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1 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16

CMO (2015) 19 letter: HPHS Reporting Guidance 2015/16

This document provides guidance for staff reporting on the actions and associated activities within CMO (2015) 19 letter. This includes:

General guidance on completion of your annual report

Topic specific reporting submission requirements

Please review these guidance notes in order to complete your 2015/16 Annual Report

Hospital Settings

NHS Boards are reminded that the CMO (2015) 19 letter encompasses policy requirements for all hospital settings. This includes acute, community, maternity, paediatric, and mental health hospitals.

Boards are required to specify ALL settings and sites that are represented within their annual report submissions and which of these five categories they each represent. Boards are also required to specify which hospital sites are not represented within their annual report submission and a brief rationale for this (e.g. if you are taking a staggered approach to implementation across sites).

2015/16 Reporting Timeframe

All annual report evidence submissions should report on actions undertaken between 1st April 2015 - 31st March 2016. Scottish Government requires all NHS Boards to submit their 2015/16 Annual reports for the CMO (2015) 19 letter on or by Friday September 30th 2016 to:

[email protected]

Quality Assurance

NHS Boards are responsible for ensuring that all relevant managerial, clinical and/or topic leads for each of the policy areas are involved in their annual reporting process. Each section within the annual report template requires a lead contributor to be named including their job title. Additional contributors can be named in appendix A of the reporting template.

Contributors should note where quantitative data is required and ensure that this is expressed in the correct format. Data submitted in the incorrect format will not be included within local or national analysis. Therefore the evidence submission for this section will be considered incomplete, unless clarified in mitigation. Where narrative responses are requested, contributors should ensure the suggested themes are included, where possible, and the word count of 500 words/1 page is adhered to.

Programmes may operate across the whole population, but where appropriate, the scale and intensity of those actions should be proportionate to need or disadvantage. This is reflected in places where information is requested on tailored initiatives or priority settings.

Local quality assurance mechanisms should be applied in advance of your submission.

mailto:[email protected]


Further Support Visit the HPHS pages on the Knowledge Network for a wide range of information and support on health improvement and inequalities in hospital settings:

www.hphs.co.uk

Summary Questions – reflecting 2015 / 16 delivery

Provide a brief description of what went well in the delivery of HPHS and provide examples e.g. developing a strategic approach to delivering training or local campaigns, building capacity for health improvement across the board, having strong leadership in place.

Provide a brief description of any barriers to progressing the delivery of HPHS and describe how you have, or plan to, overcome them e.g. improving data collection, developing capacity to embed and strengthen the HPHS ethos of health improvement in hospital settings.

Describe how you have built on activity reported in previous years.

Practical guidance

The reissued Annual Report: Reporting Measures for 2015 – 18 (v2 aligned with

reporting template February 2016) has minor alterations to some required evidence

questions and numbering. These alterations have been made to clarify evidence

requirements and does not change the overall performance measures.

The CMO (2015) 19 reporting template has undergone revisions from the format previously

used. The excel format has been replaced by a word template in order to improve the

accuracy of the reporting and support those providing the required data.

The list of content pages in this document contains hyperlinks to navigate to each of the 12

sections (A - L).

All fields in the reporting template shaded in light yellow should be completed with the

requested evidence.

All Annual Reports with incomplete evidence sections must provide exception reports in

the separate exception table at the end of each section.

Supporting documents developed as part of measuring impact can be referred to, however,

there is no need to attach these as part of your narrative assessment unless requested.

Any attachments that NHS Boards include should be referenced within the “evidence” response

as labelled appendices. These appendices should be included as attachments to the email

accompanying the submission to NHS Health Scotland.

The analysis of the annual reports will refer to the indicators in the table below:

Delivery analysis Indicator description

↔ delivery Delivery has continued as reported in Year 3 CEL (2014/15)

↑ progress Improvements in delivery have been reported from Year 3

No progress No change has been reported from the Year 3 report

- Comparison cannot be made

Data was not submitted (at all/in same format) in Year 3 CEL report

* Development

phase

Delivery impacted by delay issuing CMO measures OR new performance measure

http://www.hphs.co.uk/


Contents Page

Section A: Strategic Actions 4

Section B: Smoking 6

Section C: Alcohol 8

Section D: Maternity 9

Section E: Food and Health 11

Section F: Staff Health and Wellbeing 15

Section G: Reproductive Health 17

Section H: Physical Activity and Active Travel 19

Section I: Managed Clinical Networks – NEW 22

Section J: Inequalities and person-centred care – NEW 23

Section K: Mental Health – NEW 25

Section L: Innovative and Emerging Practice 27


Section A: Strategic Actions

Action 1

A. Provide the name and role for the executive lead responsible for implementation and

governance of the actions within the CMO (2015) 19 letter.

B. Provide details of relevant meetings to determine plans or developments with Health

and Social Care Integration Boards i.e. name meeting group (e.g. the Board), provide

date(s) of meeting inputs, name of briefing document/agenda item and

agreements/outcomes.

Attachments of minutes or equivalent are not required to be submitted.

C. Enter the name of the Health Facilities Lead(s) identified to support measures for vending,

catering, and the provision of green space developed to enable physical activity within the

NHS estate for staff, patients and visitors.

Action 2 Evidence submissions can represent all professional development programmes that

include topic-specific or generic health improvement and inequalities competencies. This

is to account for the range of locally determined relevant professional development

opportunities.

The proportion of staff should be described in relation to the total number of hospital-based

clinical staff eligible to complete related courses and should reflect staff training within

2015/16.

Name and describe each course, method of delivery and the number of attendees, along

with their roles.

Please ensure any duplicate reporting on staff training in relation to specific evidence

requirements for physical activity and mental health are referenced within the submission.

Note: if you have all the above information on training already collated on a separate sheet

for your NHS Board, you can attach this as your evidence. Ensure your attachment is

documented on the reporting template and covers all the requested areas.

NHS Health Scotland will distribute data to each NHS Board (in April / May 2016)

indicating staff who have completed modules on the NHS Heath Scotland Virtual Learning

Environment (VLE) for the following modules:

Health Behaviour Change module 1

Health Behaviour Change module 2

Raising the issue modules: Alcohol, Physical Activity, Smoking Health Inequalities: Awareness raising * Tackling health inequalities in health & social care *

Please note that unless staff have indicated on the VLE registration data that they work in

the acute setting, they will not be identified as such and therefore the data returned may be

incomplete.

* Note: these modules will be launched end February/early March 2016.


Action 3 A. As per evidence requirement. Provide details on the role and clinical areas where

clinical and medical leadership for health improvement delivery has been demonstrated.

Additionally, identify successes and challenges in gaining clinical and medical leadership?

B. Evidence of sustained health improvement practice by clinicians could include a

description of how clinicians have been delivering health improvement practice as part of

their role.

Action 4 – overall suggested word count of 600 words

A. Evidence of the impact of strategic actions could include current status of programme,

reflection on service improvement, local action plans and evidence of outcomes across

patient services, staff health and wellbeing and the hospital environment over the lifetime of

HPHS CEL (1) 2012 and current CMO (2015) 19 letter.

B. Provide a brief description of the intended and unintended consequences of the

programme in relation to your response in 4A.

C. Provide a brief description of your plans for sustaining implementation of HPHS and

inequalities focus in hospital settings.

D. Provide a brief description of your plans indicating where and how HPHS activity is being

included in the commissioning and planning for health and social care integration.

Note: Action 5 has been removed to reduce repeated reporting.

This has resulted in the numbering being altered throughout the guidance for the

remaining performance measures. The numbering on the reissued Annual Report:

Reporting Measures for 2015 – 18 (v2 aligned with reporting template February 2016)

has also been updated.


Section B: Smoking

Action 5

Specific settings to be targeted for identification of smokers and referral pathways have been

included to reflect the potential areas where referrals can be made from, including: respiratory;

vascular; cardiac; diabetes; mental health; maternity and cancer.

A. (i) Note which system is used to record the smoking status for each patient and the role of

the person who records this information.

(ii) Where known, record the number of smokers supported with Nicotine Replacement

Therapy (NRT) while in hospital. If this number is not known, note the number of

prescriptions issued for NRT products.

(iii) In order to indicate engagement with smoking cessation services while a smoker is in hospital,

record the number of smokers who set a quit date while still in hospital. The emphasis is on a quit

date being set, which can include dates following the hospital stay. Where possible, provide this

figure as a proportion of all smokers recorded in a hospital setting. If quit dates are set for when a

patient who smokes return home, indicate how they will be supported once they are home.

B. List all pathways in place or being developed, naming the setting, whether it is a targeted

setting and if aligned to a Managed Clinical Network. Note if an opt-out scheme is in operation

and if the pathway is integrated with primary care. Where possible, also provide brief details on

how the pathway/s have impacted on patient-centred care through referral to, and uptake of,

smoking cessation support.

Attachment of a local pathway is not required to be submitted.

Action 6

A. (i) Provide a brief description of your progress on tobacco policies relating to shared sites.

Shared sites are defined as NHS, and any other local authority or private estate.

(ii) Provide brief details on how the NHS Smoke-free grounds policy is communicated to staff, patients and visitors. Note all channels here e.g. online reminders, admission letters, signage, staff induction and training.

(iii) Provide brief details on how the NHS Smoke-free grounds policy is implemented (only on NHS grounds where you have full control). Compliance and adherence with the policy should include details on training staff to be more confident to approach smokers and encouraging staff to be advocates for smoke-free grounds with both patients and visitors, in addition to the aspect of staff behaviour and role modelling.

Action 7

The narrative response is intended to give you the opportunity to expand on your feedback, reflect

on progress and note any areas for improvement. The response should be kept succinct and

only be around 500 words / 1 page.

Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and

the hospital environment.


A. Your assessment of the impact of smoking actions since their introduction in 2012 should

include the following themes where applicable and appropriate:

Progress made on the NHS smoke-free grounds policy, including if the messages are

being adopted and is compliance acceptable

Any progress on supporting smoking cessation for staff, particularly in light of smoke-

free grounds

Any examples of progress e.g. in the targeted settings, partnership working, pathways,

what’s working and any shared learning.

Note any challenges to implementation of CEL/CMO actions and how they are

being addressed.

The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.


there is no requirement to attach documents as part of your narrative assessment.

If you do choose to submit documentation, please ensure this is referenced within the “evidence”

response as a labelled appendix.

Any appendices should be included as attachments to the email accompanying the submission to

NHS Health Scotland.


Section C: Alcohol

Action 8

The narrative response is intended to give you the opportunity to reflect on progress and note any

areas for improvement, assessed in relation to your NHS Board strategic plan for Alcohol Brief

Intervention (ABI) delivery.

The response should be kept succinct and only be around 500 words / 1 page.

Frame your narrative to reflect impact on patient-centred care, and if appropriate, also the

impact on staff health and wellbeing and the hospital environment.

A. Your assessment of the impact of alcohol actions since their introduction in 2012, should

include brief details on the following themes where applicable and appropriate:

Measuring impact and indicators of success

mechanisms in place to measure impact / how you capture indicators of success

integration of services, embedding of ABI delivery and mechanisms for local

partnership working

process evaluation, service evaluation or follow up

Workforce

strategic workforce development approach and workforce planning

frontline A&E and/or wider reach of ABI delivery

whole population approach or targeted work on patient / staff health and wellbeing

Support

Indicate what issues or areas of support require either national, local or peer level

support.

Note any challenges to implementation of CEL/CMO actions and how they are

being addressed.








Note: examples of alcohol brief intervention delivery in hospital settings can be provided

in Section L: Innovative and Emerging practice.


Section D: Maternity

This section has been amended to reflect the measures for breastfeeding actions in

maternity and wider hospital settings.

Action 9

This section builds upon the work that hospitals are undertaking to meet UNICEF Baby

Friendly Initiative accreditation, taking elements of the WHO International Code of Marketing

of Breast-milk Substitutes. UNICEF has developed guidance for the code. N.B. The Code

covers the wider hospital-setting.

http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/guide_int_code_health_profes

sionals.pdf

A. This evidence is looking for an outline of the mechanism or plans for local NHS Board

monitoring of WHO Code compliance. Including the mechanism to monitor compliance, who

monitors the Code, how staff are informed of the Code and the process for reporting

breaches locally.

Action 10

A. This evidence is looking for a description of the process in place to support breastfeeding

mothers who are admitted to hospital settings, out with the maternity unit, to continue

breastfeeding. The description should outline how each area is addressed, and any other

initiatives that support breastfeeding in the wider settings, for example referral routes, care

pathways, dedicated breastfeeding contact.

Responses should include (i) ensuring that procedures and drugs have as little impact on

breastfeeding as possible, (ii) how staff enable mothers to express and store milk, (iii) do

mothers have the infant in their room.

B. This evidence is looking for a description of the system or pathway in place to support

breastfeeding mothers of preterm or sick babies or those mothers encountering

breastfeeding problems to continue breastfeeding. Examples could include policies,

training, breast pump loan schemes, expressing logs and other local activities.

Action 11

A. This evidence is looking for a description of the process for how attrition (drop off) rates

are calculated using local and national data. If common causes for attrition are identified,

what actions have been taken to address these? Data collected at 5 days, 10 days and 6-8

weeks can be used to work out attrition rates.

Data sources:

Guthrie Inborn Errors Screening data

ISD - http://www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/

Infant Feeding Survey - http://www.hscic.gov.uk/catalogue/PUB08694

Local Baby Friendly audit data

B. Suggested links: Early Years Collaborative – Using the model for improvement

http://www.gov.scot/Resource/0044/00446639.pdf

http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/guide_int_code_health_professionals.pdf



http://www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/

http://www.hscic.gov.uk/catalogue/PUB08694



EYC website - http://www.gov.scot/Topics/People/Young-People/early-years/early-years-

collaborative

Action 12

A. The evidence is looking for details of the NHS Board infant feeding policy for staff

returning to work. For example, the governance arrangements for the policy, how the policy

is communicated to staff and how it is implemented.

B. A brief description is required of the facilities available to support mothers to continue to

breastfeed and /or express their breast milk on returning to work.

Action 13






A. This evidence is looking for a narrative on what difference the inclusion of breastfeeding measures within the HPHS CEL / CMO letter has made since their introduction in 2012.

Brief details on the following themes could be included where applicable and appropriate:

what changes have occurred

can the impact of changes be demonstrated

identify strengths and challenges

links to local action plans

highlight quality improvement work undertaken

note any challenges to implementation of CEL/CMO actions and how they are

being addressed.








http://www.gov.scot/Topics/People/Young-People/early-years/early-years-collaborative

http://www.gov.scot/Topics/People/Young-People/early-years/early-years-collaborative


Section E: Food and Health

Action 14

Provide the name of the individual(s) who has strategic responsibility for oversight of all non-

patient food provision (catering, retail, vending and trolley services). This may be the same

individual(s) noted in strategic action 1 C.

Action 15

All catering outlets in healthcare settings must meet the Healthyliving Award Plus (HLA+) by 31 March 2017 (or, for private sector directly operated catering outlets, at the point of contract (re)negotiation). All Catering outlets with the standard Healthyliving Award will be accepted for 2015/16 reporting, and should be working towards HLA+ by 31 March 2017.

All vending machines in healthcare settings must be aligned to HLA+ vending criteria by 31

March 2017 (or for privately operated vending machines, at the point of contract

(re)negotiation).

The information being requested this year on vending machines has been split into:

vending machines within catering contracts (generally those located within or near a

catering outlet) as these are included within HLA assessments

all other vending machines (generally located separately in corridors or foyer areas)

as these are out with catering contracts

This is to provide a baseline of vending provision which will be reviewed for future reporting.

If you are unable to report for separate vending machines as categorised above, please note

this.

Further information can be found below:

Healthy Living Award Plus:

http://www.healthylivingaward.co.uk/index

[email protected]

15 A - F. Complete the reporting table with the number of catering outlets operated and the

number of HLA assessed vending machines (within a catering contract). Record the

numbers with HLA and HLA+ assessment and the total number in operation. The columns

indicate those operated by NHS Boards, voluntary sector and private sector organisations.

Example table indicating reporting number format:

Number operated by the Health Board

Number operated by voluntary sector organisations (VSO)

Number operated by private sector organisations

Total number operating

HLA HLA+ HLA HLA+ HLA HLA+

Catering outlets 1 3 1 2 2 2 11

Vending machines within catering contract

1 2 1 1 2 2 9

http://www.healthylivingaward.co.uk/index



There is a second table under Action 15 to report all vending machines located out with

catering outlets and not covered by catering contracts. E.g. foyer, corridor etc.

If the number of vending machines out with a catering outlet is known, please note this in the

reporting template. If the number is not known, please indicate this in the template.

Note: The guidance below provides information on the criteria for healthy vending within

healthcare settings for NHS Boards.

Guidance for vending within healthcare settings

Drinks vending

• A drinks vending machine must contain water, unsweetened fruit juice and/or low-fat

milk.

• Healthyliving drinks must be prominently positioned, for example at eye level in glass-

fronted machines or listed first in product lists.

• 70% of soft drinks (by both volume and brand) must be sugar-free (less than < 0.5g of

sugar per 100ml). Soft drinks include flavoured waters.

• Sugar-free soft drinks must be prominently positioned

Snack/confectionery vending

• At least 30% of the product range must meet the healthyliving bought-in specifications

outlined in What do I need to do?

• At least one healthyliving item must be available for each type of product, for example

crisps and confectionery.

• Healthyliving items must be prominently positioned, for example at eye level, and should

be priced competitively with other products.

Refrigerated food vending

• 70% of the product range must meet the healthyliving bought-in specifications.

• At least one healthyliving item must be available for each type of product.

• Healthyliving items must be prominently positioned and should be priced competitively

with other products.

Action 16

All retail outlets and retail trolley services operated in healthcare settings must meet the

Healthcare Retail Standard (HRS) by the 31 March 2017 (or, for private sector directly

operated outlets and trolley services, at the point of contract (re)negotiation).

Further information can be found below:

Scottish Grocers Federation Healthy Living Programme:

http://www.scottishshop.org.uk/healthy-living

[email protected]

Criteria for the Healthcare Retail Standard: http://www.gov.scot/Publications/2015/09/7885

16 A – F. Complete the reporting table with the number of retail outlets and retail trolley

services operated, out of each total in operation for each column.

http://www.scottishshop.org.uk/healthy-living


http://www.gov.scot/Publications/2015/09/7885


Note: It is acceptable not to have reached the HRS in the CMO 2015/16 data reporting

period. However, the data will provide a baseline for future reporting.

Example table indicating reporting number format:

Number meeting

the HRS

operated by the

Health Board out

of the total

Number meeting the

HRS operated by

voluntary sector

organisations out of

the total

Number meeting

the HRS operated

by private sector

organisations out of

the total

Total number operating

Retail outlets 1/5 1/3 0/2 2/10

Retail trolley

services

0/2 1/5 0/2 1/9

Additionally, record any issues or challenges you have had to overcome (or are in the

process of overcoming) to achieve the Healthcare Retail Standard (HRS).

Action 17

A. Provide both the number of sites with community food co-ops and /or other social

enterprises achieving the Healthcare Retail Standard (HRS) and the total number in

operation. For those with the HRS, provide a brief description of the products and service

offered.

Previous reporting has indicated challenges in accessing local community food co-ops or

local providers of fruit and vegetables. If you have experienced any difficulties, the National

Development Officer on the NHS Health Scotland Community Food & Health Programme,

Anne Gibson, can be approached for further support and information: [email protected]

Action 18






A. Your assessment of the impact that the food and health performance measures have had

since their introduction in 2012 should include brief details on the following themes where

applicable and appropriate:

the increase in provision and availability of healthier food for staff

work with retailers to meet new standards

how the CEL measures have influenced new builds through lease contract

negotiations, build design etc.


being addressed.



Section F: Staff Health and Wellbeing

Action 19

A. Provide the name of the individual(s) who has strategic responsibility for the delivery of

the staff safety, health and wellbeing strategy.

It is expected that this lead will be in either the HR or Occupational Health department,

however, to make this clear please also note the position and department.

If your NHS Board operates under a different structure, or there is no identified strategy, note

this also. This information will help to identify links for collaborative working.

B. Provide the Healthy Working Lives (HWL) Award status for all hospital and community

hospital sites to indicate achievement towards the performance measure targets.

The reporting boxes are split for individual hospitals to be named where possible and the

information requested should be inserted under the following headings of achievement:

Bronze

Silver

Gold

continuing to work towards (indicate which level)

maintaining (indicate which level)

C. Provide a brief description of interventions which support the mental and physical health

and wellbeing of all NHS staff.

Evidencing targeted work to indicate how you provide support for areas such as

engagement, health literacy, fair work and financial inclusion is particularly encouraged.

Therefore, for responses (i) – (iv), brief details on the following should also be included

where appropriate or applicable:

how interventions have been tailored for any of the topics or settings

how interventions are tailored to meet the needs of different demographic staff groups

if the initiative is new or continuing

whether model operates on universal provision

which staff access the initiative

what works well

The interventions should be reported as categorised below (i – iv), and brief details of

examples can be included (as indicated in i – iv) which can demonstrate an impact:

(i) Supporting the mental health and wellbeing of staff. Up to 3 examples may be included:

strengthening resilience; stress risk management; mindfulness, access to self-help or

Cognitive Behavioural Therapy.

Note: You should include details of the organisational approach to stress risk management

(specifically how you meet the legal requirements under the Health and Safety at Work Act

1974 and Management of Health and Safety at Work Regulations 1999). This description

should include the responsible department and also the process in place e.g. stress risk

assessment is carried out a ward/service level and recorded in a health and safety log book.


(ii) Supporting the physical health of staff. Up to 3 examples may be included: weight

management; smoking cessation; physical activity, occupational health referral (e.g. specific

pathway/referral for musculoskeletal problems)

(iii) Promotion of health screening. Provide evidence on how you raise awareness of the

national screening programme to staff. A minimum of 1 example should be provided from

the following: cervical; breast; bowel; diabetic retinopathy and pregnancy screening. Provide

brief details on any local campaigns or connections with national awareness campaigns.

Refer to the national website for further information on health screening:

www.nhsinform.co.uk/screening/

(iv) Promotion of immunisation. Provide evidence on how you raise awareness of the

national immunisation programme to staff and specifically, promotion of staff sessions for

seasonal flu vaccination. A minimum of 1 example should be provided.

Provide brief details on any local campaigns or connections with national awareness

campaigns.

Refer to the national website for further information on immunisation:

www.immunisationscotland.org.uk

Related documentation is not required to be submitted.

Action 20




Frame your narrative to reflect impact on staff health and wellbeing, and if appropriate,

hospital environment and patient-centred care.

A. Your assessment of the impact that the staff health and wellbeing performance measures

have had since their introduction in 2012 should include brief details on the following themes

where applicable and appropriate:

the performance measures and indicators in place to identify impact and

improvement of staff health and wellbeing

the approach taken to collating and monitoring measurements

indicate where cross directorate collaboration takes place

any impact on patient care as a result of staff health and wellbeing interventions


being addressed.








http://www.nhsinform.co.uk/screening/

http://www.immunisationscotland.org.uk/


Section G: Reproductive Health

Action 21

A. For evidence of impact on numbers of repeat terminations, submit information which

indicates in what direction the trend is moving and what your contribution has been to any

reduction of the trend. Data from ISD can be included to support your submission.

Note: The ISD data on repeat terminations does not include any measure of the timeframe

between the terminations. If you have the data available, particular reference could be made

to rapid repeat terminations (e.g. women returning within 1 or 2 years) as part of your

assessment of impact.

ISD termination data can be accessed via the link below:

http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/index.asp#1396

In previous ISD published data, repeat terminations have been presented as a proportion of

all terminations. The total number of all terminations has decreased markedly in recent years

but the number of repeat terminations has shown less of a reduction. This may be because

repeat terminations tend to occur in an older age group than first terminations and the recent

fall in termination rates is more pronounced in younger women. The result of these trends is

that the proportion of repeat terminations of all terminations appears to be rising however the

rate, expressed as a proportion of all women of reproductive age, is fairly static. This latter

rate is likely to be a more useful reflection of the overall frequency of repeat terminations and

this revised methodology has been adopted this year.

B. Submit a description of how you define vulnerable women, how you identify vulnerable

women in your area and how you collate termination information on this group.

Provide a brief description of the support provided for vulnerable women within both maternity

and termination services. Include who has these contraceptive conversations with the patient.

Space has been provided for separate reporting for maternity and termination services. If

your support process and structure is the same in both settings, please indicate this in the

response box.

Complete the exception report if you are unable to provide this information and describe your

plans to identify and capture this data locally.

To support your description, ISD LARC data can be accessed via the link below:


C. The description of maternity and termination services role in the delivery of the Sexual Health and Blood Borne Virus (BBV) Framework 2015 – 2020 update should include the following:

what you are starting to do at a strategic level

where does this work report to

is any training being delivered

The reporting template allows you to report separately for maternity and termination settings.




A link to the Sexual Health and Blood Borne Virus Framework 2015 – 2020 update can be accessed below: http://www.gov.scot/Resource/0048/00484414.pdf

P17 contains the actions around LARC

Action 22




Frame your narrative to reflect impact on patient-centred care, and where appropriate, staff

health and wellbeing and the hospital environment.

A. Your assessment of the impact that the reproductive health performance measures have

had since their introduction in 2012 should include brief details on the following themes

where applicable and appropriate:

what drivers are in place to reduce the number of repeat terminations and

unintended pregnancies and how services are achieving this.

how services have improved the culture for LARC provision through wider strategic

activities.

the support offered and the conversations undertaken


being addressed.










Section H: Physical Activity and Active Travel

The required evidence has been re-structured to offer the opportunity to provide a

more comprehensive picture of delivery and interventions for physical activity and

active travel. Amendments have also been made to the required order of evidence for

action 24. Please respond to all areas where possible.

The physical activity interventions requested in the performance measures must be evidence

based and or evidence informed. This includes interventions designed to maximise the use of

the NHS outdoor estate and facilities, the integration of physical activity for patients as part of

a clinical pathway or initiatives planned to enhance the health and wellbeing of NHS staff in

the workplace.

It is recommended that NICE Guidance PH44, PH54, PH41 and PH8 (links below) is applied

in a local context where possible to inform the design and delivery of such interventions.

These may include the NHS Physical Activity Pathway, cycling or walking schemes, the use of

pedometers, the promotion of physical activity in the workplace and the use of the built and

natural environment.

Brief advice for adults in primary care: http://www.nice.org.uk/guidance/ph44

Exercise referral schemes: http://www.nice.org.uk/guidance/ph54

Walking & cycling: http://www.nice.org.uk/guidance/ph41

Physical activity and the environment: http://www.nice.org.uk/guidance/ph8

Physical activity in the workplace: http://www.nice.org.uk/guidance/ph13

Action 23

Physical activity interventions should be routinely embedded into hospital settings. NHS

Boards should focus on the priority settings of: cardiology; pulmonary rehab; mental health;

diabetes; paediatrics; oncology; orthopaedics; care of the elderly; pre-assessment and

outpatient clinics.

A. Teams or departments within NHS Boards who have revised documentation should be

named, including which settings. Please specify what information is being recorded i.e.

current physical activity levels, whether an intervention has occurred and the outcome of an

intervention (e.g. provided with written material, signpost to support, referral). Or detail the

plans in place to update documentation to record physical activity status.

Related documents (e.g. admission documents and other forms where smoking/alcohol status

is recorded) to support the evidence submission should be provided where possible.

B. Evidence of a development plan or assessment of impact of physical activity interventions

in one or more of the priority settings is requested that demonstrates a targeted, phased

approach across your NHS Board that will increase spread over time. Responses should

indicate which of the above priority setting(s) you have been able to develop and what

system or process is in place to assess the delivery and impact of the physical activity

intervention in that setting(s).

A brief summary is also required to describe the intervention in more detail and could include

the following:

which staff were trained

http://www.nice.org.uk/guidance/ph44






who delivers the intervention

which patients were targeted

how practitioner practice has changed as a result of the intervention

what made the intervention work

what were the main challenges and how were these overcome.

Note1: The impact on patient activity levels or health outcomes are not required.

Note 2: It is acceptable initially to focus interventions in one or more of the priority settings

with the intention of widening this number over the next two years.

Note 3: Insert further rows if required for additional examples. [Right click to insert another

row, or hover cursor at left edge of table to see + sign & click to insert new row]

If you are unable to report progress in at least one of the priority settings, ensure this is noted

in the exception table and detail what the challenges / barriers have been in progressing

activity.

Action 24

A. Provide specific examples of hospital based physical activity support and / or services

targeting individuals and or populations experiencing inequalities such as: those with long

term conditions; disabilities; in receipt of benefits; carers or living in areas of deprivation.

Detail (i) the system for referral to formal services, (ii) the system for signposting to local

physical activity opportunities and (iii) assessment of use, including where possible number

of staff referring, number of staff signposting, total number of staff who could refer/signpost,

uptake of referrals (access to feedback data via third parties) and any known impact of the

intervention / service on patients, staff and / or visitors where known.

B. Boards should evidence how hospital based services are partnering with community

based organisations, third sector groups, local leisure trusts, local authorities and /or other

physical activity providers to develop an infrastructure which supports signposting to, and

enables uptake of physical activity opportunities. The response should list the partners’

name, briefly detail the partnership action implemented.

C. Provide details on how improving access and use of the outdoor NHS estate for physical

activity is planned for staff, patients and the local community. Name any schemes and

initiatives in place to improve access to the outdoor estate and contribute to promoting and

enabling active travel. Detail the availability e.g. which sites are involved or if board wide, as

appropriate. Include areas such as green exercise and active travel plans in your response

along with any additional information.

Action 25







A. Your assessment of the impact of physical activity and active travel actions, since their

introduction in 2012 could include the following themes where applicable and appropriate:

Progress on active travel plan development, implementation and monitoring for staff,

patients and visitors, including partnership working with SUSTRANS and Local

Authorities.

Evaluation / impact of physical activity interventions in clinical settings (include which

setting).

Where known, provide the number of staff conducting physical activity screening,

staff providing brief advice and staff providing brief interventions (as a proportion of all

staff involved in implementing the pathway). Also note the number of staff

signposting, staff referring, patients referred, patient uptake and staff active travel

participation. Note that numbers of staff completing training is requested in Strategic

Action 2.

Physical environment / greenspace. How CEL measures have been used as leverage

for the planning / development of new builds and redevelopment /retrofit of existing

sites to create greenspace and increase access to physical activity opportunities.

Clinical settings utilising the NHS outdoor estate or indoor facilities to enable patients

to be physically active.

Updating of patient documentation to record physical activity status. How CEL has

supported this, challenges, barriers and successes.


being addressed.


There is no requirement to submit related documentation, however documents can be

submitted as part of your narrative assessment.






Section I: Managed Clinical Networks

Action 26

A. Evidence should be submitted to indicate the Managed Clinical Networks (MCNs) in

operation in your NHS Board which are aligned to HPHS and promote the use of health

improvement pathways amongst clinical staff, with appropriate support.

Provide a brief summary of MCN improvement plans with specific reference to embedding

health improvement within clinical pathways in at least one of the following:

(i) smoking cessation

(ii) physical activity

(iii) weight management

(iv) routine enquiry to identify patients vulnerable to financial stress, homelessness or

other social or environmental factors.

If you wish to provide an example in an additional setting, please add this to the other box.

The brief description should also indicate who monitors MCN improvement plans.

Note: It is acceptable initially to only have made an impact on one or more of the priority

settings (above) with the intention of widening this number over the next two years.

Action 27




Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and the hospital environment. The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken. A. Your assessment of the impact of Managed Clinical Networks on patient-centred care,

and if appropriate, also the impact on staff health and wellbeing and the hospital

environments should include details on the following themes where applicable and

appropriate:

How well the pathway works and an indication of referral numbers

Any quality improvement methodology in place to measure outcomes

note any challenges to implementation of CMO actions and how they are

being addressed.

Note: If you are unable to report on any MCNs already in place, submit information on activity and plans to develop MCNs. Include the setting, who is involved and a timescale for becoming operational.




response as a labelled appendix. Any appendices should be included as attachments to the

email accompanying the submission to NHS Health Scotland.


Section J: Inequalities and person-centred care

Action 28

This performance measure has been included to ensure that all NHS Boards will plan and

deliver hospital services that ensure routine enquiry identifies vulnerability and support is

built into person-centred care. Ensuring access to services for vulnerable groups is also

key for addressing inequalities in health outcomes. Consideration and reflection of

inequalities sensitive practice can also be noted here.

Efforts should initially be focussed on the priority settings of: paediatrics, maternity,

neurology, cancer, cardiology, mental health, respiratory and/ or HIV and Hepatitis C.

A. Provide a description and examples of any inequalities sensitive practice in hospital

settings.

Include any routine enquiry in assessment of vulnerability through:

Asking patients if they have money worries and offering a direct referral to advice

services

Support for patients who are, or are at risk of, homelessness

Support in access to services for vulnerable groups / examples of hospital based

inequalities sensitive practice (established or emerging)

Note: Each NHS Board should work to their own definition of who are targeted as

vulnerable groups and include how they define this in their response.

Additional information should also be included covering: the nature of services provided,

whether services are delivered on-site or externally; the departments / hospitals involved;

partners or agencies you are working with; which services receive onward referrals and

how services are funded.

If you are unable to provide any examples, please give brief details on any hospital based

initiatives currently being planned to build this area of activity, or note in the exception

table if no work is currently being undertaken in this area.

B. Provide a brief summary to indicate the actions within your health inequalities strategy

and/ or community planning structures which demonstrate to what extent inequalities

sensitive practice is implemented in the hospital sector.

Your response should be framed in terms of how the actions in your inequalities strategy

are interpreted for the hospital sector and could include if hospital services are designed

and delivered in relation to the needs of vulnerable groups or in proportion to need.

Note: If your NHS Board does not have, or is in the process of developing an inequalities

strategy and / or a Health Inequalities Action Plan, this should also be noted. You may find

relevant actions within your local outcome focussed plan to mitigate the impact of welfare

reform on health and health services in the document accessed by the link below:




Action 29






A. Your assessment of the impact of inequalities and person-centred care could include the

following themes where applicable and appropriate to demonstrate impact:

financial gains identified

use of welfare, housing and advice services

use of advice services delivered in clinical settings

warmer homes as a result of interventions

a decrease in foodbank use

evaluation of services


being addressed.

The above list is not exhaustive. Details on measures in place and how indicators of

success were identified should also be included.

If unable to assess impact, please note this, along with brief details of plans to build this area

of activity.


There is no requirement to submit related documentation, however documents can be






Section K: Mental Health

Action 30

Actions 30 and 31 relate to those accessing hospital services with a diagnosis of experiencing severe and enduring mental illness. Access the Mental Health Strategy 2012-2015 via the link below: Refer to page 43 for information on Health Improvement for People with Severe and Enduring Mental illness. http://www.gov.scot/Publications/2012/08/9714 The Scottish Government is due to publish a new Mental Health strategy later in 2016 to build on the 2012-2015 Strategy.

A. Provide the name of the lead(s) with responsibility for progressing the physical Health and wellbeing of patients in hospital mental health services at both a strategic and operational level. Include their professional role by NHS Board or hospital site as appropriate.

B. Provide the total number of staff working in hospital mental health settings who have received training to promote physical health. Enter the total number trained as requested for those (i) undertaking physical health assessments and (ii) those who are developing action plans to support mental health improvement. Indicate the number trained who have responsibility for (iii) both the assessments and action plans in the space provided as a separate number to negate numbers being double reported. For reporting these numbers in Strategic Action 2, ensure these are reported as pertaining to Action 30. Additionally, where known, report the following details to provide a complete picture of all the training undertaken:

name of course or module [enter all applicable, see example courses coded below]

format of course or module

role of staff completing training for each course or module you list

Training can include:

Raising the issue of physical activity – for ease, enter code RiPA

Raising the issue of smoking - for ease, enter code RiS

Raising the issue of alcohol - for ease, enter code RiA

Alcohol Brief Intervention - for ease, enter code ABI

Health behaviour Change (levels 1 or 2) - for ease, enter code HBC1 / HBC2

Other – please state details. Include relevant weight management training

If your NHS Board has been involved in the Scottish Government pilot for Distress Brief Intervention (which is operating in the hospital setting), insert DBI in the name of course box.

C. Note if relevant patient admission documentation has been revised to record the physical

health status and action plans for health improvement.

Teams or departments within NHS Boards who have revised documentation should be

named. If the information is available to you, please specify what is being recorded i.e.

current physical activity levels, whether an intervention has occurred, the outcome of an

intervention (e.g. signpost to support, referral).

http://www.gov.scot/Publications/2012/08/9714


If documentation has not been revised, note what work is in progress to achieve this.

Related documents (e.g. admission documents) to support the evidence submission are not

required to be submitted.

Action 31




Frame your narrative to reflect impact on patient-centred care, and if appropriate, also any

impact on staff health and wellbeing and the hospital environment.

A. Your assessment of the impact of mental health actions could include any work being

planned or undertaken to assess impact of service improvements to promote physical health

and wellbeing in mental health patients.


being addressed.

Note: If unable to assess impact, please report activity underway to build this area.









Section L: Innovative and Emerging Practice

Note: The information required in this section has been amended from the previous reporting

format.

Once the report analysis has been completed, all the examples reported for innovative and

emerging practice will be shared with the HPHS National Network in the form of a brief

summary and local contacts for further information. Therefore, the information you provide

should be brief.

Innovative practice should be interpreted as being a completely original project for your NHS

Board e.g. either a new approach or adopting / testing new quality improvement methodology

in the area.

A minimum of one example is required for numbers 1 – 2 below:

1. Development and piloting of opt-out services for smoking cessation services

2. Alcohol Brief Intervention delivery in a hospital setting

Enter an example for number 3 if applicable to your NHS Board:

3. Development of staff and/or patient weight management service(s)

Provide brief information for each example provided in 1 - 3, which includes: the name of the

project; setting; format, any targeting, any collaborative working and outcomes. A local

contact is also required.

Insert further rows if you wish to report additional examples. [Right click to insert another

row, or hover cursor at left edge of table to see + sign & click to insert new row]

Additional examples can also be submitted with brief details on the name of the project;

setting; format; targeting; collaborative work, and why this is innovative in your NHS

Board. These examples may include updated evidence from previous projects reported

in former CEL annual reports, if there is any further development to report or an

assessment of impact. However, it must be stated if this is an update as opposed to a

new project.

The examples should be aligned to one of the three core themes below:

Person-centred care

Staff health and wellbeing

Hospital environment

Examples are encouraged that demonstrate:

effective partnership working and collaboration

specific actions to advance equality and/or address health inequalities

mental health benefits to patients, relatives and staff.

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