Wishaw General, Monklands, Hairmyres (includes paediatric and mental health)

1. NHS Board: NHS Lanarkshire 2. Submission date: 30 April 2015 3. Named HPHS Lead: Elspeth Russell, Assistant Health Promotion Manager Contact: elspeth.russell@lanarkshire.scot.nhs.uk 4. Hospital sites represented within the submission: Site Description acute community mental health paediatric Name Wishaw General, Monklands, Hairmyres (includes paediatric and mental health) Airbles Road Centre, Beckford Lodge, Caird House Centre, Cleland Hospital, Kirklands, Kilsyth Victoria Cottage Hospital, LadyHome Hospital, Lockhart Hospital, Stonehouse Hospital, Strathclyde Hospital Dazeil Centre, Strathclyde Suite, Udston Hospital, Wester Moffat Hospital 5. Hospital sites not represented within the submission: Site Description Name Rationale provided for noninclusion community Airbles Road Centre, Beckford Lodge, Caird House Centre, Cleland Hospital, Kirklands, Kilsyth Victoria Cottage Hospital, LadyHome Hospital, Lockhart Hospital, Stonehouse Hospital, Strathclyde Hospital Dazeil Centre, Strathclyde Suite, Udston Hospital, Wester Moffat Hospital The focus of the CEL activity to date has been on the three acute sites there have been some actions that also include the community hospitals specifically the actions listed under staff health & wellbeing, food and health and smoking cessation training,. Some areas of the CEL such as breastfeeding, sexual health and alcohol ABIs in A and E departments are not relevant to the community hospitals. Smoking cessation support can be accessed across all sites however dedicated staff are only available on the three acute sites. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 1

6. Summary Feedback The key area reported to have gone well in Year 3 was the good progress made in building capacity for health improvement across the organisation both through the significant increase in the uptake of health improvement related training courses by hospital based staff and the roll out of improvement methodology to drive changes across the organisation. This comprehensive and thorough report demonstrates considerable progress across most of the CEL actions. Specific achievements noted include: Having the two PFPI reps on the CEL steering group who help to shape the action plan delivery is significant and noted as good practice. Plans to involve volunteers in HPHS CEL delivery is also noted as good progress. Health Improvement input to the Consultant Grand Round sessions at each of the acute sites during 2015/16 is noted as progress. Medical Director leading discussions on embedding PA into medical and nursing care. Progress was noted in the smoking cessation training reported in Year 3 with 699 from acute sites and 134 staff from community hospitals completing the learnpro module, in addition to informal inputs to 3904 staff. 83 staff trained in smoking related training in Year 2. Implementation of smokefree grounds and the focused awareness raising in mental health services. An increase in ABI training: 119 staff trained in Year 3 compared to 20 in Year 2. Progress in food and health, with 7 sites attaining the HLA+ award in Year 3 compared to 2 sites in Year 2, and one more community food coops / social enterprise established on site. collection in Reproductive Health was an area identified for improvement last year, and Year 3 has seen improved reporting (or progress in the rates) for all women who have contraception methods recorded on admission to termination services, noted as 100% in year 3 compared to approx. 80% in year 2. Progress in physical activity was noted across several areas: 147 AHPs were trained in PA; there is work in progress to get questions on PA and others into Trakcare; PA is being embedded at every stage of cardiac and pulmonary and stroke rehab with plans to extend options through the Managed Clinical Network; and PA is part of social prescribing programme embedded in mental health services. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 2

In terms of staff, visitors and patients, medal routes for the 3 acute sites were recently completed and the Weigh to Go and Get Active Lanarkshire programmes are also offered. 7. Recommended areas for action / improvement The main challenge for progressing delivery of the CEL was noted as embedding health improvement in core practice against a backdrop of clinical priorities and targets. Use of improvement methodology was noted as supporting change at a pace and scale that is manageable, however this is still challenging particularly around the areas of physical activity and alcohol. To address this, and increase the priority the CEL, the local Steering Group will be reviewed and more senior leadership representation sought. recording and reporting have generally been identified as an ongoing challenge. Key areas for improvement noted from the analysis of the Year 3 report are: To address data recording and reporting for ABIs, continue ongoing work with Trakcare team to improve ABI reporting and capture. Focus of this should be about embedding the ABI pathway for screening and intervention and recording data at appropriate times. First year of baseline data established in Year 3 for rates of LARC provision in maternity settings. This is noted as progress and consideration of the ongoing collection and use of this data to inform service change will be helpful in improving LARC coverage. National support highlighted and noted: The lack of legislation to support Smoke Free grounds remains a considerable challenge despite significant effort at a local level to increase awareness of the policy and its rationale. Progressing the Healthy Living Programme with retailers within the hospitals has been limited and would benefit from nationally driven solutions. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 3

Progress Indicators Delivery analysis Indicator description delivery Delivery has continued as reported in Year 2 progress Improvements in delivery have been reported from Year 2 No progress No change has been reported from the Year 2 report Comparison cannot was not submitted (at all/in same format) in Year 2 report OR new evidence for Year 3 be made NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 4

8. Submission Summary Details within the table below reflect submitted data only. Framework Area Core Actions 1 Strategic Leadership Core Actions 2 Workforce development Named contributors Elspeth Russell, Assistant Health Promotion Manager, Susan McMorrin, Senior Health Improvement Officer Delivery Analysis Evidence Submitted Exception Reported Feedback Required governance structures are in place, however, it was noted that in order to increase the priority the CEL is given in the future, the local Steering Group will be reviewed and more senior leadership representation sought. Significant levels of training undertaken related to HPHS. Core Actions 3 Quality Improvement Encouraging to see QI methods being applied to a range of HI interventions. Plans to spread QI across the organisation should enable testing and demonstration of improvement for HPHS delivery, interventions and patient pathways. Core Actions 4 PFPI Engagement Having the two PFPI reps on the CEL steering group who help to shape the action plan delivery is significant and noted as good practice. Plans to involve volunteers in HPHS CEL delivery is also noted as good progress. Feedback on how this develops will be of interest to national and local HPHS leads. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 5

Framework Core Actions Area 5 Medical Leadership Patient Pathway (PM 1, 2 and 3) Named As contributors above Elspeth Russell, Assistant Health Promotion Manager Delivery Analysis Evidence Exception Reported submitted 18.1 Smoking 1. 2. 3. Health Improvement Feedback input to the Consultant Grand Round sessions at each of the acute sites during 2015/16 is noted as progress. Medical Director leading discussions on embedding PA into medical and 14% nursing of all quit care. attempts and 18% of all 4 week quit successes are initiated within the hospital setting. This quit rate is noted as a good proportion of all quit attempts and demonstrates the value of hospital based smoking cessation interventions. Comparison with year 2 data is not possible as baseline is not the same. Staff training (PM 4) Progress noted: training reported in year 3 with 699 from acute sites and 134 staff from community hospitals completing the learnpro module, with more informal inputs to 3904 staff. 83 staff trained in smoking related training in Year 2. Smokefree status (PM 5) Continued delivery and focused awareness raising in mental health services noted. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 6

Framework Area Named contributors Delivery Analysis Evidence Exception Reported submitted 18.2 Alcohol Feedback A&E delivery (PM 1) Pauline Izat, Substance Misuse Team Leader No baseline Requirements met in part ABI Delivery has yet to be embedded into routine practice and data collection therefore data is only provided in iii) on referrals received and ABIs undertaken by the Substance Misuse service. As a proportion of all A & E attendances 0.02% were referred to the Substance Misuse Service however it is unknown if these were as a result of formal screening and others may have been screened and had an ABI but this data is not able to be reported at present. Already noted in Year 2 report by NHS L staff that this is an area for improvement. Would be beneficial to consider data and its use for service improvement. The standard within the LDP will require attention to priority and wider settings. audit (PM 2) Staff training (PM 3) No baseline Requirements met in part It is noted that mental health inpatient wards are the only areas that currently report numbers screened. Overall 2645 ABIs delivered in acute. It is noted that plans to look at data capture are underway. 119 staff trained in Year 3 compared to 20 in Year 2. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 7

Framework Area Named contributors Delivery Analysis Evidence submitted Exception Reported Feedback 18.3 Maternity BFI Award Status (PM 1) Anne Marie Bruce, Infant Feeding Coordinator, Maternity unit and both North and South CHP have full UNICEF accreditation. Community reaccreditation visit booked for May 2015. Patient Pathway (PM 2) A. A. An opt out support model with follow up in 48 hours of discharge. All women who leave hospital breastfeeding are contacted by telephone or visited by a breastfeeding support service assistant at home. B. B. Signposting and support is picked up by breastfeeding support service above. Attrition rates are recorded using infant feeding pathway forms and results are collated by clinical effectiveness C. D. C. Response notes that breastfeeding rates are low in Lanarkshire, and all women are encouraged to attend infant feeding workshops. Of further interest is whether there are interventions planned for those least likely to breastfeed. D. In addition to community support, a member of staff usually a nursery NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 8

E. F. G. nurse or maternity care assistant is allocated exclusively to cover breastfeeding support 24/7. Following discharge, support is tailored to individual need in the form of an initial home visit, a further home visit, telephone contact, volunteer support or referral to specialist support as required. E. All women are referred to the breastfeeding support service and infant feeding workshops. F. Good examples of PDSA's noted. One looking at timing of giving resources "off to a good start" and "bump to breastfeeding" DVD. 2nd PDSA is developing a text message service to deliver positive health and wellbeing messages to pregnant woman in a bid to reduce DNA rates at antenatal clinic and increase attendance at infant feeding workshops. G. It is noted that the Infant Feeding Policy supports continuation of breastfeeding when a mother admitted to hospital. This policy is due for review this year and will be more explicit regarding this. Breastfeeding support team can be contacted to offer support and advice on the management of breastfeeding while NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 9

mother undergoing treatment. NHSL also has a pharmacist allocated to maternity unit who will review and advise on safety of medications. Contraception provision (PM3) Dr.Anne McLellan, Sexual Health Consultant A. A. Support provided by midwife prior to discharge and after delivery, however vulnerable women are identified antenatally to be targeted postnatally for LARC provision /fitting prior to discharge. B. B. There have been 142 Implants LARC fitted in the last 18 months i. 26% were under 20 years old ii. 80% were SIMD 1 and 2 C. C. This is noted as 29/1000 D.Requirements met in part D. A system was not in place in Year 2 to record data therefore the rate noted above for year 3 is a baseline figure. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 10

Framework Area Named contributors Delivery Analysis Evidence submitted Exception Reported Feedback 18.5 Staff 18.4 Food Health and and Health wellbeing HLA HWL (+) Award Catering Status (PM 1) (PM 1 and 2) HLP Retailers (PM 2) Stress Risk management (PM 3) Gillian June Levick, Archibald, Head HWL of Hotel Manager, Service SALUS, Susan As McMorrin, above Senior Health Promotion Officer Coop/ Social enterprise Monitoring providers (PM 4) (PM 3) The National Retail Group is still considering how retailers like WH Smith are included in these initiatives. In the meantime NHSL s leases are been held on Tacit Relocation. Progress All 10 areas noted have that achieved 7 sites in Gold, Year as 3 in compared Year 2. to 2 sites in Year 2 have HLA+. Current stress management policy in place and reviewed. Stress Risk Assessments undertaken in departments and appropriate actions taken. Stress Management course carried out for managers and staff. Employee Counselling Service available and advised to all staff. Progress noted that 6 sites in Year 3 compared A. The current to 5 Sickness sites in Year Absence 2 have figure for community this year food is 5.02% coops compared / social enterprise with on site. 4.74% for the last financial year. Healthy Staff Support Vending (PM 5) 4) HLA & HLP Physical awards activity for (PM staff 5) (PM 6 A) All As vending Year 2, machines continued breastfeeding NHSL premises have supported healthy on options return to available. work and is part of the Maternity leave policy. 100% of catering sites have HLA Plus, 0 have Progress HLP noted: Weigh to Go programme with link to NHS sites; campaign to promote PA for staff across NHS Lanarkshire sites and RVS building at Wester Moffat developed into staff relaxation and fitness area. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 11

Partnership Framework engagement Area (PM 6 B) recording Active (PM Travel 1) planning (PM 7) As Named above contributors Dr.Anne McLellan Sexual Health Consultant Delivery Analysis Evidence submitted 18.6 Reproductive Health Evidence Board LARC rate (PM 2) Evidence Exception Reported As in Year 2, NHS Lanarkshire promotes corporate (discounted) Feedback memberships with North & South Lanarkshire Leisure Trusts. Get Walking Lanarkshire is promoted to all NHS staff via the staff bulletin & elament web site. Progress noted, rates for all women who Noted have contraception that NHSL is currently methods reviewing recorded and on refreshing admission the to termination organisational services travel is plan, 100% and in year a grant 3 compared has been to sought approx. for 80% a in year programme 2. entitled Smarter Travel NL in partnership with N L Council. It will be interesting 100% women to see offered outcome LARC of prior this to in Year 4. discharge. Uptake figures for Year 3 are 27% for under 20 s and 26 % for SIMD groups 1&2. These figures are lower than year 2 (36.8 and 27.3 respectively), however it has been noted that quality assurance is being noted for these records and figures may be underreported. TOP rates (PM 3) Evidence Progress noted: The rate of termination in year 2 was 11.8 /1000 and 10.6 / 1000 in Year 3. 27.5% of women had had a repeat termination in the ear ending 2012, with 25% the following year (year 3) showing a reduction of 2.5% of women having repeat termination. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 12

Framework Area Named contributors Delivery Analysis Evidence submitted Exception Reported Feedback 18.7 Physical Activity Named Lead (PM 1 A) Simon Martin HWL Officer, Gabe Docherty Head of Health Improvement, Susan McMorrin Senior Health Improvement Officer Staff Training (PM1 B) Progress noted. Briefing sessions developed in year 2 have been used to train 147 AHPs in PA in addition to numbers in core action 2. Patient Pathway (PM 1 C and D) Progress noted, work progressing to get questions on PA and others into Trakcare. Embedding of PA at every stage of cardiac and pulmonary and stroke rehab. Work with MCN to extend options for PA in rehab and PA part of social prescribing programme embedded in mental health services. Evaluative practice (PM 1 E) Evidence of monitoring in cardiac rehab and active health referral programme. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 13

Awareness raising action (PM 2 A, B) Progress noted with both the recently completed medal routes for the 3 acute sites and the Get Active Lanarkshire programme asking staff & public to become more physically active, with an increase of more than 27,000 pledges from last year. Partnership engagement (PM 2C), grant sought for Smarter Travel NL in partnership with NL Council will benefit patients and visitors. NHS Lanarkshire CEL (1) 2012 Annual Report Feedback: Year 3 Action 2014/2015 Page 14