Minute of the above meeting held at 9:30am on Thursday 21 April 2016 in the Board Room, Level 10, Ninewells Hospital, Dundee.

Item 8.1 Minute NHS Tayside TAYSIDE NHS BOARD Minute of the above meeting held at 9:30am on Thursday 21 April 2016 in the Board Room, Level 10, Ninewells Hospital, Dundee. Present Non Executive Members Mrs P Campbell Non Executive Member, Tayside NHS Board Dr A Cowie Non Executive Member, Tayside NHS Board Prof J Connell Chairman, Tayside NHS Board Mr D Cross OBE, Vice Chairman, Tayside NHS Board Councillor D Doogan Non Executive Member, Tayside NHS Board ( to item 13) Mrs L Dunion Non Executive Member, Tayside NHS Board Mrs J Golden Employee Director, Tayside NHS Board Mr S Hay Non Executive Member, Tayside NHS Board Mr M Hussain Non Executive Member, Tayside NHS Board ( to item 13) Councillor G Middleton Non Executive Member, Tayside NHS Board ( to item 13) Mr H Robertson Non Executive Member, Tayside NHS Board Mrs A Rogers Non Executive Member, Tayside NHS Board Professor M Smith Non Executive Member, Tayside NHS Board ( to item 13) Mrs S Tunstall-James Non Executive Member, Tayside NHS Board Executive Members Mrs G Costello Nurse Director, NHS Tayside Ms L McLay Chief Executive, NHS Tayside Dr A Russell Medical Director, NHS Tayside Apologies Councillor K Lynn Non Executive Member, Tayside NHS Board Dr D Walker Director of Public Health, NHS Tayside In Attendance Mrs J Alexander Partnership Representative Mr L Bedford Interim Director of Finance Dr A Cook Medical Director, Operational Unit Mr G Doherty Director of Human Resources, NHS Tayside Ms M Dunning Board Secretary, Tayside NHS Board Mr T Gaskin Chief Internal Auditor Miss D Howey Head of Committee Administration, Tayside NHS Board By Invitation Ms D Campbell Associate Director, Patient Safety ( for item 10.3 ) Mrs V Irons Chief Officer, Angus IJB (for item 10.2) Mrs K Ozden Director of Mental Health Services / Associate ( for item 11.1) Nurse Director Mr R Packham Chief Officer, Perth and Kinross IJB ( for item 10.2) Mr A Radley Consultant in Public Health Pharmacy ( for item 9.1 ) Professor J Connell in the Chair 1

ACTION 1. CHAIRMAN S WELCOME, INTRODUCTION AND KEY ISSUES The Chairman welcomed all to the meeting. He highlighted: The intention to hold some Board meetings at locations in other areas of Tayside; this would be dependent on officer availability and travel considerations The Board was in purdah due to the Scottish Parliament election and it was noted that the SNP manifesto included a review of the number of NHS Boards The Chairman and the Nurse Director had recently visited staff at the Management Clinical Network (MCN) for Hepatitis C. This was a world leading service with an international reputation ; Professor J Dillion has been invited to give advice to the European Parliament and overseas Governments on setting up programmes. It was noted that there was an intention to hold a future Board Development Session focussing on the success of this and the other MCNs such as diabetes and breast cancer This would showcase NHS Tayside as a leader in Scotland in a number of key areas The recent media coverage of allegations of bullying in NHS Tayside was taken seriously by the Board. Bullying and harassment was not condoned. The Chairman had spoken to the Lead Officers in the areas concerned and these allegations were being investigated and dealt with in the appropriate way. He advised of the intention of the Director of Human Resources to present in the next month plans to review the culture of the organisation This Board agenda was trialling the new format that had been agreed with the inclusion of the Chairs assurance reports at the start of the meeting. There was no planned Development Session after this Board meeting The Board noted the Chairman s update 2. CHIEF EXECUTIVE S UPDATE The Chief Executive gave an update. She highlighted: The evaluation of the requirement for Major Trauma Centres in Scotland was still ongoing. There was potential for there to be only two centres in Scotland in Glasgow and Edinburgh. Further work and discussion was ongoing with the Scottish Government Health and Social Care Directorate and senior clinicians. There had been a recent meeting with the national Lead Team where NHS Tayside clinicians had emphasised the capacity and experience in NHS Tayside as well as the patient outcomes. Further conversations were to be held and a planning forum was to be held at the end of April 2016. It was noted that evaluation work was ongoing by the University of Dundee. It would also be useful to also have a public health view and the professional advisory structure had also been requested for their input. An update would come back to the June 2016 Board meeting The Joint Inspection of Children and Young Peoples Services in Angus had started and the meeting with the health team had taken place that week. The final evaluation and assessment of the services was due on 22 April 2016. The initial feedback on the visit was expected at the end of June with the report due around the end of September/early October 2016. It was noted that these were indicative timescales 2

During discussion the following points were noted: No decision was imminent on the Major Trauma Centres and any move towards a change in the service would take time but the longer term implications for Tayside and the north of Scotland were acknowledged NHS Tayside was well represented at the national groups and was engaging fully with the Scottish Government Health and Social Care Directorate. The consultation with the professional advisory structure could only strengthen this engagement This was about getting the best outcomes for the patients around major trauma. The work undertaken by the University of Dundee covered the interdependence of services around major trauma provision. There was also a link to the provision of undergraduate and post graduate medical education in Tayside The Board noted the Chief Executive s update 3. APOLOGIES The apologies were as noted above. 4. RECORD OF ATTENDANCE ` The Record of Attendance was noted for information. 5. DECLARATION OF INTERESTS The Chief Internal Auditor declared an interest in Item 20 in reserved business, Disposal Strategy Declaration of Property Surplus to Requirements. 6. MINUTE OF PREVIOUS MEETING 6.1 Minute of Meeting of Tayside NHS Board held on 25 February 2016 The Minute of the Meeting of Tayside NHS Board held on 25 February 2016 was approved subject to the undernoted amendment: Page 137, Corporate Financial Report for Period ended 31 January 2016 (BOARD15/2016), 5 th paragraph, line four,... ( including exiting brokerage) to read... ( including existing brokerage). With this amendment noted, the Minute of Tayside NHS Board held on 25 February 2016 was approved on the motion of Mrs S Tunstall-James and seconded by Dr A Cowie. 6.2 Minute of Meeting of Tayside NHS Board held on 10 March 2016 The Minute of the Meeting of Tayside NHS Board held on 10 March 2016 was approved subject to the undernoted amendment : To note that Mrs Dunion left the meeting during the discussion on Item 5.1 Steps to Better Healthcare Mental Health Improvement Programme: General Adult Psychiatry Inpatient Services (BOARD24/2016). 3

With this amendment noted the Minute of Tayside NHS Board held on 10 March 2016 was approved on the motion of Mrs J Golden and seconded by Mrs A Rogers. 6.3 Action Points Update The Chief Executive spoke to the action points update. In relation to the Local Delivery Plan 2016/17, it was noted that that the June date may be too late for the consideration of the draft Plan before its submission to the Scottish Government Health and Social Care Directorate on 31 May 2016. A Board meeting may need to be arranged prior to 23 June 2016. The Board noted the Action Points Update 6.4 Any Other Matters Arising The Board Secretary advised that Mrs S Tunstall-James had replaced Dr D Dorward as a member on the Project Board for the NHS Scotland Pharmaceutical Specials Service (PSS). 7. COMMITTEES ASSURANCE REPORTS FROM CHAIRS 7.1 Audit Committee (BOARD35/2016) Mr Hay highlighted that monitoring of EDL (enhancements during Leave) would be undertaken by the Finance and Resources Committee. The Audit Committee would be required to consider how EDL was presented in the Annual Accounts for 2015/16 and this was to be discussed at the next Audit Committee meeting. Internal Audit would focus on medium and high priority risk areas in their work plan and it was planned to have a discussion on governance in relation o Integrated Joint Boards and NHS Boards and Local authorities at the next Audit Committee meeting. Performance against work plan Work plan is progressing in line with expectations Update on Risks 1. We continue to monitor the progress on EDL (enhancements during Leave) 2. We have requested a verbal update to the Committee around the external review relating to original build specifications for all Mental Health sites Delegated Decisions taken by the Committee None Any Other Major Issues to highlight to the Board 1. Internal Audit have completed their reports relating to IJBs due diligence and concluded that IJB members had sufficient information to determine if their resources were adequate 2. Internal Audit work plan for the coming year will be amended as a result of staffing issues. This means that the focus will be on high and medium 4

priority areas only. The focus of the work plan had been agreed at the previous audit committee meeting The Board noted the update from Mr Hay, Chair, Audit Committee 7.2 Clinical and Care Governance Committee (BOARD27/2016) Mrs Rogers highlighted that the meeting on 11 February 2016 had been inquorate and a further meeting had been held on 25 February 2016 to conclude business. The risk titles were to be amended and the mental health scoring was to be updated in light of the HSE visit and its outcome. Work had also been done on the Committee s Terms of Reference and further work was to be done on the Clinical Quality Forum s Terms of Reference. The Children and Young People risk was to be reviewed following the inspections in Dundee and Angus and the red risk at PRI was also highlighted. There needed to be further discussion on what was required in the horizon scanning section of the Chair s assurance report. Performance against workplan The meeting of 11 February 2016 was inquorate, and therefore an additional meeting, which was quorate was held on 25 February 2016 to approve the recommendations made on 11 February 2016, and ensure that all aspects of the 2015/16 workplan had been completed and the business of the Committee concluded. Update on Risks All risks were discussed at the SRMG on 4 February 2016 and had been updated for the Board meeting on 25 February 2016. Noted that Mental Health current scoring would increase The Committee requested that Public Health Performance Review was a substantive item on the agenda for the next meeting The committee authorised the review of the Clinical Governance Strategy The Committee requested that the Risk Update item be moved to the end of the Open Business of the Committee commencing May 2016 The Committee adopted the Facilitating Anticipatory Care at the end of Life Policy for the Use of Just in Case Boxes in NHS Tayside The Committee approved the Research and Governance Annual Report. The Committee noted the PRI performance against the six key measures and agreed that a reporting mechanism would be developed, similar to SEWS, which would come to each meeting from the August 2016 meeting onwards. The Medical Director would progress how to capture the benefits of improvements in care at PRI The Committee requested a report from the Mental Health Directorate at every meeting with an action plan, timescales and progress in response to the Murray Royal Hospital Adult Mental Health Inpatient Care: Health and Safety Executive Investigation and Improvement Notice 5

The Committee agreed that the level of detail in the CQF Action Note was acceptable and requested that, in future, a covering report is attached highlighting any areas of concern and emerging issues The Committee agreed that appropriate actions have been taken to address the recommendations from the Chief Medical Officer s report Any Other Major Issues to highlight to the Board The Committee raised concern in relation to the implications of HSCI on the management of the Mental Health service and noted that NHS Tayside would advise the HSE of the new Accountable Officer from April 2016 The Board noted the update from Mrs Rogers, Chair of the Clinical and Care Governance Committee 7.3 Finance and Resources Committee (BOARD40/2016) Mr Cross advised on what was to be achieved by this assurance reporting, in bringing forward an assurance to those who were not members of these Committees. He highlighted that this included the strategic risks reported to the Finance and Resources Committee were being appropriately monitored, the Committee was fulfilling its workplan, advised of the delegated decisions taken by the Committee on behalf of the Board, to highlight any up and coming business and to listen to any concerns raised by members. Mr Cross highlighted the horizon scanning and in particular the important role for the Finance and Resources Committee. This was to support the Transformation Programme Board in monitoring the workstreams and their efficiency programmes; the need for a review of the Finance Team following a number of retirals of key individuals, the need to simplify the reporting of financial information, there needed to be a closer relationship between the Audit Committee, Staff Governance Committee and the Finance and Resources Committee and the requirement for the Board to review its budget setting processes as incremental budgets were no longer sustainable. It was noted that there was an open invitation to those Board Members who were not members of the Finance and Resources Committee to come along to the meetings; or they could contact Mr Cross or Mr Bedford to discuss financial matters. It was noted that it had been highlighted in the Internal Audit Review that more work needed to be done by the Finance and Resources Committee to monitor and review the Property Asset Management Strategy. Performance Against Work Plan During the financial year the Committee referenced its work against its 2015/2016 Work Plan. The main components of the Work Plan relate to:- Approving the Strategic Financial Plan for 2015/16 2019/20; Considering corporate financial reports in respect of performance against the revenue and capital budgets; Reporting on contract awards; Consideration of Initial agreements, Outline and Full Business Cases; 6

Policy development and review; Review of Information Governance arrangements; Developing and monitoring Property and Asset Management strategies; Developing and monitoring the Sustainability and Environmental Strategy; Monitor the business of a number of sub committees, and Prepare an Annual Report following consideration of annual reports from a number of sub committees. Following a review by Internal Audit it is recognised that the Committee requires giving more attention to monitoring of the Property and Asset Management Strategy, including backlog maintenance, disposals and associated KPIs. This will be addressed during 2016/2017. The 2016/2017 Work Plan will be submitted to the Committee at its next meeting and progress against this will be reported periodically to the Committee and performance reflected in future Assurance reports to the Board. Update on Risks There are three strategic risks which fall under the scrutiny of the Finance and Resources Committee:- The first relates to failure to deliver the Strategic Financial Plan and the impact this would have on delivery of national and local plans and the potential to breach the statutory financial obligations of the Board. The current score for this risk is 25 (very high) which is the same score as the inherent risk. This reflects the current significant financial challenges the Board faces, including the requirement to repay brokerage from previous years, and the fact the Board currently has an operating service model that extends beyond its budgeted financial allocation in terms of site configuration, employed workforce resources, operational and facility maintenance costs. A recent review of benchmark data confirms NHS Tayside to be an outlier in a number of cost categories. A Transformation Programme Board has been established to support delivery of changes that will result in sustainable financial balance and cost effective service delivery, while recognising the Board s commitment to quality, safety and improving patient outcomes. The second strategic risk relates to the reduction in capital resources experienced by the Board and the impact this has on our ability to deliver the Clinical Strategy and the Property Asset Management Strategy. The current score for this risk is 20 (very high) which is the same as the inherent risk. This score reflects the level of capital resources the Board receives has continued to reduce over the last three financial years, which has had a detrimental impact on our ability to deliver capital projects in support of our strategies. It also reflects Scottish Government Health & Social Care Directorate (SGHSCD) advice that Boards should assume a flat line position regarding capital funding for the next few years. The underlying approach to managing this position is to prioritise our spend, taking account of the PAMS and Clinical Strategy, while regular dialogue takes place with SGHSCD officials with a view to exploring potential opportunities to augment our current allocation and identify potential solutions to emerging issues. 7

The third strategic risk relates to Information Governance and the impact any failure to comply with legislation and standards would have on the Board s reputation, public trust and potential financial loss. The current score for this risk is 12 (high) against an inherent risk score of 25. This reflects the Board s current strength in this area in terms of corporate governance and management arrangements including adherence to legislation and policies. It is important that the Board retains focus on this important subject and that key roles remain adequately resourced. Plans are in place to reduce the risk score to 9 (medium). Delegated Decisions taken by the Committee At its meeting on 10 March the Committee considered Report FRC20/2016 NHS Tayside Financial Framework 2016/17 2020/21. This report set out a five year Financial plan for inclusion within the Board s annual Local Delivery Plan (LDP). It was highlighted in the report that confirmation is required from the Board that financial targets for 2016/17 and beyond will be met with regard to remaining within both revenue and capital resource limits, meeting cash requirement as well as achieving the required efficiency savings. The Committee noted that consideration of the Financial Framework would normally take place alongside consideration of the LDP, however the submission date of the LDP had been deferred. This was unfortunate as the LDP provides useful context to the assumptions within the Financial Framework. Members were concerned about the level of savings required to stay within revenue limits and the ability of the Board to achieve this level of savings, given the current financial position and the fact this level of savings is much greater than the Board has achieved to date. It was acknowledged the workstreams set up under the Transformation Programme would be key to meeting these challenges, but it was felt that these initiatives would take time to bed in, and again there were concerns around the pace of change and the ability of the organisation to absorb such significant organisational change to achieve the required savings in 2016/17. Concerns were also expressed around the level of budget transfer to the Integrated Joint Boards (IJBs), the flat attribution of savings targets to the IJBs, and their ability to meet their share of the savings targets. Members also sought assurances that any savings proposals must be considered against the Board s aims of ensuring patient safety and delivering improved, safe and quality systems of care. It was, however, recognised that the level of resources notified by SGHSCD for 2016/17 and projected for the four years beyond, as detailed in the report, were unlikely to change significantly, and the Board had a responsibility to do everything it can to live within its means. After long and careful consideration, the Committee, therefore, agreed to recommend the NHS Tayside Financial Framework 2016/17 2020/21 to the Board for approval. Any Other Major Issues to highlight to the Board The Board continues to experience significant financial challenges. There is an underlying financial deficit which confirms the Board currently has an operating model that extends beyond its budgeted financial allocation. This is being addressed through a series of initiatives within the workstreams reporting to the Transformation Programme Board. It is encouraging to note the pace of overspend has slowed with promising signs of a reduced incidence of using agency staff, enhanced vacancy management procedures, initiatives within pharmacy taking effect, and procurement savings achieved. Clearly much greater progress will be required to bring the Board closer to financial balance. The financial position in 2015/16 is exacerbated by continued liability in relation 8

to enhancements during leave. This is the subject of detailed work and a firmer accrual will be reflected in the year end accounts. The other contributing factor relates to repayment of brokerage, and it is now clear that the Board has an asset disposal plan which will require careful management to ensure best value can be achieved from these sales. It is also apparent a longer term approach will be required in order to realise sufficient receipts from disposal of properties to repay the required level of brokerage. At the last Board Meeting a suggestion was made that the Finance and Resources Committee oversee a piece of work looking at the total net book value of properties declared surplus and a profiled realisation of sales. This work will be taken forward in 2016/17. Discussions are taking place with SGHSCD around the 2015/16 year end position, the overall brokerage position and any potential to mitigate the final position. Horizon Scanning The following highlights work to be commenced within this financial year. As previously referred to the product of the workstreams reporting to the Transformation Programme Board will be key to addressing the financial challenges facing the Board. The Finance and Resources Committee will be closely monitoring this work to provide assurance or give a view on how these savings are materialising, and reflected in the finance updates to the Board. The Committee will initiate the exercise referred to above relating to the net book value of properties declared surplus and a profile of anticipated sales receipts. There is a pressing need to review the finance team structure in light of the retirement of key individuals over the last 12 months or so. Work is on-going to try and simplify reporting of financial information to the Board and also development of informative financial KPIs. It is also important that there is greater clarity on costs and risks within Board papers. The Finance Directorate and Finance and Resources Committee have an important role to play in this. The importance of the relationship between the Finance and Resources, and the Staff Governance Committees is recognised, and discussions will take place around how this relationship can assist the Board meet its objectives. It is recognised that the Board needs to refine its budget setting and monitoring processes. Some improvement will be generated by the proposed approach to capturing savings within each of the workstreams, however an incremental approach to budget setting is no longer sustainable. Future budgets should reflect the service redesign that will take place through the clinical strategies and there needs to be greater involvement in budget setting at all levels of the organisation. The Internal Audit Interim Review 2015/16 identified some issues to be addressed by the Finance and Resources Committee. These have been incorporated into an action plan and progress against these actions will be monitored by the Committee. The Board noted the update from Mr D Cross, Chair of the Finance and Resources Committee 9

7.4 Staff Governance Committee (BOARD28/2016) Mr Hussain highlighted the discussion around the amount of statutory and mandatory training that staff were expected to complete, the imatter consultation was to be reported to the June meeting of the Staff Governance Committee, the work of the Whistleblowing Champion, the adoption of an Attraction and Recruitment Strategy that linked with the workforce risk, the ongoing review of the Staff Governance Committee Terms of Reference and an increase in the number of grievances was being investigated by the staff side. There was discussion about the amount of statutory and mandatory training. It was noted that there was a difficulty with the definition of mandatory training and work was ongoing to agree this definition. This was not solely an issue for NHS Tayside but was across NHS Scotland. A group had been established to look at this and seek agreement on what was mandatory training for different staff disciplines and this would be coming forward to the June meeting of the Staff Governance Committee. The effectiveness of a Personal Development Plan (PDP) as part of staff development was queried. It was noted that there needed to be meaningful conversation between the staff member and their line manager and having a PDP was promoted throughout the organisation. The current uptake was low and there was an organisational commitment for this to be increased. It was noted that the Board s imatter report would also be coming forward to the Staff Governance Committee; in some areas performance was good but in others it was not. Performance against workplan Staff Governance Standards reviewed at meeting i) All staff are appropriately trained and developed and all staff have a regular, effective personal development plan and review discussion. Concerns raised in past, with current uptake of PDPs across NHS Tayside being low, 43.8% Thus a goal has been set of reaching 80% by 1 December 2016 with an ongoing commitment to this standard across the organisation thereafter. ii) Well informed Good progress by communications department within this standard for staff, Value Your NHS, Staff Recognition Awards, H&SCI engagement and the Communications survey are examples of some of the initiatives taken across this standard. There will also be increased communications about the staff governance committee and its role as well as specific areas such as media plan around violence & aggression incidents against staff for example. Update on Risks - Corporate Risks Board Assurance Framework Nursing & Midwifery Workforce 20% increase in newly qualified nurses at Nov 2015, however organisation still facing challenges in retention. One graduate intake per year also constrains recruitment opportunities. A range of initiatives are 10

underway and with the adoption of the attraction and recruitment strategy, the visibility of these will increase. Update given on non-contract agency as part of Value your NHS programme and Workforce & Care assurance programme. Also update on e-rostering programme which is part of the Transformation Programme Board. - Health & Social Care Integration Update Report An update given to the committee reference this item, in advance of integration as of 1 April 2016. H&SCI Programme Board is the interim governing body ensuring a smooth partnership process as part of integration. Also received confirmation that the communities partnership forum is meeting and ensuring a smooth transition. Delegated Decisions taken by the Committee - Statutory/Mandatory Training Pilot Study Findings, Utilise learning to bring forward a strategy reference implementation of statutory and mandatory training within the organisation. - People Matter Consultation Consultation on People Matter strategic framework to go to relevant stakeholders before coming back to the June 2016 committee. - Whistle Blowing: Non Executive Champion, approved approach taken for this role. - Adoption of Attraction and Recruitment Strategy February 2016 Any Other Major Issues to highlight to the Board - Review of Terms of Reference of Staff Governance Committee following Internal Audit review. With suggestions for greater involvement in workforce financial governance, in liaison with Finance & Resource committee terms of reference. - The Staff Governance Committee highlighted under Workforce Information Report Quarter 3 2015/16:- Concerns around the number of grievances being reported as Union Stewards were attending a higher number than reported. It was noted that figures were dependent on information coded through the electronic reporting system. Horizon Scanning The Board should be aware of the Importance of the People Matter Strategic framework currently under consultation for the organisation and NHS Tayside Board 2016-2021. The Strategic priorities include Developing our Culture and the following key strategic elements with a range of priorities within each element. - Building a sustainable workforce - Developing a Capable Workforce - Cultivating an Engaged Workforce - Supporting Engaged Leadership - Promoting an Integrated Workforce 11

Governance will be through active engagement with the Board and Staff Governance Committee and the strategy should align with the Board s Clinical and Financial Strategies. Measurement and review of the strategic framework will be from the Board and Staff Governance Committee. As part of the People Matter Strategic Framework Consultation there is also the proposal for a Strategic People Matter Group that will oversee implementation of actions arising from the plan and support ongoing developments. The Board noted the update from Mr M Hussain, Chair of the Staff Governance Committee The Chairman thanked all of the Chairs for producing these helpful assurance updates, noted the positive feedback on their introduction and use and acknowledge the input of Mr D Cross in bringing this governance work forward 8. Corporate Performance Dashboard Ms Wiggin gave an update to the Board on the Development Session that had been held on 31 March 2016 about performance and the executive scorecard. She outlined the programme of work was being progressed to complete the corporate performance dashboard. It was noted that a meeting had been held following the Board Development Session on the requirements for finance performance measures and work was also ongoing in respect of clinical governance measures to complete the specification for both the performance review meetings and corporate dashboard. Performance measures for workforce were still not complete and work was to start to confirm would measures would be required. In addition the measures for the Integrated Joint Boards still had to be confirmed.. A minimum data set across each of the three areas was to be finalised. It was noted that there needed to be a consistent approach across all three areas to provide performance assurance. Work had also been done in respect of mental health performance indicators. The Board Thanked Ms Wiggin and Ms Lowry for their work on this Noted the update on the development of a Corporate Performance Dashboard 9. PUBLIC HEALTH 9.1 Pharmaceutical Care Services Plan (BOARD19/2016) Mr A Radley was in attendance and presented the updates to the Pharmaceutical Care Services Plan. He advised that this was a major revision to the Plan, it had last been considered by the Board two years ago, and this was the third time the Plan had come forward to the Board. He noted that there was now the ability to access much more data since the last time to inform the Plan. Mr Radley outlined the Board s duty to provide or secure pharmaceutical services care services for their respective areas and to identify gaps in service provision and publish plans to that effect. 12

It was noted that there were 92 community pharmacies located across Angus, Dundee and Perth and Kinross. The current assessment was there were no gaps in the current provision; however, there was a variance in the implementation of the pharmacy contract. It was noted that the intention was to engage with each of the contractor groups about this and the outcomes would come back to the Board at a future meeting. During discussion the following points were noted: There were good relationships in place with community pharmacies. This was beneficial in getting the best possible service for the patients and an equitable distribution of a quality service The intention was to move away from the traditional silos of primary and secondary care and work in a much more holistic way This was a high level and summarised report and much more detailed information was also available on the population, catchment area, minorities, specialist needs, disease groups and secondary care The location of community pharmacies was in the main due to historical factors. Contractors were there if their business was viable. There was the ability to put more contracts in place if required but this had not been an issue as yet There was ongoing engagement work with the Integrated Joint Boards on what was required now, and what would be required in the future. It was noted that prescribing efficiency was an area that was to be taken forward Engagement had been undertaken with public partners as part of the consultation process of the Plan. The next step in the process was consultation with the public on what was available and what they wanted of their community pharmacies Pharmacy support was available in some GP practices. The work of pharmacy technicians in reducing the prescribing spend was acknowledged. It was noted that the recruitment of pharmacy technicians was being addressed partially via primary care allocations The value of access to high quality data was reflected in this Plan Some community pharmacies had access to the clinical portal but this needed to be moved forward at a more rapid pace There was work being done in respect of health literacy but it was acknowledged that this was a three to five year project The Board: Thanked Mr Radley for presenting the Pharmaceutical Care Services Plan Noted that there was a good geographical spread and equity of pharmaceutical provision in this Plan Noted the need to raise public awareness of the Plan Noted that the Community Pharmacy Service was part of the integrated team Noted that work was ongoing with the IJBs on what information they required Acknowledged the Pharmaceutical Care Services Plan and supported its publication on the NHS Tayside website 10. ORGANISATIONAL PERFORMANCE 13

10.1 Healthcare Associated Infection (HAI) Control in Tayside for January and February (BOARD30/2016) The Medical Director advised that Dr G Phillips had now retired and both he and the Nurse Director would share the reporting of HAI Control for a short period. It was noted that there was little to report in respect of outbreaks, the hand hygiene audit was a snapshot in time and the 81% figure for ancillary staff was disappointing. There was nothing to report in respect of MRSA and with regard to VRE and universal screening, this had been introduced five years ago and as no sustainable effect had been seen, it was felt to be of little benefit. The narrative around the SABS target was highlighted. It was noted that there had been an anomaly in the recording of the denominator, in moving from a manual system to a paper based system. This had made no difference to the position other than the rate was slightly higher. The Chairman on behalf of the Board paid tribute to Dr Phillips and thanked her for her work and contribution to infection control management in Tayside. During discussion the following points were noted: It was disappointing to see that medical staff were not performing well in respect of the hand hygiene target. Hand washing was a basic and mandatory part of hand hygiene. Staff and the public were supported to challenge medical staff that had not washed their hands. A lot of work had been done in respect of skin health surveillance and hand hygiene would be considered as part of these processes In respect of the public awareness of this ability to challenge, it was noted that this was done in a variety of ways but that this could be improved upon It was acknowledged that whilst hand washing was important, there were a number of staff who were unable to use the hand washing products and there had to be a balance between this and the mandatory requirements The work ongoing around the skin health surveillance programme was noted. A Vital Signs on skin health surveillance had been circulated and 40% of consultants had engaged with the programme already as well as 30% of junior staff. The aim was to have 100% of the medical staff covered by the end of June The HEAT target for SABs had not been met or been changed since 2012. It was noted that there needed to be a national conversation on the relevance and applicability of this target SABs were of concern and were routinely monitored as they impacted on patient care. There was a need to look at the outcomes and educate staff. It was noted that this type of issue would be referred via the Clinical and Care Governance Committee NHS Tayside should understand how the top performing organisations met this HEAT target and learn and implement changes. It was acknowledged that a high proportion of the infections were community acquired It was agreed that the SAB issue should be considered and presented in a future report to the Board The Board: Noted the HAI Control Report in Tayside for January and February 2016 Thanked Dr G Phillips for her contribution to infection control in Tayside and wished her well in her retirement 14

Noted that an update would be given at a future Board meeting on what was being done to tackle the stubborn SAB rate 10.2 Tayside NHS Board Performance Report (BOARD31/2016) The Director of Acute Services presented the Performance Report to the end of February 2016. She advised that the Treatment Time Guarantee (TTG) figures had deteriorated and there were 387 patients treated in February that had waited more than 84 days. It was noted that there were a number of issues impacting on this including unscheduled admission requiring the step down of elective activity. It was noted that there had been 357 procedures cancelled; 187 in Ninewells and 170 in Perth Royal Infirmary between 1 April 2015 and 31 March 2016. This was an average of 6 to 7 patients per week whose procedures had been cancelled. An area of emerging concern highlighted to the Board was linked to urology services due to upcoming staff vacancies. It was noted that discussion was ongoing to find a regional or national solution. It was noted that there was an improving position with new out patients. The 18 week performance was unlikely to improve until the TTG and out patients services were meeting targets. The cancer 31 and 62 days targets had not been met with urology continuing to the highest risk. The Child and Adolescent Mental Health Services (CAMHS) were continuing to meet its waiting times target. The same day surgery target was also being met but there was still room for improvement to match other NHS Scotland Boards performance. Work was underway to improve this and a report was expected at the end of June 2016. The increase in emergency admissions had impacted elsewhere in the system, with an increase in length of stay. A day of care audit had been undertaken at Perth Royal Infirmary on 20 April 2016 to understand what improvements could be made. The Did Not Attend (DNA) rate had reminded the same. It was noted that a number of tests of change were being undertaken as part of the national outpatient programme. There were continuing issues with delayed discharges in Perth and Kinross in both the acute and community settings. The impact of these delayed discharges was that the surge beds remained open across Ninewells and Perth Royal Infirmary. These beds were unfunded and as NHS Tayside could not staff beds, non contract agency staff were being used. At the present time, there was no indication when this was to be stepped down. The Medical Director (Operational Unit) advised of the impact of delayed discharges in respect of the patient; losing their independence as well as an impact on the quality of their care. He highlighted that the medical readmission rate in Perth Royal Infirmary was the highest in Scotland and surgical readmission rates were the third highest in Scotland. Work was being undertaken on the readmitted patients and it was noted that in the main there were frail and elderly patients. The case notes of these patients admitted over the past six months had been reviewed to try to establish why this was the case. 15

It was noted that the findings did not identify a particular area or condition that could be attributed to these high rates. Observations on the day of care audit on 20 April 2016 had shown that of 200 occupied beds, 35% of patients did not meet the criteria to be in an acute hospital. It was also noted that half of the patients in community hospitals did not meet the criteria to be there. These delayed patients were in the main elderly, in hospital for a longer period of time, should not be in the acute care system and the vast majority were linked to social care funding packages. It was noted that the Hospital Services Mortality Rate (HSMR) continued to be very good across all hospitals in the NHS Tayside system and this was a reflection of the high quality of care. The Chairman suggested and the Board agreed that there should be a separate delayed discharge discussion following the general performance discussion. During discussion the following points were noted: Concern was expressed about the TTG performance, what was being done and assurance around any improvements and if there was anything that the Integrated Joint Boards could be doing to assist. It was noted that joint working was taking place. There were interface issues and work was being done before patients were admitted to assist with their discharge. Work to support the patient needed to be done in the acute sector as well. The TTG performance was also an issue for five other NHS Boards in Scotland who had a position similar to Tayside. There was pressure across the NHS system as a whole Work had been done to address the TTG issue. However, it was noted that some specialities would continue to be an issue as vacant posts could not be recruited to. Work was ongoing regionally and nationally for solutions and a report would come back to the Board setting out the plans for 2016/17 The Board was given an assurance that the NHS Tayside data were correct The stressful situation of patients being prepared for a procedure and then having it cancelled, possibly on more than one occasion, and the subsequent impact on their condition was highlighted There would appear to be a high level of 28 day readmission rates at Stracathro Hospital. It was noted that there were fewer patients admitted at Stracathro (there was a small denominator and it was statistically low), This skewed the figures, however, this would be kept under review In respect of the psychological therapies target per the CAMHS report, this did need to improve and the report of the Internal Audit review of CAHMS was expected soon Delayed Discharges There was detailed discussion about the delayed discharge performance and in particular the situation in Perth and Kinross. It was noted that there needed to be a whole systems approach with the Integrated Joint Board, NHS Tayside and the local authority to move away from the readmission of patients. During discussion the following points were noted: There was good partnership working across Perth and Kinross between the acute hospital, community hospitals and the Integrated Joint Boards. The day care audit had highlighted areas to be improved and the full week rapid improvement event would bring forward what needed to be done; with an improvement plan and a timeline 16

There needed to be community geriatric support and access to community packages of care and care at home. There were issues about pace of change and investing resource where it would make the most difference It was acknowledged that there was already a lot of good work going on and the evidence of what worked well should be put to good use It was suggested and support was given for an external audit to be undertaken of the delayed discharge position. There was a need to set out a plan that showed the impact and consequences of delayed discharges as well as how any additional funding resource would be used. The plan would also need to address how community facilities would be used. There was no point in continuing to schedule and reschedule procedures, if they were continually being cancelled. There had to be a clearer grip on the finance plan based on performance and a forecast needed to be given on what could be delivered and monitored. There had to be confidence in the ability to deliver this plan Consideration would be given to looking at the classification of readmission to give a better denominator It was anticipated that the resource available for delayed discharges should be reported up through the Integrated Joint Boards. The regular Performance Report to the Board should also be supplemented with this information. It was also requested that what was being done to build on best practice, in relation to delayed discharges, should also come back to the Board The Chairman asked Mr R Packham, Chief Officer, Perth and Kinross IJB to give an update on what was planned on the two areas to be addressed - reducing the same patients being re admitted to hospital and the high levels of long term delayed discharge patients whilst this did not seem to be a problem in other areas of Scotland. Mr Packham advised that the key priority was partnership and the development of an Enhanced Community System. Currently there were multi factorial issues : the structure at the moment was not as responsive to the needs of the patient, there were recruitment and retention issues with staff in the community, the prevention care service was currently only available Monday to Friday from 9:00 am to 5:00pm, there were different referral patterns, there was an issue with the number of care homes in the area and the ability to provide care as well as the standard care packages in Perth and Kinross may include more than what was actually required. It was noted that this could not be solved in isolation and there needed to be closer working with longer term solutions. It was highlighted that all additional delayed discharge monies had been committed and no sustainable difference had been made. Mrs V Irons, Chief Officer, Angus IJB reassured the Board that the Integrated Joint Boards were aware of their responsibilities in respect of delayed discharges. This was an objective in their Strategic Plans and there was very much a partnership approach in place with NHS Tayside and the three other Integrated Joint Boards. It was noted that a partnership approach was taken in anticipating the care needs of patients with the potential to reduce the likelihood of their admission. The Medical Director advised that there needed to be a better understanding of the change in the presentation patterns of elderly people with chronic disease; they could get unwell very quickly and there was no evidence in these cases that an anticipatory model of care would work. 17

Concern was expressed that Board Members needed a whole systems overview of both the delayed discharge situation and the non ability to meet the Treatment Time Guarantees (TTG). An update on the investment previously given to meet TTG needed to come forward to the Board and this should be a whole systems report. It was noted that this was already a requirement for the Scottish Government Health and Social Care Directorate and could be provided. It was suggested that a GP should be asked to review cases and data in the community and Dr Cowie would discuss this further with Dr Cook. It was noted that all areas were working together to find solutions including general practice, housing, social work and the third sector and cluster working had started. The outcomes from the work undertaken in the day of care audit at Perth Royal Infirmary and the rapid improvement event would highlight the key areas to be targeted and worked on. The Board: Noted the Board Performance Report to February 2016 Noted the different factors that were adversely driving Treatment Time Guarantees (TTG) and that a plan would come forward to the next Board meeting on how TTG would be addressed Noted the detailed discussion on delayed discharges and in particular the issues in Perth Royal Infirmary and Perth and Kinross in respect of delayed discharges and readmission rates Noted the reassurance given that work was ongoing to action delayed discharges in other foras and also the impact of delayed discharges on elective activity Director of Acute Services 10.3 Scottish Patient Safety Programme Reporting Arrangement (BOARD32/2016) The Nurse Director spoke to this report. She advised of the change in reporting structures and that Ms D Campbell, Associate Director, Patient Safety was in attendance to answer any detailed questions. The revised reporting framework had been necessary to provide the strategic leadership and direction to address the extension of the Patient Safety Programme to cover acute care, health associated infection, maternity and children, medicines, mental health and primary care. During discussion the following points were highlighted: Mrs Rogers as Chair of the Clinical and Care Governance Committee noted that she was content to approve the reporting mechanisms via the Clinical and Care Governance Committee In respect of acute care leadership walkarounds, this had recently been tested in the Medicines Directorate. It was noted that discussion was ongoing in respect of Non Executive involvement in walkarounds. The intention was to move away from an inspection type process and not to add a burden to the already busy staff. A programme of Non Executive walkarounds was to be developed ; it was stressed that these would be informal It was suggested that obesity should be included as part of the ante natal package of care outlined in the Maternity and Children workstream 18