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Page 1: ARGYLL & BUTE CHP COMMITTEE MEETING - NHS Highland · 16. Partnership Working 16.1 Argyll & Bute Public Partnership Forum Draft Notes – 27-11-12 (attached) Duncan Martin 17. Performance

Wednesday 19 December 2012

Queens Hall, Dunoon

12.30pm to 1pm Lunch

1pm - Meeting

AGENDA

1. Chairman’s Welcome Robin Creelman

2. Apologies Robin Creelman 3. Conflicts of Interests Robin Creelman 4. Minutes from Previous Meeting 4.1 Minute of Previous Meeting – 31 October 2012 (attached) Robin Creelman 5. Matters Arising 6. NHS Highland Organisational Issues

6.1 Draft Minute of Highland NHS Board – 4 December 2012 (to be tabled) Robin Creelman 6.2 NHSH Annual Review 2012 – Scottish Government Summary (attached) Derek Leslie

7. Clinical Governance 7.1 Clinical Governance & Risk Management Report (attached) Pat Tyrrell 7.2 Infection Control Report (attached) Pat Tyrrell

ARGYLL & BUTE CHP COMMITTEE MEETING

10.30am - 12.30pm – Committee Members Development Session

� Charter of Patient Rights & Responsibilities – Jane Davies, NES � Argyll & Bute Adult Protection Committee Biennial R eport April 2012 - March 2012

- Bill Brackenridge, Chair, A&B APC, Rebecca Barr, Area Manager – Adult Protection, A&B Council

� Public Health - Director of Public Health Annual Report 201 2 – Elaine Garman, Public Health Specialist, Hugh McLean, Chair, Healthy Options

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3.30pm – 4pm - Public Meeting

8. Financial Governance 8.1 Finance Report (attached) George Morrison 9. Staff Governance

9.1 Argyll & Bute CHP Partnership Forum – Draft Minutes of 15-11-12 (attached) David Logue/ Dawn Gilles/Liz McMillan

9.2 PDP/R and eKSF Implementation (attached) David Logue

10. Director of Public Health Annual Report 2012 (attached) Elaine Garman

11. Director of Operations Report (verbal) Derek Leslie 12. Review of Management Structure – Cowal & Bute/Helensburgh & Lomond (attached) Viv Smith 13. Renal Dialysis (attached) Stephen Whiston 14. Cowal 24/7 Report (attached) Stephen Whiston 15. Mental Health Modernisation Update (attached) Derek Leslie 16. Partnership Working

16.1 Argyll & Bute Public Partnership Forum Draft Notes – 27-11-12 (attached) Duncan Martin

17. Performance Management 17.1 Delayed Discharge (attached) Derek Leslie

18. Papers for Noting: 18.1 Argyll & Bute CHP eHealth Steering Group Draft Minute – 07-11-12 (attached)

19. AOCB*

20. Date, Time & Venue for Next Meeting

Wednesday 20 February 2013 at 10.30am in Rooms J03- J07, Mid Argyll Community Hospital & Integrated Care Cen tre, Lochgilphead

* to be notified to Chairman in advance of meeting

The Committee meeting will be followed by:

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Argyll & Bute CHP Committee Date of Meeting : 19 December 2012

Agenda item : 4.1

MINUTE OF MEETING OF THE ARGYLL & BUTE CHP COMMITTEE

Argyll & Bute Community Health Partnership Aros Lochgilphead Argyll PA31 8LB www.nhshighland.scot.nhs.uk/

Mid Argyll Community Hospital & Integrated Care Centre

Lochgilphead

31 October 2012

Present Mr Robin Creelman, Chairman, Argyll & Bute CHP

Mr Derek Leslie, Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Mr David Ritchie, Communications Manager, Argyll & Bute CHP Ms Tricia Morrison, CVO Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Mr Duncan Martin, Chairman, Public Partnership Forum Mr Michael Roberts, Vice Chair, Public Partnership Forum Ms Glenn Heritage, CVO Representative Ms Liz McMillan, Staffside Representative Councillor Elaine Robertson, Argyll & Bute Council Representative (by VC)

In Attendance Apologies

Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr David Logue, Head of HR, Argyll & Bute CHP Mr Stephen Whiston, Head of Planning Contracting & Performance, Argyll & Bute CHP Ms Sara Wedgwood, Chair of Clinical Governance Committee & Spiritual Care Committee, NHS Highland Mr John Dreghorn, Project Director, Mental Health Modernisation - (agenda item 14.1) Mrs Sheena Clark, PA to Director of Operations - Minute Secretary Councillor George Freeman, Argyll & Bute Council Representative Mr Cleland Sneddon, Argyll & Bute Council Representative Ms Dawn Gillies, Staffside Representative Mr Donald Barr, Area Optical Committee Representative Mr Neil Robinson, Area Pharmaceutical Committee Representative Ms Ann Gent, Director of HR, NHS Highland

1. CHAIRMAN’S WELCOME The Chairman opened the meeting by welcoming everyone to the Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead. 2. APOLOGIES Apologies for absence were noted as above.

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3. CONFLICTS OF INTEREST No conflicts of interest were declared. 4. MINUTE FROM PREVIOUS MEETING 4.1 Minute of Meeting held on 29 August 2012 Mr Michael Roberts asked that his apologies be recorded. With the above amendment the Minute of the meeting on 29 August 2012 was accepted as a complete and accurate record of the meeting. The Committee: • Approved the content of the Minute of the meeting on 29 August 2012. 4.2 Minute of Public Session – 29 August 2012 The Minute of the public session on 29 August 2012 was accepted as a complete and accurate record of the meeting. The Committee: • Approved the content of the Minute of the public session on 29 August 2012. 5. MATTERS ARISING FROM PREVIOUS MEETING HELD ON 29 August 2012 Page 4 – Helensburgh & Lomond Planning Group Ms Wedgwood requested clarification on the position regarding public engagement with Helensburgh & Lomond patients. Mr Leslie reaffirmed that the public should engage with the CHP through local Public Partnership Fora. There continued to be some challenges in establishing such a forum to cover the Helensburgh and Lomond locality however. Page 4 – Pressure Ulcer Prevention Ms Wedgwood commented on the reference to photographic data. Ms Tyrrell provided assurance that a clear policy is followed when obtaining this photographic evidence, which, Mr Creelman advised, verifies the grading of the ulcer and enables monitoring of healing. Mull PCC Mr Leslie reported on the public meeting in Mull on 16 October, attended by representatives of the CHP, Argyll & Bute Council and West Highland Housing, with an attendance of approximately 100 members of the public. The meeting addressed a number of predetermined questions relating to various areas of public concern, including outreach clinics, physiotherapy, transport, kitchen facilities. The Mull PCC Frequently Asked Questions information sheet will be updated to capture the detail of the questions and responses.

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Open Days within the new unit have been arranged for 6 and 7 November 2012. A further public session has been arranged on Mull for 4 December 2012, when the model of care for older peoples’ services will be presented again and discussed and the public given the opportunity to seek clarity around all aspects of service provision. Ms Heritage advised that a meeting of the Transport Network Partnership Initiative is scheduled to take place on Saturday 3 November 2012 at the Loch Fyne Hotel, Inveraray, attended by the representatives of the Scottish Ambulance Service, the Red Cross and the Voluntary Sector. Ms Heritage suggested that representatives from the Mull Community Council may wish to link in to this meeting which would provide an opportunity to discuss transport concerns on Mull. Ms Tyrrell stated that she would contact Councillor Mary-Jean Devon to ensure that she was aware of the above event. 6. NHS Highland Organisational Issues 6.1 Meeting of Highland NHS Board Meeting – 2 Octob er 2012 The draft Minute was circulated for information. Mr Creelman highlighted details in the Minute particularly relevant to the CHP. 110 Audit Committee – Mr Creelman requested an update regarding the Service Level Agreement with NHS Greater Glasgow & Clyde. 121 Patients Rights (Scotland) Act 2011 – Mr Creelman advised that the presentation referred to in the Minute was still to be given to the CHP. Jane Davies from NES will be attending the CHP Committee Development Session in December to discuss the work currently being undertaken from the perspective of preparing the NHS Scotland workforce for the Patient Rights Act and the forthcoming Charter of Patient Rights and Responsibilities. 122 Inequalities Action Plan - Ms Wedgwood reported on the initiatives and targeted work to reduce inequalities in poverty areas. The importance of early interventions is recognised throughout the Board area, i.e. Healthy Living Initiatives. Ms Garman reported that the Director of Public Health's Annual Report details the extensive work of the Keep Well project and on health inequalities within remote and rural settings. The report will be taken to the CHP Committee meeting in December. 123 NHS Highland Engagement with School Pupils - Mr Creelman reinforced the need for NHS Highland to continue the programme of engagement with school children and young people who are considering a career within the NHS. He acknowledged the quality of the pupils who had recently participated in the NHS Highland engagement process and the need to maximise this engagement. Ms Garman advised that within the CHP the engagement process is conducted through Curriculum for Excellence, in conjunction with Argyll & Bute Council. This approach will be refreshed, with the focus to ensure re-engagement by young people. It was suggested that pupil representation may be appropriate within the local network, i.e. Public Partnership Forum (PPF) and the Community Planning Partnership (CPP). Mr Leslie will discuss this further at the next meeting of the CPP and with the Chair of the PPF. Ms Tyrrell highlighted the Child Protection poster on display at today's meeting and advised that the details and drawings were produced with the involvement of children and young people.

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130 Chief Executive's and Directors' Report - Mr Creelman asked for clarity around the public and patient engagement process by NHS Greater Glasgow & Clyde during their current clinical review. Mr Whiston advised that the recent paper produced for the West of Scotland Planning Group is a summary of activity and confirmed the engagement process is ongoing, with Scottish Health Council involvement and continuing discussions with the NHS GG&C Lead Planner in relation to impact of the review on CHP patients. Mr Roberts advised that he is aware of information regarding the NHS GG&C clinical review and process being presented at 3 Public Partnership Forum meetings but not currently presented to the wider public. The Committee: • Noted the Minute of the meeting on 2 October 2012 6.2 Director of Operations Report Mr Leslie stated that the circulated report resulted from recommendations of the recent Internal Audit report on CHP governance and management arrangements, and featured highlights of the business of the CHP Core Team and CHP Management Team. Mr Leslie requested members of the Committee forward to him any comments/suggestions on this initial report. Mr Creelman thanked Mr Leslie for his report and recorded his support of Mr Leslie in the ongoing discussions between the CHP, Islay GPs and representatives of the community to ensure the continuation of a safe and sustainable health service on the island. Ms Wedgwood acknowledged the conciseness, brevity and succinctness of the report, together with the operational content but advised the need for a corporate view from the NHS Highland Board to clarify issues/topics which are for governance decision and those which require operational consideration and input. Mr Leslie advised that he and Mr Creelman will further consider the content of future reports and will await a corporate view from the Board. 6.3 NHS Highland Internal Audit Report – A&B CHP Govern ance and Management

Arrangements Mr Leslie provided a brief summary of the outcome of internal audit carried out by Scott-Moncrieff, to review the governance and management arrangements in place within Argyll & Bute CHP, and to consider the interaction with the Board of NHS Highland and its standing committees, as well as plans to integrate services with Argyll & Bute Council. The outcome of the report was generally positive, with management action points identified being considered and actioned by the Chairman and Director of Operations. Ms Robertson enquired about the timescale for the proposed integration of services. Mr Leslie replied that the timescale is set by the outcome of the national consultation. Broader discussions are due to take place between NHS Highland and Argyll & Bute Council and further information will be given at the next Committee meeting. Ms Wedgwood congratulated the CHP on a positive audit report.

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7. Hospital Dialysis Service Mr Whiston referred to the conclusion of the previous report in May 2012, as detailed, and advised that the purpose of this report is to update the Committee on additional actions agreed with regard to planning for the future provision of hospital renal dialysis services for a proportion of the CHP’s population in the Oban, Lorn & Isles catchment area. On 1 October 2012 CHP management representatives attended a community council meeting in Taynuilt, which was hosted to enable the public and local councillors, including the MP Alan Reid, to explore the CHP’s conclusion and to request the CHP to reconsider the possibility of an enhanced local access to renal dialysis. Particular points made at the meeting included:

� the current very high cost of transporting patients to the Belford, � the significant impact the current travel arrangements using taxis has on patients

travelling to the Belford for hospital dialysis � option of the qualified renal nursing staff from Belford (who run the unit - Mon, Wed &

Fri) coming down to provide the service at LIH unit Tues, Thurs, Sat. � indication that the community would look to fund raise to pay for the facility and buy

the equipment etc for a local unit, � the opportunity to gain income from holiday dialysis.

The CHP agreed to undertake a high level piece of work to assess whether there is a case for establishing a viable Hospital dialysis service at LIH. Mr Whiston advised that a high level macro analysis, based on current available information, supplemented by user and stakeholder feedback on current service provision, will be carried out to assess the viability of a local service. Ms Garman advised that equality and diversity regarding the number of population, the area covered and transport concerns required to be considered in relation to any proposed service. Mr Leslie commented that current discussions had attracted significant political and public interest and the review will be undertaken set against the facts and public health predictions to consider and address the concerns of those involved. Mr Roberts enquired regarding the viability of anticipating the number of renal patients and the subsequent provision of a renal nurse specialist, in comparison to the chemotherapy provision at Mid Argyll Hospital. Mr Morrison replied that a renal dialysis service requires a more complex infrastructure and therefore enhanced capital investment. Ms Garman stated that projected figures for the future development of a dialysis service should be modelling dependent, not predicted. It is not intended to present an outline business case but a written report outlining the findings and criteria to establish a viable unit will be taken to the CHP Management Team and CHP Committee in December 2012. The Committee: • Noted the findings in regarding the currently and future profile of service delivery. • Considered the criteria identified to inform the assessment of what would make a viable

“local” hospital dialysis service in Lorn & Isle Hospital. • Approved the approach outlined and the level of detail to be presented in the report.

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Mr Creelman agreed to take Mental Health Services M odernisation Project as the next agenda item. 14. MENTAL HEALTH SERVICES MODERNISATION PROJECT 14.1 Update Report Mr Dreghorn spoke to the previously circulated report. Project governance arrangements have been reviewed for the capital element of the project, resulting in the establishment of a new Capital Project Board. The first meeting of this group took place on 19 October 2012 and will meet monthly to oversee the new inpatient services mental health hospital capital project. Capital Project – the hub stage 1 submission was received on 5 October 2012 and was presented to the Project Board on 19 October. Key points within the report included: • Estimated capital cost is within the £9.45 million cap set at the start of the project. • The Facility Management (FM) and Life Cycle Costs (LCC) are currently projected to be

above the £43 per m2 set at the start of the project. These costs are currently being reviewed by external advisors (Technical, Financial & Legal) and a final report is awaited, which will to a large extent dictate whether the stage 1 submission is accepted. This process should be completed by 4 December 2012

• The design development work is progressing well with a full set of drawings likely to be available by the end of November.

Ms Wedgwood enquired about the remit of the external advisors. Mr Dreghorn assured the Committee regarding their financial and legal expertise in relation to Hub projects. The development of the Outline Business Case continues to progress, with the approvals timetable revised to : CHP Committee on 19 December 2012; NHS Board on 5 February 2013; Asset Management Group on 15 February 2013; and the Scottish Government - Capital Investment Group on 26 February 2013. Mr Dreghorn summarised the detail of the report relating to: • Inpatient services • Staff redeployment • New posts • Budget • Projected Operational Funding Gap • Resettlement Group • New hospital • Community Mental Health Service (CMHS) • Community Mental Health Service Team Base • Crisis Response Mr Dreghorn advised that the lead Architect has met with staff and service users to discuss the design of the new hospital building and the plans have subsequently been amended following those discussions. Identifying suitable premises as a base for the CMHS teams in Campbeltown and Dunoon continue to be problematic. The benefits of having all members of a CMHS team in one location has been acknowledged, therefore in both areas it is planned to develop underutilised areas of the hospital as a CMHS base, incorporating NHS and council staff. Discussions are ongoing regarding the financial implications of this proposal.

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Mr Creelman raised the issue of crisis response in Dunoon. Mr Dreghorn acknowledged the concerns and advised discussions have taken place regarding the sufficiency of the designated place of safety in the hospital. Community mental health teams are very responsive but concerns around provision during out of hours are being addressed. Mr Dreghorn reported that he is currently visiting all places of safety within the CHP and meeting with staff, management and service users and the discussions and any recommendations will be reviewed. The Committee: • Noted content of the Modernisation of Mental Health Services Update Report 8. Workforce Planning Mr Logue referred to the circulated paper summarising the detail of the monthly NHS Highland Workforce Information report. This provides a range of information on staff throughout NHS Highland and a comparison can be made on some items between Argyll & Bute CHP and other areas in NHS Highland. The paper provides a snapshot of the situation at August 2012, with some charts providing trends and historical data over the previous 12 months. Points highlighted:

• Replacement Whole Time Equivalent – use of Bank staff is reducing. • Job Families – comparable figures – NHS Highland 64.44% staff in immediate front

line patient care, 34.81% - support and administrative services staff. CHP 64.26% of staff in immediate front line patient care, 35.07% - support and administrative services staff. Senior managers – 0.74% in Highland, 0.68% in the CHP.

• Turnover and Stability – figure is currently falling, indicating a trend towards higher

turnover and possibly a more active employment market, which is also indicated by an increase in vacancies over the last 12 months.

• Occupational Health (OH) Service KPIs - KPI 2 shows the average referral to

treatment time (RTT) for seeing an OH nurse. Although improving recently this remains low. It should be noted that the target RTT for Inverness is lower than other areas. The OH is working to overcome the challenges presented by the wide geographic area and have recently appointed to a vacancy covering Argyll and Bute. Also, increased use of telephone appointments has been introduced providing a more flexible and quicker response to staff out with Inverness.

• Sickness Trends - the Argyll and Bute figure remains above that of NHS Highland

overall. There is continuing work between HR, managers and OH to address frequent or long term absences. The annual trend for Argyll and Bute follows the NHS Highland trend line for reduction and the gap has closed over the year from 0.6% to 0.2%.

• Employee relations - charts provide information on the numbers and lengths of the

various procedures being undertaken under NHS Highland Employee Relations Policies (PIN Policies). A summary for the CHP is taken to the Core Management team for discussion. Managers and HR, in partnership with the Staffside, are

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committed to reducing the time taken to complete these procedures, with regular case reviews undertaken to improve the timeline. Mr Logue advised that the CHP % of cases and lengths of completion times are similar to NHS Highland.

• NHS Highland Re-deployment Register - there are considerably more staff on this

register in the CHP than in other areas of Highland and this is indicative of the scale of service changes being enacted. The large majority of staff are on the register due to their posts being subject to change. They remain at work and undertaking their normal duties but are given priority status for any vacancies which arise. This greatly assists in the process of revising service establishments and supporting staff to move into suitable alternative posts.

• Employee Friendly Leave – the range of leave available to staff to assist them at

times of emergency, family crisis or similar events provide them with the opportunity to overcome or deal with the difficulty. NHS Highland initiatives are valued by staff and are a small aspect of staff attendance. In August 2012 total leave of this type in NHS Highland was 30.96 wte equating to 0.46% of the workforce.

Ms Wedgwood asked for clarification of the figure of 161 fixed term contracts. Mr Logue replied that this is possibly due to cultural issues around recruitment but will ensure a specific examination of this figure.

Ms Tyrrell highlighted the age profile of staff and the challenges for the CHP in forthcoming years to address any resulting issues. Ms Tyrrell asked about the appropriateness of discussing retirement plans with individual staff. Mr Logue advised that this would be appropriate in the circumstances of addressing any capability issues but the preparation for such discussions was critical to the need of the individual in relation to discussions with Managers and could also be incorporated within the individual’s eKSF/PDP procedure. 9. Clinical Governance 9.1 Clinical Governance & Risk Management Report Ms Tyrrell spoke to the previously circulated paper and highlighted a number of areas from the report. Risk Management Incidents A total of 442 incidents were reported during quarter 2 of 2012/13 which is a reduction on the previous reporting period. Slips, trips and falls remain the highest reported category of incidents in Cowal & Bute, Mid Argyll & Kintyre and Lorn & Isles. Medication and sharp incidents were the highest reported category in Helensburgh & Lomond. During the reported period the reported incidents were reported as low -242 (54.74%) and medium – 165 (37.33%), with the remaining 35 incidents still to be graded. Pressure Ulcer Prevention The CHP is continuing to implement the NHS Highland zero tolerance approach to preventable pressure ulcers. There is heightened awareness of early identification and increased reporting and a range of measures to improve the identification and management of those patients at risk of developing pressure ulcers in all hospital and community settings.

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Ms Tyrrell advised that Argyll & Bute CHP is at the lower end of reported cases but actions continue to drive down any incidences. Details are recorded on Datix and learning is shared through the Tissue Viability Leadership Group and also reported to the Board Clinical Governance Group. Ms Garman enquired about the level of CQI training for staff. Ms Tyrrell advised that actions are being taken to address identified gaps and needs in staff training and skills. Senior Charge Nurses have identified the need for ownership by teams. Ms Wedgwood asked about the plan for the care of tissue viability patients on discharge from hospital to the community. Ms Tyrrell advised that details are recorded in the patient discharge plan, with the transfer of care managed by the Community Nursing Team. Discussions have been held with and assurance given by NHS Greater Glasgow & Clyde to assure that accurate details are included in the care plan for tissue viability patients on discharge from NHS GG&C back to Argyll & Bute. Mr Roberts requested clarification on the July and August figures reported for Islay. Ms Tyrrell confirmed that the reported figures are by occupied bed day numbers and she will circulate information to provide clarification on the numbers reported. Falls Prevention Ms Tyrrell reported that a significant amount of work is being undertaken to reduce the risk and number of falls in healthcare settings; to improve the reporting information available and to highlight areas requiring support. Complaints Ms Tyrrell commented on the challenges in adhering to the 20 day response time due to the complexity of some complaints and the need to provide a concise response. Ms Wedgwood advised that this is a concern expressed in other areas and is due for discussion at the NHS Highland Clinical Governance and Risk Management meeting. Health & Safety and Fire Safety An Argyll & Bute Hospital Risk Assessment group has been established to carry out a review of environmental and statutory requirements to ensure safe practice and a safe environment for staff and patients. An action plan has been drawn up for review at the fortnightly meetings, chaired by Mr Leslie. Quality Scottish Patient Safety Focus on Medicines Management and Medicines Reconciliation continues, to address areas requiring improvement. Further detail will be provided in the next report to the Committee. External Reviews Forensic Network Review A Forensic Network Review of the Intensive Psychiatric Care Unit at Argyll & Bute hospital was carried out in September 2012 as part of a peer review to measure performance against the Low Secure Forensic Standards. A draft report has been received indicating that most standards were assessed as being at the developing stage.

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Care Inspectorate Follow Through Inspection of Services to Protect Children & Young People Ms Tyrrell advised that a follow up inspection by the Care Inspectorate is scheduled to take place in January 2013. Healthcare Environment Inspectorate Notification has been received that the HEI will undertake a minimum of 30 annual, unannounced inspections of acute and community hospitals. All hospitals within the CHP are required to reassess their compliance with the standards and further walk rounds are planned to support this process by a number of senior staff. The Committee: • Noted the content of the Clinical Governance and Risk Management Report 9.2 Infection Control Report Ms Tyrrell spoke to the previously circulated paper. Staphylococcus Aureus Bacteraemia (SAB) NHS Highland rate April–August 2012 is 20.0 per 100,000 bed days, (0.20 per 1,000 bed days). The MRSA programme has been implemented and there have been no further cases of SAB in the Lorn & Isles hospital since the last report. Clostridium Difficile NHS Highland rate April – August 2012 is 21.7 per 100,000 total occupied bed days, (0.217 per 1,000 occupied bed days) (20 cases) in patients age 65 and over using the Clostridium Difficile toxin test. Hand Hygiene NHS Highland Compliance with hand hygiene 98% in July and August 2012. Mr Roberts challenged the reported figures, particularly with regard to clinicians. During discussion it was suggested that it may be appropriate for a public representative to participate in infection control walk rounds. Ms Tyrrell acknowledged the need for locality ownership and external scrutiny to maintain compliance by all staff. Mr Creelman supported the CHP process and commented that there is scope for members of the public to receive training to enable them to participate in the carrying out of audits. Ms Tyrrell acknowledged the need for locality ownership and external scrutiny to maintain compliance by all staff, and welcomed the suggestion of a public representative. Health & Safety Executive Visit to Care Homes in North Highland

NHS Highland is working with the Health and Safety Executive on two strands of infection control work at present; one relates to improving the arrangements for managing infection control in NHS Care Homes, the other relates to community nursing staff.

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Within Argyll and Bute CHP we will ensure that actions within the plan for training and education for staff working in community settings are complied with across all sites. In addition we will work with partners in the Argyll and Bute Council and Independent Sector to share the learning and policy changes developed through the NHS Highland Health Protection Team. The Committee • Noted the content of the Infection Control Report. 9.3 Health Improvement Report Mental Health & Wellbeing Framework Ms Garman reported that the Argyll and Bute Community Planning Partnership document Strategic Framework for Mental Health and Wellbeing in Argyll and Bute 2012–2014 was launched in March 2012. This framework arose from the mental health modernisation programme and was developed from a partnership of Argyll and Bute Council, the Third Sector and Argyll and Bute Community Health Partnership. The purpose of the framework is to ensure investment in evidence informed approaches to improving mental health. A CHP action plan is currently being developed which will be governed by the Mental Health Modernisation Programme Board and the Community Planning Partnership Management Committee. Young People in Alcohol In March 2011 the Argyll & Bute Alcohol & Drug Partnership released the needs analysis report “Young People, Alcohol and Drug Misuse Across Argyll and Bute” by Barnard, Griffin and Milton which identified a number of key points in relation to young people’s alcohol use in Argyll & Bute. The Scottish Schools Adolescent Lifestyle and Substance Use Survey 2010 (SALSUS) report for Argyll & Bute indicated that:

• Compared with 2006, there has been a decrease in the proportion of 13 year old pupils who had ever had an alcoholic drink (from 63% in 2006 to 51% in 2010)

� There has been no statistically significant change in the proportion of 15 year olds who have ever had an alcoholic drink (86% in 2006 and 84% in 2010)

• In both age groups, the proportion of pupils in Argyll & Bute who have ever had a proper alcoholic drink is higher than the national average (51% of 13 year olds compared with 44% nationally, and 84% of 15 year olds compared with 77% nationally)

The CHP Senior Health Promotion Specialist: Alcohol and Drugs has undertaken research work looking at the alcohol use by 5th year pupils in three schools in Argyll & Bute and the results were detailed in the circulated report. Alcohol brief intervention work was recently delivered through a series of training events to staff working with young people within the public sector and third sector organisations. The Argyll & Bute Alcohol & Drug Partnership Children & Families group are in the process of finalising an action plan, connected to five key practice areas:

• Education, information and prevention • Diversion and prevention • Identification and response to children at risk

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• Training and Development • CAPSUM (Children Affected by Parental Substance Misuse)

Mr Leslie emphasised the value and benefits of health improvement work. There is a need to address the stigma in mental health and to advocate the importance of mental health wellbeing. It was acknowledged that the work being carried out to address concerns regarding young people and alcohol requires the sign-up of the young people and a cultural change to achieve self management. The Committee: • Noted the content of the Health Improvement Report. 10. FINANCIAL GOVERNANCE 10.1 Finance Report Financial Position At end September 2012 Argyll & Bute CHP recorded an overspend of £57,000, a significant improvement on the previous month as it represents a decrease of £128,000 on the overspend of £185,000 recorded at the end of August.

Mr Morrison summarised the budgetary performance across Argyll & Bute CHP to end September 2012 and advised on the overspending budgets caused by either unachieved savings or cost pressures. The main cost pressures being experienced are;

• Medical locum cover for vacancies and a suspension in Cowal. • An overspend on commissioned services relating mainly to increased patient referrals

to Raigmore & Belford Hospitals which are internally cross-charged on a cost per case basis.

• Locum cover for GP vacancies in Bowmore, Jura and Inveraray. • An overspend on hospital and community nursing pay costs on Bute.

In addition to the cost pressures noted above, there is also the ongoing risk relating to settlement of the patients services SLA with NHS Greater Glasgow & Clyde. No value has been agreed for this financial year and GG&C are continuing to claim that a substantial increase to the SLA value is required to reflect increased activity and case complexity.

Specific attention is drawn to the entry of “Planned Management Action”. This entry is necessary to support a forecast year-end break-even position for the CHP. However it indicates that without action to address savings target shortfalls, it is likely that the CHP will overspend by £300k. Cost Improvement Programme 2012/13 The CHP approved budget for 2012/13 contained a requirement to achieve savings of £5m. Several of these savings will arise naturally e.g. prescribing drugs coming off-patent, restricted uplift to SLA values, etc.

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Initially a balance of £2.24m required to be delivered through management action, however this has recently been reduced to £1.56m, mainly as a result of increased savings being achieved from off-patent prescribed drugs. This has enabled locality savings targets to be reduced from 3% to 2%.

Recurring targets by budget manager, sums declared achieved to date, forecast achievements based on current information, and likely shortfalls are as detailed in the report. Based on current information, there is likely to be a shortfall of £0.5m against savings targets. Mr Morrison emphasised the need for managers to take action to deliver on savings targets where a shortfall is currently predicted. Forecast Outturn for 2012/13 Overall, notwithstanding the risk relating to the GG&C SLA, Argyll & Bute CHP is forecasting a year-end break-even position. This is, of course, dependent on managers delivering on their savings targets and continuing to exercise control over emerging cost pressures. The Committee: • Noted the contents of the Finance Report 10.2 Service Level Agreement (SLA) Update Report Mr Whiston advised that the detail of the paper sets out the governance arrangements and provides a broad scope of contracts for services provided to the Argyll and Bute population for 2012/13. NHS Greater Glasgow & Clyde – Main Patient SLA The CHP participates in regular liaison meetings with senior management of NHS GG&C with regard to its’ SLA to consider and address operational and financial issues pertaining to the services it commissions. There are 2 sets of meetings, financial and operational: The SLA Finance Group oversees overall financial arrangements, including agreeing costs, variations and exclusions, managing financial risks between both organisations, taking account of West of Scotland Regional Planning arrangements as well as monitoring financial and activity performance. The SLA Operational Review Group reviews and monitors the operational delivery of services against the SLA as well as issues and progress against action achieved. There is also an emphasis on ensuring equitable access for Argyll and Bute patients to NHS GG&C services by having these formal arrangements. Service redesign are managed and lead through the CHP planning managers with consultant outreach services (specialist clinics delivered in Argyll and Bute) being the most frequent issue. Discussions are taking place with NHS Highland regarding the implementation of the Patient Management System (PMS) and the specific issues for the CHP in relation to patient flows predominantly being to NHS Greater Glasgow & Clyde. There are ongoing discussions to clarify laboratory governance following changes to the NHS GG&C laboratory management structures.

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11. STAFF GOVERNANCE 11.1 Argyll & Bute CHP Partnership Forum Draft Minute - 23 August 2012 The draft minute was previously circulated for information. The Committee: • Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of

23 August 2012 11.2 PDP/R and eKSF Implementation Mr Logue reported that at end September 2012 the CHP recorded 10.86% of reviews completed for all AfC staff (14.82% excluding Bank staff). Concerted efforts are being made in all areas to achieve the target of an 80% completion rate by end March 2013. Derek advised that he has received assurances from Managers that review dates for staff have been set which will result in an improved completion rate to ensure the target is met. 12. PARTNERSHIP WORKING 12.1 Argyll & Bute CHP Public Partnership Forum Dra ft Notes – 28 August 2012 The draft note was previously circulated for information. The Committee: • Noted the contents of the Argyll & Bute CHP Public Partnership Forum Draft Notes of

28 August 2012 13. PERFORMANCE MANAGEMENT 13.1 Delayed Discharge/Joint Performance Report Mr Leslie reported on the monthly census which indicated 1 case >6 weeks, with an exemption code due to the complexity of the case. Delayed discharge performance is a key priority in partnership working which is positively reflected in the reporting of only 2 delayed discharges breaching targets over a considerable number of months. It was agreed that the Joint Performance Report will be included in future Committee papers. The Committee: • Noted the contents of the Delayed Discharge Report.

The Committee: Noted the content of the PDP/R and eKSF Implementation 2012/13 Report

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15. Papers for Noting 15.1 CEL 27 (2012) - AHPs as Agents of Change in He alth & Social Care – The National Delivery Plan for the Allied Health Profe ssions in Scotland, 2012–2015 15.2 Proposed CHP Committee Dates 2013 The Committee: • Noted content of the above papers. 16 AOCB There was no other competent business highlighted. 17 DATE, TIME & VENUE FOR NEXT MEETING: Wednesday 19 December 2012 at 10.30am in Queens Hal l, Dunoon

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 6.2

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Argyll & Bute CHP Committee Date of Meeting : 19 December 2012

Agenda item : 7.1

Argyll and Bute CHP Clinical Governance and Risk Ma nagement Report Report by Pat Tyrrell, Lead Nurse and Fiona Campbel l, Clinical Governance Manager

The CHP Committee is asked to:

• Note the contents of the Clinical Governance and Risk Management Report.

1. CONTRIBUTION TO THE BOARD’S CORPORATE OBJECTIVES NHS Highland’s mission is to provide patient-centred services tailored to people’s needs in a systematic and consistent way – to provide quality care to every person every day. The Board approach embraces the Healthcare Quality Strategy for Scotland and also takes account of the priorities within the NHSScotland Efficiency and Productivity Framework for SR10. NHS Highland vision is to:

• Provide quality care at all times; • Support people and communities to maximise their own health; • Develop precisions driven services so that when people need our care they

experience timely, focussed, effective services that minimise the duration and frequency of contact;

• Ensure that every health pound spent delivers maximum health gain.

2. RISK MANAGEMENT 2.1 Incidents The following information relates to incidents reported in Quarter 2, the period from July to September 2012

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FIGURE 1 Argyll and Bute Incidents Last 13 months

A total of 442 incidents were reported during Quarter 2 of 2012/12.

• Cowal & Bute 100 (22.62%) • Helensburgh 13 (2.94%) • Mid Argyll & Kintyre 219 (49.54%) • Oban Lorn & Isles 99 (22.40%) • Outwith NHS Highland 11 (2.49%) (patients transferred in)

FIGURE 2 Category by Locality

In the last financial quarter slips trips and falls remained the highest reported category of incidents for Argyll & Bute – this was the case across Cowal & Bute, Mid Argyll & Kintyre and Oban, Lorn & Isles. For Helensburgh medication (2) and sharps (2) incidents were the highest category of incidents.

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FIGURE 3 Grade of Incidents by Locality

During Quarter 2 of 2012/13 the incidents reported in Argyll & Bute were graded as follows:

• Low – 242 (54.75%) • Medium – 165 (37.33%)

The remaining incidents were still to be graded. FIGURE 4 Incidents with a Major or Extreme Consequ ence

There were no major or extreme incidents reported in July, August or September 2012. Note: this figure could change as some incidents are still being reviewed.

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FIGURE 5: INCIDENTS BY LOCALITY WITH OUTCOME

Overall outcome for Argyll & Bute in Quarter 2:

• No injury / harm – 248 (56.1%) • Near miss – 44 (9.95%) • Injury / harm – 138 (31.22%) • Death – 0 • Property damage – 12 (2.71%)

2.1.2 Pressure Ulcer Prevention

Implementation of NHS Highland Zero Tolerance approach to preventable pressure ulcers continues with a range of measures being taken to improve the identification and management of those patients at risk of developing pressure ulcers in all settings. The following graphs highlight trends from April 2011 until October 2012. FIGURE 6 Rate of Pressure Ulcers developed in hospi tal per 1000 Occupied Bed

Days for Argyll and Bute

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Figure 7: Numbers and Rates of Hospital Acquired Pr essure Ulcers Grade 1 – NHS Highland

Figure 8: Numbers and Rates of Hospital Acquired Pr essure Ulcers Grade 2– NHS Highland

Figure 9: Numbers and Rates of Hospital Acquired Pr essure Ulcers Grade 3– NHS Highland

Numbers of Grade 1 Hospital Acquired Pressure Ulcers August 11 0.41

September 14 0.53

October 12 0.44

Numbers of Grade 2 Hospital Acquired Pressure Ulcers August 23 0.85

September 32 1.20

October 21 0.77

Numbers of Grade 3 Hospital Acquired Pressure Ulcers August 2 0.07

September 0 0.00

October 2 0.07

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Figure 10: Numbers and Rates of Hospital Acquired P ressure Ulcers Grade 4– NHS Highland

While the overall number of pressure ulcers being reported across NHS Highland remains reasonably static, there is a much higher number of Grades 1 and 2 being reported. This can be attributed to increased awareness and improved risk assessment which is leading to earlier identification of tissue damage. Early identification enables preventative actions to be taken to avoid further damage which can lead to more serious Grade 3 and 4 ulcers developing. The overall number of Grade 3 and 4 pressure ulcers developing within hospitals is very low across NHS Highland. Each of the Grade 3 and 4 pressure ulcers identified is subjected to increased scrutiny to ensure that all actions are taken to a) heal the ulcer and b) learn lessons to prevent future similar occurrences where at all possible. TABLE 1 Rate of Pressure Ulcers per 1000 Occupied B ed Days and Pressure

Ulcer CQI Compliance Scores for each in patient wa rd from MAY 2012.

MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER Rate

per 1000 OBDs

CQI % Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI Rate

Rate per 1000 OBDs

CQI Rate

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

COWAL AND BUTE Victoria Hospital

0 95 0 100 0 95 6 97 0 100 0 95 0 100

CCH Ward 1 0 100 0 0 0 0 0 100 6 96 CCH Ward 2 6 100 0

100 0

97.5 0

97 0

98 0 0

MID ARGYLL, KINTYRE AND ISLAY Glenaray 4 95 0 100 4 95 5 63 0 95 0 100 0 95 Glassary 0 100 0 0 0 0 0 100 0 100 Cara 0 100 0 0 0 0 0 0 Knapdale 0 100 0

100

0

100

0

100

0

100

0 0 Campbeltown 5 97.5 2 95 0 100 2 97 0 NR 0 97 4 95 Islay 0 100 0 90 0 85 20 95 0 90 0 90 0 90 OBAN, LORN AND ISLES Ward A 0 100 0 90 0 100 4 95 0 95 0 100 0 100 Ward B 3 95 0 95 0 97 5 97 0 100 0 100 8 98 Ward I 0 100 2 100 0 100 0 100 0 100 0 100 0 100 Dunaros 0 93 0 100 0 nr 0 96 0 95 0 N/R 0 N/R

Numbers of Grade 4 Hospital Acquired Pressure Ulcers August 0 0.00

September 1 0.04

October 0 0.00

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2.1.3 Falls Prevention The graph below illustrates trends across NHS Highland. FIGURE 11 Monthly Rate of Falls per 1000 OBDs in NH S Highland since January

2011

FIGURE 12: Reported Falls WITH Harm per 1000 Occupi ed Bed Days, September 2012 across Highland Hospitals

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TABLE 2 Rate of Falls with Harm per 1000 Occupied B ed Days and Falls Prevention CQI Compliance Scores for each in patien t ward from MAY 2012.

MAY JUNE JULY AUGUST SPETEMBER OCTOBER NOVEMBER Rate

per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI % Rate per 1000 OBDs

CQI Rate

Rate per 1000 OBDs

CQI Rate

Rate per 1000 OBDs

CQI Rate

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

COWAL AND BUTE Victoria Hospital

0 93 2.97 100 3 98 3 97 6 100 7 100 0 100

CCH Ward 1 0 95 0 0 6 0 0 96 6 98 CCH Ward 2 0 95 3.22

100 3

100 0

100 0

100 0 0

MID ARGYLL, KINTYRE AND ISLAY Glenaray 0 97 4.10 100 4 100 5 100 0 100 0 100 15 100 Glassary 6 100 6.67 34 0 0 0 100 10 100 Cara 0 100 0 0 0 8 8 0 Knapdale 8 100 0

100

4

100

4

100

0

100

0 4 Campbeltown 3 97 2.80 nr 0 96 3 NR 0 NR 0 100 0 94 Islay 0 95 0 95 0 83 0 52 13 NR 14 87 7 90 OBAN, LORN AND ISLES Ward A 0 100 6.67 96 0 100 0 97 4 96 5 96 4 97 Ward B 0 100 0 97 0 100 0 100 0 NR 0 100 0 98 Ward I 4 100 2.43 100 5 100 6 100 17 100 16 100 4 100 Dunaros 14 100 0 96 6 96 0 100 0 100 0 N/R 0 N/R

Wards with higher percentage of frail, older people, especially with cognitive impairment generally have higher rates of falls. In Argyll and Bute this can include all of the Community Hospitals as well as Ward I in Lorn and Islands Hospital, Oban. The work that is underway to implement the standards for Older People in Acute Care (OPAC), which also includes Dementia Standards, includes assessments of the environment within hospitals to make areas more accessible and easy to navigate for people with cognitive impairment. FIGURE 13 RIDDOR Reportable Incidents

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There were 2 RIDDOR reportable incidents for Argyll & Bute:

• 1 staff accident – hit by a moving object. • 1 fall by a member of the public, sprained wrist

2.2 Serious Untoward Incidents A serious untoward incident is a situation in which staff, or one or more patients are involved in an event which is likely to produce significant clinical, legal, media or other interest. If not managed effectively it may result in the loss of life or the loss of organisation's assets or reputation. There have been three such events in Argyll and Bute since September 2012, each of which has been investigated under the NHS Highland Serious Untoward Events policy. Immediate actions were taken where necessary to address issues of concern; full reports into these incidents with all key learning will be addressed through the CHP Clinical Governance and Risk Management Group, as well as through NHS Highland Clinical Governance Committee. 2.3 Risk Register Development Development work is being undertaken to make the management of Risk Registers within the CHP more robust. Guidance is being developed to refresh existing approaches; to make processes more dynamic and to strengthen processes for transfer of risks to the appropriate level within the CHP. Development proposals will be presented at the next CHP CGRM Group to be held in January 2013. 3 COMPLAINTS TABLE 3 Argyll and Bute Complaint Performance repo rt

Target Amber Red Aug-12 Sep-12 Oct-12

Number of complaints received 4 5 ~ 6 7 and over 7 3 4

Achievement against 20 day 80% 70 - 79% Under 69% 0% 0% 0%

Number of complaints over 40 working days old * 0 ~ 1 or more 0 1 2

Number of further correspondence over 20 working days old * 0 ~ 1 or more 0 0 0

Number of complaints categorised as high risk 1 2 3 and over 2 1 2

Two complaints related to services in Argyll and Bute have been referred by the complainants to the Ombudsman. One relates to palliative care in Cowal Community Hospital and the other to A&E services in Victoria Hospital, Rothesay. Information in relation to both cases has been provided to the Ombudsman and the outcomes of the reviews are awaited.

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4. EXTERNAL REVIEWS 4.1 Inspection of Children’s Services in Argyll and Bute Notification has been received from the Care Inspectorate of the proposed inspection of Children’s Services in Argyll and Bute, due to commence in March 2013. Argyll and Bute is one of four partnerships in Scotland in which the new inspection regime will be piloted. Rather than focussing specifically on Child Protection the inspection will review outcomes for all children and young people to provide assurances of the quality of services, particularly for vulnerable children and young people. This new scrutiny model will be Partnership-orientated and will focus on outcomes for those who use our services. The inspection is intended to be transparent, intelligence-led and risk-based, integrated and coordinated and supporting improvement. The multi disciplinary and multi agency inspection team will review the self evaluation and evidence as well as sample case records; in addition they will spend 13 days on site during March and April 2013. The inspection will focus on well we are working together to provide services to improve the lives of children and young people against 22 quality indicators. The public report will be published within four weeks of the inspection and will record findings in relation to:

o How well are the lives of children, young people and their families improving? o How well do services work together to improve the lives of children and

families? o How well do services lead and improve the quality of work and achieve better

outcomes for children and families? 5. Quality 5.1 Person Centred Care Led by the Scottish Government the national launch of the Scottish Person Centred Care Programme took place over two days at the SECC in Glasgow at the end of November. This programme, covering health and social care, will focus on the following key elements which include:

- care experience - staff experience - co-production

All Boards in Scotland are expected to implement the requirements of this programme to ensure that progress is made across health and social care to deliver person centred services and care. Heidi May, Board Nurse Director, is the NHS Highland Executive Lead for this work.

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5.2 Standards for Older People in Acute Care (OPAC) All hospitals in Argyll and Bute are working to implement these standards, many of which also support the delivery of person centred care. Inspection of progress by the HEI will focus on Raigmore Hospital in the first instance. However it is critical that we ensure that all patients receiving care in hospital are assured of the same standards and quality of services. 5.3 Scottish Patient Safety Programme (SPSP) Progress in Lorn and Islands Hospital in relation to SPSP is highlighted in the dashboard included in Appendix One. Most actions are now embedded in practice and the improvements sustained; these are measured through ongoing audit programmes within the hospital. The most challenging area continues to be medicines management and work is ongoing to identify and develop the actions that will deliver the required improvements. Since the programme began five years ago Lorn and Islands Hospital has seen a 24% reduction in Hospital Standardised Mortality Rates; this improvement has exceeded the national target of 15%. Some of the appropriate care bundles have already been spread to the Community Hospitals. These include best practice is use of Peripheral and Central Venous Catheters, use of the SBAR communication tool and Safety Briefings. Plans are now being developed to support use of improvement methodology and measurement tools to ensure that improvements are being measured and more consistent approaches are taken to sustaining improvement. Two of the Practice Development Nurses, Alison Guest and Liz Higgins, have commenced training in Improvement Science in Action with the national programme; in addition, Veronica Kennedy, Acting Locality Manager in Oban, Lorn and Isles has been accredited as an Improvement Advisor with Institute for Healthcare Improvement. This will provide us with improved leadership and capacity within Argyll and Bute to support the development of the skills and knowledge of clinical staff in application of the evidence based tools to improve quality and safety of care. 6. HEALTH AND SAFETY 6.1 Monitoring Implementation of the Managing Skin at Work Procedure Following an investigation by the HSE into a number of dermatitis cases an improvement notice was issued to the Board. As a result, amendments to the skin health surveillance programme for staff involved in wet work were made. NHSH Health and Safety Committee has set an implementation date of the end of February 2013. Health and Safety Managers have undertaken a review which indicates that some areas have fully implemented the new procedures and all areas are making progress towards implementation. Implementation will continue to be supported and monitored to ensure full implementation in advance of the target date set.

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6.2 Stress in the Workplace All areas have undertaken a staff stress survey. To consider the results and develop an action plan Focus Groups will take place in each area. All areas have nominated and trained a focus group facilitator and some areas have held their focus groups and developed action plans. The target date for all areas to have action plans in place to address stress in the workplace is the end of March 2013. Health and Safety Managers will continue to monitor progress. 7. FIRE SAFETY 7.1 Fire Risk Assessments Fire risk assessments using the 3i system continue to progress. Garelochhead; Kilcreggan; Campbeltown and Islay are complete. Lorn and Islands Hospital risk assessment has been carried out, the process of uploading information to 3i data base is underway and will be issued to managers in January 2013. 7.2 Compartmentation Survey Funding has been allocated and compartmentation work to be undertaken is being prioritised. Sub-compartmentation of wards is a key priority. Funding has also been allocated to update fire alarm systems to L1 standard in Dunoon and Oban and this work has been scheduled. 7.3 Unwanted Fire Alarm Signals The requirement for a full investigation screen to be completed within Datix for all alarm activations means the cause of the unwanted fire alarm signal is identified and actions identified to prevent recurrence. Analysing incidents and identifying preventative actions continues to have a positive effect on reducing unwanted fire alarm signals 7.4 Fire Extinguisher Training for Kitchen Staff Risk assessment has highlighted the need for additional fire extinguisher training for kitchen staff. Training has been developed and is now in the process of being delivered to all kitchen staff.

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Appendix One LIH SPSP Dashboard October 2012

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Argyll & Bute CHP Committee Date of Meeting: 19 December 2012

Item No: 7.2

INFECTION CONTROL REPORT Report by Pat Tyrrell, Lead Nurse The CHP Committee is asked to: • Note the contents of the report.

1 Aim The purpose of this paper is to update CHP Committee members of the current status of Healthcare Associated Infections (HAI) and infection control measures in Argyll and Bute CHP and NHS Highland.

2 Background In line with the NHS Scotland HAI Action Plan 2008, there is a requirement for a HAI report to be presented to the Board on a two monthly basis. 3 Scaling factor used in reporting incidence rates To ensure consistency with wider UK and ECDC reporting, and in light of decreases in the observed rates, Health Protection Scotland have changed the scaling factor used in reporting incidence rates to ‘per 100 000 bed days’ instead of the previously used ‘per 1000 bed days’. It should be noted that NHS Highland figures for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile are provisional until validated by HPS on a quarte rly basis. 4 Summary

This report provides an overview for the Board of Infection Prevention and Control with particular reference to the incidence of Healthcare Associated Infections (HAI) against Scottish Government HEAT targets, together with results from cleanliness monitoring, hand hygiene audit results and surgical site infections.

Group Target NHS Scotland

NHS Highland

Clostridium difficile

Age 65 and over

39.0 (100,000 OBDs)

30.8 For period April – June 12

32.8 For period April – June 12

Green

Staphylococcus aureus bacteraemia

Age 15 and over

26.0 (100,000) OBDs

30.2 For period April – June 12

30.2 For period April – June 12. Annual rate is 23.39 which means that the Board is still on track to meet the

Amber

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HEAT Target

Hand Hygiene 95% %

98% Green

Cleaning 90%

%

96% Green

Antibacterial prescribing

Hospital-based Empiric prescribing

Compliant Yes Green

Surgical antibiotic prophylaxis

Compliant Yes Green

Primary Care empirical prescribing

Compliant Yes Green

Source: - Health Protection Scotland/ISD/Local data.

5 Contribution to Board Objectives Our key objective is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean”. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the CHP Committee. 5 Governance Implications 6.1 Staff Governance

As additional information is distributed more widely it should ensure staff are better informed in respect of current issues relating to Infection Prevention & Control and the management of HAI in our healthcare premises - “Infection Prevention is Everybody’s Business”.

6.2 Patient and Public Involvement

The distribution of regular information to the patient/public sector should increase awareness and facilitate increased participation of patient/public representatives in the Infection Prevention & Control agenda.

6.3 Clinical Governance

By improving infection prevention & control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI.

6.4 Financial Impact

By reducing the incidence of HAI in our healthcare premises, financial savings can be achieved through lower rates of infection.

6.5 Better Health, Better Care, Better Value

By improving infection prevention & control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI.

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7 Risk Assessment By risk assessing infection prevention & control practices, we will endeavour to minimise the risk of HAI. 8 Planning for Fairness As Infection Control policies are updated they are impact-assessed for equality and diversity. 9 Communications and Engagement Work is ongoing around raising awareness with staff to make sure they consistently apply the principles of Standard Infection Control Precautions. Hand hygiene is the single most important procedure for preventing cross infection, as hands are of special significance in the transmission of infections. All Health Boards are required to demonstrate, every two months, a minimum of 95% compliance with the five moments and technique for hand hygiene. A Hand hygiene module is now available online. The module is mandatory for all staff. There are two public representatives on Argyll and Bute CHP Infection Control Group. In addition regular Infection Control reports are presented to the PPF at CHP and locality levels.

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Argyll and Bute CHP Healthcare Associated Infection Report –

December 2012

Section 1 – NHS Highland Board Wide and Argyll and Bute Issues

Staphylococcus aureus (including MRSA)

National Context

With effect from April 2011, all Boards are expected to achieve a rate of 26 Staphylococcus aureus bacteraemia (SAB) cases per 100,00 bed days (0.26 per 1000 acute occupied bed days) or lower by year ending March 2013. For NHS Highland that means no more than 73 cases. National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate April - June 2012 was 30.2 per 100,000 acute occupied bed days (AOBDs). NHS Highland’s rate was also 30.2 per 100,000 AOBDs (19 SABs), 3 MRSA and 16 MSSA, (5 True Community, 3 Contaminated blood cultures and 11 acquired in the community or hospital, mainly due to invasive devices). This is an increase on the previous quarters, (January – March 2012 there were 15 SABs, October – December 16 SABs). Each SAB is reviewed in Microbiology and if it is felt that the SAB could have been avoided or prevented, then a clinical review meeting is held with the relevant clinical team which is responsible for ensuring that learning outcomes are disseminated to staff and that processes are in place to monitor practice. July - September 2012 (unvalidated data) there were 8 SABs, all MSSA, (1 True Community and 7 acquired in community or hospital) The annual rate (invalidated) for NHS Highland, October 2011 – September 2012 is 23.39 per 100, 000 AOBDs ( National target March 2013, 26 per 100,000 AOBDs)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at:

Staphylococcus aureus :

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252

NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

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MRSA Screening NHS Boards are required to ensure MRSA screening becomes part of their local integrated approach to improving the quality of person centred, safe and effective patient care. All Boards have received the final tranche of non recurring funding. Work is ongoing to minimise the financial risk when this funding ends. NHS Highland is one of 7 Boards taking part in a pilot to test the audit tool which will measure compliance with MRSA screening. A report will be submitted to the Board in six months time. Figure 1 shows year on year Cumulative SAB numbers in NHS Highland

TABLE 1 shows the cumulative totals for SAB within Argyll and Bute CHP for the years since 2009-2010: Hospitals 09/10 10/11 11/12 12/13 Lorn and Islands, Oban 8 3 0 5 Victoria Hospital, Rothesay 1 1 0 0 Mid Argyll Hospital, Lochgilphead 0 1 0 0 Argyll & Bute Hospital, Lochgilphead 0 0 0 0 Campbeltown Hospital 0 0 0 0 Dunaros, Mull 0 0 0 0 Islay Hospital, Bowmore 0 0 0 0 Cowal Community Hospital, Dunoon 0 0 0 0 There has been one further community acquired SAB case attributed to LIH, Oban since the last CHP Committee report in Argyll and Bute. This case has been subjected to enhanced surveillance and was not HAI related. This total of five cases for LIH in 2012-2013 all appear to have been community acquired, two of which may have been healthcare associated. Each case has been subject to microbiology review; there does not appear to have been anything to have prevented these cases.

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Clostridium difficile

Clostridium difficile Infection (CDI)

With effect from April 2011, all Boards are expected to achieve a rate of 39 cases of Clostridium difficile per 100,000 total occupied bed days (OCBDs), (0.39 cases per 1000 total occupied bed days) or lower among patients aged 65 and over by year ending March 2013. For NHS Highland that means no more than 86 cases.

National data published by Health Protection Scotland (HPS) identifies that the overall Clostridium difficile infection (CDI) rate for NHS Scotland during the period April – June 2012 in patients aged 65 and over was 30.8 cases per 100,000 total occupied bed days (OBDs). NHS Highland’s rate for the same period was 32.8 cases per 100,000 OCBDs. The annual rate (unvalidated) for NHS Highland, October 2011 – September 2012 is 32.15 cases per 100,000 bed days (National target March 2013, 39 cases per 100,000 OCBDs) which means the Board is on track to meet the National HEAT Target.

Figure 2 Cumulative Clostridium difficile positive episodes in NHS Highland Patients aged 65 and over

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at:

http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx

NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of Section 1 and for each hospital within the CHP in Section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

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Initiatives to reduce CDI Cases

• Continued promotion of good hand hygiene across all staff groups and general public including the introduction of mandatory, on line training module for multidisciplinary staff.

• An action plan is being worked through to improve the use of proton pump inhibitors • A review of the Antimicrobial Prescribing Guidance in the management of infection • Briefing sessions, facilitated by Microbiology Consultants from NHS GGC are being

held at locality level for medical staff • Ensuring plans are in place to maintain the fabric of the clinical areas.

Enhanced surveillance is carried out on every CDI case with immediate feedback to staff concerned. Surveillance includes 30-day follow up from diagnosis TABLE 2 shows the cumulative CD Toxin Positive Case s in each CHP Hospital for the years since 2009-2012

Hospitals 09/10 10/11 11/12 12/13

Lorn and Islands Hospital, Oban 0 1 2 1

Cowal Community Hospital, Dunoon 3 1 2 2

Victoria Hospital, Rothesay 3 0 1 0

Dunaros, Mull 0 1 0 0

Argyll & Bute Hospital, Lochgilphead 0 0 0 0

Mid Argyll Hospital, Lochgilphead 0 0 1 0

Campbeltown Hospital 0 0 1 1

Islay Hospital, Bowmore 0 0 0 0 TABLE 3 shows the cumulative CD Toxin Positive Case s in community for the years since 2009-2012

09/10 10/11 11/12 12/13

North CHP 10 1 5 1

Mid CHP 16 14 6 5

South East CHP 19 11 12 4

Argyll & Bute CHP 2 4 2 2

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Anti Microbial Prescribing National Report on Primary Care Antibiotic Prescribing Indicators Primary care prescribers across Highland continue to have low rates of antibiotic prescribing. Preferred antibiotics now account for more than 80% of prescriptions with the 4C’s antibiotic use falling from 19.9% in 2007/8 to 10.4% in 2011/12. NHS Highland is one of only two Boards in Scotland to achieve the prescribing indicator for reduced seasonal variation in prescribing of quinolone antibiotics. Prescribers in primary care have acted upon the best practice messages regularly provided by the Antimicrobial Management Team in conjunction with the GP sub-committee and the primary care prescribing advisors. Table 4 shows NHS Highland progress against the 3 national indicators. Antimicrobial Indicator NHS Highland progress

Hospital-based empirical prescribing In acute admission areas, antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in above 95% of sampled cases.

Compliant Two areas are monitored, as required, in Raigmore Hospital. Acute Medical Admissions Unit and Surgical Admissions Ward (4A), data for August and September shows compliance with guidelines above the target of 95%.

Surgical antibiotic prophylaxis Duration of surgical antibiotic prophylaxis is less than 24 hours and compliant with local antimicrobial prescribing policy in above 95% of sampled elective colorectal surgical cases.

Compliant. Data to the end of July 2012 shows continuing compliance above 95% with antibiotic choice and duration of prophylaxis. Further data collection is currently being undertaken. Data collection for urological surgery commenced in November 2012.

Primary care empirical prescribing Seasonal variation in Quinolone use (summer months vs. winter months) is less than 5%.

Compliant. Data to the end of March 2012 indicates continuing compliance with this measure. NHS Highland is one of only two Boards in Scotland to demonstrate compliance with this quality indicator for every year since it was first measured in 2008/09.

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Hand Hygiene

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 98% compliance for September and October 2012. Non compliance with hand hygiene requirements is unacceptable and all staff must comply with the NHS Highland Hand Hygiene Policy. Hand hygiene audits are undertaken monthly by all clinical areas and the results are displayed. Hand hygiene training is provided across NHS Highland and is also available via E-learning on LearnPro NHS, the uptake of which has been steadily increasing since its launch. All areas in Argyll and Bute continue to demonstrate compliance with the standards- the results for each hospital are included within the charts in section 2 of the report. Cleaning and the Healthcare Environment

Domestic Service teams continue to carry out monthly cleaning and estates audits as per NHS Scotland National Cleaning Services Specification. Compliance with cleaning and estates across NHS Highland was 96% in September and October 2012.

The new National Electronic Domestic Monitoring tool is currently being rolled out across Scotland. This tool is based on the National Monitoring Specification which determines the frequency of monitoring according to the national codes and applies dates for completion against the various areas to be monitored. There are still some anomalies in the system which are being worked on to ensure that it is fit for purpose in Highland where areas in all hospitals are monitored each month to ensure that deviations from compliance can be rectified and standards maintained.

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at:

http://www.washyourhandsofthem.com/

NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital and community hospitals within each CHP in section 2. Information on national hand hygiene monitoring can be found at:

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on national cleanliness compliance monitoring can be found at:

http://www.hfs.scot.nhs.uk/online-services/publications/hai/

Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at:

http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

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Hand Hygiene results for Argyll and Bute Hospitals are highlighted in the charts in Section 2 of this report.

Outbreaks/Incidents Norovirus Norovirus is prevalent in the community throughout Scotland. The outbreaks across Highland were recognised and brought under control quickly and effectively with all staff from ward to Board working in partnership. Staff in Lorn and Islands Hospital, Oban were commended on the prompt recognition and effective management of the outbreak. Key learning points have been shared with other areas. Strict infection control precautions are put in place which include restricting visiting to affected wards and asking people not to visit if they have had any vomiting or diarrhoea within the previous 48hrs. Staff movement into the affected wards is also restricted. These measures help to reduce the risk of infection spreading.

Table 5 Norovirus outbreaks in NHS Highland

October 2012, MacKinnon Memorial Hospital 5 Patients & 21 Staff

October 2012, Ward 2A Raigmore Hospital 15 Patients & 13 Staff

November 2012, Ward B Lorn & Islands

Hospital

4 Patients & 8 Staff

Decontamination The Central Decontamination Unit is CE Certificated with the Medicines and Healthcare products Regulatory Agency (MHRA) which is subject to the successful application of ISO 13485:2003, Quality Management System – Medical Devices and satisfactory surveillance auditing. Following a successful bid at the Asset Management Group the washer disinfectors will be replaced in early 2013. An option appraisal paper on delivering compliant endoscope decontamination facilities for NHS Highland was submitted to the Senior Management Team for consideration and was approved. A plan has been developed to enable a compliant endoscope decontamination facility to open on the Raigmore site initially with a staged approach throughout 2013 for the peripheral sites. The Head of Decontamination is now responsible for the training, assessment and audit of staff undertaking endoscope decontamination as well as the de-cluttering and improvements in housekeeping and record keeping in all existing endoscope decontamination units. Compliance within the Independent Dental Practitioner setting will be monitored as per the recent Chief Dental Officer (CDO) letter. The CDO has written to all independent GDP with the offer of providing compliant washer disinfectors. A recent audit of GDPs was undertaken and over 80% of units were compliant.

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A working group has been established to look at what needs to be done to enable all local decontamination in theatres to be halted by the end of 2014.

Inspection

HEI Inspections

An unannounced HEI visit was undertaken in Caithness General Hospital on 3rd & 4th September 2012. They found the hospital clean and well maintained, with evidence of good compliance with sharps and linen management and the use of personal protective equipment (PPE), up-to-date audit and surveillance data was displayed on the wards and they saw staff washing their hands and using the hand gel available. The final report contained 3 requirements and 6 recommendations. Further unannounced inspection took place in Raigmore Hospital on November 21st 2012. Initial feedback from the inspection indicates that actions since the last visit are being taken forward and there have been notable improvements. Final report will be published in January 2013. Work across Argyll and Bute CHP continues to ensure that all HAI standards are implemented and sustained in all settings. Programme of visits to all hospitals by the Executive Lead for Infection Control in NHS Highland, Heidi May, is underway. Visit to Cowal Community Hospital in November was very positive; further visits to MACHICC, Lochgilphead and Campbeltown Hospital will take place on December 17th and 18th. Task force, chaired by Director of Operations, established to address key issues within Argyll and Bute Hospital. Action plan is in place and fortnightly monitoring meetings organised to ensure that timescales are being met. Infection Control nurses are delivering sessions for staff to prepare them for the inspection process and to share good practice across the CHP.

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Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ which provide information on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections. Hand hygiene and cleaning compliance completes the report card. This includes information for pan Highland, Lorn and Islands Hospital, Oban, Community Hospitals collectively for Argyll and Bute and NHS Highland out of hospital infections. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics. Understanding the Report Cards – Infection Case Num bers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month and the community hospitals within each CHP. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website: Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4& articleID=2139&sectionID=1 Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1 For each acute hospital and community hospitals in the CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out-of-hospital” report card. Understanding the Report Cards – Hand Hygiene Compl iance Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/ Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/CHP report card presents the percentage of hand hygiene compliance for all staff in both graph and table form.

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Understanding the Report Cards – Cleaning Complianc e Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ The Report Cards show the hospitals’ cleaning compliance percentage in both graph and table form.

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Abbreviations

AMT Antimicrobial Prescribing Team

AMAU Acute Medical Admissions Unit

CHP Community Health Partnership

CDI Clostridium difficile Infection

CNO Chief Nursing Officer

CVC Central Venous Catheter

CSM Clinical Services Manager

ECDC European Centre for Disease Prevention & Control

GDP General Dental Practitioner

HAI Healthcare Associated Infection

HAIRT Healthcare Associated Infection Reporting Template

HEAT Health Improvement, Efficiency, Access, Treatment

HEI Healthcare Environment Inspectorate

Hemi arthroplasty An operation used to treat fractured hip similar to a total hip replacement, but involves only half of the hip.

ICU Intensive Care Unit

JAG Joint Advisory Group

MSSA Meticillin Sensitive Staphylococcus Aureus

MRSA Meticillin Resistant Staphylococcus Aureus

PICC Peripherally Inserted Central Catheter

PPI Proton Pump Inhibitor

PVC Peripheral Venous Catheter

QUAD Quality Assurance Document

RIDDOR Reporting of Injuries, Diseases and Dangerous Occupational Regulations 1995

SAB Staphylococcus aureus Bacteraemia

SCN Senior Charge Nurse

SHPN Scottish Health Planning note

SHTM 64 Scottish Health Technical Memoranda – Sanitary assemblies.

SPC Statistical Process Chart

SAPG Scottish Antimicrobial Prescribing Group

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SICPs Standard Infection Control Precautions

SPSP Scottish Patient Safety Programme

VAP Ventilator Associated Pneumonia

Staphylococcus Aureus Bacteraemia (SAB) criteria

Contaminated blood culture

• Staphylococcus aureus isolated from blood, and • SAB diagnosis incompatible with clinical picture, i.e. no or minimal

clinical signs and symptoms indicating SAB.

Hospital acquired infection

• Staphylococcus aureus isolated from blood cultures taken 48 hours after admission or within 48 hours of discharge, and,

• The presence of clinical signs and symptoms indicating SAB

Community onset-healthcare associated infection

• Staphylococcus aureus isolated from blood cultures taken <48 hours after admission, and

• The presence of clinical signs and symptoms indicating SAB, and • At least one of the following within the past 12 months:

o Hospitalisation or invasive device management as an outpatient / community patient, or dialysis as an outpatient / community patient.

True community infection

• Staphylococcus aureus isolated from blood, and • No hospitalisation within the past 12 months • No dialysis within the past 12 months • No community or outpatient healthcare for invasive device

management in the past 12 months

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Argyll & Bute CHP Committee Date of meeting: 19 December 2012

Item No : 8.1

FINANCE REPORT REPORT BY GEORGE MORRISON The Committee is asked to: • Note the financial position at month 8 1. Argyll & Bute CHP - Financial Position at Mont h 8 For the eight months ended 30 November 2012, Argyll & Bute CHP recorded an underspend of £197,000. This is a significant improvement on the previous month as it represents a favourable movement of £156,000 on the underspend of £41,000 recorded at the end of October.

Table 1 below provides a summary of budgetary performance across Argyll & Bute CHP for the eight months ended 30 November 2012.

Table 1: Budget analysis for the 8 months ended 30 November 2012 Year to Date

Budget

Annual Budget

£'000 Budget

£'000 Actual

£'000 Variance

£'000 Oban, Lorn & Isles Locality 18,419 12,185 12,298 (113) Mid Argyll, Kintyre & Islay Locality 16,560 10,985 10,974 11 Mental Health In-Patient Services 7,660 4,982 4,982 0 Cowal & Bute Locality 12,686 8,395 8,449 (54) Helensburgh & Lomond Locality 4,965 3,201 3,163 38 Other Clinical Services 4,847 2,897 2,922 (25) General Medical Services 15,298 9,983 10,045 (62) Prescribing 17,299 11,251 10,781 470 Dental, Opthalmic & Pharmacy 12,471 7,862 7,862 0 Services from NHS GG&C 47,060 31,272 31,272 0 Commissioned Services 3,879 2,595 2,652 (57) Resource Transfer 4,538 3,026 3,026 0 Depreciation 3,303 2,192 2,185 7 Management & Corporate 8,817 4,996 5,008 (12) Budget Reserves 296 0 0 0 Total Expenditure 178,098 115,822 115,619 203 Income (1,304) (943) (937) (6) Net Budget Position 176,794 114,879 114,682 197

The main reason for the CHP’s favourable financial position is the performance of the prescribing budget. With falling prices relating to off-patent drugs, a significant underspend is developing on this budget and, as at month 8, the cumulative underspend on prescribing has reached £470k.

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Table 2 below demonstrates the impact of falling prices on four drugs which have come off patent.

Table 2: Monthly Spending on Selected Drugs

Drug

Average Monthly Cost in 2011/12

£

Monthly Cost in August 2012

£ Reduction

£ %

Quetiapine £28,259 £8,194 £20,065 71%

Donepezil £9,649 £2,058 £7,591 79%

Olanzapine £13,575 £2,438 £11,137 82%

Atorvastatin £83,579 £10,359 £73,220 88%

£135,062 £23,049 £112,013 83% For each of these drugs, volumes prescribed have remained fairly static however prices have dropped significantly creating an underspend on the prescribing budget. As can be seen from the table above, the cost reduction on these selected four drugs in August was £112,000. Across the CHP a limited number of cost pressures are being experienced. The most significant are; - Medical locum cover for vacancies in Dunoon, £173k overspent. - Medical locum cover for vacancies in Lorn & Islands Hospital, £70k overspent. - GMS budget overspend due mainly to locum cover for GP vacancies in Bowmore, Jura and Inverary, £62k overspent. - An overspend on commissioned services relating to increased patient referrals to Raigmore & Belford Hospitals, which are internally cross-charged on a cost per case basis, and also new individual care packages, £57 overspent. - Increased drugs costs at Lorn & Islands Hospital, £65k overspent. - An overspend on hospital and community nursing pay costs on Bute, £49k overspent. - An overspend on domestic services pay costs on Bute, £17k (9%) overspent.

Overall, the benefit from reduced prescribing costs and other budget underspends is more than offsetting the cost pressures noted above.

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2. NHS Greater Glasgow & Clyde SLA Agreement has been reached with NHS Greater Glasgow & Clyde on an SLA value for 2012/13. The agreed value is based on last year’s SLA plus a 1% uplift for inflation and a further £500,000 in respect of activity growth. In total, the SLA for 2012/13 has been agreed at £44.927m which is in line with our budget. However, it is important to emphasise that despite agreement on a value for this year, the issue of our claimed underpayment to NHS Greater Glasgow & Clyde remains unresolved and I expect another round of tough negotiations in 2013/14. 3. Cost Improvement Programme 2012/13

The CHP approved budget for 2012/13 contained a requirement to achieve savings of £5m. Several of these savings will arise naturally e.g. prescribing drugs coming off-patent, restricted uplift to SLA values etc, however a balance of £1.56m requires to be delivered through management action.

Table 2 below identifies recurring targets by budget manager, sums declared achieved to date, forecast achievements based on current information, and likely shortfalls.

Table 3: Argyll & Bute CHP Cost Improvement Program me 2012/13

Recurring Savings Targets Responsible Manager

Target £ ' 000

Achieved £' 000

Outstanding £ '000

Forecast £ ’000

Shortfall £’ 000

Oban, Lorn & Isles V Kennedy 461 258 203 331 130 Mid Argyll, Kintyre & Islay C West 348 272 76 300 48 Cowal & Bute V Smith 290 263 27 290 0 Helensburgh & Lomond V Smith 102 102 0 102 0 Unfunded Displaced Staff D Leslie 138 73 65 73 65 Pharmacy F Thomson 38 38 0 38 0 E-Health J Brass 35 35 0 35 0 Lead Nurse P Tyrell 32 5 27 5 27 Public Health E Garman 30 30 0 30 0 Human Resources D Logue 28 0 28 0 28 Practitioner Services J Robinson 19 0 19 0 19 Finance G Morrison 18 18 0 18 0 Procurement G Morrison 11 0 11 0 11 Planning S Whiston 10 10 0 10 0

Totals 1,560 1,104 456 1,232 328 Table 3 indicates that, based on current information, there is likely to be a shortfall of £328k against savings targets. Managers are being encouraged to take action to deliver on savings targets where a shortfall is being predicted, as failure to do so will result in a recurring deficit being carried forward into 2013/14.

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4. Forecast Outturn for 2012/13 Overall, Argyll & Bute CHP is forecasting a year-end break-even position. It seems likely that the exceptional benefit arising from prescribing cost reductions will be sufficient to offset in-year cost pressures and any shortfall against savings targets. George Morrison Head of Finance Argyll & Bute CHP 13 December 2012

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Argyll & Bute CHP Committee Date of meeting: 19 December 2012

Item No : 9.1

MINUTE OF MEETING OF THE

ARGYLL & BUTE CHP PARTNERSHIP FORUM 15 November 2012 Boardroom, Aros

Lochgilphead

Present: Derek Leslie, CHP Director of Operations (Co-Chair) Moira Newiss, CHP Business Transformation Liz McMillan, Unison (Co-Chair) (VC) Lorraine Paterson, CSM Cowal (VC) Dawn Gillies, Unison (Co-Chair) (VC) David Logue, Head of HR Alastair Craig, Senior Management Accountant Lorna Low, RCM Veronica Kennedy, Acting Locality Manager, OLI Betty Cowan, RCN Fiona Broderick, Unite Douglas Niven, Unison Pat Tyrrell, CHP Lead Nurse In attendance: Ann Williamson – Clinical Nurse Lead, Nurse and Midwifery Bank (VC) Jackie Dickson – Minute Taker Apologies : Christina West, Locality Manager, MAKI Craig McNally, Unison John Dreghorn, Modernisation Project Director Helen Duthie, Unison Linda Skrastin, CSM Helensburgh 1. Chairperson’s Welcome, Introduction & Apologies

Derek Leslie as Chair welcomed all to the meeting. Attendees and apologies were noted.

2. Minute from previous meeting – 23 Aug 2012

Item 12 Pool Car Drivers – correction – “The 21 years of age applies to larger vehicles, including ‘people carriers’, vans etc. and not to pool cars. The only restriction of this nature, currently applied to standard pool cars (Clio’s etc), is that the driver should have held a full driving licence for one year i.e. no stated age restriction.” Additionally under this item the minute should have reflected that the question of drivers with international licences should also be addressed.

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3. Matters Arising

3.1 Cessation & Implementation of Long Shifts Pat Tyrrell clarified that there are two separate policies being referred to under this agenda item; the 24 Hour Rotational Policy (concerned with those staff on permanent night shifts attending day time shifts for CPD training and development) and the second is the Cessation and Implementation of Long Shifts Policy. Both are still in draft. The 24 Hour Rotational Policy is out for consultation and going to the next HR Sub Group and the Cessation and Implementation of Long Shifts Policy is not yet agreed. Heidi May is currently in discussion on payment for minimum breaks. Liz McMillan raised the inconsistencies in application of the Long Shifts Policy in LIH; Veronica Kennedy is aware of the issues and is waiting for what is currently only guidance to be ratified as when this becomes policy it should resolve the issues.

Action: David Logue to flag up both at the next HR Sub Group meeting

3.2 Nurse Bank Ann Williamson confirmed that although shifts are still being filled locally as opposed to through the Bank there is some progress in this regard but there does remain an issue with locally filled shifts being notified to the bank retrospectively. Ann would encourage all requests to fill shifts are made via the Bank web system and calls should be made to the Bank if there is less than 24 hr notice. If local arrangements are made let the Bank know immediately to ensure that there is a reference for payment, the staff member is able to work in relation to the working time directive, registration is up to date etc. Ann reported that the telephony is being upgraded and in a couple of weeks all calls to and from the Bank will be recorded. Additionally they are working on the issue of annual leave, both the payment for and the taking of, and awaiting approval to carry forward the last quarter to the first quarter of the new financial year. Veronica Kennedy expressed concern on two fronts. Firstly as no prompts have been given to Bank staff regarding taking annual leave in the next 3 month period, annual leave may have been building and this could result in a high level of annual leave requests which in turn could cause problems filling shifts. Secondly this could impact adversely on the financial picture which is already not as accurate as it might be since the introduction of timesheets going straight from the Bank staff to Highland. Alastair concurred that there does not seem to be accurate allocation of payments and is concerned that not all payments have been processed accurately. This in turn could bring pressure on budgets that is currently not identified. Ann offered to check any discrepancies and reported these can arise for a number of reasons e.g. some bank staff have as many as five pay codes. Work is being done to resolve this by Paul Simmons and Sally Munro in relation to work on eKSF and multiple codes have not been allocated since June 2012. Derek Leslie noted that this will have a favourable impact on eKSF. Liz McMillan asked about staff who have not worked in 3 months being terminated from the Bank, Ann assured that although letters went out asking for a response, where there was no response

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each case is investigated and no one has been unilaterally terminated from the bank. Liz also asked about equal distribution of shifts and Ann confirmed they are looking at this to establish whether this is through local booking or where the Bank have filled shifts, whether all staff are responding to texts. Pat pointed out the difficulty faced in coordinating what is in effect an imperfect system and that A&B representatives should make every effort to participate in the Staff Bank Operational Group meetings and that it would be useful for the PF to receive the minutes from this group. A number of examples were cited where the Bank have approached staff to take shifts in areas which they had not specified they could cover. Given the continuing difficulties around the Bank filling shifts at short notice, the concerns around allocation of costs for shifts and management of annual leave, it was recognised that staff and managers in A&B lack confidence in the Bank system. Action: David Logue to contact Adam Palmer to agree an A&B staff side representative to attend Staff Bank Operational Group and to email localities for details of issues with the Bank and thereafter to formally submit a note of same to the Staff Bank Operational Group for their formal response. Pat Tyrrell to make Ann Williamson aware of our intentions

3.3 Update on Admin Reviews Dawn Gillies reported that the review has now started in Cowal & Bute. Derek Leslie confirmed the review has been concluded in Aros and that the Reception post is now being advertised. Moira confirmed that the generic job descriptions are now back and have been graded to 2, 3 & 4 as anticipated. Fiona Broderick confirmed that in the Mental Health team there are three members of staff displaced and in the process of being matched. This should be concluded in December 2012. Moira Newiss reported that the survey of Admin staff in relation to time saved with new procedures is providing good supporting evidence. Dawn made the point again that she feels an opportunity is being missed to address anomalies across the CHP e.g. medical secretaries’ grades, as part of this review.

3.4 Staff Survey Carried forward in Sally Munro’s absence

3.5 Staff Health & Wellbeing Plan Alison McGrory was not in attendance and asked the PF to note that work in this respect is in hand and that she will provide a report at the next PF. Action: Alison McGrory to bring an update to the next PF

3.6 Cook Freeze Carried forward in John Dreghorn’s absence

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3.7 Pool Car Drivers

David Logue reported that he had not managed to get this onto the recent HR Sub Group agenda but will take it to the next meeting. Meanwhile the existing arrangements should continue until clarification is obtained as to what NHS Highland’s policy is in this regard.

4. Finance Update

Alastair Craig spoke to the circulated paper. An improving picture as we benefit from a reduction in prescribing costs; the volume is the same but as drugs come off- patent, the costs reduce. The forecast is to break-even at year end, dependant on Managers delivering their savings targets and continuing to exercise control over emerging cost pressures. Alastair reported that the Month 7 figures are now available and there is an under spend of £41,000 as we continue to benefit from the reduction in prescribing costs. Derek Leslie cautioned that although the reducing cost of prescribing offers more confidence in a break-even at year end and offers some relief of pressure to Localities from recalibrated savings plans, care must be taken as to how we manage this underspend to ensure that we are in a position to handle any unexpected cost pressures that might arise before year-end.

5. Quality Improvement Update

Moira Newiss spoke to the circulated paper outlining the how the CHP will take forward the Quality Improvement Agenda. Moira will lead on non-clinical quality and Pat Tyrell will lead on clinical quality. Charters for key projects are being developed; these identify the project lead, scope, and problem to be addressed, the goal, benefits and performance and process measures. Reporting will be quarterly through the Core Team, two minutes for each charter and seven minutes focus given to one charter. The importance of winning staff hearts and minds to the Highland Quality System was recognised and that to this end we should celebrate success more e.g. LIH’s success with avoidable hospital deaths, LIH have achieved a 24% reduction against a national figure of 15%. Derek suggested bringing a paper on the Change Fund (Reshaping Care for Older People) to the PF; this is a programme to address the issues around bringing services and staff from different working cultures together e.g. hospitals and community services, Local Authority, Independent Providers and Voluntary sector Action: Moira Newiss to take to the Core Team and CHP Management Team the HQA and winning hearts and minds of all involved

6. Mental Health Modernisation Update

Derek Leslie spoke to the circulated paper. In particular it was noted that Tigh na Linne will close 10 December 2012

7. Highland Partnership Forum

David Logue reported that there is an exercise ongoing to update the list of staff representatives across Highland. Liz McMillan reported that there was discussion around dress code; in particular physiotherapists wishing to wear trainers whilst working in the Gym, this has been referred to the Board Nurse

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Director. Also Liz reported discussion around the integration of council and health staff e.g. eKSF, training records, access to endowments for Xmas lunch

8. Workforce Planning 8.1 eKSF

David Logue confirmed that the position is improving; 16.2% of staff have had reviews completed (22% if Bank excluded), this is ahead of the overall Highland figure of 14%.

8.2 HCSW

Carried forward in Sally Munro’s absence 9. NMAHP HCSW Policy & SVQ Implementation Plan

Pat Tyrrell confirmed that the short life working group have identified the work to be done and will present the plan to the Core Team and CHP Management Team in December 2012. Liz McMillan advised the PF that according to Muriel McNab running an SVQ programme in house is one tenth of the cost of using an external provider.

Action: Pat Tyrrell to bring the plan to the CHP Management Team and Core Team meetings in Dec 2012.

10. Arrangements for AfC Staff who undertake On cal l duties

Lorna Lowe asked two questions in relation to the circular outlining changes to the on call arrangements; the first question was that given the requirement for those on protected salary to take payment at 1.5 times rather than TOIL, has it been recognised that there is potentially a cost associated with implementation of these changes . The second question related to compensatory rest time, does Highland have a view as the circular refer to AfC Terms and Conditions which is open to interpretation. David confirmed that the effective date for changes is 01 October 2012 to be in place by end of January 2013 and that in relation to the first question, the costs may not have been identified. David Logue will raise this with the short life working group set up to deal with implementation of these changes but did make the point that protection is on a stand still basis, so frozen at the value it is when you get protection. As regards the second question David confirmed that he believed that there was work being done at a national level in this regard from which there will be guidance issued. NHS Highland will delay any formal policy in this regard until that guidance is available. Dawn Gillies raised the question of impact on the On call Radiography Service which is covered by Bank staff and will now require to be covered by locum or agency staff as such these changes are to the detriment of Bank staff. David confirmed this will be picked up in the ongoing review of that service and that all managers will be asked to complete forms identifying current arrangements so that all affected areas are identified. Action: David Logue to raise the costs aspect with the short life working group

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11. Organisational Change Update 11.1 Mental Health & MAKI

The paper was noted. 11.2 Lorn and Islands

Veronica Kennedy spoke to the circulated paper

11.3 Helensburgh, Lomond, Cowal & Bute Lorraine Paterson spoke to the circulated paper 12. AOCB

Fiona Broderick raised the matter of on line training and that this is not suitable for all staff. It was recognised that not all staff have IT skills, access to PCs or time allocated to access PCs. Action: David Logue to follow up with Sally Munro what is being done for those staff who are not in a position to undertake training on line Liz McMillan, on behalf of Helen Duthie, raised the subject of staff titles. The national guidance is Snr Charge Nurse, Snr Staff Nurse and Staff Nurse but other titles are being used including enrolled nurse titles. Action: Pat Tyrrell to clarify titled to be used with Locality Managers and CSMs Liz McMillan reported that staff side are not always being asked for availability ahead of meeting dates being set. Action: Derek Leslie to reaffirm the need for this to happen David Logue reported that an Electronic Employee Support System (eEss) is being rolled out across Highland and will be in place 01 April 2013. This employee database will allow employees to access their own records e.g. sick leave, annual leave etc. Line Managers will also have access. to relevant records of their own staff. HR staff are to receive training in December 2012. Employees will need an email address for access which again raised the issue of staff who do not have IT skills, access to PCs or time allocated for access to PCs. It was recognised as more and more information is circulated, held and required electronically there should be a consistent and positive approach by managers to address and resolve issues of skill access etc. with affected staff. Action: David Logue to provide an update at the next PF and a presentation thereafter Derek Leslie confirmed that although there has been an opening discussion with A&B Council regarding embedding the Health & Social Care Partnership,

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no decisions have been made. There are a number of models the CHP could adopt but any progression will be with full staff consultation.

13. Date, time & venue of next meeting

10 January 2013, 12:30 Aros Boardroom 21 Feb 2013, 12:30 MACHICC J05/J07 04 Apr 2013, 12:30 MACHICC J05/J07 16 May 2013, 12:30 MACHICC J05/J07 04 Jul 2013, 12:30 Aros Boardroom 15 Aug 2013, 12:30 Aros Boardroom 03 Oct 2013, 12:30 Aros Boardroom 14 Nov 2013, 12:30 Aros Boardroom

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Argyll & Bute CHP Committee Date of meeting: 19 December 2012

Item No : 9.2

PDP/R AND e-KSF IMPLEMENTATION 2012/13 1. BACKGROUND AND SUMMARY The CHP continues to work to achieve the NHS Highland target for 2012/13 that ALL Agenda for Change staff will be reviewed against a KSF post outline, with at least 80% of reviews being carried out and recorded online using e-KSF (a review to be completed for each post held) The inclusion of bank staff continues to pose a considerable challenge, many do not yet have an NHS.net e-mail address or an assigned manager and KSF outline for the post. Also there are a large proportion of bank staff with multiple contracts. Work to address these issues is continuing with the e-KSF team and managers to ensure that bank staff are engaged with and participate in the review process 2. TARGETS 2012/13 The CHP trajectory for 2012/13 and a comparison with actual performance are shown in Appendix 1. The figures continue to be below planned trajectory, but have significantly improved, reflecting the expected pattern of more reviews being carried in the latter half of the year. This increased level of activity needs to be sustained, and accelerated to ensure achievement of the end of year target. The e-KSF lead will meet again with Locality Managers to discuss the figures and particular issues in their area to review progress and address any outstanding issues.or difficulties 3. MONITORING PROGRESS The position across NHS Highland at 30 November is as follows (figures in brackets are those last reported to CHP Committee – 30 September 2012): Area All AfC

staff Review signed

off % of AfC staff

(all) % of AfC staff

(excl bank) Argyll and Bute CHP 2071 165(225) 24.14(10.86) 32.72(14.82) Corporate Services 401 73(64) 18.2(15.96) 18.53(16.24) Mid Highland 485 72(21) 14.84(4.36) 21.62(6.34) North Highland 1001 145(70) 14.49(7.06) 20.92(10.01) Operational Support Services

310 18(16) 5.81(5.28) 5.90(5.37)

Raigmore Hospital 3242 558(214) 17.21(6.77) 22.06(8.55) South Highland 747 117(32) 15.66(4.29) 20.28(5.48) Note : Extract from e-KSF 30-11-12 A&B CHP overall has currently 24.14% of all staff that have had reviews and personal development plans signed off in e-KSF.( see Appendix 2)The total percentage for NHS Highland is 17.06% (22.07% excl bank posts), therefore Argyll and Bute CHP is performing at a higher level than all other units in NHS Highland. . 4. ACTIONS FOR 2012/13

The CHP Committee is asked to: • Note the current progress against trajectory • Note the actions being undertaken to monitor and achieve progress against

trajectory.

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2 Sally Munro Workforce Development Facilitator 10 December 2012

There are still significant numbers of staff who do not have one or more of the following: named manager, e-mail address, no KSF outline or no review. Specific actions are being undertaken to address this.

5. DEVELOPMENT BENEFITS OF KSF E-KSF can be used to support redesign and service improvement processes by using the KSF outlines to support staff in changing roles, and identifying differences in knowledge and skills required. Staff receiving regular development reviews and agreeing personal development plans will support quality, service improvement and clinical governance. 6 CONTRIBUTION TO BOARD OBJECTIVES The achievement of the target is in line with the NHS Highland Board objectives. 7 GOVERNANCE IMPLICATIONS Staff Governance KSF and e-KSF are vital components of meeting Staff Governance standards. Patient focus and public involvement The KSF process enables performance management to assist with improved patient focus and public involvement where appropriate for roles. Clinical Governance KSF process provides the opportunity to monitor development activities of staff including clinical skills and ensures that staff develop and apply the appropriate knowledge and skills in order to be effective in their work. Financial Governance This is part of normal management processes. In addition, workforce costs are a large proportion of the allocated budget. KSF PDP/R and e-KSF support the effective use of staff, in particular through service change and redesign. 8. IMPACT ASSESSMENT The KSF and e-KSF processes are impact assessed at National level. David Logue Head of HR Argyll and Bute CHP December 2012

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e-KSF Reviews Report by Operational Unit For Period 01/04/2012 - 31/03/2013

e-KSF Reviews 30th November 2012

Total Posts1

NHS Highland 10068 568 5.64% 5645 56.07% 1815 18.03% 322 3.20% 1718 17.06% 22.07% 3855 38.29%A&B Mental Health Services 207 11 5.31% 108 52.17% 9 4.35% 5 2.42% 74 35.75% 88 42.51%

Argyll & Bute Central Services 134 8 5.97% 74 55.22% 15 11.19% 7 5.22% 30 22.39% 23.08% 52 38.81%Cowal and Bute Area 391 15 3.84% 166 42.46% 64 16.37% 24 6.14% 122 31.20% 38.85% 210 53.71%

Dental Service (Argyll & Bute) 93 21 22.58% 26 27.96% 13 13.98% 3 3.23% 30 32.26% 42.86% 46 49.46%Helensburgh and Lomond Area 85 5 5.88% 38 44.71% 9 10.59% 3 3.53% 30 35.29% 37.97% 42 49.41%

Mid Argyll Kintyre & Islay 583 44 7.55% 293 50.26% 107 18.35% 24 4.12% 115 19.73% 34.64% 246 42.20%Oban Lorn & Isles Area 578 61 10.55% 322 55.71% 91 15.74% 5 0.87% 99 17.13% 25.00% 195 33.74%

Argyll and Bute CHP 2071 165 7.97% 1027 49.59% 308 14.87% 71 3.43% 500 24.14% 32.72% 879 42.44%

Notes1. From e-KSF

Current position if Bank Posts are removed from 'Total Posts' - data from Workforce Information Staff List

Reviews at all stages1Reviews 'Started'1Reviews 'Completed & Not Signed Off'1

Reviews 'Completed & Signed Off'1

No Post Outline No Review

Page 1 of 1 05/12/2012

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 9.2a

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Argyll Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 9.2b

Argyll and Bute CHP Appendix 1Trajectory for e-KSF 2012-13 30/11/2012

2012/13 Profiled trajectory - all staff

Month End

No of reviews required

this month 2012/13

No of reviews required -

cumulative 2012/13

% Trajectory 2012/13

Actual % 2012/13 No of staff 2012-13(all) 2071

April 55 55 3 2.5 Target 80% all 1657May 110 165 8 3.84 Even spread(Dec-March) 414 per monthJune 120 285 14 4.71July 125 410 20 5.87August 130 540 26 7.56September 140 680 33 10.86October 145 825 40 16.23November 150 975 47 24.14December 155 1130 55January 160 1290 62February 165 1455 70March 180 1635 80

A&B CHP e-KSF trajectory 2012/13 compared to Actual

0102030405060708090

100

April May Jun July Aug Sep Oct Nov Dec Jan Feb Mar

Month

% R

evie

ws

% Trajectory 2012/13

Actual % 2012/13

Prepared by sally.munro 12/12/2012

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Argyll and Bute CHP Committee Date of Meeting : 19 December 2012

Agenda item : 10 Public Health Annual Report 2012 Report by Dr. Margaret Somerville, Director of Public Health and Health Policy Presented by Elaine C Garman, Public Health Specialist The Board is asked to: • Note and discuss the content and recommendations of the report

1 Background and Summary

The theme of this year’s annual report is the health and well-being of older people. This paper contains the report summary and recommendations; the full report is on the NHS Highland website and hard copies will be available at the meeting. http://www.nhshighland.scot.nhs.uk/Meetings/BoardsMeetings/Documents/Board%20Meeting%202%20October%202012/4.4%20DPH%20Annual%20Report-APP.pdf 2 Improving the health and well-being of older people

2.1 Summary We live in a society with an increasing proportion of older people; this success in improving life expectancy is the result of both improvements in health care and changes in the wider environment. The great majority of older people live independently and actively and we must encourage this trend to continue. However, with this increase, and particularly the rapidly increasing numbers of very elderly people, does come an increasing prevalence of long-term conditions (LTC). Many of those aged over 75 years have two or more LTC, but having a LTC does not necessarily prevent people from leading full and active lives. Older people themselves have highlighted that being busy, getting out and about, social activities and networks, housing, safe neighbourhoods and financial security are as important as health and individual lifestyle factors to their sense of wellbeing. Services and staff need to recognise this and support older people to lead the lives they want to as far as possible. In contrast to this observation, around 70% of hospital beds in Highland are occupied by people aged over 65 years. Hospital admissions for older adults are falling slightly; the fall is most marked in elective admissions for the very elderly, as day case rates increase. Emergency admissions have also fallen slightly over the last ten years with a reduction in length of stay. While these changes may not appear marked, in the context of the increasing numbers of older adults, particularly the very elderly, they represent very substantial changes to the way in which we manage older people with both acute and chronic health problems. Nevertheless, further changes are needed if we are to continue the trend in managing older people at home rather than in hospitals or other institutions. This report focuses on two conditions that are major causes of older people requiring health care: falls resulting in fractures and chronic obstructive pulmonary disease (COPD). Deaths from COPD have not reduced overall in Highland over the last 15 years and falls resulting in fractures, particularly hip fractures in older women, are higher than the Scottish average. Hip fractures are a major cause of loss of independence and reduced quality of life. Dementia is frequently present in those who are admitted to hospital with other conditions; its presence

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leads to challenges in managing older people who are less able to cope with unfamiliar surroundings or participate in planning for their care needs. There is good evidence supporting some interventions to prevent falls and reduce hospital admissions. It is important we focus on their implementation in health care and community settings, as well as ensuring our health improvement programmes, such as promoting physical activity, smoking cessation, alcohol brief interventions and weight management, take older people’s needs and preferences specifically into account. Encouraging communities to involve older people in their activities is also essential to promoting community resilience and well-being. 2.2 Recommendations The report makes a number of recommendations for NHS Highland to include or consider as it is developing its strategic commissioning plan for older people over the next year. These recommendations include recognising and managing frailty in older people, tailoring health improvement interventions for older people’s circumstances, extending anticipatory care planning and developing appropriate indicators to monitor performance and outcomes for older people. Communities and voluntary organisations can also do much to include older people within their activities and developments and older people themselves have a great deal to contribute.

3 Contribution to Board Objectives The report contains recommendations to improve preventive care and service delivery for older people, particularly through the strategic commissioning plan, and contributes to Better Health, Better Care and Better Value 4 Governance Implications

• Staff Governance: the report calls for changes in attitudes and behaviour to older people, particularly those with dementia, which may have training and customer care implications for staff

• Patient and Public Involvement: the report should ideally be widely discussed with patients and the public to ensure full implementation of its recommendations

• Clinical Governance: the report calls for a holistic approach to frail older people and to providing end of life care, which may have implications for care pathways and clinical governance

• Financial Impact: the report contains no specific resource requirements, but does support interventions aimed at reducing use of hospital-based health care which may result in cost savings

5 Risk Assessment

The report makes recommendations on improving the health and well-being of older people through actions by the NHS and others. Risk assessment may be needed as and when the recommendations are incorporated into the strategic commissioning plan. 6 Planning for Fairness

The report makes recommendations on improving the health and well-being of older people through actions by the NHS and others. Impact assessment on the report itself is not

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appropriate but will need to be considered as and when the recommendations are implemented.

7 Engagement and Communication The report has been prepared by members of the public health department with input from key stakeholders. One purpose of the report is to provide a focus for extensive engagement and discussion about the health of older people within the NHS, with Councils, the voluntary sector and the public. Opportunities to present it at Council and CHP/HSCP meetings are being arranged. The report is available on the NHS Highland website for widespread discussion. Margaret Somerville Director of Public Health September 2012

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Management structure review version 1.5. 051212

Argyll & Bute CHP Committee Date of Meeting: 19th December 2012

Item No12 Review of Management Infrastructure - Helensburgh & Lomond/Cowal & Bute Locality Report by Viv Smith Locality Manager Cowal, Bute, Helensburgh & Lomond The CHP Committee is asked to:

• Consider and endorse the recommendation 1. Introduction This paper summarises the learning from the last years interim management arrangements for the Helensburgh, Lomond (H&L) and Cowal & Bute Localities’ and makes recommendations regards the redesign of the management and leadership structure and roles and responsibilities. This paper has been discussed and endorsed by the CHP Core Team at its meeting on the 23rd November 2012.

2. Background

With the retirement of the Helensburgh & Lomond Locality Manager, a transitional arrangement was been put in place, with several corporate leads taking on some of the posts previous areas of responsibility and the Cowal & Bute (C&B) Locality Manager taking on additional responsibility, covering operational and strategic management for the Helensburgh & Lomond Locality. The transitional arrangement has now come to an end. The Locality Manager tested out the feasibility of extending the existing portfolio of the Cowal and Bute post from August 2011 to Dec 2011. After this period the Locality Manager took an extended period of leave and acting up arrangements were put in place. This gave a further period of testing utilising the Cowal CSM and PDN roles from Jan to July 2012. 3. Findings Locality Management agree that based on the last years experience, the current management structure hinders our ability across the area (Cowal, Bute, Helensburgh & Lomond) to deliver our corporate and operational objectives and performance targets. Issues identified include:

• Clinical leadership and management capacity and capability • Issues relating to existing ways of working. • Inconsistent performance in terms of senior management areas of

responsibility and accountability. • Lack of personnel in the correct role and with the relevant competencies and

experience to address the above • Concerns over robust management of budgets • Concerns over consistent application of governance requirements

4. Discussion

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Management structure review version 1.5. 051212

This paper should be considered in the context of the requirement to reduce the number of senior managers within the NHS whilst improving the quality of services and reducing variation and waste. In addition, in terms of our governance requirements and accountability for delivering a consistently high standard of service and care we cannot ignore the expectation that we must do more with less. This requirement asks us to think hard in terms of how we can make best use of scarce senior management resources in a climate of significant change and challenge. Finally we must be cognisant of the national integration agenda that is starting to be examined between NHS and Local Authorities and ensure that we are in the best possible position organisationally, to aid the integration process. It is clear that the existing structure requires adapting in order to ensure the organisation can deliver on its responsibilities across the expanded area of Cowal, Bute, Helensburgh & Lomond. (East CHP Area) The existing Locality Manager job description and associated roles and responsibilities no longer reflect the organisational requirements of an expanded portfolio. The job description should be reviewed to address this; however there remains the outstanding issue of ensuring the next level of management and clinical leadership is considered and is in place to support this expanded role. With the retirement of the H&L CSM a temporary arrangement has been put in place by way of a secondment to give the organisation time to consider what changes are required. In H&L work is required on issues such as site management, governance, and robust systems of cover and reporting. In addition a comprehensive review of the large SLA component of services in this patch is needed. In Bute a risk has been identified in terms of limited clinical leadership and management capability and capacity. The current management structure across the extended area is reflected below. 5. Financial implications

If this proposal is approved the implications of the new structure would be examined. It is anticipated that the changes would be cost neutral but this would be dependent on the outcome of relevant job description and subsequent bandings..

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Management structure review version 1.5. 051212

Locality Manager

H&L + C&B

Hotel Services

Manager C&B

CSM Cowal

CSM

Helensburgh & Lomond

Domestic

Supervisor Bute

Domestic

Supervisor Cowal

Admin/

Med Recs Manager

C&B

Admin/Med Records

Team Leads 2 x Cowal

1 x Bute

Domestic

Supervisor Helensburgh/VOL

( SLA)

Cowal

2 x SCN’s 1 x ICT TL 1 x PH TL

Bute

1 x SCN 1 x CN TL

Helensburgh

1XICT TL 1 x PH TL

1 x Operations Manager

CSM Bute

PDN Cowal and

Bute

PDN Helensburgh & Lomond

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Management structure review version 1.5. 051212

5 Recommendation

Appoint:

• 1 Area Manager C,B, H&L

• 1 x CSM Cowal & Bute

• 1 x CSM Helensburgh & Lomond

• 1 x Clinical Lead/Quality Improvement Manager C,B, H&L

• 1 x Support Services Manager C,B,H&L

• 1 x Admin and Medical Records Managers C,B,H&L

• 1 X Public Health Team Lead C&B

• 1 X PH Team Lead H&L

• 1 X Extended Community Care Team ( ECCT) Lead H&L

• 1 X ECCT Lead Cowal

• 1 x ECCT Lead Bute

• 1 XMedical Records/Admin Team Lead H&L

• 1 X Support Services Team Lead Bute

• 1 X Support Services Team Lead Cowal

• 1 X Domestic Supervisor H&L (Terminate SLA)

This may require displacement of some posts.

If approved an Organisational Change Team would require to be formed under the NHS Highland Organisational Change Policy, to ensure governance arrangements are in place for any affected staff and the engagement process could begin. This should consist of a senior manager from outwith the area affected, senior HR manager, and staff side.

It is anticipated that the remaining CHP Localities MAKI and OLI will be examined in due course to ensure corporate congruence.

The proposed new structure is detailed below

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Management structure review version 1.5. 051212

Area Manager H&L+C&B

Support Services

Manager C&B +

H&L H&L + C&B

CSM C&B

Clinical Lead/Quality

Improvement Manager

H&L + C&B

Support Services

Team

Lead Bute

Support Services

Team

Lead Cowal

Admin/

Med Recs

Manager H&L + C&B

Admin/Med

Records Team

Leads x 4 2 x Cowal

1 x Bute 1 x Helensburgh

Domestic Supervisor

H&L

Cowal

2 x SCN’s

1 x PH TL C&B

1 x ECC TL

Bute

1 x SCN

1x ECC TL

H&L

1 x ECC TL

1 x PH TL

CSM H&L

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Management structure review version 1.5. 051212

6 Contribution to Board Objectives This paper responds to the Boards objectives of achieving Better Health Better Care & Better Value. Governance Implications This paper aligns with the CHP Corporate and Governance responsibility for effective resource utilisation and maximising care. Staff Governance There are implications for staff regards a change in role and involvement, engagement and communication will be required. Patient Focus and Public Involvement Public representatives who are members of the Localities 3 Joint Management Teams will be informed if approved. Clinical Governance Clinical governance will be enhanced through the redistribution of clinical leadership and operational management. Financial Impact To be determined. Likely to be cost neutral. Equality and Diversity This restructuring ensures an equity across the enlarged area of senior management and Clinical leadership for the East CHP.

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Argyll & Bute CHP Committee Date of Meeting: 19 December 2012

Agenda item: 13

1

Assessment of the Viability of a Hospital Dialysis Service in Argyll and Bute CHP Report by Stephen Whiston, Head of Planning Contrac ting and Performance

The CHP Committee is asked to: • Note the finding in May 2012 regarding the current and future profile of service delivery and

subsequent action • Consider the report findings of the viability assessment to establish a “local” hospital

dialysis service in LIH • Consider the CHP management team assessment of the findings • Consider and decide as to the need to progress a proposal to establish a local dialysis unit

serving the Oban Lorn and Isles and Mid Argyll, Kintyre and Islay catchment areas.

1 Introduction The purpose of this paper is to update the CHP Committee on the findings of the viability assessment conducted to provide a local dialysis unit in Oban. For members reference the conclusion of the previous report in May 2012 on local hospital dialysis unit stated. “It can be seen from this overview of the current and projected future demand for renal replacement therapy does not identify an appropriate geographic point within Argyll and Bute to establish a local service enhancing access to all residents The capital and running costs of a stand alone unit are significant and the level of likely activity would not result in an affordable or cost effective use of the service and staff even based on a normal dialysis cycle for patients of 2-3 days. The location of existing units in Glasgow (Vale, RAH and IRH) and the proximity of the Belford Hospital to North Argyll clearly offers greater access in terms of proximity for the adjacent Argyll and Bute localities. The CHP should therefore look to work with NHSGG&C & NHS Highland to plan for its future provision.” Following on from this the CHP Committee requested in October that the CHP look to examine the possibility of enhancing local access to hospital dialysis by establishing whether putting a unit in Lorn and Islands Hospital Oban could be viable. 2 Hospital Haemodialysis Service – Viability criter ia

In order to undertake this piece of work the following information and pieces of work were done to assess the viability of a service:

• Existing service demand and future projections of activity • Feedback from users and referrers on the current service include its operation and

accessibility • Clinical assessment on suitability of service and size of dialysis unit. • Identifying a site within LIH to locate the unit and any knock on impacts • Identifying the indicative capital cost to build and the indicative revenue cost to run a unit • Identifying sources of capital funding and their likely availability • Assessing the affordability and value for money of the service including

benchmarking to other units • Identifying any additional sources of activity and income

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2

• Considering alternatives - Capacity and demand profile in other units, alternative provision, mobile unit, flexible provision across units, transport implications- use of local air services

• Considering any other service implications e.g. transport, recruitment, training, Laboratory support, clinical governance etc

• CHP’s strategic view re prioritisation of service development • Indicative timescale- from decision to proceed to actual opening

This report is not a formal business case for presentation and approval, but a written report outlining the findings to establish if a viable unit could be provided in Oban. 3 Findings

The report has a number of key findings which include:

o A 4 station unit will meet the future projected demand of the catchment area, operating 3 days a week.

o Providing a unit in Oban would not necessarily provide equity of access to the catchment population it would serve.

o Significant patient benefits have been identified for having a local unit and there is also support from GPs

o The capital cost of the unit is significant and it is unlikely the NHS Board would be able to consider its expenditure until 2014/15 and it is therefore not affordable at this time

o Providing a local unit would result in significant savings in transport costs and cost incurred in sending patients to Belford and this could be reallocated to meet the running costs of a local unit

o Opportunities exist to align and coordinate renal staffing resource and support between the Belford and LIH if a unit is located in Oban

o The value for money assessment illustrates that the local unit would not rate well against other units.

o It would also be poorly utilised outside its core 3 day a week window. It does however offer opportunities to increase dialysis capacity in exceptional circumstances.

o Establishing a unit in Oban or Lochgilphead would increase the cost of the Belford unit and worsen its utilisation performance

o There are opportunities now to review existing transport arrangements and look to improve this service to patients and reduce cost.

4 Conclusion The CHP management team considered the report at its meeting on the 11th December 2012. The material key points from its deliberation are:

• A local unit would provide improved access to services but its location will clearly enhance and restrict access to the service for patients across the defined catchment area i.e. Oban, Lochgilphead and Campbeltown.

• The provision of a mobile unit on the face of it offers gains for patients, but there are a range of logistical and operational issues which do not suggest this is an elegant solution.

• The capital cost of a fixed unit s significant and there is not currently funding available for this. At the earliest if prioritized by the Board this would be April 2015.

• In revenue terms a local unit does not offer value for money. It is however affordable if the cost savings in transport and repatriation of activity can be made.

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3

• How important a priority is this for the CHP with regard to service provision? The top service priority issues facing the CHP and targeting its investment in services are:

o Mental Health modernisation o Reshaping Care for Older People o Sustaining our Community and Rural General Hospital core services re acute

care, trauma and Out of hours services There are high quality renal dialysis units which have the capacity and capability to support patient need at this time and into the future. In these terms a local unit is not necessary.

• There are issues regarding current transport arrangements whch could be improved and these should be reviewed and alternatves examined provide better quality of service and are more cost effective.

5 Contribution to Board Objectives This paper responds to the Boards objectives of achieving Better Health Better Care & Better Value. Governance Implications This paper aligns with the CHP corporate and Governance responsibility for effective resource utilisation and maximising care. Staff Governance There are development implications for staff re change and involvement and communication. Patient Focus and Public Involvement There is large public interest in this issue at present in the Oban and Taynuilt area. Survey of current users has revealed patients experience and preferences from those that returned. A proactive media and public communication approach will be required supporting the outcome of the CHP committee decesion. Clinical Governance Clinical risk and action to reduce the risk will require identification and mitigation and agreement through governance structures. Financial Impact The changes identified could have a significant impact on the recurring cost base of the CHP, but it must also be tempered by the possibility of needing to redeploy resources into new service models. There is also a significant capital resource requirement for a fixed unit, which would require Health Board priortisation and agreement to fund post April 2015. Equality and Diversity Planning for Fairness impact assessment would need to be conducted if the decision was to take forward the assessment into a business case proposal to identify how location and operation of a fixed or mobile unit would affect catchment populations.

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Viability Assessment Low Maintenance Dialysis Unit LIH 1 Dec 2012

Argyll & Bute Community Health Partnership (CHP)

VIABILITY ASSESSMENT REPORT

LOW MAINTENANCE DIALYSIS UNIT

LORN & ISLANDS HOSPITAL

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 2 Dec 2012

Author: Stephen Whiston Head of Planning, Contracting & Performance

CONTENTS PAGE:- 1. Introduction……………... ……………………………………… pg 3 1.1 Report Objectives ………………………………………….. pg 3 2 Strategic context ………………………………………………. pg 3 2.1 NHS Highland Service Strategy and Quality Approach …. pg 3 2.2 Existing service provision……………………………………. pg 5 2.3 Current Service Capacity ………………………………….. pg 6 2.4 NHS Highland and WoS RRT projections………….. pg 7 3 Clinical Assessment of Suitability of LMD………………… pg 8 4. Potential Site and Capital cost……………………………… pg 9 5 Revenue Costs & VFM & Affordability assessment……….. pg 9 6 Patient feedback …………………………..………………… pg 14 7. Patient Travel…….……………………………………… pg 16 8. GP referral pathways & assessment of existing

service………………….……………………………………… pg 16 9. Equality and Diversity Impact Assessment ………..… pg 18 10. Conclusion ……………….………………………………… pg 19 11 Appendices…………. ………………………………….… pg 20

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 3 Dec 2012

1. Introduction The purpose of this paper is to consider the viability of a Low Maintenance Dialysis (LMD) Unit to be based within Lorn and Islands Hospital, Oban. The kidneys are organs that primarily excrete waste from the body in the form of urine. Dialysis or transplantation removes the waste products from the body that build up when the kidneys fail in order to maintain life. If the kidney function is reduced to 15% of normal due to disease, patients experience established renal disease (ESRD). A person with ESRD will die within weeks or months unless they receive renal replacement therapy (dialysis or kidney transplantation). The numbers of patients requiring Renal Replacement Therapy (RRT) are relatively small. However, the chronic nature of their problems, the projected future increase in numbers, the effectiveness of RRT (without such treatment patients would die within six months of presentation) and the high cost of provision, make their needs an important consideration to inform planning for future heath needs. 1.1 Report Objectives The CHP committee has requested this report to provide the CHP management team and committee with a macro level assessment on what would make a viable unit, based on currently available information supplemented by user and stakeholder feedback on current service provision. The criteria identified to undertake this assessment:

• Existing service demand and future projections of activity • Feedback from users and referrers on the current service include its operation and

accessibility • Clinical assessment on suitability of service and size of dialysis unit. • Identifying a site within LIH to locate the unit and any knock on impacts • Identifying the indicative capital cost to build and the indicative revenue cost to run a

unit • Identifying sources of capital funding and their likely availability • Assessing the affordability and value for money of the service including

benchmarking to other units • Identifying any additional sources of activity and income • Considering alternatives - Capacity and demand profile in other units, mobile

provision and its implications, transport - use of local air services • Considering any other service implications e.g. transport, recruitment, training,

Laboratory support, clinical governance etc • NHS Highland and Argyll and Bute CHP’s strategic view re prioritisation of service

development • Indicative timescale- from decision to proceed to actual opening

2 Strategic Context : The paper takes account of the following strategies:- The Renal National Service Framework (RNSF) was launched in England in January 2004. This sets out standards of care in dialysis and transplantation for the next ten years. The RNSF aims to improve patient choice in their treatment and make services more widely available closer to their homes.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 4 Dec 2012

5

In line with the Delivering for Health ethos, patients should be at the centre of the delivery of responsive care and treatments and services should be convenient, delivered more quickly, as locally as possible and as specialised as necessary The Cross Party Working Group (CPWG) for renal disease in Scotland document “A strategy for future management of renal disease in Scotland” recommends that renal units run to a maximum capacity of only 80% in order that units can accommodate patients with acute renal failure, patients who have failed temporarily on peritoneal dialysis and holiday dialysis patients. The paper also considers the NHS Quality Improvement Scotland target that NHS Boards should provide hospital dialysis within 30 minutes of all patients’ homes, allowing for the constraints of population density and geography. An assessment of dialysis travel times for current and future renal patients has been carried out to inform this paper. Drive time from current locations of existing provision is illustrated in the map below.

Map 1: Drive time zones from Renal Units

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 5 Dec 2012

2.1 NHS Highland Service Strategy and Quality Approach In undertaking an assessment of the viability of providing a Low Maintenance Dialysis unit in Oban, it is key that this assessment is considered within NHS Highlands strategic aims NHS Highlands vision is to: • Provide quality care at all times; • Support people and communities to maximise their own health; • Develop precisions driven services so that when people need our care they experience

timely, focussed, effective services that minimise the duration and frequency of contact; • Ensure that every health pound spent delivers maximum health gain. Quality is therefore at the heart of NHS Highlands vision. NHS Highland believes that a focus on efficiency without attention to quality is unthinkable but equally that promoting quality with no regard for efficiency is unsustainable. Implementation of this vision means that the characteristics of service delivery in NHS Highland over the next five years are evolving to be ones of: • promoting good health, self care and independence • High quality, integrated, equitable, needs and evidence-based, and cost-effective • Increasingly community-based with hospital beds preserved for the most acutely ill and

those with specialist needs • Integrated with, and complementary to, local authority, voluntary and independent sector

care • run by healthy, flexible, well-motivated and well-trained staff working to their maximum

potential and capability • using modern, flexible, efficient, green assets to maximum effect • With zero wastage and inefficiency across all services and no unnecessary overheads It is from this context that it is important to articulate how a local dialysis unit would meet these characteristics. To this end the following benefits have been identified for developments. Key benefits for patients include:-

• Improved local access to specialised services • Improved patient choice • Fit for purpose, comfortable and safe facilities

Key benefits for Staff include:

• Improved working environment for staff • Integrated working between acute and community staff • Training and Development opportunities for community staff • Enhancement of future recruitment opportunities for the South West of the region • Developing service and network links with renal service in Fort William and

NHSGG&C Key benefits for the organisation:-

• Increased capacity and flexibility for haemodialysis across the CHP to meet current and future demands

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 6 Dec 2012

• Effective and efficient use of existing staffing and estate resources and capability • Opportunities for future service developments within the unit • Provides services closer to home • Integrated working between acute and community • Potentially enhanced working relationships with community partners and voluntary

sector • Reduced travel costs and as a consequent a reduced carbon footprint • Offer Value for money and be affordable within our current resource. • Provides contingency service for CHP if bad weather prevents patients in Cowal or Bute

accessing IRH dialysis unit It is therefore essential for this viability assessment to be cogniscent of NHS Highlands strategic direction as well as aligning with these benefits. 2.2 Existing Service Provision Renal services are currently provided to the Argyll and Bute population from a number of hospital sites in NHS Greater Glasgow and Clyde providing both in-patient and out-patient services and the Belford Hospital in Fort William which is a satellite unit of Raigmore providing out-patient services only. The numbers of Argyll and Bute patients’ currently receiving dialysis as at 5th December 2012 by hospital site is detailed in the table below

Table1 – Current Dialysis by hospital site Argyll and Bute CHP Patients receiving dialysis fro m Hospital Site – Dec 2012 Home HD supported by Stobhill Hospital HD in Inverclyde

Locality No. pts Locality No. pts Mid Argyll 1 Bute 4

Total 1 Cowal 1 total 5 Home PD supported by Western Hospital HD in Vale of Leven Locality No. pts Bute 1 Locality No. pts Cowal 1 Helensburgh 7 Mid Argyll 1 Kintyre 2 Oban & Lorn 2 Oban & Lorn 2 Kintyre 1 total 11 Islay 1

Total 7 Hospital HD in Belford

Locality No. pts Oban & Lorn 2 total 2

This shows patients from Argyll and Bute are accessing a number of sites for dialysis services based on their clinical need and geographic access. 2.3 Current Service Capacity: - The table below outlines the current capacity and use of renal dialysis units in NHS GG&C and at the Belford hospital Fort William as at October 2012

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 7 Dec 2012

Table 2 – Hospital Dialysis Unit Capacity

October 2012 Dialysis Unit Funded capacity Activity October-12

Clyde VOL Dialysis unit 32 32 Clyde IRH Dialysis unit 68 58

Greater Glasgow Dialysis unit 409 384 Belford FW Dialysis unit 12 9

TOTAL 521 483 From the above it is clear that there is currently spare capacity within the system to support Hospital dialysis activity. In addition the WoS Regional Renal planning group is constantly reviewing utilisation and demand and the following options are being examined or can be put in place to provide additional capacity:

o Additional shifts i.e. evening and overnight dialysis sessions o Increase in kidney transplant surgery reduces demand for dialysis- GG&C have

undertaken 86 in 2012 to date an expected increase of 10 from 2011. This is building on the national and regional initiatives looking at increasing numbers of Live Donor transplants.

o Belford dialysis unit operates 3 days a week there is the potential to extend this to 6 days per week providing a further 12 sessions

2.4 NHS Highland and West of Scotland – Renal Dialysis Projections :- In 2009, the West of Scotland Renal group (WOS) sponsored a full needs assessment for RTT for end-stage renal failure. The review estimated that the increase in the clinical need for renal replacement therapy (all forms of dialysis plus transplantation) for the ten year period 2008 – 2018 would be between 17% and 21%; this included the Argyll and Bute CHP population. NHS GG&C planned its future dialysis capacity accordingly. In 2009/10 NHS Highland Health Board public health department undertook a full needs assessment for Chronic Kidney Disease and Renal Replacement Therapy for Argyll and Bute CHP population. The department’s projections indicate that by 2018 there will be 31 patients requiring hospital dialysis which this is detailed in the table below.

Table 3- Projection of RRT Numbers for the populati on of Argyll and Bute

RRT Patient Type 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Hospital Dialysis 29 31 32 33 34 35 36 37 38 39 Home Dialysis 20 22 23 25 26 27 28 29 30 31 Peritoneal Dialysis 8 8 8 8 8 7 8 8 8 8 Total Dialysis Patients 57 61 63 66 68 69 72 74 76 78 Transplant Patients 42 44 46 48 50 52 53 55 56 58 Total RRT Patients 99 105 109 114 118 121 125 129 132 136 Source: operation of the MORRIS model: v2.3 with open options for populations, DoH and NHS Kidney care

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 8 Dec 2012

Conclusion It is clear that there is currently capacity within the existing renal dialysis service which the Argyll and Bute CHP population access both in Greater Glasgow and Clyde and at the Belford in Fort William to meet not only the current demand for hospital dialysis but also the future projections for service need, a projected increase of 13. 3 Clinical Assessment on Suitability of local hospi tal dialysis service The premise is to site a local low maintenance dialysis unit at Lorn and Islands hospital in Oban. The GP practice registered population of Argyll and Bute is 88,777 (Nov 2012). The locality profile, population and configuration of Argyll and Bute CHP is: Locality Population Locality Description Oban, Lorn & the Isles 21,838 Easdale to Oban, to Port Appin to Dalmally &

Isles of Mull, Tiree, Coll & Colonsay Mid Argyll, Kintyre & Islay 21,169 Southend, Campbeltown, Muasdale,

Carradale, Tarbert, Lochgilphead, Ardfern, Inveraray, Isles of Islay & Jura

Cowal & Bute 22,037 Lochgoilhead, Strachur, Tighnabruaich, Dunoon, Bute

Helensburgh & Lomond 23,733 Helensburgh, Kilcreggan, Garelochhead, Arrochar

Argyll & Bute CHP

88,777

The Hospital Dialysis unit in Oban would draw on a catchment population of Oban, Lorn and Isles, Mid Argyll Kintyre and Islay a total of 43,000. As there are renal dialysis units in VoL DGH Dumbarton and at Inverclyde Royal Hospital , Helensburgh and Lomond and Cowal and Bute localities would continue to access this service from these locations due to their proximity and easier access to transport links to these centres. The provision of renal replacement therapy by dialysis in rural communities is challenging. In these sparsely populated areas with only a few small population centres the demand for dialysis is low but can fluctuate intermittently. The challenge to provide a low maintenance satellite haemodialysis unit as close to “home” is difficult as the clinical profile of the patients dialysising must be stable. HD treatment within the LMD unit is only appropriate for patients who have a stable condition and are at low risk. Patients would require to be carefully assessed prior to referral to the LMD unit. If a patient’s dialysis becomes unstable, or there are any other complications, they will be referred to NHS GG&C renal unit for treatment as per existing service pathways Many patients are not able to undertake home based therapies- home haemodialysis or peritoneal dialysis. This can be due to patients clinical condition and need, a patients confidence and capability for them or their carer to administer dialysis on a 3 times a week regime, control of infection etc and transplant is not an option for the majority. The provision of haemodialysis is therefore made available in a way to make best use of expensive resources- equipment and staffing.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 9 Dec 2012

The clinical lead for renal medicine and lead nurse of the renal unit in Raigmore have stated that it is there experience that in Highland it is probably more appropriate to size a unit to provide 4-6 dialysis stations and staff with 2 nurses, and have a nurse on an annualised contract to cover leave (1 band 7 and 2 band 5). Specialist consultant medical input is also required for review at monthly intervals. A 4 station unit would allow up to 8 patients per week to be dialysed typically on a Monday Wednesday Friday morning and afternoon. The issue of a dialysis unit in Oban would clearly lead to a review of its appropriate location re local access for the catchment population it would service. It would also clearly mark a potential precedent for future provision in other centres of population in the CHP area such as Dunoon, Bute and Helensburgh. It is clearly difficult to provide the same easy physical access to haemodialysis in remote areas as urban. Where provision is made it has to be accepted that there is a compromise between what would be top of the wish list and what in reality is affordable and sustainable. There is also the “theoretical” opportunity to “twin” the unit with the Belford, particularly if it is provided in Oban. This could augment the service and support sharing of specialist staff between the two units enhancing expertise and knowledge and supporting the service in contingency etc. As such the combined service could provide operating times allowing a Mon-Sat service to be provided. However, in such a scenario there would be a need to recruit more staff to Fort William as the current staffing cohort do not wish to increase hours. The newly recruited staff would incur travel time, travelling expenses and staff travelling long distances from their base is likely to be unattractive. In reality recruiting separate staff will be less problematical for service provision and is likely to be a more attractive post. 4 Potential Site for a LMD and Cost 4.1 Fixed Unit Space within one of the vacated wards at LIH in Oban has been identified as a potential site for a hospital dialysis unit housing potentially 3/4 stations and associated plant and equipment. Dumfries and Galloway is opening in December 2012 a 3 station low maintenance dialysis unit at Kirkcudbright Cottage Hospital. This facility cost £260,000 to build and equip and will operate 6 days a week providing 36 dialysis sessions. The dialysis equipment for the unit was transferred from Dumfries Royal infirmary. Capital funding for the unit has come from the Board but also local fund raising purchasing some dialysis equipment, soft furnishings etc It is estimated that providing a similar sized and specification unit in Oban would cost in the region of £350,000- £400,000 based on the Kirkcudbright costs including the purchase of 4 hospital dialysis machines. (Note this is an indicative figure only and would re quire formal work up and validation.) Funding sources for this scale of capital investment would have to be sourced from the NHS Highland Board allocation. There has also been an indication from the Oban community that it would look to fund raise to support the unit. The capital programme of the board would only see this level of funding being available from 2014/15 and this would then have to be part of a Board wide prioritisation process.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13a

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Viability Assessment Low Maintenance Dialysis Unit LIH 10 Dec 2012

4.2 Mobile Unit On paper this seems a sensible option taking the service to patients thereby improving local access. Preliminary research into this has identified a single supplier in the UK of a “mobile” modular unit. This service was provided in Welshpool in 2011 as an interim measure until their fixed unit was built. It compromised an 8 station unit housed in four articulated lorry sections providing:

• Up to 8 dialysis stations • Admin room • Reception & waiting • Disabled access and toilet facilities • Staff change

EMS Healthcare rents its units out to the NHS in the context of interim or temporary solutions whilst service is disrupted due to building works etc. It is a modular unit which support a number of health care requirements, e.g. screening, outpatient clinic accommodation etc. Initial discussion with the company indicates they could provide a 2/3 station unit with support facilities possibly in one unit. This size of unit would be more appropriate to the catchment area identified and could be best said to support a true “mobile” service. It should also be noted that the mobile solution has a number of service implications and patient benefits with regard to renal dialysis:

• Dialysis cycle of treatment is 3 times a week – poses logistical and timing issues with regard to taking the unit to Oban, Lochgilphead and Campbeltown to meet patient’s treatment needs.

• Even if the patients could only have dialysis locally 1 day a week and had to travel to other units on other days this may offer some impact to travel benefits to patients

• Based on the current demand and future needs and taking account of the 3 day a week treatment cycle of patients, it is likely the unit would have to operate 6 days a week incurring a higher staff revenue cost

• Life cycle costs of mobile units are generally higher then fixed facilities e.g. wear and tear, extra maintenance etc

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 11 Dec 2012

• The service would require to have strong operational links with fixed units to ensure patient care is not disrupted due to down time of the unit for whatever reason

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Viability Assessment Low Maintenance Dialysis Unit LIH 12 Dec 2012

5 REVENUE COSTS: The indicative revenue costs of running a 3/4 station dialysis unit have been estimated as follows:

Item WTE Total Cost

£ Basis of Cost Consultant (1 session per month) 0.02

2,900 At top point

Band 7 Nurse 0.60 29,100 At top point

Band 5 Nurse 1.20 39,500 At top point

Nursing Leave Cover 22.5% 15,400

Equates to approx 0.4 wte giving a total wte for unit of 2.2

Travel Expenses 1,000 Per Dumfries & Galloway Business Case

Training Expenses 1,000

Consumables 45,400

Cost Book average per station in hospitals of similar unit size

Service Contracts & Maintenance

5,000

Domestic Services 2,500

LIH cost per square metre 11/12 Cost Book for 100 square metres

Catering Services 8,200

LIH cost per patient week pro-rated for providing lunch to 3 patients per week & drinks to 6 patients per week

Energy Costs 1,000 Per Dumfries & Galloway Business Case

Arro Plant Water System 1,500 Per Dumfries & Galloway Business Case

Total Recurring Costs 152,500

Non-Recurring Set Up Costs 5,500 Per Dumfries & Galloway Business Case

Total Additional Revenue Costs

158,000

Note:

If proposal was to be given the go ahead, the costs would need to be verified. The above are best estimates given the limited information available & the timescale.

5.1 Revenue funding sources 5.1.1 Reallocation of Patient Travel costs An assessment of dialysis travel times for current and future renal patients for the Oban unit is illustrated in the Matrix below:

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 13 Dec 2012

Travel Time Matrix

Benefit Criteria Oban Lochgilphead Campbeltown Islay* Fort William

Oban 01:00 02:15 03:50 01:15

Lochgilphead 01:00 01:00 02:45 02:15

Campbeltown 02:15 01:00 03:35 03:15

Islay* 03:50 02:45 03:35 05:50 Fort William 01:15 02:10 03:15 05:50

Note- Car Travel times single journey. * Islay include Ferry time The current projected annual costs incurred by NHS Highland supporting (6) patient’s travel for hospital dialysis via taxis are: Oban to the Belford £55,000 Oban to the Vale & Oban to the Western Infirmary £30,000 Campbeltown to the Vale £44,000 Total £129,000 If these patients were able to dialyse locally then there would be a saving against this budget as patients would not have to travel as far. It is difficult to identify exactly what the saving would be as it is dependent upon the patient’s condition, choice and there still remain some transport costs which would be incurred. A reasonable estimate would however be in the order of £50,000 to £80,000 if the unit was located in Oban. It should be noted that the source of funding for this transport is form the Highlands and Islands Travel Scheme. 5.1.2 Repatriation of Hospital Dialysis Activity an d cost Establishing a unit in Oban would see patients repatriated back from units in Glasgow and the Belford. At present the SLAs which are in place to fund this service would only see the Belford funding transferring back to the CHP. In 2012/13 the SLA cost of renal activity at the Belford is £148,000 (NHS Highland North SLA value) 5.1.3 Holiday Dialysis - income Providing a local dialysis unit also provides opportunities for “holiday” dialysis. In the last financial year the unit at the Belford was able to offer 119 “visitor” dialyses session resulting in an income of £41,000. It is difficult to assess accurately what tourist dialysis activity income would come to Oban a conservative estimate of 20% would equate to circa £8,000. This would however be tempered by the capacity available in a 3/4 dialysis unit operating 3 days a week. 5.1.4 Affordability and Value for Money To assess the financial affordability and the value for money of a LMD unit in Oban it is useful assessing the unit against existing units in the NHS GG&C and NHS Highland. The table below illustrates the costs of these units as at 31st March 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 14 Dec 2012

The yellow shading highlights NHS Highland facilities and the green NHS Glasgow and Clyde. As one might expect the bigger units offer advantages of scale and the cost per attendance is therefore significantly lower. NHS Highlands units are more expensive per attendance with the Belford unit the most expensive. This costing analysis comparison provides a productivity value for money rating. SPECIALTY GROUP - RENAL DAYPATIENT STATISTICS AND C OSTS Source: Scottish Health Service Costs year ended March 31st 2012 Hospital No of Attendances Net Total Specialty

Cost £ Cost per Attendance £

Cost per annum 3 treatments per week £

Vale of Leven, Alexandria

4,556

829,335

182

28,475

Inverclyde Royal Hospital

9,034

1,873,428

207

32,439

Glasgow Royal Infirmary

15,357

3,382,757

220

34,457

RHSC, Yorkhill

662

130,612 197

30,863

West Hospitals

4,932

1,056,078 214

33,496

Stobhill ACH

16,129

3,527,037 219

34,207

Victoria ACH

21,641

4,050,775 187

29,280

Caithness General

1,598

410,651 257

40,199

Raigmore, Inverness

9,494

2,713,116

286

44,703

Belford

880

287,957 327

51,187

Assessing the treatment cost of the Oban LMD unit modelling a range of attendances for patients who could be dialysed locally the following is revealed:

No of Attendances

% Attendance

Hospital

(Patients x 52)

Total Direct Costs £

Net Total Specialty Cost £

Cost per Attendance £

Cost per annum 3 treatments per week £

LIH, Oban 936 100 152,500 266,875 285 44,479

No of Attendances

% Attendance

Hospital

(Patients x 52)

Total Direct Costs £

Net Total Specialty Cost £

Cost per Attendance £

Cost per annum 3 treatments per week £

LIH, Oban 796 85 145,690 254,958 320 49,992

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Viability Assessment Low Maintenance Dialysis Unit LIH 15 Dec 2012

No of Attendances

% Attendance

Hospital

(Patients x 52)

Total Direct Costs £

Net Total Specialty Cost £

Cost per Attendance £

Cost per annum 3 treatments per week £

LIH, Oban 655 70 138,880 243,040 371 57,867 This shows the unit is at the higher end of the expensive scale and it would be comparable to the cost of the other NHS Highland units. Further it is noted that repatriating activity from GG&C and Belford in Fort William will increase their attendance price and reduce their value for money rating. With regard to a mobile unit VFM and affordability rating based on the information sourced at this time it would compare similarly to the Belford costs. It should be noted greater analysis of the financial implications of this model of service would be required to take account of life cycle costs, model of service operation e.g. limited mobile or fully mobile solution etc. Conclusion The financial implications of putting in place a dialysis unit in Oban are significant both in capital and revenue terms. It requires a large capital investment from the Board which at this time at the earliest if prioritised would not be available until after 2014/15 In addition the revenue cost of the unit is also significant for the level of activity and does not offer best value for money when benchmarked to other units. This is also the case for a mobile unit. In affordability terms, the opportunity to repatriate activity from the Belford and reduce the transport costs of some of the patients notably the Oban patients would meet the estimated revenue costs (costs subject to further validation) of the unit and produce a saving. It should be noted Mid Argyll, Kintyre and Islay patients would still incur travel costs to Oban or Glasgow. With regard to the value for money assessment for NHS Highland as a whole. Clearly the loss of activity at the Belford increases its unit cost and reduces its utilisation, therefore worsening its value for money performance. 6 Patient Feedback : In order to support the macro level assessment of providing a local low maintenance dialysis unit in Oban, it was essential to obtain the views from patients currently receiving dialysis at the Belford Hospital, Fort William and Vale of Leven Hospital. A patient survey was prepared (see attached annexe) to ascertain their opinion with regard to the current service, how they currently access the service and where they would like to receive dialysis if given a choice. The survey also asked what would, in their opinion, make the biggest improvement to their experience of renal replacement therapy service. The survey was sent to the two units (Belford and Vale of Leven) for staff to hand to patients. Patients were given the opportunity to either complete the paper version and return in a Freepost envelope provided or do so online using Survey Monkey. Deadline to completion was Friday 7th December 2012. The key points of the analysis are:

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 16 Dec 2012

In total 14 questions were issued and 6 were returned and the respondents who returned questionnaires were from: A total of 7 responses out of 16 distributed were completed and returned representing a response rate of 43.75%. The respondents place of residence are detailed in the table below:

Area No of

Responses % Oban & Lorn (mainland) 4 57% Mull, Iona, Coll 0 0% Mid Argyll 0 0% Kintyre 1 14% Cowal 0 0% Bute 0 0% Islay / Jura 0 0% Helensburgh 2 29% Other 0 0% N= 7 100%

Of the 7 responses, 86% (6) were from patients who are over 70 years of age and most (57%) have been receiving haemodialysis for 6 – 10 years. Patients were asked where would you prefer to receive your dialysis and the responses are detailed below

Unit No. of Responses % Satellite Unit (NHS GG&C)

3 43%

Satellite Unit (NHS GG&C)

4 57%

Home dialysis 0 0 Total 7 100

Where respondees indicated they would prefer to dialyse at a satellite unit, they aware asked which would be their preferred location. Of the responses given, 3 patients (2 from Helensburgh & 1 from Oban) stated they would prefer to receive dialysis the Vale of Leven Hospital, Alexandria, 2 patients (both from Oban) would prefer to attend a local satellite in Oban, 1 patient (from Kintyre) indicated a preference for Lochgilphead “as central to Argyll patients”. 1 patient from Oban did not provide a response to this question. Summary It is difficult to summarise the key things that would make the biggest improvement to their experience of renal replacement therapy services, as these are personal to each patient. That said, having a local satellite unit as close to home as possible, significantly reducing travelling time, has been identified as very important.

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Viability Assessment Low Maintenance Dialysis Unit LIH 17 Dec 2012

In terms of general comments, the following provides a summary of the points made. The full results of the survey are attached as an annexe to this report. 7 Patient Travel : As expected travel and access is of particular concern to patients. A unit in Oban would obviously benefit Oban and its surrounds directly with regard to enhancing local access. There would also be travel time gains for Mid Argyll and Kintyre residents saving at least 2 and 4 hours respectively in journey time into Dumbarton. These are important patient benefits with regard to the dehabilitating effect treatment and subsequent travel this has on patients. The obvious point in this regard is whether a unit in Oban is the best location for the catchment area it would serve. To minimise travel distance and times for all patients locating the unit in Lochgilphead would seem a more equitable location for all patients. It is also apparent the correct type of patient transport for all renal patients is important and it is clear that a greater assessment of patient’s requirements is needed and a greater range of options including the SAS, taxi hire and use of the voluntary sector e.g. the Red Cross would help mitigate the impact of travel. The issue of travel access from the Islands is also important. As indicated earlier Islay residents have to travel by Ferry, equally residents on the other Islands in the Oban catchment area would also have to use a ferry. The development of Oban airport does provide a further opportunity to minimise the impact for some patients of travel if they are able to use this form of transport and where there are scheduled flights matching dialysis frequencies. At present (winter timetable) the flights to Islay, Colonsay, Coll and Tiree would probably only allow a flight out and a return on the Ferry or an extra day stay before returning. Notwithstanding this it is an alternative transport option for patients http://www.hebrideanair.co.uk/flights/Oban_Schedule d_Timetable.html It is also acknowledged that the summer timetable for air flights offers improved access in some locations with day turnarounds in Oban. 7 GP referral patterns for RRT and assessment of ex isting service

General Points 1 Outward journey is tiring, return journey traumatic, 3 times a week 2 Service “keeping me alive” 3 Kind, courteous & knowledgeable staff instils confidence 4 Worry that local staff “do not have much knowledge” about the illness 5 Worry that renal professionals are “so far away” 6 Reduced waiting time after treatment

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 18 Dec 2012

The public Health department as part of its needs assessment of RRT in 2009/10 profiled with GPs in Argyll and Bute their referral patterns for RRT. The Map below shows Referral routes used by individual GP Practices to specialist renal services (the referral on from L&I DGH also included Source: Survey of GP Practices in Argyll & Bute: 10 0% response rate (34 GP Practices)

The survey asked 3 questions:

For patients who may require renal replacement therapy:-

1. Which hospital / hospitals do you normally refer to? 2. What determines your choice of referral?

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Viability Assessment Low Maintenance Dialysis Unit LIH 19 Dec 2012

3. What improvements would you consider appropriate in meeting the needs of these patients?

All 34 Practices responded. The table below summarises the answers received from questions 2 and 3: Table 5 General Practice response regarding what de termines the choice of services referred to and suggestions for improving services to their renal patients Locality Determining the

choice (number of practices giving response)

Suggestions for improvement (number of practices giving response)

Cowal & Bute (8 practices)

Travelling distance (7); new patients go to WIG (1)

Reasonable (1) , happy (1) , none needed (1) blank (2) better transport by ambulance (1),

Helensburgh & Lochside (5 practices)

Proximity (4); Clinician at VoL is excellent & will refer on for surgery (1)

Good & helpful service from VoL (2); none needed (1); blank (1); would like to have assessment of patients with GFR <45

Mid Argyll, Kintyre and Islay (11 practices)

Travelling distance (10); patient preference (2); Excellent service provided by GRI (1)

A more local outreach/dialysis service would help patients (3); Oban would not be easier (1), Central location in Argyll would cut travelling (1); A patient hotel facility would be helpful for attending WIG; Better transport links from Glasgow airport to GRI would be helpful (1); no response (2); not long enough in practice to comment (2)

Oban Lorn & the Isles (10 practices)

Historical pathway (3): Patient choice determined by geography & travel (5); Mobility and degree of impairment determines choice of L&I DGH or WIG (1); If acute refer directly to Glasgow (1) Air links (1)

Same day electronic info’ about the frequent clinic attendances better than the current time lag in letters (1); Local clinic would be helpful as attendances initially are very frequent. (1): travelling causes difficulty to patients & for family support (1). Might consider Oban with twice weekly flights (1); Is it possible to refer to Raigmore for patients to attend Belford? (1); travel for specialist services is accepted by patients-very few renal patients(1) No response (2) No recent experience with which to comment (1); No improvements suggested (1)

The survey findings did reflect at the time satisfaction with service provision for renal patients, but it did also highlight the transport issues facing patients but acknowledging the compromise re access to specialist services. Also flagged was the advantage of having a centrally located dialysis unit. 9 EQUALITY AND DIVERSITY IMPACT ASSESSMENT: It is clear this assessment has identified an opportunity to improve access and choice to all groups for renal services if a Hospital Dialysis unit is provided in Oban. A full Impact Assessment would be required to be conducted to assess the impact on the catchment population taking account of the different location options within the catchment area.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 20 Dec 2012

10. CONCLUSION:- The way in which we manage and treat renal disease impacts greatly on the patient and their family’s life and work and although there is no cure for renal disease, there is much that can be done to improve outcomes and the quality of life for patients. There is however a balance in enhancing equitable access for patients to service and making best use of scarce resources. It is clear this viability assessment has indicated a number of issues and benefits with regard to providing a hospital dialysis unit in Oban. The matrix provides a summary in illustrative terms the outcome of this viability assessment against the criteria identified.

Table 6: Viability Assessment Summary results Matri x

Achievement Level Criteria None Partial Most Full

Meet existing & future demand/need

X

User & stakeholder Feedback

X

Clinical Assessment

X

LIH site

X

Appropriate Geographic location

X

Capital funding- prioritised

X

Revenue funding to support service

X

Affordability & VFM rating

X

Alternatives available

X

Patient access improvement

X

Other Service implications to be met i.e. staffing

X

Timescale to provide- 2 years plus***

X

A&B CHP management prioritisation assessment for development*

X

*To be identified at CHP Management team meeting 11 /12/12. *** Fixed unit circa 12 months from approval of fun ding to completion and opening

Key None Partial Most Full

This report has also identified that current transport arrangements need to be reviewed and alternatives examined and developed which should provide an improved service to patients and offer best value for money.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Viability Assessment Low Maintenance Dialysis Unit LIH 21 Dec 2012

APPENDIX 1 GLOSSARY OF TERMS/FAQ

HD Haemo-Dialysis KPA Kidney Patient Association LMD Unit Low Maintenance Dialysis Unit OPAT Outpatient Anti-biotic Therapies QIS Quality Improvement Scotland RNSF Renal National Service Framework RRT Renal Replacement Therapy WOS West of Scotland Renal Group When Is Dialysis Needed? Kidney dialysis usually isn't needed until you lose around 85 percent to 90 percent of your kidney function. Some people will need dialysis for the rest of their lives or until they find a candidate for organ donation. Other patients need dialysis for only a short time, until the acute kidney failure subsides and the kidneys are repaired. What makes people at risk of developing kidney dise ase? Main factors are, Age - 40% in the 85 and over age group, Gender , females more at risk overall age standardised prevalence of CKD stages 3-5 in people aged 18 and over in women was 10.6% and in men 5.8%, Family history , Ethnicity Advanced CKD is more prevalent in South Asian individuals in the UK; compared with White Caucasians, Socio-economic status Socially deprived people have a higher incidence and prevalence of CKD in developed countries, Obesity , High Blood pressure , Diabetes , Smoking What exactly does dialysis do? Dialysis removes waste products that the body produces every day and that the kidneys are no longer able to eliminate. These include salt, water and other harmful substances What Types of Dialysis Are Available? There are two main types of kidney dialysis. Haemodialysis is the use of an artificial kidney to replace a kidneys function and is conducted in a hospital. Haemodialysis treatments last for around four hours, and most doctors recommend that patients undergo treatment three times a week. The other type of dialysis is Peritoneal dialysis which can be delivered at home. With this type of treatment, you'll have surgery to insert a catheter into your abdomen. You'll be responsible for changing bags to remove liquid waste from your body continuously throughout the day, or you'll hook up to a machine at night that controls the removal of waste while you sleep.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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Argyll & Bute Community Health Partnership (CHP)

ANNEXE 1

RENAL DIALYSIS PATIENT SURVEY

REPORT

Version 0.1 13th December 2012

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Background In order to support the macro level assessment of providing a local low maintenance dialysis unit in Oban, it was essential to obtain the views of patients who are currently receiving dialysis at the Belford Hospital, Fort William and Vale of Leven Hospital, Alexandria. A patient survey was prepared to ascertain their opinion with regard to the current service, how they currently access the service and where they would like to receive dialysis if given a choice. The survey also asked what would, in their opinion, make the biggest improvement to their experience of renal replacement therapy service. The survey was sent to the two units (2 to Belford and 14 to Vale of Leven) on 23rd November 2012 for staff to hand to patients. Patients were given the opportunity to complete the paper version and return in the Freepost envelope or to do so online using Survey Monkey. Deadline for completion was Friday 7th December 2012. A total of 7 completed forms were returned using the Freepost envelope. No one completed the online Survey Monkey. Renal Patient Survey Results The evaluation of the feedback received has provided both a quantitative and qualitative feedback. A total of 7 (43.75%) patients completed and returned their survey forms. No on line responses were received. The following provides a brief summary of the quantitative feedback, referring to Questions 1 - 10. All questions were answered with the exception of one patient who declined to answer one question therefore totals may not match the total number of feedback form received (7).

1. Please can you indicate which age range you fit into

Years No of

Responses % < 20 0 0% 21 – 30 0 0% 31 – 40 0 0% 41 – 50 1 14% 51 – 60 0 0% 61 – 70 0 0% > 70 6 86% n= 7 100%

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2. How many years has it been since you were diagnosed with

Chronic Kidney Disease (CKD)?

Years No of

Responses % < 2 2 29% 2 – 5 1 14% 6 – 10 4 57% > 10 0 0% n= 7 100%

3. Please indicate which area you live in

Area No of

Responses % Oban & Lorn (mainland) 4 57% Mull, Iona, Coll 0 0% Mid Argyll 0 0% Kintyre 1 14% Cowal 0 0% Bute 0 0% Islay / Jura 0 0% Helensburgh 2 29% Other 0 0% N= 7 100%

4. Are you currently receiving dialysis treatment?

No of

Responses % Yes 7 100% No 0 0% n= 7 100%

5. Which type of dialysis are you receiving?

No of

Responses % Peritoneal 0 0% Haemodialysis 7 100% N= 7 100%

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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6. Where are you currently dialysing?

Respondees were asked to indicate which satellite unit they attended if they selected either option. Of the responses given, 2 patients receive dialysis at Belford hospital, Fort William and 5 patients at the Vale of Leven Hospital, Alexandria.

7. Where would you prefer to receive your dialysis?

Where respondees indicated they would prefer to dialyse at a satellite unit, they aware asked which would be their preferred location. Of the responses given, 3 patients (2 from Helensburgh & 1 from Oban) stated they would prefer to receive dialysis the Vale of Leven Hospital, Alexandria, 2 patients (both from Oban) would prefer to attend a local satellite in Oban, 1 patient (from Kintyre) indicated a preference for Lochgilphead “as central to Argyll patients”. 1 patient from Oban did not provide a response to this question.

Respondees where then asked to indicate how important the following factors were to them.

8. Having a satellite unit as close to home as possible

No of

Responses % Very important 7 100% Important 0 0% Slightly important 0 0% Not important 0 0% n= 7 100%

Unit No of

Responses % Satellite Unit (NHS GG&C) 5 71% Satellite Unit (NHS Highland) 2 29% Home 0 0% n= 7 100%

Unit No of

Responses % Satellite Unit (NHS GG&C) 3 43% Satellite Unit (NHS Highland) 4 57% Home 0 0% n= 7 100%

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Having a specific appointment time for your dialysis session

No of

Responses % Very important 6 100% Important 0 0% Slightly important 0 0% Not important 0 0% n= 6 100%

1 patient did not provide a response to this question therefore the control total is different to the total number of responses received (7).

The next two questions relate to how patients currently access renal dialysis.

9. How do you currently travel to receive renal dialysis?

Of the 3 patients who use Patient Transport Service, 2 are from the Helensburgh area & 1 from Oban. Of the 4 who use a taxi service, 1 is from Kintyre and 3 from Oban.

10. For each dialysis session, how much time do you spend travelling

(think about your total return journey)?

Hours No of

Responses % < 1 0 0% 1 – 2 3 43% 2 – 3 1 14% 3 – 4 0 0% > 4 3 43% n= 7 100%

No of

Responses % Car 0 0% Public transport 0 0% Patient Transport Service 3 43% Taxi 4 57% Other 0 0% n= 7 100%

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Of the 3 patients who travel 1 – 2 hours for each dialysis session, 2 are from the Helensburgh area and 1 from Oban. 1 patient from Oban stated that they travel 2 – 3 hours. Of the 3 patients who spend more than 4 hours travelling each time, 2 are from Oban and 1 from Kintyre.

The 3 patients who travel over 4 hours for each dialysis session, it is noted that they all travel by taxi. Of these, 2 are over 70 years of age and travel from Oban and Kintyre.

11. Patients were invited to write any observations they might like to make

regarding their travel arrangements. The following responses (4) were provided.

In terms of qualitative analysis, patients were asked some general questions as follows :

12. Please list, in order of priority, the 3 things that would make the

biggest improvement to your experience of renal replacement therapy services.

• Unit in Oban (O1) • Much reduced travelling time (O1) • When a problem arises with the dialysis I inevitably have to go

to Inverness Hospital (4 hours away). Having been a patient there for 3 ½ months in the summer I saw very few visitors. If there was a unit in Oban and a problem arose I would go to Glasgow where I would have more visitors (O1)

• Less travelling (K4) • Being kept informed by staff at all times (K4) • Courteous staff / health professionals (K4) • Reduced waiting time for transport after dialysis (H5) • Travelling time (4 hours per day) is too much. 15 minutes

would be fantastic (O6) • Hopefully I would feel a lot better knowing that the local hospital

could prolong my life (O6) • I would feel less anxious if there was a unit in Oban as I live in

fear as sometimes I have to be airlifted to Glasgow (O6) • Unit in Oban (O7)

• I am away from home for eight hours - 4 hours on dialysis, 4 hours travelling (O1)

• A unit nearer my home would not be so tiring as I am out of my home for at least 9 hours (K4)

• Cutting waiting time for transport home (H5) • The journey is extremely uncomfortable and exhausting especially

sitting in the back of taxi as I must do as there is elderly passenger in the front (O6)

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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• Reduced travelling time (O7) • When a problem arises to Raigmore if in Oban would go to

Glasgow (O7)

13. Do you have any comments that you would like to make about

renal replacement therapy services for patients with Chronic Kidney Disease (CKD) living in Argyll and Bute?

• The outward journey is tiring however the return journey is

traumatic as having had dialysis I feel light headed and all I want to do is get my head down. Even more depressing is the thought that this could continue for the rest of my life (which hopefully will be a long one). There are 4 patients from this area alone travelling over 100 miles 3 times weekly. If a unit was placed in Oban all 4 patients would travel 12 miles to have their dialysis. Also patients from Kintyre and Islay at present flown to Glasgow could be flown to Oban. The cost of the taxis weekly for the 4 patients is approx £1,500 - £1,700 (around ¾ million pounds annually). (O1)

• This service is keeping me alive & for that I am very grateful. There are times I am so exhausted with travelling 3 days weekly but realise it needs to be done and hope a unit could be installed nearer my home. My preference is to travel to Glasgow rather than Oban due to the road getting to Alexandria. I find staff kind, helpful & knowledgeable which instils confidence in me. Taxi drivers are excellent & an afternoon slot suits me best. (K4)

• I myself feel very isolated knowing that renal professionals are so far way and there have been on occasions that there have been incidents when it has been touch and go with me when I have not been taken to Glasgow quickly in an emergency. I’m sure other renal patients feel the same. Also it is frightening when local GPs & doctors do not know much about the illness in this area. (O7)

• Outward journey tiring. Return journey traumatic. 4 patients from this area travelling over 100 miles 3 times weekly (if in Oban it would only be 12 miles)

Summary A total of 7 responses out of 16 distributed were completed and returned representing a response rate of 43.75%. Of the 7 responses, 86% (6) were from patients who are over 70 years of age and most (57%) have been receiving haemodialysis for 6 – 10 years.

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It is difficult to summarise the patients 3 key things that would make the biggest improvement to their experience of renal replacement therapy services, as these are personal to each patient. That said, having a local satellite unit as close to home as possible, significantly reducing travelling time, is very important. In terms of general comments, the following provides a summary of the points made.

In 2008, NHS Quality Improvement Scotland NHS QIS) carried out a Scottish Renal Patient Experience Survey “Your Service, Your Views” in collaboration with the SRR, a Scottish charity representing kidney patients associations across Scotland. The report was published by NHS QIS in January 2010. While there is always scope for improvement, patient satisfaction with renal services in Scotland is generally high. In the survey, patients were asked to think of three ways in which their experience could be improved and one of the three areas is “co-ordination of sessions and better communication between the patient transport and dialysis services to reduce waiting times for patients”. This has been identified as an area for improvement in the Argyll and Bute Renal Patient Survey. The results of the renal patient survey will be used in the macro level assessment of providing a local low maintenance dialysis unit in Oban. Having feedback from patients who are currently receiving dialysis at the Belford Hospital, Fort William and Vale of Leven Hospital, Alexandria has been very important and of great value. Many thanks to all those who returned their completed the patient survey forms. Caroline Cecil - Champion Planning and Public Involvement Manager Argyll & Bute CHP 13th December 2012

General Points 1 Outward journey is tiring, return journey traumatic, 3 times a

week 2 Service “keeping me alive” 3 Kind, courteous & knowledgeable staff instils confidence 4 Worry that local staff “do not have much knowledge” about the

illness 5 Worry that renal professionals are “so far away” 6 Reduced waiting time after treatment

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13b

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APPENDIX 1 - RENAL DIALYSIS PATIENT SURVEY

November 2012

SURVEY GUIDANCE NOTES This survey asks about you and your health care in relation to your renal replacement therapy service. Answer each question thinking about yourself. Please take the time to complete this survey, your answers are very important to us. Please return this

survey with your answers in the FREEPOST envelope provided. If you would like to complete this survey online, you can access it at :

http://www.surveymonkey.com/s/RenalDialysisSurvey

If you have any questions, you would like help completing the survey, if you would like a copy in a different format (for example large print) or an alternative language, please contact Caroline Cecil – Champion, Planning and Public Involvement Manager, NHS Highland (Argyll and Bute CHP) on ℡01546 605680 / 605681 or email � [email protected].

Answer the questions by ticking the box to the left of your answer, like this :

1. Yes

Be sure to read all the answer choices given before ticking your answer

Please skip past questions you would prefer not to answer

It should take around 10 – 15 minutes to complete the survey

Please be assured that this questionnaire is anonymous and that all your answers

will be handled in the strictest confidence

Please ensure we receive your completed survey form no later than Friday 7th December 2012

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13b

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About You

1. Please can you indicate which age range you fit into?

< 20 years 21 – 30 years 31 – 40 years

41 – 50 years 51 – 60 years 61 – 70 years

> 70 years

2. How many years has it been since you were diagnosed with Chronic Kidney

Disease (CKD)?

< 2 years 2 – 5 years 6 – 10 years

> 10 years

3. Please indicate which area you live in

Oban & Lorn (mainland) Mull, Colonsay, Coll Mid Argyll

Kintyre Cowal Bute

Islay / Jura Helensburgh Other * * If you ticked “Other” please state _______________________________

About Your Care 4. Are you currently receiving dialysis treatment?

Yes No (please go to Question 7)

5. Which type of dialysis are you receiving?

Peritoneal Haemodialysis

6. Where are you currently dialysing?

Satellite Unit (NHS GG&C) Satellite Unit (NHS Highland)

Home

If you ticked “Satellite Unit”, please give the name of the Hospital or Unit

7. Where would you prefer to receive your dialysis treatment?

Satellite Unit (NHS GG&C) Satellite Unit (NHS Highland)

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Agenda item : 13b

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Home

If you ticked “Satellite Unit”, please state your preferred location

8. Please tell us how important the following factors are to you

Having a satellite unit as close to home as possible Very important Important Slightly important Not important Having a specific appointment time for your dialysis session

Very important Important Slightly important Not important About How You Access Renal Dialysis

9. How do you currently travel to receive renal dialysis? (Please tick all that apply)

Car Public Transport Patient

Transport Service

Taxi Other (please state) ______________________________

10. For each dialysis session, how much time do you spend travelling (think

about your total return journey)?

< 1 hour 1 – 2 hours 2 – 3 hours

3 – 4 hours > 4 hours

11. Please write below any observations you would like to make regarding your travel arrangements

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

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In General

12. Please list, in order of priority, the 3 things that would make the biggest improvement to your experience of renal replacement therapy services.

13. Do you have any comments that you would like to make about renal

replacement therapy services for patients with Chronic Kidney Disease (CKD) living in Argyll and Bute?

Once you have completed this survey, please return in the FREEPOST envelope provided to arrive no later than Friday 7th December 2012

Thank you for taking the time to complete this survey

1. 2. 3.

Argyll & Bute CHP CommitteeDate of Meeting : 19 December 2012

Agenda item : 13b

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Cowal 24/7 Review Outcome Report Stephen Whiston Head of Planning Contracting and Pe rformance The CHP Committee is asked to:

• Note the status of the review • Consider the issues with regard to the identified preliminary preferred option 11b for

service delivery o Benefits of the model proposed o The medical stakeholders have unanimously rejected Option 11b o Reservations from other stakeholders

• Consider the conclusion of the Cowal 24/7 Project Group • Identify the way forward for the review and outcome

1. Introduction The purpose of this paper is to provide the CHP Core management team with a report on the outcome of the Cowal 24/7 review. The review examined the future provision of GP out of hours s arrangements for Cowal as well as reviewing the Medical input into Cowal Community Hospital (inpatient and casualty).

2 Background

Rural GPs have been making changes over the past few years to the way they provide services once their surgeries are closed -‘Out of Hours’ (OOH) as allowed for in the GMS contract 2004.

The GP who provided the Strachur out of Hours service decided to not to do this any more – to ‘opt out in 2007’. An arrangement was put in place with the adjoining Tighnabruaich practice to cover the out of hours service. However that came to an end in 2010 when the GP also decided to opt out.

Through 2010, the CHP undertook an option appraisal process to identify an alternative service for the area. The outcome was to put in place a temporary service for 12 months as it was not possible in the timescales and for those areas alone to develop a sustainable service. The CHP committee agreed that a formal review of all GP Out of Hours Services for Cowal should be undertaken to solve the issues remaining from the temporary solution. The Lochgoilhead community wished to be part of this review and so were included, as all practices in the area had now opted out.

It was also agreed to review the medical cover within Cowal Community Hospital as there were a number of staffing arrangements which could be simplified. These included the day time Monday to Friday inpatient service contract with the GPs, which was due for renewal. The separate salaried Medical service providing casualty, GP out of hours for Dunoon and the inpatient service at night and at weekends.

This meant a comprehensive review of all aspects of the service could take place.

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In summary the review examined

o Day time Medical Input in Cowal Community Hospital (CCH) o Casualty and out of hours medical input in CCH o GP Out of Hours arrangements Dunoon & East & South Cowal o GP Out of hours Arrangements Rural Cowal ( Tighnabruaich & Strachur) o GP Out of hours Arrangements Lochgoilhead

2.1 Who is doing the review?

The Cowal 24/7 Review Group was set up in October 2011 ands is jointly Chaired by a member of the public, Heather Grier and a doctor, Brian McLachlan. Its members include;

• Members of the public representing communities from Dunoon, Sandbank etc and Rural Cowal

• Cowal Locality Public Partnership Forum

• Local Councillor

• GPs from the Town practices and Rural Practices

• Doctors from the Hospital Casualty and out of hours service

• Nursing and other staff from the Hospital and community

• Union Representation

• Scottish Ambulance Service

• Cowal Locality Management

• Argyll and Bute CHP Management

The Cowal 24/7 review process has also had invaluable support and direction from the Scottish Health Council (SHC) and the local officer is in attendance at the majority of meetings but at all those relevant to help craft and design the process to involve and engage the public.

The requirements specified are:

• CEL 4 (2010) Informing, Engaging, Consulting – ensuring the 24/7 Review offer people real opportunities to influence decisions - “Through involvement in developing & appraising ... options ... and public consultation on preferred option(s)”

The review brief including the Terms of Reference (ToR) for the review and further supporting information can be found at:

http://www.nhshighland.scot.nhs.uk/CHP/ArgyllandBut e/PPF/Pages/CowalGPServices.aspx

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Cowal 24/7 Short List of Options Characteristics 1 Centre • Covering the whole of Cowal with the service provided from Cowal Community

Hospital (CCH) 2 Centre • Service provided from CCH for Dunoon town, also covering Kilmun, Innellan etc, AND • Service provided in rural Cowal for Lochgoilhead, Tighnabruaich and Strachur GP

practice areas 3 Centre • Service provided from CCH for Dunoon town, also covering Kilmun, Innellan etc AND • Service provided in rural Cowal for Tighnabruaich and Strachur GP practice areas

AND • Service provided by NHS Greater Glasgow and Clyde (GG&C) covering Lochgoilhead

3 Current Situation - Option Appraisal

The option appraisal process is a formal technical but transparent process recommended by the SGHD and the SHC to examine the differences between service options to better inform decision making. The process involves developing a long list of options (17in this case), and then reduce these down into a short list of 7 viable options.

The process then appraises and assesses the short listed options by considering:

1. Benefits delivered

2. Risk

3. Value for money- compare cost of options

4. Affordability- what money is available

The option appraisal process is in line with Treasury Green book guidance on the process to adopt as well as the SHC guidance mentioned earlier.

3.1 What has been happening?

Since April 2012 the Cowal 24/7 Group commenced the process to refine the long list of options to a short list for formal appraisal. This included engagement with staff and stakeholders and the public to ensure their feedback informed the appraisal process.

The options were appraised by members of the project group at workshop events in June 2012 and July 2012

The Cowal 24/7 Review group when undertaking the Option Appraisal process continually reflected on the feedback received from the community, stakeholders and professionals. This included the information recorded at drop in events, feedback forms, and video submissions from the publics’ experience of using the service.

The main points from the community feedback considered in the scoring and assessment process are:-

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• Tighnabruaich residents submitted the most responses • Importance of having a doctor in the hospital and a doctor covering the out of hours work

rural and urban • Concern over travel time and response not only from Dunoon but also if the doctor is on a

call in Tighnabruaich and has to get to Lochgoilhead or vice versa • Acknowledgement that the service is costly and some 1 centre options offered better value

for money • NHS 24 experience was generally varied but clear public confidence concerns as no

representation from NHS 24 • Patient’s choice of transport to take patients to Primary Care Emergency Centres at Vale of

Leven or Dunoon or Strachur. • Concern regarding the availability/operation of taxis to the rural areas to either bring patients

into and back from a PCEC when required • Options where the doctor from the Cowal Community Hospital attends local house-calls in

rural Cowal which result in the doctor leaving casualty for more than one hour would represent an unacceptable level of clinical risk.

• The loss of local rural doctors is deemed by the community as a diminution of service as alternative options which do not provide a rural based service will result in response times being longer than currently, even if they are within the “performance standards of the service”

• Concerns about the ambulance service response times and particularly to outlying areas such as Tighnabruaich and Otter Ferry

3.2 Option Appraisal Workshop

The Cowal 24/7 Review workshop on the 4th July 2012 considered the findings of the option appraisal process in the reports and outcomes of the workshop listed below.

o Non Financial Benefits (scored against agreed criteria)- report 14/06/12

o Risks- report 21/06/12

o Costs (Affordability)- Report 04/07/12

o Value for Money (Economic Appraisal)- Report 04/07/12

The project group review and consideration of the qualitative and quantitative features of the option appraisal and the other information identified some clear conclusions which were used as the basis for deselecting particular options or differentiating the overall benefits delivered by the alternative solutions. This assessment taking into account all of the points above, and the consideration of the material information detailed, the Cowal 24/7 group were clear that none of the options individually would meet the needs of the Community Hospital and GP out of hours service without compromising some aspects of service requirements as follows:

• There will be patients who clinically require a home visit

• There will be patients who need an ambulance for clinical reasons

• Patients should be encouraged to make their own arrangements to get to a PCEC. Via a relative, neighbour or friend. If there is no alternative then the CHP will provide an agreed method of transport.

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• The PCEC is the best venue to assess and treat patients

• Leaving the hospital medically uncovered for longer then 30 minutes introduces an unacceptable level of clinical risk

• A one centre option is unacceptable

Taking this into account, the Cowal 24/7 review group has identified the following service configuration:

• A model using Cowal Community Hospital as a PCEC and rural surgeries as flexible PCEC’s

• A Model which ensures integration across the medical workforce, inpatient, casualty and out of hours to focus on multidisciplinary working and enhancing continuity of care 24/7.

• Establishing a set time for medical input into the inpatient wards (20 beds) Mon-Fri 9am to 1 pm (exact hours to be determined) covering a 4-5 hour period, per day, e.g., ensuring attendance at Admission, Transfer and Discharge meetings.

• This medical input equates to 0.5 wte doctor and is not necessarily one doctor if supplied on a rota from the existing town practices, with the casualty doctor providing medical cover outside the 5 hour period.

• Ensuring consistent local triage arrangements (re-triage of NHS 24) to ensure all patients are seen according to clinical need.

• Ensuring the correct response including putting in place arrangements with local rural surgeries to allow patients to attend out of hours appointments at their local surgery (PCEC). A clinical view had identified that over 50% of current home visit activity may not have been the most appropriate.

• Putting in place a cost effective responsive to the rural and urban out of hours activity in Cowal.

The Cowal 24/7 review group have identified a revised service option which in its view meets the objectives and service requirements and this is outlined in the table below:

The medical workforce deployed to provide the service is detailed in the table below:

O Option 11 b Shifts Wards Casualty & PCEC

Cowal Out of Hours (Home Visits)

Day Shift 8am-1pm 1 Doctor 1 Doctor Day Shift 1pm – 6pm 1 Doctor Evening 6pm-11am 1 Doctor 1 Doctor – on call

Mon – Friday

Overnight 11pm-8am 1 Doctor 1 Doctor – on call D Day Shift 8am -6pm 1 Doctor 1 Doctor

Evening 6pm-11pm 1 Doctor 1 Doctor – on call Sat, Sun & Bank

Holidays* Overnight 11pm-8am 1 Doctor 1 Doctor – on call

Note * - Bank holiday workforce will be increased in the day time to meet know additional demand in hospital during this period

The nursing workforce deployed to provide the service in casualty is detailed in the table below:

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The new option can be described as an Integrated Inpatient and out of hours service, Option 11b and its components are:

CHP employed Doctors provide;

• Casualty 24/7

• Inpatient care 24/7 (2 ward within hospital- Hospice & Supported Care (6 beds) and Admissions Unit (14 beds)

• Opportunity for employed or sessional input Mon-Fri 20-25 hours for a GP practice/practices equating to 0.5 wte doctor.

• GP Out of Hours service 365 days a year for the whole of Cowal provided by an on duty Dr at weekends during the day (8am – 6pm) who will provide home visiting and PCEC appointments for the whole of Cowal. Between 6pm to 8am that the on-call Dr will cover the whole of Cowal for visiting and rural PCEC appointments.

• Lochgoilhead can either remain with the VoL service for Out of Hours or transfer to the new service

• A Taxi will be available for any patients who cannot get transport to the PCEC for an appointment

3.3 Cowal 24/7 Review Group- reservations around Op tion 11b

The Cowal 24/7 Project Group meeting on the 23rd August 2012 considered the outcome of the appraisal process and identification of option 11b (see attached draft outcome report).

The various stakeholders expressed a range of views on the preferred option. A facilitated meeting was held with all the medical staff with a stake in the service in September to ascertain the issues with Option11b and identify a way forward these included:

• the impact on medical staff groups providing the current service

• concerns over continuity of service provision

• Medical staffing levels during the day.

This led to a pause in the project whilst further information was collated and written reports from the Medical. Nursing staff and public representatives were prepared and submitted to the Project Group for consideration.

07:00am – 3.00pm 1.30pm- 9.15pm 9.15pm to 7.30am

Nurse Practitioner ( NP) minor injuries etc

Nurse Practitioner minor injuries etc

Registered Nurse supports the Doctor

Registered Nurse supports the Doctor

Nurse Practitioner

Nursing staff also support theatre & outpatient clinics - orthopaedics in Casualty

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The Project group met on the 22nd November 2012 and reviewed the evidence presented by the stakeholder groups and to clarify the reservations expressed by members. (See attached annexes for full report) and these are summarised below:

Medical Staff Stakeholders

The medical staff stakeholder group have unanimously rejected the preferred option, expressing a number of reservations and concerns, in summary by group they are:-

Rural Out of Hours GPs

o Concern from the rural doctors regarding their ability to cover home visits for the whole of Cowal as part of the GMS response – feel level of activity too high with impact on next working day in primary care as responsible for a daytime practice M-F

o Concern that the out of hours visits did not take into account length of time of response re travel and consultation and impact on response times if there is a call at the same time for whole of Cowal

Medical Staff Mon-Fri day time (town GPs)

o The town practices are unable to supply a single doctor to cover the wards 20-25 hours Mon-Friday due to day time primary care commitments

o There will be loss of continuity of care for town GP practices patients (currently 2 practices see their own patients)

o It does not draw on pool of up to 9 GPs to guarantee medical service – offering greater sustainability re staffing and risk of employing locums

CHP Employed Doctors (Casualty and Wards/PCEC out o f hours)

o Reduces the OOH medical cover by 1/3 at weekends/public holidays.

o Combines the “town” and “rural” OOH cover. The majority of workload would be centred in Dunoon – effectively producing a “single-centre” option.

o Weekday OOH cover to be provided for home-visits and rural PCEC only.

o South Cowal PCEC patients to be seen in casualty.

o Adds 5 hours extra work to the casualty Dr 1300 – 1800 Mon – Fri to cover acute ward, rehab ward, hospice and maternity unit (previously covered by local GP).

o Weekend OOH dedicated cover to rural areas removed, workload transferred to Casualty and Dunoon OOH Drs.

o While on paper current model may look like overstaffing, cutting back is a false economy as the costs for backfill are so great and cutting back is dangerous as it takes no account of the slack in the system needed to deal with the unpredictability of workload

o Patient Transfers to the ward always arrive late afternoon which is also one of the busiest times in casualty

o The salaried medical staff do not support the withdrawal of local GP in-patient care. The ole of the local GPs is seen as being pivotal to the function and integration of secondary to primary care within a community hospital.

o The salaried medical staff do not support the withdrawal of dedicated rural OOH GPs. This service as being essential in terms of appropriate and timely first-response to the

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rural communities, enhancing the service throughout Cowal and to maintaining the PCEC response in Dunoon

o The proposed additional duties would necessitate significant change to working practices requiring changes to job plans and contracts. The he proposed changes would be resisted.

Nursing Staff Stakeholders

Issues with the current system: (from observation and experience)

o Breakfast and medicines are often interrupted by GP rounds (Wards rounds take place between the hours of approximately 07.15 – 11.00hrs)

o There is seldom the same GP from the practice 2 days in a row which can cause some continuity issues which can make the rounds lengthy

o Patients are seen in order of which GP comes in first- not in order of clinical priority.

o Much of the liaison with GPs is done by phone, with the onus on the nursing staff to assess how urgently a patient needs to be seen, mindful of the fact they may be interrupting a surgery.

o Continuity of care is lost at evenings, weekends and extended public holidays

Positive about the current system:

o The GPs visit the ward every week day and can be relied on to do so.

o GPs know their own patient’s history and their families (although there has to be some recognition that this is not all patients-exclusions being out-of-town patients)

o The GPs are skilled, experienced doctors who have built up good working relationships with the nursing team

Reflections on Option 11b by Nursing Staff;

o One doctor a day conducting ward rounds. Patients can be seen in order of clinical priority.

o There will be a doctor with responsibility for the ward patients in the hospital 24/7

o Designated ward time would means that doctors could be fully engaged in Admission Transfer & Discharge policy- attending daily multidisciplinary ‘Board meetings’ and arranged case conferences

o Breakfast and medicine rounds would be over by the time the doctor came on the wards leading to improved care experience for patients.

Emergency Nurse Practitioners Casualty Reflections

o We do not think that the Emergency Nurse Practitioner are impeded in the present model but ENPs would see more patients in the new option because the doctor would be in the wards some of the time. What I think would really help the less experienced although fully qualified ENP’s would be for the doctors to take on the role of mentor. Instead of taking over the care of a patient

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o ENPs already help with out of hours patients and again this is only in the information leaflet not the option but it is always a possibility

Other Stakeholders

SAS

o Concern there may be an increase in calls on ambulance service if GP out of hours service delayed, which would have an impact on the 999 resource availability.

Public Representatives on Cowal 24/7 Group Reflecti ons

o Option 11b has always been a flexible centre model, and must not default to a one centre model so removes several of the difficulties raised by Doctors in their paper.

o It is a principle that locums should not be used or used as little as possible should be established to underpin the model

o It is expected that the rota system could be worked so on weekdays; no GP is overburdened with daytime surgeries and OOH cover at night or at the weekends. It would appear that there is potential for the rota system to work without being onerous.

o It has been acknowledged that public holidays need more cover and has been included in the model cost and this removes one of the concerns of medical staff.

• Concerns about some of the data supplied • Further analysis and understanding of the data on OOH calls for rural and South Cowal. So

it is important to be clear about both, the materiality of it as well as the profile of demand (peaks and troughs and variability), if the visiting doctor post is to be manageable

o It is acknowledged that casualty activity is high (higher then Oban).

• The doctors are worried about the level of risk in Option 11. Is there more work required on evidencing:

o Activity level: Rural and South Cowal

o Areas of work to cover

o The balance of care between the Cowal Community Hospital doctor, visiting doctor, wards and casualty nurses

o The impact of Model of care on Mental Health, Palliative Care and other roles such as BASICS and MIMMS

• Nurse practitioner roles can be extended and better coordinated between wards and casualty improving service to patients. This needs to be in place to support the Doctor cover of Casualty and Wards, PCEC.

• The absence of a Clinical Director for the service, there is no locality lead and this is vital to deliver a quality service for patience and is recognised by all.

• Other Service redesign

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There are a number of other service redesigns which are/could impact on the service and the preferred model needs to consider:

� Psychiatric Patient Retrieval options

� Model of Care Redesign - Anticipatory Care Model and Board rounds re ATD policy

� Palliative Care Redesign and level of medical input

o There would appear to be strong arguments for the reorganization of ward cover by Town GPs on the grounds of efficiency for Nursing staff, patient benefit from protected breakfast time and skilled nursing input at key times am

4.0 Cowal 24/7 Project Group Assessment

The project group considered this information at its meeting on the 22nd November 2012. The group assessed in some detail the evidence presented and reflected that the lack of consensus on the preferred option.

The group acknowledged that some of the concerns and reservations were valid but there were clearly solutions to some of the issues i.e. increasing the day time medical input and hours of working.

The project group reflected that whilst there was a majority of the group which supported option 11b, the fact that the medical stakeholders did not support the model and the changes proposed to medical staffing. The group did not feel it could finalise the option appraisal process at this time and make a recommendation.

The project group also reflected that the new model proposed should be the start of a continual development process to enhance and improve the hospital and out of hours service. This could include developing and implementing the paramedic practitioner role, mentoring Emergency Nurse Practitioners to enhance their role and capability.

The group therefore felt it needed to obtain a view from the CHP management team and Committee as to the findings to date and how the project should be taken forward from this point.

5.0 Current Service issues

• The casualty medical staffing workforce is depleted by 68hrs per week. This is currently being covered at significant additional cost by locum medical practitioners until the review is concluded.

• Decision by local GPs to terminate their contract for day time input. The 2 remaining town GP practices delivering the service have served 3 months notice to terminate the existing hospital daytime cover M-F 8am-6pm, effective 28th Feb 2013

• The Out of Hours Drs at CCH cover the majority of the hospital in-patient service (118hrs) with the town GPs covering 50 hrs daytime

• The rural OOH cover is currently delivered by a group of local rural GPs and one from outwith, on a rota basis. The GPs are employed through the OOH Hub on a casual basis and could serve a 4 week notice period at anytime. They have however, all stated a

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commitment up to the outcome of the 24/7 process. There is a risk to service continuity. There are also operational issues ensuring the GPs stock up on emergency supplies, drugs etc and ensure safe storage of equipment and handover. Operational managers rely on the OOH Dr to monitor and alert them to any requirements. This is variable or can be at short notice. Other the current system is complex to manage and deliver in terms of corporate governance and accountability.

• The rota consists of 3 disparate groups of medical staff working in a variety of shifts. The budget is overspent even taking account of an additional 100k allocation for the period to assist with the review. One Dr is currently on extended leave which has also added to the cost and service pressure.

• The review is impacting on our ability to recruit Drs as we can only offer temporary contracts until the outcome is known.

• The long term use of locum Drs is clearly not good practice and is also impacting on staff morale

• NHS Highland is primed to start formal negotiations with the employed medical practitioners once a decision is reached.

6 Next Steps

The Cowal 24/7 Project programme from this point should the option be approved by the CHP is:

• Jan/February 2013 – Preferred option is taken out for consultation to obtain feedback and review from the public and stakeholders

• March 2013 – Cowal 24/7 project group review the feedback on the preferred option and make a recommendation on the option to be implemented

• March 2013 - CHP Management team and Committee receive recommendation for consideration and decision to implement.

7 Contribution to Board Objectives This paper responds to the Boards objectives of achieving Better Health Better Care & Better Value and the work is aligning with the Highland Quality Approach Governance Implications This paper aligns with the CHP corporate and Governance responsibility for effective resource utilisation and maximising care. Staff Governance There are implications for staff re change and involvement and communication. Patient Focus and Public Involvement

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Significant public involvements has been in place to inform, involve and reassure the community and assist them in understanding the issues we are required to address and how these changes will protect and enhance front line services by addressing inefficiencies in systems and services. SHC support in framing and reviewing the process has been integral to the work to date. Informing the community re outcome and monitoring ongoing provision will be essential. Clinical Governance Clinical risk and action to reduce the risk will require identification and mitigation and agreement through governance structures. Financial Impact The changes identified could have a significant impact on the recurring cost base of the CHP, but it must also be tempered by the possibility of needing to redeploy resources into new service models. Equality and Diversity Planning for Fairness impact assessment may need to be conducted on the outcome to ensure service changes meet access requirements.

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COWAL 24/7 REVIEW OUTCOME REPORT

ANNEXES

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Annexes

o Annexe 1 - Evidence request e-mail to Medical Staff o Annexe 2 Medical Staff Stakeholders response o Annexe 3 Ward Nursing Staff Stakeholder Response o Annexe 4 Casualty Nursing Staff Stakeholder Response o Annexe 5 Public Represenatives response

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Annexe 1-

Submission of Evidence Request to Stakeholder Medic al Staff

From: Heather Grier > To: peter.vonkaehne >; r.paterson2 robbie.coull jurgen alida.pettie glenhall >; catriona.mclaughlin < >; angela.mosley < >; louise.taylor-kavanagh >; peter.t.campbell <; sbrennan < >; fiona.murdoch < >; jpearce < >; anthony.bates < >; annettemcculloch < > CC: brian.mclachlan; Lornaahl > Sent: Sun, 21 Oct 2012 17:00 Subject: Medical response to Option 11b - 24/7 Project review

Dear Peter and Colleagues I refer to the email of the 17th October 2012 sent by Peter on your behalf regarding the above. Your response was read out to the members of the 24/7 project group at its meeting on the 18 October 2012. In order to consider matters further, the group has requested additional information. This phase of the review is trying to ensure there is evidenced based information on which to platform further discussions between divergent stakeholders' opinions regarding how to create a safe and sustainable model for OOH and in-patient care. To this end we would like the reasons, and the evidence behind such that have brought you to rejecting option 11b. We feel the detailed points and evidence are needed to see where the divergence in opinions lie. This is so potential areas of negotiation can be identified, and the areas where opinions diverge to the extend there may be no common ground. We would like clarity. It may be helpful to consider OOH and in patient services separately as well as how they would integrate as was suggested by Dr Tittmar. The doctors and GP's answers will be considered at our next meeting, together with other information agreed as action points and suggested action points from Lorna's papers issued in respect of the meeting held on the 18 September 2012. We are therefore requesting that a range of people produce their reasons and evidence based on Lorna's paper, as well as from you. Peter has stated within his email written on your behalf:- 1) This option does not represent a model that is workable in terms of clinical safety and sustainability 2) We do not feel it makes appropriate use of available resources 3) It does not build on local strengths as other successful models have done in other areas 4) It does not meet the needs of the population which it plans to serve 5) We remain unconvinced the estimated revenue savings will be realised For each of the above, could you please provide the evidence you considered and discussed and the reasons for coming to each conclusion.

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Further it would be most helpful if you could answer the following questions 1) What parts of option 11 b are in your view workable and how would your progress these? 2) What parts of option 11b are in your view unworkable, and how would you resolve these? I would be grateful if you will please respond to Brian, Lorna and me as soon as possible. It will be added to the other information to be considered. We wish to distribute all this information together from you and the others identified in time for the 24/7 members to read and digest. We wish to be able to do this a minimum of one week before the next scheduled meeting on the 22 November 2012. We are requesting that every stakeholder group ensures they or a representative with a clear mandate to represent a groups' view attends this key meeting where the next stage will be debated. We will need to make a decision to relay to the CHP soon after that meeting. This will involve deciding whether to go ahead with Option 11b or not, and will depend on an evaluation of all the evidence gathered from the action point papers and your paper. It will be a collective decision for the 24/7 Project review group. We look forward to hearing from you. Peter, just a note that I was omitted from your original email's list of recipients. Could I ask you all to please check that this email has been addressed to everyone who should be included and if you notice I have inadvertently omitted any individual please forward this to them. Many thanks Regards Heather

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Annexe 2 – Medical Stakeholder Response

1 Response to option 11b from the Rural part-time s alaried GPs 1) Option 11b rural cover has shifted over the course of its development from being essentially rural and manageable aside of daytime practice to becoming an all- Cowal visiting service - including Dunoon, which will be by its nature the source of most calls. There is considerable discrepancy between initial informal descriptions of this option and the presentation by Dr MacLachlan. Considering now what we have it is clear that the workload will be unsustainable for us rural doctors. 2) In particular, Option 11b rural cover has clearly shifted from making use of rural centre(s) to getting all mobile patients to Dunoon hospital. This is contrary to the clearly expressed desire by the rural population, the options appraisal process etc . When pushed on this point at the meeting, Dr McLachlan was abundantly clear that the rural centres will not be used. As rural doctors we can not support this. 3) Initial communication suggested that the rural doctors would visit only the rural areas of Cowal. When presented in the meeting the rural doctor had transmuted into an all-Cowal visiting doctor. It is totally unclear how large the workload for Dunoon will be, but it is clear that it will be a significant additional burden, competing with rural visits, often at the same times. 4) All in all Option 11b appears to be based on either flawed or non-existing numbers. The hub's numbers re rural visiting are quite clearly not reliable. Dr Coull's numbers have not been challenged by the health board as far as we can tell, but cover only a small proportion of the nights/weekends worked. All in all there is a total lack of reliable, trustworthy numbers regarding both workload and load distribution. 5) One particular problem with the rural visiting numbers underpinning 11b (quite apart from being likely flawed (see (3)) is that they do not take into account the length of time required for rural visits - not just travel time, but also time on scene, to e.g. observe improvement etc as revisiting is not easily possible. 6) Option 11b removes the on-call doctor during weekends daytime from the rural area and bases them in the hospital. 2 intensive 12 hour shifts on top of night on-call after a busy week in practice and followed by another week in practice is not sustainable, quite apart from reducing the overall work force significantly. Dividing the 12 hour shifts into several shorter shifts would drive up frequency of weekends worked for all of us. This would also be unsustainable. 7) Option 11b relies on triage by casualty staff for rural visiting.

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Casualty staff have made it clear that they see themselves in no place to provide a triage service. Further, it is our fear that they will have no incentive whatsoever to triage towards the centre, but will find it preferable to triage towards the visiting doctor's workload, especially when hitting resistance by the patient or being under pressure with ordinary casualty work. This will introduce a totally unpredictable element into all workload calculations and potentially introduce serious strife between staff groups who get on well right now. All in all, none of us can see ourselves working in this option as the workload associated with it is essentially unsustainable when responsible for a daytime practice. As a group we will be unable to provide a guarantee for a filled rota as we do right now. As individuals we find the proposed system not possible to combine with ordinary day time practice 11b disenfranchises us as we are 6 committed local doctors who want to provide a service to our patients but are essentially forced out. 2 Response to 11b from Dunoon Casualty and OOH Medi cal Staff (salaried staff) This option;

• Reduces the OOH medical cover by 1/3 at weekends/public holidays. • Combines the “town” and “rural” OOH cover. The majority of workload would be centred

in Dunoon – effectively producing a “single-centre” option.. • Weekday OOH cover to be provided for home-visits and rural PCEC only. • Dunoon PCEC patients to be seen in casualty. • Adds 5 hours extra work to the casualty Dr 1300 – 1800 Mon – Fri to cover acute ward,

rehab ward, hospice and maternity unit (previously covered by local GP). • Weekend OOH dedicated cover to rural areas removed, workload transferred to

Casualty and Dunoon OOH Drs (as 2.) The duty casualty doctor would be responsible for: 1. Care of all patients attending casualty Department. (A no-bypass receiving centre for the area). 2. PCEC patients 1800 – 0800 Mon – Fri, 2300 – 0800 Sat & Sun. 3. Attend emergencies in any part of hospital. 4. Act as hospital medical coordinator in major incident. 5 Care of in-patients; Acute receiving ward, continuing care ward, hospice and maternity. During weekdays 1300-1800 and whole-day Saturdays/Sunday/Public Holidays. 6. All patients attending PCEC Sat and Sun 1800 -2300 (+2) (within time-limits.) 7. NHS24 generated advice-calls Sat & Sun1800 – 0800 (within time limits) 8. “Re-triage” of all NHS24 designated home-visits (within time-limits).

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At present is responsible for 1,2, 3 and 4 only, the proposed additional duties would necessitate significant change to working practices requiring changes to job plans and contracts. We would resist any of the proposed changes. As previously indicated the salaried medical staff do not accept the proposal contained within Option 11b. In addition; The Option 11b draft advice sheet cites 24/7 Nurse Practitioner cover;

1. Casualty nursing staff Nurse Practitioners have not agreed to participate in PCEC duties. 2. Able at present to provide Nurse Practitioner for every casualty shift. No “spare”

capacity. 3. No Nurse Practitioners in wards.

The salaried medical staff do not support the withdrawal of local GP in-patient care. We see the role of the local GPs as being pivotal to the function and integration of secondary to primary care within a community hospital. The salaried medical staff do not support the withdrawal of dedicated rural OOH GPs. We see this service as being essential in terms of appropriate and timely first-response to the rural communities, enhancing the service throughout Cowal and to maintaining the PCEC response in Dunoon. The model of covering of the wards with part casualty staff and part GPs was not discussed or proposed at any stage prior to the publication of option 11b (and as far as we know it is not a model that is used anywhere else in other community hospitals - it certainly hasn't been described in other community hospitals that we have looked at). What evidence there is that this model would work? Patients transferred from IRH arrive late afternoon and this affects the workload at certain times. Dunoon casualty is close to Oban in terms of workload yet is not a consultant led unit like Oban and air ambulance transfers are running at one a week. Option 11b will risk the provision of quality palliative care and the hospice beds in this model. It means there will often be 4 different doctors in 24hrs covering the wards (8am-1pm, 1pm-6pm, 6pm-11pm, 11pm-8am) and the lack of continuity of care this involves. The loss of local GP palliative care experience should not be underestimated, nor should the time involved in just one or two patients in these beds. The 11b model doesn't actually address any of the issues that have been raised about the current system. There have been repeated complaints about GP ward rounds, management planning and trying to get hold of a GP through the day (though these are often unsubstantiated complaints). Leaving aside how valid these issues are or what's behind then, the trouble is the proposed model doesn't actually solve any of these and could easily make it worse eg it could easily be a different dr every morning doing the ward round, unavailability of the casualty dr in afternoons if they are busy, lack of availability of the named clinician with overall responsibility

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every afternoon etc. We have repeatedly spoken in the 24/7 group of how there should be an increased move to 7 day discharges - this actually impedes that. There have also been repeated claims that the current 'doctor heavy model' impedes nurse development yet we are also told that funding is not an issue for nurse development - so why or how does the current system stop nurse development or increased skill range or responsibility of nurses? Ideas for nurses to take on expanded roles to support the new system eg increased nurse clerking, ward nurse practitioners etc are all very good but haven't even started yet - they would need to be in place first and shown to be working before any changeover There has been an alarming turnover of nurse practitioners in casualty since the start of the review process. There is a group of very experienced nurse practitioners and prescribers who have retired in the last year and while some do a bit of bank work and others are being trained up, casualty nursing is less skilled now than it has been for years. How long it will be before the new nurses practitioners in training have finished their training? we're told there is a full complement of nurse practitioners but this is disingenuous as some of them have only just started the course and are fairly inexperienced Finally the whole process has looked at cutting medical staffing to save money based on average workload numbers yet it has been readily acknowledged that the workload varies hugely from very quiet to incredibly busy. With a small workforce, the only way this can be made viable is with plenty of slack in the system to take up the strain whenever it is v busy, folk are off sick, posts are unfilled etc and there are plenty of examples in recent history to show this. While on paper it may look like overstaffing, cutting back is a false economy as the costs for backfill are so great and cutting back is dangerous as it takes no account of the slack in the system needed to deal with the unpredictability of workload. The risk assessment process in particular in the option appraisal has been very flawed - or else we wouldn't be in this situation of running over the timescale with no agreement and no workable solution - and so risk needs to be taken more seriously. 2 Response from the Dunoon GPs The town practices are unable to supply a single doctor to cover the wards 8-1 Mon-Friday Thus adopting option 11b will de facto remove us from the community hospital. I am not sure if we need to say more. Everything else after that single point is more or less irrelevant. 1. The model is not sustainable because we are not involved in the hospital - so you exclude 9 GP principals - who cover each others holidays and sick leave etc.. - and not safe because there are times (e.g. late afternoon) when there are ill admissions and transfers to the ward that are expected to be looked after by the single casualty doctor even when he is busy with resus downstairs. A single doctor simply cannot be in every place at once. 2. It patently does not make use of the resource of the 9 local GP principals - who have clinical skills and local knowledge of benefit to patients and the service.

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3. It does not build on the strengths of continuity of care, local knowledge and experience and availability of up to 9 GPs all cross covering for each other. Palliative care experience. Joined up working with the Gp practice etc... 4. Lack of continuity of care, lack of provision of doctor input to the ward, fragmentation of care pathways - do not meet the needs of the community. 5. If locums need to be employed to backfill shifts and cover annual leave etc... - even if it is possible to recruit English speaking high quality locums - at current locum pay rates it could prove considerably more expensive at best. At worst it may prove impossible to staff and there is no fall back provision for cross cover if the GP are excluded.

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Annexe 3 Cowal 24/7 Options Appraisal

Response from ward nursing staff on option 11b

1 Background from nursing perspective There are 2 ward within CCH- Hospice & Supported Care (6 beds) and Admissions Unit (14 beds) Within the H&SC Unit we strive to have 2 Registered Nurses (RNs) and 1 Healthcare Assistant (HCA) on each morning and in the Admissions Unit, 2 RNs and 2 HCA’s

Prior to Nov 2012, the nursing staff supported 3 GPs each morning on their ward rounds. Wards rounds take place between the hours of approximately 07.15 – 11.00hrs Within the same time frame the nursing staff require to be involved in , breakfast & medication rounds, personal care being delivery, admissions & discharges, liaison with AHP colleagues, patients vital signs recording as well as individual nursing input such as, wound dressings, dealing with IV infusions, giving pain relief etc. . Once the GP leaves, they rely on nursing staff to alert them to any issues throughout the day. Subsequent visits by the GP to the ward are most commonly for the following reasons-1) to admit a patient that they have sent to hospital, or 2) (at the request of the nursing staff) – see a patient who has become more unwell or 3) to clerk in transfers from GG&C hospitals 2 Issues with this system: (from observation and ex perience)

• Breakfast and medicines are often interrupted by GP rounds • There is seldom the same GP from the practice 2 days in a row which can cause

some continuity issues which can make the rounds lengthy • Direct patient care time for the RNs is reduced and much of the ‘hands on’ care

is carried out by HCAs – this has been the cause of concern from the HCAs • If 2 GP come in at the same time, there is no RN overseeing or delivering care

directly • Patients are seen in order of which GP comes in first- not in order of clinical

priority. • Much of the liaison with GPs is done by phone, with the onus on the nursing staff

to assess how urgently a patient needs to be seen, mindful of the fact they may be interrupting a surgery.

• Continuity of care is lost at evenings, weekends and extended public holidays 3 Positive about the current system:

• The GPs visit the ward every week day and can be relied on to do so. • GPs know their own patient’s history and their families (although there has to be

some recognition that this is not all patients-exclusions being out-of-town patients)

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• The GPs are skilled, experienced doctors who have built up good working relationships with the nursing team

4 Positives and opportunities in 11b;

• One doctor a day conducting ward rounds. Patients can be seen in order of clinical priority.

• There will be a doctor with responsibility for the ward patients in the hospital 24/7

• There will be a feeling of the hospital being ‘one team’ with increased opportunities for the nursing teams across the hospital to work more closely together- e.g. ENP supporting clinical assessment on the wards

• There are opportunities for RNs to undertake education in enhanced assessment skills if they wish to do so and if it is considered necessary. Some staff have already shown an interest in this.

• Designated ward time would means that doctors could be fully engaged in AT&D policy- attending daily multidisciplinary ‘Board meetings’ and arranged case conferences

• Breakfast and medicine rounds would be over by the time the doctor came on the wards leading to improved care experience for patients.

• Would allow for better planning and use of RN time and skills • The HCAs would be more supported by RN with hands-on care • Patients would benefit from an increased RN input to care delivery

4 Potential issues with option 11b; • Patients might not like it • There is a perception that we are losing something • It’s change!

5 Other points to note; The GPs being independent ‘contractors’ means they have some level of choice about how engaged they are with initiatives such as; • The Model of Care work • The joint NHS Highland & A&B Councils Admission, Transfer & Discharge

Policy Currently this is variable across the individual GPs and practices. • Since Nov 2012 there are only 2 GP practices covering the ward rounds.

Although there are the same patient numbers, this already feels more efficient. • Nursing staff have always had the opportunity to tailor their development to the

work they do- until now development for ward staff has concentrated on Dementia, Long Term Conditions and Palliative Care. If the new model means that nurses will require enhanced skills in assessment and triage, then there are staff who are willing to undertake modules to allow them to do that.

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This feedback is the thoughts and reflections of th e ward nursing staff in CCH. Not all staff are 100% in favour of 11b, however th e majority of the staff who commented supported this option with only one of th e staff who gave feedback being against it. The main objection to the model was ‘it is change’ and ‘we like and are used to the GPs’ Staff felt that although there was some argument th at the GPs know their own patients and there are benefits in that, it needs t o be recognised that is only relevant if you were a patient at one of the two pr actices who are currently covering the hospital and only applied for a very s mall part of the week. 19th Nov 2012 Liz Higgins

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Annex 4

Emergency Nurse Practitioners comments on the Casualty and OOH Medical Staff Response to O ption 11b from Dunoon Drs Comment – The Option 11b draft advice sheet cites 24/7 Nurse Practitioner cover; Nurse Practitioner Response - The advice sheet is not the option and we are staffed to provide NP 24/7 cover but if a NP is off or if we have a vacancy then we do occasionally cover with Staff Nurses but they are experienced S/Ns training to become NPs and have telephone support and if it got very busy they call can staff in; this is unofficial but none of us would leave a colleague struggling and this is the way we have always worked, we do not get paid but we get our time back in lieu.

4. Drs Comment - Casualty nursing staff Nurse Practitioners have not agreed to participate in PCEC duties. Nurse Practitioner Response - we do already help with out of hours patients and again this is only in the information leaflet not the option but it is always a possibility)

5. Drs Comment - Ability at present to provide Nurse Practitioner for every casualty shift. No “spare” capacity. Nurse Practitioner Response - I think “at present” is the key part of this statement because we have a NP off at present.

6. Drs Comment - No Nurse Practitioners in wards. Nurse Practitioner Response - Enhanced skills for ward nurse were mentioned in order to clerk transferred patients back from IRH. Again this is not mentioned in the option and it is only the option that I have gone over with the nurses.

Drs Comment - There have also been repeated claims that the current 'doctor heavy model' impedes nurse development yet we are also told that funding is not an issue for nurse development - so why or how does the current system stop nurse development or increased skill range or responsibility of nurses? Nurse Practitioner Response - I do not think that the NP’s are impeded in the present model but I do think that NP’s would see more patients in the new option because the doctor would be in the wards some of the time. What I think would really help the less experienced although fully qualified NP’s would be for the doctors to take on the role of mentor. Instead of taking over the care of a patient that the NP has not managed to treat or refer completely and take the NP with him/her and mentor the NP through how they can complete the care of the patient all the way through. Drs Comment - There has been an alarming turnover of nurse practitioners in casualty since the start of the review process. Nurse Practitioner Response - Only one NP has retired in the last 11 months from a fulltime post to working 2 days a week and in addition her fulltime post has been filled with a new staff member who has 2 degrees & 6yrs experience in a Glasgow A&E and is completing the NP

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course which will be complete at the end of 2013. We are actually better staffed than we have ever been. All the nurses in Casualty can see and treat patients within their scope of competence this includes SNs and staff training to become NPs. Drs & Nurse Practitioner Response There is a group of very experienced nurse practitioners and prescribers who have retired in the last year and while some do a bit of bank work and others are being trained up, casualty nursing is less skilled now than it has been for years.(This is inaccurate information.) How long it will be before the new nurse practitioners in training have finished their training? (The New NP will be fully qualified NP at the close of 2013 but is already able to see and treat discharge and / or refer patients within her scope of competence) we're told there is a full complement of nurse practitioners but this is disingenuous as some (only one ) of them have only just started the course and are fairly inexperienced. Two NPs retired one 3yrs ago & one 2yrs ago & one NP emigrated 2yrs ago.

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ANNEXE 5 –

COWAL 24/7 PUBLIC REPS RESPONSE

20th Nov 2012

Notes In attendance Heather Grier 24/7 co chair, Cowal Locality Public Partnership Forum, Strachur community Lorna Ahlquist, Cowal Community Care Forum Development Officer and public rep support Kate Stewart Cowal Locality Public Partnership Forum, Tighnabruaich Community Tom Law Hunter’s Quay Community Council Fulton McInnes Hunters Quay Community Council Dennis Bolt Lochgoil Community Council Evelyn Hide Cowal Locality Public Partnership Forum chair and Dunoon community Purpose The meeting was a support meeting for public representatives to prepare for 22nd Nov meeting. A review of 24/7 OA to date was done and key papers discussed.eg all available papers as asked for after Sept 18th meeting. The Ward and Casualty papers from Nurses were clear and digestible. The Doctors paper often lacked evidence so that is still sought, lacked any positives or ideas about how to move forward. Evidence is still awaited from Dr McLaughlin also and some clarification of statistics from the CHP. The service needs to be patient centred. Keeping this clear focus will help to guide the development of the model. The following points were made from the viewpoint of public representatives 1 FLEXIBLE CENTRE MODEL

a) Option 11b is a flexible centre model, not a one centre model. This seems to get lost. It does seem to become a one centre model on Sat & Sun 8 am – 6pm. Does this need revisited? b) Rural PCECs are to be used . The way they would be used would be determined by a range of things and flexibility and judgement would be key. All rural surgeries should be available for use and any issues re the security of drugs and patient records should be resolvable. This needs to be worked through. Factors to consider

• principle that patients are seen in a PCEC wherever possible • clinical need • the rural GP rota – who is on and where they are based.

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• whether the GP goes to the PCEC nearest the patient or the patient goes to a rural PCEC the doctor is based in.

• in extreme circumstances the patient may go to Dunoon if the rural GP is dealing with other patients.

• weather related • what OOH call outs there are and their proiritisation

c) There is a desire to see existing Rural GPs on the Rural OOH rota. Even if new GPs/Doctors are appointed the principle of minimum use of locums and an integrated team approach results in known colleagues providing the services. d) There may be operational difficulties in using surgeries as PCECs but Public Reps feel this is possible. If there are serious issues to be resolved then those need to be concretely stated so they can be evaluated. e) The use of PCECs and the flexible centre model remove several of the difficulties raised by Doctors in their paper. f) South Cowal PCEC is located within CCH Casualty yet seems to have an unclear existence which needs definition. g) NPs seem to be clear that they help out with PCEC at times. Will that be formalized and extended? Details needed. 2 LOCUMS It is a principle that locums should not be used or used as little as possible should be established to underpin the model 3 ROTAS a) It is expected that the rota system could be worked so that no GP is overburdened with daytime surgeries and OOH cover at night or at the weekends. b) It is hoped that current rural GPs will provide this weekday service. There is only one single handed practice, therefore it would appear that there is potential for the rota system to work without being onerous. c) Sat and Sun could utilise salaried Doctors, if so Rural GP issues regarding rotas become solvable? d) clarification needed about who it is envisaged will staff the rota especially weekend. 4 STAFFING LEVELS It has been acknowledged that public holidays need more cover. A request has been made to cost that into the model. This removes one of the issues raised by Doctors. 5 RISK, STATISTICS AND MATERIALITY a) There remains a lack of clarity regarding the statistical base albeit it has improved.

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b) We need more accurate data on OOH calls for rural AND for South Cowal. It is important to be clear about both, and their patterns, if the visiting doctor post is to be manageable. c) Rural OOH visits have been analyzed but South Cowal has not. There is some disquiet about extrapolating that visits can be reduced to 12. d) The suggestion that a working group look at data was not taken up from the Sept 18th meeting – there has only been some increased sharing of data as opposed to a systematic evaluation of what data we have and what the gaps are. e) Doctors are worried about the level of risk in op 11b. does there need to be more work on evidencing that the level is too high or is acceptable? This comes down to?;

• activity level, • areas of work to cover • the balance of care between the CCH doctor, visiting doctor, ward and casualty nurses, • the impact of Model of Care, MH and PC, ( see 11 below) other eg BASICS MIMMS.

6 CLARIFY THE MODEL a) It is felt that the model is not yet well understood therefore more clarification is needed. b) It would be helpful to have a diagrammatic depiction as for the OA reports and leaflets. c) This should show Nurse and Nurse Practitioner input to the model as this is crucial to see if the model works re workload of Doctors at the CCH PCEC and on the Wards. 7 NURSE PRACTIONERS a) Reviewing the Ward and Casualty Nurses papers, it is felt that clear arguments have been made to justify an extended role.

• The increased involvement of NPs seems feasible • the Doctor cover of Casualty, Wards, PCEC may then be feasible.

b) If this is still not seen as feasible by the Doctors then further evidenced discussion is needed. It was not clear if Doctors and Nurses were talking about the same or different levels of clerking for example. c) There seems to be some operational objections to increased use of NP that appear to be able to be overcome or planned in as part of a transition period. d) Transition from one model to another should be clearly planned and any issues highlighted and resolved. For example, would more nurses be needed to ensure backfill is systematically possible. 8 DOCTOR WORKLOAD

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a) It was felt that doctor workload needs more discussion and evidence. To date the evidence tabled on activity rates shows capacity. Doctors have provided some ( 2?) scenarios where there have been issues in workload in rural Cowal and in CCH. b) If there have been more such incidents these need to be shown and the frequency of periods of overload shown. c) this then needs a risk analysis to see whether the level of risk is acceptable or not d) if it is potential solutions need to be looked at eg the OOH visiting Doctor is to be called in to back up the Hospital Doctor in op 11b. Does this solve the problem? Community Nurses are moving towards working until 10pm with anticipatory care in place, does this decrease the risk or not? e) It was noted that Dr Chris Taylor felt that working across wards and Casualty could be attractive re skill development and interest. He also felt that Casualty and the Wards could be covered by one doctor. This needs to be considered. f) Developing the role of Nurse Practitioners also needs consideration regarding workload. g) Our understanding is that Doctors will retriage not nurses – confirm this 9 CLINICAL LEAD a) The lack of a Clinical Lead needs to be addressed. Is it the intention to appoint one? If not why not? b) If appointed, what issues does this resolve for op 11b or indeed any other model? 10 OPERATIONAL ISSUES Some operational issues seem to be ‘getting in the way’ eg weekend discharge. There appear to be issues that need resolved whatever the model is. It is expected that they must be resolved 11 OTHER REDESIGN IMPACTS a) Psychiatric Patient Retrieval There are some options in this OA which would impact on Doctor workload. The responses to the PPR consultation needs to take account of workload issue. The impact of any model that involved overnight stays in CCH would need to be evaluated. b) Model of Care Redesign This will involve more people staying at home and would seem to be attempting to stop people arriving at hospital. The impact of this needs to be considered as does the Anticipatory Care Model.

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The Model of Care will involve Ward meetings ATD – it would seem very important for the GP/Doctor to be part of that meeting. Therefore the timing of GP/Doctor input on the Wards would appear to benefit from being regularized to take this into account. c) Palliative Care Redesign A new model is operating in Cowal Hospice and Supported Care Ward were there are 4 palliative care beds with designated staff who rotate between admissions/acute and CHSC on a 3 – 4 month rota. There are also 2 supported care beds. As the model develops there will be more integration between community and hospital palliative care: people will be supported over long periods of time with pc needs both in the community and in CHSP: people will increasingly make positive choices about where they want to die, with the expectation that more will die at home as per Gov policy and patient wishes. The reality of the designated staff and beds needs to be considered as well as the balance of Doctor/GP input v nursing input for this model. How do other hospices manage shifts? It would be helpful to have evidence from other areas re how Doctor cover is arranged and continuity issues dealt with. 12 GP/DOCTOR WARD ROUNDS a)It may be that the timing of the GP/Doctor input to Wards might be better if it was after protected meal times and nursing tasks am, and allowed input to the lunchtime ATD meetings as above. eg 11am – 4pm or similar. b) It would appear that there are strong arguments for the reorganization of ward cover by Town GPs on the grounds of efficiency for Nursing staff, patient benefit from protected breakfast time and skilled nursing input at key times am. c) It is hoped that GP skills and experience is retained in CCH. d) If there are issues remaining after consideration of the Nurses papers these need to be listed, evidenced and clearly evaluated as resolvable or not. d) If a GP is to cover a timeframe of 5 hours per day, is this feasible to do as a rota from the two GP practices still covering CCH or indeed to include the 3rd practice if it were to come in again? 13 CONTINUITY a) It is recognized that continuity is important. However, it only operates for Town practices and for some patients not all within those practices, and only in hours not out of hours. b) Therefore to make this a key argument for redesign as opposed to one in a set of factors to balance seems to give too much weight to it. c) There may be evidence of the importance to Town patients of being looked after by their own GP. It is important to ask that question but also the ‘what would you rather have out of the limited NHS funds available, x or y’ questions.

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d) For rural patients there is often a different perspective eg the desire for a good high quality service with good information sharing regarding their clinical needs via a variety of systems, rather than who the doctor is. e) Therefore the arguments about continuity do not seem to provide;

• enough of that kind of continuity • for a high enough percentage of patients

……..to be a major consideration as opposed to part of the balancing of an integrated efficient service.

Lorna Ahlquist notes of Public Reps meeting 20th Nov 2012

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Agenda item : 14b

Service Options Cowal 24/7 Review Of GP Out Of Hours and GP Hospital Services

Identification of the Preliminary Preferred Option by

the Cowal 24/7 Group 26th July 2011

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Preliminary Preferred option Report Version. 5 2

Contents

1 Introduction 3

2 Results 3

3 Option Appraisal Outcome Assessment 12

4 Identification of Preliminary Preferred option an d

Recommendation 14

5 Next Steps 15

Appendices

o Appendix 1 Cowal 24/7 Group Members

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Preliminary Preferred option Report Version. 5 3

Service Options Cowal 24/7 Review Of GP Out Of Hour s and GP Hospital Services

Introduction

1. The purpose of this paper is to present the findings of the option appraisal process and the recommendation from the Cowal 24/7 Review Group and their identification of the preliminary preferred option to provide GP Out of hours and GP Inpatient service in Cowal Community Hospital.

2. The option appraisal process used for this process is in line with that recommended by the Scottish Government Health Department (utilising the technique and methodology in the Scottish Capital Investment Manual (SCIM) and the Scottish Health Council guidance regarding developing and appraising options. The process adopted has been proportionate to the scale of change proposed.

3. The option appraisal process involved assessing the following:

■ Non Financial Benefits (scored against agreed criteria) – Report 21/07/12

■ Risks- Report 21/07/12

■ Costs (Affordability) – Report 04/07/12

■ Value for Money – Report 04/07/12

Results

Table 1 overleaf summarises the results of the benefits appraisal, risk assessment, affordability and value for money assessments. With regard to the benefits scoring, the higher the score the greater the benefits. For the Risk scoring, the lower the score the lower the risks

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Preliminary Preferred option Report Version. 5 4

Table 1 – Final Option Appraisal Scores and Costs

Option

Non Financial Benefits (consensus) Score

Risk Assessment Score Budget*

Cost Revenue*

Affordability £

Option 1 – Existing Service 524.18 98

£1,240,000

£1,240,000 £0

Option 2 – Existing service except Rural GPs extend coverage to Ardentinny 524.18 98 £1,240,000 £1,240,000 £0

Option 4 – Existing service except Lochgoilhead included in Rural GP service 545.39 96

£1,240,000

£1,230,000 £10,000

Option 6 – CHP employed Drs provide OOHs service with SAS/Nurse Practitioner support & Town GPs provide day time inpatient service 547.42 105

£1,240,000

SAS £1,332,000

Nurse

£1,289,000

SAS

-£92,000

Nurse

-£49,000

Option 7 – CHP employed Drs provide Hospital & Casualty service, Consortia of GPs provide OOHs service whole of Cowal 342.39 212 £1,240,000

No Cost NA

Option 8 – CHP employed Drs provide Hospital Inpatient OOHs & Weekends & Casualty 24/7. Consortia of GPs provide 397.94 179

£1,240,000 No Cost NA

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Preliminary Preferred option Report Version. 5 5

Option

Non Financial Benefits (consensus) Score

Risk Assessment Score Budget*

Cost Revenue*

Affordability £

day time Mon-Fri inpatient service. Consortia of GPs provide OOHs service whole of Cowal,

Option 11 – CHP employed Medical Staff based in Cowal Community Hospital cover the Casualty, Inpatient and Out of Hours service for the whole of Cowal from the hospital 586.82 181 £1,240,000 £1,224,000 £16,000

.

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Preliminary Preferred option Report Version. 5 6

4. Table 2 provides a qualitative analysis of the key advantages and disadvantages of each of the short listed options.

Table 2: Key Features of Short Listed Options

Option Advantages Disadvantages

Option 1 – Existing Service

1. Existing service - known and

familiar 2. Town GPs know and look after

patients from their own practice Mon-Fri at times between 8 am to 6pm

3. Town GPs involvement supports continuity of care from community to hospital for their patients

4. Rural OOH service designed to meet rural need, easily meets demand and provides an on call doctor

5. Has joint 4th highest level of non

financial benefits 6. Has the joint 2nd lowest risk rating

1. GP’s from Town practices

rather than one Doctor on the Ward it could be harder to ensure integrated and multidisciplinary working e.g. impact on protected meal breaks for patients - patients meal times disrupted

2. Rural Cowal OOH activity is

very low 3. Value for Money (VfM) • assessment is the worst

regarding inpatient input with combination of hospital and GP day time- £298,000 assessment is the worst re rural OOHs £240,000 - £9,908 per patient contact

• Would produce no saving on the available budget

Option 2 – Existing service except Rural GPs extend coverage to Ardentinny

1. If Town GPs opt to submit a

tender and win the contract provides continuity between hospital and community for their patients Mon-Fri at times between 8am to 6pm including rural practices

2. Rural OOH service designed to meet rural need and easily meets demand and provides an on call doctor

3. Similar to existing service - known and familiar

4. Increased area of responsibility of Rural GPs covering a wider area to Ardentinny,

5. Has joint 4th highest level of non financial benefits

1. Rural Cowal Out of Hours service

activity is very low 2. Town GPs do not win the

contract there is no continuity between hospital and community for their patients Mon – Fri at times between 8am – 6pm including rural practices

3. GP’s from Town practices if win contract then rather than one Doctor on the Ward it could be harder to ensure integrated and multidisciplinary working e.g. impact on protected meal breaks for patients - patients meal times disrupted

4. 5. Value for Money (VfM)

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Option Advantages Disadvantages

6. Has the joint 2nd lowest risk rating

• assessment is the worst regarding inpatient input with combination of hospital and GP day time- £298,000 6. assessment is the worst re rural

OOHs £240,000 - £9,908 per patient contact

7. GP’s from Town practices if win contract then rather than one Doctor on the Ward it could be harder to ensure integrated and multidisciplinary working e.g. impact on protected meal breaks for patients - patients meal times disrupted

4 Would produce no saving on the available budget

Option 4 – Existing service except Lochgoilhead included in Rural GP service

1. • If Town GPs opt to submit a tender and win the contract provides continuity between hospital and community for their patients Mon-Fri at times between 8am to 6pm including rural practices

2. Offers an OOH service with 1 doctor on duty at the Hospital and 1 on-call doctor

3. Rural Cowal OOH service designed to meet rural need and easily meets demand and provides an on call doctor

4. Similar to existing service - known and familiar

5. Has the 3rd Highest non financial benefits

6. Has the lowest risk score

1. Rural Cowal Out of Hours service

activity reported is very low 2. If Town GPs do not win the

contract there is no continuity between hospital and community for their patients Mon – Fri at times between 8am – 6pm –

3. GP’s from Town practices if win contract then rather than one Doctor on the Ward it could be harder to ensure integrated and multidisciplinary working e.g. impact on protected meal breaks for patients - patients meal times disrupted

4.

5. Value for Money (VfM) • assessment is the worst regarding inpatient input with combination of hospital and GP day time- £298,000 • Assessment is. worst re rural OOHs £240,000 - £9,908 per patient contact 6. Would produce no saving on the

available budget as only notional 10k saving on paper only

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Preliminary Preferred option Report Version. 5 8

Option Advantages Disadvantages

Option 6 – CHP employed Drs provide OOHs service with SAS/Nurse Practitioner support & Town GPs provide day time inpatient service

1. If Town GPs opt to submit a tender and win the contract provides continuity between hospital and community for their patients Mon-Fri at times between 8am to 6pm including rural practices

2. Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

3. Saturday and bank holiday Out of Hours drop in GP surgery in one of Strachur, Lochgoilhead or Tighnabruaich. This may meet the busiest period of Out of Hours activity Not clear

4. Has the 2nd highest level of non

financial benefits 5. Has the 4th lowest risk score

1. From 11pm to 8am the Doctor would not leave the hospital so there are no home visits by a doctor, bar detailed below. Patients may have to travel to hospital

2. However Doctor will always have to attend a small number of Home Visits e.g. care homes, palliative, care, mental health, so the hospital is left with no medical cover which could affect its emergency status during period if doctor can’t return quickly to the hospital

3. If Town GPs do not opt to submit a tender and win the contract, they would not be looking after patients from their own practice Mon-Fri at times between 8 am to 6pm

4. GP’s from Town practices if win contract, then rather than one Doctor on the Ward it could be harder to ensure integrated and multidisciplinary working e.g. impact on protected meal breaks for patients - patients meal times disrupted

5. 6. Single Doctor on duty is different

to the service provided in Kintyre which has 2 doctors on duty for Out of Hours and hospital

7. The Nurse practitioner staffing option costs £49,000 more then the available budget. The SAS practitioner staffing option costs £92,000 more then the budget. This option is not affordable

8. Value for Money (VfM) assessment is better then a salaried service as it requires less Drs and service would cover the whole of Cowal

Option 7 – CHP 1. Majority of rural Cowal can be

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Preliminary Preferred option Report Version. 5 9

Option Advantages Disadvantages

employed Drs provide Hospital & Casualty service, Consortia of GPs provide OOHs service whole of Cowal

reached within 1 hour from Dunoon if there are no delays

2. Service expected to be responsive for Out of Hours and hospital/casualty

3. Single hospital medical team offers greater opportunity to coordinate and integrate multidisciplinary working in hospital

1. Town GPs would not be looking after patients from their own practices Mon-Fri 8:am to 6pm and providing continuity of care between hospital and the community

2. If Out of Hours GP is not in the Hospital because of doing a home visit, patients may go to Casualty instead of the PCEC

3. Risk of an increase in locum doctor use for Out of Hours service

4. Has lowest level of non financial benefits

5. Has the highest risk score 6. Value for Money and affordability

assessment cannot be made as there is supplier identified for the service

Option 8 – CHP employed Drs provide Hospital Inpatient OOHs & Weekends & Casualty 24/7. Consortia of GPs provide day time Mon-Fri inpatient service. Consortia of GPs provide OOHs service whole of Cowal,

1. If Town GPs opt to submit a

tender and win the contract provides continuity between hospital and community for their patients Mon-Fri 8am to 6pm including rural practices

2. Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

3. May be more attractive to recruit GPs/Drs for designated service areas - Casualty, GP Out of Hours & Hospital ward.

1. Risk of an increase in locum

doctor use 2. If Town GPs do not win the

contract there is no continuity between hospital and community for their patients Mon – Fri 8am – 6pm including rural practices

3. Has the 3rd highest risk score 4. Has the 2nd lowest benefit

score 5. Value for Money and

affordability assessment cannot be made as there is supplier identified for the service.

Option 11 – CHP employed Medical Staff based in Cowal Community Hospital cover the Casualty, Inpatient and Out of Hours service for the whole of Cowal from the hospital

1. 2 Doctors employed by the CHP may provide greater opportunity to co-ordinate and improve continuity of hospital, casualty and OOHs care

2. Offers a financial advantage by improving the efficiency and flexibility of workforce (matching patient demand/activity across

1. Town GPs would not be looking after patients from their own practices Mon-Fri 8:am to 6pm and providing continuity of care between hospital and the community

2. Has the 3rd highest risk score 3. This is a single centre option and

unless proper transport solutions

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Option Advantages Disadvantages

hospital, Out of Hours and casualty 24/7- potentially less Drs on duty 8am-6pm Mon-Fri)

3. Majority of rural Cowal can be reached within 1 hour from Dunoon

4. Has the highest non financial benefits score

5. Is affordable within the budget and produces a slight saving of £16,000

particularly for the rural communities are put in place, there could be possible difficulties for patients coming to the Dunoon PCEC.

5. The Cowal 24/7 Review group when undertaking the Option Appraisal process continually reflected on the feedback received from the community, stakeholders and professionals including the information recorded at the drop in events, feedback forms, video submissions of members experience of using the service..

6. To this end the a number of points were considered as material in informing the scoring and assessment process and these are detailed below:

• Tighnabruaich residents submitted the most responses • Importance of having a doctor in the hospital and a doctor covering the out of

hours work rural and urban • Concern over travel time and response not only from Dunoon but also if the

doctor is on a call in Tighnabruaich and has to get to Lochgoilhead or vice versa

• Concern over the emergency response (999), the role of Scottish Ambulance service, doctors and how a first responder scheme could support this

• Doctors making better use of surgery premises to see patients out of hours in their community

• Difficulties in access pharmacy drugs out of hours • Preference for a local service based in community • Response times – especially if the doctor is required in two places at the same

time and a call occurs at the same time • Acknowledgement that the service is costly and some 1 centre options offered

better value for money • NHS 24 experience was generally varied but clear public confidence

concerns and information lacking as no representation from NHS 24 • Patient’s choice in using their own transport to take patients to Primary Care

Emergency Centres at Vale of Leven or Dunoon or Strachur. • Concern regarding the availability of taxis to the rural areas to either bring

patients into and back from PCEC when required • Options which require the existing doctor from the Dunoon Hospital base to

attend local house-calls in rural Cowal which result in deploying the doctor from casualty for an extended amount of time ( >1 hour) would represent an unacceptable level of clinical risk.

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• The loss of local doctor input is deemed by the community as a diminution of service as alternative options which do not provide a rural based service will result in response times being longer even if they are within the “performance standards of the service”

• Anxiety that the loss of a local GP out of hours service exposes the community to a greater risk of a worse outcome in an emergency situation notwithstanding: o Emergency 999 activity is low and the Scottish Ambulance Service will

respond from units based in Dunoon or travelling through the area o The GMS GP out of hours service does not respond to emergencies. Its’

criteria is: � Urgent: Within 1 hour. � Less Urgent: Within 2 hours. � Routine: Within 4 hours

o Audit and review of NHS 24 initiated GP Home visit activity identified of that 50% of home visits should have had different response e.g. delayed patient treatment as an ambulance response was actually required

o The GP out of hours activity in the rural area is very low less then 1 a week

• Day time medical workload in casualty and the ward was felt by the Doctors to be greater then 1 Doctor could provide at certain times?

• Opportunities to enhance the skills of the nursing workforce and change from current method/system of medical input would reduce medical demand as evidenced by service change in the Western Isles, Skye and in other community hospitals in Argyll.

• The SAS Paramedic Practitioner model used to augment the out of hours service as part of a team approach was operating successfully in Killin and was seen as attractive by respondents from rural Cowal.

• The scoring process used provided a “blind” individual vote followed by a discussion and subsequent recast vote to obtain a consensus view by group. It was clear at times that whilst the consensus view of delegates was developed and agreed, the representatives of the communities indicated a higher or lower score reflecting their communities’ perspective.

• There was recognition that different options had different impacts on the core

service provided within the hospital and the appraisal and final consideration process will need to take this into account.

7. The Cowal 24/7 review group also considered the responses it received to the invitation to tender for elements of the service:

o GP out of hours service either for the: o Whole of Cowal o Rural Cowal – Tighnabruaich, Strachur and Lochgoilhead

o Day Time ( Mon-Fri) Community Hospital Inpatient Service in Cowal Community:

A total of three tender responses were received:

• Town GPs willing to continue with hospital in-patient services at current rate.

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• Rural GPs willing to continue with rural out of hours service at current rates.

• Dr Coull of the Strachur Medical practice offering to provide rural out of hours service for £165k per annum. (This is £75k per annum less than current costs)

In addition the SAS submitted costs to establish a paramedic practitioner services for the whole of Cowal, overnight 11pm to 8am, for £177k per annum plus start up costs of c£75k.

Introducing the results of the tender into the various options produces the affordability results detailed in table 5 below:

Table 5- Tender submissions and impact on Short lis ted options costs

Rank Option Annual Cost (000)

Saving/ Overspend

1 Option 4 with Dr.Coull's tender £1.155m £85,000

2= Option 1 with Dr.Coull's tender £1.165m £75,000

2= Option 2 with Dr.Coull's tender £1.165m £75,000

4 Option 11 £1.224m £16,000

5 Option 4 £1.230m £10,000

6= Option 1 (current service) £1.240m £0

6= Option 2 £1.240m £0

8 Option 6 with Nurse Practitioners £1.289m -£49,000

9 Option 6 with SAS £1.332m -£92,000

This exercise shows that Option 4, based on Dr Coull’s tender would produce the greatest saving against the budget. Savings would also be made for options 1, 2 and 11.

The Tender submission process also assesses tenders against a number of other criteria:

• Proposed personnel for the scheme - The proposed medical workforce how sourced and qualifications. Sustainability of staffing arrangements

• Experience of providing the service - What experience you have of similar work, which you can bring to bear on this scheme What references can you provide

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• Programme - You are aware of the desired start date (Nov 2012) Do you see this as achievable and realistic? How you would ensure that this date is met?

• Approach to the service - What activity you would undertake in the first 6 weeks following appointment to ensure effective mobilisation of the service What would you propose in order to ensure there is seamless transition, which minimise associated costs and speeds integration How would you add value to the service

• Affordability and Value for money assessment - How does cost compare to budget How does cost compare to activity & demand profile and access and availability requirements

The CHP is to undertake further discussions with the tenders to clarify their responses with regard to these criteria. Responses will be taken into account in informing the outcome of the option appraisal process once the preferred option has been identified.

3 Option Appraisal Outcome Assessment

8. The Cowal 24/7 Review workshop on the 4th July 2012 considered the findings of the option appraisal process in the reports and outcomes of the workshop listed below.

o Non Financial Benefits (scored against agreed criteria)- report 14/06/12

o Risks- report 21/06/12

o Costs (Affordability)- Report 04/07/12

o Value for Money (Economic Appraisal)- Report 04/07/12

9. The project group review and consideration of the qualitative and quantitative features of the option appraisal and the other information identified clear conclusions which were used as the basis for deselecting particular options or differentiating the overall benefits delivered by the alternative solutions. This assessment is detailed as follows:

10. Options 7 & 8 –can be deselected at this juncture as there was no service provider identified to deliver the out of hours service for the whole of Cowal. Further these options had the lowest non financial benefits score and the highest risk scores

11. Option 2 – was deselected based on tender information supplied, as it was clear from the risk and non financial benefits scoring and the affordability and value for money assessments this had no discernable difference to option 1. Members felt the lack of a material difference between the options did not warrant its continued inclusion.

12. Option 4 and 1 - these options in characteristics terms were also very similar, the only material difference between the options was the inclusion of Lochgoilhead within the out of hour’s service within Cowal. Consequently the financial (only on paper saving) and affordability assessments of both options were basically the same. This similarity resulted in very similar risk and non financial benefit scores. Option 4 scored higher in accessibility with regard to the rural out of hours score.

13. Members also felt that an important point in both these options were perpetuating the existing rural out of hours arrangements and current day time

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medical input in terms of organisation and delivery around practice hours (Mon-Fri day time only) . The activity assessment showed significant over staffing for the activity need and inefficient use of resources.

14. Also it was reflected the local GP cover was only 50 hours out of 168 per week and therefore the continuity care aspect was broken. It was acknowledged by members that the majority of medical inpatient input was required during the day and that alongside the casualty workload this was possibly greater then 1 doctor input. It was also noted that the options were not making best use of the full capability of the Nurse Practitioners in Casualty.

15. Members therefore felt that both these two options were not fit for purpose and based on tender information supplied, should therefore be deselected.

16. Options 6 – delivered a high level of non financial benefits and low risk score. However it did not offer good a VFM rating and affordability either as a nurse practitioner or paramedic practitioner option being more expensive then the available budget.

17. Members acknowledged that the Paramedic practitioner model had been deemed attractive particularly by members of the rural community with a reassurance of a quicker response time. The examples of the service working alongside the GP out of hours service in Killin and on the Skye clearly showed its value as part of a team response, but it could not replace for a GP response. It was also noted to recruit and train a paramedic practitioner as a discrete service would take 18 months.

18. With regard to the Nurse practitioner option, it was noted by members that nursing staff whilst having the necessary skills were not trained for the “road” nature of this role and this could prove a barrier to recruitment. The SAS were clearly the most appropriate service to undertake this.

19. Members felt that taking al this into account that both these options were not fit for purpose and should be deselected.

20. Option 11 , had the highest score the in non financial benefit criteria in the consensus score. It was noted that option fell to 3rd place in the optimistic scoring, and then to 5th in the pessimistic score assessment for benefits delivered. This variation in scoring was reflected in the risk assessment of this option with it having the 2nd highest risk score. Particularly assessed as having high risk in the area of staffing, safety and capacity and demand.

21. Members reflected that this was a salaried option and offered significant opportunities to enhance the efficiency and organisation of the service across 24/7 for all patients – hospital, casualty and out of hours. However, members assessed that this option did not provide enough medical staff input for inpatients Mon-Fri day time with only 1 doctor on duty. Members also reflected that the 1 centre option would mean patients in the rural area requiring an appointment have to travel to Dunoon and this could be difficult for some patients.

22. With regard to the Value for money and affordability assessments Option 11 had the best affordability rating of all the options producing a small saving of £16,000 against the budget. In VFM terms the option was cheaper with regard to only having 1 doctor on duty day time, However, out of hours the fact there was 2 employed doctors on duty was assessed as being to high compared to the out of hours workload particularly across the 6pm- 8am period and did not therefore over best value for money.

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23. The Cowal review group therefore felt that option 11 did not meet some of the key service objectives with regard to service sustainability relating to correct staffing levels for day time and out of hours, appropriateness of response and cost and hence it was also deselected at this point.

4 Preferred Option

24. Taking into account all of the points above, and the consideration of the material information detailed, the Cowal 24/7 group were clear that none of the options individually would meet the needs of the Community Hospital and GP out of hours service without compromising aspects of service requirements as follows:

• There will be patients who clinically require a home visit

• There will be patients who need an ambulance for clinical reasons

• Patients will make there own choice to attend the PCEC and should be encouraged to make their own arrangements to get there if they require an appointment either via a relative, neighbour or friend. If there is no alternative then the CHP will provide an agreed method of transport.

• The PCEC is the best venue to assess and treat patients

• Leaving the hospital medically uncovered for longer then 30 minutes introduces an unacceptable level of clinical risk

25. Taking this into account, the Cowal 24/7 review group has identified the following service configuration:

• One Centre option which ensures integration across the medical workforce, inpatient, casualty and out of hours to focus on multidisciplinary working and enhancing continuity of care 24/7.

• Establishing a set time for medical input into the inpatient wards Mon-Fri 9am to 1 pm equating to 0.5 doctor.

• Ensuring consistent local triage arrangements to direct patients to the correct response including putting in place arrangements with local rural surgeries to allow patients to attend out of hours appointments at their local surgery (PCEC). Clinical audit had identified that over 50% of current home visit activity was not the best response for patient need.

• Putting in place a cost effective responsive to the actual rural and urban out of hours activity in Cowal. This informing the type of resource that is configured to meet appropriate need in the form of an on site doctor in Dunoon and an on-call rota covering home visits and PCEC appointments in rural Cowal between 6pm to 8am

492 Home visits Jan-Dec 2011 - triage would reduce this to approx 250) profile of activity during out of hours period is:

o Weekend & Bank holidays 8am-6pm

No. of home Visits

Frequency of Call

No of Rural PCEC

appointments

Frequency of Appointment

230 1 every 5 hours 16 1 every 72.5 hours

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o Evenings 6pm -11pm

No. of home Visits

Frequency of Call

No of Rural PCEC

appointments

Frequency of Appointment

163 1 every 11 hours

10 1 every 182.5 hours

o Overnight 11pm- 8am

No. of home Visits

Frequency of Call

No of Rural PCEC

appointments

Frequency of Appointment

99 1 every 33 hours

3 1 every 1095 hours

Note – Excludes Lochgoilhead activity

• Establishing a single medical team with a designated clinical lead for the whole service

• New roles and job descriptions to staff the service with appropriate flexibility to maximise recruitment and retention opportunities and encourage local GPs and salaried doctors to apply.

• Enhancing the capability and capacity of the nurse practitioners in casualty to allow them to increase the scope and level of activity they provide.

• The cost of staffing the revised model is estimated to be affordable within the current budget and subject to final workforce validation and discussion with the parties who submitted tenders on the validity of their proposals as well as staff consultation process for current CHP employed staff to create the workforce profile.

26. The Cowal 24/7 review group have identified a revised service option which in its view best meets the objectives and service requirements and this is outlined in the table below:

27. The new option can be described as an Integrated Inpatient and out of hours service, Option 11Bs:

28. Its components are:

29. CHP employed Doctors provide;

• Casualty 24/7

• Inpatient care 24/7

• Opportunity for employed a sessional input Mon-Fri 9am-1pm for a GP practice/practices equating to 0.5 doctor.

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• GP Out of Hours service 365 for the whole of Cowal based in Cowal Community Hospital supported by an On-Call Doctor rota to respond to Home Visiting and appointments in rural Cowal PCEC if needed.

• Lochgoilhead can either remain with the VoL service for Out of Hours or transfer to the new service

• Taxi available for any patients who cannot get transport to the PCEC for an appointment

The medical workforce deployed to provide the service is detailed in the table below:

O Option 11 b Shifts Wards Casualty & PCEC

Cowal Out of Hours (Home Visits)

Day Shift 8am-1pm 1 Doctor 1 Doctor

Day Shift 1pm – 6pm 1 Doctor

Evening 6pm-11am 1 Doctor 1 Doctor – on call

Mon –

Friday

Overnight 11pm-8am 1 Doctor 1 Doctor – on call

D Day Shift 8am -6pm 1 Doctor 1 Doctor

Evening 6pm-11pm 1 Doctor 1 Doctor – on call

Sat, Sun & Bank Holidays*

Overnight 11pm-8am 1 Doctor 1 Doctor – on call

Note * - subject to validation of workload Bank holiday workforce may be increased in the day time to meet additional demand in hospital

30. Advantages

• Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

• All home visit requests will be re assessed (re-triaged) by the Doctor or Nurse Practitioner in Cowal Community hospital to ensure the most appropriate clinical response

• An integrated workforce which can respond to town and rural service needs makes the service more responsive

• Single hospital medical team offers greater opportunity to coordinate and integrate multidisciplinary working in hospital enhancing local hospital care for patients in and out of hours

• Reduces the number of times the hospital is uncovered by Doctors out of hours and the risk

• Medical staff on duty is matched to meet the clinical workload and cope with peaks in demand in activity in and out of hours e.g. 2 doctors are on duty at the weekend.

• Reduces the need for locums

31. Disadvantages

• GPs would not be looking after patients in the hospital for own practices except for any practice with a commitment Mon-Fri between 8:am to 6pm

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• If Cowal Community Hospital and its Primary Care Emergency Centre is busy then response to rural Cowal may occasionally be delayed out of hours

• If Out of Hours GP is not in the Hospital because of doing a home visit, patients may have to wait or go to the hospital to see the doctor based there.

The Cowal 24/7 group also conducted a formal appraisal of the option for its non benefits, risks and affordability and value for money on the 26th July 2012. The summary results of the appraisal are detailed in the table below:

Option

Non Financial Benefits (consensus) Score

Risk Assessment Score Budget*

Cost Revenue*

Affordability £

Option 11b - Integrated Inpatient and out of hours service based in Cowal CH provide

676.70 125

£1,240,000

£1,053,000 £187,000

32. This option scores the highest of all the options in the non financial benefit scores. With higher scores against the Capacity, sustainability, efficiency and accessibility criteria and the same score as option 11 against clinical effectiveness as well as being slightly higher with regard to the flexibility criteria

33. The option has however the 5th highest risk score scoring slightly higher then other options against capacity and demand risks reflecting concerns with responsiveness and level of medical resource on in the day during bank holiday periods. It also had a high score against service disruption due to the scale of change with implementing the new model in the short term.

34. Appendix 2 details the non financial benefits and risk score of option 11b.

Figure 1: Key Features and Key Risks of the Preferr ed Option

Key Features:

• Ability to provide a focused and responsive GP out of hours focusing on clinical need via local triage and home visiting service for the whole of Cowal utilising an on-call doctor

• Improving the coordination and organisation of the Inpatient medical resource to

better meet patient needs and maximise the efficient use of the multidisciplinary team to deliver a 7 day a week service.

• This new service aims to be flexible providing greater integration between the medical

staff and the multidisciplinary team in the hospital for inpatients, out of hours and casualty patients.

• This model will ensure the quality of patient service is maintained and its flexibility will

not only deal with peaks and troughs in activity but ensure a sustainable out of hours

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service for all Cowal residents • The option is affordable within the budget and offers the best value for money and

would produce a saving of £187,000 Key Risks:

• Ensuring adequate staffing levels during bank holiday periods particularly over 4 day holiday periods and Cowal Games

• Managing the change and transition process to the new service model ensuring workforce is reconfigured in partnership and supporting infrastructure is in place regarding triage, hub organisation and transport etc.

• Ensuring the nurse practitioner role is developed to maximise their capability and capacity within the casualty and minor injuries service

• Ensuring transport is available for patients to attend PCEC if they cannot make their own arrangements covering Cowal

• Scottish Ambulance Service activity increases due to inappropriate use for GP out of hours response

5 Next Steps

35. Prelim preferred option identification & clarification option presented to Cowal 24/7 group meeting- 26th July

• Preliminary option appraised for non financial benefits and risks

36. Preferred option final clarification meeting – 14th August

37. Meeting with the parties who submitted tenders on the validity of their proposals and presentation of preferred option for opportunity to resubmit/review – Aug/Sept 2012.

38. Final Outcome report of Option Appraisal considered at Cowal 24/7 Project Group meeting to identify a preferred option –23rd August 2012

39. Preferred option is taken out to staff, the public and stakeholders to obtain their comments and feedback - August/September 2012

40. Cowal 24/7 Project Group review feedback and make recommendation/s on the preferred Option- 27th September 2012

41. Cowal Locality, Argyll and Bute CHP Management Team and CHP Committee consider the Option Appraisal outcome and recommendation report and make a decision on which option to implement- September/October 2012

• Cowal Locality Management Team 1st October

• CHP Management Team 10th October

• CHP Committee 31st October

Subject to the CHP decision the outcome will be to:

o Notify the local community of the outcome of the option appraisal process, including:

o Recommendation made and decision taken by the CHP committee via the agreed communication process to all stakeholders, public and staff.

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o To explain at the drop in events the service to be implemented and the time scale to full implementation.

o Explain any transition or contingency arrangements which will be put in place.

o To answer any questions from the public, stakeholders or staff.

o Following Implementation a review and monitoring process will be put in place to report back 1, 3 and 6 months on how the service is operating. A suitable process involving members of the review group and representatives of the community will be put in place,

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Appendix 1- Cowal 24/7 Review Group Members

Name Title Deputy

Heather Grier Co-Chair of Cowal 24/7 Group

Dr Brian McLachlan Co-Chair of Cowal 24/7 Group

Dr Chris Taylor Cowal Community Hospital GP Practitioner Deputy for Dr Paterson

Katie Stewart Team Lead – Community Nursing

Stephen Whiston Head of Planning, Contract & Performance

Liz Higgins Acting CSM/ Practice Development Nurse

Evelyn Hide Patient Focused Public Involvement Representative

Mhairi Mowat Patient Focused Public Involvement Representative

Carrie Munro Patient Focused Public Involvement Representative

Kate Stephens Kyles Community Council Representative

Dennis Bolt North Cowal Community Council Representative

Eleanor Stevenson South Cowal Community Council Representative

Mark Benton SAS Representative

Dr P Campbell Local GP - Dunoon

Dr J Pearce Local GP - Dunoon

Dr J Tittmar Local GP – Rural

Councillor Alex McNaughton Local Councillor

Jill McDonald or

Audrey Anderson

NHS24 Representative

John Huband Medical Staffing Representative

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Name Title Deputy? (Y/N)

Roseann Cameron NHSH Hub Representative

Caroline Champion Planning & Public Involvement Manager

David Ritchie Communications Manager

Maggie Clark Long Term Conditions Manager

Alison McCrossan Scottish Health Council

Margo Ferguson or

Lorna Low

RCN – Staff Side Representative

Dawn Gillies or Liz McMillan Unison – Staff side Representative

Lorna Ahlquist Cowal Community Care Forum Development Officer/CLPPF

Co-ordinator

Kathy Graham SCN/Wards

Tom Law Hunters Quay Community Council Representative

Dr Robbie Paterson Lead Clinician - Casualty Deputy is Dr Chris Taylor

Gaye Boyd HR Manager

Karen McMillan SCN/Head of Casualty Department

Dr P Von Kaehne Local GP – Rural Dr Tittmar attending

Tracy Ligema NHSH Hub Representative

Dr Michael D Hall Clinical Director – CHP

George Morrison Head of Finance

Valerie Kennedy Ardentinny Community Council Representative

Councillor Bruce Marshall Local Councillor

Sheila McKechnie Team Lead – Community Nursing

Pat Tyrrell CHP Lead Nurse

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Rank Description Consensus Optimistic Pessimistic

5 Option 1 – Existing Service 524.18 670.64 350.45

5Option 2 – Existing service except Rural GPs extend coverage to Ardentinny 524.18 670.64 350.45

4Option 4 – Existing service except Lochgoilhead included in Rural GP service 545.39 670.64 371.67

3

Option 6 – CHP employed Drs provide OOHs service with SAS/Nurse Practitioner support & Town GPs provide day time inpatient service 547.42 713.06 397.94

8

Option 7 – CHP employed Drs provide Hospital & Casualty service, Consortia of GPs provide OOHs service whole of Cowal 342.39 449.45 217.15

7

Option 8 – CHP employed Drs provide Hospital Inpatient OOHs & Weekends & Casualty 24/7. Consortia of GPs provide day time Mon-Fri inpatient service. Consortia of GPs provide OOHs service whole of Cowal, 397.94 498.94 296.94

2

Option 11 – CHP employed Medical Staff based in Cowal Community Hospital cover the Casualty, Inpatient and Out of Hours service for the whole of Cowal from the hospital 586.82 694.88 322.18

1

Option 11b - Integrated Inpatient and out of hours service Option CHP employed Doctors bsed in Cowal CH provide;• Casualty 24/7, Inpatient care 24/7 & GP Out of Hours service supported by an On-Call Doctor rota to respond to Home Visiting and appointments in rural Cowal PCEC if needed.

676.70 792.85 486.82

Option Overall Weighted Benefits Score

Rank based on concensus score

Option 1 Option 4 Option 6 Option 7 Option 8 Option 11 Op tion 11b

Capacity & Demand for Services 32 32 30 45 76 62 61 42

Staffing 40 40 40 25 60 60 45 35

Safety 9 9 9 9 36 27 31 18

Service disruption 7 7 7 16 24 14 24 20

Reputational 10 10 10 10 16 16 20 10

total Operational Risks 98 98 96 105 212 179 181 125

Rank 2 2 1 4 8 6 7 5

Risk Grouping

Option 2

Probability

Appendix 2 Non Financial Benefits and Risk Score- S hort listed & Preferred option

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Argyll & Bute CHP Committee

Date of Meeting : 19 December 2012 Agenda item: 15

15 MH Services Modernisation Update Report Dec 2012 (3)[2]

04/12/2012

J. Dreghorn Page 1 of 5

Modernisation of Mental Health Services Update Report (December 2012) (3) Report by John Dreghorn 1. Background

The following report provides an update on the implementation of the modernisation of mental health services in Argyll & Bute.

2. Progress Report

� Project Governance/Stage 1 Submission The Capital Project Board met on 16th November and reviewed comments from the advisors and the Project Director regarding the hubco stage 1 submission. It was agreed that significant work was required on the stage 1 submission before it would be fully acceptable to NHS Highland. The Project Director has advised hubco accordingly.

� Stage 1 Approvals As a result of the changes required to the stage 1 submission the project team will be reviewing the approvals timetable. This will be more fully reported in the January 2013 update.

� Inpatient Services The bed compliment reduced to 30 beds plus 3 minimal supervision places in the refurbished Firgrove building on 10th December, when Tigh na Linne closed.

All of the Tigh na Linne staff have been redeployed within the inpatient service.

� Staff Redeployment The redeployment of Admin & Clerical staff is almost complete. Proposals for Estates, Hotel Services, Laundry and Stores establishments will be reviewed by the workforce planning group in January.

� Archive of Mental Health Records All archive Mental Health medical records, including Clinical Psychology, have now been transferred to Box Vault in Livingstone for tertiary storage. The total number of boxes transferred to date is 500. We are currently undertaking a review of our live case notes, when that piece of work has been completed, further boxes of notes will be sent to the archive. Since transferring the records to Box Vault we have had one request for notes from the archive and this was handled efficiently. A fully integrated electronic system to request notes will be up and running by the end of this year with training being provided by Box Vault for relevant staff.

� New Posts

- A Primary Mental Health Care Worker (PMHCW) has now been appointed for Cowal & Bute. The Mid Argyll Kintyre & Islay PMHCW post is currently out to advert

� Budget

- Bridging: The previously reported bridging requirement of £500k for 2012/13 remains unchanged.

- New Service Budget: The projected operational funding gap which has been reported as

reducing in previous updates continues to close. It is expected that the new service will operate within the current mental health budget. The cost of the unitary charge for the new

The CHP Committee is asked to: � Note current key issues and progress against the action plan

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Argyll & Bute CHP Committee

Date of Meeting : 19 December 2012 Agenda item: 15

15 MH Services Modernisation Update Report Dec 2012 (3)[2]

04/12/2012

J. Dreghorn Page 2 of 5

hospital and support services building has yet to be confirmed but will be accounted for within the CHP financial plan from 2014/15 onwards.

� Resettlement Group

The last long term patients in Tigh na Linne were discharged on 10th December. Resettlement plans for a small number of very complex IPCU patients continue to be developed in collaboration with Argyll & Bute Council Social Work Department.

� Implementing Trans-national Telemedicine Solutions (ITTS) Implementing Trans-national Telemedicine Solutions (ITTS) is a Northern European funded programme involving Scotland, Northern Ireland, Norway, Sweden, Finland and Ireland that aims to benefit patients in a variety of ways by:

• Normalising the use of technology into everyday practice • Improving accessibility, situating services in local communities or in patients’ homes • Reducing unnecessary hospital visits • Fostering the development of trans-national knowledge exchange

Video-links have already been used for speech therapy, renal medicine, emergency psychiatry and remote diabetes services in partner countries. Video-links for dementia support have been successful in the north of Scotland and now Argyll and Bute CHP will use the model that is running in Norway to provide video-link advice for psychiatric emergencies. The A&B pilot will begin between clinicians in the Oban, Lorn and Isles sector and psychiatrists at the Argyll and Bute Hospital, hopefully by the end of the year. If successful this service will be rolled out to other areas of Argyll and Bute where a secure VC unit is available for patient interviews. The Centre for Rural Health, University of Aberdeen, is the lead partner organisation and is responsible for evaluation of the project.

� New Hospital Development The lead Architect met with staff users on 13th & 27th November, and 10th December, and with patient and care representatives on 13th November. See floor plans of Clinical Core Building below:- Ground Floor

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Argyll & Bute CHP Committee

Date of Meeting : 19 December 2012 Agenda item: 15

15 MH Services Modernisation Update Report Dec 2012 (3)[2]

04/12/2012

J. Dreghorn Page 3 of 5

First Floor

Design development work continues with input from Architecture and Design Scotland (A&DS)

and Health Facilities Scotland (HFS) regarding compliance with hospital building standards and the design statement. It is now expected that completed stage C designs will be available at the end of January 2013 at the earliest.

� Community Mental Health Service (CMHS)

As reported previously the Community Service Operational Guidelines are being reviewed by a joint NHS and council working group. Once changes have been agreed this document will be considered by the joint management group for introduction across all of the CMHS teams.

� CMHS Team Base

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Argyll & Bute CHP Committee

Date of Meeting : 19 December 2012 Agenda item: 15

15 MH Services Modernisation Update Report Dec 2012 (3)[2]

04/12/2012

J. Dreghorn Page 4 of 5

In early December it was confirmed that £300k of capital funding would be available this year to undertake the hospital conversion work in Campbeltown and Dunoon to house the CMHS Teams. This will complete the development work on the CMHS bases.

� Transfer of Detained Patients An option appraisal workshop which scored the non financial benefits criteria of the 8 short listed options took place on 30 November. Further workshops will take place in January 2013 to complete the options appraisal.

� Place of Safety Review The Programme Director in collaboration with the Acumen Manager continues to visit local hospitals to review place of safety arrangements and to discuss transfer of patients. During December there will be visits to Oban, Mull and Campbeltown.

� Recovery Working Group The Argyll and Bute CHP Recovery working group was initiated in February 2012, meeting on a monthly basis. Members of the group are multi-disciplinary in nature and include representation from ACUMEN and The Scottish Recovery Network. The group is raising awareness and involvement in recovery focused practice and completion of the Scottish Recovery Indicator 2 (SRI2) within clinical areas in Argyll and Bute Hospital and Community Mental Health Teams. Attendance remains encouraging as does the enthusiasm for recovery focussed practice within the group. The SRI2 process is supported by a trained SRI2 facilitator. The SRI2 process is established and nearing completion to action plan stage within the following areas:

Cowal Community Mental Health Team, Dochas Lodge, Dunoon Multi Adult Psychotherapy Service, Argyll and Bute Hospital Succoth Ward, Argyll and Bute Hospital Intensive Psychiatric Care Unit, Argyll and Bute Hospital

In addition to this the Mid-Argyll Community Mental Health Team are now progressing with their SRI2 process later this month. A Wellness Recovery Action Plan (WRAP) training session was provided by the Scottish Recovery Network facilitators for staff and service users in October 2012. A cohort of 19 were involved in the three day workshop focussing upon recovery principles and the skills to utilise WRAP within clinical practice/personal experience to promote wellness and early anticipation of crisis/deterioration in health. In 2013, we anticipate that a number of the WRAP workshop participants will be trained by the Scottish Recovery Network to become advanced WRAP facilitators. Thereafter it is anticipated that we will be in a position to support further WRAP workshops at a local level. The Scottish Recovery Network in partnership with NHS Education for Scotland are hosting an advanced facilitator workshop in December for recovery champions within the SRI2 process. Argyll and Bute CHP have two representations on the cohort of twenty.

3. Summary

During November the hubco stage 1 submission was reviewed and partially rejected. Hubco will now address the issues raised by the project team and submit a revised stage 1 report in January 2013. The concept design continues to be developed with clinical and support service staff involvement. A full stage C design not expected before the end of January 2013.

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Argyll & Bute CHP Committee

Date of Meeting : 19 December 2012 Agenda item: 15

15 MH Services Modernisation Update Report Dec 2012 (3)[2]

04/12/2012

J. Dreghorn Page 5 of 5

Work continues on the development of the OBC but this cannot be completed until the revised stage 1 submission is received. Work has restarted on identifying the best option for patient transfer. This should be completed in early February 2013. If work is completed on schedule, the Kintyre and Cowal CMHTs will be moving into their new bases in April 2013. This will mean that we have integrated or at least co located community mental health teams in all areas. This is a significant step forward in our partnership with A&B Council Mental Health Services. John Dreghorn Programme Director – Mental Health Modernisation

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Argyll & Bute CHP Committee Date of meeting: 19 December 2012

Item No : 16.1 Argyll & Bute CHP

Notes from the ARGYLL & BUTE PUBLIC PARTNERSHIP FORUM (PPF) Meetin g

Held on Tuesday 27 th November 2012 in the Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead

PRESENT Duncan Martin (Chair), Rona Blythe, Anke Brown, Fiona Brown,

Caroline Cecil-Champion, Robin Dodman, Tom Dolan, Stephanie Davy, Stephen Duffy, Moira Newiss, Susan Paterson, Michael Roberts

By video-conference : Cowal – Lorna Ahlquist, Ken Barr, Heather Grier, Evelyn Hide

Bute – Ellen Cromack Helensburgh – Mairi Harvey

Apologies Anne Austin, David Bruce, Christine Darroch, Veronica Kennedy, Lasta King, Jean

Knowles, Derek Leslie, Christine McCourt, Jeanette McIntyre, Viv Shelley, Grace Strong, Margaret Turner, Josie Walker

1 Welcome, Inductions & Apologies

Duncan Martin welcomed everyone to the meeting. Introductions were given.

2 Notes from the previous meetings : 28th August 2012 The notes from the meeting were agreed as an accurate record.

3

Matters Arising 3.1 Representation from Social Work Caroline referred to an action for Duncan from previous meetings where members had expressed concern that despite an undertaking by Social Work to ensure a representative attended Argyll & Bute PPF meetings, Anne Austin had only managed to attend once. With the integration of health and social care, having representation from Social Work is even more important. Duncan reported that he had been in discussion with Anne who confirmed she would attend when possible otherwise would nominate another representative if she was unavailable. Anne had sent her apologies for this meeting and due to other commitments no one else was available to represent Social Work. Members again expressed disappointment.

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4 Patient Central Booking Service Moira Newiss, CHP Business Transformation Manager attended the meeting to share the outcome of the Options Development / Appraisal process which looked at the future provision of Patient Central Booking Service. Some PPF members had been involved in the process. A short life working group was established to review the current patient booking service for local patients. One of the main issues with the booking system currently being used within Argyll and Bute is that localities have different staffing models for booking appointments and as such there is no standardisation across the CHP. Changes in Patient Administration System (PAS) also resulted in a move away from Patient Focussed Booking and more changes are likely in the future and there is a national trend towards a centralised service. Problems with the management of waiting lists and breaches were of particular concern to the CHP. The Review included all medical consultant outpatients (new & return bookings) and any AHP or nursing services using the current Patient Management System. The review did not look at patient booking system used by mental health, in-patients & any AHP or nursing services not using Patient Management System. The boundaries / parameters of the Review included :

• To scope and assess the advantages and disadvantages of a centralised booking service in Argyll and Bute CHP;

• To produce proposals for booking service(s) to make best use of e-health solutions and to reduce unnecessary administrative burdens;

• To improve service performance and efficiency with regard to delivery of the 18 week Referral to Treatment (RTT) programme and wider waiting times agenda;

• To improve patient choice taking into account geography and transport constraints;

• To focus on a customer care approach; and • To ensure efficient use and cost effective use of resources.

The review looked at models being used in other areas such as Glasgow & Raigmore, the cost of the current and proposed models and worked with relevant staff groups and patient representatives to develop options. Eight options were put forward, seven appraised as one option was declared an unviable. These options then went through the Options Appraisal process resulting in a preferred option being recommended to CHP. Whilst some PPF members had already been exposed to the Options Appraisal process, Moira went on to explain what this is for the benefit of other members. The purpose of carrying out an Options Appraisal process is to ensure decisions are made in an open and transparent manner and formally assess the options presented. It also ensures the views of patients, staff and other stakeholders are taken into account in the decision making process. The process looks at non-financial benefits, risks, affordability and value for money. Each option is assessed against agreed ranking / weighting criteria. In terms of the patient booking service, Option 2 a CHP centralised booking model consistently came out on top.

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A business case was presented to the CHP Core Team on 23rd November recommending that Option 2 was the preferred option with the call centre booking service based at Lorn & Islands Hospital, Oban. This was accepted and agreed. The implementation programme will start in the new year but phased to take into account the introduction of a new telephone service for the CHP, the development of a new standard operating policy. Rona acknowledged that a lot of work had gone into the review and asked how flexible the system will be for patients. Moira responded stating that the real benefit in a central booking service is that if a patient will need to wait for an appointment but could be seen in another locality sooner, then this can be offered giving patients greater choice. She said that for most patients they shouldn’t see a significant change. Duncan said that the traditional pathways are dictated by GPs and that sometimes it’s difficult for patients to persuade anything different. He asked what would happen if a patient cancels their appointment, can this appointment be offered to another person on the waiting list. Moira said this already happens in the smaller localities but not in Oban. Anke stated that one of the key problems for patients attending appointments is the need to rely on voluntary ambulance drivers and as such some appointments have to be cancelled or missed. Moira stated that this was a good point and something the CHP is well aware of. Resolutions to such problems should be picked up at locality level. Picking up on the transport issues, Fiona said that there is a lack of transport on Mull and any system should ensure appointments are made around individuals travel commitments. Moira stated that the system can “flag” issues such as this but patients are best placed to identify such problems and work with staff to ensure the best appointment times are offered. Ellen mentioned that not all patients feel empowered to ask for changes in appointment times to accommodate individual patient needs. Heather said having a booking system that could identify patients by postcode and with a common sense approach, this problem could be prevented in the first place although appreciated this would not work for patients accessing appointments in Glasgow / Paisley. Fiona asked why GPs couldn’t highlight this when making referrals. Moira said patients should be encouraged to ask GPs to do this. Duncan said that based on feedback, what is important to local communities isn’t so for NHS Greater Glasgow and Clyde. This is something that other areas outwith Argyll and Bute also experience. When asked when the new system would be operational, Moira said it would be introduced once all systems required to support it are in place. Mairi asked whether the new central booking system would include patients from Helensburgh. Moira said that currently all consultant outpatient appointments are made via Glasgow and there would be no change for patients living in the Helensburgh area. However, appointments for AHP clinics might be affected by the new CHP central booking system. Ellen mentioned that she had spent quite a lot of time at the Options Appraisal meetings and it was good to see and work with other PPF members and key staff present. However, she expressed disappointment that so few clinical staff attended and their absence could be perceived as what is important to patients is less important to them.

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Moira said that staff had been given the opportunity and agreed, their lack of attendance was disappointing. Ken asked why Oban had been chosen as the preferred centre to host the central booking system rather than Dunoon. Moira stated that the CHP Core Team had deliberated over this but Oban was the most sensible location – Oban has the largest compliment of staff and they already operate in the preferred way, staff in other localities have this as an addition to their other duties, consultants are based in Oban and it made strategic and financial sense to locate here. With no further questions, Duncan thanked Moira for attending the meeting, giving a very informative presentation which in turn stimulated good discussion. A copy of the presentation would be sent out with the notes of the meeting

Action CC

5 Feedback from Argyll & Bute CHP Committee and CHP Management Team Argyll and Bute CHP Committee Duncan provided an update from CHP Committee meeting on 31st October. Mull Progressive Care Centre Duncan stated that the new Centre was now open and he had attended a recent public open day which was attracted approximately 400 islanders representing almost 10% of the population. He described the facility as “fantastic” and had heard many positive comments although it is acknowledged there remain some issues to be resolved. The public were worried that Clinics in GP surgeries might be moved to the new facility resulting in a round trip of 100 miles for a few patients, for some of these this would be a huge problem. Fiona mentioned that she had taken this up with Derek Leslie, CHP Director of Operations. Clinical Services Review – GG&C NHS GG&C are currently reviewing clinical services which will have an impact on patients from Argyll and Bute, and will be of interest to A&B PPF members. Michael stated that he was keen to ensure appropriate engagement with local communities takes place. He had been invited to attend the GG&C Annual Review with the intention of asking what their plan was to engage with communities outwith the Health Board area but had to reluctantly pull out at the last minute. Caroline said the CHP are also keen to support appropriate engagement in line with Statutory Guidance and was liaising with the Scottish Health Council. Mairi said that GG&C are somewhat entrenched in their approach to public involvement, historical experience being quite negative. Caroline and Michael stated they were keen to work with GG&C to ensure this perceived trend is improved.

Action MR / CC At the last A&B PPF meeting, Susan referred to the experience of mothers-to-be having to attend Campbeltown Hospital to have their labour confirmed before being advised to travel to Glasgow for delivery. This causes an unnecessary delay on top of an already anxious time for parents. Michael said that unless there were good clinical reasons, he could see no reason why babies could not be delivered locally rather than mothers having to travel huge distances. A more recent example was shared where a mum went

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from Campbeltown Hospital to RAH only to be told to return home because dilation was too low (4cm rather than 5cm). The baby was eventually delivered safely in Campbeltown. Renal Services Duncan stated that renal replacement therapy is not provided within Argyll and Bute, patients receiving dialysis would normally be treated within NHS Greater Glasgow and Clyde (Vale of Leven or Inverclyde) or at the Belford Hospital, Fort William. The CHP recognises that patients would prefer to be dialysed locally but it is important to ensure any service is safe, sustainable and cost effective. The CHP is looking at current and projected future demand for renal replacement therapy and Caroline stated that to support this, a patient survey is now being carried out. Copies of all CHP Committee papers are available the public website at http://www.nhshighland.scot.nhs.uk/OurAreas/ArgyllandBute/Pages/ArgyllButeCHP.aspx Argyll and Bute CHP Management Team Duncan reported that the CHP would move to a new national telecommunications contract, the new system being provided by BT. The meeting also received the Child Protection Improvement Plan. A follow-up visit by the Inspectorate is due in the New Year.

6 Locality PPFS – Feedback

Bute Locality PPF Ellen reported that Jeanette McIntyre was unwell at the moment and as such unable to attend the meeting. Members were saddened to hear of her illness and sent their best wishes to her. Ellen said the last meeting of the Bute Practice Participation Group, which hosts the Locality PPF, had taken place recently. She expressed disappointment that as this is a practice based forum, the continual absence of a GP meant that any issues people wanted to raise could not be dealt with. Questions had asked regarding plans to enable patients to email for appointments at the surgery. The Practice Manager had stated that the Practice would support this but there are no funds to implement such a system. Ellen had recently been part of the Review Team carrying out Hospital Cleanliness monitoring at the Victoria Hospital, Rothesay. She reported that everything was fine. Ellen has now completed training in WRAP (Wellness Recovery Action Plan) and strongly advised other members to undertake this training if the opportunity arises. Ellen had been invited to participate at the Scottish Older People Assembly in Edinburgh. She said the event was well attended. A vote of no confidence had been made regarding care in the community based on some very negative feedback from patients and carers.

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Cowal Locality PPF Evelyn provided a brief update from the Locality PPF. Model of Care – this looks at community nursing supporting people to stay at home rather than being admitted to hospital. Ken said there were still issues regarding incompatibility between Social Work and NHS systems, and Third Sector / Voluntary providers resulting in an impact on how organisations interact. Palliative Care – following review of how the service is provided, the Cowal Hospice and Continuing Care model is now being implemented and this is being closely monitored by the Palliative Care Group chaired by Lorna Ahlquist. Feedback from patients is very positive suggesting they like the new facility and favourable comments from nursing staff have also been noted. Health and Social Care Integration – the Locality are looking at an integrated model of care although it is recognised there is a long way to go before full integration will be realised. Staff on the ground do work together with many initiatives already being jointly funded. Evelyn had recently been part of the Review Team carrying out Hospital Cleanliness monitoring at the Cowal Community Hospital, Dunoon. She reported the overall report was good although the worst area reported was the staff toilet where the fabric requires a degree of upgrading. Notices put up using Blutack and doors with glass partitions covered in notices were also areas where action is required. Helensburgh Locality PPF Caroline reported that the Patients Group had met last month and a decision had been made that the Group would support the role of the Locality PPF but they could not host it. Caroline will now explore other options to ensure the Locality PPF is established as soon as possible. A further update would be given at the next meeting. Mairi stated that she had taken a few A&B PPF leaflets to the Grey Matters Group, a senior’s forum based in Helensburgh. As a result of this, Caroline has now been invited to attend their next meeting to talk about the A&B PPF. It was reported that Jackie Baillie, MSP had started a new campaign to have services at RAH relocated back to the Vale of Leven Hospital in Alexandria. This resulted in a discussion about the likelihood of services being provided north of the river. Islay / Jura Locality PPF There was no representation from the Islay /Jura Locality PPF therefore there was no update. Caroline stated that she and Duncan would be attending the next meeting, 28th November. Duncan reported that the GP vacancies at Bowmore Surgery and Jura Surgery had now been successfully recruited to. Kintyre Locality PPF Susan reported that at recent Kintyre Forum for Community Care (KFCC) / Locality PPS meetings, these had been attended by NHS staff which has resulted in a number of issues now being resolved. There are still problems with Patient Transport Service

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where a patient reported the ambulance arrived the day before the appointment, arrived late on the actual day of the clinic but so late the appointment was missed. An example of inaccurate messages being given to patients was given where the patient was told they would have to go to Raigmore Hospital in Inverness although in reality the patient was taken to Campbeltown Hospital. Susan stated that carers are concerned that the advice they are being given by Council staff is that they can train to cut toenails but the training does not provide enough to enable carers to pick up other problems associated with for example diabetes. The proposed addictions service planned to commence at the beginning of this year has been put on hold as the GP who supported the service has now gone on sabbatical. Bed modelling – a group has been established to look at all emergency admissions to determine whether any of them could be prevented thus ensure patients are not admitted to hospital unless clinically necessary. Susan mentioned to the “virtual ward” whereby patients are visited at home as though they were on the ward – this is working very well. Susan stated that she felt that the Locality PPF was not supported by the CHP in the same way as other Locality PPFs appear to be. The KFCC currently do all the administration, marketing and meet the cost of hiring rooms for meeting but this is no longer sustainable as they struggle to secure funding in general which in turn places them in a fragile position. Caroline agreed to pick this up with Susan and Christina West, Locality Manager.

Action CC/SP/CW/DM/MR Mid Argyll Locality PPF Michael said that the Patient Focus Group and Locality PPF had ‘merged’ as people wanted to discuss issues wider than those relating to the Medical Centre. There had been a constructive meeting in September but the notes of the meeting had not been circulated yet. He was trying to chase this along with a date for the next meeting which is likely to take place early in the new year. Michael sits on the NHS 24 PPF and was aware that NHS 24 does not have any idea what Out of Hours (OOHs) services are available locally. The OOHs service is how people access healthcare after their GP surgery has closed (evenings, weekends and public / bank holidays). He said part of the problem stems from the fact that NHS 24 receives its information from the Highland Hub, not the individual localities / CHP which would be far more accurate. Michael stated that he intends to raise this at the Highland Clinical Governance Committee which he sits on. Referring to the local chemotherapy service, Michael reported that one patient is now receiving treatment in Mid Argyll. More patients could be treated locally however the consultants at the Beatson do not appear to be advising them that this could be an option. The local service should be given more support otherwise there is a real risk staff will loose their skills. Oban, Lorn & Islands Locality PPF Having recently taken over as Locality PPF lead, Robin provided a brief update from the Locality PPF.

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He stated that Locality PPF is very well supported by local managers and meetings are well attended. The next meeting is on 3rd December and one of the themes for discussion will be air ambulance and Patient Transport Service. A number of topics had already been identified for next year.

7 A&B PPF Action Plan Caroline stated that it had been a while since members agreed the A&B PPF Action Plan and as such, there is now a real need to drive forward the key challenges and monitor progress on a regular basis. Review ‘Core’ Function of the A&B PPF / Development of Locality PPFs One of the main actions is to review the ‘core’ function of the A&B PPF. It is proposed that the quarterly meetings held in Lochgilphead would cease but before this can be realised it is imperative that the Locality PPFs are established, developed and supported. When it was established in 2006, the vision of the A&B PPF was to ensure local issues / matters are dealt with at a local level. Locality PPF leads will continue to meet with the Duncan, Michael and Caroline but these meetings will not be open to the wider membership / public. It was agreed that Duncan, Michael and Caroline would meet with the Locality Leads to discuss this further and ensure the Locality PPFs will be in a position to support the Plan.

Action CC / DM / MR One of the concerns raised at an earlier meeting was the fact that some members depended on the ‘core’ PPF meetings to raise issues, pass comment and meet other members. Not all Locality PPFs are easily accessible to all members, this is a particular concern relating to members from the islands and one that needs to be picked up in each area. Members were happy to support the idea of a change to the ‘core’ function of the PPF and look to enhance the Locality PPFs in line with the vision. It was also agreed that an annual networking event / day would provide an opportunity for members to get together and exchange ideas. It was also suggested that the quarterly meetings with Locality Leads could be rotated so they aren’t always held in Lochgilphead. Develop PFPI Plan for Islands Caroline reflected that the islands are not well represented and as such there is a need to develop a plan to ensure these isolated communities are part of our wider engagement / involvement plan. The A&B PPF is an important forum for people living in Argyll and Bute to be able to actively get involved in how local services are planned and as such we need to do more to involve island communities with the help of the PPF. Raise the Profile of A&B PPF Members discussed the need to use local press to publicise the good stories but essentially mention where the PPF has been instrumental in this success. This will demonstrate that the PPF does work, that the PPF members do succeed in ensuring the public / patient voice is “heard”. The Locality PPFs have a role to working with Local Management to encourage this to happen.

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Engagement with People with Protected Characteristics Caroline explained individuals or groups of people who can be described as having a Protected Characteristic, for example old people, young people, people with disabilities, gypsy / travellers, LGBT (lesbian, gay, bisexual, transgender), people from different cultures. The NHS has a legal responsibility to ensure the services it provides are promoting equality, do not disadvantage people or discriminate. Having a good understanding of the issues people from the different equalities groups is essential. Using PPF members’ local knowledge and networks will support the CHP with its wider PFPI activities and meets its legal responsibilities. The A&B PPF Action Plan will remain a standing item on future agendas to ensure continued monitoring against individual targets.

8 Feedback from PPF Members Activities There was no feedback.

9 Information Sharing

No information was shared between members.

10 AOCB Susan referred to the parents of a child who since being born six months ago is still in a Glasgow hospital. The parents are desperate to get their child home to Campbeltown but have been advised there are no suitably trained staff to look after patients who have undergone a tracheotomy. They would like to know why this is the case and how they can get their child home. Caroline suggested that this is just the sort of issue that should be raised at a local level but would discuss this with Christina West, Locality Manager.

Action CC / CW / SP Stephen mentioned that ACUMEN has a new Board of Directors. Ken wanted to remind people about using NHS buzz words / phrases as it can lead to confusion. Referring to the Liverpool Care Plan he asked what was happening in Scotland and stated using the term ‘end of life care’ meant far more to people and far more dignified. Referring to the new NHS telephone contract, he asked what the impact might be on how patients access the Out of Hours (OOHs) service.

13 Date, Time & Venue of Next Meeting The next Meeting will be held on Tuesday 19 th February 2013 in Rooms J03 – J07, Mid Argyll Community Hospital and Integrated Care C entre, Lochgilphead, 10.30am to 3pm

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Distribution

Argyll & Bute Public Partnership Forum (PPF) Members Robin Creelman, Chairman, A&B CHP Derek Leslie, Director of Operations, A&B CHP Locality Managers, A&B CHP Clinical Services Managers, A&B CHP Stephen Whiston, Head of Planning, Contracting & Performance, A&B CHP Caroline Champion, Planning & Public Involvement Manager, A&B CHP Pat Tyrrell, Lead Nurse, A&B CHP Moira Newiss, CHP Business Transformation David Ritchie, Communications Manager, A&B CHP (for information) Maimie Thomson, Head of Public Relations & Engagement, NHS Highland (for information) Richard McLennan, National Patient Experience Development Manager, Healthcare Improvement Scotland (for information)

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NHS HIGHLANDARGYLL & BUTE CHP Argyll & Bute CHP Committee

Local Verification of Argyll & Bute CHP Data Date of Meeting : 19 December 2012

Delayed Discharge Monthly Census as at 15th November 2012 Agenda item : 17.1

Local verification involves all detailed validation, verification and inter-agency agreement of the data taking place locally,upon which A&B CHP and its partner authorities sign off the data as 'agreed' before onward transmission from the CHP to NHS Highland to ISD. The data will therefore be forwarded on to ISD, fully validated and verified by both NHS andsocial service colleagues.

Complex Needs (code 9) Other Codes All

Hospital Specialtyunder 6

wksover 6 wks Total

under 6 wks

over 6 wks Total under 6

wksover 6 wks Total

Campbeltown GP Acute 1 1 1 1 2 2Lorn & Islands General Surgery 1 1 1 1

Geriatric Medicine 1 1 4 4 4 1 5Total LIDGH 0 1 1 5 0 5 5 1 6

Mid Argyll Geriatric Psychiatry 1 1 1 1GP Acute 1 1 1 1Total Mid Argyll 0 0 2 0 2 2 2

Islay GP Acute 1 1 1 1Victoria Rothesay GP Acute 2 2 3 3 5 5

Argyll & Bute Council 3 1 4 12 0 12 15 1 16

Argyll & Bute CHP Total 3 1 4 12 0 12 15 1 16

Principal Reason Groupunder 6

wksover 6 wks Total

1 Community Care Assessment 9 0 92 Community Care Arrangements 2 0 23 Healthcare Assessment 0 0 04 Healthcare Arrangements 0 0 05 Legal/Financial 1 0 16 Disagreements 0 0 07 Other 0 0 09 Complex Needs 3 1 4

Argyll & Bute Council 15 1 16

Argyll & Bute CHP Total 15 1 16

To be Signed off by Argyll & Bute CHP and Council Representatives

Name Signature Date

James Robb Jim Robb

Derek Leslie Derek Leslie

20/11/2012

27/11/2012

To be returned to Information Services, Argyll & Bute CHP. 1 of 1 Issued on 12/12/2012

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Argyll & Bute CHP Committee Date of Meeting : 19 December 2012

Agenda item : 18

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eHealth Department Argyll & Bute CHP Aros Lochgilphead Argyll PA31 8LB

Minute of Meeting of the Argyll & Bute CHP eHealth Group 7th November 2012

J05/J07, MACHICC, Lochgilphead & Talisman Room, Helensburgh

Present: Dr John Lyon, Chair & Locality Clinical Director Katrina Duncan ICT Project and Liaison Manager (via VC) Ken Barr, Patient Representative, Dunoon James Brass, eHealth Manager John Dreghorn, Implementation Director, Mental Health Redesign Derek Leslie, Director of Operations George Morrison, Head of Finance, (via VC) Stephen Morrow, IT Development Manager Bill Reid, Head of eHealth, NHS Highland Elizabeth Reilly, Salaried Dental Services, (via VC) Bill Staley, Information and Projects Manager

Item 1 Apologies Apologies were noted from the following:

Dr Caroline Clark, Community Paediatrician Grace Ferguson, Clinical Director/Consultant Psychiatrist Dr Michael Hall, Clinical Director Dr Richard Sloan, MAKI Locality Representative Lhara Stevenson, PA Pat Tyrell, Lead Nurse Mary Wilson, AHP Lead (via VC) Kathleen Young, Medical Records Officer, MACHICC

The meeting thanked Dr Lyon for standing in as temporary chair noting apologies both from Pat Tyrrell and Dr Michael Hall.

The meeting was informed that Dr Clark has confirmed that she is to stand-down. The meeting thanked her for her attendance and contributions in the past and in particular her tenure as Chair.

Item 2 Minute of Previous Meeting Noting that the meeting planned for the 1st August was cancelled therefore the previous meeting was that held 2nd May 2012. The minutes of this meeting were approved with no amendment.

Item 3 Matters Arising With respect to item 6; A&E System Update Bill S confirmed that he had not been able to re-convene the Working Group to assess options for an electronic A&E system for the community hospitals. He noted that the MiIDS Project Board has asked him to look at this system providing a possible alternative in the Community Hospital context. Ken asked as to whether any of the options were looking at access to the GP record in either the A&E or OOH setting. This is not a

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Argyll & Bute CHP Committee Date of Meeting : 19 December 2012

Agenda item : 18

James Brass to make changes as discussed above and to present revised document to the

Core Management Team with a view to securing confirmation by invitees to attend future meetings.

Ken Barr to draft a letter outlining the desire of this group for a regular attendance by an appropriate GG&C representative. Letter to be approved by James Brass

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consideration although the Emergency Care Summary (ECS) and Key Information System (KIS) are designed to provide specified data and available in certain circumstances.

With respect to item 11 Katrina requested a refresh on the issues raised regarding joint working with the Argyll & Bute Council. This was given however she agreed to re-investigate these with Jim Robb. James noted that he is now an attendee of the Social Work Management Information Group.

Katrina Duncan to discuss with Jim Robb his list of concerns re communication and performance management within the CHP

Item 4 Review of eHealth Group Remit & Membership James spoke to the paper noting the changes in reporting lines, the proper position regarding NHS Highland eHealth strategy implementation and proposed membership. The inclusion of Head of Planning and Performance, Stephen Whiston, was discussed. Derek noted that although he was thoughtful about extending the membership, he had no issue with Stephen attending . Bill S noted the importance he placed on this department being a major customer of information services and also the support eHealth can provide to national initiatives, eg Treatment Time Guarantee. Elizabeth R noted that she manages the Salaried Dental service. John D noted that whilst informal methods have been successful in identifying and progressing eHealth issues pertaining to the mental health redesign project he would welcome a permanent invite to this meeting. James noted that he has approached Dr Peter Thorpe to represent secondary clinicians at this group. This representation takes on a significance with respect to the Trakcare implementation project. Derek noted that Peter is already a member of the PMS Working Group. Ken noted the absence of a representative of GG&C, James responded noting, unsuccessful, efforts to get a permanent representative. Ken offered his influence through his links with the Board Chairman, which was welcomed. Bill R noted that there is a restructuring of the NHS Highland eHealth Strategy Group reflecting recent changes. John L noted that the locality in North Argyll is named Oban, Lorn & Isles and this reflects a common approach with the council.

Item 5 Activity Highlights/Management Report An update was given on the following items in the report:-

• OneSign/Single Sign On – Imprivata: Stephen noted that this project is now progressing after a lengthy technical hiatus, together with the welcome contribution form IT colleagues in North Highland.

• The AB single domain: Stephen confirmed that work is now progressing, reflecting a significant development following input from IT colleagues in Northern Highland and having pressed Dacoll to involve Microsoft.

Derek asked Stephen to establish target dates for both this projects. • Telehealth – Maternity: James noted that the use of existing VC infrastructure was proving

adequate to meet demand for the pilot centred on the LIH Maternity Hub. John D

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Agenda item : 18

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asked about a comprehensive roll-out, James responded that this is a pilot only and at present no plans were extant for a comprehensive roll-out. As he mentioned ‘Jabber’ a description was requested. Jabber is a desktop PC based VC tool that is accepted and approved within the NHS. It can also be used in the home environment but experience in these cases has highlighted performance issues relating to local bandwidth provision.

• Telehealth – ITTS Psychiatry: James noted provision of non-recurring finance from Aberdeen University for three laptops, VC equipment and Jabber licences, to assist in improving clinical support to patients presenting at LIH from junior doctors and as necessary on-call consultants in a mental health environment. Bill R noted that this is another example of national projects attracting no recurring funding for sustained use, a sentiment shared by Derek.

• Mobile Device Encryption: Stephen reported that Dr Hall’s practice has now accepted the argument for this software to be loaded. This positive development leaves two practices, Strachur and Lochgoilhead without this software.

• eImmediate Discharge Letter: John L opened discussion by questioning the green status according to this item . He felt that the lack of an electronic solution coupled with an average month delay from date of patient discharge for the discharge letter to be supplied to primary care was approaching an unacceptable clinical risk. James noted that the lack of support form GG&C was a contributory factor to lack of progress understood to result from their capacity limitations during their implementation of TrakCare. He also noted that there is some functionality in Helix that could be exploited to plug this gap. John L noted that an electronic document delivered to primary care through SCI Gateway would be an ideal solution. James suggested that the CHP will explore the Helix option as an interim solution. However any successful implementation will rely on junior doctors entering data into an electronic system, John L felt that the age of the clinician NOT being comfortable with electronic systems is now largely at an end. Derek noted the current process of review of the provision of the admin and clerical service in the Lorn & Islands Hospital. Ken reported his recent experience of the GJNH providing a discharge document at time of discharge, Bill S noted that GJNH use Helix.

James Brass to expedite the provision of an electronic immediate discharge solution,

• Telecomms SLA Review: James reported that BT are progressing their planning and evaluation process in preparation of the switch over to their service from C&W. He reported that GG&C are prepared to provide project management resource for this work but may be asking the CHP for administrative support, also noting that a comprehensive breakdown of costing has been requested from GG&C.

• LabLinks: Stephen was delighted to report that after some delay GG&C are now fully supporting a rapid roll-out of this functionality to the Vision practices in the CHP.

• ePharmacy: John L enquired how eHealth was responding to recent problems with this system experienced by Practices in the Cowal & Bute locality. James acknowledged the problems and noted that Margaret Robertson was dealing with these.

• AWT: James reported that Mary Wilson is understood to have access to the full reporting suite of this system. As such she should be able to supply performance figures related to OT activity. It is noted that AWT could become an important provider of data to the A&B Council’s Pyramid reporting system.

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Item 6 Finance Report George acknowledged the prudent budgetary control evident in managing the department’s recurring budget. James confirmed that he had not identified how the 3% cost saving target is to be met. Derek, James and George to discuss this position out with the meeting but Derek acknowledged the challenge eHealth and other departments with a high percentage of fixed costs, salary and contracts, have meeting saving targets.

James Brass Derek Leslie and George Morrison to meet to discuss achievement of the 3% cost saving target.

James spoke to the paper provided to the meeting that states the position regarding non-recurring expenditure. He noted the major concern against the MiDIS rollout budget as no expenditure has been committed against it. He noted that funding would be used for clinical costs back-fill. The question was asked whether a similar level of finance would be available next financial year. James noted that the implementation of MiDIS was a national objective and it would be a reasonable expectation funding could be expected in future.

Item 7 TrakCare Implementation Update Bill R spoke to the Business Case paper. He reminded the meeting of the national position regarding Trakcare procurement and that NHS Highland had deliberately adopted a ‘wait-and-see’ policy to committing to deploy the system. However the licence position regarding iSoft Express is dictating an imperative towards a decision. He noted that NHS Highland has committed to implementing Trakcare. He has developed the Business Case that is to be presented to NHS highland Board in early December. He noted that the senior management team has given their support to the approach taken and to an outline business case. He acknowledged Dr Peter Thorpe’s inclusion into the PMS working Group. He noted that implementation of Trakcare will commence by 1st April 2013 with completion of the core product by end of March 2014.

With reference to the finances involved Bill R noted the following. A request had been made to the NHS in Scotland to assist to the tune of £1.5M to support NHS Highland’s implementation costs. He also noted that at £1M the recurring costs for TrakCare represent a premium of around £750k against current recurring costs for iSoft Express and Helix. These costs will have to be met by the operating units, eg A&B CHP, through efficiency savings. Bill R further noted that Forth Valley has taken a stance that whilst desirable they cannot commit to implementation of Trakcare the financial case is untenable and alternatives are being considered.

Bill R acknowledged that the Business Case recommended an option that did not wholly embrace the CHP’s considered position on its ideal Trakcare solution. This position acknowledges the scale of patient care provided either within or by GG&C. James presented his paper that states the position regarding patient care pathways with GG&C and noted that Deloitte MCS has been appointed by the CHP to examine the issues facing the CHP specifically.

Derek highlighted that there were three potential NHS Highland options available in taking forward the implementation of Trakcare, namely:-

• To be fully integrated within a single pan NHS Highland instance. He acknowledged that this is NHS Highland’s preferred option and the business case as highlighted above is predicated on this solution

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• To take a service from the NHS GG&C instance. Derek confirmed that this is the CHP’s preferred option particularly as it supports patient care pathways. However the CHP can accept the above option if it is proven that there is no clinical detriment – however that can be defined as yet.

• A hybrid where data is shared between instances or transparent open-access across instances is available. It is noted that this approach is being pursued reflecting similar cross-border patient flows in other health boards.

Derek, Bill R and James were to meet subsequently. Derek confirmed that there appears to be limited appreciation generally about the challenges and size of the Argyll & Bute CHP and specifically the extent of patient flows and on every opportunity he has attempted to improve this appreciation.

Bill R noted that the recurring costs for Trakcare will be extant should the CHP take a solution from GG&C and either the CHP’s contribution will have to be shared amongst the other three operating units or will be in addition to any cost charged by GG&C. He further noted the lack of engagement by GG&C in supporting the CHP’s preferred solution and that whilst the value of the clinical SLA is of the order of £47M this only represents about 2% of their clinical activity.

John L noted that any decision on Trakcare implementation will have to be taken with a view for providing the best solution for patient care! He further noted that the NHS is persisting in a health board based ‘silo’ approach to system provision and perhaps the opportunity to implement a single NHS Scotland solution has been missed.

John D asked whether mental health functionality is included in the proposal. Bill R noted that Trakcare is provided as a core package with a catalogue of add-on modules. His recollection is that mental health is part of the core product.

The meeting accepted that the NHS Highland Board has the responsibility to make the final decision on the NHS Highland Trakcare implementation option. Derek confirmed that he will ensure that the Board is cogniscant of the particular issues challenging the CHP’s inxclusion in the pan NHS Highland instance.

John L asked whether there should be some GP representation on the PMS Working Group. Derek confirmed that the LMC had been approached. He further agreed to ask Dr Brian MacLachlan, as the CHP representative on the NHS Highland eHealth Strategy Group, to be this representative, Dr Lyon volunteered to be stand-in if Brian would not be available.

James Brass Derek Leslie and Bill Reid to meet to discuss the CHP Trakcare implementation options and outcome to be reported at next meeting.

Derek Leslie to approach Dr Brian MacLachlan to be the CHP GP representative on the PMS Working Group.

Item 8 MiDIS Update Bill S spoke to the paper. He noted the extended project board and welcomed the inclusion of a council representative. He noted that the project was adopting the Prince2 methodology for project management. He noted that project board was keen to extend the use of the system to Cowal locality at the earliest opportunity. Finally he noted that the status of the designated clinical champion has yet to be finalised.

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Agenda item : 18

James Brass to bring paper to the next Core Management Team meeting for consideration.

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On a related point John D enquired how the CHP was dealing with interconnectivity issues of health staff working in council premises and vice-versa. James noted that these problems are being dealt with through the provision of an appropriately secure link between the NHS and Council networks.

Derek acknowledged that the CHP’s apparent greater progress on implementing MiDIS is not against corporate objectives.

Item 9 Treatment Time Guarantee Bill S spoke to the paper. He noted that the CHP’s current performance against the New Ways in-patient waiting time standard of 9 weeks indicates that there is not a clinical risk in treating patients against the twelve week legal guarantee as of 1st October. He noted that compliance against the law is to be confirmed by submission of processes and letters to the Central Legal Office for their sign-off. NHS Highland is currently working towards completing a draft of this submission and the CHP is playing a full part in this process.

Item 10 Use of Intranet James spoke to the paper. He noted that persistent network performance issues within the Cowal Community Hospital had led to the data on internet traffic as collected by the Sophos web appliances being investigated. These results are presented in the paper. There followed an extensive debate about the implications on the use of this data. Katrina in particular noted dangers with provided internet use down to a specific user level. There was general agreement that abuse of use of the internet is a management and not an eHealth issue. Bill R noted that the network and internet is a corporate system and that there is an internet use policy extant across the NHS. Derek noted that whilst there is a ‘cost’ to the service posed by private use of the internet at work any management of this needs to be done sensitively and asked for James to bring this paper to the Core Management Meeting for further consideration and agreement of a monitoring regime.

James then noted that no equivalent analysis has been done against GP Practices and he noted that this is also a responsibility of the NHS. There followed a discussion on this topic with welcome contribution from John L. Again Derek cautioned against any change to operating procedures and Practice internet use will be discussed as above.

Item 11 Argyll & Bute Council Update Katrina noted that the implementation of Carefirst to support the GIRFEC initiative has been stalled whilst the Council address technical issues with the system supplier.

Item 12 GG&C SLA Update James noted no particular issues to report.

Item 13 Papers for noting No papers were presented for noting.

Item 14 Any Other Competent Business John L noted that Immediate Discharge Letter had been discussed earlier in the meeting.

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Ken enquired as to why when contacting a GP Surgery out-of-hours the caller is not automatically transferred to NHS 24. John L noted that this was a conscious decision made to raise the profile of the NHS 24 and for the public to become familiar with the NHS 24 number.

Bill R noted the following:- • It is acknowledge that the NHS Highland Internet site needs a refreshing. In fact a

development company has been engaged to completely rebuild the site, hopefully, under the auspices of the public relations department. A similar process will occur for the intranet site.

• The eHealth Department has been relocated to the New Craigs site. He welcomed this as a very positive move as it reinforces the status of eHealth as a corporate service.

• He noted that a formal review of eHealth has recently been conducted by NHS in Scotland. The upshot is that Strategy funding has been released.

Finally John L asked whether Vision GP Practices were to receive a credit for the inconvenience caused by the recent Gemscript/INPS update? Bill R noted that he and Ken Proctor had compiled a letter on this subject for consideration with the Scottish Government but had received no reply or indeed an acknowledgement of receipt of the letter!

13. Date and Venue of Next Meetings:

2013 Dates confirmed, 10:00 for 10:30 in JO5/J07 MACHICC, VC Talisman 6th February 1st May 14th August 6th November