9.2 Mid CHP Minutes 16 March 2007

Highland NHS Board1 May 2007 Item 9.2 Mid Highland Community Health Partnership CHP General Manager’s Office County Community Hospital Invergordon IV18 0JR Telephone: 01349 855671 Fax: 0

Highland NHS Board

1 May 2007 Item 9.2

Mid Highland Community Health Partnership

CHP General Manager’s Office County Community Hospital Invergordon IV18 0JR Telephone: 01349 855671 Fax: 01349 854373 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the

MID HIGHLAND CHP COMMITTEE

Training Room,

County Community Hospital, Invergordon

Friday 16 March 2007 (10.00 am)

Mrs Gill McVicar General Manager, Mid Highland CHP Mrs Alison Phimister Locality General Manager, Ross

Cromarty & West Ness

Mr Tom Slavin CHP Accountant Mrs Caroline Matheson CHP Lead Nurse

Mr Findlay Hickey CHP Lead Pharmacist

Dr John May SSU Representative

Ms Mary MacLeod AHP Lead

Ms Kerry McLennan Voluntary Sector Representative

Mr Michael MacMillan Councillor, Ross & Cromarty (Dingwall

North)

Mr Okain MacLennan Non Executive Member Mrs Jackie Jefferson Information Support Officer (Minutes)

Dr Dennis Tracey Public Health Consultant Mrs Theresa James Locality General Manager, Lochaber Mrs Alison Hudson Locality General Manager, Skye &

Lochalsh

Mr Colin Shields Health & Safety Advisor

Ms Mairi Mackay Personnel Advisor

Ms Gail Haddock Acting Clinical Lead, Ross Cromarty &

West Ness

Dr Jim Douglas Clinical Lead, Lochaber

Ms Tracy Ligema OOH Operational & Development

Manager

Mr Hugh Campbell Ophthalmology Representative

Ms Maxine Johnston Deputy Voluntary Sector Representative

Ms Rosanne Sutherland Partnership Forum Representative

Ms Mandy Sillars Partnership Forum Representative

Mr Bob Cameron Ross & Cromarty Area Manager,

Highland Council

Mr Neil Clark Councillor, Lochaber Mrs Olwyn MacDonald Councillor, Lochaber

Mr Hamish Fraser Councillor, Skye & Lochalsh

Ms Isabelle Campbell Councillor, Skye & Lochalsh

Mr John Cross Highland HealthVoices Network

Representative (Interim)

Working with you to make Highland the healthy place to be

1 WELCOME AND APOLOGIES

The Chairman welcomed everyone to the meeting She extended a special welcome to new Committee members, Mr Findlay Hickey, CHP Lead Pharmacist and Mr Okain McLennan, Non Executive Member The Chairman also introduced Dr John May, representing the Specialist Services Unit (SSU) based at Raigmore Hospital, Inverness and Mr Graeme McLeod from Scottish Ambulance Service Apologies were noted as above

2 MINUTE OF MEETING HELD ON 20 DECEMBER 2006

The minute of the meeting held on 20 December 2006 was approved

3 MATTERS ARISING

3.1 Voluntary Sector Committee Appointments

Mrs McVicar referred to Item 6 of the previous minute, Voluntary Sector Committee Appointments She advised the Committee that she had recently received notification from

Mr John Cross that he was finding it difficult to commit to the role as he would wish and had taken the decision to stand down It was felt that it would be preferable to postpone the appointment of a new representative until the upcoming HealthVOICES election, rather than re-appoint on an interim basis

The Committee:

♦ Noted the resignation of Mr John Cross as Interim Patient/Public Representative

♦ Agreed to postpone the appointment of a new representative until the HealthVOICES

elections had taken place

3.2 Rural General Hospital

Mrs McVicar advised that the anticipated Interim Report from the event held on 20 November

06 had still not been released The draft document had however been circulated for comment and the final version was expected in June or July after the elections Progress since Mrs McVicar’s last update in December had been limited and it had still not been possible to achieve full consensus on surgical services to be provided in Rural General Hospitals (RGHs) A wider range of elective surgery was proposed but debate was continuing around which were appropriate for RGHs, this discussion was taking place at national level This was causing concern in Fort William where appointment of a fourth surgeon was being deferred until the national direction was known Mrs McVicar confirmed that she would circulate the Interim Report as soon as it became available In response to a question from Mr Okain McLennan, Mrs McVicar confirmed that the proposed new model for extended primary care teams would include Nurse Practitioners, together with different levels

of Medical and Allied Health Professionals

3.3 Staff Survey

Mrs McVicar advised that Ms Mairi MacKay was currently on sick leave The Mid Highland CHP Working Group looking at Communication and Well Informed Staff had made only limited progress; this was largely due to the amount of time HR staff were spending working

on issues in the Lochaber area, in particular, the potential closure of Glencoe Hospital

3.4 Audit Scotland – Governance in CHPs and Declaration of Members’ Interests

Mrs McVicar reiterated that, as a formal Committee of the NHS Highland Board, the CHP was required to have Declaration of Members’ Interests forms signed and lodged with the Trust Board Secretary Members who had not yet completed and returned their forms were asked to do so at their earliest convenience

3.5 FISH! Culture

Mrs McVicar briefly explained that the FISH! Culture was a training and motivational tool designed to improve staff morale and increase efficiency The philosophy is based on a

journey of conversations, actions and reflections and has four key principles: - Be There;

Play, Make Their Day; and Choose Your Attitude It had originated at a fish market in

Seattle When introduced at a recent leadership development event, it was very well-received and since then two more events had been held Feedback had been very positive; staff valued the opportunity to have time out to consider the way they worked and to explore their roles, attitudes and methods of working This was felt to be extremely important in the current climate of rapid change and further workshops were planned Mrs McVicar confirmed that she would be pleased to show the FISH! Culture DVD to members of the Committee who had not yet had the opportunity to see it

The Chairman formally welcomed the appointment of Mr Findlay Hickey who had recently taken on the role of CHP Lead Pharmacist and Mr Okain McLennan, newly appointed NHS Highland Board and CHP Committee Non Executive Member Dr John May, Specialist Service Unit Representative, was attending his first Committee meeting although the Chairman indicated that he had already been formally welcomed as a member of the Committee at a previous meeting

The Committee:

♦ Endorsed and supported the appointment to the Committee of Mr Findlay Hickey and Mr

Okain McLennan

5 LOCHABER REVIEW OF SERVICES FOR OLDER ADULTS

Mrs McVicar apologised to members who had not received all relevant papers under this item Hard copies of these were tabled She confirmed that the formal review process had been ongoing since June 06 and had entailed a vast amount of community engagement Although implementation of the review recommendations was progressing, the situation with Glencoe Hospital was causing considerable delays Unfortunately the Ministerial decision on closure had been delayed because the Scottish Health Council report had not been submitted at the same time as the Board recommendations and Service Plan Mrs McVicar highlighted the activities of a local campaign group which opposed closure of the hospital, but pointed out that the vast majority of people who had engaged with the process were supportive of both the closure and the plans for the future Further delays seemed possible but Mrs McVicar remained hopeful that the decision would come sooner rather than later She highlighted the enormous pressure that delays were causing to Glencoe staff who faced uncertainty over their futures Only five patients remained in the hospital and it was anticipated that some of these would be able to move to their new homes within the next few weeks The viability of keeping the hospital open for one or two patients was questionable; Mrs McVicar confirmed that she would be alerting the Board in early April to the possible

difficulties of managing the situation over the summer in the absence of an early Ministerial decision The Committee was asked to note that the situation was very fragile and extremely difficult, with local managers and HR staff constantly dealing with issues arising Mrs McVicar drew the Committee’s attention to the Final Service Plan Proposal dated 7 February

07, copies of which had been tabled The proposals were extremely exciting; care could be provided in the community and in intermediate care environments for hundreds of patients utilising the funds presently tied up in a 12 bedded facility

The Chairman asked Mr Graeme McLeod to clarify the Scottish Ambulance Service (SAS) perspective He confirmed that SAS were currently exploring various possibilities These included securing accommodation within Abbeyfield Ballachulish or the local police premises and the possible integration of Fort William and Glencoe to reduce on-call commitments The Committee acknowledged that local communities were very anxious about the potential loss of a SAS presence In response to a query from Ms Kerry McLennan, Mrs McVicar confirmed that the local campaign group had been heavily involved in the entire consultation process, and that any additional information they had requested had been given to them There was a brief discussion around the issue of public involvement and the lessons that could be learned for the future

Although the Glencoe decision now rested with the Minister for Health, at local level an Implementation Group had been set up to refine the action plan and identify clear objectives Working groups had been created or formalised as required Mrs McVicar emphasised that, aside from the Glencoe issue, a huge amount of work was ongoing around Rehabilitation Services in the community Mrs Caroline Matheson, CHP Lead Nurse, indicated that a clinical governance profiling exercise had been undertaken at the Belhaven Unit of Belford Hospital in Fort William Significant clinical risks had been identified, resulting in an action plan to rectify these and good progress was being made

The Committee:

♦ Noted the Final Service Plan Proposal dated 7 February 2007

♦ Noted the Update Report dated 7 March 2007

♦ Agreed the next steps in the process and supported continued implementation of the

action plan

6 MANAGEMENT OF LONG TERM CONDITIONS – CHP SELF ASSESSMENT

TOOLKIT

The document ‘Long Term Conditions Management – CHP Self Assessment Tool’ was circulated prior to the meeting, together with Mrs McVicar’s update report

Mrs McVicar reminded the Committee that a presentation had been given on the Management of Long Term Conditions and the CHP Self Assessment Toolkit at its meeting in September 06 She indicated that NHS Lanarkshire had been asked to explore implementation from a Scottish perspective Following wide consultation, several groups, including the Association of Community Health Partnerships, had provided comprehensive feedback, resulting in improvements to the tool It was set to become mandatory in April 07 and the CHP had until the end of April to complete its self-assessment and develop an action plan Clearly the time scales involved were extremely tight and in recognition of this, the CHP had been allocated funding of £10k for backfill, administrative support etc Mrs McVicar emphasised that this was a very important and high profile subject which would feed into the Board Accountability Review in summer More importantly, it would benefit patients by improving management of long term conditions and supporting self-care This was crucial in helping to prevent hospital admission and slow deterioration in quality of life

The Toolkit, which employed a partnership approach with Specialist Services, the Local Authority and voluntary sector, had been the subject of a workshop at the CHP Development Day held earlier that week This had been extremely useful for planning the next steps and exploring what was already in place in terms of policies, guidance and strategies which would impact on the Toolkit Some elements of the project, for example those involving SSU, would require a Highland-wide approach Other aspects, such as disease-specific patient information, could also be dealt with on a Highland or national level

Each CHP was required to form an Action Team to take this work forward and this would be overseen from a Highland perspective by the DHS Operational Network Mrs McVicar confirmed that a Clinical Lead for Long Term Conditions would be appointed; she had already sought expressions of interest for this role The Government had requested that during the first year CHPs should look at COPD and Rheumatology and this work would need to commence without delay Mrs McVicar suggested that the workshop at the next Committee meeting should be around Long Term Conditions Toolkit and this was agreed

The Committee:

♦ Noted the contents of the Long Term Conditions Self Assessment Toolkit

♦ Agreed that the Long Term Conditions Self Assessment Toolkit should be the subject of a

workshop at the next meeting in June 07

The Management Report was circulated prior to the meeting and Mrs McVicar highlighted the main issues as follows:

♦ The amount of time which had been taken up by the Review of Services for Older Adults

in Lochaber was again emphasised In Highland terms a vast amount of management and clinical capacity had been utilised to bring about relatively small (although extremely positive) changes The implications for future redesign projects were clear and different ways of managing change would need to be explored It was hoped that the public in remote and rural areas would also recognise the need to work with Health to improve services, perhaps by coming together in larger groups

♦ There was positive news about the Ross, Cromarty & West Ness Augmented Care at Home Team which was now functioning, with new appointments having been made and others re-advertised In addition, a welcome step towards more locally based specialist services had been taken with the opening of the new consultant-led Obstetric and Gynaecology Clinic at County Community Hospital

♦ The Asset Management Group had considered and approved the need for almost double the initial estimate of cost for Kyle Health Centre This project could now progress quickly The Broadford Hospital/Health Centre was also progressing, with a design team established and surveyors on site

♦ NHS Highland Out of Hours (OOH) Services were hosted by Mid Highland CHP, giving it responsibility for budgetary reporting The year-end overspend forecast of £980k was causing considerable concern and management action was being taken to ensure that the situation did not deteriorate further In the more remote and rural areas, activity levels were very low and costs disproportionately high This was largely due to the fact that local communities remained extremely concerned about safety if the service was reduced

in any way and the need for costly locum GP cover was impacting West Ross OOH Working Group had proposed a team of three Nurse Practitioners supported by one GP

but this would take time to establish and there was a need to reduce costs now One of the key concerns in communities was around emergency care and response times;

GPs and nurses who, in the past, were required by their contracts to be on site at all times, had frequently acted as First Responders if ambulances were not available Now this was no longer the case, a gap in emergency response times had been exposed and this was causing much angst amongst communities Discussions were ongoing with local doctors and nurses around development of a local enhanced service to provide immediate response Work with SAS was also continuing Mrs McVicar indicated that a presentation would be given to the Board in April identifying the risks and challenges and submitting a proposal fora different model for the future A consultant had been engaged to undertake a mapping exercise to provide a visual presentation of activity and to pinpoint areas of risk A draft of this was due at the end of March In response to a point raised by Mr Michael Macmillan, Mrs McVicar confirmed that there was an overwhelming need to change the way the service was delivered, both in terms of manpower and cost A wide-ranging discussion around the challenges facing OOH followed

Item 7.1 Staff Governance

Ms MacKay was not present but the Committee was referred to Appendix 1 which had been circulated prior to the meeting The improvement in staff absence rates was noted

Item 7.2 Performance Monitoring

The Committee was referred to Appendix 2 which had been circulated prior to the meeting Mrs McVicar drew the Committee’s attention to Complaints Responses She indicated that although the level of complaints was very small, the percentage figure had been skewed by a particularly complex complaint which had exceeded the 20 day response time Managers continued to work hard to reduce complaint response times Availability Status Codes (ASCs) were applied to patients who could not be seen within waiting times targets Although these were falling across Highland, there had been an increase in these at Belford Hospital This appeared to be the result of patients having been wrongly coded for a particular procedure and this was being rectified Work on ASCs was continuing and an improvement is expected in the next report Mrs McVicar highlighted dental registrations and drew the Committee’s attention to Appendix 8, Dental Services Report She confirmed that

Ms Catherine Lush, NHS Highland Dental Services Manager, would be attending the June 07 Committee meeting to discuss this in more detail

Item 7.3 Clinical Governance/Risk Management

Apologies had been received from Dr Angus Venters, who will provide an update report for the next meeting The Chairman confirmed that the NHS Quality Improvement Scotland (NHS QIS) would be undertaking their assessment of NHS Highland the following week Mrs McVicar reported that the CHP Clinical Forum had become somewhat large and unwieldy; a core group had therefore been formed, comprising of her and the lead clinicians Locality clinical fora would take forward issues arising from the core group The Clinical Governance and Risk Management Group would continue

The Committee:

♦ Remitted to Dr Angus Venters to report formally to the Committee on Clinical

Governance and Risk Management at the next meeting in June 07

Item 7.4 Health and Safety Report

Apologies had been received from Mr Colin Shields The Committee was referred to Appendix 3 which had been circulated prior to the meeting Mr McLennan highlighted

Personal Accidents which, statistically, had shown a significant increase Mrs McVicar confirmed that the Health and Safety Advisor and Partnership Forum representatives were currently investigating this to establish whether it resulted from an increase in accidents or increased reporting, and to determine if there was any pattern emerging It was hoped that further information would be available at the next Committee meeting Mr McLennan also asked if analysis had been undertaken into how many personal accidents resulted in litigation; Mrs McVicar confirmed that this information was indeed available and the incidence

of litigation was extremely modest

Item 7.5 Complaints

The Committee was referred to Appendix 4 which had been circulated prior to the meeting

Item 7.6 Premises Projects

This item formed part of Appendix 5, Finance Report, which had been circulated prior to the meeting

♦ Fort William Health Centre

This new Third Party development was now in the critical last quarter of the building stage, with a proposed completion date of 27 April 07

♦ Tain and Dingwall Health Centre

These new Third Party developments were both well into the planning stage and confirmation of funding was expected shortly

♦ Mackinnon Hospital and Broadford Practice

Funding had been identified for both the Hospital and the Practice and it was hoped that the planning stage at least would be completed during this financial year

This new Capital development was still in the pre-building stage

♦ Drumnadrochit

This new Capital development was still awaiting Capital approval, the Third Party route having failed on affordability A lease design and build was being reviewed

♦ Aultbea/Gairloch

This new development was still in the early discussion stage

7.7 Financial Performance

The Committee was referred to Appendix 5 Mr Tom Slavin reported an underspend for the CHP (excluding Hosted Services) of £64k for this financial year This was due to the favourable position within Prescribing where, in month, the position had improved by £47k with a £105k projected underspend Risks still remained in Prescribing however as the underspend was dependent upon further changes in prescribing habits The CRS target had been met on a non-recurring basis and it was the continuing aim of managers and their accountants to convert this into recurring savings As reported earlier in the meeting, the position with regard to Hosted Services was less favourable, with a forecast overspend of

£994k There had however been an improvement of £16k from last month in Sexual Health

Services but the position with regard to OOH remained unchanged with a forecast overspend

of £985k

Item 7.8 Public Health and Health Improvement

Apologies had been received from Dr Dennis Tracey The Health Improvement Report will

be circulated

Item 7.9 Delayed Discharges

The Committee was referred to Appendix 6 which had been circulated prior to the meeting Mrs Alison Phimister reported that Highland was currently out-performing the rest of Scotland There had been a concerted effort to improve patient flow and, as a result, the total number of bed days lost was reducing with a forecast 44% reduction (which equated to

39 beds) compared to the previous year Although non-availability of care home places was

a cause for concern, the overall picture was very positive with excellent joint working between Health and Social Work The Chairman congratulated Mrs Phimister on the progress which had been achieved

Item 7.10 Out of Hours Report

The Committee was referred to the Out of Hours Report which had been circulated as an addendum to other Committee papers prior to the meeting

Item 7.11 Lead Nurse Report

Mrs Caroline Matheson highlighted the Review of Nursing in the Community which had recommended the establishment of a new model for nursing in the community A two-year project to implement the recommendations had commenced in January and a Project Manager would be appointed shortly Timescales for implementation were however very short Mrs Catherine Zawalnyski, Professional Advisor for Children and Families, was currently working on the implementation of Getting It Right for Every Child (GIRFEC – the Scottish Executive’s proposal for improvements to Children’s Services) Work on the move towards Single Duty Midwifery in West Ross and Lochaber was ongoing All CHP Charge Nurses had now completed Cleanliness Champion programmes and there was a brief discussion around prevention of infections such as MRSA and the need for continued vigilance by hospital staff and visitors alike

Item 7.12 Lead Pharmacist Report

The Committee was referred to Appendix 7 which had been circulated prior to the meeting

Mr Findlay Hickey was recently appointed to the new post of CHP Lead Pharmacist and in his first report to the Committee he outlined the priority areas he intended to address Cost-effective prescribing was the key area, especially given that the volume of Primary Care prescribing was increasing at around 5% per annum Other pressures on prescribing expenditure included new SIGN guidance on the treatment of CHD and instability of generics prices Mr Hickey also highlighted the new non-medical prescribing groups such as nurses and Ms Mary Macleod advised the Committee that Allied Health Professionals would shortly

be able to become prescribers too Mr John May raised the issue of Specialist Services prescribing and there was a brief discussion around how any challenges that existed here could be resolved Mr Hickey felt that any issues were probably best dealt with on an informal basis rather than via the Area Drug and Therapeutics Committee (ADTC) He added that the SSU DTC had effectively ceased to function and it was hoped that the

differentiation between SSU and Primary Care would now become less distinct and lead to better joint working

Item 7.13 Dental Services Report

The Committee was referred to Appendix 8 which had been circulated prior to the meeting

The Committee:

♦ Noted that Ms Catherine Lush, Dental Services Manager, would be attending the next

Committee meeting in June 07

The Chairman indicated that, in future, Committee meetings would be required to be held in public, although they would not be public meetings Mrs McVicar referred the Committee to her paper and invited discussion There was general agreement to the proposal that part of the Committee meeting should be held in private to allow briefing on confidential or sensitive matters and emerging issues It was also agreed that the issue of questions from, and discussion with, members of the public would need to be explored further Members of the public could be invited to comment at the discretion of the Chairman The Committee and the CHP would also need to be aware of the public perception of such meetings, appropriate venues and publicity Generally the move to hold meetings in public was welcomed

The Committee:

♦ Supported the proposal to hold future Committee meetings in public and that suitable

venues would be identified

♦ Agreed that part of each Committee meeting should be held in private in order that

Committee members could be briefed on confidential matters or emerging issues

9 SERVICE REDESIGN – SCOTTISH AMBULANCE SERVICE

Mr Graeme McLeod, representing Scottish Ambulance Service (SAS) on behalf of his colleague, Mr Ian Donald, gave a presentation on Service Redesign He explained that SAS had a statutory requirement to have a Service Redesign Committee (SRC) in place

The National SRC met on a quarterly basis with Regional Redesign Groups meeting regularly in each region Service redesign was required when, for example, Health Boards made changes, such as closure/relocation of hospital units SAS also redesigned its own services, an example of this being the development of Pathfinder and Community Paramedics Regional Redesign Groups were headed by Regional Redesign Managers who represented SAS at NHS, Scottish Executive and other partner agency meetings and established networks with planning teams in these organisations Mr McLeod briefly outlined the stages, from notification of a redesign proposal through to implementation and project management Links with other organisations were key and Mr McLeod highlighted those already established

Mrs McVicar thanked Mr McLeod for his presentation She emphasised the close ties

between SAS and the CHP and indicated that the invitation for SAS to formally join the CHP Committee remained open Mr McLeod confirmed that SAS discussions around this were still ongoing

Mrs McVicar requested a brief update report on the situation with the Skye Air Ambulance Service Mr McLeod indicated that SAS were linking with discussions by the Broadford

Premises Development Working Group to ensure that helipad requirements were met Improvements to the local airstrip were also being explored; currently this did not meet SAS requirements for use by fixed wing craft

The issue of single-man ambulance crews was highlighted as an area of great concern to the public Mr McLeod acknowledged this and emphasised that SAS were committed to providing two-man crews (both of whom would be qualified to a minimum of Technician level) whenever possible However, the implementation of Agenda for Change (changes to staff pay and conditions) occasionally resulted in staffing shortfalls and the use of single-man crews There was a brief discussion around the use of Community First Responders who were trained in first aid and basic life support

10 PRESENTATION & WORKSHOP SESSION – UNSCHEDULED CARE AND OUT

OF HOURS SERVICES

Mrs Matheson gave a presentation on the Vision for Unscheduled Care and Out of Hours Services She explained the challenge the CHP faced in providing services in the largest and most sparsely populated part of the UK The current model relied predominantly on doctors but this was becoming unsustainable due to the difficulties in recruiting GPs to work

in OOH services In addition workforce demographic challenges existed, particularly in remote and rural areas The vision was for a move towards a multi-disciplinary team model (doctor light) which would be safe, sustainable and planned around local needs It would be closely linked with the concept of anticipatory care It was acknowledged that this model constituted a culture change for communities and some resistance was anticipated Further challenges existed around cost and the need to ensure that staff had the skills and competencies to provide a safe service There were concerns that Agenda for Change had precluded appropriate additional payments to make these posts more attractive but alternatives were being explored Mrs Matheson went on to describe how the transition was being managed using the Paisley University Unscheduled Care Programme which had already been trialled in Argyll and Bute Clinical supervision by willing GPs, telemedicine and the Review of Nursing in the Community would also play a part NHS Highland was to be part of an NHS Education Scotland (NES) pilot to assess the competencies of both new and existing practitioners Funding had been made available for this and the CHP intended to use this to employ a dedicated assessor (this would have to be a doctor)

Mrs McVicar highlighted the need for improved anticipatory and preventative care This would help to identify patients at risk of needing to use unscheduled care services The importance of this work was acknowledged and Mrs Matheson confirmed that four nurses were currently training in these areas

♦ Role of CHP Committee Local Council Members

Mr Macmillan suggested that it would be helpful for councillors (especially those newly appointed to the Committee) to receive an induction pack This could identify what would be required of them as Committee members An idea of the time commitment (frequency of meetings, preparation time involved etc) would also be useful The Committee agreed this proposal and Mrs McVicar confirmed that she