25 april 2014 highland health & social care governance ... · 25 april 2014 item 3.1 highland...

Highland Health & Social Care Committee25 April 2014

Item 3.1

HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEEReport by Deborah Jones, Chief Operating Officer

The Board is asked to:

Note that the Highland Health & Social Care Governance Committee met onThursday 20 March 2014 with attendance as noted below.

Note the Assurance Report and agreed actions resulting from the review of thespecific topics detailed below.

Present:Myra Duncan, Board Non Executive Director – ChairJan Baird, Director of Adult CareHelen Bryers, Head of MidwiferyShirley Christie, Staffside RepresentativeDr Paul Davidson, Chair, Professional Executive CommitteeDavid Flear, Patient/Public RepresentativeDavid Garden, Head of Financial PlanningGavin Hogg, Patient/Public RepresentativeDeborah Jones, Chief Operating OfficerLinda Kirkland, Interim Director of Operations, Raigmore HospitalDr Rhona MacDonald, Board Non Executive DirectorFiona MacFarlane, Pharmacist RepresentativeMargaret MacRae, Staffside RepresentativeGillian McCreath, Board Non ExecutiveGill McVicar, Director of Operations – North & MidLinda Munro, Elected Member, Highland CouncilKate Patience-Quate, Lead Nurse RepresentativeNigel Small, Director of Operations – South & MidKate Stephen, Elected Member, Highland CouncilKatherine Sutton, Associate Director, AHPsDr Susan Hussey-Wilson - Area Medical Committee Representative – GP (for Dr Chris Williams)Mhairi Wylie, Public/Patient Member Representative – Voluntary Sector

In Attendance:Bill Alexander, Director of Health and Social Care (from 10.50am)Sally Amor, Public Health Specialist (from 11.00am)Sheena McLeod, Head of Health – Children’s Services (from 11.20am via Videoconference)David Gault, Service User (Augmentative and Alternative Communications)(for Item 7.3)George McCaig, Head of Business Support, Adult Social Care (from 9.45am)Brian Mitchell, Board Committee AdministratorKenny Oliver, Board SecretaryDeborah Shanks, ConsultantDr Margaret Somerville, Director of Public Health (from 10.35am)Simon Steer, Head of Strategic Commissioning (from 9.45am)Morag Tait, Project Manager (Augmentative and Alternative Communication)(for Item 7.3)

Apologies:Mr Quentin Cox, Area Medical Committee Representative – ConsultantBren Gormley, Elected Member, Highland CouncilAilsa MacInnes, Optometrist RepresentativeAdam Palmer, Staff Side RepresentativeBrian Robertson, Head of Adult Social CareBob Summers, Head of Health & SafetyPhilip Walker, Head of Personnel

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Highland Health & Social Care Committee 1 May 2014 Item 3.1

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Sarah Wedgwood, Board Vice ChairDr Chris Williams, Area Medical Committee

AGENDA ITEMS

Chair’s Feedback from Meetings of the NHS Board Since Last Meeting

Financial Position Report as at 31 January 2014

Adult Services Balanced Scorecard

2013/2014 Highland Health and Social Care HEAT Targets Balanced Scorecardand Exception Reports from Improvement Committee

Update from Professional Executive Committee (PEC) including Draft Minute ofMeeting, Final Terms of Reference and Verbal Update from PEC Chair

Operational Unit Reports

Chief Operating Officer Report

Presentation on Services for Children and Young People and Assurance Reporton Lead Agency Delivery of Children’s Services

Review of Adult Services, Caithness

Review of response by NHS Highland to Deterioration in Quality of Care in anIndependent Care Home – Action Plan

Augmentative and Alternative Communication Update and Presentation

Prevention and Management of Falls

Strategic Commissioning Plan and Commissioning Intentions Plan 2014/2015

Adult Social Care Contract Monitoring Report

Chief Social Work Officer Annual Report 2012/2013

Consideration of Future Agenda Items

Committee Function and Administration

DATE OF NEXT MEETING

The next meeting will be held on Thursday 1 May 2014 in the Board Room, Assynt House,Inverness at 9.30pm.

HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORTMeeting on Thursday 20 March 2014

1 TOPIC: Welcome and Declarations of Interest

Issues Assurance Actions

Do members have any interest todeclare in relation to any Item onthe agenda?

Is the meeting to be Webcast?

No declarations were made.

This was confirmed. Archived for 12 months.

2 TOPIC: Committee Chair Update


What update can the Chair givenin relation to meetings held sincethe last Committee?

MD advised Chairs of Governance Committeeshad met and will meet to discuss Review ofGovernance overall. Agreed need for greateruser perspective.

Update given in relation to NHS Board on 4/2/14.Discussion on response to Independent CareHome issue, risk to Highland Forensic services,service redesign, Everyone Matters draft actionplan and governance arrangements, StrategicCommissioning Plan, approval of HighlandAdvocacy Plan, update on Highland Alcohol andDrugs Partnership Strategy and priorities, andinfection control. Mid Year Review letter notedas acknowledging benefits of integration andimpact of care Home embargoes in Highland.

Advised meeting on 4/3/14 had considered thetwo major service redesign project proposal andagreed to move to three month Consultationexercise for Badenoch & Strathspey and for anoption appraisal concerning the locations of teHub and spoke for Skye, Lochalsh & SW Ross tocome back to the next Board meeting.

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3.1 TOPIC: Draft Minute of Meeting of Performance and Finance Sub Committee – 20 February 2014


How will Sub Committee functionand provide assurance toCommittee?

Minute of meeting on 20/2/14 circulated outliningdiscussion where there was agreement for afocus on issues, rather than a general reportingformat. Short, sharp reporting required.Consideration given to avoiding duplication ofreporting. Future dates to be set to reflectreporting periods. Next date to be agreed.

Action: Date of next and future meetings to be identified –

Committee Administrator

3.2 TOPIC: HHSCC Financial Position as at 28 February 2014 – David Garden, Head of Financial Planning


What is the financial position inyear and where are currentfinancial pressures?

Tabled report indicated position to 28 February2014, indicating a forecasted out-turn for theNHS Board of a £2.5m overspend by 31 March2014. There had been little movement in Op Unitpositions since last reporting period. £1m hadbeen secured from discussion with THC. SocialCare and Care at Home remained a budgetaryconcern. Discussions taking place with SGHDas to options for facilitating break-even.Discussion concerning the causes of theexpenditure which had change the projection inNorth Highland late in the year. Noted the levelof projected overspend for North Highland andthe situation in each of the Operational Units.Acknowledged the work that had and continuedto take place and noted information whichexplained the financial position. However theCommittee is concerned and disappointed withthe financial position and asked for plans tocome forward early in the new financial yearidentifying improvement actions and theirfinancial and non-financial benefits withtimescales.

Action: Agreed to inform the Board of the Committee’s

disappointment and highlight to NHS Board needfor early consideration of three year financial plan –Chair

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What is the role of HHSCC inscrutinising financial position?

What action is being taken toaddress relevant issues?

Performance and Finance Sub Committeeprovide financial scrutiny on behalf of Committee.HHSCC to give assurance to NHS Board.

NHS/THC Strategic Commissioning Groupworking in partnership to look at pressuresrelating to Social Care and reporting to relevantmanagement meetings.

3.3 TOPIC: Adult Services Balanced Scorecard


What is current performanceagainst targets?

Circulated report outlined progress againstrelevant targets. It was confirmed that thesematters were monitored by the ImprovementCommittee and would also now be scrutinised bythe Performance and Finance Sub Committee.

3.4 TOPIC: HHSC HEAT Targets Balanced Scorecard – Kenny Oliver, Board Secretary


What are HEAT Targets relevantto Health and Social Care andwhat is current performanceagainst these?

Copy of Balanced Scorecard circulated, alongwith exception reports relating to Care at Homeservices, Detect Cancer Early Programme, Drugand Alcohol Treatment: Referral to Treatment,Cancer Services, 12 WeeksOutpatients/TTG/RTT Targets for RaigmoreHospital, and Key Diagnostic Tests at RaigmoreHospital. Noted these are monitored by theImprovement Committee and would also now bescrutinised by the Performance and Finance SubCommittee.

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3.5 TOPIC: Update from Professional Executive Committee – Dr Paul Davidson, Chair


What was considered by theCommittee at its initial meeting?

What was considered at themeeting held on 27 February2014?

Are there particular cross-professional or organisationalissues the PEC should consider?

Draft Minute from 13 December 2013 circulatedand reported this meeting related in the main torelevant scene setting discussion. There hadbeen a presentation by the Chair, and discussionin relation to relevant Terms of Reference andinitial work plan for the Committee. The agreedTerms of Reference were circulated for approval.Noted given dates of meetings and those ofHHSCC formal Minutes may not always beavailable and verbal updates may provided

It was advised discussion included generalsurgical capacity, endorsement of the direction oftravel relating to the proposed Clinical Strategy,issues relating to the Inverness Masterplan, andagreement to further consider issues relating toCancer Services.

The continued provision of Emergency Care andElective Surgery outwith Raigmore was raised. Itwas confirmed consideration was being given asto how services could be secured in the longerterm for all relevant hospital sites. OnPrescription for Excellence (PfE), and Pharmacyrepresentation on PEC, it was advised PfE wasbeing discussed at Op Unit level includingappropriate linkage to other strategies, new Dir ofPharmacy in post, and PEC would invitespecialist advice as and when required.

Action:

Clinical Strategy, once developed to be consideredby HHSCC – Dir Public Health

Presentation to HHSCC required on InvernessMasterplan – Dir of Finance/Head of Estates

Elected members to be kept informed as torelevant considerations – PEC Chair

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4.1 TOPIC: Operational Unit Reports – Directors of Operations


North and West OperationalUnit ReportFinancial Position

Waiting Times

Delayed Discharge

Obstetric Services, CaithnessGeneral Hospitala) What is current position?

Reported forecast overspend, with pressuresexisting in relation to locum costs for RGHs, Outof Hours cover and vacant Practices. AdultSocial Care issue but position better thanexpected including around Independent SectorCare.

Belford Hospital Radiology waits remain anissue. Patients offered appointments in Oban orRaigmore if appropriate. Caithness GeneralHospital endoscopy service remains a challenge,likely to worsen due to annual leave andresignation of one Endoscopist. Situation subjectto close monitoring. Chronic Pain targets unableto be met due to staffing and recruitment issues,priorities are managed, but complaints received.Service sustainability a concern.

Position in West has improved but challenges inNorth area. Sutherland area remains a concerndue to lack of availability of care Home placesand Care at Home packages. Solutions beingexplored.

Service provision is fragile, with one of threeConsultant Obstetricians in Caithness having leftin December 2013. A long term locumappointment had not come to fruition. Businesscontinuity plans in place and contingency plansconstantly updated to ensure safe service. Allwomen subject to risk assessment. Midwifeservice strong and continues 24/7. Only thosedeemed to be at high risk of requiring specialistintervention will require to travel to Raigmore.

Action:

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b) What action is being taken toaddress recruitment issues etc?

Riverbank Medical Practice,Thurso

What is the position re Out ofHours provision in South WestRoss area?

South & Mid Operational UnitBadenoch & Strathspey ServiceRedesign

D Flear advised real concern in area ofpermanent move to Midwife led service. DistrictManager advised as to concern and monitoringgroup established including councillors, tradeunions etc. Suggested private sector beengaged to aid recruitment. Advised NHSH willwork with community and any interested partieson issues relating to recruitment but currentpriority must be to ensure contingencyarrangements in place and effective.Emphasised current overall RGH Consultantvacancy level stood at 30%. Acknowledged arein a challenging and changing service landscapeand continuous change will be required toservice provision in RGHs. Multi-professionalnetwork models of care likely to be involved toprovide different models of care. HHSCC musthave sight on this issue and seek to ensure safeand effective services are delivered whilst futureservice provision considered and taken forward.

Practice vacant since December 2012 andsalaried service provided on temporary basis.No feasible applications received followingrecruitment exercise. Decision taken to move toSalaried Service through recruitment topermanent posts. Does not preclude moving toIndependent Practice in future.

Advised Rural resilience Team approachcontinues to be undertaken, with somegeographical area still difficult to cover.

Advised that sites in Aviemore are beingexplored in Partnership with the CairngormsNational Park and the in the local community.

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Scottish Government MentalHealth Strategy Review

Custodial and Forensic Services

Complaints Review Committee

Raigmore Operational UnitFinancial Position

Advised recent consideration of feedbackcorrespondence from Review Team followingvisit late 2013. Main issues raised, and NHSHresponses, were outlined relating to progresswith Dementia diagnosis; integration of healthand social care (including criminal justice andmental health, prisoner healthcare, transfer ofcustody healthcare and community justice);family involvement, rights, recovery, peer to peerwork, and employability; prevention and self-management; Veterans First Point servicedevelopment discussion and potential additionalcost burden of £350k pa; and access topsychological therapies.

Previously noted significant risk that level ofresource will not be sufficient to maintain currentservice level. National discussion has not led toresolution of issue. Service level being managedand maintained at this time. Concerns relate tomaintenance of complex forensic services.

Summary detail relating to recent CRCconsideration of complaint (in relation to servicesbefore transfer to NHSH) relating to housingsupport services withdrawal and subsequentassessment process outlined. Complaint hadthree main elements, two of which had beenupheld by the CRC. Noted service had beenreinstated prior to CRC consideration of issues.Recommendations from CRC were detailed andit was noted NHSH responsible for delivery of therequired actions. Noted staff involved had raisedconcerns relating to CRC Hearing which werenow subject to investigation.

Report indicated forecast overspend of £9.562m,with contributing factors outlined. The positiondeteriorated slightly from that for Month 9, with

Agreed need for assurance regarding application ofrelevant HR Policies – Dir of Operations (Southand Mid)

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TTG/Outpatient Waiting Times

increased costs associated with locum cover,meeting access targets, increased non-pay costsand drugs. Forensic work undertaken intounderlying influences for adverse movement andrelevant process improvement implemented.Forecast process issues identified and changesnow being progressed. Management Teamcontinue to implement Recovery Plan, withrecent progress in relation to OutpatientsRedesign, Theatre Redesign activity, and patientflow. Moving forward budgets would be re-profiled. Overall Plan seeks to deliver £14msavings over three years and will require radicalchange implementation relating to servicedelivery. Emergency and Elective patient will bemanaged as two separate flows. Costimplications arising from service outsourcingactivity also being mapped as well as costimplications relating to hosted services.

Plan for no patients to wait more than 12 weeks,at end march 2014, except in relation toOrthopaedics. Plan that no Inpatient/Daycasepatient waiting more than 12 weeks, at endMarch 2014, except for Orthopaedics. 300patients seen at Raigmore by Ross HallConsultant staff who will operate on thoserequiring surgery. Patients on IP/DC waiting listalso offered Ross Hall. Discussion underwaywith Golden Jubilee National Hospital to exploresimilar Orthopaedic See and Treat exercise.Confirmed compliance with relevant AccessPolicy. Noted recent SGHD Circular onOrthopaedic service quality will help activity.

The Committee adjourned at 11.15am and reconvened at 11.25am

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4.2 TOPIC: Chief Operating Officer Report – Deborah Jones, Chief Operating Officer (COO)


Delayed Discharge

Older People in Acute Hospitals(OPAH) Care and Comfort

Position remains challenging due to combinationof factors, with 29 individuals waiting for Care atHome packages as at 10 March 2014. Thesuspension of admissions to Care Homes, andclosures, were having an impact with particularissues in the North area. As at 10 March 2014there were 69 individuals subject to delayeddischarge. Areas of success were againidentified as the Raigmore Community SupportInitiative, leadership from District levelmanagement, collaboration with third sector toenable rapid growth in Care at Home capacityand provision of support to Care Homes with aview to lifting embargoes. Current actionincluded Innovative practice to modelling safeand effective discharge, including engagement ofCitizen’s Advice Bureau to provide advice inrelation to choice transfer issues, and relevantlearning would be shared across NHSH.

Advised progress against OPAH Action Plan astanding agenda item at Raigmore HospitalSenior Charge Nurse (SCN) meetings andDivisional meetings. Published report highlightedto all staff groups. Raigmore secured 11 placeson Dementia Champion course at University ofthe West of Scotland. NHSH DocumentationSteering Group met in January to discuss draftdocumentation and implementation of Care andComfort rounding to deliver quality nursing care.Approach being evaluated using PDSAapproach.

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Discharge Planning Chief Operating Officer overseeing review ofdischarge planning. Rapid Process ImprovementWorkshop carried out and lessons learned beingshared across Raigmore.

4.3 TOPIC: Services for Children and Young People – Dr Margaret Somerville, Director of Public Health


What is position relating toprovision of services in NorthHighland?

How will the Committee gainassurance?

Presentation given detailing areas ofresponsibility relating to NHSH, THC and PrimaryHealth Care services. The Universal pathwayPerformance Framework pathway was outlinedas was Operational Management and planning ofChildren’s Services. Noted that commissioningof services, under the relevant PartnershipAgreement was through the StrategicCommissioning Group. Annual reports andregular updates provided by the Child HealthCommissioner. The current position relating tothe Commissioning cycle was given, includingreference to the range of national targetsinvolved. Review activity was critical at this time.Performance monitoring arrangements were alsoreferenced in relation to Vulnerable Groups,Inequalities and the Transition to Adult Services.Arrangements for scrutiny of performancerelating to both commissioned and directlymanaged services were detailed.

In terms of assurance reporting (forCommissioned Services), the draft report format,this having been circulated to members, hadbeen tested at the Adult and Children’s ServicesCommittee and would be submitted also to theStrategic Commissioning Group andImprovement Committee. HHSCC would providerelevant assurance to the NHS Board. Issues

Action: Agreed copy of presentation to be issued with

HHSCC Assurance Report – CommitteeAdministrator

Action: Agreed detail of For Highland Children’s Services

Plan, and frequency of assurance reporting bediscussed at July 2014 meeting – Director ofPublic Health (DPH)

Agreed consideration required on reporting,scrutiny and providing assurance on DirectlyManaged Service (DMS) whilst ensuring links with

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Do children themselves have avoice?

What is the position in relation torecruitment and retention of staff?

highlighted included data requirement andavailability, development of outcome and processmeasures for existing gap areas, finalisation ofthe new performance framework under the ForHighland Children’s Services Plan, competingthe improvement cycle and directing this throughthe commissioning process, service integrationand funding identity, ensuring effective transitionto adult services and provision of clarity onassurance report content etc. Scorecardreflecting new full performance framework underdevelopment. Further discussion regradingperformance monitoring of directly managedservices is required.

Advised Youth Convener and Highland YouthVoice both actively involved and engaged. YouthConvener position in SGC funded. Mrs L Munrois THC Children’s Champion. There wereregular meetings with service users.

Advised this is a challenge nationally howeverHighland in strong position, especially withinRaigmore. Issues would be highlighted withinannual report.

other services - DPH Agreed report on approach to capturing needs of

care givers, and links to DMS to next meeting -DPH

Agreed report on Transitions to be presented tonext meeting - DPH

Agreed further detail in relation to role of ChildHealth commissioner be provided - DPH

Action: Agreed consideration be given to providing greater

focus on engagement issues in future annualreports.

5.1 TOPIC: Review of Adult Services – Gill McVicar, Director of Operations (North and West)


What progress is being made inrelation to redesign of Adultservices in Caithness?

Circulated report provided background to theredesign activity, seeking to build future servicesustainability. A number of key workstreams hadbeen agreed as outlined and progress wasoverseen by a Reference Group. A ProjectCharter was developed and Programme Boardestablished. Progress was reported to both the

Action: Agreed report on outcome from April 2014

workshop to be presented to May 2014 meeting –Director of Ops (North and West)

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How is PBMA activityprogressing?

Reference Group and Programme Board.Updates were given in relation to the keyworkstreams relating to community rehabilitationand reablement, palliative and end of life care,home-based services, community developmentand service capability, dementia and older adultmental health, Caithness General Hospitalredesign, and overlapping themes. An updatewas also given in relation to ProgrammeBudgeting and Marginal Analysis (PBMA)activity, this being used to assist with investmentand disinvestment decision making. It wasadvised there would be a formal Report Out fromrelevant workstreams at a Reference Groupworkshop on 29 April 2014. Reported whilstcommunity engagement had been strong but theProgramme Board was seeking to improve thisand would attend Community Council and othergroup meetings to raise awareness andengender further interest. CommunityDevelopment Officer and Community Networkeralso assisting in this. Overall, goodunderstanding of issues, including availablefinancial resource and need for appropriatedecision making.

Caithness is a pilot site for this, with GlasgowCaledonian University commissioned toundertake work. A number of members ofProgramme Board and Reference Group haveagreed to act as Advisory Panel. Supportprovided by Joint Improvement Team for initialone year period. Activity still in early stages andmuch discussion around issues relating to criteriaand weighting.

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5.2TOPIC: Review of Response by NHS Highland to Deterioration in the Quality of Care in an Independent Care Home: Action planand Progress Report – Jan Baird, Director of Adult Care


What progress is being made inrelation to the previously reportedAction Plan?

What is position in relation to GPnotification previously reported?

Circulated report detailed progress in relation tothe Action Plan previously reported to theCommittee in January 2014, this being overseenby the Adult Support and Protection Committeeand delivered through the Improvement Group.Progress against all Recommendations andactions were annotated as Green. Notedproactive activity being provided to ensureservice quality into future and this involved majorcommitment on behalf of NHSH.

Confirmed importance of this point is recognisedand will be more explicitly referenced in futurereports.

5.3 TOPIC: Augmentative and Alternative Communication (AAC) Update – Jan Baird, Director of Adult Care


What is the ‘A Right to SpeakProject’ all about?

Presentation given by M Tait, J Baird and DGault relating to project for supporting individualswho use AAC. Significant piece of work fundedby Scottish Government for three years,overseen by Project Board, and subject toProject Initiation Document and Risk Register.Project Plan in place, outlining deliverables.Working with both NES and national services.Mr Gault spoke to members and advised howAAC provided him with the freedom tocommunicate with the wider world, gave him avoice, and outlined how the alternative of nothaving AAC was such a difficult thought toconsider. The Recommendations from the

Action: Agreed update to future meeting – Director of

Adult Care

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What is the level of unmet need inHighland and the required level offinancial resource required atOperational Unit level?

What is the required trainingperiod for use of AAC equipment?

What is the anticipated impact ofSelf Directed Support and whatcan service provider do to helpusers?

project were outlined and these related torelevant research activity anddevelopment/implementation of a populationbased approach to the provision and support forthose who are required to use AAC equipmentand services. Users should have access toappropriate levels of high quality specialistassessment and support delivered as locally aspossible, with Health Boards and LocalAuthorities working n partnership and withnational AAC Services. There should beequitable, efficient and safe provision of AACequipment for those who require to use it. AllAAC providers should implement the use of localAAC pathways to ensure equitable and timeousprovision of equipment and support. The overallProject challenges were outlined as being inrelation to a required interdependency with NES,partnership engagement, and service andfinancial sustainability.

Advised no unmet in Highland at this time andcurrent resource used to help those already inreceipt of service. Working closely with MedicalPhysics to ensure efficient use of financialresource. Noted service provision not onlyrelates to equipment. Acknowledge need toensure the transition from Childrens’ to AdultServices appropriately is mapped to avoid unmetneed.

Advised stated 5 year period can be anunderestimate of that required. Need to factor inthe need to train on new equipment.

Advised this will impact of Health Care asopposed to Social Care. In terms of helpingusers, appreciation of the difficulties faced wouldbe greatly appreciated.

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5.4 TOPIC: Prevention and Management of Falls – Katherine Sutton, Associate Director of AHPs


What is the approach being takento prevention and management offalls in Highland?

Circulated report advised the NHSH FallsSteering Group had recently re-examined itsability to provide assurance in relation to theDelivery Framework for Adult Rehabilitation inScotland an the National Falls Programme inrelation to the findings ‘Up and About or FallingShort (2012). Noted taking a Highland wideapproach to identify modifiable risks by ascreening process and providing evidence basedinterventions allows provision of equitableservice across Board area. This approach hasbeen slow to develop despite screening training.All Operational Units, except Raigmore, haveAction Plans to articulate how they will implementa planned approach and providing assurancethat appropriate actions are being taken forwardat local level. Plans are owned by localoperational management and the guidance ofAHP and Nursing professional leadership. Thereport detailed a summary of the actions beingprogressed within Operational Units in theCommunity, Hospital and Care Home setting.Work within Care Homes is relatively recent, with14 Homes having been recruited to help driveactivity. Whilst overall there are significantrewards available for investment in this activity,for the NHS Board, the real benefits are realisedby patients themselves. Stated this activitycrucial to delivery of LUCAP and affects workingrelationships with other agencies. Appropriatereporting would be through the Operational Unitsand Performance and Finance Sub Committee.

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What communication andengagement activity isundertaken, who is on SteeringGroup, and what involvement isthere from First Responders?

Stated stakeholder events held through ‘BigLunch’ approach. Noted family expectation canalso need to be managed as often assumehospital admission the only appropriateresponse. Noted Fire Service, SAS and otherindependent groups all involved in SteeringGroup. At Steering Group, Lead AHPs tasked todrive forward Action Plans. Service based onability to involve range of alternatives toambulance taking patient to hospital. SASmaintain duty of care but about ability to utilise allresilience, support and training for respondersavailable resources. Issues relating to etc allimportant aspects especially for OfficialResponder personnel.

6.1TOPIC: Strategic Commissioning Plan and Commissioning Intentions Plan 2014/2015 – Simon Steer, Head of StrategicCommissioning


What progress is being made ondevelopment of Plan?

Advised Strategic Commissioning Plan would bepresented to NHS Board for discussion on 1 April2014 and would be submitted to this Committeeat the meeting on 1 May 2014.

Action: Agreed Plan to be submitted to next meeting -

Head of Strategic Commissioning

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6.2 TOPIC: Monitoring the Delivery of Contracted Services – George McCaig, Head of Care Support


What are the outcomes of thethird quarter reviews? Whatprogress made resolving issuesfrom first and second quarterreviews?

What work is being undertaken inresponse to earlier Internal AuditReview?

How do we capture the views ofservice users and their families?

Circulated report summarised outcomes from 33contracts monitored during Q3 and the progressmade in resolving issues highlighted bymonitoring in Q1 and Q2. In terms of issueresolution, from a total of 57 issues, ten havebeen resolved and 47 remain live at this time.

Noted sample checks of submitted dataintroduced, with work underway to recordevidence and develop model quality schedules.Progress made in establishing operationalmonitoring meetings with providers. Regularmeetings established with Area Managers tohighlight outstanding issues for resolution.Further ‘Understanding the Roles’ workshop heldon 5 November 2013. Development ofCommissioning Strategy continues. Meetingsheld with Dirs of Operations in North Highland tolook at Designated Manager role and discusscapacity and engagement issues. Will take time.

This forms part of the Personal Outcome Planapproach. Will also form part of activity todevelop suite of quality indicators forCommissioning purposes.

7 TOPIC: Chief Social Work Officer Annual Report 2012/2013 – Bill Alexander, Director of Social Work, The Highland Council


What progress is being made inrelation to this subject?

BA spoke to circulated Annual Report, productionof this being a statutory requirement. Topics andactivity covered by the report related to the roleof the Chief Social Work Officer, Public

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Protection, Child Protection, Adult Support andProtection, Criminal Justice, Mental Health, AdultSocial Care, Fostering and Adoption, ResidentialChildcare, Out of Authority Placements,Children’s Hearings (Scotland) Act 2011,Practice Leadership, Workforce Development,Complaints detail, and actions taken to improveservice responses. Emphasised the challengesfacing NHSH in relation to Adult Social Care,such as in relation to Mental Health activity. Alsoemphasised the groundbreaking approachadopted by the THC and NHSH as a result ofservice integration.

8.1 TOPIC: Minute of Meeting of Highland Quality Approach Leadership Group held on 22 January 2014


Any issues arising from Minute? No Issues reported. Action: Noted Minute.

9 TOPIC: Committee Function and Administration


Have the changes to the structureof the Agenda met the needs ofCommittee members?

Agreed greater focus on Operational Unit andChief Operating Officer Reports by schedulingearlier on Agenda is beneficial.

10 TOPIC: Any Other Competent Business


What progress is being made inrelation to Recruitment Fayre forSocial Care?

Director of Adult Care confirmed arrangementwere being finalised at this time

Action: Details to be circulated to members when available.

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10 FUTURE AGENDA ITEMS AND DEVELOPMENT SESSION TOPICS

Meeting on 1 May 2014: Report on Financial Impact of Enforcement of Embargoes on Admissions to Care Homes (and include as part of future reports on

Contract Monitoring) – David Garden Presentation by Dirs of Operations on Local Delivery Plans for 2014/2015 Inverness Masterplan – Director Finance/Head of Estates NoSPG Report on Review of Oncology Services – Chief Operating Officer (to be reference in COO’s report) Exception Report on drug expenditure at Raigmore Hospital – Dir of Operations, Raigmore Monitoring the Delivery of In-house Services – George McCaig Assurance relating to Partnership Working Arrangements in Raigmore (Matters Arising) - Interim Director of Operations (Raigmore) Local Delivery Plans Year End Progress Report – Directors of Operations Committee Annual Report 2013/2014 – Committee Chair Report on Charging – Brian Robertson/George McCaig – due May 2014 Health and Safety Update

Items for 1 May 2014 – from Assurance Report: Strategic Commissioning Plan – Simon Steer Complaints Review Committee – Assurance on application of HR Policies - Dir of Operations (South and Mid DOO’s report) Care Givers Needs Assessment and links to Directly Managed Service – Dir of Public Health Transitions – update on progress with Strategy – Director of Public Health Review of Adult Services, Caithness – Outcome from April 2014 Workshop – Dir of Operations (North and West)

Future Meetings: Quarterly – Risk Registers – Directors of Operations in Operational Unit Reports then quarterly thereafter Quarterly – Care Inspectorate Inspection Reports in Highland (incl comparator data pre and post integration, Action plans, timescales

for action and interim support arrangements) – Brian Robertson Standing – Adult Support and Protection Committee Minutes Standing – Suspension of Admissions to Care Homes – Exception Reports – Brian Robertson Standing – Assurance Report from Performance and Finance Sub Committee - Adult Social Care Balanced Scorecard, financial

position, HEAT targets and standards Minutes/Assurance report from Professional Executive Committee (part of COOs report) Clinical Care Strategy – Director of Public Health – due July 2014 For Highland’s Children Services Plan – Dir of Public Health – due July 2014 Highland Hospice Presentation on End of Life/Palliative Care service Transformation – Kenny Steele – July 2014 Presentations by Dirs of Operations on Service change projects in area – all Directors of Operations

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Update on Augmentative and Alternative Communication (AAC) Update – Dir of Adult Care Report on Implications of Welfare Reform on Charging for Social Care Services (include relevant trends, risks etc) – Brian Robertson Reablement Strategy – Brian Robertson Case mix profile relating to Emergency Department admissions – Deb Jones/Margaret Brown (include in COO report) – Report to NHS

Board October 2013 Local Delivery Plans Six Monthly Update – due May 2014 – Directors of Operations Care Home Risk Management Processes – George McCaig Strategic Commissioning and Training 2014-2019 – Deb Jones (COOs Report Item) Managing Patient Choice Communications Plan – Chief Operating Officer Update on associated activity affecting Maternity Services, including pre-birth activity – Dir of Social Work, Highland Council Consideration of Patient Feedback/Stories Infection Control Arrangements within Care Homes Anticipatory Care Planning Activity – Ken Proctor Report on Adult Support – Jan Baird Update on monitoring of Care Home contracts, single point of contact and escalation routes – Jan Baird Draft Commission for Integrating Care in the Highlands Legal Services – Jan Baird

Development Sessions: Self Directed Support (DVD Presentation) – RAS monitoring, mgt of identified risks, identification of ‘What Ifs’, and Staff Awareness Primary Care Care Inspectorate Inspection Criteria

11 DATE OF NEXT MEETING

The next meeting of the Committee will take place on Thursday, 1 May 2014 in the Board Room, Assynt House, Inverness at 9.30am

DRAFT FOR CONSIDERATION Highland Health and Social Care Committee1 May 2014

Item 3.2

FOLLOW UP FROM HIGHLAND HEALTH AND SOCIAL CARE COMMITTEE ACTION PLANS – SEPTEMBER 2012 ONWARDSThose items shaded grey are due to be removed from the Action Plan.

Item Action / Progress Lead Outcome/Update

01/11/2012 Agreed to set up Development Session with CareInspectorate to better understand their role andestablish collaborative working arrangements.

Director of Adult Care November Update -Matter being progressedwith Care Inspectorate.Strategic approach todevelopment sessions tofuture meeting.

10/01/2013 Agreed there be development of specificationrelating to rural resilience and service delivery inremote and rural areas.

G McVicar Being Here conferencecirculated February 2014.Report to future meetingon actions being takenforward in N Highland.

14/03/2013 Development Session Agreed to include Reablement, DelayedDischarge and Shifting Balance of Care.

B Mitchell Strategic approach todevelopment sessions tofuture meeting.

02/05/2013 OPERATIONAL UNIT REPORTS –North and West

Agreed results of Tissue viability activity to becirculated to members.

B Mitchell To be included inDOO’s report onexception basis

04/07/2013 Self Directed Support Agreed DVD presentation be given toDevelopment Session

B Robertson/B Mitchell

Information on trainingsessions circulatedFebruary 2014. Strategicapproach to developmentsessions to futuremeeting

04/07/2013 Agreed Development Session include aspectsrelating RAS monitoring, Management ofIdentified risks, identification of ‘What Ifs’, andstaff awareness.

B Robertson/M Duncan/B Mitchell

Information on trainingsessions circulatedFebruary 2014. Strategicapproach to developmentsessions to futuremeeting

04/07/2013 Adult Services Balanced Scorecard Agreed L Munro be briefed in relation to Indicators44, 56a and 56b outwith meeting.

B Robertson

04/07/2013 GMS Contract (Scotland) Agreed further update be provided to nextmeeting.

Dr K Proctor

04/07/2013 Primary Care Activity Agreed consideration be given to a DevelopmentSession relating to Primary Care Activity.

M Duncan

Strategic approach todevelopment sessions tofuture meeting

12/09/2013 Agreed presentation and layout to bereconsidered in terms of legibility.

K Oliver Issue also raised atJanuary 2014 meeting.

2

12/09/2013 Delayed Discharge Agreed implications of relevant Choice andTransport Policy to be considered by Committeeand Highland Partnership Forum.

D Jones/S Steer For Future Agenda

12/09/2013 Care Homes Report on activity of short life working group andrisk management process to future meeting.

Head of Care Support Report to January 2014meeting and action planto March 2014 meeting

12/09/2013 Care Inspectorate Inspection Reports Agreed to consider Care Inspectorate Inspectioncriteria at a future Development Session

M Duncan/D Jones/BMitchell

Strategic approach todevlpt sessions

12/09/2013 Strategic Commissioning and Training2014-2019

Noted report on training outcomes to be submittedto future meeting.

Chief Operating Officer

12/09/2013 Dir of Operations Report (Raigmore) Further data on HSMR to be sought from ISD andanalysed. Report on outcomes of analysis tofuture meeting.

Dir of Operations -Raigmore

Incorporate in DoOsreport for assurance andthen on exception basis

07/11/2013 Operational Unit Local Delivery Plans Agreed include reference to aspects relating toinequalities.

Dirs of Operations Operational Plans to May2014 meeting

07/11/2013 Financial Position Agreed exception report on Raigmore drugexpenditure be brought to next meeting.

D Garden HHSCC January 2014 –now to March 2014

07/11/2013 Respite Care Services Agreed to be an area of focus in next OperationalUnit Delivery Plans.

Dirs of Operations Operational Plans to May2014 meeting

07/11/2013 Contract Monitoring Report on contracts and monitoring, single pointof contact and escalation routes to next meeting.

J Baird March 2014 meeting

07/11/2013 Promoting Safe, Effective and QualityDischarge – Managing Patient Choice

Agreed Communications Plan be developed andsubmitted to Committee.

D Jones Future HHSCC

07/11/2013 Update on Maternity Services Agreed update be provided on associated activityaffecting Maternity Services, including pre-birthactivity.

Dir Social Work Future HHSCC

07/11/2013 Integrating Care in the Highlands – LegalServices

Draft Commission to be submitted to nextmeeting.

J Baird HHSCC January 2014

09/01/2014 Committee Agenda and AssociatedLinkages

Agreed report on restructuring of Agenda andlinkages to Governance Committee be submittedto next meeting.

M Duncan/ChiefOperating Officer

HHSCC March 2014COMPLETE

09/01/2014 Children and Young People Services Report on scope of services to next meeting. Dir of Public Health HHSCC March 201409/01/2014 Adult Social Care Agreed need to ensure improved communications

with THC and Councillors.J Baird

09/01/2014 HEAT Targets Balanced Scorecard Agreed clarification be given in relation to ‘NA’annotation.

K Oliver

09/01/2014 Strategic Commissioning Plan andCommissioning Intentions

Agreed members to be provided with detail inrelation to Improvement Groups.

S Steer HHSCC May 2014(agreed March 2014)

09/01/2014 Raigmore Hospital Financial Position Agreed not to use phrase ‘Breachers’ in futurereporting.

L Kirkland

09/01/2014 Partnership Working in Raigmore Hospital Agreed assurance relating to Partnership Workingarrangements be provided to next meeting.

L Kirkland HHSCC March 2014

20/03/2014 Performance and Finance Sub Committee Date of next and future meetings to be identified. B Mitchell COMPLETE

3

20/03/2014 Financial Position Agreed to highlight disappointment to NHS Boardalong with need to consider a three year plan.

M Duncan NHS Board

20/03/2014 Professional Executive Committee Update Clinical Strategy to be considered by HHSCC Dr Somerville HHSCC July 201420/03/2014 Agreed for presentation on Greater Inverness

Masterplan to be given to HHSCC.Dir of Finance/Head of Estates

Future HHSCC

20/03/2014 Agreed elected members to be kept informed asto relevant considerations.

Dr P Davidson

20/03/2014 South and Mid Operational Unit –Complaints Review Committee

Agreed need for assurance regarding applicationof relevant HR Policies.

Dir of Operations(South and Mid)

20/03/2014 Chief Operating Officer Report –DelayedDischarge

Agreed further reports be provided to futuremeetings.

S Steer Future HHSCC

20/03/2014 Services for Children and Young People Agreed to circulate presentation B Mitchell COMPLETE20/03/2014 Agreed detail of For Highland Childrens’ Services

Plan, and frequency of assurance reporting bediscussed at July 2014 meeting.

Dir Public Health HHSCC July 2014

20/03/2014 Agreed consideration required on reporting,scrutiny and providing assurance on DirectlyManaged Service (DMS) whilst ensuring links withother services

Dir Public Health

20/03/2014 Agreed report on approach to capturing needs ofCare Givers, and links to DMS to next meeting.

Dir Public Health HHSCC May 2014

20/03/2014 Agreed report on Transitions to be presented tonext meeting.

Dir Public Health HHSCC May 2014Verbal Update to May

20/03/2014 Agreed further detail in relation to role of ChildHealth Commissioner to be provided.

Dir Public Health

Agreed consideration be given to providinggreater focus on engagement issues on futureannual reports.

Dir Public Health

Review of Adult Services, Caithness Agreed report on outcome from April 2014workshop to be presented to May 2014.

Dir of Operations (Northand West)

HHSCC May 2014COMPLETE

Augmentative and AlternativeCommunication (AAC) Update

Agreed update to future meeting. Dir of Adult Care Future HHSCC

Social Care Recruitment Fayre Details of event to be circulated to members. Dir of Adult Care

Finance & Performance Sub Committee25 April 2014

Item 3.1

INTERIM FINANCIAL POSITION FOR 2013/14

Report by David Garden, Head of Financial Planning

The Committee is asked to:

Note: A year end overspend of £12.6 million for Highland HSCP. Note: The initial out-turn of break-even for NHS Highland. Note: The need for £2.5m of SGHD Brokerage in order to deliver break-even. Acknowledge: The need to repay brokerage in future years. Note: The level of non-recurrent savings carried forward into 2014/15 is £7m. Note: That this is subject to no significant late adjustments and audit review.

1 Introduction

This report is based on provisional year-end information and, at the time of writing, finaladjustments continue to be made. The details within the attached tables are, therefore, likelyto change however, there is no significant change expected at this stage.

2 Financial Position Overview

The information tabled at the previous committee highlighted the lack of previouslyanticipated improvements within the financial position, and this has resulted in the need torequest financial brokerage assistance from the Scottish Government.

With this resource applied to the position, along with additional resources from The HighlandCouncil (£1m) and the revised asset lives policy change (£1.6m) the NHS Highland currentout-turn stands at a minor underspend of £82,000, subject to audit scrutiny.

The provisional year end position is summarised in the table below:

N&W S&M Raigmore ASC HQ Tertiary Others HSCP A&B Corp. Central Total

Heading £m £m £m £m £m £m £m £m £m £m £m

Savings

Operational Savings not yet achieved/identified (0.4) (2.6) (0.1) (3.1) 2.6 (0.5)

In year non-recurrent benefits applied - Central 0.0 5.8 5.8

Scottish Government Brokerage 2.5 2.5

Pressures

Adult Social Care 0.1 (4.6) 3.2 (1.3) (1.3)

In-year cost pressures (2.8) (0.5) (7.3) (0.9) (0.3) (11.8) (1.4) (13.2)

Offsetting underspends/benefits 1.5 1.4 0.3 0.4 3.6 2.7 0.5 6.8

2013/14 Provisional Out-turn (1.6) (3.7) (9.6) 3.2 (0.9) 0.0 (12.6) 1.3 0.5 10.9 0.1

Previous Report - month 11 (1.7) (3.9) (9.5) 3.8 (0.9) (0.1) (12.3) 1.3 0.5 8.0 (2.5)

Change 0.1 0.2 (0.1) (0.6) 0.0 0.1 (0.3) 0.0 0.0 2.9 2.6

Operational Unit

Summary of Interim Financial Positions 2013/14

bmitc01

TextBox

Highland Health & Social Care Committee 1 May 2014 Item 5.1.2

2

As highlighted in previous reports, the adult social care budget needs to be considered as awhole, as well as a part of South and Mid Highland’s forecast, as the Unit positions aredistorted by the removal of Care at Home budgets to a central area. This resulted in theremoval of prior year underspends in South & Mid and overspends in North & West but willbe readjusted in 2014/15.

The financial tables are attached as follows;

Table 1 presents the overall income and expenditure position, inclusive of adult socialcare funding transferred in from Highland Council and excluding funding transferred outto Highland Council relating to children’s services.

Table 2 provides more detail on the overall expenditure position. The budgets for South& Mid Highland and North & West Highland operational units are now integrated budgetsinclusive of adult social care relating to their areas.

Table 3 shows the same information but excluding Adult Social Care.

Table 4 shows the total position on adult social care alone.

Table 5 summarises the position against savings

3 Operational Performance

Other than the receipt of financial brokerage, there were no significant movements withinindividual bottom lines in Month 12. The most significant variance in the table is £0.6madverse against ASC Headquarters, however this is the result of a budget transfer from HQto the two ASC operational budgets around VAT.

Raigmore’s movement is the result of a £0.2m adverse movement in the year end stockcount.

4 Brokerage

Discussions have been held with the Scottish Government Health & Social Care Directorates(SGHSCD) with regards to support in the form of financial brokerage has been previouslyhighlighted. This resource needs to be repaid to the SGHD and it is expected that this will bemanaged over three years starting with £0.5m in 2014/15.

5 Conclusion

The receipt of brokerage, along with a significant amount of non-recurrent resource, hasallowed Board to meet its financial targets in 2013/14.

The need to obtain brokerage is clearly disappointing and emphasises the need for robustsavings plans and controls which deliver recurrent savings and reduce the Boards relianceon non-recurrent resource which has grown in recent years.

3

6 Governance Implications

Accurate and timely financial reporting is essential to maintain financial stability and facilitatethe achievement of Financial Targets which underpin the delivery and development of patientcare services. In turn, this supports the deliverance of the Governance Standards aroundClinical, Staff and Patient and Public Involvement.

7 Risk Assessment

Financial risks, including the potential failure to deliver the necessary Financial Targets areincluded on the Corporate Risk register and managed accordingly.

8 Planning for Fairness

A robust system of financial control is crucial to ensuring a planned approach to savingstargets – this allows time for impact assessments of key proposals impacting on any changesto services.

9 Engagement and Communication

The majority of the Board’s revenue budgets are devolved to operational units, which reportinto two governance committees that include staff-side, patient and public forum members inaddition to local authority members, voluntary sector representatives and non-executivedirectors. These meetings are open to the public. The overall financial position is consideredat the full Board meeting on a regular basis. All these meetings are also open to the public.The overall financial position was described in “Health Check” which was sent to everyhousehold in Highland.

David GardenHead of Financial Planning22 April 2014

NHS Highland TABLE 1

Income & Expenditure Report as at MARCH 2014

Initial Current Plan Actual Variance Forecast MovementPlan Plan Summary Funding & Expenditure to Date to Date to Date Variance in month£000 £000 £000 £000 £000 £000 £000

509,790 509,718 SEHD -Baseline Funding 509,718 509,718 0 0 022,324 - Recurring Supplemental Allocations 22,324 22,324 0 0 04,773 - Non Recurring Supplemental Allocations 4,773 4,773 0 0 0

509,790 536,815 Sub total - SGHD Core RRL 536,815 536,815 0 0 0

0 26,608 - Non Core Funding 26,608 26,608 0 0 0

509,790 563,423 SGHD Funding 563,423 563,423 0 0 0

24,992 25,970 - FHS Non Discretionary 25,970 25,970 0 0 055,697 56,299 - FHS GMS Allocation 56,299 56,299 0 0 025,734 0 - Recurring Pending allocations 0 0 0 0 012,174 0 - Non Recurring Pending allocations 0 0 0 0 0

628,386 645,692 TOTAL SGHD Funding 645,692 645,692 0 0 0

85,966 87,489 Add- Adult Social Care Quantun Funding 87,489 87,489 0 0 0(7,710) (8,440) Less - THC Childrens services Transfer (8,440) (8,440) 0 0 0

706,642 724,742 Funding 724,742 724,742 0 0 0

Health & Social Care Partnership

108,421 111,870 North & West Operational Unit 111,870 113,449 (1,579) (1,700) 121145,611 163,275 South & Mid Operational Unit 163,275 166,944 (3,669) (3,950) 28120,969 32,265 Adult Social Care - Central 32,265 29,021 3,243 3,831 (588)

132,417 137,427 Raigmore 137,427 147,081 (9,654) (9,523) (131)19,812 20,794 Facilities 20,794 20,702 92 54 384,823 4,857 Integrated Pharmacy 4,857 4,998 (141) (162) 214,380 9,645 e health 9,645 9,634 11 1 10

19,119 19,000 Tertiary 19,000 19,923 (923) (900) (23)14,483 2,447 Other HCP 2,447 2,466 (19) 8 (27)

470,034 501,580 TOTAL H&SCP 501,580 514,219 (12,639) (12,341) (298.550)

179,644 180,861 Argyll & Bute CHP 180,861 179,551 1,310 1,350 (40)

Cental Services17,257 17,873 Corporate Services 17,873 17,401 473 457 1639,706 24,428 Central Costs & Reserves 21,928 13,485 8,443 8,034 409

706,642 724,742 Total Expenditure 722,242 724,655 (2,413) (2,500) 87

SG Brokerage 2,500 2,500 2,500

0 0 Surplus/Deficit Mth 12 0 (87) 87 0 87

Prev monthYear end PositionAnnual Plan

Finance - Monitoring HSCC - 1 May - Finance Rept - Interim Mth12 2013-14 tables Total Summary 22/04/2014 17:21

Income & Expenditure Report as at MARCH 2014 Table 2

Initial Current Summary Plan Actual Variance Forecast Movement

Plan Plan Health & Social Care Partnership to Date to Date to Date Variance in month

£000 £000 £000 £000 £000 £000 £000

North & West Operational Unit32,739 33,756 North Area - Caithness District 33,756 34,986 (1,230) (1,190) (40)17,753 18,403 - Sutherland District 18,403 17,778 625 545 8020,703 21,918 West Area - S,L, & WR District 21,918 23,120 (1,202) (1,111) (91)28,026 28,979 - Lochaber District 28,979 29,401 (422) (653) 2315,441 4,949 North & West Area Mgt 4,949 4,192 757 806 (49)

104,662 108,005 North & West Operational Sub Total 108,005 109,477 (1,472) (1,603) 131

3,759 3,865 N & W Hosted Services 3,865 3,972 (107) (97) (10)

108,421 111,870 Total North & West 111,870 113,449 (1,579) (1,700) 121

South & Mid Operational Unit21,030 23,021 South Area - Inverness West District 23,021 24,126 (1,105) (1,210) 10527,459 29,996 - Inverness East District 29,996 30,813 (816) (638) (179)25,053 25,936 - NABS district 25,936 25,552 384 330 543,334 3,309 - South Other services 3,309 2,960 349 366 (17)

15,733 16,218 Mid Area - Easter Ross District 16,218 17,755 (1,537) (1,507) (30)17,286 17,506 - Mid Ross District 17,506 18,956 (1,449) (1,612) 1633,604 4,368 - Mid Other services 4,368 4,389 (20) (26) 52,912 2,501 South & Mid Unit Central 2,501 2,377 124 25 98

116,411 122,856 South & Mid Operational Sub Total 122,856 126,927 (4,071) (4,272) 201

18,124 18,306 Adult Mental Health 18,306 18,248 57 57 (0)1,214 1,165 Learning Disabilities 1,165 1,075 90 72 181,755 1,490 Substance Misuse 1,490 1,414 76 73 38,107 19,459 Dental Services 19,459 19,280 179 120 59

29,200 40,419 Sub Total SE CHP Hosted services 40,419 40,017 402 322 80

145,611 163,275 Total South & Mid 163,275 166,944 (3,669) (3,950) 281

20,969 32,265 Adult Social Care - Central 32,265 29,021 3,243 3,831 (588)

Raigmore Operational Unit49,547 52,839 Surgical & Anaesth. Divison 52,839 57,458 (4,619) (4,537) (82)73,889 77,711 Medical & Diagnostics Division 77,711 78,523 (812) (785) (27)2,044 2,058 Raigmore Hotel Services 2,058 1,929 129 72 573,132 3,431 Patient Support Division 3,431 3,619 (188) (216) 282,023 (504) Raigmore Central (504) 3,767 (4,271) (4,087) (184)

130,635 135,536 Raigmore Divisions 135,536 145,296 (9,760) (9,553) (208)416 523 Research & Development 523 480 43 2 41

1,365 1,369 ACT - Additional cost of Teaching 1,369 1,305 64 28 36

132,417 137,427 Total Raigmore 137,427 147,081 (9,654) (9,523) (131)

Other H&SCP Services19,812 20,794 Facilities 20,794 20,702 92 54 384,823 4,857 Integrated Pharmacy 4,857 4,998 (141) (162) 214,380 9,645 e health 9,645 9,634 11 1 10


62,617 56,743 56,743 57,724 (981) (999) 18

470,034 501,580 Total Health & Social Care Partnership 501,580 514,219 (12,639) (12,341) (299)

18,737 19,391 A & B CHP- Oban, Lorn & Isles 19,391 20,019 (628) (600) (28)16,869 17,245 Mid Argyll, Kintyre & Islay 17,245 17,061 184 169 157,320 7,550 A&B MH In-patient Services 7,550 7,221 329 350 (21)

12,508 12,798 Cowal & Bute 12,798 12,921 (123) (135) 124,857 4,974 Helensburgh & Lomond 4,974 4,866 109 130 (21)9,231 8,681 Other clinical services 8,681 8,651 30 74 (44)

15,404 15,658 GMS 15,658 15,907 (249) (192) (57)17,075 17,007 Prescribing 17,007 16,725 282 175 1077,781 7,886 FHS Non Disc. Services 7,886 7,886 (0) 0 (0)

49,437 49,525 HCP - Glasgow & Clyde 49,525 48,471 1,054 1,000 544,074 3,995 HCP - Other 3,995 4,448 (453) (420) (33)4,603 4,652 Resource Transfer 4,652 4,653 (0) 0 (0)

11,748 11,501 Central & Corporate 11,501 10,723 777 799 (22)

179,644 180,861 Total A&B CHP 180,861 179,551 1,310 1,350 (40)

Central Services17,257 17,873 Corporate Services 17,873 17,401 473 457 1639,706 24,428 Central Costs/Reserves 21,928 13,485 8,443 8,034 409

Brokerage 2,500 2,500 2,500 0

706,642 724,742 Total Net Expenditure 724,742 724,655 87 0 87

Year end Position Prev monthAnnual Budget

Finance - Monitoring HSCC - 1 May - Finance Rept - Interim Mth12 2013-14 tables Fin Position 22/04/2014 17:21


Initial Current Summary Plan Actual Variance Forecast Movement

Plan Plan Health excluding Adult Social Care to Date to Date to Date Variance in month

£000 £000 £000 £000 £000 £000 £000

North & West Operational Unit

26,058 26,943 North Area - Caithness District 26,943 27,679 (736) (679) (57)

12,843 13,532 - Sutherland District 13,532 12,934 598 562 36

15,438 16,393 West Area - S,L, & WR District 16,393 17,483 (1,089) (972) (117)

20,749 21,607 - Lochaber District 21,607 22,704 (1,097) (1,152) 554,646 4,089 - West Area Mgt 4,089 3,369 720 740 (20)

79,735 82,565 North & West Operational Sub Total 82,565 84,170 (1,605) (1,501) (103)

3,759 3,865 N & W Hosted Services 3,865 3,972 (107) (97) (10)

83,494 86,430 Total North & West 86,430 88,142 (1,712) (1,598) (113)

South & Mid Operational Unit

12,985 13,652 South Area - Inverness West District 13,652 13,505 147 129 18

16,707 17,925 - Inverness East District 17,925 17,946 (22) (21) (1)

17,379 18,037 - NABS district 18,037 18,022 16 (4) 20

3,334 1,274 - South Other services 1,274 1,175 99 91 8

11,009 11,307 Mid Area - Easter Ross District 11,307 11,403 (96) (117) 22

10,595 10,772 - Mid Ross District 10,772 10,560 212 156 56

3,604 4,368 - Mid Other services 4,368 4,389 (20) (26) 5728 2,766 South & Mid Unit Central 2,766 2,541 225 322 (97)

76,340 80,102 South & Mid Operational Sub Total 80,102 79,542 560 530 30

18,124 18,306 Adult Mental Health 18,306 18,248 57 57 (0)

1,214 1,165 Learning Disabilities 1,165 1,075 90 72 18

1,755 1,490 Substance Misuse 1,490 1,414 76 73 3

8,107 19,459 Dental Services 19,459 19,280 179 120 5929,200 40,419 Sub Total SE CHP Hosted services 40,419 40,017 402 322 80

105,540 120,521 Total South & Mid 120,521 119,559 962 852 110

Raigmore Operational Unit

49,547 52,839 Surgical & Anaesth. Divison 52,839 57,458 (4,619) (4,537) (82)

73,889 77,711 Medical & Diagnostics Division 77,711 78,523 (812) (785) (27)

2,044 2,058 Raigmore Hotel Services 2,058 1,929 129 72 57

3,132 3,431 Patient Support Division 3,431 3,619 (188) (216) 28

2,023 (504) Raigmore Central (504) 3,767 (4,271) (4,087) (184)

130,635 135,536 Raigmore Divisions 135,536 145,296 (9,760) (9,553) (207)

416 523 Research & Development 523 480 43 2 411,365 1,369 ACT - Additional cost of Teaching 1,369 1,305 64 28 36

132,417 137,427 Total Raigmore 137,427 147,081 (9,654) (9,523) (131)

Other H&SCP Services

19,812 20,794 Facilities 20,794 20,702 92 54 38

4,823 4,857 Integrated Pharmacy 4,857 4,998 (141) (162) 21

4,380 9,645 e health 9,645 9,634 11 1 10


62,617 56,743 56,743 57,724 (981) (999) 19

382,286 401,121 Sub Total 401,122 412,506 (11,385) 0 (11,269) (115)

18,737 19,391 A & B CHP- Oban, Lorn & Isles 19,391 20,019 (628.451) (600.000) (28)

16,869 17,245 Mid Argyll, Kintyre & Islay 17,245 17,061 183.685 169.000 15

7,320 7,550 A&B MH In-patient Services 7,550 7,221 328.879 350.000 (21)

12,508 12,798 Cowal & Bute 12,798 12,921 (122.968) (135.000) 12

4,857 4,974 Helensburgh & Lomond 4,974 4,866 108.800 130.000 (21)

9,231 8,681 Other clinical services 8,681 8,651 29.540 74.000 (44)

15,404 15,658 GMS 15,658 15,907 (249.250) (192.000) (57)

17,075 17,007 Prescribing 17,007 16,725 281.998 175.000 107

7,781 7,886 FHS Non Disc. Services 7,886 7,886 (0.000) 0.000 (0)

49,437 49,525 HCP - Glasgow & Clyde 49,525 48,471 1,053.847 1,000.000 54

4,074 3,995 HCP - Other 3,995 4,448 (452.872) (420.000) (33)

4,603 4,652 Resource Transfer 4,652 4,653 (0.258) 0.000 (0)11,748 11,501 Central & Corporate 11,501 10,723 777.225 799.000 (22)

179,644 180,861 Total A&B CHP 180,861 179,551 1,310 1,350 (40)

Central Services

17,257 17,873 Corporate Services 17,873 17,401 473 457 16

39,706 24,428 Central Costs/Reserves 21,928 13,485 8,443 8,034 409

618,894 624,283 Total Net Expenditure 621,784 622,942 (1,159) # (1,429) 270


Finance - Monitoring HSCC - 1 May - Finance Rept - Interim Mth12 2013-14 tables Health 22/04/2014 17:21


Initial Current Plan Actual Variance Forecast Movement

Plan Plan Summary Adult Social Care to Date to Date to Date Variance in month

£000 £000 £000 £000 £000 £000 £000

North & West Operational Unit

6,681 6,813 North Area - Caithness 6,813 7,307 (494) (512) 18

4,910 4,871 - Sutherland District 4,871 4,844 27 (17) 44

5,264 5,525 West Area - S,L, & WR District 5,525 5,637 (112) (139) 27

7,276 7,372 - Lochaber District 7,372 6,697 675 500 175796 860 North & West Unit Central 860 823 37 66 (29)

24,927 25,440 Total North & West 25,440 25,308 133 (102) 235

South & Mid Operational Unit

8,045 9,369 South Area - Inverness West District 9,369 10,620 (1,252) (1,339) 87

10,753 12,072 - Inverness East District 12,072 12,866 (795) (617) (178)

7,674 7,899 - NABS district 7,899 7,530 369 334 35

4,723 4,911 Mid Area - Easter Ross District 4,911 6,352 (1,441) (1,390) (51)

6,691 6,734 - Mid Ross District 6,734 8,396 (1,662) (1,768) 107

2,185 2,034 South Area Other Services SW 2,034 1,784 250 274 (24)(265) South & Mid Unit - Central (265) (164) (100) (296) 195

40,070 42,753 Total South & Mid 42,753 47,385 (4,631) (4,802) 171

20,969 12,517 Adult Social Care - Central 12,517 9,244 3,272 3,807 (535)

17,109 - Care at Home 17,109 17,567 (458) (413) (45)2,639 - Business support 2,639 2,210 429 437 (8)

20,969 32,265 32,265 29,021 3,243 3,831 (588)

85,966 100,459 Total Net Expenditure 100,458 101,714 (1,255) (1,073) (182)


Finance - Monitoring HSCC - 1 May - Finance Rept - Interim Mth12 2013-14 tables Adult Social Care 22/04/2014 17:21

NHS Highland

Savings 2013/14 Position as at MARCH 2014 Table 5

In Year

B/fwd New N/R ASC Balance Forecast Outstanding

Target Target Target Target Total Savings REC Non Rec To Achieve FYE 2013/14 C/Fwd£000 £000 £000 £000 £000 £000 £000 £000 £000 £000

H&SC Partnership

252 1,352 507 2,111 North & West Operational Unit 705 995 411 4 1,402

197 1,543 426 2,166 South & Mid Operational Unit 404 1,762 0 1,286 476

1,935 1,797 (933) 2,799 Adult Social Care 450 2,349 (0) 2,349

2,595 2,478 5,073 Raigmore 2,349 127 2,597 77 2,647

0 365 365 Facilities 365 0 0

63 77 140 Integrated Pharmacy 44 31 65 96

109 85 194 e health 116 77 1 9 69

5,151 7,697 0 12,848 Sub Total H&SC Partnership 4,433 5,341 3,074 1,376 7,039

312 2,088 2,400 Argyll & Bute CHP 2,019 381 0 381

2,000 2,000 Central Costs & Reserves 4,600 (2,600) 0

122 1,000 1,122 Corporate Services 525 606 (9) 251 346

5,585 10,785 2,000 0 18,370 Total Cash Efficiency Savings 6,977 10,928 465 1,627 7,766

Next YearSavings Target

Achieved YTD

Position to Date

Finance - Monitoring HSCC - 1 May - Finance Rept - Interim Mth12 2013-14 tables CRS 22/04/2014 17:21

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NHS Highland - "At A Glance" HEAT TargetsSummary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 28th April 2014

N/A = Not Applicable, N/Av - Data not Available

Targets with a delivery date by the end of March 2014

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Child Healthy Weight Interventions Dec-13 N/A N/Av N/Av Mar-14

Smoking Cessation - 2 most deprived data zones Dec-13 N/A Mar-14

Smoking Cessation - general smoking population Jan-14 N/A N/Av N/Av Mar-14

Child Fluoride Varnish Applications Sep-13 N/A Mar-14

Financial Performance Feb-14 Mar-14

Cash Efficencies Feb-14 Mar-14

Rate of attendances at A&E Mar-14 N/A Mar-14

Targets with a delivery date beyond March 2014

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Early Access to Antenatal Services Mar-14 Mar-15

Detect Cancer Early Apr-13 Apr-15

Reduce Carbon emmissions Dec-13 Mar-15

Reduce Energy Consumption Dec-13 Mar-15

Faster Access to Specialist CAMHS - 18 weeks Feb-14 Dec-14

No Trajectory Reduce IVF Waiting Times Mar-15

4 Hour A&E Wait Feb-14 Sep-14

Faster Access to Psychological Therapies Feb-14 N/A Dec-14

Reduction in Emergency bed days for patients aged 75+ Oct-13 N/A Mar-15

Delayed Discharges - 14 days Feb-14 Mar-15

No Trajectory Access to Dementia Support Mar-16

MRSA/MSSA Bacterium Dec-13 Mar-15

C. Diff Infections Dec-13 Mar-15

NHS Highland - "At A Glance" Standards

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Alcohol \Brief Interventions Feb-14 N/A Standard

Inequalities Targeted Cardiovascular Health checks Feb-14 N/A

Breastfeeding at 6-8 week- Target 36% Sep-13 N/A N/Av N/Av

MMR uptake rates - target 95% at 5 years old Dec-13 N/A

Sickness Absence - 4% target Jan-14 Standard

SMR return rate - 90% of SMR1 returns received within 6 weeks Dec-13

No Trajectory Complaints Mar-12

No Trajectory Same Day Surgery Rate N/A

Outpatients - DNA rate - Target 6.9% Dec-13

No Trajectory Reduce Pre Operative stay N/A

eKSF & PDP's - Target 80% Feb-14

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Dec-13 Standard

All Cancer Treatment (31days) (Due for Delivery Dec 2010) Dec-13 Standard

18 weeks Referral to Treatment (Due for Delivery Dec 2010) Feb-14 Standard

New Outpatient Waiting times - 12 weeks - Ongoing Dec-13

New Outpatient Social Unavailability

New Outpatient Medical Unavailability

12 week Treatment Time Guarantee (TTG) - Completed Waits Dec-13

12 week Treatment Time Guarantee (TTG) - Ongoing Waits Dec-13

Admission Waiting List - Social Unavailability

Admission Waiting List - Medical Unavailability

Hip surgery - 98% of patients treated within 24 safe operating hrs Mar-14 N/A N/A N/A

8 Key Daignostic tests - Completed Waits N/A

8 Key Daignostic tests - Ongoing Waits Dec-13 N/A

Return Waiting List - Completed Waits

Return Waiting List - Ongoing Waits

Insulin Pumps - Under 18's Mar-14

Insulin Pumps - Over 18's Mar-14

Drug & Alcohol Treatment: Referral to Treatment Dec-13 Standard

Reduce Occupied Bed days for long term conditions Aug-13 N/A

Reduce Average Length of Stay for Continuous Episode of care N/A

End of Life Care Measure

Dementia (Unvalidated - validated position available annually) Feb-14 N/A Standard

90% of patients diagnosed with stroke admitted to a stroke unit Feb-14 N/A Standard

Reported at Board Level only


Currently reported at Board Level Only



Currently reported at Board Level only

Awaiting measure from Clinical Gov Comm.




Data sources being developed






Data sources being developed

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Improvement Committee28 April 2014

Item 4.1a

CANCER SERVICESReport by Derick Macrae, Service Manager – Cancer Services on behalf of LindaKirkland, Interim Director of Operations, Raigmore Hospital

1 CURRENT POSITION

The purpose of this report is toa) provide an analysis of Cancer Breachers for the last three months to end March, Q1 of 2014

b) to report on the Action Plans in place to mitigate the situation.

This paper should be read in conjunction with the current Cancer Target Action Plan (Appendix One of this report)

The two National and Local cancer waiting times targets are:

A 62-Day Target: time between urgent referral with suspicion of cancer to first cancer treatment.

A 31-day Target: time between the decision to treat (regardless of the route of referral) to firstcancer treatment.

A 5% tolerance level is applied to these targets, as for some patients it may not be clinically appropriate fortreatment to begin within target. Therefore, 95% of all eligible patients should wait no longer than 31 or 62 days.

In any month, NHS Highland would expect an average of 106 patients against the 31 Day Target and 60 againstthe 62 Target.

Table 1 - Performance 2010 to date:The Targets are reported and published nationally on a quarterly basis and the performance sincemonitoring began is shown below. The monthly performance since the last quarter is also shown.

62 Day - Urgent Referral to Treatment 31 Day - Decision to Treat to Treatment

Referred Treated Breached % Referred Treated Breached %

2010

Q1 to end Mar 153 150 3 98.0 299 273 26 91.3

Q2 to end Jun 169 165 4 97.6 307 282 25 91.9

Q3 to end Sept 166 164 2 98.8 317 310 7 97.8

Q4 to end Dec 186 179 7 96.2 332 316 16 95.2

2011Q1 to end Mar 199 195 4 98.0 326 310 16 95.1

Q2 to end June 158 147 11 93.0 297 282 15 94.9

Q3 to end Sept 176 172 4 97.7 309 294 15 95.1

Q4 to end Dec 179 172 7 96.1 288 281 7 97.6

2012

Q1 to end Mar 158 153 5 96.7 278 272 6 97.8

Q2 to end Jun 164 158 6 96.3 314 305 9 97.1

Q3 to end Sept 202 195 7 96.5 338 320 17 94.9

Q4 to end Dec 178 166 12 93.3 307 290 17 94.462013Q1 to end Mar 164 148 17 89.6 288 276 12 95.8

Q2 to end Jun 187 175 12 93.58 304 292 12 96.05

Q3 to end Sept 178 164 14 92.14 308 298 10 96.75

Q4 to end Dec 167 157 10 94.01 319 304 15 95.3

2014

Q1 to end Mar 174 157 17 90.2 305 279 26 91.5

Apr 14 ( at 23/4) Estimate position 3 95 3 95

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Highland Health & Social Care Committee 1 May 2014 Item 5.1.4(2)

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As can be seen above, over the 17 completed quarters since January 2010 there have been

Six failures of the 62 Day Targeto Quarter 2, to end June 2011,o Quarter 4, to end December 2012o Quarters 1, 2, 3 and 4 in 2013.o Quarter 1 in 2104

Three failures of the 31 Day Targeto Quarters ending March 2010,o end June 2010o end June 2011o end Mar 2014

As a result of the continuing failure to meet the target NHS Highland, along with three other Boards isworking with SGHD Cancer Delivery Team to bring the position back into balance as soon as possible.Appendix One describes the Plans being put into place to manage the situation. It will be formallyreviewed at a meeting with the Delivery Team in May.

The charts at the end of this report illustrates the monthly performance against both targets. Thequarterly performance can be easily affected by the poor performance in one particular month and it ispoor in the quarter just ended because of a poor performance in two months in succession.

The failures in this three month period continue to fall into the categories: 1 - Lack of Urology Capacity,2 – Breast Capacity, 3 – Endoscopy Waiting Times 4 - Radiotherapy Delays and 5 - Oncology Capacity.Appendix One describes the problems and actions being taken in each of these areas.

1. Urology Capacity

The position in Urology is mostly due to a lack of capacity at the beginning of the referral pathway tocarry out prostate biopsies. This has been addressed to some extent now with the Nurse Specialistcarrying out six rather than four clinics per month. Another member of staff has also been allocated toactively manage the expediting of tests and results for individual patients.

The maim problems in the pathway are caused by a lack of capacity to carry out upper tract andprostate surgery and unfortunately to solutions to address them are longer term one and are probablyregional rather than local.

2. Breast Capacity

The majority of the breaches encountered within Breast Surgery were at the beginning of the quarter. Itis believed that the measures implemented since then will significantly reduce this problem.

Additional clinics have been established to cope with the annual peak in demand each autumn resultingfrom Breast Awareness month. Additional theatre sessions are also being sought from otherspecialties when required to avoid patients breaching. An RPIW is also being held on 30 June focusingon improving the beginning of the pathway.

3. Endoscopy Capacity

An additional rectal bleeding clinic has been establish in the last month but there are continuingcapacity problems which are being resolved by the re-advertisement of a Nurse Endoscopist post.

3

4. Lack of Radiotherapy Capacity and Pathway Inefficiencies

The difficulties in staffing the Radiotherapy Planning Service have been discussed in some detail inprevious reports. The staff member appointed to one of the two vacant posts in December took up postin 14 April and another post was filled by an internal candidate. This leaves that latter post and oneother post now vacant.

Discussion at underway with regional colleagues in order to provide a more immediate solution.Significant progress towards the safe transfer of files and radiotherapy plans between the five CancerCentres has been made in the last month in order to facilitate this.

5. Lack of Oncology CapacityThe service is currently reliant upon two locums until the end of May and June respectively to cover thewte vacancies caused by a retiral at the end of March and a Consultant on SL until the end of May. Theconsultant on Sick Leave will not return to the sub specialty that they left.

A second attempt to appoint to the retirees post resulted in no applicants. The immediate term gap willbe provided by the continued use of locums and with the support of colleagues from other Centresthroughout Scotland. This will unfortunately mean that some patients might have to travel forassessment and possibly treatment but every effort is being made to minimise the inconvenience topatients and return to a locally based service as much as possible. This make take some time giventhat this is a UK wide problem.

It is recognised that without a fully staffed local service a revised service model will be requireddependent upon the types of service that could be best provided locally, what regionally and whatnationally. This will need a combination of solutions depending many factors such as the specialisms ofthe consultants in post, patient numbers affected, their ability to travel, whether their radiotherapytreatment could be planned and still be provided locally and in a safe manner noting that the ConsultantOncologist will not be on site in the event of any post treatment complications. Our planning so far hastaken cognisance of these issues by resorting to a GI Service with the initial consultation in Aberdeen orby video from Inverness but with treatment remaining in Inverness. Lymphoma and Sarcoma patientshowever, where the numbers affected are smaller will unfortunately have to travel to Dundee or theCentral belt for their consultants and treatment.

This work is being co-ordinated with colleagues in NOSCAN with a regional and national review led byDr Jane Barratt, recently retired President of the Royal College of Radiologists and by Dr DavidDunlop, Senior Medical Officer seconded from the Beatson Cancer Centre in Glasgow.

Adjuvant Waiting TimesThere is no national target for Adjuvant Radiotherapy waiting times ( secondary treatment after initialsurgery). The Service Redesign work mentioned above has resulted in a reduced waiting time to withinthe clinical recommended times of 8-13 weeks after surgery for Breast patients.

2 ACTION PLANS TO ADDRESS

The Scottish Government Action Plan at Appendix One overleaf summarises the actions being takenagainst each of the breach categories.

4

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

The various issues in cancer services are all interrelated and it is essential that there is a broadunderstanding that there is no simple or single fix. However the various actions planned are beingtaken with the intention of creating a robust, sustainable service going forward.

The support of the SHGD Cancer Delivery Team is expected to significantly improve compliancewith the targets.

We are also working closely within colleagues in NOSCAN and the other Cancer Centres to sustainthe service. We will be working with the National Cancer Delivery Team in order to ensurecompliance with the targets as quickly as possible.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (i.e. Trajectory)

Cancer target performance is a major priority for NHS Highland and all efforts are being made in orderto bring performance back in balance in accordance with the timescales stated in the Action Plan. It isexpected that a sustained improvement will not be possible until the end of the summer.

5

Appendix A – Cancer Target Run Charts

62 Day (Urgent Suspected Cancer to Treatment) Target Jan 10 to Mar 14

31 Day (“Decision to Treat” to Treatment) Jan 10 to Mar 14

Page | 1

NHS HIGHLAND

CANCER TARGET ACTION PLAN As at 10 April 14

An analysis of the breaches for the first three months of 2014 quantified in the columns below, identified the following six main categories of failure:

Issue Jan – Mar 14Performance

Actions Timescales Who Status ( Green = complete, Amber= underway, Red = noprogress/not possible)

1. Short Term –a) continue to optimise the time of the Upper TrackSurgeon and other Consultants by transferring patients tocolleagues with capacity as required

On-going Service Mgr Underway. Weekly planningmeetings with Consultants takeplace in order to identify patientsto be seen within target times.Variation in demand is difficult tomanage

b) Some delay at the beginning of the prostate pathway isdue to a lack of capacity for Prostate biopsies. NurseSpecialist to carry out two more clinics per month ( 4 to 6)

Immediate Complete. USC patients will bereferred for biopsy, others to beseen at clinic first.

4 62 Day )8 ( 31 Day)

31 DayBladder – 2Prostate – 5Bladder - 2

62 Day –Prostate – 4 c) Seek additional capacity at weekends for operating

with the support of a visiting service if necessaryOn-going Service Mgr This option is being explored with

concerns regarding the continuityof care once visiting surgeonsdepart continuing to be addressed.Unlikely to be implemented

d) Minimise administrative delays in the pathway byensuring that patients are tracked individually anddecision making on results etc is expedited as quickly aspossible

Immediate Service Mgr Cancer Auditer has been identifiedto carrying out this work withimmediate effect and work withinthe Service to support theclinicians.

1.Lack ofUrologyCapacity

2. Medium Terma)Appoint a locum ASP or Urologist to assist the ProstateSurgeon in Theatre and provide additional capacity forlaparoscopic prostate surgery.

31 June 14 Service Mgr To be discussed further within theDepartment and at the nextNOSCAN MCN Meeting.

b) Continue to seek NHS and private capacity in the rest of Immediate Service Mgr Prostate Surgeon capacity is a

Page | 2



Scotland as required for Laprascopic Prostatectomy andRenal Surgery

regional and national challenge ( 8out of 15 Boards breached withinUrology in February)

It has proved impossible to sourceadditional capacity within targettimes. ( ARI – 5 weeks plus for LapProstatectomy, Ross Hall and Spire– likewise.) Discussions are on-going with NOSCAN colleagues toseek a regional solution to the lackof Prostate Capacity

c) Visit better performing Urology Departments inScotland and implement any areas of best practice wherepossible

31 May 14 Service Mgr To be progressed

The major of the breaches encountered within Breast Surgery were at the beginning of the quarter. It is believed that the measuresimplemented since then will significantly reduce this problem. Recent initiatives to reduce demand and increase capacity for the one stoptriple assessment clinic will also reduce the problem further.

1. Seek operating lists from areas with spare capacitywhen required.

Complete This has been fully implementedsince Mar 14. As a result thenumber of breachers for thisreason should be significantlyreduced

2.

BreastSurgery

4 (62 Day)10 (31 Day)

2. Undertake a review of the allocated Theatre sessionswith the intention of maximising the capacityavailable to Breast Surgery at times of peak demand.

On-going Clinical Lead There is a need to maximise thenumber of all day sessions availableand restoring two of the fourTuesdays in the number whichcurrently have to be given to thevisiting Paed Surgeons. In theimmediate term all available

Page | 3



sessions throughout Surgery will beoffered to the Breast Service.

3. Review procedures for Sentinel Lymph Node Biopsies,compliant with best practice in order to provide abetter match between the availability of the NuclearMedicine service and the appropriate theatresessions.

31 May 14 Clinical Lead Discussions underway betweenNuclear Medicine and BreastSurgeons initially. Furtherconsideration to be given to amove to “day of” surgery radio-isotope injection service.

4. The Day Case Theatre ( Th10) cannot be utilised on apermanent basis for SLNBs and recons. A sessionwith main Theatres is required

31 May 14 ServiceLead/DGM

There is now agreement thatTheatre 10 should be made SLNBcompliant with the necessaryfacilities and fully trained staff.Further discussion is required toconsider when Physics staff canprovide the injection service.

5. Plan for the increased monthly referrals ( includingthe annual Autumn peak as a result of BreastAwareness month)

31 March 14 Service Mgr Being address for 2014 onwards.Additional clinics were held inMarch to see the additionalreferrals in October and November14. Capacity for an additional 40patients per month has also beenidentified ( from 175 to 215). Thiswill more than provide for themonthly average of 185 referrals.

3Endoscopy

WaitingTimes

7 (62 Day)1 (31 Day)

Review the Colorectal Pathway in light of recent breaches.31 May 14 The SGHDH have requested that

we along with NHSG review thepathway for Colorectal patients inlight of recent breaches. Underwaywith meeting to discuss data beingarranged.

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Re-advertise for Nurse Endoscopist in order to provideadditional capacity ( 5 sessions per week)

Immediate ServiceManager

The post is currently out to advertfor a second time

Provide additional capacity for the Rectal bleeding clinic Immediate Service Mgr Complete. An extra clinic per weekhas now been established.

Devolve Patient Booking Service back to Endoscopy givenspecialist nature of booking service and the need toprioritise Urgent Referrals

31 May 14 PatientBookingManager

This was initially delayed as a resultof the PMS introduction

2 (31 Day)3 (62 Day)

Short Term1. Implement the recommendations of the Rapid

Process Improvement Week

Head of Ther.Radiography

Underway. Implementation stalledgiven the SL of the Consultant andthe vacant Physics posts.

2. Continue in efforts to recruit Radiotherapy Physicslocums from Centres throughout the UK to contributeto the Planning process

Dir. Of MedPhysics

Complete

Medium Term3. Identify cohorts of patients that could be safely

referred elsewhere for planning

Service Mgr Underway. Being developed on aregional basis with NOSCANcolleagues.

4.Radiotherapy

Planning

4. Appoint to vacant Planning posts. Dir of MedicalPhysics

One post successfully appointed toand post taken up on 14 April afterthree months notice. One postfilled by internal candidate and thatpost is now being re-advertised for.This leaves another vacant post andthis is currently out to advert.

5. Work with regional and national colleagues to shareequipment and human resources where possible

Underway. Transfer of data/planscurrently introduced betweenRaigmore,Aberdeen, Dundee andEdinburgh. Lothian for Neuropatients. Discussions underway for

Page | 5



future shared working wherepossible.

3 (62 Day) 1. Continue to implement the recommendations of theRPIW

31 Aug 13 DGM Underway but delayed followingthe sick leave of Dr Kelly and thelack of a permanent BreastOncologist

2. Continue in efforts to appoint a replacement fourthConsultant who retired on 21 March 14.

31 May14 Service Mgr Current advertisement in BMJcloses on 14 April with noapplicants. Being advertised for athird time at the end of the month.

3. Seek continuing locums and support from otherCentres to cover sub specialty gaps in the immediateterm and perhaps permanently.

ongoing Servic e Mgr Work on-going with Aberdeen andDundee to provide support for GI,and Lymphoma and Sarcoma.Locums also in post until the end ofMay and June to provideChemotherapy and Breast support.

Discussions are on-going with thesupport of NOSCAN to make thesearrangements for permanent andsustainable.

4. Transfer as much activity as possible from theConsultants to other colleagues eg Nurse Specialiststo see Returns

Complete NurseSpecialist

Underway. Nurse Specialistreviewing case load and waiting liston a regular basis.

5. Consider and implement recommendations ofreview being undertaken by Dr Barrett

30 Jun 14 Consultants To be discussed within department

5OncologyCapacity

6. Consider recruiting Consultants to undertakeweekend clinics (least preferred option)

On-going Service Mgr Trialled during March for breastpatients. May be re-established if

Page | 6



it locum doctors cannot besustained. Batching nature ofactivity is proving difficult forremainder of team

7. Continue to explore mutual aid from NOSCANcentres in the immediate term and in the longerterm in order to ensure provision of a sustainableservice.

Service Mgr Complete. Options are limitedwithout additional capacity beingsourced for some or all of theCentres.

6Gynaecology

1 (62 Day)1 ( 31 Day)

Review the Gynaecology Pathway. There are multiplereasons for failure

31 May 14 Cancer Lead To be undertaken

Improvement Committee28 April 2014

Item 4.1b

ACCESS TARGETS

Report by Linda Kirkland, Interim Director of Operations, Raigmore Hospital

1 CURRENT POSITION

This paper summarises performance against 3 Access targets and 4 Key EndoscopyDiagnostic Tests (4 Key radiology Diagnostic tests are detailed in a separate paper)

New Outpatient waiting times – maximum wait of 12 weeks from GP referral(Target is 100% compliance).

Treatment Time Guarantee (TTG) admission waiting times – maximum of 12 weeksfrom decision to treat. This is a legal requirement.

Referral to Treatment Time (RTT) – maximum of 18 weeks from referral to treatment.(Target is 90% of patients)

4 Key Endoscopy Diagnostic Tests – No patient will wait over 2 weeks for urgent/urgentsuspected cancer (USC) or 6 weeks for a routine appointment. NHS Highland has set alocal target of 4 weeks for routine.

Outpatients

Previous reports to the Improvement Committee showed the number of patients at month endwaiting over 12 weeks and 15 weeks for the Outpatient Waiting Time Target. This report is notavailable due to lack of data for Service Planning from the Patient Management System (PMS).

There are a number of specialties which are problematic. The pressures and actions taken toaddress the specialties under pressure are outlined in greater detail under Section 2 below.Additional temporary capacity was put in to place in pressured specialties in the first threemonths of 2014 to reduce the numbers waiting at the end of March 2014. Orthopaedics was nottargeted due to the size of the pressure. The main challenges ongoing continue to be are ENT,OMFS, Gynaecology and Orthopaedics.

Table 1 shows the numbers of outpatients unbooked and booked over the 84 day target as atApril 2014.

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Highland Health & Social Care Committe 1 May 2014 Item 5.1.4(3)

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Table 1

Booking status

Specialty Booked Unbooked Total

A&E 2 2

Breast Surgery 1 1 2

Cardiology 17 1 18

Child Psychiatry 2 26 28

Clinical Genetics 2 2 4

Clinical Oncology 1 1

Community Dental 1 1

Dermatology 9 7 16

Diabetic 1 1

Ear, Nose and Throat 21 6 27

Endocrinology 7 1 8

General Medicine 1 1

General Surgery 15 15

Gynaecology 19 23 42

Neurology 13 13

Neurophysiology 5 5 10

Neurosurgery 2 1 3

Ophthalmology 14 15 29

Oral and Maxillofacial Surgery 32 8 40

Orthodontics 4 1 5

Orthopaedics 126 75 201

Paediatric Medicine 1 1

Plastic Surgery 1 1

Respiratory Medicine 2 3 5

Restorative Dentistry 3 3

Total 283 194 477

Treatment Time Guarantee (TTG)

Table 2 below outlines the completed Treatment Time Guarantee (TTG) performance for themonths of April 2013 to February 2014 and shows the number of TTG completed waits over 12weeks by specialty. Action Plans to address pressures are detailed in Section 2 below.

3

Table 2

Orthopaedics 51 56 41 4 5 13 13 3 5 6 12

ENT 11 7 2 1 1 1 5

Urology 15 10 2 2 4 1 2 3 2 4

Ophthalmology 20 21 23 5 1 2 2

OMFS 6 12 2 11

Orthodontics

Gynae 1 1 1 1 1 2

Breast 1 2

Colorectal 1 1 1 1

Upper GI 1 1 1Vascular

Plastic Surgery 2

Comm Dental 1

Pain Mgt 1 2

Surg Paeds

General Medicine 2

Haematology

Neurology

Paediatric Medicine

Rehabilitation Medicine

Renal

Respiratory Medicine

Rheumatology

Argyll & Bute

North

West

Total 106 108 70 11 12 18 19 11 8 17 32

April May June July August September October November December January February

4 Key Diagnostic Tests – Endoscopy

Table 3 below shows the waiting times for urgent suspected cancer (USC), urgent, routine andsoon referrals.

Table 3

Current Endoscopy Waits as at 10th April 2014

0-14 days 14-28 days >28days TotalUSC 15 39 22 76Urgent 13 23 16 52Routine 1 35 46 82Soon 0 0 2 2Total 29 97 86 212

Previous reports showed that routine appointments were being booked in 0 to 14 days usingslots for urgent activity. This report shows an improving position with minimal routine patientsnow being booked in to slots that should be used for urgent referrals. However, there are stillroutine patients booked 14 to 28 days and urgents booked over 28 days, so continued work isrequired with scheduling.

The booking of endoscopy patients to be relocated to endoscopy service. Patient focussedbooking methodology will continue to be used but it is anticipated that the relocation of bookingstaff in to the new endoscopy unit will improve booking and scheduling practices.

4

Referral to Treatment Time (RTT)

Overall performance is above the 90% target. However, the overall linked pathway performancedemonstrates that not all patient pathways are being captured and measured. Work is ongoingto improve percentage of linked pathways as this will give a more accurate percentage figure inrelation to RTT performance against the 90% target.


The actions that are being worked through to improve the delivery of both the Treatment TimeGuarantee (TTG) and the outpatient waiting times are set out by specialty below:-

Orthopaedics

TTG

Significant pressure within the admissions still exists in orthopaedics, with over 100 patientswith an April breach date unable to be seen within the month of April. In addition to the existingcapacity shortfall a large number of patients who were made unavailable in January to March,as they did not take up offers at Ross Hall, are now available. These patients have beenprioritised in April displacing patients with April breach dates. Currently the hospital is utilisingall the available sessions within theatre Monday to Friday, however no additional sessions outwith this has been organised. A review of the demand and capacity within the service isongoing with a view to establishing the theatre sessions required to meet the demand.

Outpatients

Significant pressure exists within the outpatient setting of the orthopaedic service, currently over600 patients are waiting longer than 12 weeks for their appointment as at March 2014. Asreported previously 300 patients were seen as “see and treat” project with Ross Hall.

Discussions are underway with the Golden Jubilee National Hospital (GJNH) to provide a seeand treat package of another 300 patients to address the outpatient backlog.

There is a piece of work to be conducted in early 2014/15 to assess and rationalise theperipheral clinic commitments.

Urology

TTG

The pressure with TTG urology patients is a result of pressures with urological cancer patients.Cancer patients are provided with the priority for theatre space and this has an impact onpatients being seen within their 12 week date. Laparoscopic renal urology procedures are aparticular pressure and only one consultant carries these out. His workload has been prioritisedto concentrate on these cases. Capacity has been sought in the private sector and at GJNH butthere is none available.

Outpatients

There are significant outpatient pressures in return appointments. Return patients currently waitconsiderably longer than is clinically desirable. New outpatient waiting times meet the targetbut may deteriorate due to the need to convert capacity to return outpatients. Canceroutpatients continue to be a pressure for the service, urological cancers account for significant

5

breaches. A review has taken places around pathways and reserving one stop clinic spaces forhigh risk cancer cases with the low risk patients being seen in routine clinics. This in turn willadd pressure to the routine new clinics. There has been a review of provision of TRUS biopsyclinic capacity for prostate cancer patients with a plan to increase this capacity from June 2014to 6 lists per month an increase of 2 lists per month on the current capacity. This should allowthe service to maintain a 21 day wait from referral to TRUS biopsy for urgent suspected cancerpatients.

ENT

TTG

To date the TTG position has been maintained with the exception of a very small number ofpatients who required to be cancelled at short notice due to urgent patients being prioritised orcancellations due to bed or theatre staff pressures. This position will become difficult tomaintain in May & June as a result of the additional outpatient clinics held in February andMarch.

Outpatients

Delivery of the 12 week waiting time for new outpatients slipped during 2013. This was due toconsultant sickness, retirement and maternity leave. Long term locums were used as partialmitigation against the impact of these issues. In December the projected position was that therewould be 478 breaches at the end of March. A plan was put in place that cleared this backlog.

The position for 2014/15 will continue to be challenging as ENT continues to have staffingissues. One consultant and one Associate Specialist have recently retired. There is one parttime locum consultant in post providing some capacity. Two of the existing consultants haveeach picked up an additional EPA to provide capacity. The vacant consultant post is beingadvertised for the second time. Work is ongoing with Service Planning to review demand andcapacity and establish the long term requirements for ENT in particular how best to use thevacant associate specialist post.

Neurosurgery

TTG

Neurosurgery TTG activity is provided in NHS Grampian.

Outpatients

The Neurosurgery service is a visiting service from Aberdeen. During 2013 it was agreed thatnew patients should be given 30 minutes for an appointment rather that 20 minutes and thatreturn patients should be given 15 minutes rather than 10 minutes. This reduced the capacity tosee patients by a third. The new times per patient are in line with national recommendationsand with practice in other areas. Long appointment times are required to reflect the complexand difficult discussions which take place with this cohort of patients. The service agreementhas to be renegotiated to provide additional visits as it is now challenging to maintain theoutpatient waiting times. There is close work with the visiting neurologists to provide additionalvisits on an ad-hoc basis

6

Plastic Surgery

TTG

The Plastic Surgery service is a visiting service from NHS Lothian. The team provide both clinictime and surgical day case operating. Due to pressures on theatre capacity it is not alwayspossible to provide a full second operating list for the Registrar who operates in parallel with theConsultant. This is leading to pressures in delivering TTG as there is no flexibility to operate onalternative days due to the visiting nature of the service.

OMFS

TTG

The OMFS department currently has one consultant vacancy out of 2 posts.Major Head & Neck surgery which takes place at Raigmore has the impact of reducingoperating time for the routine TTG workload. Often this type of patient can be in theatre inexcess of 12 hours. Discussions are underway at North of Scotland Network level to establishthe best quality of service for this category of patient. There are approximately 12 – 15 Highlandpatients per year who require complex Head and Neck surgery. Due to staffing pressures inNHS Grampian the NHS Highland consultant also need to support Grampian with their majorcases.

Outpatients

The vacancy is impacting on the ability to provide a service for the routine non-urgent group ofpatients. Historically, even before the second consultant left, there was regular use of long termlocums to deliver the waiting times. Agreement has now been reached to develop a job plan forthe vacant post and proceed to advert. However, it is acknowledged that it will not be an easypost to fill. The short term plan is to use Consultant Locums when available to help with theroutine patients. A risk remains that this will not be sufficient to fully deliver the 12 weekguarantee on a regular basis.

Ophthalmology

TTG

The 12 week TTG target is regularly delivered for Ophthalmology with the exception of a verysmall number of patients who breach. This can be due to the availability of general anaestheticcover or a children’s bed on the required day.

NHS Highland is required to ensure that the 12 week guarantee should not be used to measurewaiting times for cataracts. Patients waiting for cataract surgery should wait no more than 9weeks. Plans are now in place to deliver and monitor this in 2014/15.As at April 2014 therewere 51 patients out of 303 who have currently waited more than 9 weeks for surgery.

Outpatients

The Ophthalmology outpatient position has regularly been delivered but only through use ofwaiting list work and regular use of a “bank” consultant ophthalmologist. There are significantissues with space and room utilisation. Recently a RPIW event took place which is enabling thedepartment to reflect on current practice and make changes to improve efficiency. It is expectedthat the RPIW will deliver and maintain continuous improvements throughout 2014. Progresswill be regularly reported.

7

Gynaecology

TTG

This target can be achieved with full consultant staffing. There is currently a consultant vacancycovered by locums which is causing some pressure.

Outpatients

Compliance with gynaecology outpatient waiting times continues to be a challenge. Thenumbers waiting beyond 12 weeks reduced to 38 at the end of March only with additionalwaiting list activity and this is likely to be required for the months ahead. Recruitment willcommence shortly to appoint a substantive seventh consultant. It is currently occupied by alocum obstetrician until the end of January. The post is about to be advertised now in order totake advantage of the known availability of a candidate with an interest in gynaecology.

Obstetric Scanning

The scanning service is unable to meet scanning targets for dating and detailed scans due tounfilled vacancies. Repeated and wide adverting has been unsuccessful. There has been agood response for training posts but there is a 2 year lead in time for trainees to be fullyproficient. There is a national shortage of obstetric scanners. The service is beingsupplemented my medical staff scanning but this impacts on outpatient clinic capacity.

General Surgery

TTG

There have been a small number of breachers each month, in the main due to cancer patientstaking priority for theatre space. Job planning for 2014/15 is beginning to impact in particularwith Colorectal and Upper GI. The Service is dependent on clinicians agreeing to work severalextra sessions/month to achieve TTG.

Outpatients

To date there have been no issues with waiting times. However, this month and going forwardit is anticipated that there will be ongoing shortfalls due to job planning.

Work is ongoing with clinicians to agree capacity to deliver the waiting times for TTG andoutpatients. This will result in significant financial overspend and reflects the goodwill work donein 2013/14 where little cost was incurred for extra activity. The service is working with PatientBooking Service( PBS) to ensure all capacity is utilised. However, Patient FocussedBooking(PFB) has been on hold since PMS launch. This has resulted in an increase in DNA/CNA s. Once PFB service is restored, a trial of text remind will commence.

A business case being completed for 5th Colorectal Surgeon to address Raigmore’s capacityshortfall but a 6th consultant may be required to address NHS Highland colorectal pressures.Retirements and resignations in Caithness and Belford Hospitals will result in increasedworkload in Raigmore. Measures are being discussed on how this workload can be managed.

Cardiology

The Catheter Laboratory is still experiencing capacity challenges for PCIs and angiograms. Thedepartment is exploring extending 2 days in the week to allow additional procedures.

8

Outpatients

A capacity shortfall continues for new and return outpatients. New capacity being provided byadditional waiting list clinics by substantive consultants.

Gastroenterology

Outpatients

Pressures exist with new and return outpatients. Capacity is being supplemented by Synpatiklocum agency (weekends) and additional waiting list clinics by substantive consultant. A longterm locum has been secured to support the service. The locum commences in June 2014 for6 months. Capacity and demand data for this service is being reviewed with the ServicePlanning Department.

Diabetes & Endocrinology

A fourth consultant has been appointed to the service and taking up full consultant duties inJune 2014. This will provide additional capacity for new and return patients.

Neurology

Outpatients

There are capacity pressures which will require to be addressed through some additionalwaiting list sessions.

Respiratory

Outpatients

Long term sickness of one consultant combined with the resignation of a clinical assistant haveadded to capacity problems within this service, particularly with respect to Caithness clinics.Additional capacity has been provided by Synpatik locum agency (weekend clinics). Recentlyadvertised for a locum consultant without attracting any interest. A consultant retires at end ofthe summer and this post has been approved for recruitment.

Sleep Service

There are a number of issues regarding this service relating to clinic capacity and availability ofa sleep study bed. This has been partially resolved with the ring fencing of the sleep study bed.

Rheumatology

Outpatients

Capacity is being met for new patients with one substantive and one part time locum consultant.Return patients remain an issue and support from Synpatik locum agency is ongoing. Thedepartment has advertised and failed to recruit substantive consultants. The service is trying torecruit visiting specialist doctors through contacts with the Madrid Rheumatology Society.

9

8 Key Diagnostic Tests

Endoscopy

Efforts are being made to address endoscopy capacity shortfall which is currently 5 sessionsweek. The initiatives identified in the RPIW in 2013 remain in place. Delays to scope are citedas part of the delays to colorectal cancer treatment.

The appointment of a trained Nurse Endoscopist would address the current shortfall but despiteseveral adverts it has not been possible to recruit to this post. A further attempt is being madethis month with post going out to advert mid April. Funding is available for this post.

There is an ongoing Gastroenterology vacancy which has not been filled despite severalchanges to the post to make it more attractive to potential applicants. A 6 month locum hasbeen secured and will take up post in June. It is anticipated that he will provide 1-2 endoscopysessions per week.

Job planning for 2014/15 is currently ongoing. It is anticipated that addressing the consultantadministration burden will release time for Direct Clinical Care. This potentially could result in anextra endoscopy session per week.

New Endoscopy Unit and Centralised Decontamination Unit

The endoscopy unit is relocating to a new refurbished unit in June 2014. This will providefurther physical capacity. Decontamination of endoscopes moves from the endoscopy serviceto a new purpose build EDU (Endoscopy Decontamination Unit) which is located some distancefrom the new endoscopy unit. This will result in significantly increased turnaround times.Added to this are more stringent reprocessing practices to ensure compliance with nationalguidance.

These factors outline the need to purchase a significant number extra endoscopes to deliver theendoscopy service as currently provided.

Radiology

See separate Improvement Committee Paper.


Specialty Impact

OrthopaedicsTTG

OrthopaedicOutpatients

Work will continue to ensure patients are booked in turn and theatre listsare fully utilised. However, there is a continuing capacity shortfall partiallymet by additional waiting list initiative operating. There is reluctance fromconsultants to undertake additional sessions due to disagreement aboutpayment rates. It is unlikely that a zero TTG position will be reached for31 March 2014.

The Ross Hall “see and treat” package is complete in terms of outpatientactivity. As stated earlier in the report anther see and treat exercise willbe undertaken with the Golden Jubilee National Hospital for another 300outpatients. GJNH will also deal with any patients requiring surgery. This,in conjunction with improved utilisation of the existing clinics andrationalisation of peripheral clinics will assist in addressing the capacityshortfall.

10

UrologyTTG

Cancer pressures will continue to impact on TTG and may requirecontinued use of Private Sector to support TTG patients to free capacityfor cancer patients.

ENTOutpatients

It is anticipated that the ENT outpatients will remain a pressure given theconsultant and associate specialist vacancies. Waiting list initiative clinicswill be required to meet waiting times.

OMFSTTG

Outpatients

The consultant vacancy and Head and Neck cancer pressures in NHSHighland and Grampian is causing pressures on TTG.

It is anticipated that the assistance of the NHS Grampian consultant willmaintain outpatient waiting times.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE

TTG: - At the end of March 2014 all specialties apart from orthopaedics are planning to beachieving TTG. However, patient cancellations due to bed and theatre staffing pressures andpatient prioritisation due to cancer cases are continuing risks that may contribute to TTGbreaches.

Outpatients: - At the end of March 2014 all specialties apart from orthopaedics are planning toreturn to planned performance of meeting 12 weeks. Staffing pressures, particularly consultantvacancies remain a risk to meeting targets.

Regular monitoring of the progress against all the above plans will take place on a weekly basisas part of the weekly Raigmore Hospital Access meeting.

Linda KirklandInterim Director of Operations, Raigmore Hospital21 April 2014

Improvement Committee28 April 2014)

Item 4.1c

DIAGNOSTIC RADIOLOGICAL TESTS AND INVESTIGATIONS

1 CURRENT POSITION

This report describes the position with regard to performance against standard for the 4 keydiagnostic radiological tests and investigations of CT and MRI scanning and Barium andUltrasound examinations, all of which must be performed and reported within 6 weeks.

NHS Highland internal targets require that 90% of reports be available within 7 days ofexamination, 100% within 14 days, meaning that the wait for diagnostic imaging to beperformed should in principle not exceed 4 weeks.

Capacity – Scanning and Reporting

Both of the above elements have been affected by capacity issues- wait to examination by the number of scanning slots available and- wait to report by the number of consultant radiologists available to perform this task.

Graph 1 below shows how the difference between MRI scanning capacity (number ofpatients that can physically be scanned per week) and waiting list demand has created ashortfall which currently stands at an average of 22 patients per week:

NHS HIGHLAND • RAIGMORE HOSPITAL

MRI Demand and Activity - WeeklyApril 2012 to March 2013

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Demand Activity Average Demand Average Activity

Source: Referrals & Activity extracted from RIS Author: Sammy MacDonald, Service Planning Department

Graph 1 – Difference between capacity and demand in MRI

Graph 2 below shows how the use of outsourcing for reporting of any appropriate case over10 days old, coupled with additional reporting locally, has resulted in a downward trend, thespike in January caused by the ‘See and Treat’ orthopaedic MRI cases and additional CTweekend lists.

bmitc01

TextBox

Highland Health & Social Care Committee 1 May 2014 Item 5.1.4(4)

2

Cross Sectional Imaging - Weekly Reports Outstanding

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Graph 2 – Backlog of CT and MRI reports

Barium cases are few in number and reported within a week, and Ultrasound cases arereported predominantly by the sonographers within a day or two of the examination takingplace, and therefore these two modalities are consistently within the 6 week target.

Current performance

The time spent waiting to perform and report the examination is reviewed weekly.

On April 22nd 2014 the waits and reporting performance* were as shown below:

No. waiting 4weeks or less**for scan

No. waiting over4 weeks** forscan

% (number)unreportedafter 1 week

% (number)unreportedafter 2 weeks

CT 218 123 30% (30) 10% (10)MRI 293 85 34% (57) 10% (16)Barium 7 2(non-

responders)20% (2) 0% (0)

Ultrasound 760 41 4% (1) 0% (0)

*The above data has not been adjusted to reflect patient choice in appointment date** 6 week cut off for ultrasound

The data above shows that on April 22nd 2014 there were 208 patients for CT and MRIbreaching the internal 4 week target waiting to be scanned, compared with 400 and 216presented in the January and March reports respectively.

Graphs 3 and 4 below show performance for both scanning and reporting for outpatientsagainst target:

3

CT Run Chart (Completed Waits) 2013-14

Outpatients only

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Graph 3 – Completed waits for CT patients (reported in month)

MRI Run Chart (Completed Waits) 2013-14

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Graph 4 – Completed waits for MRI patients (reported in month)

4


Taking each modality in turn the action plan to bring performance up to standard is asfollows:

CT & MRI1. To continue to outsource to Medica Reporting Ltd, such that no case will go longer than

14 days unreported. Those cases deemed inappropriate for outsourcing (for clinical oroperational reasons) will have to remain in house and the time to report monitored, suchthat local resource can be targeted appropriately.

2. In parallel with the above to continue recruitment efforts. Outsourcing will be used asbackfill as required, to ensure lack of substantive posts does not compromise thereporting performance.

3. Ensure that the rota that was implemented on March 3rd 2014 delivers consistently thebenefits that were anticipated.

4. Continue to explore the options for greater utilisation of Caithness and Belford capacity.Uplifting capacity at the Rural General Hospitals to allow 9am to 5pm scanning Mondayto Friday would require utilisation of bank staff at Caithness General (cost approximately£400 per week) and a locum radiographer at Belford Hospital (cost approximately£1,500 per week) – either option would deliver the scanning of around 20 additionalpatients per week.

5. Identify additional capacity in other Board areas for the specialist examinations such asmusculoskeletal (MSK) ultrasound and arthrograms. The numbers for these exceedlocal capacity and thereby cause patients requiring such techniques to wait longer thanis desirable.

6. Increase the number of sessions for cases requiring general anaesthetic. Currently only6 such scheduled scans per month can be provided (3 per fortnight), with the next freeslot often being more than 4 weeks in the future, so discussions are underway with theanaesthetic team to assess the available options to allow an increase either in length ornumber of sessions.

Barium & UltrasoundAs noted above, barium and ultrasound examinations are comparatively small in numberand reported within one week and one to two days respectively, allowing consistentachievement of the 6 week standard for 98-100% of cases. Prolonged wait of 4-6 weeks forultrasound appointment can on occasion happen for musculoskeletal (MSK) cases whichare performed by consultants but the almost immediate reporting mitigates the effect.


Scanning capacityImplementing an extended working day in the MRI section was recognised during theRPIW as the best means to ensure all patients are seen within the target of a maximum 4weeks wait. The rota has been in place since March 3rd 2014 and has delivered anaverage of an additional 30 scans per week, such that all new appointments (other thanthose requiring a general anaesthetic or other co-dependency) can be delivered within a

5

period shorter than 4 weeks. However similar work is required to deliver improvements inCT performance, as without it there will be a requirement for ad hoc additional sessionseither locally or at the RGHs.

Reporting capacityThe most noticeable impact, until recruitment to vacant posts is successful, will continueto come from use of outsourcing, which delivers a far greater degree of control overbacklog size (and departmental performance) than previously. This also includes use oflocal radiology consultants delivering reporting sessions out with their defined job plans.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (i.e. Trajectory)

An element of outsourced reporting will be continue to be used on an ongoing basis, allcases meeting the appropriate criteria unreported after 10 days will still be allocated tothis pathway. Should the desired maximum wait for report be reduced then this can bereflected in the protocols put in place within the department although until consultantnumbers are stabilised this would be challenging.

Waiting times for scans however will not improve until the capacity issues have beenresolved. The formal rota change on March 3rd 2014 is designed to achieve this in relationto MRI, and the graph below shows that the number of patients waiting over 4 weeks hasimproved substantially. However the projected reduction of this number to zero has notyet happened due to the issues of cases requiring general anaesthetic and thoserequiring a technique (such as an arthrogram) which is only delivered by a single-handedspecialist at Raigmore. These two scenarios apply to 9 out of the 12 patients currentlywaiting more than 4 weeks, and clearly these patients will benefit from the work that isongoing to address the capacity issues.

Number of MRI patients waiting >4weeks

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Graph 5 – Number of MRI patients waiting more than 4 weeks for scan

6

CT performance: similar analysis of caseload type is ongoing for CT patients. Additionalcapacity being provided at the RGHs would allow the number of patients waiting morethan 4 weeks to be brought to zero by allowing the more specialised examinations (suchas CT-guided biopsies) to be performed at Raigmore in a more timely manner, but in theabsence of a capacity increase (whether by ad hoc means or a structured, formalapproach) the number of patients waiting more than 4 weeks is at risk of at bestremaining static or indeed rising along with demand.

Highland Health & Social Care Committee1 May 2014

Item 5.2

DRAFT ACTION PLAN

Assynt House

Beechwood Park

Inverness IV2 3BW

Tel: 01463 717123

Fax: 01463 235189

www.nhshighland.scot.nhs.uk

PROFESSIONAL EXECUTIVE 27 FEBRUARY 2014 – 9.00 am

Present:Paul Davidson (PD) [In the Chair]Rod Harvey (RH)Alison Hudson (AH)Deborah Jones (DJ)Linda Kirkland (LK)Gill McVicar (GMcV) – by VCKen Proctor (KP)Nigel Small (NS)Cameron Stark (CS)

In Attendance:Ron Coggins (RC) – Item 3.1Eric Green (EG) – ItemNick Kenton (NK) – ItemMargaret Moss (MM) – for Katherine SuttonLorraine Power (LP)Norman Sutherland, Buchan Associates (NSu) – Item

Apologies: Helen Bryers (HB), Brian Robertson (BRb), Ian Scott (IS) and Katherine Sutton.

SUBJECT REPORT

1. ACTION PLAN – PROFESSIONAL EXECUTIVE COMMITTEE – 19 DECEMBER2013

1.1 The Action Plan was approved.

2. MATTERS ARISING / UPDATES

2.1 There were none.

3. MAIN TOPICS

3.1 PAN-HIGHLAND GENERAL SURGICAL SERVICES

The Chair welcomed Ron Coggins to the meeting. RC spoke to the Committeeregarding General Surgical Services in NHS Highland. He advised that therewere a lot of views as to how surgical services in the North could change andhighlighted that there had been some discussions with clinical colleagues in theNorth of Scotland. Some of the issues raised during RC’s presentation included:

Delivering the generality of surgery. Provision of emergency surgical services Provision of general elective surgery (e.g. hernia, gall bladder) The need to change the way surgical as a speciality views itself – there

were increasing sub-specialities (breast, vascular etc.) leaving a visible gapin relation to more basic general surgery.

It was emphasised that the current exercise was not “Raigmore-centric”and was Pan-Highland.

There were currently 13 consultant surgeons in Raigmore – 3 Breast, 3Vascular, 4 Colorectal, 2 Upper GI and 1 General. However only 3 of theseconsultants were currently delivering the whole generality of surgery.

Mention was also made of the need for consultants to undertake a certainnumber of cases to remain competent.

2

Regional solutions could be considered e.g. with Elgin in Grampian In patient emergency care could be concentrated on one site staffed by all

surgeons with one on-call rota for Raigmore, Belford and CaithnessGeneral. This would allow the peripheral sites to rationalise activities andconcentrate on delivering elective care.

It was recognised that the current situation had not been planned but hadevolved and that this would need to evolve further to accommodate theadditional sub-specialties on site at Raigmore.

There was a possibility of moving some of the generality of surgery to theperiphery

The PEC welcomed the opportunity to discuss this issue in detail and endorsedthe direction of travel. It was remitted to RC give further consideration to theissues highlighted and aim to gain further support for the proposals, prior toreporting back to the June meeting of the PEC.

ACTION PEC endorsed the direction of travel regarding this issue.

Remitted to RC to consider further, gain support for the proposals andreport back to the June meeting of the Committee.

RC – PEC 26/06/14

3.2 NHS HIGHLAND CLINICAL STRATEGY – HEALTH & SOCIAL CARESERVICES FIT FOR THE FUTURE

DJ spoke to the report advising that Margaret Somerville was seeking feedback totake the document to the next stage in crafting a strategy which could also beused as guiding principles. Prior to discussion the PEC agreed that there was aneed for such a plan and that this would need to be supported and championed.

Some of the issues highlighted included:

AH advised that there were a number of areas of work ongoing which werenot captured in the draft action plan and confirmed that she would feed thisback to MS.

It was generally felt that 22 pages for a strategy was too long and that thestatements detailed in section 2 – under “Principles for the development,provision and delivery of service models of care” (paragraphs 1-15) moresuccinctly described what was required.

It was agreed that the final document should be short, concise and clinicallyfocussed while highlighting the need for transformational change.

This could then be backed up by a more detailed strategic plan which wouldinclude individual action plans for the operational units.

There was a need for clinicians to be sited on this document and to haveownership of it.

ACTION To feedback comments / suggestions and proposed amendments toMargaret Somerville

Margaret Somerville to be invited to attend next meeting of the PEC todiscuss this item further.

DJ

MS – PEC 24/04/14

The PEC adjourned at 10.40 am and reconvened at 10.50 am

3.3 GREATER INVERNESS MASTER PLAN

PD welcomed Nick Kenton, Eric Green and Norman Sutherland to the meeting topresent this item. NK spoke to the report outlining the progress to date andproposed way forward in relation to the Greater Inverness Masterplan. Clinicaladvice was sought from the PEC regarding broad principles defining the type ofserviced that need to be delivered at the Raigmore site, and this would need to beframed within the clinical strategy. A guiding principle which was suggested wasthat only “acute episodic care” should be delivered at the Raigmore site.

3

NSu outlined the stages of the process: Understanding of the estate we have, and where. Vision of how this could change in the future and identifying the best fit for the

future. What can be achieved in the short-term (2-3 years) and the longer-term (10-

15 years).

EG highlighted that there were some constraints relating to PFI properties such asNairn, Invergordon and New Craigs. CS emphasised the need to adopt Leanprinciples when considering any redesign of services.

PD asked how the PEC could help with this area of work. NSu advised that PECcould assist in agreeing the definition for services to be delivered on the Raigmoresite and support the strategic direction of travel. He also suggested that PECmight have a key role in agreeing weighting for the options appraisal, in reviewingany options and supporting the formal option appraisal process.

There was some discussion around the definition. PD asked if everyone wascomfortable with the term “acute episodic care”. CS suggested that there was aneed to include something about the intensity. KP suggested that there wasreference to “specialist” care. AH suggested the use of the definition of acute caregiven in the previous report by MS (in section 3.2 of the report). This suggestedwas endorsed and it was agreed that there should be further clinical discussionbefore a further report was submitted to a future meeting of the PEC.

ACTION To finalise definition as endorsed by PEC.

To ensure there is further clinical discussion prior to a further reportbeing submitted to a future meeting of the PEC.

NK / EG

NK / EG – FuturePEC – Date TBC

3.4 CANCER SERVICES – SCOPING DISCUSSION

DJ spoke to the circulated report. It was noted NHS Highland faced significantOncology service sustainability challenges for an ongoing period ahead. Theissues related specifically to workforce challenges that had severely impacted onthe Consultant group and also other key workforce teams. These challenges werenot specific to NHS Highland and there had been urgent regional and nationalreviews from 2013 onwards. DJ advised that alternative options were currentlybeing looked at. PD noted that the update to this meeting was for information onlyat this stage and suggested that a further report should be submitted to the nextmeeting of the PEC.

ACTION Further report to be submitted to the next meeting of the PEC. DJ / DerickMacrae – PEC

24/04/14

4. FORWARD PLAN

4.1 There was some discussion around the forward plan. DJ confirmed thatoperational units should be able to submit items for the agenda and askedDirectors of Operations and Clinical Leads to give thought to any issues thatwould require a decision by PEC or that PEC might need to be aware of.

GMcV suggested that when the notes of the meeting were issued that this shouldalso include a note asking for potential items to be submitted by a relevantdeadline.

Items currently identified on the forward plan included:

24 April 2014 Cancer Services – Deborah Jones / Derick Macrae

26 June 2014 Pan-Highland General Surgical Services – Ron Coggins

4

Future Meeting – TBC Greater Inverness Masterplan Clinical Pathways

ACTION DOOs / Clinical Leads to consider relevant issues for consideration atfuture meetings of the PEC.

DOOs / ClinicalLeads

5. AOCB

5.1

5.2

Terms of Reference for Professional Executive Committee – it was agreedthat LP would circulate the Terms of Reference, approved at the December 2013meeting, to all members for information.

Lead Social Worker Representative – it was noted that Brian Robertson, Headof Adult Social Care would retire on 31 March 2014 and it was agreed that arequest would be submitted for a depute to attend PEC committee meetings untilthis vacancy was filled.

LP

LP

6. DATE OF NEXT MEETING

6.1 The next meeting will be held on Thursday 24 April 2014 at 9.00 am in the BoardRoom, Assynt House.

The meeting closed at 11.45 am.

Highland Health & Social Care Committee1 May, 2014

Item 6.1(1)

NORTH AND WEST OPERATIONAL UNIT REPORTReport by Gill McVicar, Director of Operations

The Committee is asked to Note the content of the report.

IntroductionThis report will provide an overview of activity in the Unit and will highlight key pieces of workand areas of concern.

1. Financial Position

Although the final position is yet to be verified, the N&W Operational Unit's financialperformance is showing a year-end overspend of £1.579m, an improvement of £121k fromlast month. This comprises an increase of £114k in Health offset by a reduction of £235k inAdult Social Care.

As previously reported, the main pressures in Health budgets are within OOH (£885k) andMedical locums at Caithness General Hospital (£599k), Belford Hospital (£199k) and ChronicPain Service (£81k) as well as costs relating to 4 vacant practices in N&W accounting for£500k of the current pressure. It can be seen that significant effort by staff and managers hasprevented a worse position. The pressure areas highlighted will necessitate significantredesign to bring back in line.

Adult Social Care is showing an improvement of £235k mainly because of VAT recoverablebenefit from the Centre £153k and an improvement in staff costs.

2. Waiting Times Targets

2.1 Belford HospitalWaiting times within the control of Belford are being met. However, there continues to be anissue with the visiting services, in particular, orthopaedics, chest and radiology.

Belford is piloting real time admissions on the new Patient Management System (PMS)which means nursing staff are admitting, discharging and transferring patients on the systemand this is progressing very well .

2.2 Caithness General HospitalReal time reports have been difficult to achieve due to the new PMS system. However,endoscopy continues to be problematic and is the subject of a Rapid Process ImprovementWorkshop planned for May.

2.3 Chronic PainThe challenging Consultant staffing situation continues. The waiting times targets for newpatients are being achieved through additional sessions, over booking and therefore overrunning sessions and a massive amount of goodwill from the staff concerned. None of this issustainable or affordable within the present budget. In addition and very worrying, is that theachievement of waiting times targets for new patients is at the expense of return patients andwaiting times for them is now at an unacceptable level. It must be stressed that this is a

chronic and not an acute service and by its very nature, will have a high return rate. Thesituation in North Highland is currently exacerbated by the fact that one of the Consultants iscurrently not available to work and it has been difficult to find suitably experienced locums.There appears to be a national shortage of staff in this specialty.

3. Delayed Discharge

The situation in the North has been gradually improving with the lifting of embargoes in CareHomes. However, there are still people awaiting places for whom the only alternatives are ata considerable distance and for whom there are clinical and family reasons that interimplacements would not be considered to be appropriate. A re coding exercise has thereforebeen undertaken and this has further reduced the delayed discharge numbers. However, theindividuals are still in hospital which is not the best place for them to be and every effort isbeing made to expedite their transfer as soon as care home beds in the area becomeavailable.

The as yet unverified position at the April census date was that there were no people waitingfor more than 28 days for discharge.

4. Review of Adult Services, Caithness

The working groups are continuing their work and will report out at a Reference Groupsession chaired by the Director of Operations at the end of April.

In order to achieve better patient flow in Caithness General Hospital, some physical layoutchanges are required. To assist with this, Healthcare Planners visited the area for two daysrecently, they met with staff and assessed the available facilities. Their report is awaited butalready they have made some suggestions that could be implemented relatively quickly thatwould help to improve the flow and use of space.

5 Obstetric Services, Caithness General Hospital

Although the staffing situation is unchanged, the contingency plan has not had to be put inplace.

Short term locum cover is in place April / May for vacant Consultant Obstetrician post andsubstantive post out to advert.

A full time midwifery post also out to national advert, trying to attract experienced midwives toarea. Midwifery staffing level is stable meantime with low staff absence / sickness rate.

Recruitment and retention issues have been identified as an issue for Highland council aswell as health teams in the Caithness area more generally and discussion has taken place inthis regard at the Caithness District Partnership and with the Trades council.

Due to the ongoing challenges, a working group will be established to review and makerecommendations for the future.

6. Skye, Lochalsh and Wester Ross Redesign

The NHS Highland Board agreed that the recommendations of the Steering Group and thepreferred location of a new build ‘Hub’ constituted major service change and approved therequest to move to formal public consultation together with the draft consultation materials.

Although a preferred site in Broadford is land already owned by NHS Highland adjacent tothe new Health Centre and Care Home, further work has been done on other possible sitesand a site appraisal workshop is planned for the end of April. Following this the consultationprogramme will be developed and the consultation launched in Mid May.

7. Riverbank Medical Practice, Thurso

The process of changing the Practice to being salaried to NHS Highland is underway. It hasalso been an unsettling time for the Practice Staff, who have continued to provide anexcellent service to patients in very difficult circumstances. The decision to move to thesalaried option will give them some job security and allow for a review of terms andconditions to bring them into line with other NHS Highland staff.

We have been very fortunate in the calibre of locum Dr and the continuity that they havebeen able to provide in the Practice and we are indebted to them for their commitment. Workis currently ongoing to develop a job description for Salaried GP’s working at Riverbank andwe plan to go to advert shortly. The practice will also be advertising shortly for a permanentPractice Manager, who will manage the day to day running of the practice and lead theongoing Quality Improvement work.

Significant development work has already been undertaken in the practice with the support ofthe GPs and practice staff, since the Operational Unit took over, including reviewing andamending the appointment system, the introduction of online ordering of repeat prescriptions,the introduction of serial prescribing, the introduction of INR testing and dosing in thepractice, the introduction of regular visits to the Care Homes and a weekly ward round at theDunbar Hospital, and a Patient Participation Group (PPG) has also been established. Theabove has been done in addition to the normal day to day care provided to patientsregistered with the practice by the GPs and Practice Nurses.

The PPG first met in June 2013 after an open day in the practice in March and a publicmeeting was held in May 2013 to explain to patients how the practice was currently runningand to identify patients who were interested in being part of a PPG. After several initialmeetings the PPG formed a committee with a chair, vice-chair and secretary and developedthere terms of reference.

The PPG ran a patient survey during November to gather patients views on the servicesprovided by the practice, and have then worked with the practice and the Operational Unit toidentify areas for improvement. The main area of concern from patients was regarding aperceived lack of ‘continuity of care’ and the practice is working hard to ensure that patientsare aware of who the regular doctors are that are currently working in the practice, and thatthey are able to see a doctor of their choice if they wish. Although the GP’s working in thepractice are locum’s i.e. not permanently employed by NHS Highland the majority of themare working there on a regular basis (although not necessarily every week) and are keen toensure a high level of care to patients.

The PPG has been successful in getting funding from RCOP (Reshaping Care for OlderPeople) to publish their first newsletter, which will be available to patients from mid April andalso received funding to pay for a venue for their first Open meeting on 1st May. Furtherinformation regarding the PPG including terms of reference, results of the survey andminutes of PPG meeting are available on the practice website. www.riverbankpractice.co.uk.The PPG also has a facebook page (Riverbank PPPG), and is on Caithness.org. If patientswish to contact the PPG they can through the practice website or through the suggestionslips which are in the waiting room at the practice. The PPG will continue to work with thepractice and Operational Unit to improve services to patients.

8. Care at Home

We are delighted to welcome the Care at Home staff following the devolution of the serviceto the Operational Units on 1st April. This is a tremendous opportunity to further integratefront line services and to better support and develop the Home Care staff who will now bebased where possible with the integrated teams.

The Care at Home Managers have been appointed, Gill Brown for West and Andrea Maddenfor North and they will report to the Area Managers.

9. Integrated Team Working

9.1 There is a Highland wide group looking at this to ensure the Personal Outcome Planningpaperwork is fit for purpose, this continues to be tested as it changes in the pathfinder sites.

9.2 District Care Planning (DCP) meetings are being embedded in all District Teams acrossNorth & West. These meetings pull together all professional groups to look at dischargeplanning, recourse allocation and discussing support for vulnerable adults in the community.

9.3 Self Directed Support (SDS) as of the 1st April 2014 it has been a legal requirement tooffer SDS to everyone being assessed as requiring a social care service. This work isclosely linked with PoP as this focus on person centred outcomes. Training for all staffgroups is ongoing at this time. With regard to Resource Allocation System (RAS) with givesan indicative budget this work also requires completion. The work on this is also linked withmaking changes to Care First system which will accommodate the RAS and the PoPpaperwork.

10. The Care Experience

10.1 Care Assurance

This work is supported by the standards are based around the Clinical Standards for OlderPeople in Acute Care (2002). The OPAC self assessment documentation has beencompleted for Belford, CGH and MMH and inspections are now anticipated this year. Northand West Area OPAC MDT Practitioner Groups have been established in order to ensure thehospitals are prepared. This will require focus of attention on dementia training and personcentred assessment and care planning and ensuring the environment is dementia friendly.

Whilst the existing programme of observation and formal audits will now focus on the threesites, the N and W Leadership Group which includes all the District Managers will meetregularly to monitor progress and share good practice across all our health and care homesettings.

10.2 Lanarkshire ReportThe Lead Nurse has reviewed the Lanarkshire report for the Patient Safety and QualityGroup and as part of this process has benchmarked the operational unit against the findingsof the review. Some similar themes to the Francis report are evidence which will inform theOPAC and person centred programme which are work streams which will directly influenceexperience of care and are being incorporated in the updated Delivery Plan.

10.3 Tissue Viability

10.3.1 Measuring Improvement – From the middle of 2013 with the appointment of twoAdvanced Nurse Practitioners in Tissue Viability one in Raigmore and one in primary carethere have been enormous strides forward. An OPAC assessment of Raigmore hospital

reported favourably in relation to pressure ulcer prevention. There is strong evidence of theimpact of these roles for example admissions to Raigmore hospital due to pressure ulcershas reduced by 87% in a year, there have been no serious events or deaths for over 850days, grade 3 /4 pressure ulcer development post admission has significantly reduced. Asimilar picture is emerging in north Highland although the community post has been in placefor a shorter duration with the fixed term contract ending in August.

10.3.2 Summary of the Advanced Nurse Tissue Viability Key Activities1. Acts as the first point of contact for the majority of wounds which require a specialist

review2. Reviews all DATIX for pressure ulcers and reviews all significant cases as a priority.3. Involvement with the audit of the National Pressure Ulcer Programme.4. A team member of the NHSH roll out of Negative Pressure Wound Therapy policy

and equipment release.5. Is a key member of the Complex Wound Registry for NHS Highland6. Leading the training of health and social care staff in the prevention of pressure

ulcers in all health and social care settings.

10.3.3 Evidence

The reduction in admissions due to pressure ulcers is indicative of the use of the telehealthservice being extended into primary care and a collaborative approach between the twoANPS in Tissue Viability and the contribution of the Tissue Viability Advanced Practitioner,Senior Practitioner and SSKIN Bundle Facilitators. The facilitators aim to improve theprevention of pressure ulcers in community. A full evaluation of the impact of these roles isbeing undertaken in order to provide the evidence base to continue the roles in the long term.

10.3.4 Improvement WorkThe progress is the result of improvement work which includes;

The Easy Access e clinic continues and is receiving positive feedback from staff. It has beennoted that as an outcome, the number and frequency of visits by nurses in the community topatients with long standing wounds has reduced as a result of receiving specialist advise onmanagement and treatment.

Staff training in the use of the Talley Pumps –for use with patients who require TopicalNegative Pressure continues. The daily £18.50 hire charge that was applied to each pumpon hire has been removed as a direct result.

10.3.5 Appropriate Pressure Relieving Equipment –The steering group have now agreed to a long term plan which will see NHSH move towardsa ‘3 Tier Mattress System’. Mattresses and cushions will be categorised into A B and Cgrades. A new Mattress selection guide is now available. As noted previously, a shortage of‘very high risk’ mattresses has been identified and £40k has been made available to addressthe shortfall in north highland. However, this is far short of the £150k which was theestimated cost of procuring the required number to both increase and renew the existingstock which is old and requires to be replaced. The Lead nurse has highlighted this risk tothe Patient Safety and Quality Group and the chair of the Highland Clinical GovernanceCommittee.

10.3.6 Training

The Pressure Ulcer Prevention and Compression bandaging/support hosiery trainingprogramme is to be delivered across region early in 2014, topical Negative pressure. Theeducation programme continues to all NHSH care homes.

10.4 Continence improvement workThe continence service review led by the Lead Nurse for North and West unit is now alsofocussing on testing patient first level assessment. This work is being built into the review ofnursing documentation and care and comfort rounds.

The community nursing caseload reviews are providing good evidence of the currentworkload the home delivery service creates for the teams and work is progressing to identifyalternative models of care in order to create capacity.The agreed HAI education programme as a result of the HSE improvement notice continueswith success and uptake is being monitored carefully across Highland led by Lead Nurses

10.5 Scottish Patient Safety Programme – Community HospitalsCurrently the working group is mapping the uptake of SPSP bundles in all communityhospital sites and aims to agree priorities for spread at the next meeting. A learning event isproposed for the summer for community hospital staff.

Other improvement work includes; Chronic Obstructive Pulmonary Disease discharge bundle has been through Plan Do

Study Act cycles in Rosebank Wing CGH. The last test of change now inclusive ofpatient feedback. Once this is evaluated, bundle will ready to be rolled out.The development of the link practitioner role for community will ensure the patient canbe supported in the community following discharge.

11. Infection Prevention and Control

11.1 Hand HygieneHand hygiene audits continue to be undertaken monthly by all clinical areas, the results aredisplayed at ward level and any non compliance addressed.

All 18 departments/wards are consistently reporting compliance of over 95% target acrossthe unit. The average score between October 2103 and January 2014 are shown below.

Table 1 Hand hygiene ResultsMonth Average Hand Hygiene results %Jan 14 to March 14 96%

11.2 Health Care Environment

Health Care Environment InspectionsFollowing HEI inspections to Belford and Caithness General last year the 16 week updateshave been provided to the HEI Inspection Team and all improvements and recommendationshave been addressed.

Domestic Service teams continue to carry out monthly cleaning and estates audits as perNHS Scotland National Cleaning Services Specification. All sites in North and West haveachieved the 90% (with the exception of Lawson) compliance rate for domestic monitoringand Estates Monitoring March 2014as follows.

Table 2 Cleaning audit results March 2014

Dunbar 95.07

Broadford 90.7Lawson Memorial 98.72

Migdale 95.14Portree Comm Hos 94.5

Wick Town & County 94.91

Belford 96Caithness General 95.91

Table 3 Estates audit results March 2014

Dunbar 100

Broadford 91.8Lawson Memorial 92.42

Migdale 98.90Portree Comm Hos 100

Wick Town & County 99.20

Belford 98.0Caithness General 95.95

11.3 Clostridium difficile cases (C Diff)

As previously reported, North and West are investigating why Clostridium Difficile incidenceis not decreasing. A North Area C Difficile Working group has now been established whichhas multi disciplinary engagement and a work plan has been developed which includesmeasures such as a review of prescribing of antibiotics, standards of cleaning andappropriate use of Actichlor.

Table 4 Clostridium difficile cases (C Diff) in North Area year end March 14

CGH LAWSON GP

2013/14 (to date) 8 1 8

2012/13 10 0 11.NHS Highland reports all C diff toxin positives to Health Protection Scotland. Surveillanceshows that North Area figures are not showing a significant increase, however, there has notbeen any decrease from year to year.

Of the cases detected, 4 refer to patients who suffered a recurrence of infection out with thesurveillance protocol cut off of 28 days, so are reported as new infections. 1 patient has had3 recurrent episodes.

3 patients have had previous admissions to Raigmore Hospital within previous 12 weeks.None of these patients have been found to have links during their stays in Raigmore or withany of CDiff incidences in Raigmore.

The community cases are from different locations and no link has been detected related tohospitalisation or other healthcare event. 2 patients had been on holiday prior to symptomscommencing, but not in the same place.

The gentacmycin testing equipment is now in place but not yet being used due to trainingrequirements in CGH. Anti microbial prescribing audits are being undertaken. The situation isbeing closely monitored.

Table 5 Clostridium difficile cases (C Diff) in West Area

MMH Belford GP

2013/140 2 4

11.4 SAB Incidence - Cumulative SAB Positive Totals

There were 7 cases in total (three Rosebank, one in MacKinnon and three in the Belford

11.5 Outbreaks

There have been no recent outbreaks.

12. Maternity Services

12.1 Obstetric UltrasoundOn going difficulties remain around recruitment of ultrasongraphers with required expertise tofulfil the role of obstetric ultrasonography. There is currently no service in Skye, Fort Williamand East Sutherland (Lawson Memorial Hospital). Currently women from all localities travelto Inverness for scanning. Fetal Medicine Unit at Raigmore continue to have significantstaffing challenges therefore for the time being it will not be possible to introduce an outreach service to other localities.

12.2 Maternity & Early Years CollaborativesMidwives are fully engaged in this work as per NHS Scotland requirements with the over all

aim of reducing inequalities and improving clinical outcomes for mothers and babies.Reporting through N&W Quality & Patient Safety Forum, the work links with the FrancisReport , Scottish Patient Safety Programme and Person Centred Care. Examples of workbeing currently being undertaken by midwives in the operational unit are:- CO2 monitoring forall pregnant women, Reduced Fetal Movement Leaflet, Hypno-birthing Service, Trial / Pilot ofthe revised NHSH Antenatal Plan through joint working with Children’s Services / HighlandCouncil, Community Midwife Assessment Unit, Invergordon.

12.3 Education & TrainingMidwives and all other health care professionals involved in maternity services within N&Wattend regular obstetric & neonatal emergency training in order to minimise risks of untowardevents. Links with Risk Management in general. Sessions are well attended and evaluation ispositive. Training & Practice Development Midwife (Sarah McLeod) is working on thedevelopment of LearnPro modules to allow easy access to learning materials to furtherimprove knowledge & skills.

12.4 Community Midwifery Units (Skye & Fort William)Both units continue to provide birth option for low risk women. Fort William have delivered 18women so far this year, which is above average.

Skye service have not only provided birth option in Broadford but also had several successfulhomebirths.

Skye Midwifery team has recently developed an on line user group and now have aFacebook page which is well used by local women.

12.5 Community Midwifery ServicesAs above – similar challenges around provision of on call for homebirth.So far in 2014 there have 2 homebirths in Wester Ross & Skye a further request has beenreceived for Skye.

Community Midwifery Day Case Unit, located in County Community Hospital in Invergordonprovides a good option for women to receive care locally rather than have to travel toInverness. Midwives work closely with Obstetric/Midwifery colleagues in Raigmore. Althoughresource is located within S&M Operational Unit women from Sutherland use the service andit is therefore a good example of collaborative working between midwifery teams across theOperational Units.

12.6 Health Visiting Service – Sutherland AreaThere are currently vacant Health Visitor posts and staff sickness, with only one HV coveringSutherland area. This is impacting on midwifery work load and discharge to HV care in postnatal period. There is ongoing liaison between health and council managers re contingencyplan.

A Health Visitor post is out to advert although recruitment is not proving successful as yet.

12.7 National Midwifery Workload ToolThe Tool has been ratified by the Scottish Government and the first national run will takeplace this year July – September. Mary Burnside, Lead Midwife (North) sits on the nationalmaternity working group and is leading on training of midwifery teams and implementation inNHS Highland. Midwifery teams are becoming familiar with the use of tool on SSTS and willhave ongoing opportunities to give feedback to the national working group regarding itsapplication for remote and rural practice.

12.8 NHS Highland Maternity Services DashboardThe electronic tool is now fully operational, capturing varied data around numbers ofbookings, births, breast feeding rates etc. throughout NHSH. Also captures data on untowardevents, therefore flagging up trends. The tool requires modification for Community Midwiferyuse and Lead Midwives are working on this with IT colleagues.

12.9 Midwifery SupervisionSupervisors of Midwives within N&W continue to ensure that the function is carried out as perstatutory requirement. Recent Annual Local Supervising Authority audit held in Inverness on25th March was very successful with an expected excellent report from Mary Vance, LocalSupervising Authority Midwifery Officer. Mary Vance also visited, on an informal basis, toHenderson Wing, CGH and the Caithness team, where useful discussion took placeregarding the service model and recent challenges re obstetric staffing.

13. Self Management

The” Let’s Get On with It Together” Partnership continues to work with NHS Highland toembed a culture of self management through support to implement the NHS Highland SelfManagement Strategy & Action Plan. Activity includes:-

· Lay led training to promote self management with health professionals has beendeveloped and will be tested in April

· Work with Living it up Highland to develop an information directory supporting selfmanagement

· Development of self management ambassadors in community to support lay lededucation and peer support

14. KSF (Knowledge and Skills Framework)Social Care staff are being encouraged to engage with KSF as an alternative to the Councilsystem, this work is ongoing as post are matched into the systems which also accommodateContinuous Learning Framework (CLF) which is a social care requirements.

15. Administrative and Clerical ReviewAdministrative and Clerical staff are crucial to the smooth running of both clinical andmanagerial business. A review has been ongoing for some time and it was decided to hold athree day Kaizen event to expedite the process. It was clear from observations that therewas duplication and variation in how the support was being delivered across the Unit andalso inequity of provision. Work to identify waste was enlightening and all areas have beenusing the waste wheel and 5S to improve the working environment. There is an ongoingtraining programme to ensure that all staff are aware of the tools and methodology.

Day 1 of the Kaizen event, led by the Director of Operations, was used mainly for teachingon the Lean methodology from Virginia Mason and Days 2 and 3 were intensive and focusedon achieving outcomes. The event was very successful and produced a robust action planwith some key work streams which the team will report on in 30, 60 and 90 days. We arevery grateful to the Admin team who support the Board Nurse Director, who willingly sharedtheir experience of a Rapid Process Improvement Workshop and the outputs from thatwhich, some of which we will implement immediately.

16. Delivery Plan

The monitoring section of the 13/14 Delivery Plan has been being reviewed by the UnitSenior Management Team and will be presented at Committee as requested.

The Plan for 14/15 is in development and is being cross referenced to the draft NHSHighland Improvement and Co Production Plan. The key aspects will also be presented atCommittee.

Gill McVicarDirector of Operations23rd April, 2014

Highland Health & Social Care Committee1 May 2014Item 6.1(2)

SOUTH AND MID OPERATIONAL UNIT : QUALITY AND SERVICE PLANS 2013/14

This paper represents the End of year Up-date on the key aspects of the Unit development plan. The up-date columnindicates a high level, headline summary of the position against each action.

ItemOperational

DeliveryRequirements

Timescale Lead Risks Finance Links Updates

1. Focus ondevelopment ofIntegrated Teamsand maximise useof combinedresources inDistricts

Recruitment ofDistrict Managerposts complete.Aim for fullintegration andco-location of allDistrict Teams byMarch 2014

Unit ManagementTeam

Ability to deliversavings along withservice redesign.

Ability to co-locateteam members

Re-design to bedelivered withinexisting budgets

Key requirementof Adult ServicesIntegration

Pathfinder sitesfunctioning andteams co-located in NairnandInvergordon.Dingwall teamto be co-locatedin New HC fromMay 2014. Co-location plans inplace forInvernessEast/West.PersonalOutcome Planbeing ‘tested’ inInvergordon.All deliveredwithin existingbudgets. Lackof budget forintegration hasbeen a problemespeciallyaround IT andOffice moves.

2. Care Homes:Takemanagementresponsibility andintegrate into Unitstructure

CommencesApril 2013

DOO/Head of AdultSocial Care

Requires robustcommunicationsaround staffing,financial andservice deliveryrequirements

Change ofresponsibility tobe deliveredwithin existingbudgets


Transfer ofmanagementresponsibilitysuccessfullycompleted. CareHomes now partof Unit’sOperationalBusiness. Unithas 3 managedcare homes.Work underwayto reviewstaffingstructureswithin CareHomes

3. Care at Home:Takemanagementresponsibility andintegrate into Unitstructure

Commencesearly 2013/14

DOO/Head of AdultSocial Care

Requires robustcommunicationsaround staffing,financial andservice deliveryrequirements

Change ofresponsibility tobe deliveredwithin existingbudgets


Delay indevolution toOperational Unitdue to CareInspectoraterequirements.Transition Plandeliveredrevisedmanagementstructure andintegration on 1April 2014.RPIW completedon Care atHome Pathway.

4. Progress thedevelopment of asingle hospitalsite solution inBadenoch &Strathspey

Initial AgreementSummer 2013OBC / FBC 2013– 2015

Completion /Occupation2016/17

DOO Potentialrequirements forHUB ‘bundle’

Identification offundingmechanisms

Identification ofsuitable site

Potential toachieve withinbudget

Eradicatessubstantialbacklogmaintenancecosts

Achieves HQArequirementsand meets needto modernisehealthcarepremises

DevelopmentGroup has metregularly. 6PublicWorkshopsheld. Locationand sitesidentified.Publicconsultationcommences inApril 2014.

5. Progress the newTain HealthCentredevelopment

Constructionstarts July 2013

Completion dueJuly 2014

DOO Impact ofproblems withother schemeswithin ‘bundle’.

Board has agreedFull BusinessCase (FBC)

Meets HQArequirements

Building worknowcommenced andon target forcompletion andhandover in May2014.

6. Progress the newDrumnadrochitHealth Centredevelopment

Consultation anddevelopmentunderway.

Completion due2015

Area Manager(South)

Governmentwithdrawal offunding (low risk)

Land donationwithdrawn (lowrisk)

Board has agreedOutline Businesscase (OBC)

GovernmentCapitol moniesallocated andavailable


Site/location ofnew buildidentified.Planningpermissionrequested.Funding inplace

7. Progress tocompletion thedevelopmentwork at DingwallHealth Centre

Start on site July2013

Completion dueFebruary 201

Area Manager (Mid) Governmentwithdrawal offunding (low risk)

Board has agreeOBC

GovernmentCapitol moniesallocated andavailable


Work almostcomplete.Handoverplanned for May2014

8. HighlandRheumatologyUnit Redesign:Work withRaigmoreHospital tosupport serviceredesign andmaximise bedflexibility at RossMemorial Hospital

Additionalconsultantappointment2013

Refurbishment byOctober 2013

Revised serviceoperational byMarch 2014

Area Manager (Mid) Failure to appointnew consultant

Delays inrefurbishment ofexisting building

Financial plans tobe identified anddeveloped early2013/14

Supports theobjective ofdelivering ‘carecloser to home’and maximisinguse ofcommunityservices

Publicengagementgroupestablished andreviewing use ofsite. Workunderway toplan transfer ofRheumatologyservice fromRaigmoreHospital.

9. Work withHighland Hospiceto developoperational plansfor temporaryservice decant toCountyCommunityHospital,Invergordon

Develop transferand transitionplans 2013/14

Hospice to usevacant FyrishWard for servicedelivery: 2015

Area Manager (Mid) Withdrawal ofproposal byHighland Hospicecould mean longterm vacant spacein PFI site.

No additional costto NHS Highland

Supportspartnershipworking

Detailed plansand formalagreement inplace withHighlandHospice

10. EstablishVasectomyService at NairnHospital as partof initiative tomaximise use offacility

Developmentwork withRaigmoreHospitalunderway.Service tocommence May /June 2013

Area Manager(South)

Withdrawal ofservice byRaigmore Hospital

Minimal additionalcosts to besupported viaRaigmoreHospital

Supports theobjective ofdelivering ‘carecloser to home’

Frees upRaigmoretheatre space

Work is atdevelopmentstage includingidentification ofcosts andpotentialactivity. Focuson vasectomies.GPs completedtraining andready tooperate.

11. Introduce revisedmedical covermodel at RNI,Inverness

CommencesMay/June 2013

District Manager Potential inabilityto recruit.Potentialdisengagement byPractices

SLA developedwith keyobjectives linkedto total availablefunding

Supportsdelivery of HQA

New medicalcoverarrangementscommenced on1

stSeptember

2013 andfunctioningsuccessfully.

12. Day Hospital /Day ServiceRedesign:Develop single,unified service inInverness to meetusers health andsocial care needs(York DayHospital andMacKenzieGardens)

Single combinedservice byNovember 2013

District Manager Charging andaccess issues tobe addressed

Redesign to bedelivered withinbudget

Meets AdultIntegration andHQArequirements

LEANmethodologyused acrossHealth andSocial Careservices inInverness.Unified servicein place andused as goodexample ofeffectiveintegratedworking. Workcommenced tolook at co-location ofservices.

13.Complete ElderlyMental HealthService RedesignInitiative

Initiativesunderway

Full completionby December2013

DOO/Mental HealthProject Manager

Delay inimplementingrevised bedconfiguration

Requires somecommunity re-investment ofresourcesreleased byclosing ElderlyMental Healthbeds

Supportsachievement ofSG MentalHealth Strategy

Fyrish Ward,Invergordonformally closedand investmentin communityservicescompleted.Additional bedcapacity forElderly MH atNew Craigsagreed as partof wider bed re-configuration.

14.Complete MentalHealth RehabService Redesign

Close one Rehabward at NewCraigs andestablishCommunityRehab Team byAugust 2013

DOO/Mental HealthProgrammeManager

Inability toredeploy staff toother postsDelay inestablishing newteam structure

Requires somecommunity re-investment ofresourcesreleased byclosing MentalHealth Rehabbeds

Supportsachievement ofSG MentalHealth Strategy

New CommunityRehab servicecommencedSeptember2013. 3remaining longstay patientssuccessfully re-patriated intothe community.

15. Review and re-organise ‘FirstContact’ MentalHealth Servicesin NorthernHighland

Implement ‘joinedup’ First ContactMental Healthaccess service byDecember 2013

Mental HealthProgrammeManager

Organisationalchange delaysassociated withre-configuration ofexisting services

Any redesignwould bedelivered withinexistingresources

Links to HQAand MentalHealth Strategy

This initiativehas notprogressed asplanned and issubject toreview of theserviceimprovementmethodology.

16. Further progressPsychologicalTherapiesRedesign

Aim to achieve 18week target byDecember 2014

DOO When full capacityreached withinPsychologicalTherapies

To be deliveredwithin existingbudgets. SomeQuIST moniesbeing used.Possible optionfor use of accessmonies.

Meets HEATrequirement

Significantongoing work toachieve thetarget byDecember 2014.

17.Review andintroduce newSLAs for OOHServices inBadenoch &Strathspey andNairn

Negotiate andimplement byJuly / August2013

Primary CareManager

Failure to agreefunding / SLA withexisting OOHproviders

Financialnegotiations totake place2013/14

2 year SLA inplace with localGPs in B&S forongoing OOHprovision. 1year deal agreedfor Nairn

18. Implement newGMS EnhancedServices acrossthe Unit

Commences April2013

Primary CareManager

Requiresindividualpractices to signand agree SLA

Financialnegotiationsongoing

Aims to supportdelivery ofquality primarycare services

Limitedopportunitiesfor newEnhancedServices.Part of ‘KeepWell’ initiativebeing deliveredvia EnhancedService

19. Implement newSPSP initiativesin Mental Healthand Primary Care

As per NHSHighland /nationalrequirementsthroughout2013/14

MH ProgrammeManager andPrimary CareManager

Potential lack of‘buy-in’ (low risk)

Initiatives to bedelivered withinexistingresources

Links to nationalSPSP roll-out

Both SPSPinitiativesprogressing inline withnationallyrequiredtimescales

20. Maximise impactof Change Fundinvestment, withemphasis onadmissionavoidance, earlydischarge andShifting theBalance of Care

Various initiativesneed todemonstrateevidenced impactby March 2014

Unit ManagementTeam

Cessation offunding in 2 yearsrequiresdevelopment ofexit strategy

Investmentoverseen byHighland widemulti-agencygroup

Links to nationalrequirementsand guidelineson Change Fundinvestment

Various ChangeFund initiativesin place.‘Virtual’ teamfocussing onpatient flowin/out ofRaigmoreHospital.

21. Contribute to andimplementactions arisingfrom Care /Clinical Pathwaysdevelopment

As per NHSHighlandrequirementsthroughout2013/14

ClinicalDirector/ProfessionalLeads/ DOO

Unrealisticexpectations:Requires focus onkey pathways andassociated actions

Financial input tobe assessed foreach pathway

Meets HQArequirementsand ensuresconsistentapproach forservice delivery

Limitedprogress.Further workrequired acrossHighland

22. Implementactions in theOlder Persons inAcute Care(OPAC) ActionPlan

Timescales alldetailed in OPACAction Plan fordelivery in2013/14

Lead Nurse No major issuesidentified

Actions to bedelivered withinexistingresources

National strategy Unit hasdeveloped adetailed OPACplan.

23. Review andrevise relevantVoluntary Sectorand other externalSLAs to ensurealignment withdeliveryobjectives

Dependent onend point ofindividual SLAs.

Progress wherepossible during2013/14

DOO/AreaManagers

De-stabilisation /lack of flexibility tochange amongstproviders.

Large volume ofSLAs

Financial positiononcontracts//SLAsto be agreed witha whole NorthernHighlandapproach

DesignatedManagersidentified foreach SLA

24.Implementrequirementscontained withinNational AHPDelivery Plan

As per national /NHS Highlandrequirements in2013/14

Lead AHP No major issuesidentified

Requirements tobe deliveredwithin existingresources

National strategy Unit Lead AHPpostcommenced inSeptember2013. Key focuson the AHPdelivery planrequirements.

25. Review andredesignhealthimprovementservices toensurealignmentwith deliveryobjectives

Complete by Dec2013

Unit managementteam/PHP/Head ofHealth Improvement

No major issuesidentified

Delivered withinexistingresources

Supportsdelivery of healthimprovementHEAT targets

Re-focus onhealthimprovementand healthpromotinghealth serviceunderway.

Highland Health & Social Care Committee1 May, 2014

Item 6.1(3)

RAIGMORE HOSPITAL OPERATIONAL UNIT REPORTReport by Linda Kirkland, Interim Director of Operations

The Committee is asked to Note the content of the report.

Introduction

This report will provide an overview of activity in the Unit and will highlight key pieces of workand areas of concern.

1. Financial Position

The final 2013/14 year end position for the Raigmore Operational Unit was total expenditure

of £145.3M against a budget of £135.5M, resulting in an overspend of £9.76M (7.2%). There

were four main themes where expenditure exceeded available budgets: locum cover

(£2.8M); provision of additional activity (£2.2M); drug costs (£0.7M) and non-pay costs

(£2.6M). In relation to saving targets, Raigmore achieved their 2013/14 savings target of

£2.47M of which recurring savings totalled £2.35M.

2. Waiting Times Targets

Outpatients

Previous reports to the Improvement Committee showed the number of patients at month

end waiting over 12 weeks and 15 weeks for the Outpatient Waiting Time Target. This report

is not available due to lack of data for Service Planning from the Patient Management

System (PMS).

There are a number of specialties which are problematic. The pressures and actions taken to

address the specialties under pressure are outlined in greater detail under Section 2 below.

Additional temporary capacity was put in to place in pressured specialties in the first three

months of 2014 to reduce the numbers waiting at the end of March 2014. Orthopaedics was

not targeted due to the size of the pressure. The main challenges ongoing continue to be

are ENT, OMFS, Gynaecology and Orthopaedics.

Treatment Time Guarantee (TTG)

The actions that are being worked through to improve the delivery of both the Treatment

Time Guarantee (TTG) and the outpatient waiting times are set out by specialty below:-

Orthopaedics

TTG

Significant pressure within the admissions still exists in orthopaedics, with over 100 patients

with an April breach date unable to be seen within the month of April. In addition to the

existing capacity shortfall a large number of patients who were made unavailable in January

to March, as they did not take up offers at Ross Hall, are now available. These patients have

been prioritised in April displacing patients with April breach dates. Currently the hospital is

utilising all the available sessions within theatre Monday to Friday, however no additional

sessions out with this has been organised. A review of the demand and capacity within the

service is ongoing with a view to establishing the theatre sessions required to meet the

demand.

Outpatients

Significant pressure exists within the outpatient setting of the orthopaedic service, currently

over 600 patients are waiting longer than 12 weeks for their appointment as at March 2014.

As reported previously 300 patients were seen as “see and treat” project with Ross Hall.

Discussions are underway with the Golden Jubilee National Hospital (GJNH) to provide a

see and treat package of another 300 patients to address the outpatient backlog.

There is a piece of work to be conducted in early 2014/15 to assess and rationalise the

peripheral clinic commitments.

Urology

TTG

The pressure with TTG urology patients is a result of pressures with urological cancer

patients. Cancer patients are provided with the priority for theatre space and this has an

impact on patients being seen within their 12 week date. Laparoscopic renal urology

procedures are a particular pressure and only one consultant carries these out. His workload

has been prioritised to concentrate on these cases. Capacity has been sought in the private

sector and at GJNH but there is none available.

Outpatients

There are significant outpatient pressures in return appointments. Return patients currently

wait considerably longer than is clinically desirable. New outpatient waiting times meet the

target but may deteriorate due to the need to convert capacity to return outpatients. Cancer

outpatients continue to be a pressure for the service, urological cancers account for

significant breaches. A review has taken places around pathways and reserving one stop

clinic spaces for high risk cancer cases with the low risk patients being seen in routine

clinics. This in turn will add pressure to the routine new clinics. There has been a review of

provision of TRUS biopsy clinic capacity for prostate cancer patients with a plan to increase

this capacity from June 2014 to 6 lists per month an increase of 2 lists per month on the

current capacity. This should allow the service to maintain a 21 day wait from referral to

TRUS biopsy for urgent suspected cancer patients.

ENT

TTG

To date the TTG position has been maintained with the exception of a very small number of

patients who required to be cancelled at short notice due to urgent patients being prioritised

or cancellations due to bed or theatre staff pressures). This position will become difficult to

maintain in May & June as a result of the additional outpatient clinics held in February and

March.

Outpatients

Delivery of the 12 week waiting time for new outpatients slipped during 2013. This was due

to consultant sickness, retirement and maternity leave. Long term locums were used as

partial mitigation against the impact of these issues. In December the projected position was

that there would be 478 breaches at the end of March. A plan was put in place that cleared

this backlog.

The position for 2014/15 will continue to be challenging as ENT continues to have staffing

issues. One consultant and one Associate Specialist have recently retired. There is one part

time locum consultant in post providing some capacity. Two of the existing consultants have

each picked up an additional EPA to provide capacity. The vacant consultant post is being

advertised for the second time. Work is ongoing with Service Planning to review demand and

capacity and establish the long term requirements for ENT in particular how best to use the

vacant associate specialist post.

Neurosurgery

TTG

Neurosurgery TTG activity is provided in NHS Grampian.

Outpatients

The Neurosurgery service is a visiting service from Aberdeen. During 2013 it was agreed that

new patients should be given 30 mins for an appointment rather that 20 mins and that return

patients should be given 15 mins rather than 10 minutes. This reduced the capacity to see

patients by a third. The new times per patient are in line with national recommendations and

with practice in other areas. Long appointment times are required to reflect the complex and

difficult discussions which take place with this cohort of patients. The service agreement has

to be renegotiated to provide additional visits as it is now challenging to maintain the

outpatient waiting times. There is close work with the visiting neurologists to provide

additional visits on an ad-hoc basis

Plastic Surgery

TTG

The Plastic Surgery service is a visiting service from NHS Lothian. The team provide both

clinic time and surgical day case operating. Due to pressures on theatre capacity it is not

always possible to provide a full second operating list for the Registrar who operates in

parallel with the Consultant. This is leading to pressures in delivering TTG as there is no

flexibility to operate on alternative days due to the visiting nature of the service.

OMFS

TTG

The OMFS department currently has one consultant vacancy out of 2 posts.

Major Head & Neck surgery which takes place at Raigmore has the impact of reducing

operating time for the routine TTG workload. Often this type of patient can be in theatre in

excess of 12 hours. Discussions are underway at North of Scotland Network level to

establish the best quality of service for this category of patient. There are approximately 12 –

15 Highland patients per year who require complex Head and Neck surgery. Due to staffing

pressures in NHS Grampian the NHS Highland consultant also need to support Grampian

with their major cases.

Outpatients

The vacancy is impacting on the ability to provide a service for the routine non-urgent group

of patients. Historically, even before the second consultant left, there was regular use of long

term locums to deliver the waiting times. Agreement has now been reached to develop a job

plan for the vacant post and proceed to advert. However, it is acknowledged that it will not be

an easy post to fill. The short term plan is to use Consultant Locums when available to help

with the routine patients. A risk remains that this will not be sufficient to fully deliver the 12

week guarantee on a regular basis.

Ophthalmology

TTG

The 12 week TTG target is regularly delivered for Ophthalmology with the exception of a very

small number of patients who breach. This can be due to the availability of general

anaesthetic cover or a children’s bed on the required day.

NHS Highland is required to ensure that the 12 week guarantee should not be used to

measure waiting times for cataracts. Patients waiting for cataract surgery should wait no

more than 9 weeks. Plans are now in place to deliver and monitor this in 2014/15.As at April

2014 there were 51 patients out of 303 who have currently waited more than 9 weeks for

surgery.

Outpatients

The Ophthalmology outpatient position has regularly been delivered but only through use of

waiting list work and regular use of a “bank” consultant ophthalmologist. There are significant

issues with space and room utilisation. Recently a RPIW event took place which is enabling

the department to reflect on current practice and make changes to improve efficiency. It is

expected that the RPIW will deliver and maintain continuous improvements throughout

2014. Progress will be regularly reported.

Gynaecology

TTG

This target can be achieved with full consultant staffing. There is currently a consultant

vacancy covered by locums which is causing some pressure.

Outpatients

Compliance with gynaecology outpatient waiting times continues to be a challenge. The

numbers waiting beyond 12 weeks reduced to 38 at the end of March only with additional

waiting list activity and this is likely to be required for the months ahead. Recruitment will

commence shortly to appoint a substantive seventh consultant. It is currently occupied by a

locum obstetrician until the end of January. The post is about to be advertised now in order

to take advantage of the known availability of a candidate with an interest in gynaecology.

Obstetric Scanning

The scanning service is unable to meet scanning targets for dating and detailed scans due to

unfilled vacancies. Repeated and wide adverting has been unsuccessful. There has been a

good response for training posts but there is a 2 year lead in time for trainees to be fully

proficient. There is a national shortage of obstetric scanners. The service is being

supplemented my medical staff scanning but this impacts on outpatient clinic capacity.

General Surgery

TTG

There have been a small number of patients who breach each month, in the main due to

cancer patients taking priority for theatre space. Job planning for 2014/15 is beginning to

impact in particular with Colorectal and Upper GI. The Service is dependent on clinicians

agreeing to work several extra sessions/month to achieve TTG.

Outpatients

To date there have been no issues with waiting times. However, this month and going

forward it is anticipated that there will be ongoing shortfalls due to job planning.

Work is ongoing with clinicians to agree capacity to deliver the waiting times for TTG and

outpatients. This will result in significant financial overspend and reflects the goodwill work

done in 2013/14 where little cost was incurred for extra activity. The service is working with

Patient Booking Service ( PBS) to ensure all capacity is utilised. However, Patient Focussed

Booking (PFB) has been on hold since PMS launch. This has resulted in an increase in DNA/

CNA s. Once PFB service is restored, a trial of text remind will commence.

A business case being completed for 5th Colorectal Surgeon to address Raigmore’s capacity

shortfall but a 6th consultant may be required to address NHS Highland colorectal pressures.

Retirements and resignations in Caithness and Belford Hospitals will result in increased

workload in Raigmore. Measures are being discussed on how this workload can be

managed.

Cardiology

The Catheter Laboratory is still experiencing capacity challenges for PCIs and angiograms.

The department is exploring extending 2 days in the week to allow additional procedures.

Outpatients

A capacity shortfall continues for new and return outpatients. New capacity being provided

by additional waiting list clinics by substantive consultants.

Gastroenterology

Outpatients

Pressures exist with new and return outpatients. Capacity is being supplemented by

Synpatik locum agency (weekends) and additional waiting list clinics by substantive

consultant. A long term locum has been secured to support the service. The locum

commences in June 2014 for 6 months. Capacity and demand data for this service is being

reviewed with the Service Planning Department.

Diabetes & Endocrinology

A fourth consultant has been appointed to the service and taking up full consultant duties in

June 2014. This will provide additional capacity for new and return patients.

Neurology

Outpatients

There are capacity pressures which will require to be addressed through some additional

waiting list sessions.

Respiratory

Outpatients

Long term sickness of one consultant combined with the resignation of a clinical assistant

have added to capacity problems within this service, particularly with respect to Caithness

clinics. Additional capacity has been provided by Synpatik locum agency (weekend clinics).

Recently advertised for a locum consultant without attracting any interest. A consultant

retires at end of the summer and this post has been approved for recruitment.

Sleep Service

There are a number of issues regarding this service relating to clinic capacity and availability

of a sleep study bed. This has been partially resolved with the ring fencing of the sleep study

bed.

Rheumatology

Outpatients

Capacity is being met for new patients with one substantive and one part time locum

consultant. Return patients remain an issue and support from Synpatik locum agency is

ongoing. The department has advertised and failed to recruit substantive consultants. The

service is trying to recruit visiting specialist doctors through contacts with the Madrid

Rheumatology Society.

Key Diagnostic Tests – Endoscopy

Current Endoscopy Waits as at 10th April 2014

Previous reports showed that routine appointments were being booked in 0 to 14 days using

slots for urgent activity. This is now an improving position with minimal routine patients now

being booked in to slots that should be used for urgent referrals. However, there are still

routine patients booked 14 to 28 days and urgents booked over 28 days, so continued work

is required with scheduling.

The booking of endoscopy patients is to be relocated to endoscopy service. Patient focussed

booking methodology will continue to be used but it is anticipated that the relocation of

booking staff in to the new endoscopy unit will improve booking and scheduling practices.

RTT

Overall performance is above the 90% target. However, the overall linked pathway

performance demonstrates that not all patient pathways are being captured and measured.

Work is ongoing to improve percentage of linked pathways as this will give a more accurate

percentage figure in relation to RTT performance against the 90% target.

Radiology Waiting Times

The time spent waiting to perform and report the examination is reviewed weekly.

On April 22nd 2014 the waits and reporting performance* were as shown below:

No. waiting 4

weeks or less**

for scan

No. waiting over

4 weeks** for

scan

% (number)

unreported

after 1 week

% (number)

unreported

after 2 weeks

CT 218 123 30% (30) 10% (10)

MRI 293 85 34% (57) 10% (16)

Barium 7 2(non-

responders)

20% (2) 0% (0)

Ultrasound 760 41 4% (1) 0% (0)

*The above data has not been adjusted to reflect patient choice in appointment date

** 6 week cut off for ultrasound

The data above shows that on April 22nd 2014 there were 208 patients for CT and MRI

breaching the internal 4 week target waiting to be scanned, compared with 400 and 216

presented in the January and March reports respectively.

Action plans for CT & MRI

1. To continue to outsource to Medica Reporting Ltd, such that no case will go longer than14 days unreported. Those cases deemed inappropriate for outsourcing (for clinical oroperational reasons) will have to remain in house and the time to report monitored, suchthat local resource can be targeted appropriately.

2. In parallel with the above to continue recruitment efforts. Outsourcing will be used asbackfill as required, to ensure lack of substantive posts does not compromise thereporting performance.

3. Ensure that the rota that was implemented on March 3rd 2014 delivers consistently thebenefits that were anticipated.

4. Continue to explore the options for greater utilisation of Caithness and Belford capacity.Uplifting capacity at the Rural General Hospitals to allow 9am to 5pm scanning Mondayto Friday would require utilisation of bank staff at Caithness General (cost approximately£400 per week) and a locum radiographer at Belford Hospital (cost approximately £1,500per week) – either option would deliver the scanning of around 20 additional patients perweek.

5. Identify additional capacity in other Board areas for the specialist examinations such asmusculoskeletal (MSK) ultrasound and arthrograms. The numbers for these exceed localcapacity and thereby cause patients requiring such techniques to wait longer than isdesirable.

6. Increase the number of sessions for cases requiring general anaesthetic. Currently only 6such scheduled scans per month can be provided (3 per fortnight), with the next free slotoften being more than 4 weeks in the future, so discussions are underway with theanaesthetic team to assess the available options to allow an increase either in length ornumber of sessions.

Action Plans for Barium & Ultrasound

As noted above, barium and ultrasound examinations are comparatively small in number and

reported within one week and one to two days respectively, allowing consistent achievement

of the 6 week standard for 98-100% of cases. Prolonged wait of 4-6 weeks for ultrasound

appointment can on occasion happen for musculoskeletal (MSK) cases which are performed

by consultants but the almost immediate reporting mitigates the effect.

Cancer

Over the 17 completed quarters since January 2010 there have been

Six failures of the 62 Day Targeto Quarter 2, to end June 2011,o Quarter 4, to end December 2012o Quarters 1, 2, 3 and 4 in 2013.o Quarter 1 in 2104

Three failures of the 31 Day Targeto Quarters ending March 2010,o end June 2010o end June 2011o end Mar 2014

As a result of the continuing failure to meet the target NHS Highland, along with three other

Boards is working with SGHD Cancer Delivery Team to bring the position back into balance

as soon as possible. There are plans being put into place to manage the situation. It will be

formally reviewed at a meeting with the Delivery Team in May.

The charts at the end of this report illustrate the monthly performance against both targets.

The quarterly performance can be easily affected by the poor performance in one particular

month and it is poor in the quarter just ended because of a poor performance in two months

in succession.

The failures in this three month period continue to fall into the categories: 1 - Lack of Urology

Capacity, 2 – Breast Capacity, 3 – Endoscopy Waiting Times 4 - Radiotherapy Delays and

5 - Oncology Capacity.

Urology Capacity

The position in Urology is mostly due to a lack of capacity at the beginning of the referral

pathway to carry out prostate biopsies. This has been addressed to some extent now with

the Nurse Specialist carrying out six rather than four clinics per month. Another member of

staff has also been allocated to actively manage the expediting of tests and results for

individual patients.

The main problems in the pathway are caused by a lack of capacity to carry out upper tract

and prostate surgery and unfortunately to solutions to address them are longer term one and

are probably regional rather than local.

Breast Capacity

The majority of the breaches encountered within Breast Surgery were at the beginning of the

quarter. It is believed that the measures implemented since then will significantly reduce this

problem.

Additional clinics have been established to cope with the annual peak in demand each

autumn resulting from Breast Awareness month. Additional theatre sessions are also being

sought from other specialties when required to avoid patients breaching. An RPIW is also

being held on 30 June focusing on improving the beginning of the pathway.

Endoscopy Capacity

An additional rectal bleeding clinic has been established in the last month but there are

continuing capacity problems which are being resolved by the re-advertisement of a Nurse

Endoscopist post.

Lack of Radiotherapy Capacity and Pathway Inefficiencies

The difficulties in staffing the Radiotherapy Planning Service have been discussed in some

detail in previous reports. The staff member appointed to one of the two vacant posts in

December took up post in 14 April and another post was filled by an internal candidate. This

leaves that latter post and one other post now vacant.

Discussion at underway with regional colleagues in order to provide a more immediate

solution. Significant progress towards the safe transfer of files and radiotherapy plans

between the five Cancer Centres has been made in the last month in order to facilitate this.

Lack of Oncology Capacity

The service is currently reliant upon two locums until the end of May and June respectively to

cover the wte vacancies caused by a retiral at the end of March and a Consultant on SL until

the end of May. The consultant on Sick Leave will not return to the sub specialty that they

left.

A second attempt to appoint to the retirees post resulted in no applicants. The immediate

term gap will be provided by the continued use of locums and with the support of colleagues

from other Centres throughout Scotland. This will unfortunately mean that some patients

might have to travel for assessment and possibly treatment but every effort is being made to

minimise the inconvenience to patients and return to a locally based service as much as

possible. This may take some time given that this is a UK wide problem.

It is recognised that without a fully staffed local service a revised service model will be

required dependent upon the types of service that could be best provided locally, what

regionally and what nationally. This will need a combination of solutions depending many

factors such as the specialisms of the consultants in post, patient numbers affected, their

ability to travel, whether their radiotherapy treatment could be planned and still be provided

locally and in a safe manner noting that the Consultant Oncologist will not be on site in the

event of any post treatment complications. Our planning so far has taken cognisance of

these issues by resorting to a GI Service with the initial consultation in Aberdeen or by video

from Inverness but with treatment remaining in Inverness. Lymphoma and Sarcoma patients

however, where the numbers affected are smaller will unfortunately have to travel to Dundee

or the Central belt for their consultants and treatment.

This work is being co-ordinated with colleagues in NOSCAN with a regional and national

review led by Dr Jane Barratt, recently retired President of the Royal College of Radiologists

and by Dr David Dunlop, Senior Medical Officer seconded from the Beatson Cancer Centre

in Glasgow.

Adjuvant Waiting Times

There is no national target for Adjuvant Radiotherapy waiting times (secondary treatment

after initial surgery). The Service Redesign work mentioned above has resulted in a reduced

waiting time to within the clinical recommended times of 8-13 weeks after surgery for Breast

patients.

3. Delayed Discharge

The situation in Raigmore has not improved much over the last few months. As at 24th April

there are 8 patients awaiting residential placements, 14 awaiting Care at Home and 7 in the

other category. In addition there are 11 patients awaiting Community Hospital transfer.

4. Partnership Working

The Local Partnership Forum have been actively involved in the development of the

Raigmore Recovery/Delivery Plan. There is now a strong committee which is meeting

regularly and discussing and agreeing the way forward in a number of areas including

Everyone Matters, i Matter, Health and Safety and Staff Governance.

5. Huddle

As part of the Raigmore World Class Management drive, a daily huddle has been in

operation for some time. This has evolved significantly over the last few months with a major

change over the last week. The huddle takes place at 830 everyday providing a temperature

check on how safe the hospital is each morning. Over the last week, this has been opened

from charge nurses and management to now an open invite to every member of staff across

the hospital. The first of these meetings took place on 24th April and the attendees were

asked “what can we do today to improve the quality and safety of care to our patients” We

committed to try and fix before the next day as many of these issues as possible. They

ranged from blood request documentation to cigarette stubs in the entrance. The meeting

was very well attended across all groups of staff and it is hoped that this will grow in both

size and success.

6. Recovery/Delivery Plan

The plan has been developed and continues to evolve. It focuses on 3 main areas and is

actively reviewed on a weekly basis. The plan will be presented at the meeting.

Linda Kirkland

Interim Director of Operations

24th April, 2014


Item 6.2

1

CHIEF OPERATING OFFICERS REPORT

Report by Deborah Jones, Chief Operating Officer, NHS Highland

The Committee is asked to note the contents of this report.

1 PURPOSE

The purpose of this paper is to provide the Health and Social Care Committee with an updateon current HEAT performance (exceptions only) and operational issues not addressedthrough operational unit papers.

2 PERFORMANCE

The “Full Report on the future of residential care for older people in Scotland” has beenpublished earlier than expected. This report has been introduced to the Adult ServicesCommissioning Group, who noted the very useful contribution it will make to thedevelopment of a Quality Schedule, and refinement of the sections of the StrategicCommissioning Plan dealing with this area. The report will now represent a significantworkstream for Older People Improvement Group, which has been tasked with consideringthe report and making recommendations.

2.2 Delayed Discharge

The Chief Operating Officer will give a verbal report on the delayed discharge position atannual census point as data will not be available for inclusion with the papers for thiscommittee

3 OPERATIONAL ISSUES

3.1 Patient Management System Go Live Update

The pan-NHS Highland PMS has now been formally live since 3 March 2014 and its use is“bedding in” across the area. Technical issues post go live have been minimal andIntersystems (the system supplier) and NHS Highland technical staff continue to work closelytogether. The Intersystems team on-site presence has been agreed for April and thispresence will reduce over May and June as issues reduce and are resolved.

NHS Highland is now beginning to initiate Phase 2 and other downstream project workincluding electronic triage of referrals, bed management and reporting which will includeTreatment Time Guarantee (TTG) functionality.

Close liaison continues with the Information Services Division of National Services Scotland(ISD) and the Scottish Government around the development of the required reporting fromthe system. The waiting times reports have been developed and are currently in the testingand validation cycle as planned. There are in effect two parallel testing phases, one locally

2

within our data warehouse and one nationally via ISD. It is planned to have this phasecomplete by the end of April which will allow the required reporting to proceed.

As expected, there have been a number of non-technical issues identified around medicalrecords and clinics and the Programme Office are continuing to work closely with the serviceto resolve.

3.2 National Falls Management Project in Care Homes

The Scottish Government are behind a pilot scheme in reducing falls within care homes.Three areas in Scotland were identified as test sites with north highlands being one of them.There are 15 care homes involved five of which are NHS care homes (identified below:

1. Care home - Inverness (Mandaville withdrew)2. Southside - Inverness3. Wade Centre - Kingussie NHS4. Grant House - Grantown-on-Spey NHS5. Mains House - Newtonmore6. Wyvis House - Dingwall7. Fodderty House- Dingwall8. Lochbroom - Ullapool NHS9. Pulteney House - Wick NHS10. Seaview House - Wick11. The Meadows - Dornoch12. Oversteps - Dornoch13. Castle Gardens Care home - Invergordon14. Mull Hall Care home - Invergordon15. Invernevis- Fort William NHS

This has involved enhanced input around falls prevention with identified staff beingresponsible for cascading information on to their own staff group. The basis of theinformation is the Care Inspectorates documentation and guidance for managing andpreventing falls in Care Homes.

Liz Sinclair and Julie Lewis senior staff at Pulteney house are the senior staff involved andhave created an in house training package for all staff to undertake – they have delivered thistraining in Pulteney and have seen a marked reduction in falls as a consequence. Thenational coordinator for this role invited Julie and Liz to join a meeting via Skype where theygave feedback and spoke about their work. The project officers were so impressed theyhave decided to, with some small changes, adopt Julie and Liz’s practice across the project.

Julie and Liz have also been invited to be part of the training DVD to accompany the trainingmaterials which will be developed following the pilot.

3.3 NOSCAN Report on the Review of Oncology Services

The NOSCAN review of the Oncology service in the North and Inverness in particular is on-going. This project is also being supported at a National level as a result of the appointmentof Dr David Dunlop, a Medical Oncologist from the Beatson in Glasgow as part time SeniorMedical Officer (SMO) at the Scottish Government. Dr David Dunlop will be supporting theregional NOSCAN work to bring the three north Cancer Centres together as one cohesiveOperational Unit to the benefit of patients in the north.

3

Dr Jane Barrett, recently retired President of the Royal Colleague of Radiology isalso working on a part time basis until the middle of May, acting as a locum and providingdirect patient care service here in Inverness, but also to advise on the service sustainabilityissues in Highland.

Many of the recommendations previously made around the need to agree pathways andestablish mutual aid arrangements from other Centres in Scotland have been put in place asinterim solutions are we are currently reliant upon colleagues from Aberdeen and Dundee tosee GI and Lymphoma Radiotherapy Cancer Patients.

Deborah JonesChief Operating OfficerDeputy Chief Executive

Health and Social Care Committee1 May 2014

Item 8.1

STRATEGIC COMMISSIONING PLAN FOR OLDER PEOPLE

Report by Simon Steer (Head of Strategic Commissioning) and Gillian Grant (TeamLeader, Contracts) on behalf of Deborah Jones, Chief Operating Officer

This report provides a final draft of the strategic commissioning plan for older people, asapproved by the NHS Board on 1 April 2014. The Health and Social Care Committee isasked to note the plan and agree the further and ongoing actions required.

1.0 Background

1.1 The previous report to the Health and Social Care Committee on the strategiccommissioning plan was on 9 January 2014. At this meeting, the Committee:

Noted the general approach being taken and progress made to date; Noted the challenge of developing capability and capacity to do the work; Endorsed the decision for an initial focus on older people; and Endorsed the approach being taken to develop initial commissioning intentions and

a further strategic commissioning plan.

1.2 Since January 2014, further work on the plan has progressed, which has beenoverseen by the Adult Services Commissioning Group.

1.3 A final draft of the strategic commissioning plan was presented to the NHS Board on 1April 2014, alongside the strategic commissioning plan for the Argyll and ButePartnership.

1.4 At this meeting, the Board received a joint presentation from the Co-Chairs of the AdultServices Commissioning Group (Stephen Pennington, Scottish Care; and DeborahJones, Chief Operating Officer). At this meeting, the Board:

Noted the joint report, covering the strategic commissioning plans of both NorthHighland and Argyll and Bute Partnerships;

Noted the respective plans, appended to the report; Noted the accompanying presentations; Agreed the strategic direction and imperatives as set out in both plans; Agreed that the direction to be reflected in local operational delivery plans; Noted the further work required to refine and further develop the strategic

commissioning plan for older people; Noted the further work required to develop strategic commissioning plans for

other client groups; Agreed to the development of a single strategic commissioning plan covering the

whole NHS Highland area; and Agreed that the strategic commissioning plan would be the subject of an annual

review report to be presented to April meetings of this Board.

1.5 A drafting and electronic copy of the strategic commissioning plan for older peopleconsidered by the NHS Board, is circulated with this report. Copies of a final designedversion will be available at Committee.

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2.0 Next Steps

2.1 The further areas of work are now required as follows:

a) A project plan is to be mapped out for how to progress the strategic prioritieswithin the plan (eg how to move the market to Grade 4’s by 2019; how to ensuresufficient quantity of trained/experienced staff; how to transition towards a tariffetc).

b) As part of the detail of a) above, and as also referred to in item 8.2 on the Healthand Social Care Committee agenda, a quality schedule is being co-produced forinclusion in future contracts, which will ensure a shared understanding of serviceexpectations, outcomes and targets. It is intended that this area of work willinvolve a series of workshops with stakeholders between June and August 2014.

c) Local delivery plans are required in order to articulate how the strategiccommissioning plan will be delivered across Highland at a local level;

d) Contact with current and future providers and any interested stakeholders, whohave comments to make on this strategic commissioning plan; and/or wish towork with NHS Highland and its partners to achieve the stated priorities andoutcomes. In the fee rate confirmation letters issued for 2014-2015, all providershave been alerted to the plan and directed to a copy of it;

e) The commissioning direction of the other client groups requires to be consideredand set out in more detail during 2014-2015;

f) Ongoing iterations of this strategic commissioning plan is required as part ofcontinued dialogue with current and future service users, their carers andproviders of services, to ensure robust future planning; and

g) A planning for fairness impact assessment is to be developed.

2.2 These required further actions will be set out in a project plan, to be overseen by theAdult Services Commissioning Group.

3.0 Contribution to Board Objectives

3.1 The Strategic Commissioning Plans meet the Board’s quality objectives in thefollowing ways:

Quality Objective How Objective Is Met By StrategicCommissioning Plan

1. Our Vision and Strategy(supports Better Health, Better Care,Better Value)

Plan provides clarity of direction forservices for older people.

2. Improvement and Change(supports Better Health, Better Care,Better Value)

Plan focuses on key areas of change toaddress current challenges and improvethe service user and carer experience.

3. Living our Values(supports Better Health, Better Care,Better Value)

Plan promotes the service user at thecentre of decision making andtransparent relationships withstakeholders.

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4. Engaging Effectively(supports Better Care)

Plan has been co-produced withcommissioning partners and there arestructures in place ensure meaningfuland wide ranging engagement.

5. Focussing on Population Health(supports Better Health)

Plan highlights health inequalities andsets out measures to address them.

6. Promoting Community Responsibility(supports Better Health)

Plan focuses on prevention, selfmanagement and promotion ofcommunity involvement.

7. Delivering Integrated Care(supports Better Care)

Plan promotes cross-sector servicedelivery and a level playing field.

8. Delivering Person Centred Services(supports Better Care)

Plan focuses on the needs of the serviceuser, and to delivering or facilitatingservices which meet these needs.

9. Delivering Safe and Effective Services(supports Better Care)

Plan focuses on ensuring services aredelivered, where, how, when and at alevel of quality that service users want.

10. Delivering Efficient Services(supports Better Value)

Plan highlights the need to ensureeffective and efficient services which addvalue to service users.

4.0 Governance Implications

Staff Governance Patient and Public Involvement Clinical Governance

Staff; Patient; Public; Clinical and other Sector engagement is a key component of thestrategic commissioning plan. The implications for all of these areas are an increasedengagement in the strategic planning of the best way to meet the identified needs of theHighland population.

Financial Impact

Strategic commissioning is expected to have a positive financial impact by providing acomprehensive framework for planning investment, reinvestment and disinvestment and useof assets, across all sectors, with a view to optimising outcomes and promoting preventionand self management. Detail of financial impact will be contained within the local deliveryplans.

5.0 Risk Assessment

Upon completion of the local delivery plans, a risk assessment will be required to assess therisks of the proposed actions within them.

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6.0 Planning for Fairness

A full planning for fairness impact assessment requires to be undertaken in respect of bothstrategic commissioning plans and any necessary amendments to the plan will be taken intoaccount in its annual review. The impact assessment will be completed by the end of June2014. The subsequent local delivery plans will also be impact assessed.

7.0 Engagement and Communication

Full consultation, engagement and involvement with all key stakeholders underpins theapproach to developing the strategic commissioning plans within both Partnerships.

Simon Steer, Head of Strategic CommissioningGillian Grant, Team Leader (Contracts)

23 April 2014

V0.1.13 Better Health | Better Care | Better Value

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Highland Strategic Commissioning

Plan for Older People

2014-2019

bmitc01

TextBox

Highland Health & Social Care Committeee 1 May 2014 Item 8.1


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[Drafting Note: drafting notes are included throughout the strategic commissioning plan, to provide further information for the NHS Board’s attention. These will be removed from the final version].

Content

Foreword

Part 1 The Context

Strategic commissioning plan for Highland

Introduction

Highland profile

The challenges

Part 2 The Plan

Meeting Highland’s needs

Resourcing What does good look like?

Changing from the present to the future state

Applying a commissioning approach to care at home provision

Applying a commissioning approach to care home provision

Applying a commissioning approach to other areas

Taking Highland commissioning intentions forward

Other population groups

Action

Appendices

Appendix One | Glossary Appendix Two | Current Developments Appendix Three | References


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[Draft] Foreword This is the first Highland strategic commissioning plan. It has been co-produced with all sectors and representatives of carers and service users through the Adult Services Commissioning Group. The plan will encompass all adult care groups over the next year but at this point, it is focussed firmly on meeting the needs of older people in Highland. It is our first step on an important journey to better understand and better meet these needs. Throughout the development of this plan, we have aimed to place the service user at the centre of our thinking. Development of this strategic commissioning plan is an evolving process, where the journey of establishing solid relationships with and between commissioning partners, has been a critical achievement. The challenge for the coming years is to build on this relationship as we take a shared approach to investment, reinvestment and disinvestment decisions and the risks associated with these. This will not be an easy process and through this plan we seek to be open and transparent and need to be brave enough to challenge and be challenged. Deborah Jones Stephen Pennington NHS Highland Scottish Care Co-Chair Co-Chair Adult Services Commissioning Group Adult Services Commissioning Group


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Part 1 - The Context

Strategic Commissioning Plan for Highland This Strategic Commissioning Plan for Older People has been co-produced by NHS Highland and its commissioning partners, in order to communicate:

The service user and carer outcomes we are striving to deliver;

The current Highland position and intended direction;

The shape and profile of future services which will best meet service users’ needs;

How this transition will be made;

Future dis-investment and re-investment decisions;

Future engagement with providers; and

Information to enable providers to position their service to deliver provision that people in Highland need and want.

Introduction Background In Highland, we (NHS Highland and commissioning partners) are committed to achieving the best possible outcomes for our population and service users. We believe that services should be person centred and enabling, should anticipate and prevent need as well as react to it, should be evidence based, acknowledge risk and should provide for flexibility and choice. In order to achieve this, we must focus our activity on providing or facilitating only those services which service users need and want, continuously improving the service user experience and building on service users’ strengths. In doing so, we need to take steps to remove any areas of activity which do not add value to achieving these objectives. We wish to ensure our population have a real choice of quality provision for service users to access services directly, should this be their wish. In order to achieve this, we need to be able to stimulate and shape the market to be able to achieve better outcomes and value, through a variety of service models which meet service users’ needs and expectations. This first strategic commissioning plan focusses on services for older people over the next five year period (2014-2019). The approach to articulating our strategic commissioning plan is an evolving process and more detailed direction for both older people and other population groups will be produced over 2014-2015. This plan is also the first step to considering the longer term needs of the population beyond 2019, and looking ahead to 20-30 years time.


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What is a commissioning plan and why do we need one? The purpose of this strategic commissioning plan is to set out the Highland approach to commissioning services for older people between 2014-2019 in terms of quantified quality, volume, value and location, and to set out how this is to be achieved. NHS Highland currently spends around £500m per annum on providing or delivering adult care services, with around half of this on older people. The challenge for this plan is to ensure that this resource is used to achieve the outcomes based on what people have told us they need and our understanding of what would meet these needs. The plan also needs to move us away from traditional ways of thinking about meeting people’s needs in terms of beds and buildings and towards a greater emphasis on early intervention and anticipatory support. In achieving this shift, it is intended that a more vibrant and energised care market will be created; maximising potential for self directed support and creating opportunities for greater choice and innovation for how people’s needs can be met. In the context of increasing service demands, a finite budget, and a historic service profile, this approach will mean a different commissioning relationship with partners and will mean a refocussing or decommissioning of traditional services and transition towards service models in line with this plan, to ensure that resources are being targeted in the most appropriate way. In describing what a commissioning plan is, it is also useful to clarify the commissioning process, to ensure a shared understanding. A simple illustration of the commissioning process is noted in Figure 1 below, which sets out commissioning at a strategic and operational level, notes the key steps involved and highlights the importance of the service user at the centre. [Drafting Note: detailed information on the commissioning process is intentionally not provided within the plan, and significant detail is contained elsewhere. It is the intention over coming months, to develop a web based compendium of commissioning resources with commissioning partners - and led by Scottish Care with JIT input].


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Figure 1

It is our intention also that this strategic commissioning plan is as concise as possible, setting out the strategic direction only and thereby maximising focus and clarity. The plan is set out in two distinct parts;

part one provides the context and draws out the key points that require consideration. This is intentionally high level, as these key points are drawn from far more detailed information elsewhere (Strategic Health Needs Analysis, Carers Strategy, Housing Strategy etc) and it is not the purpose of this plan to repeat the detail here;

part two describes where we are aiming to get to and how we need to transition to get there.

This strategy, once agreed, will require to be translated through local delivery plans, which will set out how this strategic direction will be applied to localities across Highland. Who wrote this plan and how has it been developed? This is a strategic commissioning plan for Highland, developed through a co-productive approach by NHS Highland and its commissioning partners – and has involved a cross sector Project Team, with the developing work overseen by the wide range of representation round the Adult Services Commissioning Group. The Adult Services Commissioning Group is the vehicle established to involve as many sectors and representatives as possible in the making of strategic decisions about adult care. It is therefore not NHS Highland’s plan, but a jointly owned plan for Highland.


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It is our intention that broader strategic commissioning plan will be taken forward by a range of improvement groups. However, most of these improvement groups are at an early stage at the present time (leaning disability, mental health, acquired brain injury). Given the focus of this plan on older people, we have concentrated on the key priority areas identified by the older people’s improvement group within this document. [Drafting Note: the preparation of this plan has been overseen by the ASCG, whose role, remit and contact details will be attached as a link in the final report] Crucial to the development of the plan and setting the priorities for the future, has been the inclusion of service users, their carers, as well as input from providers and their representatives and these key stakeholders have been included as partners at every level and stage of the plan’s development. This approach will continue as the strategic commissioning plan both evolves and also considers the longer term challenges beyond the five year duration of this plan, as well as the strategic commissioning priorities of other population groups. What do older people say commissioning should mean for them? The foundation of this plan is to ensure that services are commissioned which meet service users’ needs. The Highland Senior Citizens Network have told us that this is what commissioning should mean for older people:

“Strategic commissioning will recognise and value the huge

contribution made to our communities by older people. Quality

commissioning will be about us as older people - including those

of us with high support needs and our carers - achieving the

outcomes which enhance our quality of life, enabling us to live

and die well. We will be healthier for longer and enjoy improved

social, physical and psychological wellbeing as in the diagram

below (Figure 2). To meet these outcomes we will be enabled

to participate as full expert partners throughout all the

commissioning stages: analysing; planning; doing; and reviewing.

These outcomes are dependent on a range of areas such as

health care, both physical and mental, housing, equipment,

transport, information, advice, technology, leisure, learning,

environment, community, safety and financial welfare. Strategic

commissioning will therefore ensure that partners and services

from all sectors work effectively and efficiently together. This

includes primary and acute care being intimately involved to

permit effective solutions to be developed.


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We recognise that resources are limited and that we, and all

our partners, will need to make choices. We believe our full

involvement is imperative to build and maintain trust in

decisions and to allow joint responsibility to be taken for

choices made. In Highland there is a particular need to ensure

that service users and carers in local communities are

empowered to develop their own effective solutions to local

needs. In short, strategic commissioning means there is nothing

about us without us.

What is our vision for Strategic Commissioning? We want to

live well. This means being the lead in choosing what is

important in our lives, what services are important to support

us in our aspirations and how they are delivered. We believe

that if providers listen to what we are saying then the

outcomes we need are more likely to be achieved.

There must be nothing about us without us”.

The diagram at Figure 2 below illustrates the person centred approach we need to take to ensure that what we commission accurately reflects what people need, not what the statutory sector decides they need. In the words of the Highland Senior Citizens Network we must ensure there is “nothing about us without us”. This person centred approach is aligned with the personalised or self directed support approach to commissioning.

Figure 2


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What will the plan achieve? The following sets out the key priority areas to be delivered through this plan:

Ensure the best available evidence is used for making decisions Support providers and the people of the Highlands to make decisions based on evidence regarding effectiveness and efficiency care options.

Increase transparency on price and quality Provide the people of the Highlands with information on how much their health and social care costs and how outcomes compare so they can become informed consumers and make informed choices.

Pay for value Design new payment structures that incentivise quality, efficiency and effectiveness.

Enhance quality, efficiency and capacity of care at a local level Strengthen local decision making in older people investment decisions; and give communities better tools for making such decisions.

Increase dignity and quality of care for seriously/terminally ill patients Support Highland’s people to plan in advance to ensure health care and other end of life decisions are honoured. Provide secure electronic access to advance directives. Encourage provider training and education in end-of-life care. Establish a process that engages seriously and terminally ill patients in shared treatment decision-making with their clinicians and carers. Use tele-health care and redesign methods to improve access to palliative care.

Focus on prevention Create the conditions that support and engage the population of the Highlands enabling healthy lifestyle choices. Self management, particularly for those living with long term conditions, must remain a priority. Tackling health inequalities for example, targeting those who are most vulnerable, should remain a priority for all services.

Build the foundation of a sustainable health and social care system across all sectors Ensure there is an appropriate quality, supply and distribution of care workers across all sectors.


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Highland Profile To develop a strategic commissioning plan, we need to start by understanding population needs and strengths and to consider this information alongside other relevant factors impacting on the current and future delivery of care services. Detailed analysis of population needs is provided by the NHS Highland Strategic Health Needs Analysis. [Drafting Note: work is in progress with partners to bring the SHNA more alive and to make the information more accessible. This will be included alongside the commissioning compendium resource referred to earlier]. Some of the key points from this analysis are noted below: Population Like other parts of Scotland, Highland’s population is both increasing and getting older. The following issues are highlighted from the projected population composition:

By 2035 the population of Highland is projected to be 255,257, an increase of 15.2% compared to the population in 2010. The population of Scotland is projected to increase by 10.2% between 2010 and 2035.

As noted at Figure 3 below, over the 25 year period to 2035, the age group that is projected to increase the most in size in Highland is the 75+ age group. This is the same as for Scotland as a whole.

Also as noted at Figure 3 below, the age profile is projected to also significantly change, over this same period with a 47% increase in 65-74 year olds and a 111% increase in people aged 75+, a significant increase in this age group compared to the Scottish average;

Figure 3

life expectancy is expected to increase for both men and women in Highland, at a rate greater than the Scottish average;


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variation regarding life expectancy, with the lowest life expectancy in Inverness Merkinch (67 years of age) and the highest in Nairn rural (83 years of age).

the highest rates of projected growth are in Inverness and Badenoch and Strathspey, and projected falls in Sutherland.

One of the biggest anticipated challenges facing Highland is the projected increase in the 75+ age profile. Nevertheless, it is not assumed that advancing age will automatically result in incapacity, poverty and a demand on adult services. Many older people are healthier, fitter, contribute to third sector activity or family caring responsibilities and have accumulated substantial assets. Our resources therefore need to be directed to not only those who are unwell or frail, but to continuing preventative activities to keep people active and in good health. Over the next year as our commissioning approach evolves, there is also a need for a greater understanding of the issues and financial challenges associated with other population groups. For example, we are currently seeing a significant financial pressure in terms of young adults with complex needs. Work is being initiated to develop a greater understanding of the projected impact in this area. Workforce In an employment market already showing signs of skills shortages in the care sector, there is projected to be a lower percentage of working age population and over the period to 2035, the dependency ratio is expected to fall significantly. The unemployment level within Highland (November 2013) is just 2% of the working population. The lowest unemployment level is currently in Inverness South (0.8%) and the highest is in Wick (5.7%). A significant number of care sector providers are already experiencing difficulties in recruiting and retaining care workers. As the delivery of quality services is dependent on the continued availability of trained and experienced staff, this is a critical area to be addressed where sector wide efforts and wider collaboration is required to promote and incentivise care as a career opportunity. In planning to meet future service demands, we must also capacity build the workforce to support the delivery of quality care. Carers Carers undertake a crucial and demanding role in caring for their loved ones. With an estimated input value of £224m per annum, there are 21,000 people in Highland who provide an hour or more of unpaid care a week; of this total, 7,000 carers in Highland provide more than 35 hours care per week and 5,000 provide over 50 hours per week. Over one third of these carers do not get access to the information they need. There are also a number of carers, undertaking a caring role, who do not see themselves as such, and efforts are required to identify these people and offer support. The work undertaken to inform the Highland Carers Strategy 2014-2017 shows that, whilst improvements have been made, carers are not yet receiving the level of information or support they need in order to equip, assist and support them in their caring role in order to ensure continued good health and quality of life.


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The Highland Carers Strategy identifies six key aims that carers and partners in Highland wish to achieve: 1) to be identified 2) to be supported and empowered to manage their caring role 3) to be enabled to have a life outside caring 4) to be fully engaged in the planning and shaping of services 5) to be free from disadvantage or discrimination related to their caring role 6) to be recognised and valued as equal partners in care.

In part two of this Strategic Commissioning Plan, we set out specific commissioning intentions to further support carers. Health Within Highland, 18.6% of the total population consider themselves to be limited (either a lot or a little) in relation to long term health issues. Furthermore, 50% of the population who are over 50 years of age live with at least one long term condition; 50% of those aged over 70 years of age have at least two long term conditions. Services need to respond appropriately and join up services where service users have more than one long term condition. A health and social care needs assessment for older people with dementia was carried out (2013) and concluded that the true number of people with dementia cannot be known. This is because some people will be in the early stages of the disease, and will not yet have sought help, or are not yet diagnosed. It is possible, however, by using the EuroCoDe4 rates, to estimate that 3,719 people in the Highland area can be expected to be suffering from dementia in 2013. As of November 2012, 1,864 people were identified by General Practices as having dementia, which is 50% of the predicted number. Figure 4 below shows the age breakdown of the population of people currently predicted to be suffering from dementia.

Figure 4


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The expected increase in the prevalence of dementia particularly in older people has current and future challenges for acute and community care, as well as awareness implications for the wider community. Primary and Acute Care The NHS Highland Board is required to have a 3-5 year clinical strategy as part of its Local Development Plan called “Health and Social Care Services Fit for the Future”. This document is currently being developed and will be signed off in autumn 2014. The high level aims and drivers for change within this plan are:

providing safe, sustainable, effective and efficient delivery of health and social care

improving population health

reducing health inequalities The case for change is clearly made based on knowledge that:

the health needs of our population are significant and changing, with increasing complexity and multi-morbidity in an increasingly elderly and frail population;

there is an increasing gap in health outcomes between the best and worst off in society;

more is needed to support people to manage their own health and prevent crises; and

services are not always organised in the best way for patients for example providing support for people to stay in their own homes where appropriate.

In terms of current health services, two areas which have a significant impact on the experience of older people are delayed discharge and emergency admissions: Based on the January 2014 Census, and illustrated at Figure 5 below, Highland is above the national average in terms of bed day rate per 1000 population, but significantly below Aberdeen City; Edinburgh, South Lanarkshire, Western Isles, Edinburgh and East Lothian.

Figure 5


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The graph at Figure 6 below shows how Highland successfully managed down the (over four week) delayed discharge position for several months in the late autumn 2013, in sharp contrast to national trends, but that care home suspension of admissions and the care at home capacity have since had a major impact. This appears to have combined with a current cohort of frailer people who need more support to be discharged.

Delayed Discharge by Length of Delay HIGHLAND (February 2012 to February 2014) Over Four Weeks

Figure 6

When compared to the national position (Figure 7) below we can see that Highland has proportionally more longer waits than the national average. These waits are not all related to care home unavailability.

Delayed Discharge by Length of Delay SCOTLAND (February 2012 to February 2014) Over Four Weeks

Figure 7

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In terms of reason, the Figure 8 below shows the growth in delays related to the chronic problems related to the care at home and care home service capacity.

NHS Delayed Discharges Over Four Weeks by Reason for Delay HIGHLAND (January 2010 to February 2014)

Figure 8

Compared to Scotland, we have a relatively low level of system/process delays (ie assessment reasons), but major capacity issues.

Clear commissioning priorities therefore emerge from analysis of the above delayed discharge data: these are the lack of accessible capacity in terms of care at home and also care homes and alternatives to these options such as housing with support. The other current health area impacting on the service user experience, relates to emergency admissions.

Trend in Bed Days by Type of Admission, Highland Residents 2001 -2012

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The above graph (Figure 9) shows that the current trend for elective and emergency admissions have shown a steady decline. Had everything remained the same, we would have expected an exponential increase in the number of emergency and elective admissions of 65+. The difference between expected activity and actual activity shows the benefit achieved by new ways of working and is allowing us to manage the demographic impact within existing resources. However, there is still a level of emergency admissions experienced by older people which we consider needs to be reduced and further prevention, improvement and action in this area is required. Reablement Although Highland has committed a policy of developing a robust reablement approach, to date this has been subsumed within the general care at home provision and only a limited number of people have experienced actual reablement. We are committed to developing a reabling focussed service which would have:

A clear process that enables people to access the service and that can cope with flows of demand;

A well trained workforce who are clear on the outcomes that are expected;

A set of measurements which helps demonstrate which people are benefiting from the approach and is able to indicate if any staff need further support and training in the work;

Leadership to ensure the service is delivering what might be expected;

A clear link between therapists working within the service and the staff delivering the day to day reablement;

A clarity of where the reablement programme sits within the care pathway;

The opportunity to follow up and sustained action after the service has ended;

A focus on the emotional as well as the practical and physical needs of older people

Housing Housing and housing related services are integral to promoting the health and independence of people with care needs. As people move through their lives, particularly as they age, their needs change and their house design can often pose challenges. The housing profile of Highland shows that 13.5% (13,752) of the population are aged 65+ and living on their own; with 7.7% (7,841) aged 75+ and living on their own. Just under 60% of those who live on their own, have a care at home package in place. As this age group increases, so does the likelihood of demand on care services, along with a potential need for their housing to be adapted to help people carrying on living independently. Through the Highland Housing Strategy 2010-2015, work is progressing to ensure that more people with community care needs are successfully living at home

independently and to enable people to live in a home of their own through a number of means, including:


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Building all affordable houses to ‘Housing for Varying Needs’ standards and, in appropriate new build developments, provide enhanced whole-life design features.

Ensuring that new developments are in sustainable locations; and that all the elements to deliver the housing / services in the long term are in place.

Improving access to existing adapted housing including by improving stock information and developing ways to enable re-use of adapted properties.

Continuing to improve equipment and adaptations processes and take measures to speed up assessment and installation; support user involvement.

Supporting rolling out implementation of telecare / telehealth.

Reviewing use of and access to sheltered housing / related accommodation across Highland.

There is a need to consider the opportunities to increase extra care housing and the potential contribution of extra care housing in areas such as the north, where the care home market is unlikely to change significantly. Geography and Transport As noted below in Figure 10 The geographic area of NHS Highland poses unique and substantial challenges in delivering or facilitating services, due to around 40% of the Highland residents living outwith the main population and settlement areas providing locally important services.

Figure 10


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Geographic challenges have a clear link with the transport challenges faced. Highland unsurprisingly has a higher than average number of cars per household, with car ownership considered more of a necessity than luxury. Low population densities, long distances between settlements and high fuel costs all impact on access to current services. These issues, along with public transport and connectivity issues, are being separately considered by the multi-agency regional transport strategy for the Highland and Islands. Within the small communities and indeed across the whole of Highland, assisting and empowering communities to support their local population and to deliver services to meet their local needs, is a crucial aspect of this strategic commissioning plan. The Community Networker posts in place across Highland are intended to support this community cohesiveness objective. The Challenges The key challenges summarised from the Highland profile, and the areas requiring action, are as follows:

Delayed discharges.

Emergency hospital admissions.

Patient flow.

Increase in the number of older people generally, and those with a long term health condition.

Workforce availability.

Level of support to carers.

Availability of services to promote independence.

Transport to access services. As will be described later in this document, we have the further challenges of:

Service quantity and quality.

Uneven spread of service provision across Highland.

Unequal distribution of provision between in-house and independent sector provision.

Static or reduced financial resources.

The increase in demand and anticipated level of available future resources means that we require to adopt a significantly different approach and one which needs to focus on:

improving service user and carer outcomes.

single points of access.

prevention and health improvement.

promoting independence.

changing the current culture regarding approach to risk.

strengthening community and partnerships.

equity.

maximising value.

building on individual / community assets and strengths.


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There are therefore a number of very significant challenges facing NHS Highland and its commissioning partners. In this part one, we have provided the context for these challenges and have highlighted the key obstacles that need to be addressed. The following part two goes on to set out our vision of the future and the prioritised tangible actions needed to be taken.


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Part 2 – The Plan Meeting Highland’s Needs Meeting the needs of service users and building on their strengths in delivering care - where, how and when they want it, is the foundation of this strategic commissioning plan and its key objective. Put simply, there is no sense in providing, arranging or facilitating services which the service user does not want. There are significant challenges in ensuring service user individual outcomes are met and as such, it is vital we continuously engage with current and future service users, so that we know what is, and continues to be, important to them and be able to meet these needs. The focus of meeting the service user’s needs is the underpinning approach to current and future service delivery being adopted by NHS Highland, as illustrated at Figure 11 below:

Figure 11

Through previous and recent engagement, this is what the Highland Senior Citizens Network have told us what is important to older people:

Maintaining Independence by:

• Accessible information and advice

• Accessible transport

• Appropriate, safe, warm housing

• Accessible support to stay in our own homes

• Accessible technology and equipment

• Accessible means of support including Self Directed Support

• Feeling we live in a safe and secure environment

• Providing quality support for carers


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Receiving quality care at the right time in the right place from people

we trust:

Paid staff must value and respect us as people, respecting our

human rights; they too must be valued, skilled and supported

Care needs will change over time, both increasing and decreasing, so

care must be flexible and accessible:

respite care of our choice especially in rural areas

intermediate care to maximise recovery and promote independence

local response in an emergency and medical care in a crisis

end-of-life care in the place of our choice.

Reducing loneliness and increasing social connections through:

Regular opportunities for social interaction both in our homes and

outside

Digital technology where it helps us to stay in touch

Service providers understanding that service delivery in itself is an

important social connection

Maintaining and improving mental and physical wellbeing by:

Accessible activities that we enjoy

Support to stay as healthy as possible, including accessible medical

care

Helping to build confidence to continue old activities and to try new

ones Resourcing Current and Future Resourcing

We spend £500m on adult care and of this, around half is spent on older people. The composition of the spend, by service type, is illustrated below.


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Highland Health and Social Care Spend (High Level); 65+

Figure 12

The above chart (Figure 12) shows Highland spend in 2010/11 mapped out across community and institutional provision. The key issue here is that roughly 64% of expenditure takes place in the provision of institutional and residential care, whilst only 36% of spend relates to community based provision. The chart below (Figure 13) shows in more detail how this expenditure breaks down.

Highland Health and Social Care Spend (Detailed); 65+

Figure 13


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Figure 14

Figure 14 shows how this spend maps out across operational areas. By using weighted populations to take account of characteristics like rurality, gender balance etc, we can see that there is considerable variation that cannot be explained by population characteristics. It is this variation that drives spend patterns. The role of the Local Delivery Plans is to describe the investment patterns we require to meet need, rather than the historical patterns we currently have. The following section “What does good look like?” summarises the components that will inform these plans. What Does Good Look Like? The first key question (raised by the analysis above) is: “Were we to start from scratch, rather than simply using historical spending patterns... Is this the way we would plan or commission expenditure?” The answer is invariably no”. Our plan is therefore to reverse this investment profile over the next five years. The second key question is, in terms of results, “what does good look like?”. Whilst this plan is really all about outcomes, our ability to measure these is only developing and we have therefore identified the following process and output measures as useful proxies to allow us to gauge achievement:

Reducing non-elective admissions

Reduced emergency readmissions

Reduced delayed discharges of care

Reduced admissions to residential care (nil from acute hospital)

Reduced numbers needing longer term care

High numbers supported through reablement/recovery to need no further care


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Improved quality of care

Availability of trained and experienced staff

Informed and supported carers

Increased and strengthened community capacity

Increased patient satisfaction

Increased population health and wellbeing [Drafting Note: performance metrics have been developed by the Strategic Key Performance Indicators Group. Rather than detailing these here, a link will be provided in the final plan to both indicators and current performance]

Our strategic commissioning focus The need for new solutions to meet people’s needs through emergence of recovery based and outcome based models of care:

Build on evidence from public health

Build on management and self-management with multi-disciplinary teams and across all sectors

Building on the evidence from re-ablement with health partners Improving health outcomes for older people

Dementia care with early diagnosis

Falls prevention

Managing continence

Stroke recovery services

Focus on the evidence from housing solutions

Focus on the evidence from new technologies

Focus on the evidence for tackling social isolation

Focus on assessments that improve outcomes

Focus on evidence that improve wellbeing Commissioning and decommissioning priorities

Devolved care at home provision

Development of community resources and integration

Single point of access to care

Improved service quality across all sectors

Shift of percentage of in-house care at home provision

Hospital admission/discharge

Increased awareness and improved support for people with dementia and their families

Equitable access to the right level and type of service, at the right time

Increased number of people in receipt of self directed support

Redesigned telecare

Increased use of assistive technology

Improved access to information and respite for carers

Implementation of the promoting excellence framework

Self management


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Outcomes to be delivered

people are healthy and have a good quality of life.

people are supported and protected to stay safe.

people are supported to maximise their independence.

people retain dignity and are free from stigma and discrimination.

people and their carers are informed and in control of their care.

people receive end of life care in their preferred setting/location.

people are supported to realise their potential.

people are socially and geographically connected and have a sense of belonging.

we deliver services effectively, efficiently and jointly. It is our vision that by 2019, the experiences of service users, carers, the workforce, providers and professionals will transition from the current state to the 2019 described position:

The service user experience

In 2014… By 2019…

Service users do not believe that they are fully involved in decision making which does not allow joint responsibility for decisions made.

Service users will be the lead in choosing what is important in their lives, what services are important and how they are delivered.

Comprehensive co-production.

The carer experience

In 2014… By 2019…

Significant developments have been made over recent years but frustrations remain, with too many carers still unidentified (or identified too late) and therefore cannot be assisted to access services. Carers also feel that their calls for help are only partially heard.

Carers truly seen as equal partners.

Help when you need it – fast, responsive flexible support.

Quality implementation and review process with measurable impacts.

Preventative investment in services for carers.

The same support regardless of geographical area.

Accessible information.

Carer leads in organisations.

Multi-skilled people working with carers.

Peer support groups.


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Workforce experience

In 2014… By 2019…

Three overriding issues appear to cause difficulty with recruitment, retention and morale within the workforce: 1) Low status of care workers 2) Remuneration levels 3) Lack of a sustainable career pathway

Achieved improved status for care workers

Improved pay levels reflecting improved skill and quality levels

Established career pathways that allow care workers and their skills to remain within the sector

Provider experience

In 2014… By 2019…

Inequitable pricing structure which favours in house services

Transactional approach/relationship

Improving sector relationships

Level playing field

Payment for quality and value

Collaborative approach

Genuine joint strategic commissioning

Clinical and practice experience

In 2014… By 2019…

The right resource is not always available at the right place at the right time.

Improved range of services available through a single point of access and integrated teams.

Changing from the present to the future state How do we make the change and what can we do differently within a fixed budget? Whilst delayed hospital discharge represents one of our greatest challenges, perversely it also represents one of our greatest area of flexibility and opportunity for redesign. Simply put, the beds that we currently use to accommodate people who are delayed in hospital awaiting provision of more appropriate care represent a more expensive way of providing a less appropriate service. If we can make changes here, it will benefit both service users and the system as a whole. Delayed hospital discharge is a symptom of problems across the whole care system. It highlights that we have neither the range nor capacity of services that we require to meet people’s needs. Addressing it is not simply a case of improving discharge planning – it also affects support and capacity in the community and the availability of appropriate supportive care for the period immediately following discharge. At the present time, delayed hospital discharge represents an expensive way of providing the wrong care, in the wrong place, at the wrong time – at the wrong cost to the individual and system, and with the wrong outcome for the individual.


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During the calendar year 2013, an average of 114 people per month aged 65+ experienced a delayed hospital discharge. These people used 23,368 bed days during the period of their delay. Within this number of bed days:

5,072 bed days resulted from care at home packages not being available (representing an opportunity cost of £1.7m); and

7,999 bed days resulted from care home placements not being available (representing an opportunity cost of £2.7m).

We know that a delay in discharge home or to the right care setting has an adverse effect on people. There is also a huge cost to the system of care as well. In terms of the total number of bed days (23,368), this equates to 64 beds in the health system which could be used differently. This represents an opportunity cost of £8m per annum (£344.31 per day). If we look at the care system and try to find areas where we could do better, quite possibly at less cost, then we end up focussing on emergency admissions and delayed discharges of care. Treating these issues as a priority will, we believe, positively impact on the other care system issues. Whilst it is over-simplistic to assume that full “opportunity costs” can be recovered, the challenge for this strategic commissioning plan is the recognition that over 23,000 bed days in the system could, and should, be used differently. We can clearly evidence that investment to prevent unplanned admission and delay in hospital will provide better outcomes for service users. The identified priority areas for such investment are care at home and care home services. Community capacity, day care and tele-health care have also been identified as further priorities which require to be developed.

The challenge is how to find this investment. If the opportunity cost of current patterns is £8m; then we can reasonably aim to commit a portion of this for reinvestment. Local plans will define the detail about the level of costs and the opportunity to recover them, but the key message from this plan is that if we can get better use out of these bed days, then the benefit will be felt either in terms of meeting the challenge of a frailer population; or in making space for us to do something differently with those beds; or to release the resource associated with these beds for reinvestment in the services we know we need, such as Care at Home.


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Applying a Commissioning Approach to CARE AT HOME Provision High Level Care at Home Commissioning Intentions

What does care at home provision currently look like in the Highlands?

The national picture shows a decline in the number of care at home service users, but an increase in the number of hours they receive. This reflects the move from provision of domestic care to the provision of intensive packages of care to sustain people as independently as possible in their own homes.

NHS Highland has a low level of care at home provision comparative to elsewhere in Scotland, and sits third lowest per 1,000 of the population for the number of older people receiving intensive home care (10+ hours per week). Conversely, the number of people who spend the last six months of their lives either at home or in community settings, is marginally higher in Highland than the Scottish average.

At November 2013, there were a total of 17 care at home providers registered in Highland; 16 independent/third sector providers and the in-house provider. There have been five new care at home providers enter the market in Highland over the last three years, and one departure (due to quality issues). Of the new providers, the majority are small/locally based operators.

There are currently around 1,985 care at home service users in Highland in receipt of a total of 13,400 hours of care a week:

Around 60% of hours are delivered by the in-house service;

Around 40% hours are delivered by independent sector providers.

The quantity and quality of care at home provision is also causing current significant challenges:

In the more remote and rural areas, there is currently reliance on in-house provision due to the lower volume and cost of provision in these areas making it less attractive to independent sector interest on current payment arrangements;

Demand for care at home has increased across all areas. Around 5,072 bed days were lost in 2013 as a result of people waiting for a care at home package. Planned investment and securing additional growth in the sector is taking time to come to fruition, as the availability of trained and experienced staff is posing a challenge;

In the more populated areas, independent sector providers have been competing with one another and also with the NHS, to recruit staff;

At least of 60% of the current volume of provision is below a grade 3 (Figure 15), due to the large scale in house service graded a 2 (weak) for care and support during 2013. The quality goal is for all provision, both in house and independent sector, to be grade 4 or above by 2019.


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Figure 15

What do we know about the need for care at home?

Projecting forward, based on existing patterns of care at home provision, we can say that, if nothing changes apart from the increase in population, we will need to provide care to an additional 49 people by 2019. However, we know that we currently have a shortage of care at home provision and that people tell us that they want more options to be cared for at home. This is therefore likely to be a very significant underestimate.

An approximate estimate of the current gap in provision is outlined below:

Historically, there can be up to 40 people at any time, delayed in hospital awaiting a care at home package.

Estimated unmet need for people in hospital of 40 people @ 10 hours per week = around 400 hours per week / £322k per annum.

Estimated unmet need in the community of 246 people @ 10 hours per week = 2,460 hours per week / £2m per annum.

The estimated cost of this current unmet need is £2.3m per annum. Supply

The current split between in-house and independent/third or not for profit provision is around 60% / 40%.

In-house provision is paid at a higher rate than independent/third or not for profit provision.

There is currently competition between providers to recruit.

Not all geographical areas of operation are deemed sustainable.

Not all providers receive high quality ratings via inspection.

It has been an aspiration to move towards reablement, however at the present time there are only 15 specified reablement workers and reablement investment has been focussed on the in-house service.

0% 20% 40% 60% 80% 100%

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Care at Home Gradings 2013 IS and In House Minimum Care and Support Grading

Independent/Third Sector

In House


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Strategic Commissioning Direction What does care at home provision look like in the next five years?

Care at home needs to change from the current state to offer:

Sufficient capacity to meet need

Highland wide coverage

Consistent high quality

A range of models (eg sitter service, reablement)

Flexible and responsive services

We need to rapidly grow capacity and capability of quality care at home provision to meet unmet need. To do this, we need to change the way that we work with all providers through:

Collaborating on recruitment;

Developing a single tariff for all care at home providers by the end of 2014;

Commitment to purchase rates enabling payment of living wage;

Collaborating on geographical zoning for providers so that caseloads/runs are sustainable;

Revising the balance of in-house/independent provision to ensure that this reflects commissioning and SDS principles; and

Investing an additional £1m spend on care at home 2014-2015.

Reablement is not yet fully integrated as a philosophy and there is currently low uptake, with only a limited number of people currently benefiting from this service. The current key model of care at home is therefore a traditional maintenance service, as opposed to a service with a reabling focus. There is a need to roll out reablement practice across all sectors. To do this we will review the use of the £1.4m currently invested in reablement to ensure that it is meeting these aims.


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Applying a Commissioning Approach to CARE HOME Provision

High Level Care Home Commissioning Intentions

What does care at home provision currently look like in the Highlands?

There is a high level of use of care home beds for older people in Highland in comparison with elsewhere in Scotland. The mean age of resident is comparable with the national average at 83 years of age. The length of stay in a care home is shorter than the national average for periods of up to 3 months but longer than the national average for periods of stay longer than a year.

As at November 2013, there were a total of 59 care homes for older people in Highland offering a total of 1,741 beds:

25% of the care homes are operated in-house by NHS Highland, provide 12% of beds and have an average size of 13.5 beds.

75% of the care homes are operated by independent or third sector providers, account for 88% of beds; and have an average size of 35 beds.

The supply of care home provision has evolved through historic purchase patterns, rather than by design, with the result of an uneven spread of provision across the area. The current focus of services purchased, is on a traditional, long stay, care home model.

The quantity and quality of care home provision is currently causing significant challenges:

Independent sector care home occupancy during 2013 was an average of 95%. With current suspension of admissions in place, this reflects actual usable vacant capacity of 2.5%;

The net effect of the care home closures and new capacity is an overall reduction of 30 beds;

In quality terms, 39% of all care home beds during 2013 were considered to be adequate or less by the Care Inspectorate, in terms of care and support (Figure 16);

Figure 16

10%

16%

13%

38%

21%

1%

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Care Home Gradings 2013 IS and In House Minimum Care And Support Grading


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In December 2013, 63% of vacant care home placements were unavailable as a result of unsatisfactory quality;

Out of the 1,741 capacity, 32 beds are dedicated for respite use and only 3 beds are being used for intermediate or palliative care;

The availability of trained and experienced staff is a challenge, with a trend of poor quality care resulting from a high turnover of staff.

Not all care homes have en-suite (toilet and bath/shower) provision.

What do we know about the need for care homes?

We currently purchase 95% of the available independent sector care home capacity, and operate the current 192 in house beds to full capacity.

If nothing changes apart from the increase in population, we will need to provide care to an additional 42 people by 2019. However, we know that we currently have a shortage of care home provision. This is evidenced by:

Up to 30 people being delayed in hospital at any time awaiting a care home package. This equates to 7,999 occupied bed days per year, representing an opportunity cost of £2.75m;

The estimated cost of meeting this current unmet need is £915k per annum (gross nursing care home rate).

We know that some people start off waiting for care at home, but end up needing a long term care home placement; and

The vast majority of admissions take place direct from hospital.

Supply

The in-house care homes predominantly operate small scale provision in the more rural locations.

The cost of in-house provision is higher than independent sector provision – impacted upon by the scale and location of services.

The model of provision in both sectors is mainly a traditional care home service. We do not have many “step up/down” beds

There is competition between providers to recruit in in the small number of locations where both sectors are present.

Not all geographical areas of operation are deemed sustainable.

Not all providers receive high quality ratings via inspection.

Strategic Commissioning Direction What does care home provision look like in the next five years?

The care home sector needs to change from the current state to offer:

Sufficient capacity to meet need

Highland wide coverage

Consistent high quality


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A range of models (eg intermediate care / step up/down/supported accommodation)

Flexible and responsive services

We need more quality provision and flexible use of care home resources. To do this, we need to change the way that we work with providers through:

Implementing a quality schedule: The quality goal is for 95% all provision, both in-house and independent sector, to be grade 4 or above by 2019.

Commissioning short term, reabling care, as an alternative to hospital;

Exploring new models of care such as housing with support

Collaboration on workforce issues to ensure a sustainable pool of sufficiently trained and qualified staff;

Collaboration with communities on alternative models to meet local needs.

Applying a Commissioning Approach to Other Areas Work is currently being undertaken to develop commissioning intentions for the services below: End of Life Care There is a need to support Highland’s people to plan in advance to ensure health care and other end of life decisions are honoured. We aim to provide secure electronic access to advance directives and encourage provider training and education in end-of-life care; establish a process that engages seriously and terminally ill patients in shared treatment decision-making with their clinicians and carers; and use tele-health care and redesign methods to improve access to palliative care. Detailed work is yet to be undertaken on this. Telecare

Telecare refers to a service which uses a combination of alarms, sensors and other equipment, to help people live more independently and safely in their own home. There are currently 2,486 people in Highland aged 65+ who use a telecare service. This represents 62% of all people using telecare and 5% of the total 65+ population. The vast majority of service users have an alarm (93%), and only a small number have telecare (4%) or both (2%). Highland has the fourth lowest use in Scotland of telecare amongst those aged 75+. There is therefore scope for improved uptake of telecare through promotion of:

Community alarms

Equipment that aid daily living (either stand alone or connected by sensors to a centre)

Tracking or monitoring devices

Health monitoring (vital signs) and interactive products linked to risk management

Communication devices

Information and advice


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Forecasting requires more work to understand the role of telecare in reablement but also response mechanisms in care at home. Day Care

There are total of 30 registered day care services for older people operating in Highland, offering 465 places; 16 day care services are operated by the in house service (delivering 65% of day care places) and 14 day care services by independent/third sector providers (delivering 35% of places). Services are provided in a combination of stand alone services or as part of a care home service. In several areas across Highland, there has been a transition away from delivering a traditional day centre model, towards a more flexible and community encompassing community resource. Community Activity In addition to third sector activity in providing care home, care at home and day care services, there are a number of third or not for profit services operating in Highland, delivering a range of support and preventative services to benefit older people, such as community transport, health and wellbeing hubs and social contact services. As set out in the appended current developments (Appendix One), a number of Community Networkers are now in place to support and develop community initiatives and to work alongside other community based areas of work such as Living it Up, Lets Get On With It and Health Inequality Workers. As mentioned previously, all of these third or not for profit services and this community activity provide essential local networks for service users and are vital to ensuring people feel connected, involved and informed.


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TAKING HIGHLAND COMMISSIONING INTENTIONS FORWARD In taking forward our stated intentions in terms of care at home and care homes; and the emerging intentions for day care, telecare and community capacity, we would wish to convey the following messages to our partners: Key Market Messages/Opportunities – What We Are Looking For:

Local and accessible services.

Increase opportunities for individuals and communities to improve their health and wellbeing.

Reduced demand for intensive high cost service.

Increased flexible and rapid response short term alternatives to hospital admission.

Improved quality and choice of provision.

Disinvestment from poor quality services, services delivering poor outcomes for service users or services which are not aligned to NHS Highland’s stated outcomes.

Increased and improve the use of technology.

Sufficient availability of qualified and experienced staff working in care.

Characteristics of Commissioning Partners

Demonstrably and consistently places the service user at the centre of their service.

Promotes service user independence and can demonstrate improved service user outcomes.

Operates transparently and routinely engages with service users and relevant stakeholders.

Willingness to adapt, innovate, change and improve.

Solutions focussed.

Delivers quality, efficient and effective services.

Competent trained staff and a commitment to the living wage.

Willingness to collaborate with other providers to achieve quality and efficiency.

Commitment to addressing inequalities and variations.

Procurement/Contract Intentions

Consideration of most appropriate procurement options eg promotion of co-production and community based partnership ventures.

Using the experience and knowledge of users, carers and providers to help shape future service specifications.

Implementation of person centred and outcome based specifications.

Implementation of outcome based monitoring, with a continuation of some input and output monitoring.

Implementation of a payment related quality schedule.

Level playing field.

Movement toward tariffs.

Flexible contracts for self directed support compatibility.


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Other Population Groups This plan has focused on older people but there is a need to look in a similar level of detail at other client population groups, such as adults with a learning disability, mental ill health, acquired brain injury etc. It is intended to take the learning from the development of this plan, to inform the approach to developing separate plans for other key population groups and to do so during 2014-2015. Again, it is intended that a co-productive approach will underpin the development of these further plans, with the respective Improvement Group playing a key role. Action This strategic commissioning plan has set out the intended direction of Highland and highlighted what services for older people are required over the period 2014 to 2019. Further areas of work are now required as follows: a) Local delivery plans are required, in order to articulate how the strategic

commissioning plan will be delivered across Highland;

b) Contact with current and future providers and any interested stakeholders, who have comments to make on this strategic commissioning plan; and/or wish to work with NHS Highland and its partners to achieve the stated priorities and outcomes

c) The commissioning direction of the other client groups requires to be considered and set out in more detail during 2014-2015; and

d) Ongoing iterations of this strategic commissioning plan is required as part of

continued dialogue with current and future service users, their carers and providers of services, to ensure robust future planning.


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Appendix One Glossary

Care worker

Paid care worker, employed by a care provider or by a service user through self directed support, to deliver care services in accordance with an agreed care plan.

Carer

Unpaid carers (as distinct from care workers) who provide care to family members, other relatives, partners, friends and neighbours of any age affected by physical or mental illness, disability, frailty or substance misuse.

Commissioning The planning of (all types of) investment to achieve agreed outcomes for defined populations.

Commissioning Partners

Agencies across all sectors in Highland, as represented at the Adult Services Commissioning Group, who have an interest in the commissioning of adult care, who are committed to forging positive working relationships and engage with openness and transparency, mutual respect and a joint understanding of their roles and responsibilities.

Decommissioning

Means the process of disinvesting from a service, normally for the purpose of reinvesting in other services, in line with an agreed commissioning vision and approach.

Older Person

For the purposes of this document, an older person is considered to be someone aged 65 or over.

Procurement

The process by which public bodies purchase goods, service and works from third parties - one element of the wider commissioning process.

Strategic Commissioning

All the activities involved in assessing and forecasting needs, links investment to agreed desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place.


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Appendix Two Current Developments

Care at Home Commissioning

Establishment of a cross-sector short life working group, which is now a care at home commissioning and development group.

Outcomes: o Establishment of weekly allocation meetings, at which there is collaboration

between all providers in order to meet demand and expedite discharge from hospital.

o Improved communication with and between providers. o Improved recycling of resource through packages being highlighted for safe

reduction. o Developing commissioning approach for April 2014 and beyond.

Improvement Lead (Care Homes)

Establishment of a post to promote partnership working with third and independent sector care homes and day care services and to promote quality issues and care standards across these services.

Outcomes: o A quality, appropriate, person centred experience for service users which

reflects changing need and demand. Quality Schedule

Developing arrangements for a cross sector and pan Highland quality schedule approach, to be co-produced with users, carers and providers of care services, and implemented from April 2015. This area of activity will also include co-producing arrangements for independently eliciting user and carer views on the services they receive.

Community Networkers Eleven Community Networker posts are now in place across Highland, to support the shift of resources into community based support and preventative care. The Community Networkers have access to the Community Initiative Fund to support and develop local initiatives – and make a real and immediate difference to peoples lives, from the purchase of cushions for more comfortable seating at lunch clubs; to beauty treatments for older people given by college students; and the purchase of a rowing boat and table tennis equipment to enable older people to exercise. Living it Up Living it Up is a programme working with five local partnerships across Scotland (including Highland/Argyll and Bute) aimed at empowering people to improve their health and well-being.


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It is initially aimed at the over 50s but will also be of benefit to people living with long term conditions, care givers and those who just want to keep healthy, happy and safe. Living it Up will deliver innovative and integrated health, care and wellbeing services, information and products via familiar technology enabling people to keep better connected with their communities and those they care for and receive care from. These technologies will include TV, mobile phone, games consoles, computers and tablets.


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Appendix Three References

Figure 1 AUDIT SCOTLAND (March 2012) Commissioning Social Care (based on work by the IPC, Oxford Brookes University, 2007) Figure 2 KATZ, J. HOLLAND, C. PEACE, E. (ed. BLOOD, I) (2011) A Better Life – What Older People with High Support Needs Value, published by Joseph Rowntree Foundation Figure 3 NATIONAL RECORDS OF SCOTLAND (2014) Highland Council Area – Demographic Factsheet Figure 4 STARK, C. (2013) Older People with Dementia Health and Social Care Needs Assessment Figure 5 INFORMATION SERVICES DIVISION (2014) Delayed Discharges in NHS Scotland Figures from February 2014 Census Figure 6 INFORMATION SERVICES DIVISION (2014) Delayed Discharges in NHS Scotland Figures from February 2014 Census Figure 7 INFORMATION SERVICES DIVISION (2014) Delayed Discharges in NHS Scotland Figures from February 2014 Census Figure 8 INFORMATION SERVICES DIVISION (2014) Delayed Discharges in NHS Scotland Figures from February 2014 Census Figure 9 NHS HIGHLAND (2014) NHS Highland Emergency, Elective and Day Case Trends Figure 10 NHS HIGHLAND - HEALTH INFORMATION AND HEALTH INTELLIGENCE (2013) NHS Highland Population Density Figure 11 NHS Highland (2013) Highland Quality Approach (Adapted from Virginia Mason) Figure 12 NHS HIGHLAND (2010-2011) Highland Health and Social Care Spend (High Level) Aged 65+ Figure 13 Highland NHS HIGHLAND (2010-2011) Highland Health and Social Care Spend Aged 65+ (Detailed)


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Figure 14 NHS HIGHLAND (2010-2011) Variation in Spend Across Planning Areas Figure 15 Analysis from Care Inspectorate Data Store: Care at Home Gradings 2013 – Independent Sector and In-House Minimum Care and Support Gradings Figure 16 Analysis from Care Inspectorate Data Store: Care Home Gradings 2013 – Independent Sector and In-House Minimum Care and Support Gradings


Item 8.2

MONITORING THE DELIVERY OF IN-HOUSE SERVICES

Report by George McCaig, Head of Care Support, on behalf of Deborah Jones, ChiefOperating Officer

This report outlines the proposed activity to be undertaken during 2014-2015 in relation toin-house services, to reflect the outputs required by NHS Highland to discharge relevantresponsibilities as strategic commissioners and sets out the expectations for noting byCommittee Members.

1.0 Background

Strategic Commissioning Plan for Older People

1.1 The Strategic Commissioning Plan for Older People at 8.1 of the agenda, sets out thehigh level commissioning intentions, focussing in particular on care at home and carehome services. Within this plan, the following is noted as commissioning priorities:

The care at home needs to change from the current state to offer:

Sufficient capacity to meet need Highland wide coverage Consistent high quality A range of models (eg sitter service, reablement) Flexible and responsive services

The care home sector needs to change from the current state to offer:

Sufficient capacity to meet need Highland wide coverage Consistent high quality A range of models (eg intermediate care / step up/down/supported accommodation) Flexible and responsive services

Furthermore, the procurement and contract intentions are also stated, as follows:

Consideration of most appropriate procurement options eg promotion of co-production and community based partnership ventures.

Using the experience and knowledge of users, carers and providers to help shapefuture service specifications.

Implementation of person centred and outcome based specifications. Implementation of outcome based monitoring, with a continuation of some input and

output monitoring. Implementation of a payment related quality schedule. Level playing field. Movement toward tariffs. Flexible contracts for self directed support compatibility.

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1.2 The key messages from the plan are that:

a) improved quality is required to attain the strategic commissioning plan’s goal of allproviders attaining a Care Inspectorate grade 4 (good) or above by 2019;

b) a tariff approach should be implemented; andc) there should be a level playing field between sectors.

2.0 In House Service Provision 2014-2015

2.1 In moving further towards a level playing field between sectors, the following outputsare proposed:

Quality ScheduleThe in-house adult social care services delivered by NHS Highland (care at home, carehome, housing support and support) have previously not been subject to the samecontractual arrangements (or internal service level agreement) applied to providerscontracted to provide the same services.

In transitioning towards a more level playing field, it is important to apply theexpectations of contracted services to those delivered in house, in terms of the servicespecification, quality and provision of information. It is therefore proposed to develop aquality schedule with all in house services, which will be monitored in the same way asexternal services. This schedule will ensure a shared understanding of serviceexpectations and will also serve as a service level agreement regarding outcomes andtargets.

Independent Review of Care Services

The developing quality schedule activity will also include co-producing arrangementsfor independently eliciting user and carer views on the services they receive. This isintended to feed in to existing contract monitoring arrangements and again, it isintended this would also apply to in house services.

Personal Outcome Plan

Once trials are complete and the process embedded, the outcomes of the annual clientreviews will also feed into this process providing a measure of the quality of service theindividual client is receiving.

3.0 Governance Implications

Staff Governance

Patient and Public Involvement

Clinical Governance

Financial Impact

No anticipated impact regarding these areas at this time.

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4.0 Risk Assessment

No anticipated impact regarding this area at this time. It is highlighted that by widening thecontract monitoring approach to in-house services that any issues would be highlighted andrisks minimised.

5.0 Planning for Fairness

No anticipated impact regarding this area at this time. It is highlighted that the intention ofthe proposals described within this report are to ensure parity with the arrangements in placewith independent and third sector providers.

6.0 Engagement and Communication

Engagement with operational management and staff will be required to implement theproposals internal. Wider engagement and communication is regarding the development ofthe quality schedule is already being taken forward as part of the commissioning strategy.

George McCaigHead of Care Support

10 April 2014


Item 9.1

HEALTH AND SAFETY UPDATEReport by Bob Summers, Head of Health and Safety

Introduction

1.0 The Chief Operating Officer and Chairs of the Health and Safety Committee Chairswrote to the Directors of Operations and Head of Estates in November 2013 about the newlyrevised Health and Safety Improvement Programme. The programme was split into twoimprovement plans, a corporate and operational plan and units / services were asked toensure that the appropriate planning, implementation and monitoring arrangements were inplace to deliver the outcomes.

1.1 Appendix 1 provides the detail on the improvement areas, outcomes, reportingtimeframes governance and monitoring arrangements. The corporate level plan hasidentified “leads” and “responsible persons”. The identification of leads for the operationalplan has been left to the discretion of the Operational Health and Safety Groups.

Improvement Programme

1.2 Governance & Assurance. The diagram below outlines the governancearrangements and assurance framework for Health and Safety across the Board. This will bereflected in the forthcoming Health and Safety Policy update.

1.3 Promotion & Planning. The plans have been discussed and promoted in mostcases with each of the Directors of Operations (DOO’s) over the past couple of months eitherdirectly or through the Operational Health, Safety and Fire Groups which are jointly chairedby the DOO and staffside. Local planning has begun and the groups are beginning to reportprogress into the Health and Safety Committee as agreed, with Health and Safety managersfacilitating the process.

1.4 Delivery & Reporting. There is less emphasis on the production of detailedpapers and now more on populating the respective plans and using this to drive and set thecommittee and operational group’s agenda on a quarterly basis. Both plans are now hostedon a cloud / web based collaborative planning tool. This makes the updating, collaborationand sharing process far simpler, more consistent across four operational units and easierwhen it comes to providing documentary evidence for completed actions.

1.5 Progress So Far. The programme was launched in Nov, and the new planningtool was introduced in Feb 14, so there has been an initial delay as a result of training,synchronising Operational group meetings with Committee meetings, uploading andlocalising plans etc however the new populated plans and reporting format will be in place bythe 15 May 14. Increasing workload and staff vacancies may also have a slight impact ondelivery timescales. The intention is to make these plans as “live” as possible, in other wordsas new risks arise, they will be prioritised and added accordingly.

1.5.1 Since Nov 13, corporately a number of improvements have been made with respectto:

Governance, Assurance and Policy Framework for managing health and safetyacross NHS Highland

Identifying Moving and Handling training needs for care at home staff Violence & Aggression training for residential care Establishing systems for face fit testing staff for protection against respiratory

infections Lone working e.g. improvement interventions for high risk community staff groups

(see below) Fire safety risk assessments Devising safe systems of work for entry into confined spaces (Estates focused) Legionella risk assessments and written schemes of control Sharp Safety

Slower or less progress has been made in respect to:

The safe use and management of bed rails in in-patient, residential care andcommunity settings

Agreeing the responsibilities and provision of appropriate training for the RegisteredPremises Officer role

1.5.2 Operationally, the following improvements have been made since Nov 13:

Improved local governance, agenda planning and attendance Operational plan has been populated locally with action leads Health and Safety walkrounds dates have been established and combined with other

improvement visits, for example HEI Health and Safety Awareness Days have been organised in NW and SM, likewise

with Raigmore and Argyll & Bute but they will adopt a different approach.

A greater focus over the next 2 years on workplace risk assessment. This will involve

focused support and more active hands on training, supported by a risk assessment

workbook (draft at present) which outlines typical task / discipline based hazards and

a range of generic controls. This will assist managers to establish and implement a

range of site and task based assessments.

In addition to improving the quality and extent of risk assessments, there will also bea specific focus on

o Lone Workingo Generic & Patient Specific Moving & Handling Taskso Fire safetyo COSHHo Sharps Safety

Incident Management & Reporting

2.0 Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) RegulationReports

NHS Highland is required, under the RIDDOR regulations, to report deaths, certaincategories of injuries, dangerous occurrences (near-misses), time based absences andoccupational diseases if it is caused by an accident “arising out of or in connection with work”to the Health and Safety Executive (HSE). With respect to deaths, these are reportable,whether or not they are at work, if it is caused by an accident arising out of or in connectionwith work, so this may include patient deaths. It is also an offence not to report events thatmeet the criteria.

2.1 The RIDDOR Regulations and reporting categories changed significantly this year,thus it has not been possible to provide a side by side comparison. However over the past 12months we have made a number of notifications and reports to the HSE

RIDDOR Notifications for 2013-2014Reportable RIDDOR Event 2013-2014

Fatality 1*

Specified injury (previous major) 14

Over 7 day absence 23

Dangerous occurrence 2

Work related disease 6

Injury to member of public taken tohospital

4

Grand Total 50

* Subject to a HSE Investigation in Raigmore on 23 Apr 14

By comparison, the RIDDOR notifications made to the HSE, since 2010 were as follows:

2010-2011 492011-2012 382012-2013 45

2.2 Sharp Safety. The Health and Safety (Sharp Instruments in Healthcare)

Regulations were enacted in May 13. The purpose of the regulations is to reduce needlestick

injuries and the risk of exposure to blood borne viruses in healthcare. The key features of the

new regulations include more specific requirements on: risk assessment, elimination,

prevention and protection, training, reporting and response and follow up post exposure. In

terms of elimination, the principle is to replace conventional needles with safety engineered

devices.

A Sharps working group was formed last year this reported to the health and safetycommittee. So far, a number of devices have been changed, policies and procedures havebeen reviewed and published, needlestick incident reports have been redefined withinDATIX, and a letter with supporting guidance will be distributed this month to the OperationalUnits for action, with a specific focus on improving training uptake which is currentlyinadequate.

2.3 Lone Working An initial paper was submitted to the Health and Safety Committee inFeb 12 about our current position in managing high risk community groups with respect tosafe lone working. The paper identified a number of risk gaps in our existing systems andpractice for these groups, such as; risk assessment, local procedures, escalation, situationalawareness etc. Two pilots were carried out across some of our community teams using alogging in and out mobile phone service which is managed by a call centre.

As a result of this work a lone working improvement plan has been devised and will be rolledout across all at-risk community teams over the next two years. Progress will be monitoredby the Health and Safety Committee and Operational Health and Safety Groups. A businesscase will be submitted at the end of May to support the procurement of a lone working mobilephone service which utilises existing phones. NHSH lone working is likely to increase, notdecrease, as the balance of care shifts more into the community, so it is important we reviewour systems now and make the necessary improvements to protect our frontline staff. .

HSE Activity

2.4 HSE activity over the past year has been limited, as their role has become morereactive than proactive as a result of the government deregulation agenda and the Fee forIntervention Scheme, where duty holders are charged for the regulators enforcement timewhere material breaches of health and safety law are identified.

Bob SummersHead of Health and SafetyApril 2014

Headquarters: NHS Highland, Assynt House, Beechwood Park, INVERNESS IV2 3BW

Chair: Garry CouttsChief Executive: Elaine Mead

Assynt HouseBeechwood ParkInverness, IV2 3BWTelephone 01463 717123Fax 01463 235189www.nhshighland.scot.nhs.uk

Date 29 October 2013Your RefOur Ref bs/nf improvement prog 2014_2016.doc

Dear Colleague

NHS HIGHLAND HEALTH AND SAFETY IMPROVEMENT PROGRAMME 2014–2016

1.0 Introduction. Our purpose in writing is twofold. Firstly, to share the recently updated Health andSafety Improvement Programme. Secondly, to ask you to ensure that appropriate arrangements are put inplace to facilitate delivery of the plan in your area along with monitoring and reporting mechanisms. Thefollowing paragraphs provide some background information on the development of the plan and somesuggestions for how it should be handled. We have not been prescriptive on this as we feel that you are betterplaced to decide on the arrangements for your own particular area.

1.1 Background. In August 2010, the NHS Highland Board ratified the Health and Safety Policy andStrategic Implementation Plan. In 2011 a rolling work programme was launched to deliver the key priorities setin that strategy along with those identified in the National Occupational Health and Safety Strategic Frameworkfor NHS Scotland – ‘Safe and Well’, launched in March 2011. The programme identified and set priorities atboth Corporate and Operational Level, the delivery of which was overseen by the Health and SafetyCommittee and the Operational Health and Safety Groups respectively.

1.2 Drivers and Risk Profile. The policy, strategy and work programme exist to ensure NHS Highlandmeets its duty of care to its staff and others, by providing, in a prioritised manner, a safe workplace free fromthe risk of foreseeable injury and ill health. However over the past 19 months, our risk profile, particularly in theNorth, has changed so significantly, as a result of the Adult Social Care integration and the operationalrestructuring process, that the previous 2011 programme requires revision and updating to reflect thosechanges.

1.3 Revised Programme. In Aug 2013, the Health and Safety Committee endorsed the revisedHealth and Safety Improvement Programme 2014-2016. This is a consolidation of the more significant riskstaken from a range of other sub plans which are maintained and managed by various working groups andindividuals. This approach will provide the Health and Safety Committee, and the Operational Units, withoversight and assurance that the “right risks” have been identified and prioritised for action. The programme issplit into two improvement plans and has the following focus:

Corporate Improvement Plan. An outline1, with themes and planning / reporting timeframes isshown at Appendix 1. The plan focuses on making improvements in existing systems and/or devisingnew proactive systems of risk control, for example: routine safety leadership walkrounds, competencebuilding for senior-frontline managers, a clear monitoring strategy, improved access to training, as wellworking through a series of prioritised compliance based issues. The operational units will be requiredto implement some of these new systems as and when they are developed and rolled out.

1 The full programme is detailed and will be forwarded for information only to Dirs of Ops. The Operational Units Health and SafetyManager(s) will hold the most up to date version.

cthom02

TextBox

Appendix 1

Operational Improvement Plan. An outline, with themes and planning / reporting timeframes isshown at Appendix 2. The plan, takes a similar approach as above, with the main intention of reducingthe level of reactive unplanned work (“reacting” to incidents and HSE interventions for example isexcessively costly) by establishing more proactive systems and local procedures to managing our keyrisks. The key focus of this plan is risk assessment. The plan takes a templated approach. It sets outcore areas of improvement work required across all the Operational Units, but also recognises thateach unit is different, and will have its own unique issues / risks to manage, hence the addition of alocalised template.

Interdependencies. Both plans, Corporate and Operational, are structured into similar themes whichrepresent the key components of a Health and Safety Management System. Whilst there are separatework streams within each plan, they are interconnected and linked, and some aspects, for example,cannot be implemented operationally until the work is completed at a Corporate level.

1.4 Ownership & Delivery. This work programme is “owned” by NHS Highlands’ Board, anddischarged and operationalised through the Chief Operating Officer to the Operational Units via the Directorsof Operations across their management structure. A number of leads, predominately subject matter experts,have been identified for each of the work strands identified in the Corporate plan. No leads have beenidentified in the Operational plan, this has been left to the discretion, control and planning activities of theOperational Health and Safety Groups.

Health and Safety Managers, whilst they are not accountable for the delivery of this plan, they do have a keyand fundamental role in technically guiding and supporting their Directors of Operations and managers toplan effectively.

1.5 Governance and Monitoring Arrangements. The Health and Safety Committee willmonitor progress, on a quarterly basis, against the standards and timeframes set in the improvementprogramme, and provide direction as and when required. The corporate plan will help to set and drive theCommittees quarterly agenda planning cycle.

Operational Units are to adopt a similar approach through their established groups. They should work throughthe template improvement plan, using the “year of focus” and the “First Progress Report to Committee” date(shown in full plan – not appendices) to plan and set their quarterly agenda. To help coordinate this effort anagenda planning / reporting template has been produced (detailed in the full plan), this should help set amore focused agenda to deliver the required improvements.

Routine updates will be provided to the Highland Health and Social Care Partnership as and when required.This will include issues relating to progress, impacts affecting delivery, major incidents, press / media interestetc. In addition from 2014, the Operational plan will from part of the Operational Units Delivery Plan.

1.6 Reporting Timeframes Each action / piece of work in the corporate plan has a “designated lead /risk owner”, a “Year of Focus” (2014-2015 or 2015-2016), and a “First Progress Report to Committee”. Thelatter is not intended to be a completion date, but it is a forecasted planning date, so issue owners / leadsshould forward plan, and use these dates as initial milestones, and be in a position to update the committee onprogress. A similar approach has been taken with the Operational Plan, except units will be required toundertake some initial planning to identify work strand leads.

Headquarters: NHS Highland, Assynt House, Beechwood Park, INVERNESS IV2 3BW

Chair: Garry CouttsChief Executive: Elaine Mead

1.7 Conclusion. Health and Safety practice cuts across all organisational and professional boundaries,whether they are clinical or non-clinical issues. We commend this Improvement Programme to you and areconfident that it will improve both the health and safety of our staff, our patients and others that we work with,enhancing both the quality and efficiency of our services.

Yours sincerely

Deborah JonesChief Operating Officer

Elaine WilkinsonJoint Chair of the Health and Safety Committee

Anne GentDirector of Human Resources

Elspeth CaithnessJoint Chair of the Health and Safety Committee

Corporate Health and Safety Improvement Plan 2014-2016 Outline Summary Only

Plan Themes

Governance, Policy & Leadership

Revise & Update the Boards Health and Safety Policy

Chairs of HS Committee to Attend Op Group Meetings at Least 2 per year

Devise a topic/hazard based safety walkround system for senior managers,based on the "visible and felt leadership" model, that focuses on action, people

and systems.

Plans & Objective Setting

Working Sub Groups to have Terms of Reference, Outcomesand Work Programme in Place, progress to reported

quarterly basis

Risk Assessment

Identify and Create a more efficient solution for sharing common task basedGeneric Risk Assessments for frontline units

Risk Based Compliance

Safety

Fire Safety - risk assessments to be placed on 3i Fire Master system, deliverytraining plan, deliver on site emergency evacuation exercises

Management of Contractors - finalise procedures, adopt THC approved

contractors list, carryout options appraisal to manage existing ASCcontracts, Run Awareness Education Session for Non Estates Managers with

Contract Authorising Powers e.g. Med Physics, eHealth, Telecoms

Window Restrictors - devise plan to Assess Higher Risk ASC Sites & FitRestrictors, Risk Assess & Establish a PPM Programme for Health & Social

Care sites, establish window management procedure

Electrical Safety - For ASC Sites, review previous ECS report & confirm that

remedial actions have been carried out. Confirm by on site visit. DeviseElectrical maintenance programme

Working at Height - Establish, Rollout & Commence Implementation

of Estates based Working at Height Plan

Confined Spaces - Establish, Rollout & Commence Implementation ofEstates based Confined Spaces Plan

Community Equipment Project - Undertake NHS Highland Wide scoping

exercise and identify key priorities, opportunities and risks for action

Lifting Equipment - ASC Sites Only - Merge and Develop Equipment Schedules,Develop PAT testing Database and Contract

Electric Profile / Bed Rail Management - Devise Appropriate Systems &

Arrangements for Managing Bed Rails effectively and safely in In Patient

Settings, produce & implement procedures. Scope out requirements forcommunity & ASC sites. Establish Maintenance Programme for Electric Profiling

Beds

Lone Working - Post evaluate 2 High Risk Community LW Pilots, PrepareBusiness Case, Seek Approval to Proceed, Identify Funding & Resource,

Prepare Project Charter and Develop LW improvement plan for high riskcommunity areas

Moving & Handling - review & update MH policy & procedures. Continue to

deliver competency assessments in high risk areas. Undertake AB Baseline

Audit & Commence AB keyworker system. Review and improve MH inductionprocess. Identify training needs for Care at Home, Deliver MH plan Outcomes

for Residential Care and LD units.

Medical Gases - Continue to work through the Medical Gases Work Plan, keythemes for 2013 include development of corporate and operational

documentation, identify training needs and development clear arrangements

for transportation of medical gases

Health

COSHH

Management Arrangements - Audits for medium-high risk areas,

Improved Surveillance, Improved COSHH Assessment Accessibility,

Generic Assessments for Ward Areas

Sharps Safety - devise sharp safety plan, inform Op Directors +clinical leads re risk assessment, traditional needle replacement

programme, training

Water Safety - Legionella Risk Assessment, Management & MaintenanceArrangements to be verified and Implemented for ASC Sites, Water

Safety Written Schemes to be Established for Hospital Sites, Raigmore1st, Water Safety Written Scheme Implementation Programme to be

devised

Asbestos Management - Existing Healthcare Buildings to be added to THC

Online Asbestos Register

Health & Wellbeing - Review Terms of Reference, Membership andWorkplan for MH in the Workplace and provide clearer guidance and

support to the operational units to improve health

First Aid at Work - Facilitate ASC Units to Risk Assess their First Aidrequirements and implement NHSH FAW Polciy

DSE -Revise & update current DSE management arrangements, online training,

risk assessment resource & streamline DSE payments between ASC units &existing Health Units

Competence & Training

Development - Revise RPO Training, Sharps Safety for Non Clinical Staff, Identify

Appropriate Manager Competencies and devise blended training & learning materialto support the newly revised / updated HS responsibilities, Estates legionella

training, Contractor induction process, estates working at height, identify VA training

needs for ASC units

Identifying Delivery Solutions - online DSE trgsolution, identify First Aid at Work training options

Delivery - IOSH Safety for Senior Executives, Board Development Day, COSHH

Assessor & Awareness Training, Rollout of MH Competency Assessment

Consultation & Communication

Develop Quarterly Safety Bulletin

Redevelop Health and Safety Intranet Page

Health and Safety Handbook

Monitoring

Standardisation of ASC Incident Reporting Procedures

Undertake Quarterly Thematic DATIX Incident Reviews & Analysis, feed into Op HS

Groups, & place on HS Committee Agenda for discussion & direction. Themes asfollows:

Feb 14 - Sharps - Clinical & Non Clinical Incidents

May 14 - Violence & Aggression + Lone Working + Security

Aug 14 - Slips Trips Falls (Staff)

Nov 14 - Slips & Trips (Patients)

Feb 15 - Estates Incident Data

Review

Undertake a Corporate Systems Review and feed into 2014 & 2015 Annual Report

Planning & Reporting Timeframe's

Nov 13

Face Fit Testing Strategy

First Aid at Work

DSE

Feb 14

Fire Safety - Risk Assessments, Training Delivery, On SiteEmergency Evacuation Exercise

Window Restrictors

Confined Spaces

Community Equipment Project

Electric Profile / Bed Rail Management

Lone Working

Moving & Handling

COSHH including sharp safety plan

Health and Wellbeing

VA Training Needs for ASC Units

ASC Units Incident Data Analysis & Review

Incident Analysis - Review of Sharp Injuries

May 14

Health and Safety Policy - Agree Management Responsibilities

Window Restrictor - PPM Programme

Lifting Equipment - ASC Units Only - Equipment, Inspection &Maintenance Schedules,

Community Bed Rail Management - Scope out existing management

arrangements in the community and ASC units

Care at Home Lone Work Risk Assessment

Moving & Handling Update

Medical Gases Update

Incident Analysis - Review of Violence & Aggression + Lone

Working + Security

Training Update include Senior Management HS Training

Annual HS Review

Aug 14

Review of Chair attendance to Op HS Groups

First DRAFT of Health and Safety Policy Rewrite to be considered

ASC Contract Management Transfer Review

Electrical Safety - For all ASC sites - review previous ECS report

& confirm that remedial's have been actioned

For ASC Sites - Establish maintenance contract to undertake PAT testing

Development of Sharp Safety toolkit for non-clinical at risk staff

Identify Legionella Training Needs for Estates & others

Update on Moving & Handling Competency Assessment Rollout

Incident Analysis - Review of Slips Trips Falls (Staff)

Nov 14

Update on DRAFT Visible Felt Leadership Walkround Model for

Senior / Middle Managers

Review of e-Risk Assessment Solutions

Management of Contractors - finalise policy, awareness session for

non-estates contract managers

Ratify Window Restrictor Procedure

Electrical Safety - Update progress with Electrical Maintenance on ASC sites

COSHH - Make Generic Ward H Assessments easily accessible +Bio Assessments for Incidental Healthcare Work

Training Update

Draft HS Quarterly Bulletin

Lone Worker Audit Feedback

Incident Analysis - Review of Slips Trips Falls (Patients)

Feb 15

Moving & Handling Policy Review

Redevelopment of Health and Safety Intranet Website

Physical Restraint Audit Findings

Incident Analysis - Review of Estates Incident Data

May 15

Devise Health and SocialCare Employee Handbook

COSHH - feedback from further skin audits- clinical areas only

Control of Contractors Audit

Moving & Handling - Audit Completion & Implementation of

Generic and Individual Risk Assessments

Aug 15

Agenda to be based on Issues Carried Forward

Nov 15

Management of Contracts Induction Training Process - Update

Scope feasibility of standardising all RIDDOR reportable systems

Denotes a KPI

bsumm01

Text Box

Appendix 1

Operational Health and Safety Improvement Plan 2014-2016Outline Summary Only

Plan Themes

Governance & Policy

Realignment of OpHS Groups

Improve Attendance to Groups and Committee

Realign Group Agenda to Plan

Representation of ASC Unit Managers

Agree Dates

HS Leadership Walkrounds

Annual HS Awareness Session

Plans & Objective Setting

Produce an 2 Yr Operational Plan

Set Management Responsibilities

Risk Assessment

HS Groups to ensure that:

Sites / departments / local managers undertakerisk assessment and implement their findings

Monitor / audit the progress of riskassessment planning at a local level

Frontline Units &Managers

Ensure, through audit, that each site has a localmechanism in place to undertake and implementrisk assessments in line with NHS Highlands PN03Risk Assessment Procedure

Identify, Nominate and release staff or riskassessment training

Focus Risk AssessmentAreas for Frontline Units &Managers -PROPORTIONATE & WHERERELEVANT !!

Violence and Aggression

Moving & Handling

Bed Rail Management

Lone Working

Occupational Road Risk

Risk BasedCompliance

Safety

Management of Contractors

Fire Safety

Window Restrictor Maintenance

In-Patient Bed Rail Management

Health

COSHH - ManagementArrangements

COSHH - Sharp Injury ReductionIntervention

COSHH - Skin Health

COSHH - Water Safety Management

Mental Health in the Workplace

Competence &Training

Improve compliance with Statutory & Mandatory TrainingProspectus

Identify Those NOT Trained and bring up to date

HS Managers devise 2 Year Operational UnitTraining Plan

Local Managers to retain robust on site training records

Moving & Handling

Risk AssessmentTraining

Sharps SafetyTraining

Consultation & Communication

Operational Units to decide on best approach to ensure good communicationof health and safety activities with local managers, staff and staffsiderepresentatives.

Monitoring

Active

RIDDOR

COSHH - Audit & Closing the Loop

COSHH-Skin Health

Lone Working

Moving & Handling

Risk Assessment

Violence & Aggression

Reactive

DATIX Reviewing, Analysing & Acting on Data

Review

Review Op HS group progress against plan and submit report to HSCommittee for Annual Report

Planning & Reporting Timeframe's

Nov 13

Discuss, Agree & Set Date for Annual HS Awareness for Senior - Middle Managers

Feb 14

Realignment of Op HS Groups

Identify Local Operational Risks

Fire Safety - Establish and delegate management responsibilities as per Fire Policy

COSHH

Ensure managers of medium-high risk areas are implementing the newprocedures

Audit - Feedback COSHH Audits into Op HS Groups, ensure local units act onfindings and implement recommendations

Water Safety - Ensure Pseudomonas flushing regime to be implemented

May 14

HS Groups - Directors of Ops to improve management attendance to Op Unit andArea HS Groups. This is a KPI

Responsibility - Delegate Management Responsibility for the delivery of this plan,preferably risk owners

Risk Assessment

Group to ensure that Sites / departments / local managers undertake riskassessment and implement the necessary findings

RA Training Gaps to be identified and staffreleased for training

Fire Safety Arrangements

Site based Emergency fire action plans to be up to date, withthe arrangements in place to implement it

Frontline Managers to ensure staff havereceived training

Lone Working - Identify high risk lone worker staff / teams and auditcurrent performance

Moving & Handling - Monitor the completion of LearnPro MH Modules, report intoGroup, and take action where necessary

Sharps Safety - Implement Sharp Injury Reduction Plan

Aug 14

Mental Health in the Workplace - Identify Hot Spot Areas/Groups/Teams,Risk Assess and Implement Action using HSE Management Standards

Physical Restraint Monitoring - VA Prevention Manager toSupport Op Units

Nov 14

Safety Leadership Walkrounds - Combine key staff HS issues (e.g. Fire Safety,House Keeping, Skin Health, Moving & Handling practice etc) with existingpatient safety walkrounds

VA Risk Assessment - VA Prevention Manager to Support Op Units in auditinguptake and promoting use of individual VA risk assessment & management plan

Moving & Handling Risk Assessment

Complete Generic MH task RA

Monitor implementation of patient specific RA's/ mobility charts

Safe Use of Bedrails - Implementation of Bed Rail policy to be monitoredthrough OPAC Audits. Op HS Groups to assure itself through that audits arebeing conducted and bed rail use is being assessed and improved

Training - Op HS Managers to Devise 2 year Training Programme based onoutcomes from this plan

Sharp Safety Baseline Audit - Undertake a baseline review of NES NeedlestickModule Uptake for Clinical / Ward staff. Promote module locally and improveuptake by 40% against the baseline figure.

Feb 15

Lone Working

RA's to be completed and implemented for high riskcommunity teams

Local Managers to update and revise LW local procedures and establish andtest escalation routes. Staff to be briefed accordingly and records maintained

Training - Local Managers to Identify Staff who are NOT currently "in date" withthe Statutory Health and Safety training, report findings into HS Group.Managers to be encouraged to prioritise & update out of date staff (taking a riskbased approach). This is a KPI.

Risk Assessment Audit - Audit RA improvements made in 2014, determine RAtraining efficacy and reinforce continuing effort

Review Performance & Progress against this plan and the 2 KPI's at the end ofYear and report findings into Op Units SMT/Core Team, HS Committee and Headof HS.

May 15

Improvement Frontline Training documentation andrecord keeping

Risk Assessment - ensure each site has an agreed mechanism in place forundertaking, reviewing, implementing and recording RA's

Skin Health - Undertake local skin reinforcement audits, feedback to HSGroup, direct and take appropriate improvement action

Aug 15

Senior Management Walkrounds - Trial topic / hazard based (senior-middlemanager level )safety walkrounds, based on the "visible and feltleadership" model, across a mix of selected sites integrating with othersafety related walkrounds where ever possible

Nov 15

Sharps Safety Audits

Devices. Ensure that staff using safety engineered sharp devices have beentrained appropriately

Training. Undertake 2nd reinforcement audit to encourage uptake of NESNeedlestick Module. Improve completion by 80% compared to the baseline in2014.

Moving & Handling Audits

Review Generic and Specific Risk Assessments - Completion & Implementation

Denotes KPI

bsumm01

Text Box

Appendix 2

Highland Health and Social Care Committee1 May 2014

Item 9.2

NHS HighlandHighland Health and Social Care Committee Annual Report

To: NHS Highland Audit Committee

From: Myra Duncan, Chair, Highland Health and Social Care Committee

Subject: Highland Health and Social Care Committee Report 2013/2014

1 Background

In line with sound governance principles, an Annual Report is submitted from the Highland Healthand Social Care Committee to the Audit Committee. This is undertaken to cover the completefinancial year, and allows the Audit Committee to provide the Board of NHS Highland with theassurance it needs to approve the Governance Statement, which forms part of the AnnualAccounts.

2 Activity 2013/14

The Committee met on 6 occasions during the year to monitor and scrutinize the activity of theOperating Divisions in their delivery of their objectives, individually and collectively. It hasmonitored the delivery of the Divisional Operational Plans through regular and milestoneoperational reports and received specific reports on areas identified by the Committee. Particularfocus has been in the following areas:

monitoring of the financial position and actions taken to achieve financial targets, particularlythe Raigmore Operating Division stabilisation and recovery plans and Adult Social Carebudgets

performance monitoring of HEAT targets and standards and the Adult Services Scorecardand actions taken to achieve targets

seeking assurance and monitoring actions regarding access to and the quality of adult socialcare services. In particular the development of the response to a deterioration in care qualityat an independent Care Home and monitoring the action plan and application of learning;monitoring the delivery of contracted services through routine reporting, and the developmentof contracting such as establishing multi-professional support and the quality specification

progress with the development of the Strategic Commissioning Plan, services for children and young people, particularly developing scrutiny of directly managed

children’s services and assurance on commissioned services action taken to reduce the number of patients whose discharge from hospital is delayed and

the length of their delay, major service redesign in Badenoch & Strathspey and Skye, Lochalsh & SW Ross, and

emerging work on service redesign in Caithness. monitoring Change Fund Plans and activity

The committee has considered reports on progress in implementation of the Maternity ServicesStrategy, activity taking place in the area of prevention and management of falls, an update onthe implementation of ‘A Right to Speak’ the national strategy for augmentative and alternativecommunication, the Local Urgent Care Action Plan, the Chief Social Work Officer’s Report andprogress on the evaluation of service integration. The committee would like to thank all thosewho have attended the Committee to present reports and information.

2

The Committee has held two Development Sessions during the year:

Health Inequalities, 26 August 2013 Committee Governance and Effectiveness, 1 November 2013

The outcomes from these sessions were endorsed by the Committee and reported to the Boardas part of the Committee’s Assurance Reports.

As a result of these sessions the Committee has restructured its Agenda to align with its businessand reflect its subcommittee structure. It has standing reports from its subcommittees, and anitem on children’s services performance monitoring, receives the minutes of other committeeswhich report to it, namely the Adult Services Strategic Commissioning Group and the HighlandQuality Approach Leadership Group, and receives minutes for information from the HighlandAdult Support and Protection Committee and the NHS Highland Adult Social Care Forum.

The Committee has presented an Assurance Report of each of its meetings to the Board andresponded to questions on its areas of work. The Assurance Report includes a list of memberspresent at each meeting and attendees.

The Chair of the Committee attends the regular meetings of the Chairs of the Board’s governancecommittees which have been established during the year.

The Chair of the NHS Highland Adult Social Care Practice Forum is a member of the Committee.

3 Sub Groups

The Committee has established two sub committees during the year for specific purposes tosupport its work.

The Performance and Finance Sub Committee provides oversight and scrutiny of performanceagainst HEAT Targets, Integrating Care, Finance and Operational Delivery. Its role is to monitorperformance, agree actions to mitigate the risk of adverse performance, and provide assurancethat operational delivery plans are delivered. It is chaired by a Non Executive Director member ofthe Committee. Its Terms of Reference are included as Appendix 1.

The Professional Executive Committee provides clinical advice on relevant issues, clinicalleadership to ensure a high quality, sustainable service, it champions and facilitates change, andensures that a patient and client focus of care is maintained and a continuing focus on reducinghealth inequalities. The Chair of the Professional Executive Committee is a member of theCommittee. Its Constitution is included as Appendix 2.

Both these sub committees will be reviewed after their first year of operation.

4 External Reviews

An Internal Audit of Corporate Governance took place during the year which included a review ofthe governance of North Highland. This commented on the large volume of work for theCommittee and recommended that a sub committee structure was put in place. The subcommittee structure described above was being established at the time of the Audit.

Reports from external organizations, such as inspections of services, are reported to theCommittee together with action and improvement plans, which are monitored by exceptionthrough operational reports. During the year the Committee considered a report ‘Overview ofCare Inspectorate Inspection Reports in Highland’ which highlighted the position regarding Care

3

Inspectorate gradings of registered services and received the Older People in Acute CareInspection report for Raigmore Hospital from Healthcare Improvement Scotland.

5 Any relevant Key Performance Indicators

At each meeting of Highland Health and Social Care Committee both the HEAT BalancedScorecard and the Adult Social Care Balanced Scorecard have been presented, and emergingissues from either of these reports are picked up and reported on through the Chief OperatingOfficer’s report or a further report is requested. These further reports identify the issues and theactions being taken to improve performance are outlined. Following the establishment of thePerformance and Finance Sub Committee, the Committee has delegated the scrutiny of theseScorecards to this sub committee. The sub committee will provide the Committee with anassurance report following their scrutiny and the Committee retains the right to ask for furtherand/or additional reports and information in considering this assurance report.

6 Emerging issues and key issues to address/improve the following year

The Committee will focus on its main purpose which is scrutinizing and monitoring the delivery ofoperations against strategic plans and providing assurance to the Board, including identifyingareas where the Committee is uncertain that plans will be delivered.

Effective Performance MonitoringThe newly-established sub committees and restructuring of the agenda will provide capacity andthe environment to support effective scrutiny across the Committee’s areas of responsibility andprovide a balance across health and social care activity. Further development of the assuranceplatform for children’s and young people’s services will enhance that.

Preventing Governance Gaps and OverlapsThe Committee will work in a complementary way with the Board’s other governance committees,taking assurance from their scrutiny of issues relevant to the Committee and providing furtherscrutiny when requested. The regular meetings of the Chairs of the Governance Committees willsupport this. There are ongoing discussions between senior officers of The Highland Counciland NHS Board executives to develop operational mechanisms for reporting and providingassurance and for the provision of information to the Health Board and The Highland Council.The Committee will take cognisance of these as relevant to its role, particularly to preventduplication in presentation and scrutiny of information on integrated services.

Committee EffectivenessThe Committee will continue to hold development sessions to provide opportunity to enhance itsunderstanding of, and consider in more detail, areas within its responsibility. It will continue toreview its ways of working to ensure that items are discussed in a timely, participative andinformed manner. The Committee, in conjunction with the two subcommittees, will review theiroperation.

Maximising the Benefits of Improvements in ServicesThe Committee will want to ensure that the opportunities provided by service improvements arerealised for the benefit of users. There is major service redesign work taking place in Badenoch& Strathspey and Skye, Lochalsh and SW Ross, emerging work in Caithness, the reconfigurationof the tower block in Raigmore, and continuous improvement through the Highland QualityApproach. Also the challenges in recruitment of staff will prompt consideration of different waysof providing services. The Committee will look to engaging users and staff in this work andidentifying benefits, and for sharing of ideas, learning and integrated approaches across servicesand the Operating Divisions.

4

Public Bodies (Joint Working) (Scotland) Act 2014The Committee will need to be assured that it is compliant with the above Act in its Terms ofReference.

7 Conclusion

The Chief Operating Officer concludes that the systems of control within the remit of the HighlandHealth and Social Care Committee are considered to be operating adequately and effectively.

Myra DuncanChairHighland Health and Social Care Committee18 April 2014

Appendix 1Performance and Finance Sub Committee Terms of ReferenceAppendix 2Professional Executive Committee ConstitutionAppendix 3Highland Health and Social Care CommitteeList of Members and attendance at meetings 2013-2014

Appendix 1

F I N A N C E A N D P E R F O R M A N C E S U B C O M M I T T E ET E R M S O F R E F E R E N C E

1. Committee Remit

The remit identified by the Committee is:

PurposeThe Finance and Performance Sub Committee will provide oversight and scrutiny ofperformance against:

HEAT Targets Integrating Care Finance Operational Delivery / Change

The role of the Committee will be to monitor performance, agree actions to mitigate the riskof adverse performance and provide assurance that operational delivery plans are delivered.

The Committee will review all aspect of performance but will focus on the exceptions toassist and support operational teams to focus on critical priorities areas.

Committee Membership Chair – to be determined x 2 Non-Executive Members of the Board x 2 Highland Council Representatives Chief Operating Officer x 3 Directors of Operations Health of Financial Planning Head of Planning and Performance Clinical Representative (to be nominated by the Health and Social Care Committee x 1 Public Health Representative

If any member cannot attend a committee meeting – deputies will be permitted.

Administrative Arrangements

The Committee will meet on a two monthly basis.

The Committee will receive and consider the Balanced Scorecards outlining Highland Health& Social Care performance against the LDP, HEAT, and local targets and the targets set outin the Highland Partnership Agreement.

A full report from the Sub Committee will be included within the formal agenda of HighlandHealth and Social Care Governance Committee. This report will inform the HH&SCC of theperformance of the HH&SCC in relation to the LDP, HEAT, local targets and the targets setout in the Highland Partnership Agreement. It will highlight areas for the consideration of theCommittee, such as opportunities for service improvement, wider implementation of goodpractice and areas for continued and/or further scrutiny

2

Work Plan

The Sub Committee will undertake an annual risk assessment of the Operational UnitDelivery Plans and respective targets. This process will identify areas of high, medium andlow performance risk which will be taken as agenda items for the Sub Committee.

The Balanced Scorecards, which measures HHSC performance against HEAT targets andthe targets set out in the Highland Partnership Agreement, will be presented to the SubCommittee on a two monthly basis. The scorecard will identify areas of suboptimalperformance and emerging issues which will be scrutinised by the Committee.

The Sub Committee will receive rigorous, accurate and relevant information in advance ofmeetings to allow it to undertake timely review of activity and performance. Reports providedone week in advance of the meeting should highlight:

Proposed corrective actions Impacts anticipated from these actions

The Sub Committee will consider other performance issues as they emerge during thecourse of the year.

The Sub Committee will receive regular reports from each of the Operational Units onexamples of good practice in their area that they judge could be rolled out across the Board.

Accountability

The Finance and Performance Sub Committee is accountable to the Highland Health andSocial Care Committee.

The HH&SCC can direct the Finance & Performance Sub Committee to scrutinize specificareas and provide a report to the committee.

Appendix 2

PROFESSIONAL EXECUTIVE COMMITTEE

The guiding principles of a north Highland PEC would be that it:-

is patient and client focussed care to promote the health and wellbeing ofcommunities,promotes and provides a high quality of patient care across the continuum.provides strong clinical / professional leadership,

brings together the clinical aspects of decision making across the operationalunits in a collaborative fashion,

is an integral part of the HH&SCS Governance and Accountability Framework.

The PEC would be constituted effectively as a Sub Committee of the HH&SC GovernanceCommittee and would be accountable to the Chief Operating Officer.

The Chief Operating Officer in agreement with the Health and Social Care CommitteeGovernance Committee would determine the mode of operation and work plan of the PEC.

The role and function of the PEC would be as follows,

To provide clinical advice and comment on relevant issues and decision makingacross North Highland Operational Units to the COO and thereby the HHSCPGovernance Committee.

To ensure operational collaboration and alignment across the 3 North HighlandOperational Units.

To provide clinical leadership and empowerment to ensure a high quality, sustainableservice across the continuum of care.

To maintain a patient and client focus of care.

To champion and facilitate change and transformational redesign and innovation.

Highlight and identify health promotion and disease prevention in the elimination ofhealth inequalities.

To develop links with key professionals and other stakeholder organisations.

Support the quality of care with the financial balance.

The PEC would not have a professional representative function

Operational Arrangements

The PEC will meet every two months synchronised at a defined time period with the HH&SCCommittee meeting. The committee will be administered by the support function of theHH&SC Committee.

Chairmanship

The chairman will be initially appointed by the Chief Operating Officer to support the creationand early development of the PEC with a view to formally establishing an election processwithin 6 months of the first meeting taking place.

2

The PEC chair will rotate every two years through nomination and election from within thecommittee

The PEC chair will be invited to become a member of the H&SCC

Administrative Support

Administrative support would be through existing arrangements with central support services.The first meeting of PEC has been identified as Thursday 19th December 2013 from 0900hrsto 12.00 midday in the Board Room at Assynt House Inverness

Reporting Arrangements

The accountability and reporting arrangements will be to the Chief Operating Officer, whohas an operational responsibility for care provided by the Operational Units across NHSHighland, and is a member of the HH&SC Committee.

The substance of the reports by the PEC will include operational decision making,governance issues and the development of strategy and vision, and these would be reportedto the HH&SC Committee through the Chief Operating Officer and or Chair of the PEC.

Appendix 3

HIGHLAND HELATH AND SOCIAL CARE GOVERNANCECOMMITTEEMEMBERSHIP AND ATTENDANCE 2013/14

Membership from 1 April 2013 – 31 March 2014:

Mrs Myra Duncan, Chair

Ms Deborah Jones

Mr Brian Robertson

Dr Paul Davidson (from October 2013)

Ms Janet Spence (from February 2014)

Mrs Gillian McCreath

Mr Ian Gibson (to June 2013)

Dr Rhona MacDonald (from August 2013)

Cllr Bren Gormley

Cllr Linda Munro

Cllr Kate Stephen

Mr Adam Palmer (to end September 2013)

Ms Shirley Christie (from 1 October 2013)

Mrs Margaret MacRae

Mr Gavin Hogg

Mr David Flear

Ms Mhairi Wylie

Dr Chris Williams

Mr Quentin Cox

Mrs Gill McVicar

Mr Nigel Small

Mr C Lyons (to end December 2013)

Mrs Linda Kirkland (from 1 January 2014)

Ms Fiona MacFarlane

Mr Malcolm Jones

Mrs Ailsa MacInnes

Mrs Katherine Sutton

Mrs Helen Morrison (to end December 2013)

Ms Kate Patience-Quate (from 1 January 2014)

Dr Helen Bryers

Mr David Garden

In Attendance:

Mr Philip Walker

Mr Bob Summers

Appendix 3

Attendance from 1 April 2013 – 31 March 2014:

Member 2/5/2013 4/7/2013 12/9/2013 7/11/2013 9/1/2014 20/3/2014

Myra Duncan

Deborah Jones

Brian Robertson A

Dr Paul Davidson n/a n/a n/a A

Janet Spence n/a n/a n/a n/a n/a A

Gillian McCreath

Ian Gibson n/a n/a n/a n/a n/a

Dr R MacDonald n/a n/a

Cllr B Gormley A A A A

Cllr L Munro A A

Cllr K Stephen A

Mr A Palmer A n/a n/a n/a

Ms S Christie n/a n/a n/a

Mrs M MacRae

Mr G Hogg

Mr D Flear A A A A

Ms M Wylie A A A A

Dr C Williams A

Mr Q Cox A

Mrs G McVicar A

Mr N Small A

Mr C Lyons A A n/a n/a

Mrs L Kirkland n/a n/a n/a n/a

Ms F MacFarlane A A A A

Mr M Jones A A A A A

Mrs A MacInnes A A A A

Mrs K Sutton A

Mrs H Morrison A A n/a n/a

Ms K Patience-Quate n/a n/a n/a n/a A

Dr H Bryers A A

Mr D Garden A

Mr P Walker A A A A A A

Mr B Summers A A A A A A


Item 10.1

1

Highland Adult Support and Protection Committee

Tuesday 26 November 2013Committee Room 3, Highland Council HQ

Glenurquhart Road, Inverness

Present:Pam Courcha – Independent ChairpersonLaura Gillies – Lead Advisor for ASP, NHS Highland and Chair of ASPCDelivery GroupFiona Malcolm – Solicitor, Legal Services, Highland CouncilDr Ishbel Hartley – General Practitioner RepresentativeCllr Kate Stephen – Political Champion for Older PeopleBrian Robertson – Head of Adult Social Care, NHS HighlandGus MacPherson – Supt., Police ScotlandJan Baird - Director of Adult Care, NHS HighlandFiona Palin – Head of Social Care, The Highland CouncilKarin Campbell – Principle MHO, The Highland Council

In attendance:Pene Rowe – Development Officer, Adult Support and Protection

ITEM DISCUSSION / DECISION ACTION

Welcome & Introductions:Pam Courcha welcomed new members: Laura Gillies, the new LeadAdvisor for ASP and Chair of the Delivery Group, and Dr Ishbel Hartley,representing GPs in Highland.

Pam Courcha went on to declare an interest in respect of her role as aWelfare Guardian for her daughter and parent of a son with ASD.

Apologies:Apologies were noted from Elaine Mead, Janet Spence, David Goldie andSheilis MacKay

2. Minutes of previous Meeting:The minutes of the meeting held 20 August 2013 were accepted as a trueaccount.

3. Matters Arising:

4.11 - National Policy Forum Minutes: Due to the timing ofHighland ASPC meetings, minutes of the most recent National PolicyForum meetings are not available. It was agreed to include a link tothe Policy Forum webpage in each set of ASPC minutes:http://www.scotland.gov.uk/Topics/Health/Support-Social-Care/Adult-Support-Protection/Policy-Forum

4.13 – Publication of Committee Minutes – This issue was taken tothe Communications Group for consideration as part of the revisedCommunications Strategy. In the interim it has been ascertained thatthe minutes are made available to the Health and Social CareCommittee and are circulated to all elected members.

Clerk toCommittee


Item 10.1

2

A request was made for a rolling Action Plan to be circulated with theminutes, or in advance if delays in publication are anticipated. Thiswas agreed.

8 - Improving Management Information – Due to unforeseencircumstances this action has yet to be completed. Paper to bebrought to next meeting.

10 – Training for Committee Members – In view of the paper beingpresented at Item 4 it was decided to defer the proposed casestudy until the next meeting.When setting meeting dates for 2014 rooms will be booked toallow for a 1345 start and possible over-run to 1615.

11a – Response to Code of Practice Consultation – It was felt thatHighland ASPC could not add anything more to the comprehensiveASDW response and should, instead, add its support to this.

PR

PR

SC

PR

4. Committee Remit in relation to interface and governance issues

between ASP, AWI and MH – Potential impact on Committee role:

Karin Campbell and Fiona Malcolm spoke to their paper. They explained

that they were putting forward the issues for discussion and for the ASPC

to decide what is relevant and how the inter-related pieces of legislation

should be used in Highland.

Pam Courcha asked what the picture of governance was prior to

integration of health and social care. Fiona Malcolm stated that

responsibility for governance had not been changed by integration and

the committee had not addressed the wider legislative issues prior to this.

It was explained that this had been because of an expectation of National

guidance but this had not been forthcoming. It was noted that the Mental

Welfare Commission is beginning to recognise their role in adult support

and protection.

There was considerable discussion of the relevance of the numerousreports and data sets that could possibly be made available. It was notedthat quantitative data, alone, is meaningless without context and properanalysis. It was recommended that any Mental Welfare Commissionserious case review or report being brought to the ASPC should beaccompanied by a report from Karin Campbell on the implications.

It was suggested that the MWC should be requested to inform the ASPCof Highland cases which it becomes aware of, especially where theypropose to conduct a serious case review.In terms of other reports it was noted that: Karin Campbell attends the ADSW Mental Health sub-group and can

report back from this. Laura Gillies will be the ASPC representative on the ADSW ASP sub-

group and can report back from this.It was agreed that both Karin and Laura should appoint deputes toattend should they be unable to.

It was noted that there is a need to consider how information fromthese groups is disseminated beyond the ASPC.The following specific recommendations were made:(i) The suggested Standing Item 1 – this should only apply where

relevant to the ASPC.

KC/LG

Comms sub-gp


Item 10.1

3

(ii) Training should be a routine item, reported through the DeliveryGroup, and should demonstrate how Adults With Incapacity (AWI),Mental Health, ASP and other legislation is inter-woven andconsolidated into training around protection legislation.

(iii) The Delivery Group should advise how far the ASPC Training sub-group should be responsible for delivering the key skills set for staffwhose primary role is adult care.

(iv) There is a need to gather data on how many referrals under ASPlegislation end up being dealt with through AWI/MH legislation, andthis should inform training.

(v) Investigation and Chairing of case conferences and reviews needs tobe included in the training programme.

(vi) There is a need for reassurances that data can be analysed toprovide meaningful information before requiring its collection. Onlycases where ASP criteria are met should be included and the lessonsextracted for the Committee.

It was agreed that a sub-group of the Delivery Group should beestablished to tease out the issues in terms of relevance to the ASPC andthe knowledge required by ASPC members. This sub-group shouldinclude Kath Gordon, the Performance Manager, and should report backto the Committee on recommended Key performance Indicators and whatit would entail to gather pertinent data.Action: Jan Baird to take to Delivery Group for 17th December.

JB

5. National Priorities and Local Activity:Pam Courcha explained the remit of the National Policy Forum and itsfocus on the five national priorities. She reported that there is a clearexpectation that ASPCs will discuss these, and she recommended thatthese should become standing items on the Committee agenda. It iscurrently unclear what feedback is required and Pam Courcha isexploring this with Scottish Government. What is clear is that reporting onlocal activity in relation to the national priorities is expected as part of the2012 - 2014 biennial report.

Pam Courcha noted that reports on national progress against each of thefive priorities had been circulated with the Committee papers and it wasexpected that members had read these in advance of the meeting.Additional points made at the meeting were as follows:a) Financial HarmPam Courcha informed the Committee that the National ConvenersForum has decided to commission a tv advert focussing on financialharm. Each committee has committed to contributing toward the costs,which are expected to be under £3K.

(i) Adult Protection and Trading StandardsPene Rowe reported that she and Lawrence Bronny had met with thePolice and Trading Standards working group and agreed to take forwarddevelopment of a joint conference in March 2014 (provisional date 14th).

Pene Rowe reported that there had been a major development nationallywith the seizure of a Scotland-wide, organised crime, target list of adultspotentially responsive to scams, etc. This is currently being analysed inpreparation for release of localised lists for each ASPC.ACTION: Pene Rowe and Laura Gillies to work with TradingStandards to develop a local protocol for handling screening anddisclosure, etc. PR/LG


Item 10.1

4

(ii) Universal Credit:Karin Campbell requested the Committee to note the introduction ofUniversal Credit in Inverness and the need to monitor vulnerability tofinancial abuse as predators become aware that potentially vulnerableadults will soon be receiving monthly payments. She suggested that theCommittee should consider how to engage staff re: the potential impacton referrals. Brian Robertson expressed the view that there was a dangerthat this would be straying across the Committee's demarcationboundaries, and he recommended that this cross-cutting and 'political'issue be taken to Safer Highland for consideration.Actions:Pam Courcha to raise with Safer Highland Leadership Group.Laura Gillies to raise with Training sub-group for inclusion in level 1awareness raising.

(iii) Involving Banks:Pam Courcha informed the Committee that Royal Bank of Scotland (RBS)is leading on ASP for the banking industry and has made directrepresentation to each ASPC chair. For Highland the lead person isCatherine Browning, Strategic Manager for Vulnerable Customers.Action: Pam Courcha, Janet Spence and Laura Gillies to meet withCatherine Browning to discuss potential involvement withCommittee activity, including potential involvement with theFinancial Harm conference.

b) A&E:Jan Baird reported that Highland has volunteered to participate in thenational project. Phase 1 will involve an audit at Raigmore and peripheralA&E centres. Jan Baird commented on the noticeable lack of ASPinformation in A&E waiting areas despite the recent refresh mailing ofleaflets and posters.

Concerns were expressed that some forms of adult abuse do not presentto A&E. There is a need to consider other routes of admission, e.g. adultsadmitted straight to inpatient wards from care homes.Action: Jan Baird and Laura Gillies to discuss at their meeting nextweek.

c) National Data Set:It was noted that a restricted data set would be issued in December butthere continue to be issues in respect of definitions, e.g. a referral.Action: Kath Gordon to be requested to comment on the feasibilityof gathering the required data to populate the new template.

d) User/Carer Support:It was noted that one approach could be to widen contracts with localservice providers. However, after discussion at the Quality AssuranceGroup, it had been decided to pilot a user/carer questionnaire at casereviews, starting from November 25th. This has been developed withAdvocacy Highland but concerns were expressed that comments on thedraft had not been acted upon and that the questionnaire could beremodelled in a more helpful way, applying the lessons learned from therecent action learning approach to improving practice in under-performingcare homes.Action: Questionnaire to be taken back to QA Group for furtherconsideration.

PCLG

PC/JS/LG

JB/LG

KG

SC


Item 10.1

5

e) Residential Care:Concerns were expressed that the national project does not encompasscare at home.

It was noted that there had been recent ASP issues with a local carehome and that Jan Baird has been commissioned to review how theinvestigation was handled. A report will be made to the Health & SocialCare Committee in January 2014, and this is expected to contain 4 keyrecommendations.Action: Jan Baird to bring full report to the next ASPC Meeting. JB

6. Large Scale Investigations – Draft Protocol:The draft LSI protocol, prepared by Janet Spence, has been circulated forcomment. It was noted that this should be informed by evidence from thereport on the recent local LSI, as this is one of the recommendations.

Point 2.3 - It was agreed that Scottish Care should be included in thegroup to be consulted.

Actions:Comments to be sent to Janet Spence by Mid-December.Final draft to be brought back to February meeting for furtherconsideration in light of expected publication of the National Codeof Practice.

Councillor Stephen asked that it be put on record that she welcomed thispiece of work.

JS

AllJS

7. Improvement Planning:a) Improvement Plan Progress Updates:

1.1 Training - It was noted that Laura Gillies, the new Lead Adviser,has been tasked with reviewing this as a priority.Action: Laura Gillies to bring a specific report to the nextCommittee meeting and to work with the Training Group toprepare a presentation for the Development event in January.

5 (iic) Case Record Audit – This has taken place but the audit reporthas yet to go to the QA Group prior to presentation to Committee.Action: Report to come to next Committee.

5 (iii) Improvement of Recording Process - This has gone live. It ishoped to have some initial data by the end of December.Actions:Ian Thomson to provide a report for the next meeting.Kath Gordon to provide a data report for the next meeting.

6 Red Flagging:A Key Information Summary (KIS) system is being developed so thatGPs can access information out-of-hours. This may be used insteadof red-flagging.Action: Jan Baird and Ishbel Hartley to work up a proposal totake to the GP Sub-group.

LG/JG

SC

ITKG

JB/IH


Item 10.1

6

8. Quality Assurance:a) Guardianships dataJan Baird spoke to the report prepared by Kath Gordon in respect of thedata currently available on the system relating to Guardianships.Actions:When dealing with the action at 4 (above), the Delivery Group isasked to consider how useful this data is and what meaningfulinformation can be extracted from it.Kath Gordon to be invited to the Delivery Group meeting on 17thDecember.

b) KPIsThe development of ASP KPIs is currently with the Strategic KeyPerformance Indicator Group (SKPIG), an Adult Care short-life workinggroup tasked with reviewing the usefulness of current KPIs.

JB

KG

9. Feedback from Safer Highland Meeting of 22 October 2013:Pam Courcha reported that there is currently a major review of theCommunity Planning Partnership and Safer Highland Leadership Groupstructures with a view to reducing the number of meetings and improvingpartnership working. The aim is to streamline attendance and avoidduplication.

Charts illustrating the proposed new structure were discussed at theSafer Highland meeting. It is possible that the restructuring could result inthe loss of both the ASP Delivery Group and the Quality AssuranceGroup. As a result there will be a need to review membership and remitonce again.

Pam Courcha stressed that the statutory nature of the Adult Support &Protection Committee must be taken into consideration.Gus Macpherson reported that the Chairs of each Committee will receivea personal briefing on the proposals, in the near future. Things won’tchange overnight but individual Committee structures will be examined,with a view to refining them in a way that works for each.Action: Restructuring to be placed on the agenda for the 2014Development Event. PC

10. Development Event 2014:There was a brief discussion which agreed the following: A date in mid-January should be sought. Pene Rowe to circulate

13th, 15th and 17th to assess which is best. A morning meeting is preferred, starting with coffee and registration

and possibly ending with lunch. The key business to be dealt withbetween 1000 and 1300.

Topics identified during the current meeting include:o Widening the remit to include aspects of AWI and MHo Restructuring and membershipo Refresh of the Training Strategy.

PR

11. AOCB:a) Councillor Stephen reported that she had heard rumours that personalestates are sometimes over-charged by Care Homes for periods of carebeyond the date of death. She expressed the view that this couldconstitute financial abuse.


Item 10.1

7

Fiona Malcolm and Brian Roberts responded that this was likely to be acontractual issue allowing charges to be made for up to 2 weeks beyondthe date of death.

12. Date, Time and Venue of Next Meeting:Dates for 2014 ASP Committee Meetings (1345 - 1615):11th February CR227th May CR219th August CR211th November CR2o be circulated with the minutes.

1

HIGHLAND QUALITY APPROACHLEADERSHIP GROUP

NOTE OF MEETING held on Monday 24th February 2014, Boardroom, Assynt House, Inverness

Present: Linda Kirkland, Interim Director of Operations Raigmore (Chair)

Elaine Mead, Chief Executive

Nigel Small, Director of Operations, South Mid

Maimie Thompson, Head of Public Relations & Public Engagement

Ian Bashford, Board Medical Director

Heidi May, Board Nurse Director

Maryanne Gillies, Clinical Governance Manager

Nick Kenton, Director of Finance

Ray Stewart, Quality Improvement Lead

Gill McVicar, Director of Operations, North West (via vc)

Administrator: Rachel MacDonald, PA to Interim Director of Operations, Raigmore Hospital

Detail Action1. Welcome & apologies

Linda Kirkland welcomed everyone to the meeting and introductions were made.

Apologies were received from: Derek Leslie, Deborah Jones, Anne Gent,Margaret Somerville, Gavin Hookway and Jan Baird.

2. Previous Minutes

The minutes of the previous meeting held on 22nd January 2014 were agreed asbeing an accurate record.

3. Matters Arising

3.1 Nursing Workstreams added to HQA DatabaseHeidi May reported that leads have been identified for each nursing workstreamAll data is anticipated to be entered on the database shortly.

3.2 Diabetes Managed Clinical NetworkLinda reported that this progressing as planned, however the diabetes skygateway is proving to be a sticking point. Linda is currently in negotiations withBill Reid regarding the MCN management role and administration support for theretinal screening pathways. Once the workload has been identified areamanagers will be allocated to the pathways. Further discussion is required by thisgroup to agree the level of support managers will require to address the lack ofownership within the MCN.

Action:Elaine Mead to discuss with Deborah Jones. EM

4 Staff Experience – National Staff Survey

Ray Stewart briefed the group on the iMatter Staff Experience national projectwhere it is hoped that NHS Highland will be in the early first wave of Boards to rollit out. He advised that while this is a questionnaire based process to get views

bmitc01

TextBox

Highland Health & Social Care Committe 1 May 2014 Item 10.2

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Detail Action

from staff fundamentally it is Quality Improvement Process. He further explainedthat it is done down to team level with the ownership of the results as well as anyidentified improvements being owned by the team. This is where it isfundamentally different from the current National Staff Survey. It was agreed byall present that the organisation is fully committed to engaging with staff and theimportance of listening to their opinions on what currently works well and actingon feedback relating to areas which can be improved on.

Discussion ensued regarding the most effective method of implementing thispiece of work and addressing issues raised by staff. It was discussed that it maybe better to identify pilot areas to undertake a PDSA method using agreedquestions to prompt further conversations rather than a pure questionnaire basedapproach. It was however recognised that the national Staff Experience ProjectiMatter was an integral part of Everyone Matters the 20/20 Workforce Strategyand we would be implementing as part of our ongoing plan.

Operational Units are identifying themes from the current Staff Survey results andwill report back to the Highland Partnership Forum on this.

Actions:Ray to liaise with the Operational Units to potentially identify areas for the earlyroll out of iMatter.

Staff experience to be added to the agenda as a standing item and Ray to reportback each month.

RS

RM

5. HQA Leadership Group Reporting Structure

It was agreed that the group will report through the Operational Units into theSenior Management Team.

6. HQA Activity

6.1 Embedding Patient Experience into HQA Activity

Discussion ensued on how to embed patient experience into HQA activity. Thereis a lot of positive work being undertaken and it is important that this is reflected inthe experience of all customers who are in contact with the organisation, whetherby letter, telephone or in person, within the primary care and acute sector. It wasagreed that any changes implemented must be data and outcome focused tomanage frontline interaction with staff, in order for all patients to receive excellentcare from the first moment of contact.

Actions:Ian Bashford to work with Mirian Morrison and Rachel Hill to identify informationbeing collected through SPSP in order to triangulate clinical outcomes.

Nigel Small to send the group information on Birmingham Community Trust whichrecently won a customer service award with the aim of embedding this intocustomer care within NHS Highland.

Linda to ask Ray to take forward Customer Care work, focusing initially on all staffworking on reception to receive customer care training.

IB

NS

LK

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Detail Action

6.2 Communication of HQA activity

There was discussion on how to communicate HQA work which has beenundertaken and it was agreed that information presented at RPWI report outsdoes not give clarity on work carried out if staff/public are unfamiliar with thedepartment and the systems which have been improved. It must be clear how theBoard’s objectives are linked to the HQA work to ensure staff and the public areaware of what is being carried out and why.

It was agreed that process owners and sponsors must be fully aware of remit oftheir role in order for workstream leads to be confident in taking a step backfollowing an RPIW. It was suggested to hold a process owners workshop, givingfeedback on what is working well and areas where improvement is required.

Action:Linda, Maryanne Gillies, Gill McVicar and Maimie Thompson to discuss furtherand take forward.

LK, MG, GM &MT

7. HQA Training Strategy

Linda advised that approximately 2000 staff have undergone 5S training and the5S training video is now available on the intranet:

http://intranet.nhsh.scot.nhs.uk/HQA/Training/Pages/5S.aspx

Areas have been identified for RPIWs to be carried out in 2014. The dates ofwhich are still to be agreed.

Action:Heidi to arrange for 5S to be rolled out in all hospitals across the Board and to beundertaken in all stock rooms. Consideration is to be given to begin this processin theatres.

Linda to confirm whether 5S training is included within NHS Highland inductionpacks for new members of staff.

8. HQA Branding

The group was asked to consider effective methods of branding the HQA andbring ideas to the next meeting.

9. HQA Staff & Financial Resources

Linda talked through the financial paper detailing the HQA staffing expenditure,advising that seconded posts within the team are coming to an end between Apriland July 2014. Linda has requested confirmation from QUiST on numerousoccasions on the level of funding which they will provide however this has notbeen forthcoming. Once QUiST funding has been identified it was proposed thateach Operational Unit fund the financial shortfall.

Action:Linda to discuss funding with Deborah, Gill and Nigel. Once agreement in placeElaine will discuss with the Board.

LK

4

Detail Action10. Monitoring & Evaluation Framework

Deferred to next meeting.

11. AOCB

Maryanne reported she is currently working on a paper scoping the 4 SPSPprogrammes, detailing their aims and objectives. This will identify the work whichis required to be done and the resources the posts required to undertake thework. It was suggested this would be a suitable topic for discussion at a BoardDevelopment session.

Action:Maryanne will discuss the paper with Linda once completed.

12. Date of Next Meeting

Wednesday 26th March, 2.30pm – 4.00pm, Boardroom, Assynt House


Item 10.3

ADULT SERVICES COMMISSIONING GROUPMinute of Meeting Held at 2.00pm on 13 February 2014, Skye Room, Assynt House

PRESENTDeborah Jones (DJ) NHS Highland (Co-chair)Stephen Pennington (SP) Scottish Care (Co-chair)Michelle Manzie (MMZ) Scottish CareIan McNamara (IM) Highland Senior Citizens NetworkMhairi Wylie (MW) Highland Third Sector PartnershipSimon Steer (SS) NHS HighlandGeorge McCaig (GMc) NHS HighlandLiz Smart (LS) NHS HighlandGillian Grant (GG) NHS Highland

APOLOGIESMike Martin (MM) Joint Improvement TeamElaine Adams (EA) Highland Community Care ForumMaxine Johnston (MJ) Alzheimer ScotlandGill McVicar (GM) NHS HighlandNigel Small (NS) NHS HighlandLinda Kirkland (LK) NHS HighlandKen Proctor (KP) NHS HighlandBrian Robertson (BR) NHS HighlandJanet Spence (JS) NHS HighlandCouncillor Kate Stephen (KS) The Highland CouncilBill Alexander (BA) The Highland CouncilDavid Goldie (DG) The Highland Council

Business Action1.0 Apologies

1.1 As noted above.

2.0 Minute of Previous Meeting

2.1 The minute of the previous meeting held on 2 December 2013 wasdiscussed as follows:

a) Item 2 of the previous minute: DJ confirmed that BA had beeninvited to the meeting to give a presentation on the restructuringwithin The Highland Council, but had a prior commitment of amember seminar so was unable to attend. DJ confirmed that shewould put this item on the forward plan for the agenda. DJ

b) Item 3 of the previous minute: it was noted that LS had providedthe requested information.

c) Items 3 and 4 of the previous minute: with regard to the SDSslide/presentation, SS to pick up with JS on her return.

SS

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d) Item 6 of the previous minute: it was agreed that JB shouldproceed to implement the draft proposal for the sensoryimprovement group. GMc noted that he had a forward plan ofImprovement Group dates. It was agreed to distribute these withthe minute.

JB

GMc/MS

e) Item 8 of the previous minute: it was noted that MMZ’s name wasidentified against the action regarding NHS representation atADSW/JIT. JB to take forward with BA.

JB

2.2 The minute of the meeting on 2 December 2013, was otherwiseagreed as accurate.

2.3 DJ confirmed that the minutes of the ASCG would now be going to theNHS Health and Social Care Committee for information.

3.0 Strategic Commissioning Plan

3.1 DJ highlighted that the draft strategic commissioning plan has nowbeen discussed at a number of NHS committees, to ensure there is anawareness of the area of work and as preparation for the final reportgoing to the Board on 1 April 2014, along with a joint presentation bythe ASCG co-chairs, DJ and SP. DJ noted that the Board recognisesthat the draft is work in progress, that it has a focus on older peopleand will continue to evolve after this iteration – highlighting that thejourney is as, if not more, important than the plan. DJ suggested theneed for a debrief after the draft goes to the Board, in order to learnfrom the process to date and discuss how to develop this further.

DJ

3.2 DJ invited GG to talk through the draft strategic commissioning plan(V6) circulated the previous day.

3.3 GG acknowledged the lateness of sending the draft and took themeeting through the detail of the document, highlighting that the draftwas still work in progress with gaps still to be populated; wording stillto be added to “gel” the sections together; and the visual of thedocument will look different and more user friendly when final draft isprepared.

3.4 The following were noted as the key discussion and action points onthe draft plan:

a) GG to incorporate the specific revisions discussed. GG

b) LS noted the need to consider the longer term challenges beyond2019. LS to provide wording regarding focus on prevention (page7).

LS

c) MW asked for clarification on commissioning partners to beincluded.

d) IM suggested a need for clarification of procurement andcommissioning terminology and for the focus to be more clearly oncommissioning – what service users want, not what they areprepared to accept. IM to provide some commissioning focussedwording.

IM

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e) It was agreed that there is a need to include the philosophy ofcommissioning and the difference between strategiccommissioning and the commissioning function, and that (Harvard)referencing also needs to be included.

GG

f) MW suggested the need to recognise duplication of funding. MWto revert to GG with proposed wording. DJ recognised that therewas a need for a longer term market intelligence piece of workaround this area.

MW

g) DJ queried with the meeting that they were comfortable with thedecommissioning concept, and all recognised that this was animportant part of transitioning from the current state to meetingpeople’s future needs, so long as it is done in a transparent andequitable way.

h) LS to send round detail from the SHNA undertaken last year. LS

i) DJ highlighted the need for service user outcome measures toinform commissioning requirements and invited the meeting toconsider, in advance of the next meeting, how we couldcommission an external provider to capture objective informationfrom users and carers on the services they receive, and to reporton this monthly. This information could then be triangulated withother performance data available and Care Inspectorate gradingsetc. DJ proposed that the dimensions for this would then be usedto create a quality schedule. Furthermore, it was suggested that aprocurement process could be undertaken in the next year, with aview to both the arrangement to elicit views of service user/carersand also the quality schedule going live in 2015. A generalconsensus to this proposal was indicated, along with anagreement that Change Fund monies could be utilised for this. Itwas agreed to discuss further at the next meeting in April.

ALL

DJ

j) DJ invited members of the ASCG to consider graphics and designinput to the plan and to contact GG in this regard.

ALL

3.5 Members of the ASCG were invited to submit any comments on thedraft strategic commissioning plan to Gillian Grant([email protected]) by Monday 24 February 2014.

ALL

4.0 Date of Next Meeting

4.1 The next meeting will take place at 10.00am on 17 April 2014, BoardRoom, Assynt House.


Item 10.4

Adult Social Care Practice Forum

Tuesday 5th November 2013 at 10:30 amBoard Room, JDB

Chair Janet Spence - Programme Manager (Modernisation & QualityAssurance)

Minute Liza MacFarquhar - Clerical Assistant

Present Elaine Mead - Chief ExecutiveBrian Robertson - Head of Adult Social CareIan Thomson - Project Manager, Change Support TeamArlene Johnstone - Complex Case Planning ManagerGraeme MacKinnon - Team Manager, East RossLyn Johnson - Unit Manager, The Montrose CentreKara McNaught - Social Worker, Inverness East UrbanGraham Jepps - Day Care Officer, The Corbett CentreAngela Longmate - Social Care Worker, Dail Mhor HouseChristina Muddit - Senior Social Care Worker, Telford CentreShona Knight - Social Worker, Black Isle, Muir of Ord & DingwallSheilis MacKay - Advocacy HighlandPam McAllister - Care at Home Manager, West RossHelen Robertson - Social Worker, SkyeIan Clayton - Resources Manager, Corbett Centre & Cabarfeidh Centre

Item Discussion/Decision Action1. Apologies

None

2. Introduction to Elaine Mead, Chief Executive, NHS HighlandJanet welcomed all to the meeting, and Introduced Elaine Mead.

Elaine explained that this is the first and only Adult Social Care Forum in Scotland. Theboard see this as an opportunity for you to give your professional opinion on the way NHSHighland runs its business.

Elaine explained that there is an Area Clinical Forum, made up of people from differentprofessions. E.g. GP’s, opticians, Allied Health Professionals etc. This forum wouldgenerally formulate advice to the NHS Highland board. Elaine gave an example of an ideathe Board had for some surgical procedures to be performed in Fort William to ease thepressure on Raigmore, where the Area Clinical Forum advised against this. This exampleshows how forums can have a say. Elaine expressed her hopes for the Adult Social CareForum and explained the importance of this from the Board’s perspective. Elaine asked forpeoples initial thoughts on this.

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Ian expressed that he feels very positive and feels that this is a good opportunity.Brian added that it is important to understand that the forums are representatives for thewhole workforce. He sees this as an opportunity for the service to gain the confidence itneeds to build our expertise. Brian also added that the chair of the forum will become aboard member. Elaine added that she expects that forum members will be well connectedso that they can represent their colleagues.

Janet added that she expects that the forum will grow as time goes on.Discussion followed around everybody’s initial thoughts with the key points being:

The forum is not the place to bring up personal agenda’s

Sheilis introduced herself, explaining that she can offer the point of view of a serviceuser.

Arlene suggested having the 3rd sector represented. Elaine felt that this was a goodidea, but better waiting until the forum is up and running. Brian added that the 3rd sectoris well represented in other forums, and agreed that it would be best to wait.

Graeme Jepps added that the workforce need to understand the importance of this & thevoice they have.

Ian asked if there are specific duties a Board Member takes on. Elaine gave an overviewof duties, and advised that their own post would need to be backfilled.

Many felt that it was a great opportunity

Brian added that people who come to meetings need to be prepared to speak, raiseissues, offer advice and debate. Also attend as often as possible.

Janet confirmed that everybody was happy with this, and still wanted to be part of theforum.

3. Verbal Report introducing the new Personal Planning DocumentationIan explained the Personal Outcome Plan document & what this is trying to achieve. Headded that the hope is that these plans will go onto CareFirst. It has been rolled out to 5test sites at the moment. Ian asked for feedback on this.

A discussion followed around the good and bad points of the new document, comparisonto the SSA, the effectiveness of the individual filling it in and hopes for it being more personcentred than the SSA. All agreed the following:

It is a significant change

Gathers important information

Specialist assessments may still need to be done

Need to see feedback from Test Sites and staff in different disciplines, serviceusers and carers to see how it can be further developed

4. Paper on “The Role of the Social Worker”Not Discussed

5. Membership of the Adult Social Care Practice ForumA discussion took place around membership of the forum, and the following were electedto represent their category’s & Areas :Adult Social Work - Graeme Mackinnon , East Ross & Kara McNaught, InvernessCare at Home - Pamela McAllister, West Ross & Meg Shaw, DingwallLearning Disabilities - Lyn Johnson, Lochaber & Graham Jepps, InvernessCommunity Mental Health Service - Diane Spence, InvernessOccupational Therapy - Arlene Johnstone, HighlandService Improvement - Ian Thomson, HighlandCare Support - James Bain, Highland

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Service User/Carer - Sheilis MackayResidential Care For Older People - Christina Muddit, Fort Augustus & AngelaLongmate, StrotianDay Care for Older People - Christina Muddit, Fort Augustus & Angela Longmate,Strotian

It was agreed that others would also remain involved, and that the forum would constantlychange.

6. Chair of the Adult Social Care Practice ForumAll agreed to wait for further information regarding backfilling of posts before appointing achair.Janet agreed to stand in until the chair is formally appointed.

25 april 2014 highland health & social care governance ... · 25 april 2014 item 3.1 highland...

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