Highland NHS Board 13 April 2010 Item 4.6 CHIEF EXECUTIVE’S AND DIRECTORS’ REPORT EMERGING ISSUES AND UPDATES 1 ANNUAL REVIEW – LETTER FROM SCOTTISH GOVERNMENT AND MID YEAR REVIEW NHS Highland had its Annual Review with the Cabinet Secretary, Nicola Sturgeon, on Monday 7 December 2009. The Annual Review letter has now been received by the Scottish Government and is attached as Supplementary Paper 1. The date for the 2010 Annual Review has been set as Tuesday 22 June 2010. The Mid Year Review with the Scottish Government Health Directorate (SGHD) took place on Friday 8 January 2010 via video conference. The purpose of the meeting was to review our progress in the following areas: Action points from 2009 Annual Review Finance 2009/2010 and 2010/2011 HEAT Targets 18 Week Referral to Treatment Service Redesign The letter providing formal feedback from the review is attached as Supplementary Paper 2. This gives the detail for each of the above items, but the key points contained within it are: Action points from 2009 Annual Review – as it was only one month since the Annual Review this item was not considered in order to concentrate on other areas. Finance 2009/2010 and 2010/2011 - SGHD were assured that NHS Highland plans to meet all financial targets in 2009/2010, and that they were confident that NHS Highland is well prepared going into 2010/2011 and that the staff side are well engaged with the Board on the challenge ahead. HEAT Targets – This discussion focused on 5 key areas, sickness absence, Healthy Weight of Children, Delayed Discharges, Psychological Therapies and Hospital Acquired Infections. Whilst all of these targets remain challenging SGHD were assured that plans were in place to improve our position in all 5 areas identified. 18 Week Referral to Treatment/Access Targets – They acknowledged problems in Oral surgery and Neurology due to staff sickness and Consultant vacancies. SGHD recognised the increase in pressure in some specialties due to the severe weather and also wanted to know more about the impact rural clinics have on delivery of the 18 Week RTT target. Service Redesign – We updated SGHD on the community engagement work currently ongoing in Skye & Lochalsh. Conclusion SGHD recognise that NHS Highland faces challenges on a number of issues, improving services, maintaining tight financial control, and maintaining remote and rural services. They were assured that NHS Highland is well placed to meet these challenges.
Transcript
Highland NHS Board13 April 2010
Item 4.6
CHIEF EXECUTIVE’S AND DIRECTORS’ REPORTEMERGING ISSUES AND UPDATES
1 ANNUAL REVIEW – LETTER FROM SCOTTISH GOVERNMENT AND MID YEAR REVIEW
NHS Highland had its Annual Review with the Cabinet Secretary, Nicola Sturgeon, on Monday 7December 2009. The Annual Review letter has now been received by the Scottish Government and isattached as Supplementary Paper 1. The date for the 2010 Annual Review has been set asTuesday 22 June 2010.
The Mid Year Review with the Scottish Government Health Directorate (SGHD) took place on Friday 8January 2010 via video conference. The purpose of the meeting was to review our progress in thefollowing areas:
Action points from 2009 Annual Review Finance 2009/2010 and 2010/2011 HEAT Targets 18 Week Referral to Treatment Service Redesign
The letter providing formal feedback from the review is attached as Supplementary Paper 2. Thisgives the detail for each of the above items, but the key points contained within it are:
Action points from 2009 Annual Review – as it was only one month since the Annual Reviewthis item was not considered in order to concentrate on other areas.
Finance 2009/2010 and 2010/2011 - SGHD were assured that NHS Highland plans to meet allfinancial targets in 2009/2010, and that they were confident that NHS Highland is well preparedgoing into 2010/2011 and that the staff side are well engaged with the Board on the challengeahead.
HEAT Targets – This discussion focused on 5 key areas, sickness absence, Healthy Weight ofChildren, Delayed Discharges, Psychological Therapies and Hospital Acquired Infections.Whilst all of these targets remain challenging SGHD were assured that plans were in place toimprove our position in all 5 areas identified.
18 Week Referral to Treatment/Access Targets – They acknowledged problems in Oral surgeryand Neurology due to staff sickness and Consultant vacancies. SGHD recognised theincrease in pressure in some specialties due to the severe weather and also wanted to knowmore about the impact rural clinics have on delivery of the 18 Week RTT target.
Service Redesign – We updated SGHD on the community engagement work currently ongoingin Skye & Lochalsh.
Conclusion
SGHD recognise that NHS Highland faces challenges on a number of issues, improving services,maintaining tight financial control, and maintaining remote and rural services. They were assuredthat NHS Highland is well placed to meet these challenges.
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2 BREASTFEEDING UPDATE
2.1 Strategic Elements – The Breastfeeding Strategic Framework 2010-2013 (copy attached forBoard Members) has been ratified by the Area Nursing and Midwifery Committee.
The Framework’s overarching strategic aims are to:
Increase breastfeeding rates at birth by 5% by 2013. Increase breastfeeding rates at 6 – 8 weeks to 33.3% by 2011. Ensure that both maternity units and CHP’s achieve full Baby friendly Accreditation by 2011.
It adopts a logic model approach to implement the strategic objectives which are:
1. Implement UNICEF Baby Friendly Initiative (BFI) throughout NHS Highland.2. Train volunteers to support breastfeeding throughout NHS Highland.3. Promote the participation of the NHS Highland baby welcome sticker scheme in NHS
premises, partnerships and the public sector. This in turn will raise the profile ofbreastfeeding and support and encourage mothers who choose to breastfeed.
4. Implement a system of data collection which is accurate and performance monitored byNHS Highland Improvement Committee from both the Scottish Birth Register (S.B.R) andthe Child Health Surveillance Programme – Pre-School (CHSP-PS) system
2.2 UNICEF Baby Friendly Initiative – NHS Highland has embraced the UNICEF BFI.
Raigmore hospital was re-accredited with the Baby Friendly status in October 2009.Caithness General achieved the Baby Friendly status in November 2009 and received theiraward on 19 March 2010. This ensures that NHS Highland has succeeded in achievingguidance from CEL 14 with both their larger maternity units achieving full BFI accreditation.
All four CHPs have reached Stage 1 in the BFI process and are currently working towardsStage 2 this year.
A strong network of breastfeeding trainers is thriving throughout NHS Highland offering localtraining and advice. The network is managed by the infant feeding advisors and consists ofmidwives, health visitors, public health nurses and community nurses.
2.3 Breastfeeding Peer Support – NICE 11 guidance, CEL(2008)36 and UNICEF BFI all requestthe development of an externally accredited peer support network to support, promote andencourage breastfeeding. Research has demonstrated that provision of such a network canenable women to breastfeed for longer. This is currently being implemented in NHS Highland.Breast feeding support workers have been recruited and training in Inverness, Rothesay andAlness completed. Peer groups for Golspie and Thurso will commence in April, with acontinued roll out of training after to Skye and Wester Ross, Lochaber and Argyll &Bute. Alltraining follows the NHS Highland Draft Volunteer Strategy and targets areas of lowbreastfeeding rates.
2.4 Promote the participation of the NHS Highland baby welcome Sticker scheme in NHSpremises, partnerships and the public sector – With the support of the Breast Feeding etcScotland Act (2005), this scheme was re-launched in 2007 and participating businesses arelisted on the NHS Highland website. Further details of implementation are outlined in theBreastfeeding Strategic Framework on page 22.
2.5 Implement a system of data collection which is accurate and performance monitored byNHS Highland improvement committee – To collect accurate statistics, as shown in Section3 of the Breastfeeding Strategic Framework, NHS Highland uses the:
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1. Scottish Birth Record, (breast feeding rates at birth, discharge from hospital) and2. Child Health Surveillance System- pre-school (breast feeding rates at 6-8 weeks)
NHS Highland CHSP-PS quarterly data for 2009 is as follows:
March 2009 June 2009 September 2009NHS Highland 28.7% 32.9% 30.9%Argyll and Bute 24.4% 30.6% 31.8%
Work is underway through implementation groups to ensure that data recording in both these systemsis accurate and improved. The groups are chaired by Sally Amor (Child Health Commissioner forNHS Highland)
2.6 New Initiative – In order to support mothers who have significant difficulties in maintainingbreast feeding, the Infant Feeding Advisors will commence a weekly clinic at Raigmore hospitalon the 6th of April 2010 and deal with complicated breastfeeding problems. In addition, a“tongue tie” division service is included in this clinic. Referrals will be seen at the breastfeedingclinic and if deemed significant the procedure will be performed there too. ENT dept havesupported this with emergency cover in the rare event of any problems.
3 GETTING IT RIGHT FOR EVERY CHILD (GIFREC)
Highland Partnership have now implemented Getting it Right across all services and areas includingfor children who are at risk and in need of protection, looked after children and in universal services.The project team are all reassigned bar the project manager who continues to support theimplementation managers to embed the practice. Progress is monitored through Chief Officers Group– children and young people with reports received directly from the service managers groups in eacharea. Specific issues for Health are also raised through the Children’s’ services network.
The evaluation of the approach by Edinburgh University was published in December 2009 andevaluation work continues to explore the impact of the changes on children’s outcomes. This furtherwork will be available shortly as part of a series of 10 themed reports produced to date.
Work continues to explore possible electronic solutions to sharing information and further streamliningprocesses.
4 HIGHLAND CARERS STRATEGY
The Strategy has been developed by NHS Highland in partnership with the Highland Council andHighland Community Care Forum and is now in the third year of its four year life span.
It has been updated each year to reflect the development of the work around adult Carers in Highlandand is complemented by an Integrated Implementation Plan which sets out to provide a co-ordinatedaction plan for the Statutory and Voluntary Sector partners to achieve the objectives of both theHighland Carers Strategy and the Carers Information Strategy.
Much of the work in 2009-10 has focused on the development of the Highland Carers Support Planwhich has been revised to ensure that it complies with the requirements of the National Minimum
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Information Standards for Carers’ Assessment and Support and the outcomes focused Personal PlanFramework which is being developed jointly by Highland Council and NHS Highland to replace theSingle Shared Assessment.
The new Carers Support Plan has been developed with Carers input through the Highland CarersProject and has recently been successfully trialled on a small number of carers in Inverness. The Planwill be rolled out to Highland Council and NHS Highland staff following the associated training in theautumn of 2010.
It is recognised that training of staff in all areas of carers issues will be key to achieving many of thedesired outcomes for carers. A training strategy and plan has been developed jointly by NHSHighland, Highland Council and Highland Community Care Forum ensuring that there is acomprehensive menu of courses available that enable appropriate training to be targeted at specificgroups of staff who have different levels of interaction with carers. Voluntary Sector Staff andCommunity Pharmacists will also be invited to take part. Thus it is planned to deliver the training overthe course of the next year on four different levels as follows:
1. Induction Training for all new staff–leaflets for induction packs, website etc
2. Carer Awareness Training for all staff who have contact with carers – increasing carerawareness, evidence from carer testimonies
3. Carer Support Plan Training for all staff who will be working alongside carers – aimed atkey staff supporting carers
4. Modular Working with Carers Training Course for identified carer champions in eacharea.
The training programme will commence in May and continue through to March 2011 with breaksduring the school holidays. The updated strategy and implementation plan provide the detail of thework which has focused on the need to raise awareness among staff of carers’ issues; the importanceof using the Carer’s Support Plan (as part of the core Personal Plan process) to assess and meetcarers need; as well as providing opportunities to increase the skills and confidence of carers tocontinue in their role through the provision of information, advice, training and peer-support. This workhas incorporated progressing actions contained within the Carers Information Strategy.
5 JOINT COMMUNITY CARE PLAN – CONSULTATION PROCESS
The first draft of a new Highland Joint Community Care Plan has been considered by the Housing &Social Work Committee and also by the NHS Highland Board. The plan’s strategic direction has beenbroadly welcomed. The plan’s messages include the need for significant change in how adults inneed are supported in our communities. Given this, there is a desire within the partnership for a wide-ranging engagement and consultation on the plan.
The draft plan is detailed and while every effort has been made to make it accessible it wasrecognised that specific materials needed to be developed to promote effective engagement with amuch wider audience. The materials developed for that purpose are detailed below.
Consultation Booklets/Online SurveysA shorter set of materials has now been prepared which provide a “snappy synopsis” of the challengesthat we face and our approach to developing community care services to meeting those challenges.
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Four booklets have been prepared which cover the range of activity, and these will be replicated infour online surveys.
They cover our services for: Older adults in need Younger adults in need (16 to 64) Mental health and/or substance misuse All adults in need; common approaches
People are encouraged to complete the response sheet which asks three questions in relation to theinformation provided:
Are these outcomes the important ones? Are there other issues we should consider? Are these the improvements we need to make?
Broader EngagementThe booklets will be distributed widely, including through service points, libraries, pharmacies and GPsurgeries, and the online surveys will be available for those with access to the internet. A set ofsupporting materials (flyers etc) are being prepared to ensure the existence of the consultation isadvertised, and work is underway with the Public Relations sections to ensure that it is properlypublicised. It is also hoped that the consultation booklets will form the basis for discussion in a rangeof settings. With the assistance of Highland Community Care Forum, we aim to engage with a rangeof “harder to reach groups” including representatives from minority ethnic groups across the Highlandcommunity.
Next StepsThe period of consultation will run from April to June inclusive. Responses from the booklet and onlinesurvey will be sought between April 5th and June 15th 2010. It is proposed that a summary offeedback document is produced to share the analysis of responses with those that participated.
Finally, the aim will be to produce an updated draft of the Highland Joint Community Care Plan tobring to the October NHS Board.
6 JUNIOR DOCTORS
2009/10 is the fourth round of Scottish Medical Training (SMT; formerly known as ModernisingMedical Careers) whereby recruitment is undertaken nationally by NHS Education Board for Scotlandon an annual basis. Applications for GPST and Specialty Training Programmes are significantlyreduced throughout the United Kingdom generally and significantly reduced to Scotland. Theapplication for GPST Programmes is very significantly reduced compared to last year. WithinScotland, the North of Scotland Deanery is the least favoured Deanery for applications.It is evident that a significant number of Junior Doctors are not applying for training schemes followingtheir Foundation Years, either seeking employment (especially in Australia and New Zealand) orwithdrawing from a career in medicine altogether.
In 2008/09 NHS Highland filled most of the training rotations. There were 174 training posts in NHSHighland: 30 in Foundation, 34 in Foundation 2, 34 in GPST and 76 in Specialty TrainingProgrammes. Most of the Specialty Training Programmes were filled with the exceptions in Obstetrics& Gynaecology, Paediatrics and a small number in General Medicine. There were significant GPSTProgramme gaps in rotations, especially involving Caithness General Hospital in Wick and Lorn &Isles District General Hospital in Oban (5 out of 9 and 4 out of 9 Doctors in the junior doctors rotasrespectively), which have been covered to varying degrees by LATs, LASs and Locum Agencies.
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In 2009/10 (the current application round) the overall training numbers were reduced in Scotland, butNorth of Scotland Deanery only lost 2 Training Programmes. All applications have been processed,interviewed and posts offered in Round One, which closed on 29/03/10. Thereafter there is a 2ndRound with offers due to be completed by 14/06/10 and information on confirmed posts accepted willonly be notified to NHS Boards on 03/07/10. A snapshot of the position at 29/3/10 for NHS Highlandis as follows:
1. Foundation Programmes: It is anticipated that all FY1 posts will be filled and this is dependanton students passing their Medical Finals. There is no reason to suggest, at this stage, that thiswill not be the case. All the current FY1 posts have been filled and it is anticipated that theFY2 posts will be filled, although it is expected that a few may opt out of the FoundationProgramme.
2. Specialty Training Posts – Most of these posts have now been offered throughout NHSScotland. There are concerns that a number of North of Scotland rotations will not becompletely filled, even after the 2nd Round and these include Obstetrics & Gynaecology,Paediatrics, General Medicine and Emergency Medicine.
3. GPST: There are 349 GP ST Programmes available in NHS Scotland and there were 407applications, 406 were short listed and 306 were deemed appointable after Round One. If allthe posts are accepted there will be a shortfall of 43 Programmes to be offered in Round Two.In the North of Scotland the rotations involve NHS Highland and the Islands; there are 22 threeyear GPST posts of which only 7 have been accepted, leaving 15 vacant Programmes forRound Two. There are 9 four year GPST Programmes of which only 2 have been accepted todate, leaving 7 vacancies for Round Two.
It is evident that Junior Doctors are applying for multiple programmes, such as General Practice,General Medicine, Psychiatry and Surgery, which is a significant change from last year, where therewere very few multiple applications to different specialties.
This explains the significant number of posts offered, but not accepted to date. The potential impactwill be most severely experienced by the NHS Highland Rural General Hospitals, especially in Wickand Oban. As the three year GPST Programmes involve 18 months in General Practice and 18months in various Specialties such as Medicine, Surgery, Obstetrics & Gynaecology, Paediatrics,Anaesthesia, Emergency Medicine, the effect will impact Raigmore Hospital although it is impossibleto quantify at the present time.
A Risk Analysis has been carried out on all the posts deemed at high risk of remaining vacant giventhe present assumptions throughout all the Operational Units in NHS Highland. Each Operational Unithas been requested to produce a Contingency Plan on Planning Models that would suggest the JuniorDoctor posts will be filled at 50%, 25% and 0% level.
7 PARTICIPATION IN NHS SCOTLAND
Updated National Guidance – Involving People
The Scottish Government Health Directorate (SGHD) has issued updated guidance underCEL(2010)04, on 10 February 2010. The guidance “Informing, Engaging and Consulting People inDeveloping Health and Community Care Services” sets out the responsibilities of NHS organisations,and gives general guidance to inform practice. Briefly, the key general points are:
NHS organisations should communicate routinely with local communities about plans andperformance.
Public Partnership Forums are one mechanism for routinely engaging local people.
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Joint / partnership services should have joint action on communication and engagement. Methods of engagement must be planned and designed to ensure people are not excluded
from the process (Equality impact assessment of methods). Engagement actions should reflect the National Standards for Community Engagement. GPs and other independent contractors are expected to engage with patients and local people
when planning change to services.
It also includes some information about NHS responsibilities at times of major service change, andrefers to associated guidance from the Scottish Health Council1. Although there is no clear definitionof “major” change, it is typically associated with the closure of a hospital, or other change which has amajor effect on a group or groups of patients. NHS organisations should seek advice from SGHD onwhether a service change is considered “major”.
In a major service change there is a series of additional formal processes including: Developing options Appraisal of options2
Potential for Independent Scrutiny (of the case for change and the change proposals) Ministerial approval of an NHS Board’s decision
Participation Standard
The new, national Participation Standard for the NHS in Scotland will be introduced from April 2010.The Standard is in 3 parts – 1) Patient Focus, 2) Involving people in service planning, improvementand change, and 3) Corporate Governance. The approach to self assessment mirrors that used byQuality Improvement Scotland, although there is still important detail to be clarified. During 2010/11,NHS organisations will gather evidence to be reviewed during 2011/12. This evidence is likely toinclude feedback from the patient surveys undertaken at the turn of the year as part of the national“Better Together” service improvement programme. The first report of survey findings is expected byJune 2010.
NHS Highland position
There is work in progress to update the strategic aims for participation in NHS Highland, and to set outroles, rights and responsibilities, using the Scottish Government’s concept of the mutual NHS – wherestaff and local people are co-owners of the NHS3. This will incorporate the updated national“Informing, Engaging…” guidance, and will expand on the NHS Highland Brief Guide to Participationdeveloped to support the Strategic Framework, and updated following the Board Strategy Day on 2March 2010. The work is at an early stage, and will be developed with direct input from staff andpublic partners. It will be written to complement the NHS Highland Framework for Communications.
8 REGIONAL PLANNING – NORTH OF SCOTLAND PLANNING GROUP & WEST OFSCOTLAND PLANNING GROUP
A copy of the Briefing from the North of Scotland Planning Group for February 2010 is circulated asSupplementary Paper 3 to this update. A copy of the Briefing from the West of Scotland PlanningGroup for March 2010 is circulated as Supplementary Paper 4 to this update.
1Guidance on Identifying Major Health Service Changes. Scottish Health Council, February 2010.
2Involving Patients, Carers and the Public in Option Appraisal for Major Health Service Changes. Scottish
Health Council, February 2010.3
Better Health Better Care Action Plan. Scottish Government, December 2007.
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9 REVIEW OF HEALTH SERVICES IN SKYE AND LOCHALSH
Following scoping work, public meetings and the wider engagement exercise a Health ServicesWorkshop was held at the Dunollie Hotel in Broadford on 12 February 2010 and was independentlyfacilitated by Health Journalist and Broadcaster, Pennie Taylor. The delegates heard the feedbackfrom the engagement exercise as well as information about the National and Highland context,rationale for change, current services and financial backdrop. Those present had opportunitythroughout the event to question and to state their concerns and suggestions and to explore optionsfor the improvement and, in some cases, redesign of health services in Skye and Lochalsh to makethe best use of the available resources and provide the best possible services, to as many people aspossible, as close to their homes as possible.
Those invited to take part in the workshop include representatives of all community councils, HighlandCouncillors, MPs and MSPs, locality and clinical staff, managers and representatives of partnerorganisations. A wide range of experience, expertise and perspectives were represented.
The aims of the workshop are listed below and delegates agreed that these had been met. To give feedback on the recent engagement exercise To provide accurate information on needs assessment and finance in an open and transparent
manner To provide information on the national perspective in particular, Shifting the Balance of Care,
Long Term Conditions and Reshaping Care for Older People To provide information on current services To provide an opportunity for delegates to ask questions and clarify any outstanding issues To provide an opportunity for delegates to assist in prioritising the actions for the future
The workshop agreed some key issues that require further action:- Culture change is required Resources need to be used to best effect and demonstrate value for money Communication needs to be improved within the system and with the public The two hospitals need to work better together Clarify the roles of the two hospitals and establish what is required for the future to enable a
clinical brief for a future new build to be drawn up. We need to use specialist services differently and reduce follow up in secondary care Reduce amount of unnecessary travel for patients, review transport options We need to focus on supporting health and health improvement, anticipating risk and early
intervention to avoid preventable hospital admission Exploit the potential of technologies through telecare, telehealth etc Better integration in health and across health and social care Review of roles and responsibilities Review of available treatments Multi professional. Multi skilled team approach Review of how NHS 24 is working, triage and out of hours options Public involvement in making tough decisions Ongoing dialogue
A Reference Group comprising representatives of key stakeholders will now be established to agreethe priorities and timescales and to oversee progress. Mrs Ann Bethune, immediate past Chair of MidHighland CHP has been invited to chair the first meeting of the Reference Group and it is hoped thatthe first meeting will take place in April 2010.
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Communication tools will be developed to ensure that the people of Skye and Lochalsh are able to beinvolved if they so wish and certainly informed of progress.
10 REVIEW OF RHEUMATOLOGY SERVICES
This is a brief update to ensure that Board members are aware of the ongoing Whole system reviewand the anxieties that have arisen. A full report will be presented to the Board later in the year.
The Rheumatology Service has been under considerable pressure for some time and waiting listinitiatives have been required in order to meet targets. This speciality was identified by NHS Highlandas a priority for review and work has been going on for some months to identify the patient flow issues,challenges and potential solutions. There is no new resource immediately identifiable to allow forservice expansion and therefore redesign of existing services and a change in the way we deliver careand treatments is required. It is essential that efficiency is demonstrated before any investment canbe considered. Following that, should additional resource still be required, proposals will be discussedby NHS Highland Planning Group.
An Independent Consultant, supported by Wyeth Healthcare, was invited to work with us in March,2009 and she has provided a draft report which has been helpful in clarifying the priorities for attentionand has been used to assist with working group focus. NHS Highland has commented on the draftreport and suggested some amendments, some factual inaccuracy issues and some in connectionwith the report recommendations out with the original remit. Unfortunately, the IndependentConsultant has been on extended leave and has been unable to meet to agree a final version, thereport therefore has not yet been published.National Guidelines and standards are also being used to guide the review.
10.1 The Context
The Shifting the Balance of Care and Long Term Conditions agendas that have frequently beendiscussed in NHS Highland, have an impact on Rheumatology as we endeavour to support selfmanagement, care and treatment closer to patients’ homes and avoidance of hospital admission.Rheumatoid Arthritis was identified at national level as a priority condition for action by CommunityHealth Partnerships as part of Long Term Conditions strategies.Rehabilitation and Re enablement services need to be available in local communities to reduce theneed for long and often very painful journeys for patients and these are patchy across Highland.
However, the need for a Specialist service is not in doubt, on the contrary, the local development workis aimed at protecting the specialist service and making it more accessible in a more timely fashion forthose who require it most. In particular, early referral and intervention for new patients, and urgentaccess through GPs for patients with complex conditions and unstable disease are key. Discussionswith GPs and Rural General Hospital Clinicians have been fruitful and a more shared care model ispossible. However, there are learning needs which require to be addressed before this can beimplemented effectively.
Specialist Nurses have been appointed in recent years but are not able to fulfil their full potential as atpresent, they are involved in the delivery of biologic drugs which require to be infused. This servicecould be delivered by other staff and at local centres and some progress has been made towards this.
Specialist Therapists based in Dingwall are under considerable pressure and colleagues in local areashave expressed concern that they would require updating and support in order to care for patientslocally and to provide earlier intervention when required. Telehealth options may well be helpful innetworking this kind of service and support.
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In recent years several new drugs have become available for the treatment of Rheumatoid Arthritisand related conditions. The use of these drugs has been supported by NHS Highland although thishas not featured in financial planning and therefore the large increase in cost has had to absorbed inalready overstretched budgets.
Three strands of work are ongoing:-
Inpatient services Out patient and Local Services development Education and Training
10.2 Efficiency Savings
At the same time as the Review, NHS Highland has required all Operational Units to find efficiencysavings and the Rheumatology service is not immune to that. In particular, the HighlandRheumatology Unit in Dingwall needed to contribute to the Mid Highland CHP target and staff wereasked to consider how best this could be achieved. No savings had been identified by December andtherefore something needed to be done urgently. Several options were put to staff and the closure of4 beds was thought to be the least disruptive at short notice. This was also in keeping with theexpectation of NHS Highland Board which, in April required all Units to review bed stock and to ensurethat only those beds that are absolutely necessary are being maintained in order to facilitate the shiftin the balance, local service improvement and efficient management of all available resources.Subsequent direction required all elective services to be reviewed and managed in line with the needfor savings and meeting targets.
This move has caused considerable unrest and has been the subject of much media interest. NHSHighland has been at pains to point out that although the Unit is part of the Review, the reduction ofbeds is an efficiency measure and will not prejudice the outcome.
The Rheumatology Unit at Ross Memorial Hospital in Dingwall is a highly thought of Unit, much valuedby patients who use it, nevertheless a review of how it is operating, admission policy and efficiencyhas been part of this Redesign to ensure that it is meeting the needs of all patients in Highland andthat there is equity of access and service provision.
10.3 Next Steps
There is a need to take stock of information gathered and work done to date in the three workinggroups in order to plan the next phase of the review. This is being planned and the involvement of aBoard Non Executive Director is sought.
11 WHEELCHAIR SERVICES MODERNISATION
The NHS Highland Wheelchair and Seating Service (WSS) is currently undergoing a period ofmodernisation and improvement to fulfil the recommendations that were made in the 2006 ScottishGovernment report “Moving Forward” and the subsequent national action plan launched in April 2009.
The Highland WSS has been allocated an additional £1.15m in funding spread over the three year lifeof the project, from April 2008 to March 2011. The purpose of the modernisation project is to improve:patient involvement, the repair and maintenance service, information management and patientinformation; as well as building capacity and modernising the wheelchair fleet.
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Since May 2009 there has been a significant increase in clinical, technical and administration staff whoare helping to increase the amount of patients seen, improve access and to reduce waiting times.Between April and December 2009 there has been a 63% increase in the amount of patientappointments compared to the same period in 2008. The majority of first time equipment is issuedwithin four weeks of referral.
The service is currently in the process of modernising its standard fleet wheelchair to a more modernlightweight piece of equipment. The repair and maintenance facility that the WSS currently offers isbeing expanded to cover all patients across the Highlands, West Grampian and the Western Isles.
In April 2009 the WSS began a collaboration with a local “not for profit” organisation ILM Highland.ILM’s handy person service has been working to offer us a cost effective repair and delivery service aspart of our “shifting the balance” strategy. Since the beginning of the pilot in April 2009, ILM Highlandhas successfully carried out over 400 delivery, collections and repairs of wheelchairs across Ross-Shire, Caithness and Sutherland.
In January 2010 all five wheelchair services carried out a user satisfaction survey with 10% of theirpatients. The survey included six core questions set by the Scottish Government around responsetimes, centre staff, information, equipment repairs and maintenance. The results were collated andshowed that 85% of the patients surveyed were happy or very happy with the services provided by theHighland WSS. One area that was highlighted for improvement was patient information about theservice. The WSS is in the process of developing patient information which will shortly be available inleaflets, booklets and on the NHS Highland internet site.
One of the main initiatives for the coming year will be to develop and implement a system ofcommunity based prescribing and delivery of standard wheelchairs. In November 2009 a successfulskills maximisation event was held in Inverness for Allied Health Professionals (AHPs) from across theHighlands. The participants examined how some of the assessment, prescribing and delivery ofwheelchairs could be transferred to community health care workers. The WSS will be working with theNorth CHP to pilot this piece of work.
Chief Executive’s OfficeAssynt House
1 April 2010
lpowe01
TextBox
SUPPLEMENTARY PAPER 1
St Andrew’s House, Regent Road, Edinburgh EH1 3DG
www.scotland.gov.uk 1.
sgHealth Delivery Directorate
John Connaghan, Director
T: 0131-244 3480 F: 0131-244 2042E: [email protected] Dr Roger GibbinsChief ExecutiveNHS HighlandAssynt HouseBeechwood ParkInvernessIV2 3BW
___3 March 2010
Dear Roger
NHS HIGHLAND: MID–YEAR REVIEW 2009-10
1. I am writing to summarise our discussion via video conference on 8 January. Thepurpose of which was to look at progress against key HEAT targets in 2009-2010 and atyour preparations for 2010-2011, progress against 2009 Annual Review Action Points andthe finance plan which underpins all of these actions. I took the opportunity to record myown and Kevin Woods’ sincere thanks to all staff across NHS Highland for their efforts inresponding to the HIN1 outbreak and also in coping with the severe weather conditions inDecember and early January. We were most impressed by the considerable efforts made bystaff to ensure the continued delivery of patient care.
Action Points from 2009 Annual Review
2. I was conscious that it was only around a month since the NHS Highland AnnualReview took place; therefore we concentrated on your preparedness for 2010-11.
Finance 2009/10 and 2010/11
3. John Matheson opened the discussion on the Board’s financial position by asking foran update on the current year position. We were assured to receive confirmation thatNHS Highland plans to meet all financial targets in 2009/10. We note that this requires theachievement of significant levels of savings, over and above the Efficient Government target.We were also pleased to note the removal of the underlying deficit at the very start of thefinancial year. We asked about your state of preparedness for 2010/11. You explained theneed to deliver savings through service redesign which is being undertaken under 11specific initiatives. You confirmed that good progress is being made this is within anincreasingly challenging economic climate. You went on to explain that the Board’sapproach during next year will be to progress the efficiency programme alongside improvingquality and the experience of patients. You also, recognise that there needs to be absolutefocus on consultant job planning. In summary you told us that you were confident that youwere well prepared going into 2010/11 and that staff side were well engaged with the Boardon the challenges ahead.
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St Andrew’s House, Regent Road, Edinburgh EH1 3DG
www.scotland.gov.uk 2.
HEAT Targets
4. We moved on to discuss performance against key HEAT targets and standards. Onmanaging sickness absence you informed us the level at November 2009 was 4.5% whichwas an improvement against the October level of 4.8%. You assured us that you willcontinue to maintain focus on this important target to improve and sustain performance. Weasked about your progress to increase the number of interventions to progress the HEAT 3Healthy Weight of Children target. You explained that you are focussing on deliveringinterventions through the Mini X programme in schools and that all CHPs have recruited tokey posts to support delivery of the programmes and both Councils are also involved. Youare also looking to learn from good practice. You are presently behind trajectory, however,are confident that you will be back on track by the end of 2011. We asked that you includeyour action plan for improving performance in the 2010 LDP.
5. We asked for an update on the position on delayed discharges. . You advised usthat at the end of November 2009 there were 25 patients waiting over 6 weeks for dischargeand while the position had improved at the end of December it remained a significantchallenge to sustain the zero position. You assured that you and both partners arecommitted to developing home care packages to allow these patients to return home. Weasked for an update on the availability of psychological therapy services. . You informedus that there are still significant waiting times for these services, however you have recentlyappointed another therapist and were streamlining the booking structure which should havea beneficial impact on waiting times. The Highland wide Psychological Therapies Groupwas reviewing the provision of therapies in light of the national psychological services matrix.
6. We discussed your progress against key HAI indicators. . We were pleased to notethat C-Diff cases appear to be falling and current rates are already below the 30% reductionneeded. You also told us that Staph. Aureus Bacteraemas (SABs) rates are improvingyear on year, however cases remain significantly higher than the projected trajectory for theHEAT target and NHS Highland will need to bring cases down significantly over theremainder of this year to March 2010. We discussed the Healthcare EnvironmentInspectorate (HEI) inspection visit to Raigmore Hospital which took place over 15 and16 December 2009. The report has since been published by the HEi on 8 February. TheReport reveals a number of positive findings and the Inspectorate has commended theBoard in its work for preventing infection. The Report also recognises that there are areasfor improvement and you have given us an assurance that all of the areas identified arebeing addressed through a Board Improvement Plan.
Access
7. We then moved on to discuss the 18 week referral to treatment target. We asked ifyou could give us an indication of the overall end-March position. You explained that therewere specific pressures in oral surgery and neurology due to sickness leave and consultantvacancies. We suggested that you should speak to the Access Support Team about waysto minimise the impact of these pressures. You confirmed that there had been a number oforthopaedic breaches due to the severe weather and that travel difficulties had necessitatedthe cancellation of some peripheral clinics across the area. You had also sustainedcancellations in ENT. We acknowledged the increased pressure you have been underrecently and that we wanted to better understand the issue around rural clinics and theimpact on the 18 week RTT target and we asked you to write to us on that.
St Andrew’s House, Regent Road, Edinburgh EH1 3DG
www.scotland.gov.uk 3.
8. We then discussed the 18 weeks Referral to Treatment Measurement for 2009/10-2010/11. The targets for delivery at 31 March 2010 are 70% for admitted completeness andan aspirational target of 70% for non-admitted pathways. You advised us that while youexpect % compliance to increase over 2010/11 NHS Highland does not at this point expectto achieve 70%. We concluded the discussion and reminded you that robust trajectories foradmitted and non-admitted performance would be agreed as part of the 2010/11 LDPprocess.
Service Re-design
9. We moved on to discuss service re-design and you informed us that you werecurrently considering how best to progress service redesign across Highland to ensure thecontinued provision of high quality, safe, sustainable services across the Board area whichalso provided value for money. We were already aware of the consideration around servicesin Skye and Lochalsh which were still at an early stage. You advised us that feedback fromthis early community engagement was to be fed back to people at a workshop on12 February. Attendance at this workshop would include members of the public, partneragencies, clinicians and local Councillors and MSPs. The next steps in taking any servicechange forward would be determined following the 12 February workshop and we asked youto provide a report on next steps once the way forward had been agreed. We discussed theprocess of change more generally and you confirmed that the Board will be giving this moreconsideration over the coming months. We reminded you confirmed that theHealth Directorates are available to offer advice and support on all aspects of servicechange process and handling.
AOB
10. We asked about progress on prescribing work and your progress on implementingScriptswitch. You explained there had been considerable interest from CHPs and that GPswere also enthusiastic. We asked that you provide a report on the recent trial of Scriptswitchin 6 GP practices and what next steps might be in relation to area wide implementation ofScriptswitch.
Conclusion
11. We had a very constructive discussion and it is clear that NHS Highland faceschallenges on a number of fronts, including improving access, maintaining tight financialcontrol and sustaining remote and rural services. However, we were assured thatNHS Highland is well placed to meet these challenges. Once again, may I extend ourthanks for how well NHS Highland coped with these additional pressures.
Yours sincerely
JOHN CONNAGHANDirector of Health Delivery
North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles
NHS Board Briefing February 2010
A meeting of the NoSPG Executive was held on 3 rd February 2010. The following briefing has been prepared to update the North NHS Boards on the outcome of the meeting.
NoSPG Projects
Cardiac Services The Regional Delivery Plan (20062010) was approved in 2007, since which time it has become apparent that aspects of the original plan would benefit from wider discussion, to understand individual Board and regional implications in relation to activity, cost, repatriation, impact on service capacity, patient flow and any future changes. A workshop has been scheduled for 24 th February in Aberdeen with the aim of refreshing the Regional Delivery Plan.
CAMHS A proposal was submitted and agreed to appoint a clinical lead to develop the regional obligate network for Tier 4 CAMHS and provide leadership to the CAMHS project through to Outline Business Case.
Child Health The final bid for year 3 National Delivery Plan funding (£2,158,585) was approved and will now be formally submitted to Scottish Government for approval.
A proposal is being developed for the establishment of a Neonatal network across the North and will be presented to NoSPG at its next meeting.
A draft workplan for 2010/11 was submitted for approval and includes sustainability of general paediatrics, sustainability of critical care, development of a child protection network and a neonatal implementation plan. Workforce issues will be critical across these areas. The workplan was approved.
Oral Health & Dentistry The original term of the project comes to a close at the end of March 2010, however, NHS Boards have been asked to approve an extension as there are outstanding issues still to be taken forward. It was agreed that these should be prioritised and the required resource identified before any decision was agreed.
Obesity Management, including bariatric Surgery A successful planning day was held on 15 th December 2009, at which four of the six NHS Boards were represented. There was enthusiasm to work regionally and it was proposed that a regional MCN be established. A subgroup will be established to take this forward and will aim to provide NoSPG with a draft Regional Delivery Plan by July 2010.
AHP Strategic Alliance This group has now been stood down as a formal sub group of NoSPG and outstanding issues will be taken forward by the NoS Nurse Directors Group. NoSPG extended their thanks to Mrs Judith Catherwood for her hard work during her time as Regional AHP Advisor.
NORTHOF SCOTLAND PLANNING GROUP
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North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles
HUB Co. Mr Fraser Innes has been appointed as Programme Director, initially for two years. The procurement process is now well underway and financial close is expected in November 2010. Four front runner projects have been identified, including a health and care village, two new health centres and a resettlement project.
National Work Streams
Remote & Rural Implementation Group The six monthly performance management report has been submitted to Scottish Government and the workplan has been revised to address all outstanding actions to the end of the project in June 2010. An exit strategy is being developed.
A workforce summit is being planned for May 2010 and will bring together work ongoing around the RGH medical workforce and the acute care workforce within remote and rural community hospitals.
National Diagnostics Steering Group It has been agreed that Mr Vince Shields, Service Manager, NHS Grampian will represent the North on this group.
Specialist Advisory Group on Audiology It was agreed that Mr Alisdair Chisholm, Director – Better Care Without Delay, NHS Grampian would represent the North on this group.
NoSPG Business Management
Annual Report 2009/10 The Annual Report will be presented to Boards with the 2010/11 workplan and a report detailing all the project specific events which have taken place over the last year.
Workplan 2010/11 The workplan has been drafted and will be subject to NoSPG approval.
NoS Workforce Development Group A proposal was agreed to establish this as a formal sub group of NoSPG to take forward workforce issues across the region. The proposal was agreed and Mr Mark Sinclair and Mrs Anne Gent will jointly Chair the group, with one of the Chairs becoming a member of the NoSPG Executive.
NoS Nurse Directors Ms Heidi May has intimated her wish to resign as Chair of the group and nominations are sought for a replacement.
North of Scotland Public Health Network Thanks were extended to Dr Lesley Wilkie for her work as Clinical Lead of the network. Dr Sarah Taylor, Director of Public Health & Planning, NHS Shetland will take over the role.
Retiral of Mr David Sullivan NoSPG members extended their thanks to Mr Sullivan for all the work that he has taken forward on their behalf over the last few years and wished him well for the future.
Date and time of next meeting The next meeting will be held on 14 th April 2010 in Inverness.
A meeting of the Board Chairs will take place on 17 th March in Aberdeen.
WEST OF SCOTLANDREGIONAL PLANNING GROUP
Briefing Paper
The following in a resume of the outcomes of the West of Scotland Regional Planning Group Meetingheld on the 26th March 2010
1 Workforce update- CEL 28 Implementation Implications
Members received a report that to fully implement CEL 28 in the WoS would require an increase in of37% consultant establishment and 63% in specialty doctors, with 1-1 replacements paediatricmedicine and emergency medicine (Scotland 60% specialty & 40% consultants) to fill the gap in reloss of junior doctors in training surgery. West of Scotland numbers had now been submitted to thenational group.
2 Neonatology Services
Further clarification had been received on the national policy regarding implementation of the Reviewof Neonatology Services and its implications to medical and nursing workforce and whether this hadservice rationalisation implications. John Froggats letter to CE 10/03/10 directing Boards that not allrecommendations would be implemented and in the interim they were to implement the staffing tool fornursing levels to provide necessary assurance re staffing and skills levels.
3 Assisted Conception – Report from Regional Sub Group & Infertility Network
The Group received a report to on scoping exercise and recommendation. It was noted across WoSBoards funded different cycles funded, and different policy re same sex couples. Members discussedthe options to revert back to 2 cycles. Reflection by members this should be the recommendation tothe new National Group and the paper would be submitted to support this.
4. Report from Prescribing Work stream:
Douglas Griffin DoF presentation to members the outcomes of the work he had been leading toidentify cost saving and improve practice and service quality- the work streams were
Statins Prescribing and Therapeutic Switches: lead Margaret Ryan NHS GG&C – significantopportunities to target and correct prescribing practice and save money
Quality & Outcomes Framework: lead Jeff Ace NHS D&G –identified limited opportunity in QoFto change prescribing practice- require enhanced service initiative
National Publicity Campaign: lead Adrian Dalby SGHD - Huge potential on this 75% repeatprescribing enormous amount of waste –solution community pharmacists directly at the source ofthis linked into new contract with incentives to control area.
NHS Lothian Approach to Prescribing Management: lead Sean MacBride-Stewart – Summaryvery tight control of prescribing and formulary use- “conservative” in approach strength on costcontainment in formulary application
GP Practices Peer Reviews: lead Alan Lawrie NHS Lanarkshire- focusing GP practice bydeveloping traffic light indicators reports, support and follow up visits.
2010/11 work will examine areas of Anti TNF prescribing, expenditure on blood plasma and review ofLucentis and AMD prescribing.
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5 Update on Cardiac Services – Non Invasive Imaging Strategy: Gordon McLean
Group received an update on the work in developing a service strategy for non invasive imaging forthe WoS. It was reported that one of the benefits of standardising non invasive CT across the WoScould see a 35-40% reduction in invasive procedures and resultant gain in theatre time.
RPG endorsed next steps to get regional agreement on clinical outcomes, priorities, workforce &equipment implication as well as DCAQ etc- implementation within context. Recognition not afinancial commitment from group re timeliness & funding, report back to WoS in due course
6 Resource Prioritisation
The Group considered the outcomes of the WoS process re prioritisation of service developmentproposals as listed below:
The group approved PET scanner cost -10/11 only looking at in year cost of 300K phasedimplementation and noting that national top slicing of Boards will continue next 2 years, WoS to writeand request move to regional commissioning from national top slicing.
TAVI development not approved will go forward as proposal for national service consideration. CRTand Endoscopic ultrasound, not approved, further information required for next meeting.
7 Bariatric Surgery
Golden Jubilee National hospital is in process of finalising operational plans to commence a regionalbariatric service by the end of April/May for NHS Forth Valley, NHS Dumfries & Galloway and Argylland Bute CHP. They would be establishing a referral criteria and pathway management which theywould share with the Boards concerned shortly. GJNH will be open to discuss other referrals fromother Boards once established
8 Proposal for WoS RPG Annual Planning Event
Members recorded the success of this year’s event on the 15th March 2010 at the Beardmore Hoteland Conference Centre, Clydebank. Focusing on efficiency, productivity and redesign, report andpresentations would be available shortly.
Stephen WhistonHead of Planning, Contracting and PerformanceArgyll & Bute CHP
