUBMISSION Financial Trajectories Revenue Outturn RRL Saving/ (Excess) 1,000 Revenue Performance Trajectory Saving / (Excess) against Core RRL as at the end of: 000s 5.01 June (5,000) 5.02 July (6,000) 5.03 Aug (7,000) 5.04 Sept (7,500) 5.05 Oct (6,000) 5.06 Nov (5,000) 5.07 Dec (4,000) 5.08 Jan (3,500) 5.09 Feb (2,500) 5.10 Mar (1,000) (2,000) (3,000) (4,000) (5,000) (6,000) (7,000) (8,000) June July Aug Sept Oct Nov Dec Jan Feb Mar Month Cumulative value of efficiency savings as at the end of: Total 000s 5.11 June 8, July 10, Aug 13, Sept 16, Oct 21, Nov 26, Dec 32, Jan 36, Feb 42, ,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, Mar 47,000 0 Efficiency Savings Trajectory June July Aug Sept Oct Nov Dec Jan Feb Mar Month Form 5 - Trajectories

242 242 NHS HIGHLAND INITIAL LDP SUBMISSION Financial Planning Assumptions Line no Key Assumptions / Risks Value Risk/ Assumption/ % Assumption Risk Assessment Impact / Description Risk rating (please select from dropdown) Savings achievement - Cash efficiencies required to 6.01 breakeven = 47m at present plans for 32m of this 19.55m or 42% High risk and as yet unidentified savings amount to 42% of overall savings requiement High Risk identified. High Risk Medium Ris Low Risk 6.02 Savings achievement - Cash efficiencies required to breakeven = 47m at present plans for 32m of this identified m or 22% Medium risk savings amount to 22% of overall savings requiement Medium Risk Savings achievement - Cash efficiencies required to 6.03 breakeven = 47m at present plans for 32m of this m Savings identified as low risk amount to 22% of overall savings requiement. Low Risk identified. Both Raigmore and North & West unit have had considerable cost pressures in the plan 6.04 Ability to mamage cost pressures High Risk assumes funding of part of the overspends but the units require to reduce their cost base 6.05 New Medicine Fund 2.25m assumed funding Estimate of NHS Highlands a share of the NMF will not be sufficient to cover the pressures. Medium Risk 6.06 HEP C An increase in the national target has been included within the assumptions Low Risk 6.07 TTG 2.7m Funding to support to the achievement of TTG - Commitment of 2.7m for for Vangaurd High Risk 6.08 Pay uplifts 9m Figure includes 1& pay uplift and 0.7% of incremental drift included in the current plan Low Risk 6.09 Inplementation of Living Wage 2.3m NHS Highland adult services require over 2m to cover the calcutated uplifts Low Risk 6.10 Prices Included non pay, SLA's energy and PFI inflationary uplifts Low Risk 6.11 Future years uplifts NHS Highland is assuming 1.5% uplifts for future years for Health. Medium Risk The increased level of backlog of replacement programmes for medical equipment and ehealth is 6.12 Capital - Equipment causing concern - any equiment failures cause considerable risk. This risk has increased over the last High Risk few years and will continue to rise Form 6 - Assumptions & Risks

243 243 Highland NHS Board 28 March 2017 Item 4.7 RISK APPETITE Report by Nick Kenton, Director of Finance The Board is asked to: Discuss and approve the proposed risk appetites as set out in this report Summary The Risk Management Steering Group (RMSG) has put forward a set of proposed risk appetites for the Board to discuss and approve. These were largely drawn up by a Short Life Working Group (SLWG) comprising three non-executives and chaired by the Director of Finance (executive lead for risk management) with only minor amendments made by the RMSG. The approach and the suggested risk appetites were endorsed by the Audit Committee (the governance committee charged with overseeing the risk management process) on 7 March Background NHS Highland approved a Risk Policy in December 2015 see link below. 2%20Board%20meeting/5.6%20Risk%20Managment.pdf A requirement of the Policy is for the Board to set its appetite for various risk categories each year. The categories in the Policy (which include links to the Quality Objectives as they were in 2015/16) are as follows: Table 1 Risk category Strategic/ Reputational Clinical People Innovation and Transformation Quality Objectives 1. Implementing our vision and strategy 2. Improving population health and reducing inequalities 10. Delivering our targets 3. Creating a caring, person-centred experience 4. Providing safe and effective care 7. Engaging our people 5. Transforming our services 6. Designing integrated care 8. Promoting creativity, innovation and research

244 244 Finance and Sustainability 9. Ensuring value and sustainability The appetite for risk is defined in the Policy as follows: Table 2 Risk appetite (classification) Hungry Open Cautious Minimalist Averse Definition Eager to be innovative and to choose options offering potentially bigger rewards despite greater inherent risk. Willing to consider all options and chose the one that is most likely to result in success, while also providing an acceptable level of reward. Preference for safe delivery options that have a low degree of inherent risk and may only have limited potential for reward. Preference for ultra-safe business delivery options that have a low degree of inherent risk and only have a potential for limited reward. Avoidance of risk and uncertainty is a key organisational In May the Risk Management Steering Group (an officer Group, chaired by the Chief Executive) drafted a paper for Board consideration. This paper reflected the officers understanding of the Board s likely tolerance for risk, by category. It is important to note that these risk appetites were not recommended by the officers (who, generally speaking would have had a higher tolerance for risk) but rather they reflected the officers understanding of the Board s likely risk appetite. The resulting paper was considered by the Board in May see link below. g%2031%20may%20/4.11%20risk%20management%20policy.pdf The suggested risk appetite by category from this paper are summarised in the table below. Table 3 Risk Category Strategic/reputational Clinical People Innovation & transformation Finance & sustainability Risk Appetite minimalist cautious averse minimalist cautious open open hungry minimalist cautious It was clear from the discussion at the Board that members felt the suggested risk appetite was too timid and officers welcomed this view. It was proposed to have a more detailed discussion at a Board Development session and to come back to the Board with revised proposals.

245 245 Subsequent to this it was agreed to form a Short Life Working Group (SLWG) of interested Board members to review the suggested risk appetite as there was significant pressure on Board Development agendas. The first meeting of the SLWG took place in December. In short, the SLWG members felt that the level of appetite previously suggested was indeed too timid. In addition, it was felt that a league table presentation of risk appetite categories (as set out in Table 2 above) was not helpful as it implied increasingly risky behaviour moving up through the categories. This is not necessarily the case and the context is crucial. For instance there may be clinical decisions were an open approach to risk appetite is actually less inherently risky than an averse approach. It was therefore felt it would be more helpful to present the categories in a circular format with the person at the centre in line with the HQA. The proposals from the SLWG were then discussed at the RMSG on 15 February Minor amendments were made, including a decision to put the organisation at the centre of the diagram rather than the person. Open Strategic/ Reputational Clinical People Organisation Cautious open Finance and Sustainability Open hungry Innovation & Transformation

246 246 However, the RMSG accepted in full the proposed revised risk appetites recommended by the SLWG. These are as follows: Table 4 Risk Category Strategic/reputational Clinical People Innovation & transformation Finance & sustainability Risk Appetite open open open open hungry cautious open The methodology and the proposals were subsequently endorsed by the Audit Committee on 7 March Recommendation The Board is asked to discuss and approved the risk appetite levels suggested by the RMSG Contribution to Board Objectives Governance Implications Robust risk management is core to good governance. It is important that the Board formalises its appetite for risk and does so by risk category. This provides guidance and cover for operational decision making that requires the balancing of risk (particularly when these decisions carry risks that cut across several categories). There are no direct staff, clinical or financial governance impacts as such, but this formalisation will greatly assist with managing risks that may impact all these categories. Risk Assessment It is felt that the formalisation of risk appetite will in itself reduce the Board s risk by giving staff guidance as to how to manage risks across various categories. Planning for Fairness Formalising risk appetite will contribute to a planned approach to operational decision making and permit time for impact assessments of key proposals on services. As the policy is applied and specific projects developed equality impact assessments will be completed where necessary. Engagement and Communication This issue has been discussed at the Board meeting, twice by the SLWG and also by the RMSG and the Audit Committee. Nick Kenton Director of Finance 10 March 2017

247 247 Highland NHS Board 28 March 2017 Item 4.8 FIVE YEAR CAPITAL PLAN & INDICATIVE TEN YEAR CAPITAL PLAN Report by Nick Kenton, Director of Finance The Board is asked to: Approve the attached five year capital plan 1 Background and Context Every year NHS Highland is required to submit a Capital Plan to the Scottish Government that sets out our proposed investment in our infrastructure for the coming five years. This year s Plan includes an indicative ten-year look ahead. This Plan is set in the context of the Asset Management Strategy that was approved by the Board in October The Plan has been scrutinised in detail by the Asset Management Group (AMG), which is content to recommend it to the Board for formal approval. This Plan highlights all proposed capital expenditure on projects that are either planned or in progress. Also included is likely income from other sources such as disposal of assets no longer required. The Plan includes projects funded from traditional public sector capital (provided by the Scottish Government direct) as well as potential projects to be funded by up-front investment from out-with the public sector and paid for from revenue allocations. The plan should be seen in the context of continuing significant constraint on the NHSScotland capital position. Broadly, the Board s capital plan is underpinned by four sources of funding: Formula capital this is NHS Highland s fair share of non-specific capital funding and the Board has discretion over how this is utilised Specific capital funding this is funding that depends on specific Scottish Government approvals, via a business case process Income from the sale of assets Revenue funding this is where funding for an asset is made available via a non-profit distributing arrangement whereby the upfront funding is sourced out-with the public sector and the Board then pays a revenue charge for utilising the asset There is continuing constraint on the first three sources of funding. The formula capital for NHS Highland will be 6.616m for 2017/18. There is no uplift from the /17 amount and considerably less than 16m received in 2010/11 (the final year before resources became increasingly constrained). In tandem with this, the Scottish Government has given a clear steer to boards to address backlog maintenance in their property portfolios. In the last two years the capital programme has very much reflected this guidance and there was commitment made on backlog maintenance of 2m per year to eliminate the high risk areas. This has led to a resultant minimal investment in equipment replacement programmes. The 2017/18 plan has tried to address this with focus on investing in high risk areas within medical equipment and ehealth issues with the limited fund available. 2 Process Followed It is clear that there is insufficient capital to support the asset base as it is currently configured. In order to reach a balanced capital plan it is necessary to adopt a risk management approach that requires a significant degree of compromise across the key capital streams, which are as follows:

248 248 Estates / property ehealth Medical equipment Radiology equipment Each stream has a lead officer who was charged with prioritising the requirements according to risk. These prioritised lists were discussed and refined at the Asset Management Group. Through a degree of compromise, it was possible to include most of the top priorities on the plan that were rated as high risk. Some however could not be included in the plan, as in previous years. This will be detailed in the PAMS (Property Asset Management Strategy) document that will come to the board for approval in July 2017 The 2017/18 plan includes 1.3m set aside for estates backlog maintenance, along with reinstatement of 0.9m from /17 keeping this at the agreed minimum of 2m, 1.3m for medical equipment, 1.3m for ehealth and 0.6m for Radiology which addresses all prioritised high risk elements. The Board remains on course to hit the national target of reducing significant and high risk estates backlog maintenance to 10% of the total backlog by Some priorities for the Board have had to be identified subject to bids to Scottish Government where we are competing for scarce capital with all other boards. This may cause problems going forward if these schemes are not funded, however the plan is reflective of the best that can be achieved with the current level of funding. The Asset Management Group plays a key role in monitoring the position in-year and agreeing amendments to the plan to deal with unanticipated pressures or slippage. There is specific funding in the 2017/18 plan for the continuing Raigmore Critical Care & Theatres refurbishment ( 8.5m) which is on course to complete in 2018/19. As a result of the constraints on publicly funded capital, the Scottish Government has introduced revenue-funding solutions based on non-profit distributing models. The new Tain Health Centre (which opened in 2014) was delivered under one of these models - the hubco model. This year s Five Year Plan includes the redesign projects for Badenoch and Strathspey, Skye, Lochalsh and South West Ross. It is expected that these will be delivered via the hubco model as a bundle to maximise value for money and minimise financing costs, although specific funding for the purchase of the land has been agreed by Scottish Government. Funding for the remainder of the Smarter Office project for Inverness, and the agreed Radiotherapy replacement programme make up the remainder of the 2017/18 funding on the Central funding section. For clarity the funding (and corresponding expenditure) sections shown listed below are still under discussion with Scottish Government and are therefore not guaranteed and are subject to due process (20171/8 figures): The New investments projects Property m Investment programmes - HUB/NDP - 2m Proposed ehealth- Schemes over 1.5m m 2 Plan The plan attached in appendix A & B below is our current understanding of the funding position for the next 10 years. Although the plan has not previously needed to include a 10 year look ahead it is important that we align the plan with the Board s Asset Management Strategy (AMS). This is to allow more complete planning at government level and to ensure consistency across plans. The plan is a development of last year s plan but includes projects arising from the Inner Moray Firth Master Plan and the other redesign work going on around NHS Highland such as hospital redesign across NHS Highland and some high cost ehealth issues which are all under discussion

249 249 with Scottish Government. The plan reflects discussions with Scottish Government regarding the planned new Elective Care Centre in Inverness - one of four locations in Scotland selected to receive funding. Appendix A and B below show the funding and expenditure commitments within the 10 year Capital plan. The plan also includes potential funding for Inverness Primary care premises, we are aware that the population of Inverness is increasing and several developments are in place to further increase housing, we will need to ensure the provision of Primary Care is able to keep pace with this. We also want to be able to address existing concerns in some of the existing facilities. Work is beginning on redesign in Lochaber which may involve a replacement hospital for Belford, subject to due process. We are working with colleagues in Highland & Islands Enterprise and Highland Council to ensure that any impact on health services arising from the impending investment in aluminium processing in Lochaber is understood and planned for. In order to continue to provide quality services we are constantly reviewing the estate and its relevance to the services we deliver from it. In Dunoon and Rothesay we recognise there may be options that would allow us to redesign services that will improve the experience for patients and improve efficiency. This work has started and will be detailed further in the AMS. Work is continuing on the Inner Moray Firth Master Plan and we are in discussion with Scottish Government over how to best present and take forward this important piece of work. Again this will be explained further in the AMS document. It is also incumbent on us to drive every possible efficiency out of the Capital Budget we are allocated, so we are introducing a new process for managing the expenditure that ensures the procurement strategy for each piece of expenditure maximises the use of existing national contracts and early results are encouraging that significant savings can be had without a reduction in quality. This is a challenging plan to deliver, we are having to change the resource profile of the team that is used to deliver most of this work, this is key if we are to grasp the opportunity to get the estate that supports many of our services configured and built to meet the demands of modern healthcare. This will need to be resourced properly and this will be kept under review as the work progresses. As part of this, we are in dialogue with colleagues in NHS Grampian with a view to sharing capital planning resources across the region. 3 Contribution to Board objectives The projects listed in this plan will help to ensure the continuity of services by the planned replacement of equipment and assist the efficiency agenda by delivering the new facilities that the Board needs to modernise its service delivery. 4 Governance Implications Staff Governance There are no particular staff governance issues around the overall Plan, each individual project will have its own staff engagement. Patient and Public Involvement Each project will have appropriate patient and public engagement. Clinical Governance Each project will comply with clinical governance as part of the project delivery.

250 250 Financial Impact The capital aspects of the Plan are reflected in the attached schedule. There will be revenue consequences of the Plan these are dealt with on a project-by-project basis in accordance with the business case process. 5 Risk Assessment The individual projects have their own risk assessment and risk governance arrangements. For the significant projects, this will be detailed in the Asset Management Strategy. The risks associated with the backlog in maintenance and equipment replacement will also be in the Asset Management Strategy. The components of this plan (and the items excluded from it) have been subject to a risk assessment process. 6 Planning for Fairness This will help ensure equity of access to patients by improving the sustainability of services in NHS Highland. 7 Engagement and Communication A communication plan is in place to communicate to staff and patients what is planned and appropriate press releases will be prepared at the key milestones to inform the public. Nick Kenton Director of Finance 16 March 2017

251 251 Appendix A

252 252 Appendix B

253 253 NHS Highland Board 28 March 2017 Item 4.9 STATUTORY SUPERVISION OF MIDWIVES 1. Annual LSA Audit of Standards Supervision for midwives: moving from a statutory to an employer led model for Scotland Report prepared by Dr Helen Bryers, Head of Midwifery, on behalf of Heidi May, Board Director of Nursing The Board is asked to: Note the LSA Audit Report for - 17 Note that this is the final LSA Audit report Note the transition arrangements and anticipated timescales for the changes from statutory to employer led supervision of midwives Contribution to Highland Quality Approach Strategic Framework and Annual Objectives This report contributes to the following Board Strategic priority: Effective Quality of Care: providing appropriate safe care 1. Outline and results of the Annual LSA Audit Report The attached report contains the findings of Annual LSA Audit from April - March This annual report provides NHS Highland with details on compliance with the standards set within the NMC Midwives Rules and Standards (NMC, 2012). The Executive Summary (p 4) commends the Highland Supervisors of Midwives (SOM) on achieving the standard (Midwives Rule 9) that all midwives (247) received an annual review with their SOM in which their practice was reviewed and offered support for NMC revalidation. NHS Highland SOMs fully met eight of the nine NMC Standards and partially met one of the Standards. One Standard, Rule 4, was partially met. This standard asks that the LSA develops a mechanism to ensure that the Local Supervising Authority Midwifery Officer (LSAMO) is notified of adverse events. This is done through the use of an adverse event Scottish Trigger tool (Appendix 1 to the Annual Audit Report). The audit showed that the Scottish trigger tool is implemented across NHS Highland and that these trigger tools were reviewed by a SOM. However, it was noted that not all of the trigger tools were notified to the LSAMO by use of the on-line database.

254 254 The SOM team acknowledged that there was a need to ensure that the process for completing and uploading the trigger tool into the LSA database was followed and agreed a system of cross referencing through NHS Highland maternity risk management process to ensure that all adverse triggers were recorded onto the LSA database. The LSA Audit Report is presented to the Board, Clinical Governance and NMAHP Leadership and Advisory Committees to ensure that the contents of the report are shared and to acknowledge the contribution that statutory supervision of midwives makes to the governance agenda, including how Supervisors of Midwives can enhance protection of women and their babies. 2. System Change: moving from a statutory to an employer led model of supervision for midwives in Scotland This will be the last annual LSAMO report and audit of NMC Midwives Rules and Standards. In response to the Morecambe Bay Inquiry, the Nursing and Midwifery Council (NMC) and the United Kingdom (UK) Government, propose to separate statutory supervision of midwifery supervision from regulation. As Regulation is a matter reserved to the UK Parliament and the Department of Health (DH) in England, this will be taken forward through a change to the legislation before 31 st March This is now completed and the legislation (section 60 of the Nursing and Midwifery Order) has been changed. The main changes relating to midwifery in the legislation (NMC Order) are: The statutory role and function of the LSA, the LSAMO and the SOM cease to exist The removal of the requirement for the NMC to provide the statutory supervision of midwives, a recommendation of the Morecambe Bay Inquiry The NMC statutory Midwifery Committee is abolished Legislative change will mean that the LSA, the Local Supervising Authority (in Scotland this is the Health Board), along with the statutory roles and functions associated with its responsibility for governing the standard of midwifery practice on behalf of the NMC will cease to exist. Removal of this additional layer of regulation brings midwives in line with other professions and means that governance for the standard of midwifery practice will rest exclusively with employers. This includes investigation of alleged misconduct or impaired fitness to practise and referral to the NMC where required; and is consistent with current processes and requirements for nurse registrants. 3. Moving Forward Ministers in all four countries have agreed with the NMC decision and have supported work on the development of a professional, employer led model of supervision for midwives which preserves the supportive, rather than regulatory aspects of supervision in practice. All four UK countries have developed a model to take this forward. 2

255 255 In Scotland, this new model has been agreed by the Scottish Government in January 2017 and is now moving into an implementation phase which will be led by a national group. The new model will be based on clinical and restorative supervision. The fundamental aim of clinical supervision is to promote best clinical practice through a process of reflection, discussion and review of all aspects of clinical care; including the relationship between midwives, women and families. Restorative supervision is designed to address the emotional needs of staff and help them build resilience levels by reducing their own stress and burnout levels; thereby improving health and wellbeing. It creates a relationship that nurtures and cares for the person being supervised as well as facilitating reflection and self-awareness through critical analysis, exploration of events and feelings. It is proposed that Scotland s clinical supervision for midwives is based on: group supervision for cohorts of a maximum of 10 midwives, with sessions taking participants through a restorative process midwives attending a minimum of 1 group session per annum one to one supervision for individual midwives as required confidentiality and contracting for all sessions appropriate record keeping. 4. Implementation In January this year, the Cabinet Secretary gave her approval to implement this new employer led model of supervision for midwives which retains the supportive, rather than regulatory aspects of supervision in practice. National work is ongoing to support NHS Boards to implement the new supervision model in This work is being led by Anne Holmes, National Midwifery Advisor in the Chief Nursing Officer s department. A national implementation group has been set up to support and advise Boards on the implementation of the new model. This work will include provision of a national information and education package for local use. 5. Contribution to Board Objectives This report contributes to effective quality of care and safe care by ensuring that midwifery staff have an annual dedicated time allocation and mentor support to reflect on clinical practice. This will help to maintain high standards of midwifery practice. 6. Governance Implications Over the next year, NHS Highland needs to phase out the current model of statutory supervision and implement the new model of professional supervision. Over this period, there will be implications for staff who are currently SOMs and the loss of their roles. Some of these SOMs may wish to become mentors in the new model. In addition, midwives interested and willing to become the new mentors need to be identified and trained. This work will be 3

256 256 lead and monitored through the Lead Midwives Group and the work guided by the national implementation group.. 7. Planning for Fairness The new model of clinical supervision will be for all midwives in clinical practice. This will be subject to national evaluation over a three year period. It is anticipated that the model will then be rolled out to other healthcare professionals in Scotland as a model of supportive supervision for clinical practice. 8. Engagement and Communication The implementation plan for the new model will be communicated to Boards through the work of the national implementation group. The membership of the group will include a Head of Midwifery and representatives of the current supervisors of midwives, as well as academics and public representation. Within NHS Highland, communication will be through Nursing Midwifery and AHP (NMAHP) Leadership Committee and the Lead Midwives Group. Helen Bryers 15 th march 2017 Further Reading/ References NMC 2012 Midwives rules and Standards Available org/publications/standards NMC 2012 Supervision, Support and Safety, Report of the quality assurance of the local supervising authorities (LSAs) Available org/publications/midwifery-supervision Nursing and Midwifery Order 2001 Available Nursing & Midwifery Council (NMC) (2015) The code professional standards of practice and behaviour for nurses and midwives. London: 4

257 257 LOCAL SUPERVISING AUTHORITIES ANNUAL REPORT APRIL MARCH 2017 Yvonne Bronsky Local Supervising Authority Midwifery Officer January

258 258 Introduction The purpose of this report is to inform NHS Highland of how they are meeting the standards set within the Nursing and Midwifery Council (NMC), Midwives rules and standards (2012). This annual report provides the detail to comply with rule 13 of the NMC (Midwives) Rules Nursing and Midwifery Council The NMC was established under the Nursing and Midwifery Order 2001, as the body responsible for regulating the practice of those professions. Articles 42 and 43 of the Order make provision for the practice of midwives to be supervised. The local bodies responsible for the discharge of those functions are the LSAs. The NMC commissioned the King s Fund to review statutory supervision in the United Kingdom and they published their findings in 2015 The NMC as the health care professional regulator should have direct responsibility and accountability solely for the core functions of regulation. The legislation pertaining to the NMC should be revised to reflect this. This means that the additional layer of regulation currently in place for midwives and the extended role for the NMC over statutory supervision should end. (King s Fund 2015) The recommendations of the King s Fund Report were subsequently accepted by the Nursing and Midwifery Council in January The Chair of the Council wrote to the Department of Health Minister calling for the government to provide an opportunity to amend the NMC s legislation. 2

259 259 In the meantime, statutory supervision of midwives as it is currently framed must continue until the law changes. The NMC and the LSAs will need to develop strategies for ensuring that the Midwives rules and standards continue to be met in the interim. At present the Scottish Government has convened a Transitioning Supervision of Midwives taskforce group, the purpose of this group is: To oversee the transition from the regulatory model of statutory supervision for midwives to a national professional and employer led model of clinical and peer supervision for practising midwives within Scotland. (Scottish Government 2015) The Department of Health consultation findings were published on 11 th January 2017 which signals the steps anticipated to be taken in the coming months. While the Government acknowledges the concerns raised by midwives in relation to these changes, it also sets out clearly why it believes they are important. The response signals the Government will recommend these changes to parliament. Although these changes mean that supervision will no longer be linked to regulation, this does not mean that it will not exist at all. Plans for a new model of supervision are now well advanced in each of the four countries of the UK. We are confident that the things about supervision most valued by midwives will continue in the future. It s important to remember that these changes do not alter the status of midwifery as a distinct profession with its own standards. There will be no change to the protected title of midwife, and delivering a baby remains a protected function for a midwife or a medical practitioner. Parliament will debate the changes in spring 2017 and if approved, they are set to come into force shortly after. Until the law changes, what is required of midwives remains the same and this is set out in the Midwives Rules and Standards and the Code. (NMC January 2017) 3

260 260 Executive Summary This report contains the findings of the annual LSA audit and as we move forward into new ways of working an opportunity has been taken at this time to include and highlight two clinical governance priorities. 1. The number of supervisory reviews and supervisory investigations undertaken from January to December NMC Midwives rules and standards Rule 10 (2012) 2. Midwives preparation for revalidation NMC Midwives rules and standards Rule 9 (2012) and the NMC The Code (2015) Rule 9 Standard MET 247 midwives registered their intention to practise within NHS Highland. All of these midwives were issued with an annual review tool to complete and date to meet with their named SoM. It is commendable that the SoM team all achieved the standard of ensuring that they met with their supervisees to review their practice and support them in preparation for NMC revalidation. Rule 10 Standard Partially Met Supervisory reviews were undertaken following untoward incidences as identified on the Trigger List for reviews (Appendix One). 4

261 261 NHS Highland Supervisor of Midwives Reviews, Investigations and Outcomes August 15 to 31 st December Practice year No of Reviews No of cases where good practice was identified No of midwives with learning points (SBARs) Practice year No of Investigations No of midwives involved in investigations Outcomes from investigations x LAP x LAP 5

262 262 Statutory Supervision of Midwives Annual LSA Audit of Standards NMC Midwives rules and standards NHS..HIGHLAND...

263 263 Standard One Rule 4 Intention to practise notifications are sent to the NMC by the annual submission date specified by the Council Intention to practise notifications received after the annual submission date are sent to the NMC as soon as reasonably practicable Guernsey Benchmark 1.1 Public protection is placed at risk if midwives do not submit their Intention to Practise (ItP) to the NMC by the required annual submission date 1.2 Midwives risk lapsing or losing their midwifery registration if ItPs are not submitted in time to the NMC All midwives have a named Supervisor of Midwives (SoM) to submit their ITP to Accurate information and completion of ITPs submitted to the NMC by the date set by the Council SoM team self assessment, comments and supporting evidence All midwives within NHSH have a designated SoM to whom they submit their ItP form. SOP developed for Employment Services team to ensure newly appointed midwives have submitted ItP and are allocated SoM. SoM_SOP_Newly_Re cruited_midwives_dra All submissions have been on time as per NMC requirements. Submissions received after usual submission date would be dealt with swiftly and recorded on the LSA Database in a timely manner LSA verification and comments Clear evidence of a robust system in place to ensure all midwives have their ItP signed and uploaded by a SoM prior to commencing clinical practice. Evidence supplied that highlighted SoMs have taken an active lead to ensure both the directorate management team, senior charge midwives and bank managers are fully advised of process to be followed. Measurement Met MET Partially Met Not Met 7

264 264 Standard Two Rule 6 All records relating to the care of the woman or baby must be kept securely for 25 years Guernsey Benchmark 2.1 LSAs have inadequate data protection policies for the retention of midwifery records LSAs ensure that there are clear and comprehensive local guidelines for the secure retention of midwifery records that addresses all requirements 3.1 Midwives do not store records securely, this poses a risk to public protection Midwives comply with systems designed to accurately and securely store records for 25 years SoM team self assessment, comments and supporting evidence All maternity records are returned to the Medical Records department at Raigmore Maternity Unit and then sent on to Livingston for central storage. They would be stored as per protocol for 25 years in a secure environment Maternity records in the Community Midwifery Units and Caithness are stored within medical records departments in the Rural General or Community Hospitals. They would be stored as per protocol for 25 years in a secure environment LSA verification and comments Robust evidence available of training and education processes for all midwives in relation to data protection and medical records storage. Evidence supplied indicating robust process of ensuring community midwifery diaries that contain clinical information are securely stored. Measurement Met MET Partially Met Not Met 8

265 265 SoMs and midwives also work in accordance with NHSH policy Health and Social Care Records Manage Standard Three Rule 9 Each practising midwife within its area has a named SoM from among the SoMs appointed by the LSA At least once a year a SoM meets each midwife for whom she is the named SoM to review the midwife s practice and to identify her education needs All SoMs within its area maintain records of their supervisory activities, including any meeting with a midwife All practising midwives within its area have 24 hour access to a SoM Equitable and effective supervision for all midwives working within the local supervising authority Support for student midwives to enable them to have access to a supervisor of midwives Strategy to enable effective communication between all SoMs. This should include communication with SoMs in other LSAs Monitor and ensure that adequate resources are provided to enable SoMs to fulfil their role Consistency in the approach taken by SoMs to the annual review of a midwife s practice which include the SoM undertaking an assessment of the midwife s compliance with the requirements to maintain midwifery registration Ensure the availability of local systems to enable SoMs to maintain and securely store records of all their supervisory activities Guernsey Benchmark 4.1 The LSA consistently exceeds the recommended ratio of 1 SoM to 15 midwives (1.1, 1.2, 1.3, 1.4, 1.6) 4.2 The annual review identifies that a midwife has failed to meet the requirement to maintain their midwifery registration (1.5) LSAs have processes in place to ensure that recruitment supports the necessary number of SoMs to maintain the required ratio and that SoMs have adequate resources to undertake their role LSA Guidelines are clear in giving direction to SoMs as to the content of the annual review so that the SoM undertakes this in a co that a midwife has complied with the requirement to maintain their midwifery registration 9

266 266 Measurement SoM team self assessment, comments and supporting evidence Each midwife has a SoM appointed from within the NHSH area Annual reviews with named SoM are carried out utilising the electronic proforma which is uploaded to the LSA Data Base. All annual reviews are recorded on the Data Base Standard proforma used by all NHSH midwives LSA verification and comments All midwives within NHS Highland have a named SoM and as such have been notified by their named SoM of their annual review date. All midwives have been supplied with the Scottish LSA annual review template to complete prior to meeting their named SoM and ALL midwives eligible for an annual review with their named SoMs have had one undertaken in the past twelve months. Met MET Partially Met Not Met Annual review paperwork -17.d All SoMs are aware of the requirement to record activity on the database. and their personal requirement to maintain accurate reporting. SoM Rota is available to all areas within NHSH to allow staff to make contact with their own SoM or the designated on call SoM. It is commendable that this standard has been met during what has been a challenging year for midwives and SoMs within NHS Highland. It is envisaged that when the statutory supervision model is replaced that all midwives will use their annual review paperwork as a platform for revalidation preparation and to date many 10

267 267 SOM_Rota_-20 17(1).xlsx NHSH ratio is in line with nationally agreed ratio of 1:15. However variation across operational units. Some SoMs take responsibility for higher ratio and do not feel it is compromising safety. Midwives choice and R&R geography has impacted on some caseloads. Currently 6 out of the 18 NHSH SoMs have a caseload exceeding ratio of 1:15 SoMs have been accessed by their supervisees to request help and support in their preparations for revalidation. Robust system of communication noted between SoMs and between SoMs and supervisees. Evidence supplied to confirm that all records relating to supervision outwith open investigations are stored electronically and review/investigation paperwork is returned to the LSA office upon completion for safe storage. LSAdbReport.pdf 1 SoM re-appointed 1 SoM resigned Total of 18 SoMs Any new or orphaned midwives requiring a SoM have been allocated to SoMs with lower ratios. 11

268 268 All NHSH SoMs have addresses and utilise this to communicate effectively across vast area which we cover. Good communication through NHSH SoM forum which meets bi-monthly. NHSH_SoM_MINUTE S 14th_Jun_.d LSA Midwife attends NHSH SoM Forum on a regular basis. All SoMs use the electronic annual review proforma and upload this to the LSA database. Annually SoMs are checking registration dates and when fees due at ITP review. This runs in tandem with NHS Highland registration checking system. SoMs should complete monthly activity sheet on LSA database. This identifies time spent on supervision. NHSH allocate 4hrs / month for supervision. Additional hours to undertake a supervisory investigation is negotiated locally with line managers. 12

269 269 SoMs have a system for keeping a record of dates SoMs have undertaken investigations, to ensure fair allocation of work across NHSH SoM group. Utilise standard paperwork /processes and support of LSA Midwife for investigations. Standard Four Rule 10 Develop a system with employers of midwives and self employed midwives to ensure that a Local Supervising Aut Midwifery Officer is notified of all adverse incidents, complaints or concerns relating to midwifery practice or allega of impaired fitness to practise against a midwife Guernsey Benchmark 5.1 LSAs do not complete supervisory investigations in an open, fair and timely manner LSAs have developed mechanisms to ensure investigations are carried out fairly, effectively, efficiently and to time SoM team self assessment, comments and supporting evidence LSA verification and comments Measurement Met Partially Met Not Met Robust systems are in place across NHSH for reporting of adverse incidents, complaints and concerns. All of above would be discussed at Risk SoMs gave assurance that the Scottish trigger list for supervisory reviews is implemented across NHS Highland. Partially Met 13

270 270 Management meetings and SoM present. Use of DATIX and Trigger Form for reporting. Process for identifying cases and reporting by SoM to LSAMO /onto LSA database. Updated_Trigger_Fo rm_may_15[2].docx NHSH Trigger form in use. Cross reference to Supervision Trigger List and SoM undertakes chronology for onward reporting to LSA Midwife. Whilst the system of notifying SoMs when a review was required worked well in the early part of the year it is notable that the number of reviews for NHS Highland undertaken by SoMs is not comparable with the knowledge of triggers amongst the SoM team present and on further discussion with the SoM team it was accepted that further work in this area is required to give assurance that ALL triggers are being reviewed timeously by a SoM. SOP_LSA_TriggerRe flow%20chart%20fo porting UpdatedSepr%20supervisory%20 SOM%20LSA%20Tri gger%20rota%2020 Risk management meetings are held in localities on a regular basis. SoM on group membership. 14

271 271 Terms_of_Reference _N&W_MRM_Group_O These are followed by Maternal Morbidity and Perinatal Mortality meetings to allow discussion between multidisciplinary team members SoM input and review of cases / complaints at all of these meetings SoM investigations carried out when practice is below what is normally expected or required. NWH Maternity Incident Complaint R SoMs utilise LSA Review and Investigation processes in relation to undertaking an investigation. Support and guidance of the LSAMO & LSA Midwife SoMs maintain accurate records of investigations and forward reports to LSAMO. They are verified for content and standards. SoM minutes are circulated amongst the group who further disseminate to local 15

272 272 teams. Maternity Dashboard can identify trends and changes in activity within each locality SAER / Clinical incidents learning points discussed & shared, standing agenda item on SoM forum NHSH_SOM_Forum_ Agenda_-_Wednesda Standard Five 6. Supplementary Evidence of Statutory Supervision Representation by SoMs: SoM representation at clinical governance meetings Som representation at clinical guideline development SoM team self assessment, comments and supporting evidence Operational Units have Quality & Patient Safety / Clinical Governance meetings. LSA verification and comments Evidence supplied highlighting the input of SoMs within clinical governance meetings and Measurement Met MET Partially Met Not Met 16

273 273 SoMs present / invited to meetings. SoM representative on NHSH CG Committee NHSH Clinical Guideline Group SoM representation from across NHSH teams on this group SoM representation at Maternity Clinical Risk Meetings (Raigmore / Inner Moray Firth and N&W OU) involvement of individual and the team of SoMs when new clinical guidelines are being developed and current guidelines are being reviewed. Standard Six 7. Supplementary Evidence to demonstrate SoM effectiveness in ensuring safe practice SoM interface with audit activities Evidence to demonstrate SoMs are involved in networking activities SoM team self assessment, comments and supporting evidence LSA verification and comments Measurement Met Partially Met Not Met 17

274 274 Record Keeping Audits Workforce Planning review of establishment setting supporting safe staffing levels. Workload tools outcomes discussed at SoM forum. Support with case reviews and midwifery practice across operational units. SoM on membership of NHSH Nursing Midwifery Allied Health Professional Leadership Committee SoM on membership of the NHSH Revalidation Working Group Networking through NHSH Lead Midwives Committee and Maternity & Neonatal Services Strategy and Co-ordination Committee. Evidence supplied highlighting role and input of SoMs when audits are undertaken across NHS Highland. Documentation reviews routinely undertaken when a SoM is involved in reviewing care following an adverse event. MET 18

275 275 Standard Seven 8. Supplementary Evidence to demonstrate SoM development of leadership skills SoM involvement in identifying and encouraging future SoMs to undertake preparation programme SoM involvement in providing mentorship, support and preceptorship for student midwives, student SoMs and newly qualified SoMs Leadership on SoM initiatives across the Board SoM team self assessment, comments and supporting evidence SoMs have undertaken mentorship training and identified SoM for support to student midwives. LSA verification and comments Evidence supplied of SoM involvement in West of Scotland University pre-registration midwifery programme. Measurement Met MET Partially Met Not Met SoM involvement noted in planning to develop a preceptorship programme for newly qualified midwives. SoM involvement in Compassionate connections work noted. Evidence supplied of leadership demonstrated by SoMs when providing advice and support ot women and midwives around issues where women s choices are outwith parameters for low risk care in a low risk setting. 19

276 276 Standard Eight 9. Supplementary Evidence to demonstrate SoMs interface with users of maternity services SoM involvement with MLSC SoM accessibility to users e.g. user strategy, user involvement, user questionnaires SoM advocacy for women i.e. in care planning SoMs supporting women s choices SoMs proactive in the promotion of Normal Birth Patient Opinion input from SoMs SoM team self assessment, comments and supporting evidence Information leaflet on Supervision is available to all women. Notice boards with information available in Raigmore & Caithness Maternity Unit. Women are given support in decision making with regard to place of birth during contact with community midwives and completing birth plans. Offered meeting with SoM. Home births, Free birth SoM involvement meeting with women LSA verification and comments Robust evidence supplied identifying the advocacy role undertaken by SoMs. Robust evidence supplied highlighting the role of the SoMs in supporting women s choices. Measurement Met MET Partially Met Not Met Facebook pages Skye & Sutherland teams 20

277 277 IMG_0117.PNG Priniciples of KCND supported Highland wide Provision and evaluation of Hypnobirthing Classes. New birthing programme for expec Positive feedback from women, supporting normal birth and positive birthing experience. postnatal postnatal questionnaire 1a.pdf questionnaire 1b.pdf postnatal postnatal questionnaire 3a.pdf questionnaire 3b.pdf Hypnobirthing Training for midwives representing all community teams within NHSH. Supporting standard provision of hypnobirthing techniques / classes as part of mainstream antenatal education programme. Two SoM s are Responders on Patient 21

278 278 Opinion links below to recent posting complimenting Midwifery Services in A&B. Similar postings have been made over the last year ranging from Breast Feeding Support, Post Natal Care in the Community, Intra Partum Care and sadly following the loss of a baby these were from a range of maternity services within NHS Highland Standard Nine 10. Supplementary Evidence to demonstrate SoMs are responsible for ensuring that the LSA database is updated and maintained SoM team self assessment, comments and supporting evidence The LSA audit team will review the following evidence on the LSA database as part of the audit process LSA verification and comments The SoMs have demonstrated commitment and dedication whilst fulfilling their role in this challenging year and the evidence supplied through the database entries is commendable. Measurement Met MET Partially Met Not Met 22

279 279 SoM /Supervisee caseload SoM PREP/CPD activities ITPS are uploaded Annual supervisory reviews Personal details of supervisees The LSA midwife highlighted that the role of the named SoM during investigations undertaken in NHS Highland is commendable and has been reflected through supervisees attending their investigation interview having fully reflected on the care they gave and many instances given of the supervisees and named SoM having already agreed and implemented an action plan to mitigate against reoccurrence. 23

280 280 Statutory Supervision Trigger List Appendix 1 Category Definition Stillbirth Baby born dead from 24 weeks of pregnancy Major obstetric haemorrhage Estimated blood loss 2500ml, or transfused 5 or more units of blood or received treatment for coagulopathy (fresh frozen plasma, cryoprecipitate, platelets). (Includes ectopic pregnancy meeting these criteria). Eclampsia Seizure associated with antepartum, intrapartum or postpartum symptoms and signs of pre-eclampsia. Renal or liver dysfunction Acute onset of biochemical disturbance, Cardiac arrest No detectable major pulse. Pulmonary Oedema Clinically diagnosed pulmonary oedema associated with acute breathlessness and O2 saturation <95%, requiring O2, diuretics or ventilation. Pulmonary Embolus Increased respiratory rate (>20/min), tachycardia, hypotension. Diagnosed as high probability on V/Q scan or positive spiral chest CT scan. Treated by heparin, thrombolysis or embolectomy Acute respiratory dysfunction Requiring intubation or ventilation for >60 minutes (not including duration of general anaesthetic). Cerebro-vascular event Stroke, cerebral/cerebellar haemorrhage or infarction, subarachnoid haemorrhage, dural venous sinus thrombosis. Status epilepticus Unremitting seizures in patient with known epilepsy. Anaphylactic shock An allergic reaction resulting in collapse with severe hypotension, difficulty breathing and swelling/rash. Septicaemic shock Shock (systolic blood pressure <80) in association with infection. No other cause for decreased blood pressure. Pulse of 120bpm or Intensive care admission Coronary care admission Maternal Death Unexpected Admission of a Term Baby to Neonatal ITU South East and West Region Supervisors Quality Improvement Group (SQIG) Document Number: 12 Adapted for use across South East and West Region October 2010 Implement April 2008 Reviewed - April 2013, Dec 2015 Review Dec 2018 more. Unit equipped to ventilate adults. Admission for one of the above problems or for any other reason. Include CCU admissions Women who have booked for maternity services and up to one year post delivery 24

281 281 Highland NHS Board 28 March 2017 Item 4.10 INFECTION PREVENTION & CONTROL REPORT Report by Catherine Stokoe, Infection Control Manager and Dr Vanda Plecko, Consultant Microbiologist/Infection Control Doctor, on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control The Board is asked to: Note the position for the Board. Note the progress to reduce and manage healthcare associated infections. Contribution to Highland Quality Approach Strategic Framework and Annual Objectives Contribution to Board Objectives One of the key objectives is to reduce to an absolute minimum the chance of acquiring an infection One of whilst the Board receiving key healthcare objectives and is to ensure reduce our to hospitals an absolute are clean minimum the chance of This acquiring report an presents infection a comprehensive whilst receiving view healthcare of Infection and Control to ensure and Prevention our hospitals data are and clean. activities This report relating presents to annual a comprehensive work plan for scrutiny view of and HAI feedback. data and activities for scrutiny and feedback from the Board. 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. 1. Background and summary The table below shows NHS Highland Infection Prevention & Control targets and performance data. The quarterly data presented below for Clostridium difficile and Staphylococcus aureus NHS Highland is calculated using December 2013 occupancy data. Group Target NHS Scotland NHS Highland Clostridium difficile Age 15 and over HEAT rate of 32.0 cases per 100,000 OBDs to be achieved by year ending 03/17 July-Sept 31.4 July Sept 34.0 Oct Dec 42.0 Red (HPS validated) Red (NHSH data) Staphylococcus aureus bacteraemia HEAT rate of 24.0 cases per 100,000 AOBDs to be achieved by year ending 03/17 July - Sept 33.2 July Sept 32.8 Oct Dec 34.4 Green (HPS validated) Red (NHSH data) Hand Hygiene 95% 95% Green Cleaning 92% 95% Green Estates 95% 97% Green

282 282 Source: - Health Protection Scotland/ISD/Local data. Additional note: The decision to exclude NHS Highland bed occupancy data 2014/2015 and 2015/ from ISD publications remains. The quarterly data presented above for Clostridium difficile and Staphylococcus aureus is calculated using December 2013 occupancy data The Board need to note that we have breached our Staphylococcus aureus bacteraemia case number target and the HEAT target will not be met, however we remain within predicted parameters. We remain on trajectory to meet our target for Clostridium difficile (CDI); however this position remains changeable. Achievements The work being undertaken by the Infection Prevention and Control Team in conjunction with Healthcare Improvement Scotland and Health Protection Scotland, to review the audit methodology relating to hand hygiene and the standard infection control precautions (SICPS) has been presented nationally at the Scottish Patient Safety Programme National Event. This work will be utilised by Healthcare Improvement Scotland to inform the national SICPS audit review and tool development. The SICPs auditor post, appointed till end of March 2017, has undertaken hand hygiene validation audits across NHS Highland. An average compliance of 93% has been demonstrated. The work undertaken by the HAI QIF (Healthcare Associated Infection Quality Improvement Facilitator) has been presented as a poster at a recent Scottish Patient Safety event. The appointment of an experienced Infection Prevention and Control Nurse to a vacancy within the Raigmore Infection Prevention and Control Team has occurred, and they commenced in post in January The Infection Prevention and Control Nursing Team are to hold an Infection Prevention and Control Study day on 27 th of April 2017, in conjunction with the Infection Prevention Society which will raise awareness of infection prevention and control strategies to all staff working within NHS Highland. 2. Challenges The Infection Prevention and Control Nurse in the North, covering maternity leave, is currently providing 15 hours to the Infection Prevention and Control service having had to reduce their level of cover due to work commitments in their substantive post. Support is being provided by the wider Infection Prevention and Control Team as necessary, and this arrangement continues to be monitored by the Lead Nurse North and West Operational Unit, and the Infection Control Manager. New requirements from Health Protection Scotland for surgical site surveillance will include all colorectal and vascular surgical procedures as of April A scoping exercise has established the number of procedures performed, and the resource implications for the Infection Prevention and Control Surveillance team. The cessation of voluntary surveillance on the reduction of long bone fracture and repair of neck of femur surgery from April 2017 will occur. This will be reviewed once the new surveillance fields have commenced.

283 283 The E-Health teams within NHS Highland and NHS Greater Glasgow & Clyde, and ICNET (infection control software programme) Project team have successfully transferred automated microbiological data from NHS Greater Glasgow & Clyde to Argyll and Bute. Weekly meetings are in place to progress this work. NHS Highland has logged a compliant with ICNET in relation to the timeframe for completion which is now being indicated as summer 2017 due to capacity issues within ICNET due to the forthcoming implementation of Ultra Pathology. Whilst we await completion of this automated transfer, the risk that human factors might result in errors and delays in infection control information being received in a timely and accurate manner remains, due to the reliance on manual data inputting and dissemination of laboratory results. The HAI Quality Improvement facilitator post appointed on a fixed term contract will end on the 31 st March The loss of this post will result in the cessation of some of the current work streams being undertaken to improve compliance and reduce healthcare associated infections; whilst other areas will be absorbed by the existing Infection Prevention and Control Nursing team resulting in an additional work load. The Data analyst post appointed on a fixed term contract will end on the 31 st March The loss of this post will result in a reduction of a dedicated review of healthcare associated infection cases, and the associated information generated from this post. The loss of this post and its role and responsibilities would be absorbed by the Infection Control Manager and the Infection Control Doctor, but could not be fulfilled to the same level as it is currently. 3. Risks The Board need to note that we have breached our Staphylococcus aureus bacteraemia case number target and the HEAT target will not be met, however we remain within predicted parameters. Whilst we remain on trajectory to meet our target for Clostridium difficile, this position remains changeable. We are currently unable to calculate our Staphylococcus aureus, and Clostridium difficile HEAT target rates due to the data quality and completeness issues relating to NHS Highland bed occupancy data; we will use case numbers until this is resolved. 4. Planning for Fairness An equality impact assessment is available from the author on request Catherine Stokoe Infection Control Manager Vanda Plecko Consultant Microbiologist & Lead Infection Control Doctor, February

284 284 NHS Highland Healthcare Associated Infection Report 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: 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. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: Staphylococcus aureus bacteraemia target The target for /2017 for NHS Highland is 24 cases or less per 100,000 acute occupied bed days for Staphylococcus aureus bacteraemia (SAB) including MRSA. For NHS Highland this means no more than approximately 60 cases by 31 st March 2017, as of 31 st January 2017 we are reporting 66 cases. The target for 2017/2018 remains as above. The Board need to note that we have breached our Staphylococcus aureus bacteraemia case number target for /2017 and the HEAT target will not be met, however we remain within predicted parameters. 1.2 Trends NHS Highlands position as of 31 st January 2017 (data not yet validated by HPS) is tabled below. 1 st April - 31 st January 2017 MSSA = 65 MRSA = 1 Total SABs = 66 Cases Preventable = 9 (including 3 contaminants) Peripheral vascular device (1); PICC line (1); Vascular catheter (1); surgical site infection (1); urinary catheter (1); Suprapubic Catheter (1); Not preventable = 40 Unknown = 11 Under Investigation = 6 Hospital Acquired Cases = 12 (18%) Community Acquired Cases = 31 (47%) Healthcare Associated Cases = 20 (30%) Contaminant = 3 (5%) Total = 66 For definitions of above classifications please see section 2 page 14 Of the 31 community cases above the breakdown into categories of source is listed below:

285 285 6 cases are under investigation. Out of area visitors account for 5 cases in total; which breaks down into 2 skin infections and 3 of an unknown source. Argyll & Bute Operational Unit; 3 cases in total; which breaks down into 1 skin infections and 2 of an unknown source. North & West Operational Unit; 4 cases in total; which breaks down into 2 skin infections, 1 urinary tract infection, and 1 septic arthritis. South & Mid Operational Unit; 13 cases in total, which breaks down into 1 surgical site infection, 5 skin infections, 4 of an unknown source, 1 respiratory infection, 1 intravenous drug user and 1 discitis. It should be noted that the classification of skin infection utilised above relates to a wide variety of sources determined by Health Protection Scotland. Our cases range from an infected flea bite, to infected eczema. Whilst the overall number of SAB cases appears to be fairly consistent, the number of cases this year to date which are classified as community acquired, does appear to have increased from previous years. Data for 2015/16 identifies that community cases accounted for 16% of the overall cases, compared to 47% to date for /17. Comparable figures for hospital acquired infections have identified a percentage decrease of 7% to date (25% in 2015/16 and 18% /17 to date). This reflects the challenge of only 9 infections being identified as preventable. All SAB cases undergo a review by the Infection Prevention and Control team, and local clinical teams. Any actions identified following investigation are actioned through the appropriate groups, and monitored through the Operational Unit Infection Prevention and Control meetings. Figure 1: NHS Highland Staphylococcus aureus bacteraemia Cumulative Case numbers year on year since The information presented in the graph below is based on NHS Highland case numbers data 70 NHS Highland staph aureus Bacteraemia- Cumulative chart Cumulative Case Numbers April May June July Aug Sept Oct Nov Dec Jan Feb March Heat Target to Current Initiatives A review of practice, of the Insertion and management of peripheral vascular devices is underway; this will inform us of areas for improvement. Implementation of routine MRSA screening for all dialysis patients has commenced following a recent review of a SAB case. 5

286 286 The action plan developed to implement actions to reduce staphylococcus aureus bacteraemia is in place and monitored through the Infection Control Improvement Group and Control of Infection Committee. 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. Information on the national surveillance programme for Clostridium difficile infections can be found at: Clostridium difficile HEAT Target The target for /2017 for NHS Highland is approximately 32 cases or less in patients aged 15 and over per 100,000 total occupied bed days. For NHS Highland this means no more than approximately 78 cases by 31 st March 2017, as of 31 st January 2017 we are reporting 64 cases. The target for 2017/2018 remains as above. 2.2 Trends NHS Highlands position for Clostridium difficile infections as of 1 st April to 31 st January 2017 (data not yet validated by HPS) is tabled below. NHS Highland CDI s 1st April to 31 st January 2017 Total CDI Cases aged 15 and over = 64 Healthcare Associated = 32 (50%) Community Acquired = 24 (38%) Unknown = 5 (8%) Under Investigation = 3 (4%) Aged = 15 Aged 65+ = 49 For definitions of above classifications please see section 2 page 14 There have been 5 re-occurrences in patients with previous history Clostridium difficile during the period September to January Figure 2: NHS Highland Cumulative Toxin positive Clostridium difficile Infection Age 15 and over, year on year since The information presented in the graph below is based on NHS Highland case number data

287 Current Initiatives A trial of an Ultra-violet light decontamination unit is underway in Raigmore Hospital. This technology is proven to reduce the viral and bacterial load of the environment and enhance the effectiveness of manual cleaning. This trial will be reported on in June Antimicrobial Management Management of Infection Guidance Recently updated sections of guidance include treatment of meningitis, management of neutropenic sepsis and additional information on oral step down therapy for intra-abdominal infections. Co-amoxiclav Prescribing Project A review of GP co-amoxiclav prescribing data for 12 months to September 2015 highlighted 13 practices with a prescribing rate above the national average. In January, the Infection Control Doctor sent each practice a letter asking for reflection on prescribing patterns and potential areas for change. Pharmacist prescribing advisors worked closely with the practices to review prescribing and identify areas for improvement. A comparison of the 12 months to September showed prescribing had reduced by 16.6% (267 prescriptions). Individually, 6 practices reduced prescribing by between one third and one half with a further 5 reducing by between 5% and 20%. In the two remaining practices, prescribing did not change in one (a very small practice) and increased in the other. This practice is now taking part in a quality improvement project to aid decision making around appropriate antibiotic use. Use of co-amoxiclav in primary care will continue to be monitored. Acute Hospital Antibiotic Prescribing Audits The result of the latest audit cycle of antibiotic prescribing in Belford Hospital was presented to the Antimicrobial Management Team (AMT) in January by a junior member of the medical team. Data from August was compared to October with improvements noted in documentation of indication (from 72% to 91%) and documentation of oral duration or review of intravenous therapy (from 44% to 82%). 7

288 288 In Caithness General, a similar audit has produced mixed results, mainly due to the high turnover of medical staff affecting the delivery of feedback prior to them moving to another position out with NHS Highland. The induction pack for new and locum staff contains specific information promoting use of the NHS Highland guidelines and the audit criteria. Raigmore Urology Department conducted an audit of surgical prophylaxis which showed good adherence to guideline recommendations for those procedures that required antibiotics and those procedures that did not. The data was welcomed by the AMT as evidence of implementation of the current protocol. 3 Hand Hygiene Reporting 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: Each Board is responsible for monitoring and reporting hand hygiene compliance data. 3.1 Current Hand Hygiene Compliance Rates NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas, and compliance rates are being sustained above the 95% target. The previous quarterly rates (October to December ) identifies an average of 96% for hand hygiene compliance across NHS Highland. Any areas identified during the audits, as requiring action, are reported immediately to the relevant person for actioning. NHS Highland hand hygiene rolling monthly self audit programme continues across all clinical areas, and the Infection Prevention and Control Team (IPCT) with the support of the SICPs (standard infection control precautions) Auditor, continue to perform validation audits and education to improve compliance. The completion of validation audits by the SICPs Auditor, appointed to support the IPCT till 31 st March 2017, has occurred. An average of 93% compliance is being reported to date. NHS Highland continues to pilot a newly designed standard infection control precautions (SICPS) compliance monitoring tool, in conjunction with the Healthcare Improvement Scotland Project Team. Whilst this review is underway hand hygiene compliance data collected across all NHS Boards will continue to occur utilising the existing tool and methodology designed by Health Protection Scotland in Cleaning and the Healthcare Environment Keeping the healthcare environment clean is essential to prevent the spread of infections. 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: Each Board is responsible for monitoring and reporting the cleanliness of hospitals. 4.1 Current Rates

289 289 The monthly cleaning and estates audits, conducted as per the National Cleaning Services Specification and through the use of Synbiotix (the Facilities Management Scotland web based audit tool), demonstrate compliance rates are being sustained above the locally defined targets (92% domestic monitoring and 95% estates monitoring). The previous quarterly rates (October to December ) identify averages of 97% for domestic monitoring, and 98% for estates across NHS Highland. Any areas identified during the audits, as requiring action are reported immediately to the relevant person A series of unannounced Independent Public Peer Review audits is in progress; these occur across all hospital sites in NHS Highland. 4.2 Healthcare Environment Inspections (HEI) The report for the HEI Inspection of Belford General Hospital (25 th and 26 th October ) was published on the 18 th of January This was a very positive visit and resulted in one requirement and one recommendation: Requirement 1: NHS Highland should ensure that infection prevention and control input is documented prior to purchase of items out with the national procurement system. Recommendation a: NHS Highland should document communication with patients and relatives regarding the risks associated with invasive device use and the care and monitoring of the device use Both areas identified have been actioned and completed. On the 7 th and 8 th of February 2017, a HEI Inspection team attended the Raigmore Hospital Site, and undertook an unannounced healthcare associated infection follow up visit of the Theatre Department. The draft report will be received on the 22 nd of March. Verbal feedback from the Inspection team was very positive, and they identified that all previous requirements had been met. The date of publication for the finalised report is the 18 th April Benchmarking continues against all the national HEI inspection reports published, in order to ensure learning is disseminated. 5. Outbreaks/ clusters and multidrug resistant isolates associated with NHS Highland Ward 5A Raigmore Hospital continues to screen all inpatients for Vancomycin resistant enterococci (VRE), following the identification of 3 cases in November. No further cases of infection have been identified since this time, and the control measures adopted of admission and discharge screening is to be reviewed in February. Vancomycin resistant enterococci are specific types of antimicrobial-resistant bacteria that are resistant to the drug, Vancomycin. Enterococci are bacteria present in the gut, and female genital tract, and are commonly found in the environment. They pose an issue in healthcare due to their association with antimicrobial resistance. January 2017 saw an increase in Influenza A cases, within the general population. Both Raigmore ward 2C and Caithness Rosebank ward, were closed for short periods to allow for the management of Influenza A patients. 6. Surveillance 6.1 MRSA Clinical Risk Assessment (CRA) Screening Audit In 2010 Health Protection Scotland provided a Clinical Risk Assessment tool comprising of three questions, to NHS Boards in order to ensure a consistent risk-based approach to mandatory MRSA swab screening is undertaken. As part of the national mandatory MRSA screening Programme, quarterly compliance data is submitted by NHS Boards to provide assurance that Clinical Risk 9 Assessment (CRA) compliance is at or above 90%.

290 290 MRSA KPI Compliance % NHS Highland NHS Scotland 2014/ 2015 Jan - March Q4 2015/ Apr- June Q1 2015/ July Sept Q2 2015/ Oct Dec Q3 2015/ Jan March Q4 2015/ April- June Q1 2015/ July Sept Q2 2015/ Oct Dec Q4 71% 75% 72% 78% 76% 84% 86% 86% 78% 83% 78% 83% 80% 82% 84% 82% 6.2 Escherichia coli (E. Coli) Bacteraemia surveillance As of 1 st of April the surveillance of Escherichia coli (E. Coli) Bacteraemia became a mandatory requirement for all NHS Boards to undertake. Data is collected by the Infection Prevention and Control Team in conjunction with the relevant clinical teams, and cases discussed to identify learning. 1st April 31 st January 2017 Total Cases = 171 Hospital Acquired = 30 (18%) Healthcare Associated = 35 (20%) Community Acquired = 101 (59%) Not Known = 3 (2%) Under investigation = 2 (1%) The table below presents the figures reported by Health Protection Scotland, January 2017, for the period July to September Healthcare associated Ecoli Infection rate Community Ecoli infection rate (annualised) NHS Scotland 37 per 100,000 bed days 53.3 per 100,000 bed days NHS Highland 32 per 100,000 bed days 50.8 per 100,000 bed days 6.3 Surgical Site Infections (SSI) NHS Highland continues to monitor SSI rates through mandatory and voluntary surveillance. The clinical teams alongside the Infection Prevention & Control Surveillance team and the Scottish Patient Safety Programme team (Acute adult workstream: SSI) are working jointly to review incidents of infection, and ensure that care practices are evidence based and maintained. From April 2017 Health Protection Scotland are requiring Boards to adopt changes to the requirements of national SSI surveillance. Colorectal surveillance and major vascular surgery surveillance will become mandatory; and in addition there will be changes to the current classifications of emergency and elective surgery. A scoping exercise has established the number of procedures performed, and the resource implications for the Infection Prevention and Control Surveillance team. The cessation of voluntary surveillance on the reduction of long bone fracture and repair of neck of femur surgery from April 2017 will occur. The work undertaken to reduce infections in this surgery is well embedded which is excellent for both patients and staff. The cessation of this voluntary light survelliance will be reviewed once the new surveillance fields have commenced. RAIGMORE 30 DAYS READMISSION ELECTIVE COLORECTAL SSI Colorectal SSI rate Jan -November identifies the SSI rate as 14.4%, (152 procedures with 22 infections).

291 291 Figure 3: Number of cases between elective colorectal SSI. no of cases between Raigmore Colorectal Number of cases between Infections day surveillanc period, not SSI date of surgery Series1 Series2 Series3 RAIGMORE 30 DAYS READMISSION ORTHOPAEDIC SSI Total Hip replacement (THR) surgery continues to have a low rate of SSI. January November, there have been 392 procedures with 1 infection (0.25%), compared to 0.28% for Figure 4: Monthly SSI rate in Total Hip Replacement surgery Jan November 11

292 292 Hemi-arthroplasty surgery continues to have a low rate of SSI. Jan Nov there have been 198 procedures with 0 infections (0%). On the 30 th of Nov it had been 402 days since the last Hemi-arthroplasty SSI. Figure 5: shows monthly SSI rate for Hemi arthoplasty surgery Jan 2010 Nov Neck of femur excluding Hemi-arthroplasty surgery continues to have a low rate of SSI. Jan Nov there have been 127 procedures with 0 infections (0%). On the 30 th Nov it had been 509 days since the last surgical site infection.

293 293 Figure 6: Monthly SSI rate for fracture Neck of Femur excluding hemi-arthroplasty 2010 to Nov NHSH 10 DAYS POST DISCHARGE CAESAREAN SECTION SSI Elective C-Section Jan-Nov there have been 300 procedures with 9 infections (3% SSI rate). A small increase is noted from the previous year. Full year data for 2015 identified the rate as 2%, however the rate stills remains low. Figure 7: shows monthly SSI rate for elective C Sections, 2010 to November 13

294 294 Emergency C-Section Jan-November there have been 316 procedures with 8 infections (2.5%). A small increase is noted from the previous year. Full year data for 2015 identified the rate as 2.3%, however the rate stills remains low. Figure 8: shows monthly SSI rate for emergency C-Section, Jan 2012 to Nov Each SSI case is discussed and reviewed for areas of improvement by the C-Section SSI group. The SSI action plan continues to be implemented, and monitored through the SSI group. The Surgical site infection prevention bundle continues to be tested and implemented within the Theatre department. Healthcare Associated Infection Reporting Template (HAIRT) Section 2 Healthcare Associated Infection Report Cards The following section is a series of Report Cards that provide information, for each acute hospital and key community hospitals in the Board, on the number of cases of Staphylococcus aureus blood stream infections and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. Understanding the Report Cards Infection Case Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. SAB cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). For each hospital the total number of cases for each month, been reported as positive from a laboratory report, on samples taken more than 48 hours after admission. Understanding the Report Cards Hand Hygiene Compliance Hospitals carry out regular audits of how well their staff are complying with hand hygiene. Each hospital report card presents the combined percentage of hand hygiene compliance with both opportunity taken and technique used broken down by staff group.

295 295 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. Understanding the Report Cards Out of Hospital Infections CDI and SAB (including MRSA) bacteraemia cases are presented as Out of Hospital Infections and are not attributable to a hospital. This section identifies those infections from community sources such as GP surgeries and care homes, and those from positive samples taken from patients within 48 hours. Abbreviations SAB Definitions Definitions: Hospital acquired infection (HAI): Positive blood culture obtained from a patient who has been hospitalised for 48 hours. OR patient was transferred from another hospital, the duration of in-patient stay is calculated from the date of the first hospital admission. OR If the patient was a neonate/baby who has never left hospital since being born. OR The patient was discharged from hospital in the 48hr prior to the positive blood culture being taken. OR A patient who receives regular haemodialysis as an out-patient. OR Contaminant if the blood aspirated in hospital Healthcare associated infection (HCAI): Positive blood culture obtained from a patient within 48 hours of admission to hospital and fulfils one or more of the following criteria: 1. Was hospitalised overnight in the 30 days prior to the positive blood culture being taken. 2. Resides in a nursing, long term care facility or residential home. 3. IV, or intra-articular medication in the 30 days prior to the positive blood culture being taken, but excluding IV illicit drug use. 4. Regular user of a registered medical device e.g. intermittent self-catheterisation, home CPD or PEG tube with or without the direct involvement of a healthcare worker (excludes haemodialysis lines see HAI). 5. Underwent any medical procedure which broke mucous or skin barrier i.e. biopsies or dental extraction in the 30 days prior to the positive blood culture being taken. 6. Underwent care for a medical condition by a healthcare worker in the community which involved contact with non-intact skin, mucous membranes or the use of an invasive device in the 30 days prior to the positive blood culture being taken e.g. podiatry or dressing of chronic ulcers, catheter change or insertion. Community infection: Positive blood culture obtained from a patient within 48 hours of admission to hospital who does not fulfil any of the criteria for healthcare associated bloodstream infection. Not known: Only to be used if the SAB is not an HAI, and unable to determine if Community or HCAI. CDI definitions Definitions: Healthcare-associated CDI: a case with onset of symptoms on day three or later, following admission to a healthcare facility on day one, OR in the community within four weeks of discharge from any healthcare facility. This may apply to the current hospital or a previous stay in another healthcare facility, e.g. in another hospital, a long-term care facility or other healthcare facilities (e.g. outpatient departments etc.) Community-associated CDI: a case with [onset outside of healthcare facilities, AND without discharge from a healthcare facility within the previous 12 weeks] OR [onset on the day of admission to a healthcare facility or on the following day AND not resident in a healthcare facility within the previous 12 weeks] Unknown association: a case who was discharged from a healthcare facility 4 12 weeks before symptom onset ADTC Area Drugs & Therapeutics Committee AMAU Acute Medical Admissions Unit CDI Clostridium difficile Infection CNO Chief Nursing Officer HEAT Health Improvement, Efficiency, Access, Treatment GDP General Dental Practitioner AMT Antimicrobial Prescribing Team CHP Community Health Partnership CMO Chief Medical Officer CVC Central Venous Catheter ECDC European Centre for Disease Prevention & Control HAI Healthcare Associated Infection 15

296 296 HAI QIF Healthcare Associated Infection Quality Improvement Facilitator HPS Health Protection Scotland JAG Joint Advisory Group CPE Carbapenemase-producing Enterobacteriaceae PICC Peripherally Inserted Central Catheter PVC Peripheral Venous Catheter PPI Proton Pump Inhibitor RIDDOR Reporting of Injuries, Diseases & Dangerous Occurrences Regulations 1995 SHPN Scottish Health Planning Note SICPs Standard Infection Control Precautions IPCT Infection prevention & control team HAIRT Healthcare Associated Infection Reporting Template HSE Health and Safety Executive HFS Health Facilities Scotland MRSA Meticillin Resistant Staphylococcus Aureus MSSA Meticillin Sensitive Staphylococcus Aureus SAB Staphylococcus aureus Bacteraemia SPC Statistical Process Chart Hemiarthroplasty: Operation to treat fractured hip (only involves half of hip) SHTM Scottish Health Technical Memoranda SAPG Scottish Antimicrobial Prescribing Group SPSP Scottish Patient Safety Programme

297 297 NHS HIGHLAND REPORT CARD NHS Highland Staphylococcus aureus bacteraemia (SABs) monthly case numbers SAB's NHS Highland 14 MRSA MSSA Total SABS Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS NHS Highland Clostridium difficile infection monthly case numbers C.difficile NHS Highland 12 Ages Ages 65 plus Ages 15 plus Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Ages Ages 65 plus Ages 15 plus Feb March April May June July August Sep Oct Nov Dec 2017 Jan

298 298 Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Board Total AHP Ancillary Medical Nurse Jan 2017 Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Board Total Jan 2017 Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Board Total Jan 2017

299 299 NHS HIGHLAND RAIGMORE HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Ages Ages 65 plus Ages 15 plus Feb March April May June July August Sep Oct Nov Dec Jan Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

300 300 NHS HIGHLAND CAITHNESS GENERAL HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Ages Ages 65 plus Ages 15 plus Feb March April May June July August Sep Oct Nov Dec Jan Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

301 301 NHS HIGHLAND BELFORD HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Ages Ages 65 plus Ages 15 plus Feb March April May June July August Sep Oct Nov Dec Jan Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

302 302 NHS HIGHLAND LORN & ISLANDS HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Ages Ages 65 plus Ages 15 plus Feb March April May June July August Sep Oct Nov Dec Jan Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

303 303 NHS HIGHLAND NORTH & WEST OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Dunbar Hospital, Thurso Town & County Hospital, Wick Lawson Memorial Hospital Golspie Migdale Hospital, Bonar Bridge MacKinnon Memorial Hospital, Broadford Portree Hospital, Isle of Skye Staphylococcus aureus bacteraemia monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 Ages Ages plus Ages 15 plus Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

304 304 NHS HIGHLAND SOUTH & MID OPERATIONAL UNIT COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card include: Ross Memorial Hospital, Dingwall County Community Hospital, Invergordon Royal Northern Infirmary Community Hospital, Inverness Town & County Hospital, Nairn Ian Charles Hospital, Grantown on Spey St Vincent s Hospital, Kingussie For the purposes of monitoring New Craigs Psychiatric Hospital is included in this report card. Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 Ages Ages plus Ages 15 plus Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

305 305 NHS HIGHLAND ARGYLL & BUTE CHP COMMUNITY HOSPITALS REPORT CARD The community hospitals covered in this report card 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 Staphylococcus aureus bacteraemia (SABs) monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 Ages Ages plus Ages 15 plus Hand Hygiene Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total AHP Ancillary Medical Nurse Cleaning Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total Estates Monitoring Compliance (%) Feb March April May June July August Sep Oct Nov Dec Jan 2017 Total

306 306 NHS HIGHLAND OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 MRSA MSSA Total SABS Clostridium difficile infection monthly case numbers Feb March April May June July August Sep Oct Nov Dec Jan 2017 Ages Ages plus Ages 15 plus

307 307 NHS Highland Board 28 March 2017 Item 4.11 CORPORATE PLANS FOR CHILD PROTECTION AND LOOKED ATER CHILDREN AND YOUNG PEOPLE Report by Dr Stephanie Govenden Lead Doctor Child Protection and Looked After Children and Sally Amor Child Health Commissioner on behalf of Hugo Van Woerden Director of Public Health and Executive Lead for Children and Young People Background and summary NHS Highland has corporate responsibilities with regard to keeping children and young people safe (Child Protection) and as a Corporate Parent for Looked after Children and Young People. These responsibilities are detailed in both Scottish Government Legislation and related policy and guidance. The NHS Board has a proven track record of commitment and engagement in Child Protections Committees in Argyll and Bute and Highland and to its role as a Corporate Parent. The Board has a pro active approach to looking at employment opportunities for young people leaving care and engages in the CHAMPS Board in the Highland partnership and the Corporate Parenting Board in Argyle and Bute. These activities are core to integrated working for children and young people in the Argyll and Bute and Highland partnerships. The Corporate Plans appended to this paper set out the responsibilities and related governance arrangements for the NHS Highland Board with regard to these two areas of responsibility. The scope of the Plans is for all NHS Highland Directors, employees and health staff including those in the commissioned service in the Care and Learning Service Highland Council. The Strategic Goals outlined in the reports will be implemented through the NHS Highland Child Protection and Looked after Children and Young People Governance Group. This is co-chaired by the Deputy Director of Nursing and the Lead Paediatrician for Child Protection and Looked after Children. This group reports to the NHS Highland Children and Young People Planning Forum and informs integrated service planning for children and young people and related improvement work in the Highland and Argyll and Bute Partnerships. The Corporate NHS Highland Plan forms the NHS health contribution for the Highland and Argyll and Bute Corporate Parenting Strategies. The NHS Highland Board is asked to: Note and agree the proposed Corporate Plan for Child Protection Note and agree the proposed Corporate Plan for Looked After Children and Young People Agree to updates on progress to be included in the Child Health Commissioner report to the NHS Board in autumn 2017

308 308 Report The Corporate Plans are appended to this report. 3 Contribution to Board Objectives The revised role and remit will address a range of Board objectives as follows: Objective 2: Improving Population Health and Reducing Inequalities Objective 3: Creating a Caring, Person-centred Experience Objective 4: Providing Safe and Effective Care Objective 5: Transforming Services Objective 7: Engaging our People Objective 9: Ensuring Value and Sustainability 4 Governance Implications Staff Governance Patient and Public Involvement Engagement and consultation with Care Experienced Young People through the Highland CHAMPS Board will inform the work Clinical Governance (including Information Governance, where relevant) None of note Financial Impact None of note 5. Risk Assessment None of note 4. Planning for Fairness An equality impact assessment is available from the author on request 5. Engagement and Communication None of note Stephanie Govenden Lead Consultant Paediatrician Child Protection Sally Amor Child Health Commissioner/Public Health Specialist 23 February 2017

309 309

310 310 NHS Highland Child Protection Corporate Plan Summary The Child Protection Corporate Plan sets out the corporate responsibilities and related governance arrangements for the NHS Highland Board to keep children and young people safe. The Plan details a series of strategic goals and actions required to strengthen child protection processes across the organisation over the next two years. The Strategic Goals outlined in this report will be implemented through the Child Protection and Looked After Children and Young People Governance Group. This is chaired by the Deputy Director of Nursing and the Lead Consultant Paediatrician for Child Protection and Looked After Children. This group reports to the NHS Highland Children and Young People Planning Forum and informs integrated service planning for children and young people and related improvement work in the Highland and Argyll and Bute Partnerships. The scope of the paper is for all NHS Highland Directors, employees and health staff including those in the commissioned service in the Care and Learning Service Highland Council. Introduction All children and young people deserve to be safe, no matter who they are or what their circumstances. All Directors and employees in NHS Highland have a duty of care to protect children and young people. These responsibilities range from leadership roles for the Executive team and corporate services, and staff participation in formal processes to the everyday duties of all staff to respond appropriately at every level of the organisation to a concern about a child s welfare and safety. The Board has a responsibility to ensure the necessary knowledge and skills across the organisation to achieve this to best effect. The NHS Board has a proven track record of commitment and engagement in Child Protections Committees in Argyll and Bute and Highland. This plan focuses on the specifics of the NHS s contribution to keeping children and young people safe from significant harm. Background The corporate responsibilities of the NHS Board are detailed in child protection legislation, as a number of Acts, including: Children (Scotland)Act 1995; Adoption and Children (Scotland) Act 2007; Protection of Vulnerable Groups (Scotland) Act 2007; Children s Hearings (Scotland) Act 2011; Children and Young People (Scotland)Act Importantly, the Scottish government is committed to its duties under the United Nations Convention on the Rights of the Child (UNCRC). The Convention includes four general principles that are not only rights in themselves but underpin every other right within it, these are: For rights to be applied without discrimination (Article 2) For the best interests of the child to be a primary consideration (Article 3) The right to life, survival and development (Article 6) The right to express a view and have that view taken into account (Article 12)

311 311 National Guidance for Child Protection in Scotland and Child Protection Guidance for Health Professionals was published in 2014 and 2013, respectively. Intercollegiate training guidelines published in 2014 also inform the Board s responsibilities. In addition to legislation the Scottish Government published revised guidance to Child Protection Committees in Child Protection Health Services There is a Lead Paediatrician for Child Protection for the Board who provides expert advice and consultation to the Board. Clinical teams in the Highland Health and Social Care Partnership include the paediatric medical team at Raigmore with the Child Protection Advisors in the commissioned service Care and Learning. They also work with Forensic Medical Examiners where medical examinations are required. In Argyll and Bute Health and Social Care Partnership, the Child Protection Advisors work with the Lead Paediatrician (Greater Glasgow and Clyde SLA) with Greater Glasgow and Clyde Forensic Medical Examiners. Child Protection clinical practice is supported by Regional Managed Clinical Networks in both the North (HHSCP/Care and Learning Highland Council) and the West of Scotland (A+ HSCP). They have responsibility for setting clinical standards and core data sets with related scrutiny and oversight activity. Child Protection Committees (CPC) Children and young people are kept safer by good partnership working. Highland and Argyll and Bute each have a Child Protection Committee (CPC) whose principal role is to ensure that positive child protection outcomes are achieved through continuous improvement, strategic planning, public information and communication. NHS Highland is a key statutory partner in the CPC, with representation by the Director of Public Health, the Child Health Commissioner and the Lead Doctor for Child Protection and Looked After Children. Key to protecting children is that relevant professionals appropriately share information according to current government and local policy. The primary role of the CPCs is to ensure that the across the Safer Highland Partnership in Highland and through the Public Protection Chief Officers Group in Argyll and Bute, there are adequate measures in place to protect and safeguard the welfare of children. The governance structure below details the governance and lines of accountability for child protection: Overview of Governance Structure

312 312 Safer Highland Partnership NHS Highland Board HHSCP Children and Young People's Planning Forum A&B Public Protection Chief Officers Group Highland CPC A&B HSCP Child Protection & Looked After Children Clinical Governance Group Argyll & Bute CPC Child Protection Vision, Values and Strategic Goals The NHS Highland Vision for keeping children and young people safe is informed by legislation, national policy and professional best practice. Our vision is that all staff feel both confident and competent when making decisions in the context of child protection. We aim for staff to be supported by a positive internal response to incidents and concerns. NHS Highland values listening, treating people with respect and dignity and recognises that children and young people are equally entitled to receiving excellent and compassionate care from our organisation. The strategic goals that inform how will deliver the vision are detailed below: Strategic Goals 1. Embed child protection processes into mainstream working across the organisation. 2. Develop a culture of learning that is reflective and adaptive, to include incorporating learning from any significant case reviews into NHS Highland s policies and working practices. 3. Deliver high quality multi-agency training to meet professional and national standards for child protection training to allow staff to fulfil their roles. 4. Measure and monitor the quality of our work through an effective audit process. 5. Provide up to date, appropriate advice and support that will enable staff to make the right decision at the right time for children. 6. Work in partnership with all agencies within the Child Protection Committee to demonstrate continuous learning and improvement and to raise awareness of child protection matters within the community. 7. Provide guidelines and policies for staff to fulfil their child protection responsibilities. Achieving the Strategic Goals 1. Goal 1: Embed child protection processes into mainstream working across the organisation. With the introduction of child protection training across the organisation we will ensure that staff and managers have all necessary processes in place to consider child protection matters within their clinical teams, including those staff whose work is exclusively with adult

313 313 patients. It is envisaged that child protection is a regular topic for discussion within a multidisciplinary setting where this is relevant to clinical practice. 2. Goal 2: Develop a culture of learning that is reflective and adaptive, to include incorporating learning from any significant case reviews into NHS Highland s policies and working practices. NHS Highland supports and contributes to initial and significant case reviews conducted by the CPCs. Learning from local and national significant case reviews, with direction and guidance from the Child Protection Committees, will be disseminated to staff through training events and updates. Staff will be invited to consider the implications of these for current practice and to model best practice throughout the board and across teams. The SCR process is separate to internal NHS procedures such as serious adverse event reviews. 3. Goal 3: Deliver high quality multi-agency training to meet professional and national standards for child protection training to allow staff to fulfil their roles. NHS Highland staff will participate in, support and contribute to child protection training that is delivered to health staff and to multi-disciplinary and multi-agency groups. We will develop and publish our child protection health staff training strategy with the support of the child protection learning and development coordinator. 4. Goal 4: Measure and monitor the quality of our work through an effective audit process. The Child Protection Clinical Governance Group oversees the monitoring and audit of NHS Highland s child protection processes. Staff will be invited to audit relevant topics of their own choosing as well as key indicators of progress. Audit is one method of providing required assurances to the board and thus the Child Protection Committee that NHS Highland meeting the required standards. 5. Goal 5: Provide up to date, appropriate advice and support that will enable staff to make the right decision at the right time for children. NHS Highland has a number of resources for staff who have child protection queries. Resources include web based information, accessible both on the intranet and internet, and a range of fully qualified staff that are available for advice, support and guidance. NHS Highland is committed to updating the web resources including those to support training and to ensuring that staff know who to contact for advice when they have a concern. 6. Goal 6: Work in partnership with all agencies within the Child Protection Committee to demonstrate continuous learning and improvement and to raise awareness of child protection matters within the community. It is a government requirement that the Child Protection Committee provides evidence of continuous learning at a local level. NHS Highland is a key agency that contributes to the work of the CPC and is closely involved in its work to demonstrate the multitude of ways in which lessons have been learned and practice has changed as a result of direct experience of challenging child protection events. NHS Highland is actively supportive of all health staff who work across agencies and in the third sector to support vulnerable children who have experienced abuse or are at risk of abuse. We are committed to working with partners to

314 314 protect children and young people in Highland, in the knowledge that child protection is everyone s business. 7. Goal 7: Provide guidelines and policies for staff to fulfil their child protection responsibilities. Staff at every level of our organisation require appropriate guidance to support their clinical practice and to use as a basis for making difficult decisions and informing risk in cases where they are considering child protection matters. This guidance may be multi-agency or specifically directed at health staff working a child protection context. NHS Highland will contribute to the writing and production of relevant guidance for staff working with children, young people and their families where there is a child protection concern. The guidance will be subject to all due scrutiny through local clinical governance processes and the review of the Child Protection Committees to ensure it is fit for purpose. Next steps The Strategic Goals outlined in this report will be implemented through the Child Protection and Looked After Children and Young People Governance Group. This is chaired by the Deputy Director of Nursing and the Lead Paediatrician for Child Protection and Looked After Children. This group reports to the NHS Highland Children and Young People Planning Forum and informs integrated service planning for children and young people and related improvement work in the Highland and Argyll and Bute Partnerships. It is proposed that the NHS Board be advised and updated annually on progress being made alongside consideration of Child Protection Committee Annual Reports from the Highland and Argyll and Bute Partnerships. NHS Highland Relevant Contact Information: Pat Tyrrell, Deputy Director of Nursing Dr Stephanie Govenden, Lead Paediatrician for Looked After Children and Child Protection Sally Amor, Child Health Commissioner

315 315 NHS Highland Corporate Parenting Plan Summary This Corporate Plan sets out the responsibilities and related governance arrangements for the NHS Highland Board as a Corporate Parent for Looked after Children and Young People. The Plan, informed by legislation and Scottish Government policy, details a series of strategic goals and actions required to strengthen our approach as a Corporate Parent across the organisation over the next two years. The Strategic Goals outlined in this report will be implemented through the NHS Highland Child Protection and Looked after Children and Young People Governance Group. This is chaired by the Deputy Director of Nursing and the Lead Paediatrician for Child Protection and Looked after Children. This group reports to the NHS Highland Children and Young People Planning Forum and informs integrated service planning for children and young people and related improvement work in the Highland and Argyll and Bute Partnerships. The Corporate NHS Highland Plan forms the NHS health contribution for the Highland and Argyll and Bute Corporate Parenting Strategies. The scope of the paper is for all NHS Highland Directors, employees and health staff including those in the commissioned service in the Care and Learning Service Highland Council. Introduction It is well recognised that looked after children and young people remain one of the most vulnerable groups within our society. The term looked after refers to all children and young people who are looked after by the local authority and all care leavers up to age 26 years. Looked after children and young people are less likely to live a healthy and peaceful life where they have achieved their full potential compared to their counterparts who are not looked after (Education Outcomes for Looked After Children 2014/15 Scottish Government). They have often been faced with adversity and trauma at an early age, and the effects of those experiences can be lasting and potentially very damaging. In order to grow and thrive they need systems that support and nurture them proactively, and that can take into account the typical challenges they might face. These challenges include frequent changes of address and uncertainty over their carers or parents, placements and education (2010, Looked after Children and Young People. NICE guidance, PH28). NHS Highland strives to be a responsible corporate parent working with the partnerships in Argyll and Bute and Highland Council to provide joined up services for looked after children and young people. This supports the sharing of expertise and experience to promote the best possible outcomes for these children and young people. Background The Scottish government introduced the concept of corporate parenting through the Children (Scotland) 1995 Act, which was targeted at local authorities. Most recently through the Children and Young People (Scotland) Act 2014 the government has specified who corporate parents are, and what is expected of them. There is a clear message from senior politicians that looked after children and young people are a priority for all organisations in Scotland. The legislation and guidance makes explicit the fact that all partners have a duty to

316 316 safeguard the welfare and wellbeing of looked after children and young people, and to ultimately secure nurturing, positive childhoods, from which these vulnerable young people can develop into successful learners, confident individuals, responsible citizens and effective contributors. (Children and Young People (Scotland) Act 2014: Statutory Guidance on Part 9: Corporate Parenting: Scottish Government.) The legislation requires that these are embedded within organisations and that all organisations are jointly responsible for securing the rights and well being of looked after children and care leavers who are ordinarily resident within the health board area. A Needs Assessment undertaken in 2013 by NHS Highland showed that proportionally, Highland had more looked after children and young people in residential care (16% in Highland, 13% in Argyll and Bute, versus 9% nationally) and a greater percentage of children with additional support needs compared to Scottish averages (24%, compared to 11% nationally). Available from: HealthSciences/Documents/Publications%20+%20Resources/LACYP%20Review%20Final %20Report%20June% pdf [accessed September ]. Local audit work (Highland Partnership Looked After Children and Young People Data Commentary 1 January December 2015), shows that in terms of health needs there were developmental concerns in around a quarter of boys aged under 16 and in a third of girls aged 5-9 years. With regard to maintaining a healthy weight, Highland data revealed a concerning pattern of a rising proportion of LAACYP who are overweight as they get older (between 4 and 15 years) resulting in 40% of girls aged years, who have a body mass index above the normal range, compared to a Scottish national average of 28% at risk of overweight or obese, amongst 2-15 year olds. Most recent Scottish government figures show that 93% of all children and young people in residential care have additional support needs, and a majority of these are social, emotional and behavioural in nature (Children's Social Work Statistics Scotland 2014/15, Scottish Government). Health Services for Looked After Children and Young People It is the duty of each corporate parent to assess the needs of the children and young people in its care and to provide each and every child with the opportunity to access the services they need and to promote the interests of looked after children. Within the Argyll and Bute Partnership health assessments for Looked After Children and Young People are undertaken by community paediatrics with ongoing health needs met by nursing colleagues. Within the Highland Partnership the health needs are assessed by the commissioned service in the Care and Learning Service. A review of data collected within the service, recently taken to the HHSCP Committee is informing a review and refresh of the health assessment and access to services and colleagues from Argyll and Bute are invited to be part of the discussion. The healthcare needs can be considered under the headings illustrated below in Fig.1:

317 317 Care Prevention Promotion Acute care needs including managing children with complex physical and mental health needs in residential and secure placements. Prevention covers the timely identification of health needs from initial health assessments with appropriate onward referral, through to addressing the mental health needs of looked after children. Promotion: Access to universal health services by looked after children, including primary care, dental services and vaccinations. Fig. 1 Pyramid of care to support the needs of looked after children. Collaborative Working with Partners Getting It Right For Every Child is an approach that is firmly embedded in the Highland Partnership through the use of the Highland Practice Model and related GIREFC processes in Argyll and Bute. Integrated service models further promote joint working between NHS, social care, education with health staff working within family teams to provide wrap around care for all children and young people. This system provides us with many opportunities to share best practice and to work together to provide joined up care for the looked after children and young people entrusted to us. Overview of Governance Structure CHAMPS Board For Highland s Children Leadershi p Group NHS Highland Board HHSCP A&B HSCP Children and Young People's Planning Forum Child Protection and Looked After Children and Young People Governance Group Corporate Parenting Board A&B Getting it Right for Argyll and Bute s Children Looked after Children and Young People Vision and Values and Strategic Goals NHS Highland has set out its key actions for the promotion of the health and wellbeing of looked after children below. These have been discussed and developed with the Looked After Children s Health Improvement Group (Care and Learning) and the Looked After Children s & Child Protection Governance Group (NHS Highland) and taken through the Children s and Young People s Planning Forum within NHS Highland. Following the introduction of these actions, progress towards achieving them will be tracked through an audit process, overseen by the NHS Highland Child Protection and LAC

318 318 governance group. In October 2017 the audit findings will be reported and reviewed and a follow on plan made for further actions. All findings and data will be shared with the Highland council through the looked after children s (health) improvement group so that where necessary, joint decisions can be made to best promote the welfare of looked after children and young people. Strategic Goals 1. Demonstrate visible corporate leadership by the NHS Board for the health and well being and access to quality services for children and young people. 2. Listen to the voice of looked after children and young people and incorporate their views and opinions wherever possible to promote their health. 3. Record and report looked after children s health information accurately and consistently. 4. Prioritise the mental health needs of looked after children and young people. 5. Promote awareness and knowledge of the specific health issues that looked after children face and how these can be addressed to relevant staff. 6. Enable close collaboration between health partners to ensure timely assessment and referral for looked after children who have additional health needs. 7. Provide support through the transition to adulthood for looked after children using our services aged 16 to 18 years. 8. Contribute to the Child s Plan health information to promote looked after child s wellbeing. Table 1. Corporate Parenting Goals for NHS Highland to promote the wellbeing of looked after children. Achieving the Strategic Goals Goal 1: Visible leadership training and development for Board Members and senior leaders with Who Cares? Scotland. Training and awareness raising with the NHS Board members and Operational Directors will be provided every two years. Goal 2: Listen to the voice of looked after children and young people and incorporate their views and opinions wherever possible to promote their health. NHS Highland will continue to participate in the young people s Champions Board in both the Highland and Argyll and Bute Partnerships which listens to the views and concerns of young people who are looked after. NHS Highland will work to engage looked after children and young people in awareness of their health needs and what it means to them, to be well, and healthy. Through the Child Protection Committeee, NHS Highland supports the introduction and use of Viewpoint, a software tool to gather children s views and thoughts. This will be used to direct areas of work and action and reports can be used as indicator to help us know how well our aim is being met. Goal 3: Record and report looked after children s health information accurately and consistently.

319 319 NHS Highland staff are working with looked after children across both Partnerships while health staff in the Care and Learning Service Highland Council are also supported professionally through NHS Highland. We will collect and share relevant information on an ongoing basis and add to and expand upon our existing data on the health of local looked after children through the improvement group structure. Goal 4: Prioritise the mental health needs of looked after children and young people Within the Highland Health and Social Care Partnership and Argyll and Bute children s and adolescent mental health team there is existing expertise in managing the acute and chronic mental health needs of looked after children and young people. There is a current programme of work being rolled out to both understand the full extent and range of mental health need experienced in the region by looked after children and young people, and to understand the needs of staff and carers who support children and young people who are looked after. Goal 5: Promote awareness and knowledge of the specific health issues that looked after children face and how these can be addressed to relevant staff. Whilst we recognise that certain staff groups such as Community Paediatricians have an expertise in caring for looked after children and in adoption and fostering, training and awareness are key to the action plan. NHS Highland will highlight the importance of focusing on the needs of looked after children and young people and their particular vulnerabilities through its wider training programme and through specific training events for key staff groups. These will be carried out face to face or online and NHS Highland will make available online training resources for staff to learn more about the specific health needs of looked after children. Goals 6, 7 8: Enable close collaboration between health partners to ensure timely assessment and referral for looked after children who have additional health needs; provide support through the transition to adulthood for looked after children using our services aged 16 to 18 years; contribute to the Child s Plan health information to promote looked after child s wellbeing. NHS Highland and partners in Argyll and Bute and Highland Council are involved in joint working to improve the health of looked after children. A Looked After Children (Health) Improvement Group has been established with links back to each partnership as part of Integrated Children s Service Planning arrangements. The group has identified four key themes or areas of work to focus upon, as follows: Early identification of health issues and appropriate timely referral when a need is identified. Communication and documentation at all levels between carers and parents, children themselves and between professionals when communicating concerns affecting a looked after child. Delivery of expert care including: o Workforce development (including foster carers) o Health assessments o Quality of health information within the Child s Plan o Governance Universal service delivery.

320 320 Within each area identified, a programme of work will be delivered to address the specific and relevant concerns. Next steps The Strategic Goals outlined in this report will be implemented through the Child Protection and Looked After Children and Young People Governance Group. This is co-chaired by the Deputy Director of Nursing and the Lead Consultant Paediatrician for Child Protection and Looked After Children. This group reports to the NHS Highland Children and Young People Planning Forum and informs integrated service planning for children and young people and related improvement work in the Highland and Argyll and Bute Partnerships. It is proposed that the NHS Board be advised and updated annually on progress being made alongside consideration of Corporate Parenting Annual Reports from the Highland and Argyll and Bute Partnerships. NHS Highland Relevant Contact Information: Pat Tyrrell Deputy Director of Nursing (co Chair Looked After Children and Child Protection Governance Group) p.tyrrell@nhs.net Dr Stephanie Govenden, Lead Doctor for Looked After Children and Child Protection (co Chair Looked After Children and Child Protection Governance Group) stephanie.govenden1@nhs.net Sally Amor Child Health Commissioner sally.amor@nhs.net

321 321 THE COMMUNITY EMPOWERMENT ACT: ASSET TRANSFER REQUESTS Highland NHS Board 28 March 2017 Item 4.12 Report prepared by Helen Sikora on behalf of Hugo van Woerden, Director of Public Health and Health Policy This report is for information, to inform the Board of: The framework and supporting documentation developed by Public Health to enable NHS Highland to respond to Asset Transfer Requests meeting the regulations implemented under the Community Empowerment Act Background The Community Empowerment (Scotland) Act was passed in June The Act places new duties on a range of public sector bodies and provides new rights for community organisations. These include rights for community bodies to request ownership, lease, management or use of publicly owned buildings or land whether or not they are available for sale or deemed surplus to requirements by the owning body. There are a number of implications for NHS Highland including being able to respond to requests from communities for transfer of assets. On receipt of a request, NHS Highland must assess the request its economic, social and environmental benefits and whether it contributes to reducing inequalities. Requests must be granted unless NHS Highland has reasonable grounds to refuse. The Scottish Government s final guidance on Asset Transfer Requests was published in January 2017, and can be found on: Guidance for community transfer bodies: iwhat type of community bodies are eligible, who asset transfer requests can be made to, how to make a request, how the relevant authority will process it, and rights to review and appeal. Guidance for relevant authorities: who can make a request; registers of land and provision of information; procedures for processing requests and matters to be considered in making a decision. It also covers review and appeal procedures Developing the framework A short life working group, co-ordinated by Public Health, developed a process for Asset Transfer Requests that meets the requirements of the Community Empowerment Act and the Scottish Government s final guidance. Public Health worked with the North & West Operational Unit, Estates and the Scottish Government-funded Community Ownership Support Service to develop this framework. We are currently testing this process with a community body in Applecross who have expressed an interest in taking ownership of an NHS Highland asset. 1

322 The framework for dealing with Asset Transfer Requests proposes an informal expression of interest stage to determine the viability of the request before progressing to the more formal legislative stage. The Estates Department have the leadership role in any asset transfer request, with the District Manager/ Locality Manager having a key role in gathering required information and liaising with the community body. Operational management meetings can also be used to assess asset transfer requests with input from district managers, estates, contracts, HR, finance and communications and engagement and make a recommendation to the Asset Management Group for approval before going to NHS Highland Board for final sign off. Workshops and briefing sessions have also been delivered to operational units to inform and raise awareness of this new framework and how to deal with asset transfer requests under the Community Empowerment Act. Documents developed The following documents are attached which support the organisation to implement the new regulations for Asset Transfer Requests. These documents will be available on the NHS Highland website from April Appendix 1: A guide to asset transfer requests and the Community Empowerment Act Appendix 2: Asset Transfer Request Flowchart Appendix 3: NHS Highland Asset Transfer Request Guidance Pack: includes the framework and supporting documents for dealing with requests Planning for Fairness 322 An equality impact assessment is available from the author on request 2

323 Appendix A guide to asset transfer requests and the Community Empowerment Act What is the Community Empowerment Act? The Community Empowerment Act sets out a plan for empowering all the people of Scotland. This means everyone can get involved and help to make important decisions. Communities can be groups of people in the same local area, or groups of people with a common interest. People feel better when they have a say about what happens in their communities. They can make things better because they know what will work for them. People feel more confident and learn new skills when they have the right support. This can mean: more jobs more access to services and support less crime better health more equality Public service providers should give communities a say in how services are given. Examples of public service providers are hospitals, schools, police, and local councils. Communities should also have help to do things for themselves if they need help. This could be for things like taking over a building for people to meet and socialise, or helping people learn new skills. People who shape and run public services should ask local people what services they need. They should also ask how these should be delivered. The Scottish Government thinks this is important and this is why they introduced a new law called the Community Empowerment (Scotland) Act Helen Sikora, NHS Highland

324 324 Taking over publicly owned land or buildings Local councils, government organisations and other public bodies own or rent lots of land and buildings, like schools, hospitals, parks and forests. Sometimes not all of the building or land is being used. The building could be put to better use by the community or used to the best benefit of the community The Scottish Government wants to change the law so that community organisations can ask to take over control of these buildings or land. The local council, government organisation or other public body will have to listen to what the community would like to do. If the community organisation s plan is better for local people, they will be allowed to buy or rent the land or building. NHS Highland will ask community groups who want to take over publicly owned land or buildings to fill out an application form. This helps makes sure that the community organisation is open to everyone, speak for their community and the plan will benefit local people. This is called an Asset Transfer Request. Helen Sikora, NHS Highland

325 325 How to make an Asset Transfer Request to NHS Highland NHS Highland encourages community organisations to first speak to their District Manager to find out more about their ideas to benefit the community. The District Manager will ask the community group to fill out an Expression of Interest form. This is a short form to help open a discussion between the community organisation and NHS Highland. This is to help the community organisation put a plan together about how their ideas might work before they spend lots of time completing a longer formal application. Once NHS Highland has looked over the Expression of Interest, they will: contact the community group to progress the plan ask for more information or let them know if there are any problems with their plan and why If the plan is suitable the community group will be asked to fill out a formal application form. This does require more time and the community group will have to provide some documents to evidence that they are eligible and how the plan will benefit the community referring to national, regional and local outcomes ( The community group has at least six months to complete this form and return it to NHS Highland. NHS Highland has up to six months to assess the formal application and let the community organisation know their decision. Community group contacts District Manager Community group complete Expression of Interest form NHS Highland responds to expression of Interest form 6 months Community group complete formal application form 6 months or more if delays occur and NHS Highland are informed. NHS Highland responds to the application with a decision The documents you need and further information is available on the NHS Highland website (insert link to NHSH website) Helen Sikora, NHS Highland

326 Appendix 2 - ASSET TRANSFER REQUEST FLOW CHART INFORMAL EXPRESSION OF INTEREST NHSH publishes: Register of assets Community group contact NHSH District Manager for initial discussion Community group prepares and submits Expression of Interest Support offered via COSS to community to prepare formal request 2. FORMAL REQUEST NHSH key contacts review/comment on application YES All required information provided/ organisation is eligible?? NO Community group prepares and submits formal application 3. ASSESSMENT Request additional information/ respond Comments collated and reported to OU management team OU management team make recommendation Approval required from Asset Management Group and finally the Board DDO sends Decision Notice to community group 4. FORMALISING THE OFFER Contract negotiation between NHSH and community group Community group responds to formally take up the offer Option to appeal to Ministers

327 Appendix NHS HIGHLAND GUIDANCE FOR ASSET TRANSFER REQUESTS Please follow this guidance to respond and deal with asset transfer requests 1. Informal Expression of Interest The Expression of Interest (EOI) stage helps the Community Transfer Body (CTB) develop their proposal and determine its viability before going through the extensive formal application stage. This informal stage has no legal standing under the Community Empowerment Act and the CTB has the right to proceed to the formal request stage regardless of the outcome of the EOI and without engagement with the District Manager. The Community Transfer Body (CTB) contacts the relevant District Manager to discuss their proposal informally. The District Manager signposts the CTB to the Community Ownership Support Service for advice and support to develop their proposal. The CTB completes the Expression of Interest (EOI) - see ANNEX 1. The CTB return their completed EOI to the District Manager The District Manager sends the completed EOI to the Estates Department (Helen Emery). The Estates Department review the request and advises the District Manager of the viability of the request (checking compliance with legal, property handbook, planning and clarity of ownership). Estates have 2 months to respond. The District Manager checks the CTB is eligible - see ANNEX 2 for eligibility guidance under the Community Empowerment Act (seek guidance from the contracts team) The District Manager reports to their Operational Management Team with a recommendation to accept in principle, require further information, or refuse the request. The District Manager responds to the CTB on behalf of the Operational Management Team with the outcome of the EOI see ANNEX 3 letter template.

328 Formal Request The formal request stage follows the legislation set out in the Community Empowerment (Scotland) Act Timescales and requirements are determined by the Act. The CTB has 6 months to complete the Formal Request form see ANNEX4. The CTB sends the completed Formal request form to the District Manager The District Manager checks the formal request is ELIGIBLE and COMPLETE If the request is NOT ELIGIBLE or NOT COMPLETE the District Manager responds to the CTB explaining why If the request IS ELIGIBLE and COMPLETE the District Manager sends an Acknowledgement to the CTB see ANNEX 5 letter template The District Manager forwards a copy of the request to KEY CONTACTS: a. Estates Helen Emery (to log; update property management system; notify tenants) b. Contracts Jacqueline Paterson c. HR (if staff implications) Gaye Boyd d. Finance Iain Addison e. Deputy Director of Operations f. Communications and Engagement Maimie Thompson The key contacts each review the request and provide comment/ advice to the District Manager Eligibility - see ANNEX 2 The constitution must be sent with the formal request form. The eligibility criteria for ownership, lease and management: is set out in the Community Empowerment Act Complete request means that: The CTB has: identified the asset; the reason for the request, the price they will pay; any conditions if lease; the benefits. And included: a copy of the constitution; information about how the CTB will find the transfer and use of land; evidence of stakeholder support; evidence of financial sustainability. Acknowledgement must include: The validation date of the request; the expected timescale for a decision (max 6 months); information on the appeals process. If another public body is affected, they must be notified and must respond within 14 days.

329 Assessment of Request The District Manager collates the comments/ advice received from the key contacts. This is then reported to the operational unit management team (see Annex 6 assessment checklist) The operational unit management team meet to assess the request. This meeting should involve the key contacts (listed above in section 2). The operational unit management team recommends that the request should be accepted, refused on reasonable grounds, or if further information is required. The District Manager liaises with the Estates Department following this recommendation. If the transfer request is recommended to be approved, the Estates Department seek approval from the Asset Management Group and finally the Board. The Deputy Director of Operations issues the DECISION NOTICE to the CTB on behalf of the operational unit management team see Annex 7 letter template Estates log the decision and publish the update on the NHSH website (removing personal information) Reasonable grounds for refusal might include: Not being able to demonstrate: knowledge/ experience; financial sustainability; equal opportunity; stakeholder support The same request has been received within 2 years The request restricts NHSH s ability to carry out its functions The panel/ key contacts must set out what is required and expected to meet the criteria. Decision notice must include: Whether the request has been approved or refused. If refused there must be an explanation of the reasonable grounds and notification of the appeals procedure. If approved the request must include: any terms or conditions for use/ lease/ownership; the date the request was made; the name of the community group; the land/asset subject to the request Restrictions of use and any consequences if these are not met

330 Formalising the offer The CTB submits its offer to the Deputy Director of Operations to formally take up the rights as per their request within 6 months The Deputy Director of Operations notifies the District Manager once the offer is received The District Manager works with the CTB with support from Estates to agree the contract the terms and conditions of the asset transfer Contract agreement must include: Date of transfer The price/ rent and any other terms and conditions e.g. planning or funding If both parties agree the contract timescale of 6 months can be extended, however the community group can appeal to ministers if there are delays. 5. Appeals The CTB has the right to submit an appeal if it is refused, against any terms and conditions, or if a decision is not provided within the timescale. This process is set out in the Community Empowerment Act Reporting requirements: The Estates department must: Update and maintain the assets register Keep and maintain a log of request, acknowledgements and decision notices issued Report annually (financial year) on asset transfer requests. The first report is due in June 2018 and every June thereafter. The report must state: a. How many asset transfer requests were received b. How many requests were agreed or refused c. For requests agreed to, what has been the result d. If appeals have been made, how many have been allowed, dismissed, or resulted in a change e. If any decisions have been reviewed, how many have been confirmed, modified or substituted by a different decision

331 ANNEX Asset Transfer Request Expression of Interest Form Stage 1 NHS Highland is committed to community asset transfer that will bring benefits to communities. It can be a valuable part of supporting and sustaining local communities in Highland and contribute to objectives within the Local Outcome Improvement Plan, for example, or others that would be likely to promote or improve: Economic development Regeneration Public health Social wellbeing, or Environmental wellbeing Before submitting an application interested voluntary and community organisations (VCOs) are encouraged to discuss their options, their suitability and the scope of community asset transfer with their District Manager. These informal discussions will help to finalise requirements and prepare for the process of making a formal application for asset transfer request. NHS Highland recognises that developing the business case and preparing an application for asset transfer request can be both time consuming and resource intensive. Therefore the Expression of Interest stage has been designed to assess whether any potential application will meet the suitability criteria. It should not take long to complete and should avoid wasting valuable resources on an application that may not be eligible or suitable. Applicants that meet the suitability criteria will be invited to complete a formal application for asset transfer. Please try to complete all sections of the form and write not applicable if a section does not apply. Please note: the outcome of the Expression of Interest does not prevent VCOs submitting a formal application for asset transfer request under the Community Empowerment (Scotland) Act The intention of the Expression of Interest stage is to open dialogue between the VCO and NHS Highland and an indication of the success of an asset transfer request under the Act.

332 Please provide details of the voluntary or community organisation (VCO) making the application Name of VCO Address of VCO Telephone Number Address 2. Please provide your contact details Your Name Contact Address Telephone Number Address Position in the VCO 3. Type of voluntary or community organisation What type of VCO are you? Do you have a formal constitution, governance document or set of rules? *If so please send a copy with this form*

333 What is the structure and purpose of your voluntary or community organisation? How many people are involved in your VCO; i.e.:-management Committee; Paid Full-Time Staff; Paid part-time staff How many members does your organisation have? When was the VCO established? What is the purpose and main activities of your VCO? Does your VCO have previous experience of managing an asset? If yes please provide details

334 5. Please tell us about the asset (building or land) you are interested in. Please refer to the NHS Highland asset register. Name of Asset Address of Asset 334 Type of transfer you are interested in (Transfer of ownership, leasing or other rights). If leasing what length of lease is required? Please indicate the price the organisation is offering for either the lease or ownership of the asset 6. Please tell us:- A. What do you want the asset for? B. What benefits will this bring to the local community?

335 335 Signed Position... Name. Date.. Please your completed form to your local District Manager with Community Asset Transfer as the subject heading. The addresses for District Managers are listed below:- Inner Moray Firth North & West Donellen Mackenzie, Inverness West Gavin Sell Inverness East & Nairn Margaret Walker, B&S Christopher Arnold Mid Ross, East Ross Kate Earnshaw Skye, Lochalsh, Wr Ross Lorraine Coe Sutherland Mike Flavell Caithness Marie Law Lochaber

336 ANNEX Community Organisation Eligibility The following definitions and requirements are taken from Part 5 of the Community Empowerment (Scotland) Act Further guidance is available at Meaning of community transfer body (1) In this Part, community transfer body means (a) a community-controlled body, or (b) a body mentioned in subsection (2). (2) The body is a body (whether corporate or unincorporated) (c) that is designated as a community transfer body by an order made by the Scottish Ministers for the purposes of this Part, or (d) that falls within a class of bodies designated as community transfer bodies by such an order for the purposes of this Part. (3) Where the power to make an order under subsection (2)(a) is exercised in relation to a trust, the community transfer body is to be the trustees of the trust. Community transfer bodies that may request transfer of ownership of land (1) A community transfer body falls within this section if (e) it is a company the articles of association of which include provision such as is mentioned in subsection (2), or (f) it is a Scottish charitable incorporated organisation the constitution of which includes provision that the organisation must have not fewer than 20 members, or (g) it is a community benefit society the registered rules of which include provision that the society must have not fewer than 20 members, or (h) in the case of a body designated by an order under paragraph (a) of subsection (2) of section 77, the order includes provision that the body may make an asset transfer request of the type mentioned in section 79(2)(a), or (i) in the case of a body falling within a class of bodies designated in an order made under paragraph (b) of that subsection, the order includes provision that bodies falling within the class may make an asset transfer request of that type. (2) The provision mentioned in subsection (1)(a) is provision that (j) the company must have not fewer than 20 members, and (k) on the winding up of the company and after satisfaction of its liabilities, its property (including any land, and any rights in relation to land, acquired by it as a result of an asset transfer request under this Part) passes (i) to another community transfer body, (ii) to a charity, (iii) to such community body (within the meaning of section 34 of the Land Reform (Scotland) Act 2003) as may be approved by the Scottish Ministers, (iv) to such crofting community body (within the meaning of section 71 of that Act) as may be so approved, or (v) if no such community body or crofting community body is so approved, to the Scottish Ministers or to such charity as the Scottish Ministers may direct

337 ANNEX 3 Subject: Asset Transfer Request 337 Date: Your Ref: Our Ref: Enquiries to: Extension: Direct Line: Dear... I am writing in response to the Expression of Interest you submitted on [insert date] which relates to [insert name of asset]. I have now reviewed the information you provided and have sought advice from officers in the Estates Department who have checked compliance with legal and property requirements. Based on this initial assessment I accept your request in principle and would like to invite you to proceed to Stage 2 of the Asset Transfer Request. I have attached the Stage 2 form and guidance to this letter. Please complete this form by [insert date 6 months from this letter]. OR Based on this initial assessment we are unable to proceed with your request. This is because [insert reason for refusal e.g. not owner, not compliant with planning/ legal requirements or not the right type of organisation/ not constituted etc.]. OR We are unable to proceed with your request as we require further information. Please send us [insert information required] by [insert timescale] so we are able to assess the suitability of the asset transfer request. If you require any further information or would like to discuss you request in more detail please do not hesitate to contact me. The Community Ownership Support Service is a Scottish government funded programme, set up to help community-based groups in Scotland to take on land or building assets for their community. Contact COSS by at coss@dtascot.org.uk or by telephoning: Please note that under the Community Empowerment (Scotland) Act 2015 voluntary and community organisations have the right to request asset transfer and submit a formal application, regardless of the outcome of the Expression of Interest stage. Yours sincerely, [Insert name] Deputy Director of Operations

338 ANNEX Asset Transfer Request Formal Request Form Stage 2 This formal request form should be submitted after the Stage 1 Expression of Interest application has been approved. However Community Transfer Bodies can submit this form independently, without completing the Expression of Interest stage. This Stage 2 Application Form aims to collate all the information that NHS Highland will need to make a decision about the eligibility of the asset transfer request under Part 5 of the Community Empowerment (Scotland) Act The range of information required for each section will vary depending on the nature of the asset transfer request. Please provide as much information as possible for each section to ensure that NHS Highland can effectively process your application. Please write not applicable if a section does not apply to you. The information required to complete this form should be drawn from a range of existing documentation including:- Constitution of the Organisation Business Plan Asset Management Plan Annual Reports Please send copies of the following documents to support your application: Constitution Annual Report Business Plan Evidence of support from stakeholders Relevant policies (e.g. equal opportunities, environmental, child protection, health and safety) Community Transfer Bodies should refer to the requirements of asset transfer requests under the Community Empowerment (Scotland) Act The Community Ownership Support Service is a Scottish government funded programme, set up to help community-based groups in Scotland to take on land or building assets for their community.

339 1. Details of the Community Transfer Body (CTB) applying Name of CTB Address including postcode Telephone Number Address Main contact details Name Contact Address Telephone Number Address Position 3. Legal status of the organisation What type of organisation are you? Registration number (for example charity or company number) Do you have a written constitution? If so please attach. When was the organisation established?

340 Structure and purpose of the organisation Please identify current Board/ Management Committee/ Trustees/ Directors and Chair How often does the governing body meet? Please identify how many people are: full time staff, part time staff and volunteers How many members does your organisation have? Briefly describe the organisation s main aims and objectives 5. Experience of the organisation Please provide details of any experience the organisation has of managing an asset Briefly describe any current activities the organisation provides

341 The asset (building or land) the organisation is interested in Name of asset Address of asset UPRN if known (unique property reference number) State the type of transfer you are interested in (ownership, leasing or other rights). If leasing what length of lease is required? Please provide details of any modifications that will be required to make it suitable for the organisation s use Please indicate how much the organisation wishes to pay and/or any other conditions they wish to include (please note that assets will be transferred at market value unless agreed by Scottish Government)

342 Use of the asset Please explain why you making this request Describe how you will use the asset If the asset will be used by the public please provide details of opening times and any entry or hire charges What population will the asset serve briefly describe who will use it How will the asset transfer request contribute to national, regional and local objectives or outcomes? Please provide reference to any relevant documents.

343 Benefits of the asset transfer request Please describe the benefits of the organisation s use of the asset Economic Development Regeneration Public health Social wellbeing Environmental wellbeing Addressing inequalities Any other benefits, for example promoting inclusion

344 Community support for the asset transfer request Please give details of any consultation you have undertaken with stakeholders Please describe the support the organisation has for the asset transfer request from stakeholders 10. Project planning Please provide indicative timescales for the completion of the asset and transfer Please detail any funding you have secured so far to fund the project Please provide details of any other funding applications you are awaiting a response or any other sources of funding you might have access to e.g. donations or loans

345 11. Financial Information Please complete the table below to provide a breakdown of costs and income for the first three years of the project. Please note that depending on the nature of the asset transfer additional information may be required to demonstrate financial sustainability. A. Expenditure Please specify project start up and running costs (salaries, overheads such as building maintenance, heating, insurance, council tax) Year 1 start up costs Years 1 running costs Year 2 running costs Year 3 running costs Year 4 running costs Year 5 running costs B. Income Please specify the income for the project (trading activities, fundraising, grants, other forms of income) Year 1 income Year 2 income Year 3 income Year 4 income Year 5 income 345

346 346 C. Please indicate the projected profit/ loss for each year Year 1 Year 2 Year 3 Year 4 Year 5 Expected time to break-even If your project does not break-even within 5 years please explain why:

347 Project Management Please describe how you will promote any services that will be provided from the asset Please provide information on how the asset will managed to ensure compliance with statutory requirements and to ensure the asset remains fit for purpose Describe how the project will be monitored and evaluated Identify the main risks to your project and any actions you will take to mitigate the effect

348 Declarations I declare that all the information and statements contained within this application are true. I declare that the asset will NOT be operated as a commercial/ private sector enterprise. Main contact: Signed Position... Name. Date.. Chair of Organisation: Signed Name. Date.. Please send your completed form to the appropriate District Manager marked with Community Asset Transfer.

349 349 The contact details for District Managers are: Inner Moray Firth Inverness West Donellen Mackenzie Alder House Cradlehall Business Park Caulfield Road North Inverness IV2 5GH Inverness East & Nairn Gavin Sell Alder House Cradlehall Business Park Caulfield Road North Inverness IV2 5GH Badenoch and Strathspey Margaret Walker Alder House Cradlehall Business Park Caulfield Road North Inverness IV2 5GH Mid Ross, East Ross Christopher Arnold Alder House Cradlehall Business Park Caulfield Road North Inverness IV2 5GH North & West ANNEX 5 Skye, Lochalsh, Wester Ross Sutherland Caithness Lochaber Kate Earnshaw District Offices Mackinnon Memorial Hospital High Road Broadford Isle of Skye IV49 9AA Lorraine Coe Administration Department Lawson Memorial Hospital Station Road Golspie KW10 6SS Mike Flavell Caithness General Hospital Bankhead Road Wick Caithness KW1 5NS Marie Law Fort William Health Centre Camaghael Forth William PH33 7AQ

350 ANNEX Date: Your Ref: Our Ref: Subject: Asset Transfer Request Acknowledgement Enquiries to: Extension: Direct Line: Dear... This letter is to acknowledge receipt of your asset transfer request in relation to [description of land]. I confirm that the request is made in accordance with the legislation and all required information has been provided. The validation date for this asset transfer request is [date]. (Select A, B or C) A: [I confirm that no other asset transfer request has been received in relation to the land to which your request relates and the land has not been advertised for sale, nor has NHS Highland entered negotiations or initiated proceedings with a view to transferring or leasing that land. We therefore consider that NHS Highland is prohibited by section 84(2)of the Act from selling, leasing or otherwise disposing of the land described above other than to [name of community transfer body] until your request is concluded.] or B: [An asset transfer request has already been received from [name of other community transfer body] in relation to [description of land to which other request relates]. The land has not been advertised for sale, nor has NHS Highland entered negotiations or initiated proceedings with a view to transferring or leasing that land. We therefore consider that NHS Highland is prohibited by section 84(2)of the Act from selling, leasing or otherwise disposing of the land described above other than to [name of other community transfer body] until that request is concluded.] or C: [I confirm that no other asset transfer request has been received in relation to the land to which your request relates. However, [the land has been advertised for sale] / [NHS Highland has already entered negotiations / initiated proceedings with a view to transferring or leasing that land]. We therefore consider that NHS Highland is not prohibited by section 84(2)of the Act from selling, leasing or otherwise disposing of the land described above to someone other than [name of community transfer body], despite your request having been received.]

351 351 Notice of this asset transfer request will be published online at and sent to any tenants or occupiers of the land or building. Any representations made to NHS Highland about this request will be copied to you, and you will have at least 20 working days to comment on them. The request will be considered by the Operational Unit Management Team. We will give you notice of our decision whether to agree to or refuse your request, and our reasons for that decision, by [date 6 months from validation date]. If you do not receive a decision by that date, you may appeal to the Scottish Ministers. You may also appeal if your request is refused, or if the request is agreed but the decision notice specifies material terms or conditions which differ to a significant extent from those specified in the request. Guidance on making an appeal is available on the Scottish Government website ( If you have any questions about the asset transfer process please contact [contact details]. Yours sincerely, [Insert name] Deputy Director of Operations

352 352 ANNEX 6 Asset Transfer Request Assessment Checklist This checklist can be used by the District Manager to log comments and recommendations from the key contacts once they have reviewed the formal request. This will be shared with the operational unit management team to inform the assessment of the asset transfer request. Estates: Helen Emery Comments received Date received: Insert comments here Contracts: Jacqueline Paterson Comments received Date received: HR: Gaye Boyd Comments received Date received: Finance: Iain Addison Comments received Date received: Communications and Engagement: Maimie Thompson Comments received Date received: Deputy Director Operational Unit Comments received Date received: District Manager Comments:

353 353 ANNEX 7 Date: Your Ref: Our Ref: Enquiries to: Extension: Direct Line: Subject: Asset Transfer Request Decision Notice Dear... I am writing in response to the Formal Request Form you submitted on [insert date] on behalf of [insert name of community organisation] which relates to [insert name of asset]. NHS Highland has now reviewed and assessed the information you have provided. If agreed use the following: I am very please to let you know that your request for [lease/ transfer of ownership/ other rights] has been approved. [Please insert any terms and conditions of the transfer request here].. If you wish to proceed, you must submit an offer to us at the address above by [date at least 6 months from date of notice]. The offer must reflect the terms and conditions attached, and may include such other reasonable terms and conditions as are necessary or expedient to secure the [transfer] / [lease] / [other rights] within a reasonable time. OR if refused use the following: We are unable to approve your request for [lease/ transfer of ownership/ other rights] at this time. This is because [insert reason for request not being approved]. I would like to thank you for your interest in the asset and for the time you have taken to submit an asset transfer request. In the meantime if you require any further information or would like to discuss the outcome of your request in more detail please do not hesitate to contact me. You have a right to appeal to the Scottish Ministers to review the decision or any terms and conditions attached that differ to a significant extent from those specified in your request. Any appeal must be made in writing within 20 working days from the date of this notice. Guidance on making an appeal is available at on the Scottish Government website. Yours sincerely, [Insert name] Deputy Director of Operations

354 354 NHS Highland Board 28 March 2017 Item 4.13 Chief Executive and Directors Report Emerging Issues and Updates Report by Elaine Mead (Chief Executive) Realising Realistic Medicine The Chief Medical Officers Annual Report (2014/15) on Realistic Medicine (published in Februray ) has been followed up with her second Annual Report (2015/16) Realising Realistic Medicine (February 2017) The Report highlights the multi-professional, national and international support that has been received to adopt Realistic Medicine in Scotland. It includes practical examples and shared learning from around Scotland showcasing the work underway. Realistic Medicine puts the person receiving health and care at the centre of decision-making and encourages a personalised approach to their care. The key aims of reducing harm, waste and tackling unwarranted variation are the same aims underpinning our own Highland Quality Approach, and is one of our underpinning initiatives in our Strategic Quality and Sustainability Plan. NHS Highland Gaelic Language Plan Work is ongoing to prepare our submission for the next iteration of NHS Highland s Gaelic Language Plan. Submission is due on 18 September 2017 which is the latest possible date permissible under the Gaelic Language (Scotland) Act There is a requirement to review, redraft and publicly consult on the next iteration before September. A review of delivery against the plan published on 18 September 2012 has now been prepared and further discussions have been arranged with Bòrd na Gàidhlig to discuss our monitoring report, high level aims and next steps. The Bord highlighted last year that they were concerned that NHS Highland did not have a consistent point of contact to oversee the day-to-day responsibility of monitoring the plan, following various staff changes. It has taken some time to address this matter but Etta Mackay (Lead Partnership Representative and native Gaelic speaker) has been approached and has agreed to provide advice to NHS Highland. She will act as a point of contact with Bòrd na Gàidhlig and will be supported by Maimie Thompson, head of PR and engagement, who will oversee development, consultation and monitoring of the plan on behalf of the Chief Executive and Chair of NHS Highland. It is anticipated that the revised draft plan and update on the consultation will be brought back to the Board of NHS Highland for its May meeting with final sign off at the July meeting. Any final issues will then be addressed in advance of the Plan being submitted to Bòrd na Gàidhlig in September. NHS Highland Local Patient Access Policy Our local policy on access published in 2013 has been updated and since November has been considered by various committees and clinical groups. Although the paper was published with the Board papers in January 2017, the paper was not

355 355 considered by members as it emerged that the Area Clinical Forum had not had an opportunity to consider the revised policy. The Area Clinical Forum will formally consider the paper at their meeting on 23 rd March and an update will be provided for board members at the meeting. Stonewall Update Following NHS Highland s submission to the Workplace Equality Index, Stonewall have presented feedback and a report outlining good practice and priorities for improvement to support employees who are lesbian, gay, bisexual or transgender (LGBT). Stonewall reported that NHS Highland has scored very well for any organisation taking part in the Workplace Equality Index for the first time and that NHS Highland had the most returned questionnaires for the staff survey component of any organisation in their first year (over 1,300 staff participated). NHS Highland has been advised by Stonewall to work towards the following priorities, some of which they are able to support: Building capacity for equality and LGBT awareness training Establish a network for LGBT staff and LGBT allies Improve the monitoring of workforce data Staff communication and raising awareness A policy to support transitions in the workplace Confidential contacts for staff experiencing bullying and harassment Over the next few months an action plan will be drawn up to take forward these priorities. The Equality Outcomes and Mainstreaming Report (presented at today s Board meeting) includes the Stonewall work programme to demonstrate how NHS Highland is embedding equality and diversity and as a key action under the equality outcome Increase diversity in leadership and workforce participation. NHS Highland staff recognised at prestigious awards Raigmore based Inflammatory Bowel Disease (IBD) nurse Dave Armour was recognised nationally after he was named IBD nurse of the year at this year s final of the British Journal of Nursing (BJN) Awards in March. Dave was nominated by Crohn s and Colitis UK for the quality and nature of the work he does and for epitomising the real meaning of person centred care. NHS Highland s midwives were also honoured at this year s Royal College of Midwives Annual Midwifery Awards. Raigmore-based midwife Claire MacPhee won Emma s Diary Mums Midwife of the Year 2017 for the Scottish region after being nominated for the support she gave to an older mum during pregnancy. Claire was praised for making mum-to-be Debbie McDonnell feel respected, empowered and special with Debbie stating that Claire was born to do this job and the profession is richer for having her. Sutherland s midwifery team were shortlisted at the same awards for team of the year. The team were praised for always putting the women in their care first, looking for new ways to find out what local women want, and how they can support them in meeting their needs.

356 356 Scottish Local Government Elections 2017: Guidance for NHS The Scottish Government has advised on the formal guidance on the conduct of business during the Scottish Local Government Elections campaign. In particular, it provides guidance on dealing with the media and candidates, during purdah which came into effect from 13 th March and will remain until the elections take place on Thursday 4 May All non-executive members and staff should take account of the guidance contained in the Annex to enable appropriate action in relation to personal conduct or in responding to enquiries from the media or candidates. The

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358 358 HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEE Highland Health & Social Care Committee 28 th March 2017 Item 5.1 The Board is asked to: Note that the Highland Health & Social Care Governance Committee met on 2 March 2017 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below. Committee Members: Melanie Newdick, Board Non-Executive Director In the Chair Dr Andrew Evennett, Non-Executive Board Director Gill McVicar, Director of Operations, North and West Georgia Hare, Deputy Director of Operations, South and Mid David Park, Director of Operations, Inner Moray Firth Joanna MacDonald, Director of Adult Social Care David Garden, Head of Financial Planning Alison Hudson, Lead Nurse Margaret MacRae, Staff side representative Dr Chris Williams, Area Medical Committee Representative Gavin Hogg, Patient/Public representative Ann Pascoe, Board Non-Executive Director Dr Gaener Rodger, Board Non-Executive Director Margaret Davidson, Elected Member, Highland Council Hamish Fraser, Elected Member, Highland Council In Attendance: Simon Steer, Head of Strategic Commissioning George McCaig, Head of Business Support Sally Amor, Child Health Commissioner Donald Macleod, Asst Divisional Nurse Manager Antonia Reed, Clinical Lead, Primary Out of Hours Care Evan Beswick, Project Redesign Manager, Primary Out of Hours Care Christine MacLeod, Lead Adviser (Adult Support & Protection) Ruth Mantle, Alzheimer Scotland Dementia Nurse Consultant Ruth Daly, Board Secretary Fiona MacBain, Committee Administrator, Highland Council Apologies: Apologies were received from Janet Spence, Hugo Van Woerden, Mhairi Wylie, Jan Baird, Quentin Cox, Bren Gormley, Shirley Christie and Jaci Douglas. Assurance Ratings; (For clarity these relate to the topics indicated not the whole subject area) Not Assured Partly Assured, Further info/actions needed Assured

359 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Declarations of Interest Issues Item Assurance Further Action Do members have any interest to declare in relation to any Item on the agenda? 359 The Chair declared an interest in Item 4.1 Respite Care as a previous recipient of respite care services. 2 Highland Quality Approach - Transforming Urgent Care in Highland - Antonia Reed/Evan Beswick Antonia Reed summarised key successes and progress, including GP resignations that had precipitated the new service in two communities. Details were provided on recruitment and training of Advanced Nurse Practitioners (ANPs) and First Responders, as well as funding sources and community engagement. The emphasis was on working with communities to find local solutions and helping them to build sustainability and capacity within the communities. Trials of a clinician being based in the hub were summarised and had proved unworkable, with clinical governance issues having been taken into consideration for the inclusion of NHS 24 and the Scottish Ambulance service. Across Highland equity of access to service was being sought with issues such as drive times, population size, activity and area specific risks being considered when planning new services. Efforts were being made to ensure ANP contracts included Continuous Professional Development and, although additional pay could not be offered to them and to paramedics in the same way it could be offered to doctors, other enticements were being considered such as additional study time and flexible study methods. It had proved helpful if staff could be offered a mixture of shifts, not just Out of Hours. Continued engagement and negotiation was taking place to help to reassure communities and encourage local participation in First Responders and other resilience approaches, together with the Scottish Ambulance Service, 3 Update on progress to further meeting towards the end of the year

360 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March 2017 and increasingly using the Council s resilience planning as a template for emergencies. The Committee s support on the Board s decision to implement the changes was sought and received. 3 Adult Support and Protection - Presentation of Biennial Report - Christine MacLeod Issues Item Assurance Further Action The report covered and various issues were highlighted including progress with training and increases in referrals. The legislation, which was now 10 years old, was considered valuable and should continue to be communicated to the public. 360 Work was required to track the percentage of staff who had undergone the training and ensure all who required it were receiving it. Face to face training was preferred but there was a Learnpro module for staff who were unable to attend in person. Training for carers would continue to be rolled out. The role of advocacy in supporting people was highlighted. Reference to referral numbers from various organisations suggested 37 referrals from NHS but this was from NHS Highland Secondary Care. It was explained that the information was from a set selection of options from the Care First system. The importance of agencies working together was emphasised, with local examples provided. With regard to the high numbers of reported referrals from the Police service, a new pathway was now in place to ensure only genuine adult protection cases were being counted. Future updates to include clarity on figures and the context of people being trained. (To July meeting in year planner) 4

361 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Assurance Report from 5 January 2017 Issues Item Assurance Further Action 3.2 Action Plan and Forward Planner Quentin Cox to be added to the apologies. Alison Hudson should be in attendance as Area Clinical Forum Representative, not as Lead Nurse. The report was not by the Director of Operations Item 3.3 (d), balanced scorecard results, should be amber not green. Issues Item Assurance Further Action Staff wellbeing was covered by the Staff Governance Committee and by the HHSCC 361 Discussions were ongoing between the chairs of both committees about possible duplication. Gill McVicar pointed out that some practical and operational issues were picked up by the HHSCC and that Director s reports included staff issues Agreed that the Action Plan did not need to be circulated but would be held as an administrative document Committee Administrator. The Chair to consider the HHSCC terms of reference and governance to clarify and avoid duplication with other committees Melanie Newdick 5

362 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Matters Arising from Last Meeting Issues Item Assurance Further Action Invoice payment - George McCabe clarified the situation with regard to concerns about invoice payments that might have been delayed. 362 The delay that had been of concern had been due to a technical issue and projects were underway to reduce the number of invoices that required processing. People who were owed money were not being disadvantaged. 3.4 Care Inspectorate Reports - Simon Steer Issues Item Assurance Further Action The complaint and investigation process was explained. The aim was to have no gradings with a score lower than 4, with 6 being the maximum. Discussions were currently underway on care home fees and contracts. Agreed a development session on care homes would be arranged in May 2017, to include care inspectorate gradings Simon Steer 3.5 Operational Unit Reports Issues Item Assurance Further Action North and West Recruitment Alternative recruitment measures were summarised and included sandwich boards, lorry advertising and social media, including staff to staff which worked well, targeting graduates in certain areas, offering trials and taster sessions and portfolio careers. Work was being undertaken to introduce more Noted that the exception reports had been appended. 6

363 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March flexibility into the recruitment process, for example acknowledging applications and being able to contact people who had expressed an interest. There had been times, especially in rural hospitals, when beds had been closed due to staffing issues for safety reasons. Offering a recruitment and retention premium for remote and rural areas was not yet permitted but additional training was offered. Work being done to inform school children of health and care careers was summarised and was encouraged, and there is involvement with Developing the Young Force. It was acknowledged that more could be done in this regard. The re-naming of care at home workers was being considered in North and West, to embed them more fully in Integrated Teams. Referral to Treatment times Referral to Treatment times were due to be back on track by the end of March Care home/care at home Inner Moray Firth Impact of Cancer Target breaches Lack of availability of care home places in Skye, Lochalsh and Wester Ross was raised as a concern and work was ongoing on how to develop this for the future and more immediately, both care home places and care at home. Alternatives to care homes are being explored It was difficult to quantify the impact on patients without a clinical review of individual cases. An RPIW on prostate cancer was likely to shorten pathway waiting times. Difficulties were being experienced recruiting an additional urologist. Some of the breaches were only narrowly outwith the target. The committee are assured that work is ongoing around this issue, and also note the concerns 7

364 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Ringfenced beds A summary was provided on the reablement services to self-management and care at home. Professional Lead for Social Care Report Fostering and adoption, delivered through the Highland Council Adult Services Beds ring-fenced in Nairn and the RNI for direct community admissions, for stays of less than 7 days, had been used for 30 patients who would otherwise have had to go through Raigmore. Indicator of relative need was being developed to help measure the impact of reablement. Excellent grades had been awarded by the Care Inspectorate Integration and delivery of services had brought positive changes. Workforce issues Concern remained but solutions included 11 trainee social workers being currently in place, ongoing work with the UHI Care Academy and placements being offered within community settings to a wider variety of staff than previously. d) Director of Social Work Report Joanna Macdonald noted e) Adult Flow High Level Value Stream George McCaig 8

365 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March 2017 Issues/Risks Issues/Risks Issues/Risks Issues/Risks 365 An Internal Audit had been undertaken of the High Level Value Stream project to improve evidence of progress and success. An Internal Audit had been undertaken of the High Level Value Stream project to improve evidence of progress and success. 3.6 Standardised Mortality Ratio Donna Smith The Committee adjourned at 11.05am and reconvened at 11.20am Issues Item Actions Further Action The importance of accurate reporting for Hospital Standardised Mortality Rates was summarised. Problems with implementation of a new patient management system in 2014 meant that data between then and late 2015 was unreliable for planning purposes. Actions to develop standard procedures Highlandwide were summarised in the paper. The importance of correct coding was emphasised and work that was ongoing to improve this was highlighted and included tightening procedures around immediate and final discharge letters, which involved the Area Clinical Forum and Area Medical Committee. GP input would be helpful /17 Local Delivery Plan Targets Balanced Scorecard (a) Health Margaret Brown (b) Adult Social Care George McCaig (c) Monitoring the Delivery of Adult Social Services Simon Steer 9

366 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March 2017 Issues Item Assurance Further Action The format and extent of included data was to be discussed at the development session after the meeting. 366 Delayed Discharges were broken down into 5 categories, with some having complex needs including dementia. The 6.9% DNA (Did Not Arrive) rate was higher for mental health appointments and should be considered for separate reporting. Performance Indicators for Health and Social Care required to be in context of benchmarking and improvement to be meaningful. Comparison with other health boards on a regular basis would be helpful and this was being done and was included in the Health and Wellbeing report. Exception Report: 4 options were outlined for service delivery, with recommendations for putting targets in place for options 1 and 2, these to be considered by the Joint Monitoring Committee, and thereafter to the General Medical Council meeting in November (their next meeting in May 2017 being a single-issue agenda). The current model for measuring activity was not considered helpful and required to be changed. The need to provide additional home care was emphasised. Terminology around the various benchmarks should be clarified. Confirmed content with the assurance report on the delivery of the local delivery plan targets in /17 10 Agreed new options would be brought back to the HHSCC meeting in May 2017 (on year planner) Identified further areas for scrutiny at future meetings. Noted the exception reports in the Director of Operations

367 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Report. 3.8 Operational Unit Quality and Savings Plans Update Presentations by the Directors of Operations Issues Item Assurance Further Action Gill McVicar gave a presentation which included the following: Government aims The role of the Highland Social Care Partnership Three key areas in the plan Better Value issues Performance Monitoring Scottish Government 6 key areas of focus and measures North Highland Targets Work in progress, detailed data was awaited and once compiled would be submitted electronically to the Committee then to Board before submission to the Scottish Government There was a clear aspiration in mental health settings to down-size institutional type care, and to reduce bed days in acute care, particularly in Raigmore. Avoiding unnecessary admissions, reducing length of stay and improving and speeding up discharge procedures,, were key aims. It was estimated, through day of care studies that 20-30% of patients in acute setting and 50-60% in community hospitals did not require to be there and alternatives were being explored. Radical new thinking about patient flows and strengthening primary and community care was required. It was suggested that a completelynew approach was required to map out individual community s needs as part of a joint Council and NHS exercise, to establish what a good health and care system would look like. Reference was made to the already agreed discussion on care home issues that would take place at the next meeting in May 2017.

368 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March 2017 NHS Highland Work Streams Balanced scorecard approach to planning Current work and scale of challenge 4 Early Diagnosis and Support in Dementia - Ruth Mantle Issues Item Assurance Further Action There were around 4000 people in Highland with dementia and this was expected to double in the coming 25 years. Access to quality post diagnostic support was essential and the link with detailed figures would be circulated. The work being undertaken and the challenges for the future were summarised. 4.1 Respite Care Information was sought on interaction with primary care, and feedback to GP records. It was important that communities were encouraged to work with the health services to diagnose people and get support in place early. Issues Item Assurance Donald MacLeod summarised the report and key points including: 368 The importance of the carer support plan was emphasised. There was a need to reduce the stigma of caring and to encourage people to acknowledge their carer role and seek support. Professionals needed to be aware of their role in identifying carers. A network of family carers would be helpful and staff within the 12 Agreed that consideration should be given to what should be recorded and how data could be captured to ensure an accurate picture was provided to the committee Ruth Mantle to send link to data (done)

369 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Care through family and informal carers was worth an approximate 10b to the Scottish economy. Poverty and mental health were key issues. There had been a significant shift in resources towards carers and details of ongoing work were provided. Community based models were referenced. Legislation was summarised. It was important that people were aware of what support was available and that it could be provided through contract. one health service who also had family caring roles should be encouraged to seek support. Respite needs to be considered on a wider and ongoing basis as opposed to the traditional residential week. Creative breaks from caring need to be developed and offered 13

370 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March GP Cluster Activity - Update - Dr Chris Williams Issues Item Assurance Further Action The cluster set-up period was coming to an end and Cluster Quality Leads had attended a national event. The SPIRE (Scottish Primary Care Information Resource) campaign was due to start this was a new data information system for GPs. 370 With regard to cluster performance reporting, this had not been finalised. A regular update to the committee would be helpful. Much work would be bottom-up, with GPs identifying issues in their local areas. It was likely that useful data from this would also be transmitted upwards with quality improvement in mind, noting that duplicate reporting should be avoided. 5 Financial Position /17, Report by David Garden, Head of Financial Planning Issues Item Assurance Further Action Reference in the report to Month 8 should be Month 10. David Garden highlighted 3 issues: Following a meeting with the Chair, a more user friendly report format would be introduced for the next financial year.. The capital to revenue transfer of 2m had been approved by the Scottish Government. Referring to Raigmore underlying pressures, part of the 47m gap in comprised underlying pressures in both North and West and at Raigmore and around 6m had been set aside in the plan to tackle that. 14 Confirmed the content of the report accurately reflects the current financial Position Agreed that it is assured that plans are in place to achieve the financial target for /17 Agreed the advice

371 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Attention was drawn to the Month 10 forecast detailed in the report. Break-even was still forecast but with a large amount of non-recurring savings, and a remaining risk of 2m. New medicine s funding of 500k had been received and would offset the Central overspend of 900k. that is given to the Board in relation to this 6 Children s Services - Sally Amor a) Assurance Report to Commissioner b) Children s Services Assurance Report c) Raigmore Children and Young People s Health Services HHSCP d) Supporting Mental Health and Wellbeing of Looked After Children and Young People Development Project Report DEFERRED in order to dedicate sufficient time to consider the reports 15

372 HEALTH AND SOCIAL CARE COMMITTEE ASSURANCE REPORT Meeting on Thursday 2 nd March Dates of Next Meetings Issues Item Assurance Further Action The meeting closed at 1pm The next meeting of the Committee will take place on Thursday 4 th May 2017 in the boardroom at Assynt House 14/5/17 draft agenda, 28/4/17 papers issued Future Meetings; 4 th MAY am 14/5/17 draft agenda, 28/4/17 papers issued 6 th July am 7 th SEPTEMBER 9.30am 11/8/17 draft agenda, 25/8/17 papers issued th NOVEMBER 9.30am 20/10/17 draft agenda, 10/11/17 papers issued 16

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374 374 Item : 4 DRAFT MINUTE OF ARGYLL & BUTE HEALTH & SOCIAL CARE PARTNERSHIPP (HSCP) INTEGRATION JOINT BOARD WEDNESDAY 30 NOVEMBER, COUNCIL CHAMBERS, KILMORY Present : Councillor Kieron Green Robin Creelman Christina West Dr Michael Hall Louise Long Denis McGlennon Dr Peter Thorpe Elaine Wilkinson Liz Higgins Elaine Garman Caroline Whyte Glenn Heritage Linda Currie Maggie McCowan Catriona Spink Councillor Anne Horn Councillor Elaine Robertson Mary Watt Argyll & Bute Council (Chair) NHS Highland Non-Executive Board Member (Vice Chair) Chief Officer, Argyll & Bute HSCP Clinical Director, Argyll & Bute HSCP Chief Social Work Officer Independent Sector Representative Secondary Care Adviser, Argyll & Bute HSCP NHS Highland Non-Executive Board Member Lead Nurse, Argyll & Bute HSCP Public Health Specialist, Argyll & Bute HSCP Chief Financial Officer, Argyll & Bute HSCP Argyll & Bute Third Sector Interface Lead AHP, Argyll & Bute HSCP Public Representative Unpaid Carer Representative Argyll & Bute Council Argyll & Bute Council Staff Representative (Council) VC : Anne Gent Councillor Mary-Jean Devon Director of Human Resources, NHS Highland Argyll & Bute Council In Attendance : Stephen Whiston Lorraine Paterson Allen Stevenson David Ritchie Jane Jarvie Alison McGrory Sheena Clark Head of Strategic Planning & Performance Head of Adult Services (West Head of Adult Services (East) Communications Manager (Health) Corporate Communications Manager (Council) Health Improvement Principal PA to Chief Officer (Minutes) Apologies : David Alston Dawn McDonald Kevin McIntosh Betty Rhodick Heather Grier Chair, NHS Highland Board Co-Chair Joint Partnership Forum Staff Representative (Council) Public Representative Unpaid Carer Representative

375 375 ITEM DETAIL ACTION 1 WELCOME The Chair welcomed everyone to the meeting and introductions were made. 2 APOLOGIES Apologies were noted. 3 DECLARATIONS OF INTEREST There were no declarations of interest. 4 DRAFT MINUTE OF INTEGRATION JOINT BOARD & ACTION LOG 5i Living Wage Elaine Wilkinson asked for confirmation that following the detailed financial assessment process with providers, that no care provider would be disadvantaged by the negotiated uplifts in payments. The Chief Officer confirmed this to be the case. 5vi Performance Report Elaine Wilkinson had requested that the report highlighted all red flag indicators and the actions to address any deficiencies in performance, to give assurance to the IJB at an early stage that these are being addressed and improved. It was agreed to discuss this further under agenda item 5.5. DRAFT MINUTE OF SPECIAL IJB MEETING The Minutes were approved by the IJB. The Chief Officer advised that she has written to the Argyll & Bute Council Chief Executive requesting additional funding of 185k to support the implementation of the pause to the proposals at Struan Lodge and Thomson Court. The request will be considered at the Policy & Resources Committee on 15 December. 5 BUSINESS 5.1 Public Health Report The NHS Highland Director of Public Health Annual Report Loneliness as a Public Health Issue will be widely distributed and a web link sent to the IJB. EG It is recognised that social and emotional loneliness are a significant public health issue and can occur during life transitions. The report sets out a wide range of recommendations to be taken forward by all Community Planning Partners in Argyll and Bute. The HSCP is a key stakeholder in this agenda and communities will benefit most from a preventative approach to this problem. 2

376 376 The Integration Joint Board : Recognised the impact of loneliness and isolation on the health of the people living in Argyll and Bute. Supported the recommendations laid out in the report to reduce the impact of loneliness in older people. Agreed that loneliness should be addressed as part of work of the locality planning groups. Acknowledged the capacity issues for 3 rd Sector volunteers to support this work. 5.2 Clinical Care & Governance Report A summary of the report was presented by Liz Higgins, Lead Nurse. Restraint Training - all staff working in acute mental health are up to date with restraint training following a programme of five 3-day restraint training courses delivered in August-October. Systems have been developed to ensure that staff training does not lapse and plans are in place to book staff on refresher training. Complaints it was reported that 24 health and 7 social work complaints were received between July-September. A copy of the risk assessment tool was included in the report to the IJB for their information. Lorn & Islands Hospital (LIH) Laboratory Services since August laboratory services in Oban have been subject to a number of inspections, both formally and mock in preparation for formal inspections, which included : An inspection was undertaken by UK Accreditation Service (UKAS) in August when a number of recommendations were made relating to quality assurance and competence standards. As a result, external support was commissioned to assist the local team in preparing an options appraisal for longer term sustainability. Evidence of the actions will be submitted to UKAS in December in preparation for a repeat inspection in January Following the UKAS inspection, LIH invited the Scottish Blood Transfusion Service (SBTS) to carry out a mock MHRA inspection. The inspectors raised concerns regarding evidence of audits and quality management. A corrective action plan has been submitted to MHRA. A number of recommendations and actions to address the issues identified from all of the laboratory inspection reports are being progressed with the locality, NHS Highland and NHS Greater Glasgow & Clyde. 3

377 377 An update on laboratory services in LIH will be provided to the IJB meeting in January Hospital Standardised Mortaility Ratio (HSMR) data for LIH has been noted as increasing and further scrutiny and improvement work is ongoing. NHS Highland continues to work closely with Health Care Improvement Scotland to identify the reasons for the increase in the HSMR figures and improvement plans have been submitted. Craigard Care Home, Bute - as a result of concerns raised by the Care Inspectorate during an unannounced inspection in September the local Health & Social Care Teams have been working with the Care Inspectorate to support the care home management to implement an improvement plan to address the key concerns from the inspection. Despite the joint work of the Care Inspectorate and HSCP staff, inspectors formed the view that the care home would not meet the improvement requirements set out within the action plan within the agreed timescales. A Court date of 9 December is set for consideration of the removal of the care home registration. Local teams are working closely with residents and their families to identify alternative placements. A group will be set up to review the learnings from Craigard. AS The Integration Joint Board : Noted the content of the report, the risks identified and the risk management plans. Recorded their thanks to the Bute team for their input in supporting the management, residents and families of Craigard Care Home. 5.3 Infection Control Report At end October in Argyll & Bute there have been 4 cases of Staphylococcus aureus (SAB) and 6 cases of Clostridium difficile (C.diff). Any learning points identified are communicated to all clinical teams via the Cleanliness, Hygiene & Infection Control Committee. Argyll & Bute Hand Hygiene compliance was as detailed. NHS Highland is reviewing the audit processes in terms of monitoring confidence of reporting. Cleaning & Healthcare Environment any areas identified during the monthly audits as requiring action are reported immediately to the relevant person. A series of unannounced independent Public Peer Review audits has commenced across NHS Highland. E.Coli Bacereaemia Surveillance surveillance will become a 4

378 378 mandatory requirement for all NHS Boards to undertake from 1 April IC Net a successful test of the live data was carried out and it is hoped the full functionality of ICNet will be up and running by end November. The Argyll & Bute Infection Control team have integrated well with the NHS Highland-wide team and work together to mitigate risks created by the lack of an integrated IT system to support practice. The infection control nurses are well supported by the microbiology team in Raigmore. The Argyll & Bute Team wish to record their thanks to Dr Jonty Mills, Infection Control Doctor (ICD) for his professional advice and leadership. The role of ICD has now ben assumed by Dr Vanda Plecko. The Integration Joint Board noted : the performance position for the HSCP. the progress to reduce and manage healthcare associated infections. 5.4 A&B HSCP Risk Register It is a requirement of the Scheme of Integration and the Partnership s Risk Management Strategy that partner bodies develop shared risk registers that will identify and record risk related to the delivery of services under integration functions. The circulated document continues to be developed with the support of the Health & Safety team and will be a bi-annual report to the IJB. It was agreed that IT infrastructure should be added to the register. EH The Integration Joint Board noted the Strategic Risk Register and the actions taken to mitigate the risks. 5.5 Performance Report Health & Wellbeing Outcome Indicators The Head of Strategic Planning & Performance referred to Elaine Wilkinson s concerns regarding assurance that the IJB are aware of all red flag indicators and the actions being taken to address deficiencies in performance. He acknowledged the concerns and explained the reporting timelines for each of the outcomes, which impact on the availability of accurate, timeous information. It was highlighted that due to the recent national release of missing data and new indicators supplied by the Scottish Government the number of indicators has increased from 93 to 101, which has resulted in a number of amendments to outcome measure. These changes have also had an impact on performance. 5

379 379 After discussion, it was agreed that the reporting framework for the performance report will be reviewed and discussed further with Elaine Wilkinson. SW/CW The circulated report detailed the performance outcome for : Outcome indicator 3 people are able to look after and improve their own health and wellbeing and live in good health for longer 10 indicators are on track and 1 is off track and red flagged. Outcome indicator 4 people, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. There are 15 indicators being measured against this outcome, 9 are on track and 6 are off track and red flagged. The Integration Joint Board noted : The performance against outcomes 3 and 4 for quarter 2. The progress with regard to the HSCP performance against outcomes 3 and 4. The action identified to address deficiencies in performance as detailed in the exception reports. 5.6 Finance i) Budget Monitoring Report the Chief Financial Officer reported that the forecast year-end outturn position is a projected overspend of 1.2m. This is a deterioration from the previous reported period due to updated estimates of savings to be delivered in -17, particularly in relation to savings to be delivered from Social Work Services. The previously approved financial recovery plan requires to continue to be implemented and monitored to ensure the delivery of a year-end balanced budget, with the focus on the delivery of the savings from the Quality & Financial Plan to reduce expenditure on a recurring basis. The Integration Joint Board noted : the overall Integrated Budget Monitoring report for the October period, that as at the October period there is a projected year-end overspend of 1.2m primarily in relation to the deliverability of the Quality and Financial Plan, the cost of medial locums and increased demand for social care services. the progress with the delivery of the Quality and Financial Plan and the forecast shortfall in delivery of savings, and consider the approach to reviewing these as part of the budget planning process for agreed that the previously approved financial recovery plan requires to continue to be implemented to ensure the delivery of a balanced integrated budget for the -17 financial 6

380 380 year, and that the focus should be on achieving recurring savings. ii) Budget Outlook & the report outlined the estimated budget gap for Integrated Services for and The challenges of the -17 position place additional pressure on the budget position for and the additional savings required to be identified as a result of this. There is some uncertainty around the funding available from partners and the funding of cost and demand pressures, which is contributing to the continuing funding gap. This will be kept under review with any changes to the forecast being timeously reported to the IJB. The Integration Joint Board : noted the indicative budgets and resulting budget gap for of 10.0m and for of 6.4m approved the development of the Quality and Financial Plan for the next two years in line with the estimated budget gap and the previously agreed timeline. noted that further reports will come forward to the IJB on the budget outlook as and when further information becomes available. noted the requirement for the IJB to approve a balanced Integrated Budget by 31March Update on CrossReach/Auchinlee The IJB Chair advised on representations from Councillor Kelly and Councillor Philand. They have expressed their concerns regarding the possible closure of Auchinlee Care Home and the implications for Kintyre residents and for other care home residents in Argyll & Bute. The possibility of a multi-functionality premises in Kintyre is supported by Councillor Kelly. The Head of Adult Services (West) provided an overview in relation to the notification to the HSCP on 3 August 206 by the CrossReach Board that they were minded to close Auchinlee. The decision to close was based on: Significant financial losses in the last 3 years which the CrossReach Board has now assessed that it can no longer sustain. High vacancy rate in the care establishment and the inability to recruit and retain staff with an over-reliance on agency staff, which if continued would impact on the safety and sustainability of care provision. Risk of reputational damage to CrossReach by continuing to provide a service which fails to achieve high ratings from the Care 7

381 381 Inspectorate. Restrictions from the Care Inspectorate on new admissions to the unit until improvements were achieved. This has now been lifted. Condition of the building and the resulting significant refurbishment of the property likely to be required over the next 3 years with the required investment in the order of 255,000. The HSCP Chief Officer and Senior Managers met with Crossreach executives, to discuss the extent of a partnership agreement and advised the HSCP s intention to provide support within available resources and capability to retain and progress a meaningful partnership. Crossreach submitted their final revised partnership proposal on 23 November. IJB members are very mindful of the impact that a decision to close Auchinlee Care Home by CrossReach would have on the residents and their families and acknowledged the work of the Strategic Management Team, the locality management and Crossreach to develop a proposal to retain the service locally. The IJB discussed the partnership proposals, considering the level of risk to the HSCP in relation to governance, safety, service sustainability finance and the potential wider impact on service provision across Argyll & Bute. The IJB agreed that they could not support the partnership proposals from CrossReach and supported the Strategic Management Team to continue to engage in partnership discussions with CrossReach to determine whether a more acceptable arrangement was possible, which would require to be materially different from that currently proposed. If a mutually acceptable partnership agreement cannot be reached and CrossReach serve notice to close Auchinlee Care Home, the HSCP local team will work with residents and their families to identify alternative care placements within and outwith Argyll, based on individual needs assessments. The Integration Joint Board : noted the imminent risk of the CrossReach Board making a decision to close the Auchinlee Care Home noted the work undertaken by the HSCP to prevent this closure and the alternatives which have been considered and assessed (long list and short list) considered the conclusion reached as at this time and considered the other implications of retaining this care home provision in Kintyre noted the stated intention to commence work to develop a 8

382 382 future model of care for Elderly dementia care for the West of Argyll. 5.8 Kintyre Dialysis Evaluation Report The circulated paper detailed the outcome of the evaluation of the Kintyre dialysis unit which has been successful in delivering the new Hub and spoke model of dialysis to a remote and rural area, reducing travel and improving the health & wellbeing of patients. This success also demonstrated that this model could potentially be replicated elsewhere in Argyll & Bute. The Integration Joint Board : considered the outcome of the evaluation of the pilot and approved the recommendation to continue the Dialysis service as a core service, expanding its catchment area to cover Mid Argyll. noted the implications and expectations for the rest of Argyll and Bute. Supported a scoping exercise to look at the viability of a Dialysis Unit within Bute and remitted this to the Strategic Management Team to progress as part of locality planning. 5.9 Chief Social Work Officer Report The report summarises the Chief Social Work Officer (CSWO) Annual Report covering the period 1 April March. Each year the CSWO is required to submit a report to Scottish Government to support the Scottish Government s Chief Social Worker Advisor in his role in promoting and reporting on social work matters and to provide benchmarking and good practice information that could be shared across Scotland. The report was submitted on 31 st September. The CSWO report for Argyll & Bute sets out the activity of the social work service. The format has been changed this year to provide more detail, to give the council and the public more information about social work services. The Integration Joint Board noted the Chief Social Work Officer Annual Report 2015/16 and noted that new statutory guidance on the role of the Chief Social Work Officer has been published by the Scottish Government Chief Officer Report The Chief Officer highlighted points from the paper. Relocation of the inpatient mental health services from Argyll & Bute Hospital to Mid Argyll Hospital. Building and alteration 9

383 383 works commenced in October and are anticipated to be completed in March Community drop-in events have been organised to inform the community and provide them with an opportunity to view the plans. Scottish Health Care Awards - Volunteer award presented to John Webb, First Responder and Heartstart trainer with Garelochead and Rosneath Peninsula Community First Responders - the Audiology Team at Lorn & Islands hospital received the top team award following the implementation of new facilities and equipment unique to Scotland. The Integration Joint Board noted the Chief Officer Report. Date of Next Meeting : Wednesday 25 January 2017 at 1.30pm Council Chambers, Kilmory, Lochgilphead 10

384 384 ACTION LOG INTEGRATION JOINT BOARD ACTION LEAD TIMESCALE STATUS 1 IT support to be looked at regarding C West Ongoing Webex use for IJB meetings. 2 Equalities Outcome Framework to D Ritchie / Completed be included in Comms & J Jarvie Engagement Strategy Progress service redesign proposals Heads of Service Ongoing 3 as detailed in the templates. 4 Equality Impact Assessments as noted. Heads of Service Ongoing 5 Engagement & Consultation Allen Stevenson March 17 Feedback to the IJB 6 The IJB will be updated as part of the budget process as to the position with future years funding and cost pressures. C Whyte Ongoing 7 Include mandatory and statutory E Higgins January 17 training in future Clinical Care & Governance (CC&G) Report 8 Delayed Discharge trend E Higgins January 17 information to be included in CC&G report to the IJB 9 Lorn & Islands Hospital Laboratory inspections - update to IJB on monitoring of recommendations E Higgins January Review reporting framework for the performance report and discuss further with Elaine Wilkinson. Stephen Whiston January 17 11

385 385

386 386 CLINICAL GOVERNANCE COMMITTEE ASSURANCE REPORT 7 February 2017 NHS Highland Board 28 March 2017 Item 5.3 Committee Members: In Attendance: Ms Myra Duncan, Chair Ms Valerie Barker, Public Member Ms Elspeth Caithness, Staffside Representative Dr Paul Davidson, Associate Medical Director Dr Andrew Evennett, Chair of Area Clinical Forum Dr Michael Hall, Associate Medical Director, Argyll and Bute (videoconference) Dr Rod Harvey, Board Medical Director Dr Katherine Jones, Clinical Director, North & West Operational Unit Dr Ken MacDonald, Associate Medical Director, Raigmore Hospital Ms Heidi May, Nurse and Midwifery Director Mr Alexander Murray, Public Member Dr Ian Rudd, Director of Pharmacy Prof Hugo Van Woerden, Director of Public Health Ms Mirian Morrison, Clinical Governance Development Manager Mr Jim Docherty, Clinical Lead for IT Ms Claire Wood, Associate Director, AHPs Ms Susan Russel, Principal Officer (Nursing), Highland Council Ms Kate Patience-Quate, Lead Nurse, South and Mid Ms Helen Bryers, Head of Midwifery (Item 5a) Ms Karen Marnoch, Supervisor of Midwives Ms Fiona Campbell, Clinical Governance Manager (videoconference) Ms Fiona MacBain, Committee Administrator, Highland Council 1. Apologies Apologies were received from Mr Mike Evans, Non-Executive Board Director, Dr Gaener Rodger, Non-Executive Director, Dr Michael Foxley, Non- Executive Director, Dr Stewart MacPherson, Clinical Director, South & Mid Operational Unit, Ms Janet Spence, Head of Care Services Improvement and Dr Kevin Holliday, Consultant Anaesthetist.

387 Declaration of Interest There were no declarations of interest. 2. Assurance Report and Action Plan of 6 December and Matters Arising Issues/Risks Assurance Actions Alex Murray referred to Item 4, ehealth update, where it was stated: error reports in the GP Electronic Care System were thought to be unique to Highland and resolution of the issue was beyond the remit of the Committee. Ensuring conversation always took place with patients about medicines was helpful in avoiding errors. While accepting that the operational maintenance and correction of errors was outwith the remit of the committee, he expressed concern that the data available for clinicians should be complete, up to date and current. He felt the committee should be looking more closely at that problem that had occurred to ensure further occurrence did not occur and to obtain a statement guaranteeing the problem had only affects three practices. Ian Rudd explained that the problem had related to the drug list on emergency care summaries used in hospitals and that three practices had experienced IT issues which had resulted in repeat prescriptions not being updated. The issues had been investigated and addressed and it had highlighted the importance of conversations about drugs taking place between clinicians and patients, not only to avoid errors such as this but to ensure prescribed drugs were actually being taken and that additional drugs obtained outwith prescription were not being taken. Patient conversation was an established safety check. 6.2 South and Mid Exception Report, there were 16 Standards for from Health Improvement Scotland, not 12 as stated. Update on the investigation into issues at the Lorn and Islands Laboratories. The external investigation was complete and a formal report had been sent to the Medicines & Healthcare Products Regulatory Agency, with an accompanying letter from the Medical Director, who added that an action plan and governance structure had now been put in place. It was hoped that accreditation would be regained in due course. Agreed the matter go onto the rolling action plan for future updates. 2

388 388 Item 10(c), Food, Fluid and Nutrition, The reported increase in Restraint and Violence data, as detailed in the previous A&B Exception Report The level of the use of restraints was being monitored The issue of new nursing documentation was still to be discussed by the Chair and the Nurse Director and should remain on the action sheet. Agreed information be circulated after the meeting when available Fiona Campbell/Fiona MacBain 3. Case Study as there was no case study available this was deferred. 4.1 Argyll & Bute, including action log of the A&B HSCP Clinical and Care Governance Committee of 1 November Issues/Risks Assurance Actions Review of the model of mental health in-patient care. The review was underway. 4.2 South & Mid, including minutes of 19 January 2017 Issues/Risks Assurance Actions Reference was made to 5 SAERs: 4 in Mental Health Services and one in Community Care There were challenges around suicide prevention storm training, which was a recurring theme in several SAERs, particularly in relation to access to training due to limited availability of trainers, which was a board-wide risk. Guidance was sought on the level of information that was wanted in future exception reports, which varied from unit to unit. During discussion, it was suggested that the report should capture all key risks, particularly areas which could be considered a trend to allow sharing across the Board. Good practice could 3 Agreed Mirian Morrison find out who was the owner of the Storm training risk.

389 North & West, including minutes of 11 January 2017 also be included. Issues/Risks Assurance Actions The 14 week SAER deadline was a challenge and reference was made to improvements in Falls. Non-compliance with Scottish Patient Safety Programme escalation documentation was discussed. The QPS sub-group was proving helpful in proactively tracking SAERs and promoting sharing of learning. Escalation documentation had been discussed at the SPSP Committee and processes clarified to avoid repetition. Staffing remained a challenge, especially in Caithness. Various workforce action plans were in place. 4.4 Raigmore Hospital, including minutes of 10 November and 8 December Issues/Risks Assurance Actions Two SAERs were summarised, both of which highlighted the risks of cognitive bias. Two complaints were referenced, both of which had SAERs in progress. A national issue had been identified in radiology IT systems (PACS) which involved patient identifiers. Actions had been identified and at least one of the cases would be used in the patient safety alert to highlight awareness of the risks of cognitive bias. Other means of sharing learning from these cases were being considered. Both cases had been identified for review prior to the complaint being received. A report was due to be presented to the QPS group on the assessment of the risk that there had been incorrect clinical decision making as a result. The importance of remaining sceptical of data was emphasised, and questioning data that did not seem correct was encouraged. Jim Docherty explained that National Services Scotland (NSS) had undertaken a full enquiry 4

390 390 which had highlighted the impact a change in the Carestream product had on the PACS system, because NSS had not been informed, but the impact in Highland had been minimal; other Boards had experienced more significant changes. Contracts had since been amended to ensure all changes were notified to users. The differences between missing data and the more serious issue of misleading data were referenced. Hospital flow, capacity and pressure on acute patients was highlighted as a challenging area. A new hospital mortality review process had been introduced. There had been a visit from the Scottish Patient Safety Programme national team on January The previous system had involved reviewing a random selection of deaths 2-3 months retrospectively, whereas the new system would involve the review of every death within 48 hours to check for triggers that would lead to a Level 2 review. Generally positive reports from adult and mental health workstreams had been received. 4.5 Highland Council Children s Service Clinical Governance Group Issues/Risks Assurance Actions Reporting on SAERs commissioned by the Child protection Committee (CPC). Discussions were ongoing but not yet concluded and a summary was provided of where reports were currently presented. Current SAERs were being undertaken by external lead reviewers and due to be reported to the CPC. The route for the learning to be sharing with the Clinical Governance Committee was still to be finalised. NHS Highland already had representation on the CPC. Susan Russel and Heidi May to continue discussion on the reporting process for SAERs presented to the CPC Record Management issues included: Transport of The archiving of inactive patient records, and Susan Russel to speak to Ruth Daly 5

391 patient information between hospitals, with a case of missing maternity paperwork highlighted, and the case of a filing cabinet being wrongly removed for recycling (although safety retrieved). A school based immunisation team was being investigated to ease pressure on school nurses. Storm Training 5. Executive Leads Reports by Exception 391 processes to tackle this, were being investigated as a matter of urgency. Andrew Evennett confirmed that the professional secretary of the GP Sub-Committee would welcome Storm training information. about crossover with the NHSH Record Management Plan Susan Russel to contact the GP Sub- Committee secretary. Issues/Risks Assurance Actions a. Implementation of Caithness Midwife Led Community Midwifery Unit and Hub and Spoke model for maternity and gynaecology services in the Highland Health and Social Care Partnership Heidi May Helen Bryers gave a summary of progress including the implementation oversight groups, midwifery workforce issues and the interim clinical lead, caseload management and tie in with national framework, training and support issues, and clinical pathways. Additional accommodation had been secured and work was ongoing on issues relating to that, as well as ongoing engagement and communication with the local community. Freedom of Information requests had increased and were proving time consuming. A group was considering ambulance provision and technical support measures were also being worked on, such as VC and electronic maternity summaries. In terms of the clinical risks around transport, accommodation and staffing, options such as staff rotation were being considered and while full assurance could not be provided in areas of fragility such as Caithness, successful CMUs had been managed in remote locations with similar recruitment difficulties, through varied workforce 6 Agreed Heidi May speak to the Chair of Board about the need for a written report to the Clinical Governance Committee on compliance with the national review, which the Board had asked for assurance on.

392 392 models. Communication with the public on an ongoing basis was recommended to counteract negative press reports. A transition-period report would be given to the Board and exception reports thereafter. 5b Safety Action Notice on Nasogastric Tube misplacement This SAN had been sent to all UK Health Boards, with Heidi May the Executive Lead on implementation. With a deadline of July 2017, this work was being taken forward by the Complex Nutrition Subgroup of the Food, Fluid and Nutrition Group which reported to the Clinical Governance Committee, although a report would also be provided to the Board. 6 Quality Dashboard Mirian Morrison, Clinical Governance Development Manager Issues/Risks Assurance Actions The use of the dashboard at future meetings for scrutiny and agenda preparation was discussed, as it identified critical area on which to focus attention. The high level view should be used for meetings, with a static PDF version created for those without NHS system access. Jim Docherty would work on access solutions for non-nhs staff, including access to the bed occupancy report, and future consideration would be given to making it available on the website but this was not recommended at this early stage. Clinical units were adapting to its use and it was expected that the QPS groups should be using it. It was important the dashboard information was correct, complete and current. 7 Return Outpatients Waiting List - Margaret Brown, Business Support Directorate 7 Agreed known issues with the dashboard that required committee attention could be raised via the Chair or by ing the committee administrator (Fiona MacBain). Issues/Risks Assurance Actions A summary of the report and the eight The systems were more robust than they Agreed Margaret Brown draft a Returns

393 recommendations were provided, as follows: 1. Target additional resource to the existing outstanding data quality issues. 2. Continue dialogue with Intersystems to investigate system modifications to Trakcare PMS to reduce/remove the chance of user error e.g. incompatible dates. 3. Reach agreement as to when the Performance Report can be published and agree any changes required to the current format. 4. Agree a tolerance with each speciality for each group of PRDs. 5. Implement a planned programme of review for the patients reported as waiting beyond their PRD, with initial focus on those patients in the most clinically urgent group with the longest slippage. 6. Review each non-mmi speciality to ascertain how they are using the PMS ROPWL, assess the clinical risk of the reported position and agree a solution to resolve identified data quality issues. 7. Agree a Local Policy for Return Outpatients and establish booking protocols, in the absence of national guidance 8. Establish a working group to oversee the implementation of the above recommendations chaired by the Medical Director. 393 previously were although data errors were still being uncovered and dealt with. More training was now underway than previously. The report was now produced on a weekly basis and was widely circulated, as well as data being put onto the dashboard. Clarification was sought that the Clinical Directors/Associate Medical Director Raigmore were included on the distribution list With regard to tolerance, account was now being taken of the amount of slippage, i.e. the likelihood of clinical impact. Resources were required to automate tolerance data, on a speciality by specialty basis, to identify patients beyond acceptable slippage tolerance. Following tolerance implementation, statistics still required improvement but were better than previously reported (with 16,449 previously deemed to have slipped, compared to 9,133). Focused efforts were required for the 259 patients who had slipped beyond their 24 week review date, albeit there could be some data errors within this, but additional resource in this area was required to complete this review and reduce this risk. The dashboard had a breakdown of these patients by specialty. Operational Managers obtained these reports regularly and should be sharing them with Clinical Leads. The Medical Director highlighted some of the risks in particular specialties where the model of care relied heavily on a high number of return patients for therapeutic interventions, such as ophthalmology. A clinical group was required to look at unnecessary return appointments as part of a 8 Policy, for initial implementation at Raigmore, with input from Rod Harvey and Ken MacDonald, to be brought back to the Committee in April 2017 for consideration. Additional input would be sought from operational units and their QPS groups before eventual Board approval would be required. Agreed the operational unit QPS groups should regularly receive and consider the output from the Returns report. Noted the progress made on the original recommendations to improve Return Outpatient Waiting List performance reporting and the actions still required. Agreed Margaret Brown would distribute the circulation lists for the Returns report for Committee consideration via the committee administrator.

394 394 local booking policy for return patients. With no national guidance likely to be available in the short term for Returns, a local policy/framework was required, for example to consider how many Could not Attends (CNAs) incidents a patient could have and remain on the waiting list, a decision that was at present down to individual clinicians. A local policy was likely to start with Raigmore due to the high numbers of patients. There was a GIRFEC escalation policy for children. Clinicians acceptance of any Returns policy was vital and one set of rules with a reasonable number of offers was recommended, to avoid complication. The Chair suggested the QPS groups considered the data and the clinical risks around small specialities to start with. Assurance could be provided to patients through holding letters, rather than inviting complaints from patients who were waiting. It was suggested that a draft policy proposal be put to the Committee for consideration in the first instance. It should firstly be considered by the QPS groups and would in due course have to be adopted by the Board as part of the Local Access Policy. 8 Organ Donation Committee (ODC) Annual Report and Workplan Dr Kevin Holliday on behalf of Dr Rod Harvey (Report presented by the Committee Chair, Myra Duncan, also Chair of the ODC) Issues/Risks Assurance Actions The ODC was part of a UK wide network, although It was not known for certain if the specialist Noted the report. it reported to the Clinical Governance Committee. nurses being based in Aberdeen were having a The ambition was to make OD a core activity and detrimental effect on donations but this was the develop an NHS Highland-wide policy, with perception, due to the distance and feeling of loss improved engagement with clinicians and of accessibility. Early recognition of potential 9

395 395 addressing local concerns about activity levels. cases and referral to the SNOD was vital. Significant issues highlighted included: Specialist nurses were now supported from Aberdeen rather than on-site. The successful donation at the Belford hospital which had been used as a national case study. The workplan for the future, including the strategy for donation in the Emergency Department The commissioned memorial for Raigmore, to be launched during the OD week in September Clinical Governance Progress Report - Mirian Morrison, Clinical Governance Development Manager Issues/Risks Assurance Actions a. Complaints Formal complaints had reduced and performance against target, at 58%, was improved. Feedback was being scrutinised and complaints were being encouraged to be dealt with informally at an early stage if possible. The new NHS Scotland Model Complaints Handling Procedure (Model CHP) was due to be in place by April 2017, with a two stage complaints procedure. Other changes included getting feedback from complainants. Progress in rolling out the new CHP included discussions with independent contractors, and roll out to the GP Sub-Committee and others, including Dental Services, which had been relatively proactive in adopting the new procedures. With regard to awareness raising training, investigating officers and managers would be targeted first, followed by front line staff with emphasis on early complaint resolution. It was a long document for some independent contractors to adopt in its entirety. The performance indicators for the new system would not be easily comparable with the previous systems indicators, because of the new two-tier approach. 10 Noted current performance against the 20 working day target and the new arrangements for Complaints handling from April Agreed Mirian Morrison would provide the CHP briefing to Heidi May.

396 396 The complaint system was being streamlined with the Highland Council. b. Scottish Public Services Ombudsman (SPSO) Report There were challenges around the number of recommendations and actions being issued by the Ombudsman, some challenging to implement and evidence, and with considerable focus on the complaint process and adherence to SIGN guidelines. c. Adverse Events A day of training for Chairs on SAERs was planned in May Overall complaint numbers had gone up by around 15-16%, but the percentage being referred to the Ombudsman had remained around 5-6%. Discussion took place on the benefits and drawbacks of the Chief Executive signing off all complaints. This was likely to be reviewed, with consideration being given to the Operational Directors being able to sign off relevant complaints. SPSO only looked at cases once they had been through a Board s complaint process. Data on Falls in this report was different to that reported to the Board due to different measurement data, and this was being tackled. In relation to the mediation error decrease at Raigmore, it was explained that when the system was under pressure, reporting numbers tended to drop. Further, the overall numbers were relatively small so short-term changes were less significant. There was a perceived underreporting of medication errors. The Medical Director referred to the need to consider the reported data as a control chart, pointing out the difficulties in measuring variation in the figures reported. Further analysis would be available on the dashboard. Noted the cases being considered by the SPSO as at 29 November and the Investigation Report into the care and treatment of Ms A. Noted the adverse event report including major and extreme adverse events that had been reported in quarter 2. 11

397 397 The new electronic prescribing system has gone to the North of Scotland group for endorsement, thereafter to the Scottish Government as part of a collaborative bid, with possible implementation in April 2018, requiring the Board to decide to prioritise investment in the system ahead of other systems that were seeking resources. d. Risk Management The Risk Management Steering Group, chaired by the Chief Executive, was reviewing risks with a focus on high risks. The risk register module in Datix had been purchased and it was intended that all risk registers be on the system by the end of March Agreed the Clinical Governance Risk Register be considered by the Committee at the beginning of Hospital Mortality and HSMR Update - Rod Harvey, Medical Director Issues/Risks Assurance Actions A summary of the HSMR situation included the recent change in the review methodology to investigate concerns raised over the previous 18 months in 3 NHS Highland hospitals. Investigation had uncovered areas of good practice and areas for improvement, with coding errors being considered to have had a significant effect on the HSMR. The latest HSMR data, embargoed until 21 February 2017 was shared with the Committee. Attention was drawn to the five drivers to reduce HSMR by 10% by end December 2018 and to achieve high reliability of safe, person-centred and effective clinical care processes. Improvements in quality of care were being implemented and, going forward, there was a focus on the improvement plan. Some back dated coding had taken place but it was not considered a productive use of resource. Each hospital had an HSMR group to work on the improvement plan and this would also be monitored by the QPS groups. Noted 11. Care of Older People in Acute Hospitals Dementia Ruth Mantle, Alzheimer Scotland Dementia Nurse Consultant, on behalf of Heidi May, Nurse Director Issues/Risks Assurance Actions 12

398 Progress was being made to implement the Standards of Care for Dementia in general hospitals with around 50 Dementia Champions in NHS Highland and support from the Alzheimer Scotland Dementia Nurse Consultant It was essential there was ownership from acute general hospitals to ensure the work was embedded and sustainable. National identification and guidance on measures to evidence improvements against 10 Dementia Care Actions were not finalised and the third Dementia Strategy was expected in February This was the last nationally funded cohort of dementia champions so there was a focus on recruiting from general as well as acute hospitals, targeting areas where the most benefit from protected time could be achieved. Monthly recording was due to start of the levels of protected time being achieved. There was an education programme with the University of Stirling, Dementia-smart for nurses, with a pilot for a 4-day shorter version for trained nurses. The dementia nurse practitioner post was vacant and under review and emphasis was made on the importance of the post, given the need for protected time in Raigmore. In previous years there had been a dedicated post within the mental health liaison team for older people, and this had become more generic. A protected full-time equivalent post within that team would be useful. The Chair referred to the elderly population and the need to protect the dementia resources. Noted 12. Terms of Reference for the Clinical Governance Committee Issues/Risks Assurance Actions The Chair referred to the ongoing review of administration, membership and reporting committees and sought comments on the Committee s Terms of Reference which had last been agreed in 2012 Issues raised included: In relation to quorum and the minimum number of non-executive Board members present, some non-executives were also on the Committee in connection to other roles, for example, Andrew Evennett was both a non-executive and Chair of the Area Clinical Forum. 13 Agreed the Terms of Reference be redrafted and circulated for further comment, that consultation be undertaken with the Operational Directors on their preferred level of involvement, and the matter be considered again in April 2017.

399 13. Boarding - Ken MacDonald, Associate Medical Director Discussion ensued on who were members, which posts were ex-officio members, and who were required attendees but not members of the Committee. For example, the Supervisor of Midwives was recommended to sit on Board Clinical Governance Committees. Discussion took place on whether the Operational Directors should be members of the Committee or whether the Clinical Directors would feed back issues to them. It was suggested that the Operational Directors role was attending their own QPS groups. It was decided that they should be consulted. Mirian Morrison was undertaking a review of the reporting committee list. The sourcing of the public members required clarification. The Associate Director, AHPs, and the Principal Officer (Nursing), Highland Council were in attendance to ensure Clinical Governance extended across the Council/NHS boundary. Issues/Risks Assurance Actions 399 The Information Services Division definition of a boarder was a patient who is managed by an individual consultant or consultant team but outwith the allocated inpatient area for that consultant s speciality, although the definition was not watertight, and examples of the subtleties were provided. Disadvantages of boarding included a patient potentially missing care that would be provided by the specialist nursing team on a particular ward, Boarding was closely tied to flow and demand. An expanded ambulatory care facility had been opened to reduce inpatient stays and occupied bed days, there was a focus on reducing delayed discharge, with some Scottish Government officials due to visit to help with this later that week. Also key was the availability of beds in community hospitals and care homes. Pressure on the system was increased in winter. With regard to increasing the safety of boarders, 14 Agreed to keep Boarding on the rolling action sheet.

400 400 they tended to be seen last by the relevant medical team, there was a suggestion in Scottish national data of increased mortality rates in patients boarded for more than 48 hours, although this was an association rather than a direct consequence. Boarding happened as a result of pressure in the system. Figures were tabled showing boarder rates in Raigmore for the previous three months, noting that Raigmore had not been boarder-free for around two years. The majority of boarders were medical patients on surgical wards. On the day of the meeting was the highest recorded number of boarders, at 54, with 45 having been the previous high. One of the risks was the tracking of boarders and an example of the tracking sheet was displayed. and reducing the risk of boarders being lost, a close daily check was kept on their location and progress. The aspiration was for boarders to receive similar medical input to non-boarded patients, in line with the boarding policy, to identify the most ideal patients to board, which are those who are due to be discharged the following day, and to avoid boarding unsuitable patients, particularly those with dementia. The Chair emphasised the importance of keeping people out of hospital in the first place. Concern was expressed about the small number of surgical boarders, although it was explained that most were orthopaedic patients and were being cared for in an appropriate ward (4A). Heidi May suggested consideration of the designation of wards and the number of surgical beds that were available and a meeting was planned on 8 February to look at bed reconfiguration. Diversifying the skills of nursing staff should also be considered and this was being looked at. Reference was made to sections of a surgical ward that were being used for medical patients on an ongoing but temporary basis and these patients were being classified as boarders. A purposeful strategy and reclassification would help, and these should be considered at the QPS group. Reference was made to the extent to which boarders and their mortality should be tracked. Boarding was never in the individual patient s best interests but was necessary for the overall flow of the system. 14. In-patient Experience 15

401 401 Issues/Risks Assurance Actions 15. Any Other Competent Business Noted the action plans prepared by Raigmore Hospital, South and Mid Community Hospitals, Belford Hospital, Mackinnon Memorial Hospital and Caithness General Hospital. Issues/Risks Assurance Actions a. Board Internal Audit Plan 2017/18 Under the auspices of the Audit Committee, the Board is putting together its Internal Audit Plan for 2017/18. As part of this process, each of the Board s Governance Committees has the opportunity to reflect on its areas of responsibility in terms of seeking assurance and identify if there are any that it might ask for support from an internal audit. 13. Date of next meeting: 18 April 2017 The committee considered any areas to put to the Audit committee, including: Why an audit would be helpful and what value it would add to current assurance arrangements The purpose of the audit The scope - what the audit includes and excludes Agreed members would forward any issues to be considered for auditing to the Chair by the end of February The meeting ended at 1.30pm 16

402 402 DRAFT MINUTES Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: NHS Highland Board 28 March 2017 Item 5.4 Adult Social Care Practice Forum Present: Janet Spence Head of Care Services Improvement CHAIR (JS) Ian Clayton Resource Manager-Learning Disabilities (IC) Sheilis Mackay Manager of Advocacy Highland (SM) Christine Macleod Lead Adviser (Adult Support and Protection) (CM) Adam Palmer Employee Director (AP) James Bain Team Leader (Resources and Performance) (JB) Bernice Nott Social Worker (BN) Christina Mudditt Senior Social Care Worker (CMu) Laura Haddow Admin Assistant (LH) Monday 23 rd January 2017 at 10am In Attendance: Iain Ross Head of e-health (IR) AGENDA ITEM 11 ONLY SUBJECT REPORT / ACTION 1. APOLOGIES: Lyn Johnson Manager, Montrose Centre Fabien Camus Practice Support Officer Ian Thomson Lead Social Work Officer (North and West) Ruth MacDonald Lead Social Work Officer (Inner Moray Firth) Angela Longmate Social Care Worker Shona Knight Team Manager (Mid Ross) Pamela McAllister Care at Home Officer Moira Helliwell Trainee Social Worker DECLARATIONS OF INTERESTS None of the attendees has any interests to declare. 2. WELCOME All in attendance knew each other so introductions were not required. JS advised that in principle, Ian Thomson had agreed to take on the role Chair of this Forum once she has retired. Discussion will need to be had at the March Forum with regards to how he will be supported in this role. A Vice Chair will need to be nominated all were asked to consider if this is a role they d be interested in undertaking. In response to a question about what would happen once she retired, JS confirmed she had been advised that her post will be recruited to and a revised job description had been agreed. 3. MINUTES OF THE PREVIOUS MEETING HELD ON 24 TH OCTOBER a) APPROVAL The draft minutes from the previous meeting were approved as an accurate record. b) MATTERS ARISING AND UPDATES Care at Home Update Inner Moray Firth Operational Unit AP confirmed that the structure of the

403 403 new service has been defined. Staff remaining in the in-house service will need to attain an SVQ3, given their enablement role. JS expressed concern that there may be staff who will struggle to achieve a qualification at this level. CMu indicated that some experienced staff have left the Telford Centre because of the expectation placed upon them to achieve an SVQ3. This had resulted agency staff being used at times, which was unhelpful for the residents. The qualifications requirements and anticipated challenges will be discussed at the Care at Home Learning and Development Sub-group, which is chaired by FC. North and West Operational Unit AP advised that staff were close to being transferred to Agenda for Change terms and conditions. Consideration is being given to up-skilling employees so that they are able to fulfil more than one role. IC spoke about the difficulty he has been experiencing with the recruitment of staff; CMu flagged that the same issue exists in Care Homes. She suggested that this was perhaps due to employment in the care sector being negatively represented on prominent platforms. She also spoke about delays that could ensue following appointment of new staff whilst awaiting PVG checks from Disclosure Scotland or opportunities for staff to access necessary training. My Home Life JS again reflected on the My Home Life presentation and how powerful it had been. SM was unable to attend the last Forum and stated that she was still unsure about what My Home Life was. As CMu has participated in My Home Life, she outlined its purpose and what it entailed. Referring to her own experience of using the picture cards, CMu said that she had found this to be an effective method of encouraging shy staff to be more confident in speaking openly. CMu will bring the picture cards to the next Forum to let SM see them. JS highlighted the My Home Life website on which more information can be found. ACTION CMu will bring the My Home Life picture cards to the next Forum to let SM see them. CMu AP 4. OPERATIONS OF ADMISSION AND DISCHARGE PROTOCOL/SCOTTISH CARE REPORT The report written by Carolanne Mainland (Scottish Care) which discusses discharge difficulties in the Inner Moray Firth area between October 2015 and May had been circulated prior to today s meeting. It was noted that there was no issue with the Admission and Discharge Protocol itself but problems were arising with its application. AP confirmed that he had had a discussion with Heidi May who would in turn follow up with lead nurses. The various challenges were discussed, for example assessing an individual in hospital can give very different results to an assessment carried out in the home environment. The Adult Services Commissioning Group had commissioned the report. JS will follow up and offer comments on behalf of the Forum. ACTION JS will liaise with the Adult Services Commissioning Group in respect of the Scottish Care Report. 5. SCOTTISH CARE REPORT JS This was discussed under the previous agenda item. ACTION None. 6. CONSULTATION OF NEW HEALTH & SOCIAL CARE STANDARDS 2

404 404 ACTION JS explained that the Scottish Government is in the process of creating a single set of national care standards within one booklet which will replace the 23 sets which currently exist. This single set of standards will apply across all care settings. The set of new standards was discussed at a previous meeting of the Care Standards Steering Group, where the consensus was that the development of the single set of standards was a positive step. Feedback from members of the Forum was also positive in respect of the reduction from 23 sets to a single set as well as the design and language used in the new standards. It was noted that inspection methodologies will be updated in order to align them with the newly developed standards. JS offered to share NHS Highland s consultation response with anyone who was interested in this. None. 7. LEARNING AND DEVELOPMENT UPDATE FC was not in attendance at today s meeting but JS confirmed that he would be able to provide a full update at the March Forum. ACTION None. 8. FEEDBACK FROM THE NHS HIGHLAND BOARD (29 TH NOVEMBER ) ACTION JS was not present due to being on annual leave however, she was able to report that it had been forecasted that NHS Highland would break-even at the end of the financial year as long as the Scottish Government approved the transfer of 2.5 million from capital to revenue. It is anticipated that the next financial year will be even more challenging than the current year. JS reported that Highland Council had received its annual settlement from the Scottish Government on 15 th December. It is anticipated that NHS Highland will receive 6%-8% less money from Highland Council as a result of the settlement. BN felt that it might be helpful for NHS Highland to be explicit about what it is no longer able to fund. It was suggested that Joanna MacDonald, Director of Adult Social Care, be invited to the next meeting of the Forum in order to provide an update on the latest financial position and discuss the impact of savings that need to be made in 2017/18. None. 9. FEEDBACK FROM THE HIGHLAND HEALTH AND SOCIAL CARE COMMITTEE (10 TH NOVEMBER ) JS was not able to provide feedback due to being on annual leave. ACTION The minutes of the Highland Health and Social Care Committee will be circulated. 10. FUTURE TOPICS FOR CONSIDERATION Health and Social Care Delivery Plan LH 11. E-HEALTH UPDATE JS had invited IR to meet with the Forum due to ongoing concerns about large numbers of Adult Social Care staff still on Highland Council systems and not having access to NHSH IT kit or systems. IR explained that six months ago, it had been agreed that all staff who had transferred from the Highland Council to NHS Highland would be given IT equipment by NHS Highland and access to the network would be arranged and vice versa for NHS Highland staff who transferred to Highland Council. The original deadline for this piece of work was 31 st December but this has proved to be unachievable. A new deadline of 31 st March 2017 was then 3

405 405 ACTION targeted but IR explained that this will also not be achievable due to various technical and financial challenges. IR advised that the Project Board is due to meet again tomorrow where the deadline will be discussed. With regards to transferring shared drives across to the NHS Highland network, IR explained that Fujitsu have not yet provided the information required to facilitate the transfer. He also added that there is an estimated shortfall of 200 laptops which provides a financial challenge for NHS Highland. Work is currently being done to overcome this. Members of the Forum were aware that the Council s IT provider was due to change in April. It was noted that Wipro will be taking over the contract for IT support from Fujitsu. An assurance was given by IR that regardless of what happens, access to systems such as CareFirst and CM2000 will be maintained. Further to that, IR confirmed that NHS Highland staff currently accessing the Highland Council network will not lose access to it until they are guaranteed to have access to the NHS Highland network; their Council issued IT equipment will not be taken away until it is certain that NHS Highland issued equipment will be available. CMu asked about when Care Homes could expect to receive NHS Highland issued IT equipment; IR was unable to provide a timescale. JS suggested that the work being carried out by e-health with Social Workers in Inverness might be being driven by the impending office re-design project. IR stated that the work is being driven more by Highland Council s desire for a clear split. JS reiterated the concerns of the Forum that after nearly five years postintegration, so many staff were still working on Council IT systems and did not have access to basic NHS Highland resources such as the Intranet. IR acknowledged that this piece of work is long overdue. IR further advised that whilst there is no project plan at present, this will be developed in due course and will include timescales. None. Date, time and venue for remainder of 2017 meetings Monday 27 th March Board Room, John Dewar Building (9.30am-12.30pm)* Thursday 25 th May Board Room, John Dewar Building Thursday 27 th July Board Room, Assynt House Thursday 28 th September Board Room, Assynt House** Thursday 30 th November Board Room, Assynt House** **Denotes that the venue may change depending on the duration of the refurbishment of the ground floor in Assynt House, to be advised closer to the time. *All meetings are 1pm-4pm except where indicated 4

406 406 DRAFT Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel NHS Highland Board 28 March 2017 Item 5.5 DRAFT MINUTE of MEETING of the AREA CLINICAL FORUM Board Room, Assynt House, Inverness 26 January pm Present Dr Andrew Evennett, Area Medical Committee (Chair) Rev Dr Derek Brown, Area NMAHP Advisory Committee Mr Quentin Cox, Area Medical Committee Mr Neal Drummond, Area Dental Committee Mrs Alison Hudson Area NMAHP Advisory committee Mrs Margaret Moss, Area NMAHP Advisory Committee Mr Duncan Martin, Patient Representative Ms Gill McVicar, Director of Operations, North & West Mr Adam Palmer, Employee Director Dr Robert Peel, Raigmore Mr Duncan Railton, Area Dental Committee Mr Thomas Ross, Area Pharmaceutical Committee Ms Catriona Sinclair, Area Pharmaceutical Committee In Attendance Ms Heidi May, Board Nurse Director Prof Elaine Mead, Chief Executive Mrs Christine Thomson, Committee Administrator 1 WELCOME AND APOLOGIES Andrew Evennett welcomed those present to the meeting. Apologies were received from Mr Donald Goskirk, Dr Rod Harvey, Mrs Margaret Steventon, Mrs Caroline Tait. 1.1 DECLARATIONS OF INTEREST Andrew Evennett declared he was an executive partner of Nairn Healthcare Group. Quentin Cox declared he was Deputy Chair of the Scottish Consultants Committee of the BMA. It was agreed to commence the meeting with consideration of the item on Health & Social Care Delivery Plan. This document had been previously circulated to members of the Forum.

407 407 2 HEALTH & SOCIAL CARE DELIVERY PLAN Gill McVicar gave a presentation of the Health & Social Care Delivery Plan, confirming that the plan brought together previous guidance. She advised that the status quo was not an option for the delivery of services and the aim was to maximise resources better to ensure that people are looked after at the right time by the right people and are discharged home as quickly as possible. She stressed the need for an integrated Health & Social Care system focussing on prevention, anticipation and supported self-management. The aim was to make best use of resources and reduce waste and variation and to provide better care, better health and better value by ensuring that resources were spent to the best effect and ensuring that the hospital was a place of last resort. She advised that whilst there was a move away from regional boards, more emphasis was being placed on regional working. Four major programmes of activity were noted as health and social care integration, national clinical strategy, public health improvement and NHS Board reform. The aim of the Health and Social Care partnerships was to plan and deliver well coordinated care that is timely and appropriate to people s needs giving the right care at the right time in the right place, and to reduce inappropriate use of hospital services, shifting resources to primary and community care and supporting the capacity of community care. She advised that this was linked to the GMS contract and stressed the national clinical strategy framework for the next years emphasising the strengthening of primary and community care and the improvement of secondary care. She further advised of the emphasis on public health improvement with a strong focus on lifestyle and behaviours with prevention and early intervention being the key messages and some patient services being delivered on a national basis. She stressed the importance of research and development and digital health advising that there would be an investment of 70 million over 5 years concentrating on primary care, mental health, social care, cancer and elective capacity. In summary the aim was to treat people as equal partners with their clinicians, less medical intervention, shorter episodes of acute care with an increase in care in the community. In addition there would be a focus on prevention, early intervention and early years, focus on more active lifestyles, effective support for mental health and more sensitive end of life support. Elaine Mead confirmed that the current model for delivery of health and social care was not fit for the future but that Highland was well placed with integrated Health & Social Care services and the Integrated Joint Board. She stressed the need to come to a new model of care drawing attention in particular to the increasing proportion of older people in society. Some discussion took place as to how to implement the plan and in particular how to persuade the public that a move from hospital to community care was the correct way forward. It was stressed that communities had to be brought on board. With regard to the difficulty in attracting and retaining home carers, Adam Palmer advised that this had been recognised and there was now some degree of career progression with SVQ training to provide the opportunity to develop further. Rob Peel suggested that the issue lay in delays in moving people out of acute care and stressed the need to reduce long stay patients. Elaine Mead advised that people are often seen out of hours and the doctor has to make a decision as to whether they can keep the patient safe if there is no alternative then that person will be admitted to hospital and there are then often delays in transfer of care to community hospital. Elaine Mead compared the weekly costs of an acute bed at 3500, community bed 2500, care home 1500, private sector 649, at home with 2 visits of 30 minutes per day 200. It

408 408 was noted that many people could be discharged with some extra support and that the increase in community care could be paid for by a reduction in acute beds. On a query from Duncan Railton re the dental emergency care set up it was noted that whilst the GP may have greater knowledge of the patient it was noted that anticipatory care plans were not accessible 24/7. Margaret Moss highlighted the issue of the number of professionals within the NHS approaching retirement age and suggested that increased community resilience could be achieved by volunteers joining a community workforce. She suggested that this would require significant cultural change. Elaine Mead advised that the aim would be to use technology as much as possible thus freeing up professionals to deal with the most complex cases. Elaine Mead advised that some issues would be dealt with nationally such as a control centre for children s services whilst others would be localised with technology enabling people to make more decisions themselves. She further stressed the need to rebalance the system and allow people to take more responsibility for their own health. The Forum: Noted the terms of the Health & Social Care Delivery Plan 3 THE MODERN OUTPATIENT A COLLABORATIVE APPROACH The previously circulated publication from Scottish Government was noted. It was noted that this had been discussed at the AMC meeting held on 24 January The general principals of the document were noted as to increase self-management and primary care/community capacity; to reduce return appointments; to reduce new referrals and to reduce DNAs. Key transformational areas were considered to be the prevention of unwarranted attendance/admission/referral; optimisation of what should be done in hospital only; prevention of delay and creation of community capacity. The current state was noted as being new outpatient consultant referral as a default for assessment, diagnosis and treatment; consultant led hospital based services which are predominantly face to face consultation and generate routine return appointments; under utilisation of extended multidisciplinary team skills, independent practitioners and community based assets; with the future state being envisaged as primary care/community service led care for non complex care; virtual consultation and patient initiated review; standardisation of return demand variation generated in secondary care; extended scope practitioners/ advanced nurse practitioners; maximisation of the roles of the extended MDTs, pharmacy, optometry, AHPs and other independent practitioners. It had been noted that this was one of two high level value streams and that focus was being placed on specialties with significant delay. Both new outpatients and return outpatients had to be considered. The need for timely access to advice and treatment and support ensuring that the patient is seen by the correct person according to clinical needs was stressed Creating the modern outpatient is about using patient management plans allowing patients to be looked after in the community by GPs with appropriate support from secondary care. To

409 409 reduce unnecessary appointments there was a need to understand return demand considering variation, prioritisation of areas and standardisation of booking systems. The core principles of strengthening self management, accessing support and emphasizing competency based roles were noted together with the recognition of the role of the GP as an expert clinical generalist and optimising the use of IT. Elaine Mead stressed that 7 specialities were being highlighted where there are significant delays and advised that she had felt that the principals had been reasonably received by the GPs against a background of caution. It was considered that triaging could only happen successfully if there was a sufficient amount of quality information given. Duncan Railton advised that the job plans discourage clinicians against the use of phone calls and e mails but Elaine Mead felt that the job plan should be structured in a way that supported the value of phone calls. Catriona Sinclair advised that the challenge was to persuade the public to use pharmacy more and that this would require a change of culture. Communication was considered to be the key with many consultants following up by means of phone review as opposed to automatic appointments. The aim was to give patients more autonomy in terms of accessing review. Elaine Mead advised that reviews had taken place in gastroenterology and cardiology where almost half the patients had been discharged from follow up. She advised that the overall aim was to maximise the use of outpatient time thus releasing consultants time which could be spent on the most complex cases. The Forum: Noted the work being undertaken on the collaborative approach Noted that his would be considered at the Development session on 30 January Agreed that there was a need to move quickly on this issue by holding a balanced debate and pushing confidence back into the system. Agreed to take this forward to the Advisory Committees with a positive message to take to the workforce which would allow beds to be used more appropriately. 4 MINUTE OF MEETING HELD ON 24 NOVEMBER The minute of the meeting held on 24 November was approved with one amendment as follows: Page 7, item 15.3 insert the word planned before the words date of discharge. 5 MATTERS ARISING 5.1 Appointment of Representative on Asset Management Group Duncan Railton confirmed that he was still able to attend every alternate meeting of the Asset Management Group. However a replacement was required for Quentin Cox. Clinical representation on the AMG was considered very useful. After some discussion it was considered that it may be possible to co-opt a representative from one of the professional advisory committees and it was agreed to request Eileen Anderson, the new Chair of the AMC to take up this position.

410 410 The Forum Agreed to request Eileen Anderson, Chair of AMC to fulfil the role of ACF representative on the Asset Management Group. 5.2 Neuro psychology update Andrew Evennett referred to the separately circulated update from Claire Woods and it was noted that Michael Perera was working on some cost benefit data. It was further noted that the option of transferring neuro psychology patients to adult mental health was not viable as specific competences were required. The Forum Noted the update. 6 REALISTIC MEDICINE It was noted that the Steering Group on Realistic Medicine had not yet met. The Forum Noted the update. 7 CHAIRS REPORTING Andrew Evennett advised that realistic medicine was the main issue at present and that updates from the Steering Group should be widely spread. Margaret Moss suggested that the principals of realistic medicine were seen across all sectors and that it would be useful to share realistic practice between Boards. It was noted that the Chief Medical Officer s annual report would be issued in February. The Forum Noted the Chair s report 8 FEEDBACK FROM HIGHLAND HEALTH AND SOCIAL CARE COMMITTEE It was suggested that the minutes of the meeting of the Highland Health and Social Committee should in future be circulated with the papers. Meanwhile it was noted that there was a new format to the balanced score card on health and wellbeing actions. Items discussed at the previous meeting were as follows: directors reports from North & West and South & Mid, strategic commissioning plan; Assessing and Identifying Learning Disability Across the Life Course; north coast (Sutherland) redesign; high level stream work; community resilience, GP clusters; financial position. The Forum Noted the feedback from HHSCC. 9 ASSET MANAGEMENT GROUP 9.1 Minute of Meeting of 20 December The previously circulated minute of the meeting of 20 December was noted, in particular the transfer of 2m from capital to revenue.

411 411 The Forum Noted the update 10 REPORTS/MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES 10.1 Area Nursing, Midwifery and AHP Advisory Committee There had been circulated draft minute of meeting of 22 November which was noted. Alison Hudson advised that the professional leadership committee and the advisory committee both had a different role and that it had been agreed that the meetings of the two groups would be aligned whilst retaining their own identity. The aim was therefore that the meetings would take place on the same day with the leadership followed by the advisory. It was further noted that the Terms of Reference would require to be updated in order to reflect these changes. The need for frontline staff to contribute to the advisory committee was again stressed Psychology Advisory Committee There had been circulated draft minute of meeting of 10 November which was noted. A further meeting had been held on 19 January 2017 at which the documents of Health & Social Care Delivery Plan and the Modern Outpatient had been considered. Emphasis was placed on valuing careers and training and skilling trainees. It was further noted that when the professional lead for clinical psychology was appointed, they would also attend the ACF meetings Area Dental Committee There had been circulated draft minute of meeting of 30 November which was noted. There had been issues with administrative support in respect of the elections and it was hoped that the election process would be completed soon. It was noted that practice inspections now involve fully private practices and that they need to ensure they are registered with Health Improvement Scotland by 1 April Duncan Railton further advised that the Board had been written to regarding the poor advertising of the orthodontist post and it was agreed that a copy of this be forwarded to Andrew Evennett. Some discussion took place as to how to facilitate dissemination of minutes of ACF and it was noted that this was being investigated. It was felt that in addition to minutes some other form of dissemination of the work of ACF was required perhaps by means of a newsletter 10.4 Area Medical Committee There had been circulated and noted draft minute of meeting of 22 November. A further meeting had taken place on 24 January 2017 at which items discussed had included The Modern Outpatient; review of constitution, the creation of the hospital sub committee; consent documentation; the concept of the investigation treatment room which Stewart MacPherson and Ken McDonald have been investigating; lean accounting, which had highlighted the amount of waste on drugs being sent for disposal At this stage Alison Hudson left the meeting. Andrew Evennett advised that the AMC had been asked to consider an additional item, this being Local Patient Access Policy. This had been circulated together with the changes. Margaret Moss did not feel this should have been considered and felt that the updated policy should have been circulated to all the advisory committees with sufficient time to study the document and seek comments. It was agreed to consider this at the next meeting of the Forum when the various advisory committees had been given time to study the document.

412 412 The main areas of concern were the fact that if someone gave less than 24 hours notice this often counted as a DNA Area Optometric Committee There was no report Area Pharmaceutical Committee There had been circulated draft minute of meeting of 21 November which was noted. A further meeting had taken place on 23 January at which the following items had been discussed: realistic medicine (concern had been expressed that pharmacy is only mentioned briefly in the document); recruitment and retention, where it was noted that recruitment of pharmacists to GP practices had left gaps in the hospital and community sector. It was noted that NHS Education Scotland has 170 training places per year and that pro rata NHS Highland should have nine places but in actual fact have only two. It had been agreed to write to NHS Education Scotland expressing concern that NHS Highland was not receiving its fair share of training places. In addition the Director of Pharmacy was working with schools of pharmacy to try to obtain undergraduates. It was agreed that the ACF should support the APC on this issue and that Catriona Sinclair should draft a letter to NES expressing concern which would be sent to the ACF to endorse prior to being sent. The APC also had concerns that the prescribing budget (called the pharmacy budget) could not be directly influenced by pharmacists but its name insinuated that it was ours to control. It was suggested that the budget be renamed as the prescribers budget to try to ensure ownership of this cost centre by all prescribers within NHS Highland. The APC requested and received the support of ACF in this suggestion Healthcare Scientists Forum There was no report. The Forum Noted the updates from the Professional Advisory Committees. 11 NHS HIGHLAND BOARD MEETING - DATE 11.1 Infection Prevention and Control Report There had been circulated Infection Prevention and Control Report by Catherine Stokoe, Infection Control Manager and Dr Jonty Mills, Consultant Microbiologist, on behalf of Heidi May, Board Nurse Director and Executive Lead for Infection Control which was noted Chief Executive s and Directors Report There had been circulated Chief Executive s and Directors report which was noted Medical Education in NHS Highland There had been circulated report by Dr E Watson, Director of Medical Education on behalf of Dr R Harvey, Medical Director which was noted. It was further noted that the GMC were likely to visit in summer and not all requirements for post graduate training were being fulfilled at present. The Forum Noted the circulated Board reports.

413 FOR INFORMATION 12.1 Attendance Record The updated attendance record was noted. The Forum Noted the attendance record. 13 Dates of Future Meetings The dates of meetings in 2017 were noted as follows: 23 March May July September November ITEMS FOR FUTURE ACF MEETINGS Items for future meetings were noted as follows: Maternity services review 15 ANY OTHER COMPETENT BUSINESS There was no other competent business 16 DATE OF NEXT MEETING The next meeting will be held on 23 March 2017 at 1.30pm in the Board Room, Assynt House Inverness. The meeting closed at 4.30pm

414 414 Asset Management Group DRAFT MINUTE of MEETING of the NHS Highland Asset Management Group Anteroom Assynt House Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel s.uk Tuesday 24 th January 2017 Present: In Attendance: Alasdair Lawton, Non-Executive Director & Chair - (AL) Alister McNicoll, Deputy Head of ehealth (AM) Eric Green, Head of Estates (EG) George Morrison, Director of Finance A&B (GM) VC Mike Hall, Associate Medical Director A&B (MH) VC Nick Kenton, Director of Finance (NK) Steven Brown, Section Head Electromedical Equipment Services (SB) Bob Summers, Head of Health & Safety (BS) Alex Javed, Service Manager - Laboratories & (interim) Radiology (AJ) Kate Leishman, Capital Project's Support & Performance Manager (minute) (KL) David Park, Director of Operations, Inner Moray Firth Operational Unit (DP) David Whyte, Chief Clinical Technologist (DW) Melanie Newdick, Vice Chair NHSH Board (MN) Philip Wilson, Project Manager (PW) Sarah Wilson, Estates Project Administrator (SW) Karen McNicoll, Divisional General Manager (KM) Michelle Fraser, Capital Accountant (MF) Welcome/Introductions: Alasdair Lawton welcomed the group & apologies were noted on behalf of; Christina West, Elspeth Caithness, Katherine Sutton, Duncan Railton & Michael Foxley. 1. MINUTE OF THE MEETING HELD ON TUESDAY 20 th December The minutes were approved as an accurate record. 2. MATTERS ARISING 2.1; Belford mobile phones/pagers, at November s meeting the group asked for clarification of the ability to move the system to another location & address the contract query. No update has been submitted. 1

415 ; RNI Dishwasher replacement, work is still on-going so this item is forwarded to February s AMG. 2.3; Proposed smaller group to scrutinise & approve Business Cases through development paper to be presented moved to February s meeting. Actions; 2.1 AM/Iain Underwood to check if the system can be moved to another location in the future if required. CS to check the contract, findings to come back to February s meeting. 2.2 DW & CS, to look at the National Contract & potential of use of the machine in York day Hospital, Alistair Wilson will be contacted to discuss. Findings to come back to February s meeting. 2.3 EG to produce a paper of his suggestion for a smaller approval group at February s meeting. 3. CAPITAL MONITORING Month 9; 46% of the budget has been spend. MF advised that the low spend is being addressed, meetings have taken place or are planned to take place this week with all the Capital budget holders to ensure all the budget is spent by year end. There has also been an additional funding allocation of 30,000 for the Greenspace Project however work on this project is a Revenue cost, so a virement will be required. Slippage of 500,000 has been utilised to address the negative contingency budget issue. EG, advised that the delay in spending with Estates projects was due to partially due to waiting for the decision on the Capital to Revenue uplift & the procurement procedure on construction projects. Projects start in April & there is a large amount of work carried out on project definition before anything can be procured or go to tender. Action; All Capital budget holders to keep updating MF on their spending to ensure all funds are spent by year end. 4. RISK MANAGEMENT/BACKLOG MAINTENANCE ehealth AM informed the group that ehealth are still revising their Risk Register as well as looking at their Risk Management Strategy & Business Continuity. A new Manager has been appointed who will lead on this body of work. ehealth have also been working closely with John Burnside from Estates on their Business Continuity plans. AM advised that he sits on the new NHSH Risk Management group & ehealth s risk register along with other departments will be collated into the NHSH co-operate Risk Register which is managed by Mirian Morrison Clinical Governance Development Manager. AL asked AM to bring information on ehealth s top 5 risks to February s meeting & the full papers to the March AMG. EG advised of the importance of looking at all the risks & plans for all schemes/infrastructure & look at all potential options not just replacement & or new builds. SGHD policy is very clear in that NHS Scotland assets are to be used efficiently, coherently & strategically to support 2

416 416 Scottish Government's plans & priorities & identified clinical strategies & models of care to provide, maintain & develop a high quality, sustainable asset base that supports & facilitates the provision of high quality health care & better health outcomes. As well as ensuring that the operational performance of assets is appropriately recorded, monitored, reported & reviewed &, where appropriate improved/alternative ways of working, all this has to be reflected in NHS Highlands Asset Management Strategy (AMS). Action; AM to bring his top 5 risks to February s meeting & the full papers to the March AMG. PMN; AJ Radiology Risk Register moved to April s AMG. 5. INVERNESS COMMUNITY EQUIPMENT STORE The AMG is asked to approve the purchase of additional racking & a replacement genie lift within the Inverness community equipment store. Additional racking will increase storage capacity from 277 linear meters to 326 linear meters (an 18% increase). Highland Council s asset management group have approved capital funding to cover the cost of the cost of this work, as well as a recurrent contribution towards the running costs of this Inverness store. A request is being made for an NHSH capital code to enable cross charging & work to commence. In 2006, following the closure of Craig Dunain, the Inverness community equipment store relocated to Seafield Road under a 20 year lease. Significant investment was made on industrial longspan racking, a genie scissor lift & a turbex thermal decontamination unit. Highland Council remain the tenant but operational responsibility transferred across to NHSH through the Partnership Agreement. Due to the reduced storage footprint in Seafield Road, in 2006 an interim store was identified for paediatric equipment at a disused nursery in Culcabock & has remained in use ever since. From the outset, the Culcabock site was far from ideal & has deteriorated since with no running water or heating & a site entrance which does not readily accommodate the movement of bulky items. This culminated in a NHSH Health & Safety report stating that the store was not suitable for its intended purpose. This, along with a review of the community equipment service in the Inner Moray Firth Operational Unit (IMFOU) recommending the closure of the Invergordon store & pooling resources within Inverness to improve service resilience & infection control practices were key drivers for maximising the use of space within Seafield Road. Various options were explored with input from store staff, paediatric clinicians & IMFOU Estates & Health & Safety managers. However, it was felt that specialist knowledge was also required so Complete Storage & Industrial Solutions (CSI Group) were approached to support the process as they have a proven track record of successfully designing & completing work within community equipment stores in Argyll & Bute, Edinburgh, and Glasgow & Livingston. Significant alterations were not considered viable due to being over the mid-way point of a lease agreement. Any solution also needed to be readily transferable to an alternative location. Consequently, the agreed approach is to; Alter the layout of existing longspan racking, purchase an additional 5 bays, create additional shelf levels & purchase a more appropriate genie lift to maximise shelving use. The completion of this work to maximise storage capacity within Seafield Road will produce significant benefits; co-location of adult & paediatric equipment. Paediatric clinicians have completed work to rationalise existing assets to work within the agreed m2 footprint. The 3

417 417 rationalisation of store sites within IMFOU to support stock control & the implementation of an electronic asset management system. As well as reduced moving & handling risks for staff & Improved infection control practice. Using CSI to alter & supply additional racking is strongly recommended as this contractor has specialist knowledge of community equipment & warehouse environments, as well as demonstrable competence in completing such work. Any further delays will also drive up costs due to an imminent rise in the price of steel. Purchasing a new genie lift from IAPS is also strongly recommended due to the trade in discount, staff training provided & subsequent aftercare support to ensure compliance with statutory LOLER requirements. The cost for the additional racking & Genie lift including trade in of existing model is 12,333. PW advised that CSI were approached as warehousing is unfamiliar territory for Health Services. PW has had discussions with John MacIver, Estates Officer, who will liaise with CSI in terms of supplying all the relevant paperwork & arranging the works to take place. The financial arrangement is for NHSH to provide a Revenue code & pay CSI for the equipment & work, NHSH will then invoice Highland Council. MF to liaise with PW to arrange this, MF also advised that the equipment will be added to the NHSH Asset Register as a Donated Asset. Action; Approved 6. CAPITAL OVERVIEW NHS Scotland overview of capital position report was issued to the group for information purposes only. The purpose of the report is to provide a high level summary of the asset base supporting the provision of healthcare across Scotland in the context of the ambitions within the National Clinical Strategy & the planned level of investment. The report sets out a number of key opportunities for investment & risks associated with the asset base that should inform the development of a strategic service & corresponding asset plan for NHS Scotland. 7. MRI SCANNER RAIGMORE The Radiology Department has two MRI scanners, one purchased via the capital route in 2010 & the other upgraded to the same specification in 2012 via an operating lease which expires in October It is recognised that there is little likelihood of sufficient capital funding being available in 2017/18 to allow procurement via this mechanism without deprioritisation of other capital programmes. As such the rolling five year capital plan does not currently incorporate the MRI scanners, necessitating a decision as to funding mechanism associated with the replacement timetable. The scanners & associated coils are becoming increasingly unreliable & inefficient with several periods of unplanned down time within the past twelve to eighteen months which impacts on inpatient scanning as well as outpatient waiting times, causing significant disruption to patients with the equipment failing without warning & patients having to be cancelled at the last minute when already in the MRI department. The costs associated with the current lease initiated in 2012 are 124K per annum, while a likely capital cost (excluding installation) would be between 750K & 1M. A period of six months notice needs to be given on the lease by 3rd April 2017, otherwise the lease automatically renews for a further three months. Once notice is given then the scanner will 4

418 418 be removed on or prior to 3rd October 2017, so any decision as to extension or removal & replacement needs to be reached in the next few weeks. This will allow the project management team, delivered locally principally by Estates & Radiology but supported by the National Imaging Lead for Scotland, to put in place the necessary arrangements to enable commencement of the programme. Four options have been explored which are; extend lease on scanner one & delay replacement of scanner two, replace scanner one via operating lease & delay replacement of Scanner two, replace scanners one & two via operating lease & lastly replace both scanners via capital. The preferred option is to replace scanners one & two via operating lease. Procuring a second scanner via this mechanism would of course introduce a hitherto un-resourced revenue cost pressure of a further 142K (excluding installation). These additional lease charges would however be covered by a transfer of budget from the NHSH depreciation budget as there will be a reduction in depreciation as there will no longer depreciation costs relating to a capital asset. The recommended option from a service & financial perspective is that both scanners are replaced in as tight a timeframe as possible & the unavailability of capital requires that to be done by means of operating leases. However it is suggested that while commitment to procure two scanners could be made within 2017/18 the revenue implications associated with the second lease arrangement could be moved into 2018/19 by phasing the installation. That would mean that the additional revenue spend in 2017/18 would be associated with the installation of scanner 1 only, estimated to be 100K. NK asked AJ if the Regional working aspect has been fully explored to ensure NHSH do not duplicate any services that are available elsewhere. AJ advised that there is a large amount of work on-going throughout Scotland in terms of MRI procurement & there is engagement with the National Imaging Lead Mike Conroy. AJ also advised that currently Raigmore already carry out MRI s for NHS Grampian & this will continue. KM added that the preferred option does not preclude continuing discussion & shared services at a regional level. The North of Scotland Planning Group is currently focusing on Radiology workforce planning, staff retention & recruitment however imaging is something that can be addressed in the future. EG commented that previously when major equipment has been renewed no plans for enabling works or modifications have been requested & or costed. Will the proposed new machines require any modifications? AJ advised that the company who will supply the machines have advised that the modifications required will be minimal. EG said that the electrical supply would have to be upgraded & this requires costing & funding for this would have to be identified & allocated. Estates should be involved with this & any other major equipment purchase to ensure enabling works is planned & the related costs identified. EG also asked if 2 was the correct number required as previously Katherine Sutton had said 3 scanners may be required. AJ said that the service has grown but if there were 3 machines then staffing numbers would need to increase. AM, advised that rather than having an extra scanner changes to the delivery of the service & service enhancement are being looked at; for instance running 7 days a week. EG, said that information on service enhancement & alternative working practices should be included in the AMS as this would be well received. Action; Option 3 Approved 5

419 CARDIOLOGY ULTRASOUND The fixed echocardiography ultrasound machine (Philips ie33) is currently out of commission due to ECG board failure, probe failure & user control failure. The portable echocardiography ultrasound machine (GE Vivid Q) has limited clinical use due to image quality concerns. Both machines are based in Lorn & Islands Hospital, Oban, with the portable unit used to provide outreach cardiology services to Mull, Islay, Lochgilphead & Campbeltown. Both machines lie on the Medical Physics asset list & would normally be replaced via a rolling replacement programme based on a normal life expectancy of 7-8 years. The Philips machine is due for replacement 2017/18. The GE machine is due for replacement 2019/20. Both machines have deteriorated over the last two years in terms of image quality, with the Philips machine suffering a recent total breakdown, which has removed it from clinical use. This leaves the portable GE machine as the only service option, despite on-going image quality concerns. Independent quality assurance assessment by Glasgow Medical Physics has highlighted significant image quality concerns involving both machines, with software & hardware failures also identified on the Philips machine. SB informed the group that replacement of the fixed machine is recommended. A quote has been provided the replacement cost is 62, plus VAT. There is currently a loan machine from GE & they are happy to extend this loan until the new machine is installed. The portable machine will not be replaced at this time as it works to the specification required. AL asked if the budget allowed for this purchase, MF confirmed that funds have been allocated. AL also asked if procurement had been approached to ensure best value for money & that they are on the Procurement National Frameworks. DW advised that GE are on the NHS Supply Chain but he s unsure if they are on the Framework however he will look into this & ensure we are getting the best deal possible prior to ordering. Action; Approved 9. PHOTOTHERAPY UNIT LAWSON MEMORIAL HOSPITAL Phototherapy (light therapy delivered by specialised cabinet) is a second-line therapeutic intervention used to treat common chronic, debilitating skin conditions such as psoriasis & eczema. Phototherapy is also used in the management of many less common conditions, including cutaneous lymphomas. Small numbers of patients with alopecia & vitiligo, both of which have a hugely negative impact on quality of life, can be treated with prolonged courses of UVB or PUVA. There is a striking discrepancy in NHS Highland phototherapy provision compared with the rest of Scotland; we provide the poorest access to both UVB and PUVA for our patients. With only one UVB & one UVA machine at Raigmore, our waiting times are longer than desired, & many patients in remote and rural areas simply cannot travel so far so often because of home or work commitments, or frailty. People living distant to Raigmore Hospital e.g. Caithness, Far North Sutherland & Fort William areas are most disadvantaged. The lack of fair access to phototherapy is not in keeping with the Highland Equality Approach which espouses we provide person-centred care. This is frustrating & disappointing for patients, the Dermatology team & our GP colleagues. It inevitably leads to such patients progressing to second-line systemic drugs to control their skin disease. Such drugs require 6

420 420 costly baseline tests such as chest X-rays, tuberculin antigen testing & many other bloods, plus on-going return visits for review & monitoring blood and urine tests, some of which must be sent onwards for specialised tests at other hospitals. Discussion has taken place with the management team at the Lawson Memorial Hospital (LMH) in Golspie, who are willing to staff 5hrs on Monday, Wednesday, Friday s to allow 8 week courses of phototherapy to take place for patients who reside in the north, 52 weeks of the year. This will allow approximately patients to attend the LMH for phototherapy. To go ahead & establish this service, there is a need to purchase a Phototherapy Unit (UVB Irradiation Booth); this has been quoted at 23,144 plus VAT. Also required is a Hybec MED tester at 560 plus VAT & a Portable radiometer & probe 3200 plus VAT. The 2 additional items are required to define the starting dose for UVB to be delivered by the actual unit & the radiometer & probe are to ensure the safe dose is being maintained throughout the treatment; the total cost is plus VAT. DW informed the group that as this is a service development & not a replacement of equipment there it is not in the Capital Plan, if this is something we should be providing a decision will be required on how this is financed. The cost of the installation & work to the existing power supply would be around 1,000. EG asked what the clinical rationale for this was? DW advised that cost savings was the best rationale; due to patients travel, accommodation & drug costs for patients. All present questioned the number of patients per day stated in the paper as the general feeling was this was high. CP asked if there would also be a staffing implication, would staff have to be trained to use the machine, DW advised that nursing staff at Ross Memorial would be trained locally. EG, said that reducing the number of patients that have to travel large distances to be treated at Raigmore is a good thing however how much of a service improvement will this actually be. We could spend the money on this piece of equipment when it could be used to a greater benefit for patients elsewhere. The clinical rationale & service improvement information is missing from the paper. All present agreed that this information should be provided as well as clarification on the number of service users. Clarification is also required on the reasons behind the choice of location to be provided. AL requested that Louise MacFarlane (Consultant Dermatologist) attends to present the paper & answer any questions. CP advised that Gill McVicar should also be involved in any discussions. Action; Paper to be revised to include the clinical rationale & all relevant data for this purchase, to be presented at February s AMG. 10. A.O.C.B. AM asked due to the nature of the requests the AMG receive, & the questions that are asked, these are almost like a Business Case, do we have a Business Case template that could be used so people are fully aware of what information they have to provide. AL commented that this is something he has requested numerous times in the past. EG said that he has tried several times to draft a template but agreement by all was never forthcoming, EG agreed to draft & present a template at February s meeting. EG also said that it should be the Service Managers that attend to present their request, as DW himself or AM that present these requests they are there to support & scrutinise the request the same as the other members of the group. CP commented that if the AMG are 7

421 421 questioning whether it s a legitimate service development this is not necessarily a discussion for the AMG. These decisions should have been agreed by the areas Senior Management Team (SMT) prior to submission to the AMG. NK agreed that the issue of the service needs should be agreed by the relevant SMT & the results should come to the AMG so we are not questioning the need, as this should be clear. NK expressed that a checklist should be part of the template so we can ensure that Procurement, Finance etc. have been consulted. AL agreed that this would be of benefit & if all the information required is not provided & signed off then the Business Case is rejected. CP suggested that the agenda is controlled that way if it s not got that sign off then is not added to the agenda, all present agreed with this suggestion. There being no other business the meeting was closed. Date of Next Meeting Tuesday 28 th February 2017 Venue: Ante room Assynt House Agenda items & papers must be submitted by 12 noon on Monday 20 th February

422 Asset Management Group DRAFT MINUTE of MEETING of the NHS Highland Asset Management Group Anteroom Assynt House 422 Assynt House Beechwood Park Inverness IV2 3BW Tel: Fax: Textphone users can contact us via Typetalk: Tel s.uk Tuesday 28 th February 2017 Present: In Attendance: Alasdair Lawton, Non-Executive Director & Chair - (AL) Alister McNicoll, Deputy Head of ehealth (AM) George Morrison, Head of Finance A&B (GM) VC Carol Marlin, Monitoring Accountant - (CM) Eric Green, Head of Estates (EG) Nick Kenton, Director of Finance (NK) Steve Colligan, Head of Radiotherapy Physics (SC) Steven Brown, Section Head Electromedical Equipment Services (SB) Alex Javed, Service Manager - Laboratories & (interim) Radiology (AJ) David Whyte, Chief Clinical Technologist (DW) David Park, Director of Operations, Inner Moray Firth Operational Unit (DP) Sarah Wilson, Estates Project Administrator (minute)(sw) Michelle Fraser, Capital Accountant (MFr) Heather Cameron, Senior Project Manager (HC) Michael Foxley, Non-Executive Director (MF) Claire Stewart, Procurement Manager (CS) Louise MacFarlane, Consultant Dermatologist (LM) Susan Shand, Service Manager Medical Division (SS) Eileen Anderson, Representative of Area Clinical Forum (EA) Helen Emery, Property Manager (HE) Welcome/Introductions: Alasdair Lawton welcomed the group & apologies were noted on behalf of; Elspeth Caithness, Mike Hall, Kate Leishman and Bob Summers. 1. MINUTE OF THE MEETING HELD ON TUESDAY 24 th January 2017 The minutes were approved as an accurate record. 1