forth valley nhs board...2013/12/10 · 2014 and would take approximately a year to complete. it...
TRANSCRIPT
FORTH VALLEY NHS BOARD A meeting of FORTH VALLEY NHS BOARD will be held on 10th DECEMBER 2013, 9.30AM in the BOARDROOM, FORTH VALLEY NHS BOARD HEADQUARTERS, CARSEVIEW HOUSE, CASTLE BUSINESS PARK, STIRLING.
Please notify apologies for absence to Lesley Bogan, Corporate Services Assistant email [email protected] or telephone 01786 457247
AGENDA
1/ APOLOGIES FOR ABSENCE For Noting 2/ DECLARATIONS OF INTEREST For Noting 3/ MINUTE OF FORTH VALLEY NHS BOARD MEETING HELD ON 15
OCTOBER 2013 For Noting
4/ MATTERS ARISING 5/ LOOKED AFTER CHILDREN
(Presentation led by Angela Wallace, Director of Nursing) For Noting
6/ FINANCIAL & PERFORMANCE ISSUES
6.1 6.2
Executive Performance Report to end October 2013 Finance Report to end October 2013
For Noting For Noting
7/ REPORTS FROM SUB COMMITTEES
7.1 Minute of Performance & Resources Committee meeting held on 5 November 2013
For Noting
7.2 Minute of Audit Committee meeting held on 18 October 2013
For Noting
7.3 Minute of Endowment Committee meeting held on 18 October 2013
For Noting
7.4 Minute of Clinical Governance Committee meeting held on 11 October 2013
For Noting
7.5 Minute of Staff Governance Committee meeting held on 22 November 2013
For Noting
8/ EQUALITY AND DIVERSITY UPDATE (Paper led by Angela Wallace, Director of Nursing)
For Noting
9/ STIRLING CARE VILLAGE OUTLINE BUSINESS CASE (Paper presented by Tom Steele, Director of Projects and Facilities)
For Approval
10/ INNOVATION STOCK TAKE (Paper presented by Jane Grant, Chief Executive)
For Approval
11/ NHS SCOTLAND WAITING TIMES AUDIT FORTH VALLEY RESPONSE (Paper presented by Fiona Ramsay, Director of Finance)
For Noting
12/ ANY OTHER COMPETENT BUSINES For Noting
Forth Valley NHS Board 10 December 2013 This report relates to Item 3 on the agenda
Minute of Forth Valley NHS Board Meeting held on 15 October 2013
(For Approval)
1
FORTH VALLEY NHS BOARD DRAFT Minute of the Forth Valley NHS Board meeting held on Tuesday 15 October 2013 in the Forth Valley NHS Board Headquarters, Carseview House, Castle Business Park, Stirling. Present Mr Brendan Clark Dr Stuart Cumming Mr Charles Forbes Dr Graeme Foster Mr James King (Chair) Ms Fiona Gavine Mrs Helen Kelly Ms Jane Grant Councillor Corrie McChord Dr Peter Murdoch Mrs Fiona Ramsay Ms Julia Swan Councillor Gary Womersley Professor Angela Wallace In Attendance Ms Elsbeth Campbell, Head of Communications Mrs Ann Duffy, Committee Administrator (minute) Ms Margaret Duffy, Director of Integration Mr Tom Steele, Director of Projects & Facilities Mr Mark Bell, NORD Architects (for item 3 only) Ms Sam Booth, Maggie’s Regional PR Advisor (for item 3 only) Mr Brian McGinlay, NORD Architects (for item 3 only) Ms Liz MacMillan, Oncology Department Manager (for item 3 only) Ms Claire Tattersal, Service User (for item 3 only) 1. APOLOGIES FOR ABSENCE
Apologies for absence were intimated on behalf of Dr Allan Bridges, Mr Tom Hart, Mr Alex Linkston and Dr Vicki Nash
2. DECLARATIONS OF INTEREST
There were no declarations of interest.
3. MINUTE OF FORTH VALLEY NHS BOARD MEETING HELD ON 20 AUGUST 2013
The minute of the Forth Valley NHS Board meeting held on 20 August 2013 was approved as a correct record.
4. MATTERS ARISING
No matters arising of note
5. MAGGIES CENTRE DEVELOPMENT
The NHS Board received a presentation “Maggie’s Centre Development FVRH” by Mr Mark Bell, NORD Architects.
1
Ms Samantha Booth gave an introduction into how Maggie’s was established, how it works for patients and how it has progressed to date. Ms Claire Tattersal also shared with the Board her own personal experience and how Maggie’s had helped her. She highlighted the support and benefits available from Maggie’s and the peaceful environment away from the busy hospital routine. Mr Bell then proceeded with the presentation, which highlighted:
The Loch-side Pavilion Key Landscape Features Prior to FVRH redevelopment 2000 Maggie’s - relationship to hospital Environment Site and Landscape Heritage Traditional Manufacturing Larbert House Enhancing Existing Pathways Reinstating Native Woodland Layout of Internal Areas Structure and Interiors
In the discussion that followed, Mark Bell confirmed that work would commence on site in March/April 2014 and would take approximately a year to complete. It was established that an expected 1500 patients would use the Maggie’s centre in the first year following completion. In answer to a question from Mr Charles Forbes asking if only cancer patients would use the centre, it was confirmed that cancer patients and their families only would use the facilities. In answer to a question from Ms Julia Swann regarding accessibility, it was established that parking spaces would be available at the centre and the main visitor’s car park would be on the pathway from the Oncology Unit. Mr Tom Steel advised that NHS Forth Valley were due to submit planning consent and discussions were ongoing with Laing O’Rourke. Dr Peter Murdoch agreed that this was a very exciting opportunity and that the project and concept promises to enrich, inform and compliment a whole range of existing services.
Mr King thanked Mr Bell for his informative presentation and a special thank you to Claire for sharing her personal experience with the Board.
6. FINANCIAL & PERFORMANCE ISSUES
6.1 Executive Performance Report to end August 2013 The NHS Board considered a paper “Executive Performance Report to end June 2013”, presented by Ms Jane Grant, Chief Executive. Ms Grant highlighted the following as detailed within the report Chief Executives Summary
Forth Valley Royal Hospital Woodlands Flu Vaccination World Sepsis Day
2
OPAC SPSO Awards/Conferences/Interest Finance Report Corporate Risks
The Board also discussed the Delayed Discharge census which included ongoing discussions with all local authorities, weekly reporting and issues to be address prior to winter. Ms Julia Swann requested that the Board be given information on child flu immunisation and the benefits. The Board also discussed the improvement, on a wider scale, of the smoking cessation initiative. Ms Helen Kelly discussed the ongoing campaign to encourage staff flu vaccinations. She highlighted that over 1300 staff members had been vaccinated in October 2012 and it was hoped that this trend would continue in 2013. After a detailed discussion, the NHS Board noted the Executive Performance report to end August 2013.
7. REPORTS FROM SUB COMMITTEES
7.1 Minute of Performance and Resources Committee meetings held on 3 September and 1 October 2013 The NHS Board considered the minute of the Performance and Resources Committee meetings held on 3 September and 1 October 2013.
Mr King highlighted the following, detailed within the minute:-
Update of the Balance Score Card Discussion around the 20/20 Vision Unit Finance Performance
The NHS Board noted the minute of the Performance and Resources Committee.
7.2 Minute of Audit Committee meeting held on 7 June 2013
The NHS Board considered the minute of the Audit Committee held on 7 June 2013. Mr King highlighted the following, detailed within the minute:-
Annual Internal Audit Audit of 2012/13 accounts
The NHS Board noted the minute of the Audit Committee held on 7 June 2013.
7.3 Minute of the Endowment Committee meeting held on 7 June 2013
The NHS Board noted the minute of the Endowment Committee meeting held on 7 June 2013.
7.4 Minute of the Clinical Governance meeting held on 16 August 2013 The NHS Board considered the minute of the Clinical Governance meeting held on
3
16 August 2013. Ms Fiona Gavine highlighted the following detailed in the minute:-
Presentation from Ms Yvonne Bronsky, Local Supervising Authority Midwifery Officer, South East and West of Scotland
HAI 24/7 Working Balanced Score Cards
The NHS Board noted the minute of the Clinical Governance meeting held on 16 August 2013
7.5 Minute of the Staff Governance Committee meeting held on 24 September 2013
The NHS Board considered the minute of the Staff Governance Committee meeting held on 24 September 2013 Mr Brendan Clark highlighted the following from the report:-
Manual Handling Development of Operational Integration Priorities Joint Management Team Update Clackmannanshire and Stirling Partnership Annual Report
The NHS Board noted the minute of the Staff Governance meeting held on 24 September 2013.
7.6 Minute of the Clackmannanshire & Stirling Partnership Board meetings held on 11 June and 17 September 2013
The NHS Board considered the minutes of the Clackmannanshire & Stirling partnership Board meetings held on 11 June and 17 September 2013.
Mr Gary Womersley raised the issues within Health & Social Care, which would be discussed under item 10 of the agenda. The NHS Board noted the minute of the Clackmannanshire & Stirling Partnership Board meetings held on 11 June and 17 September 2013.
7.7 Minute of the Falkirk Partnership Board meetings held on 17 June and 13 September 2013
The NHS Board noted the minutes of the Falkirk Partnership Board meetings held on 17 June and 13 September 2013.
7.8 Report of the Pharmacy Practices Committee The NHS Board considered the Report of the Pharmacy Practices Committee Mr Charles Forbes discussed the issues raised from the report and advised that item 2, application from Walter Davidson & Sons Ltd., would be dealt with at a future meeting of the Pharmacy Practices Committee. Page 2, para: 8, should read on 28th November 2012. The NHS Board noted the Report of the Pharmacy Practices Committee and the amendment as highlighted above.
4
8. DISPENSING SERVICES KILLIN MEDICAL PRACTICE
The NHS Board considered a paper “Dispensing Services – Killin Medical Practice” presented by Ms Fiona Ramsay, Director of Finance Ms Ramsay gave a detailed background to the report. She advised the Board that at its meeting of 2 October 2013 the Area Pharmaceutical Committee (APC) considered the criteria of the regulations. The APC agreed there were no exceptional circumstances which would require the Killin GP practice to continue to dispense and its recommendation was that the Health Board should require the GP practice to discontinue dispensing to its registered patients as dispensing services would now be adequately met by Walter Davidson & Sons Ltd. This position is supported by Dr Peter Murdoch, Interim Medical Director and Dr Stuart Cumming, Associate Medical Director, Primary Care and the Board is asked to consider the content of the report and formally approve the requirement for the Killin GP practice to discontinue dispensing services to its registered patients. The NHS Board noted the paper and approved the recommendations put forward by Ms Fiona Ramsay.
9. CAPACITY & WINTER PLANNING The NHS Board received a presentation “Winter Planning 2013/14” accompanied by a detailed report, by Dr Peter Murdoch, Interim Medical Director The presentation highlighted:-
Context for 2013/14 o National Event 27 September 2013 o National Guidance & Checklist o Unscheduled Care Plan/Capacity & Flow work o Phasing of planning and prioritisation
Approach o Whole system approach o Local Unscheduled Care Plan (LUCAP) – core detail to winter plan o Additional focus on winter plan
Focus o LUCAP – overview, short and medium term o Intermediate short term focus
Additional key actions
Joint working groups and social media.
Dedicated “Winter Zone” on NHS Forth Valley website
The NHS Board discussed in detail the plans in place for winter contingency and the introduction of the Rapid Access Frailty Unit. Ms Grant confirmed that there would be a huge focus from the NHS Board going into winter with a focus on the key issues to steer through this winter.
5
6
10. The NHS Board considered a presentation “Integration Stocktake” by Ms Margaret Duffy, Director of Integration Ms Duffy highlighted the following as detailed in the presentation
Integration Stocktake Context Christie Commission on Future Delivery of Public Services (2011) Renewing Public Services (2011) A means to an end – what is the question? Estimated growth in over 65 years – population: Forth Valley 2010 – 2020 Lifestyle choices and Impact of Disease in Forth Valley – Over 65’s Public Bodies ( Joint Working) (Scotland) Bill – May 2013 Where are we now? Next Steps – Key meetings and Timetables
In the discussion that followed, the Board agreed the need to ensure effective integration with local authorities in order to have the best outcomes for people. The Board discussed the culture and transition of integrating services and the importance of a strategic plan to help drive the change needed across all areas. Mr Forbes agreed that the Christie Report was directed to the people, and he stressed the need to look at being flexible to provide the care for the people who need it. Dr Cumming highlighted the need to recognise barriers and to take the lead and deal with a solution focus which would assist in working towards an agreed model of care. Following a detailed discussion the NHS Board noted the “Integration Stocktake” update from Ms Duffy.
11. 2014 PROGRAMME OF MEETINGS
The NHS Board considered a paper “Schedule of Meetings 2104” presented by Ms Jane Grant, Chief Executive. Ms Grant asked the Board to note that the Performance & Resources Committee meeting would now move to 9:00am and that the NHS Board meetings would remain at 9:30am The NHS Board noted the schedule of meetings and the changes highlighted by Ms Grant.
12. ANY OTHER COMPETENT BUSINESS
There being no other business, Mr King closed the meeting at 11:50am
1
FORTH VALLEY NHS BOARD 10 December 2013 This report relates to Item 6.1 on the agenda
Executive Performance Report to end of October 2013
(Paper presented by Mrs Jane Grant, Chief Executive)
For Noting
2
NHS Forth Valley
Board Executive Performance Report October 2013 Position
3
Contents
Page
Purpose of report
3
Chief Executive’s Summary
3
Recommendations
7
Section 1 - Balanced Scorecard & Performance Summary
Attached
Section 2 - Corporate Risk Summary
Attached
Section 3 - Healthcare Associated Infection Reporting Template (National Template )
Attached
4
1. PURPOSE OF REPORT The purpose of this Board Executive Performance Report (BEPR) is to provide assurance to the NHS Board on the overall performance of NHS Forth Valley. The overall approach within NHS Forth Valley continues to underline the principle that performance management is integral to the delivery of quality improvement and core to sound management, governance & accountability. The need for transparent and explicit links of performance management and reporting within the organisational structure at all levels is critical. Key areas of performance are highlighted in the performance summary (Section 1) focussed around the Balanced Scorecard (BSC), quality improvement agenda, which includes national Health, Efficiency, Access and Treatment (HEAT) targets from the Local Delivery Plan. This report provides an update to end October with some relevant November updates for 2013. 2. CHIEF EXECUTIVE’S SUMMARY The past two months have been a challenging period for NHS Forth Valley. There has been significant activity underway in preparation for the winter and festive period. Every effort has been made to ensure our services are robust to cope with the increase in emergencies winter brings as well as the need to deliver routine elective care across the system. We have also been working towards the Annual Review of NHS Forth Valley’s performance which will be on the 9th December in Forth Valley Royal Hospital. We look forward to welcoming the Cabinet Secretary, colleagues and members of the public to highlight much of the good work that is underway as well as underling where further improvement is required. A number of these issues are considered throughout this report. Performance & Resource Committee The Performance and Resources Committee (P&RC) received a full report on performance against the Balanced Scorecard at the meeting on 5th November. A number of areas were considered in detail under each of the BSC headings. An improved position in respect of the 4hr Emergency Department wait was noted with work underway to ensure more consistent delivery. General Access targets were considered noting the progress with the 12 week TTG. Significant challenges around the 18 week RTT and the number of patients waiting over 12 weeks for an outpatient appointment were highlighted. Detail within key specialties was considered where recovery plans were described. It was stressed however that it may take some time for a number of the specialties to meet the 12 week target and there was ongoing discussion with the Scottish Government in this regard. The continued delivery of the cancer targets was acknowledged. The increasing issue of delayed discharges was also considered noting an ongoing rise in bed days occupied bed patients delayed in their discharge. This was noted as not ideal from a patient’s perspective as well as adding to the overall capacity and flow challenge throughout the system. The work with Local Authorities was underlined with a number of issues requiring to be addressed. Meeting the absence target of 4% continues to present challenge with a summary of ongoing action noted. The work to review the Francis Enquiry into Mid Staffordshire was considered in detail. The findings of the review undertaken by Professional Advisory Groups, Unit Teams,
5
patients and carers were presented noting key themes and actions required. Key issues around being more systematic with feedback and learning from complaints, greater consistency of measurement and visible leadership at all levels were highlighted. It was noted that a subgroup of the SMT had been created to progress the high-level action plan around the themes identified. The (P&RC) will be updated quarterly with the Board receiving a full summary at its meeting in February. The report also considered an update on major capital projects. Of note is the P&RC approved a plan to open 22 additional beds on the Stirling Community Hospital site to provide additional capacity over the winter period. There are extremely limited options available to the Board in relation to ‘surge’ capacity and within the timescale and resources available this was the only viable option. Capacity last winter was a challenge across Scotland and it is prudent for Forth Valley to be well positioned to cope with the emergency and elective demand. It is anticipated that this facility will be ready for use by the 1st of January 2014. Finance A balanced financial position is reported to the end of October 2013 and a balanced financial position is projected for the year end. Cash Savings requirements are fully reflected in the Unit and Corporate Financial positions. There are no new issues emerging in the current financial year. Funds have been transferred to the Unit Budgets in line with the Winter Plan. Given the focus on delivery of access targets projections are being updated to reflect additional activity planned this year – at present this is not presenting a financial risk and is covered from a combination of local funds remaining from the budget approved at the start of the year for this purpose augmented by a funding provided by the National Access Team. An updated brokerage schedule reflecting the current status of property sales was reported to the Performance and Resources Committee at the beginning of October. This has also been discussed with SGHSCD including identification of where risks lie. The main focus of work is updating the five year Financial Plan to reflect the draft Scottish Budget/local Strategy discussions and on ensuring underlying sustainability of the financial position including management of financial pressures and delivery of savings on a recurrent basis. Frailty Unit As part of our work to review capacity and flow across the area a new ‘one-stop’ service has been introduced to improve the care and treatment of frail older people and help reduce avoidable hospital admissions. The service enables GP’s to refer patients to a rapid access clinic at Forth Valley Royal Hospital where a range of tests and investigations can be carried out together with an assessment by a consultant geriatrician. The new service is run in conjunction with social work and allied health professionals who are able to put a care package in place which will normally allow patients to return home the same day. The impact of the service will be monitored over the coming months including the experience of patients to ensure benefits are realised.
Launch of Living it Up The Cabinet Secretary, Alex Neil recently, launched ‘Living it Up’ at the Peak Sports Centre in Stirling. With the use of touch screen technology, patients are now able to get personalised healthcare advice through this digital health project. It is designed to link
6
patient’s needs and interests with professional advice, local services, activities and events, and can be accessed via computers, smartphones and TV’s. It is anticipated that this new technology will reach a wider audience with a greater health impact. Quality Improvement Reliable Rescue A local team have been invited to present the innovative work undertaken in Forth Valley around reliable rescue. The national Acute Adult Safety Programme are coordinating a learning session in Salford Royal Hospital in conjunction with the Salford team and the UCLP on deteriorating patients. The aim of this session is to continue and expand the sharing of learning deteriorating patients, including Sepsis work. This is a good opportunity for Forth Valley to add further to the learning and also gain feedback from other areas. Sepsis Study Day The 5th Annual Sepsis Study Day took place on 22nd November. This year focused on the significant work being done around the Sepsis 6 bundle as well as Antimicrobial Resistance and Stewardship. This was also attended by Improvement Advisors from Healthcare Improvement Scotland. The Simulation Centre supported the day with interactive workshops which involved a simulation mannequin and sepsis vignettes. Audience participation was facilitated by the use of a hand held voting system, where the fate of the mannequin was decided by them. This session proved particularly useful for all who attended as they felt they had put the learning they had received into action. The Scottish Ambulance Service spoke of the collaborative work they have been involved with Dr Dan Beckett around the use of bedside lactate measurement – a first in the UK. Awards / Conferences / Interest I would like to highlight a number of awards and nominations over the past two months with congratulations to all. Sally Boa, who recently completed a secondment at Strathcarron Hospice, won the Innovation Award at the Scottish Health Awards 2013, for her efforts to improve quality of life for terminally ill patients. This is a tremendous achievement. NHS Forth Valley were also finalists in a number of other categories with a number of Teams represented at the Awards ceremony including the Acute Care Team; Senior Learning Disability Nurse Caroline Gill and her team; Sister Midwife Debbie Forbes and Alison Kilgour, founder of charity So Precious. Significant effort goes into submissions for the Scottish Health Awards and being shortlisted is a notable accomplishment. The dedication and commitment shown by a Forth Valley nurse towards helping people with cancer has been recognised at the 2013 Macmillan Excellence Awards. Sandra Campbell, a Macmillan Nurse Consultant for Cancer and Palliative Care recently received the Partnership Excellence Award.
7
3. RECOMMENDATIONS The Board is asked to note: The key items of information detailed within the Chief Executive’s Summary of this
report The main areas highlighted in the Balanced Scorecard and Performance Summary -
Section 1 The Corporate Risks Summary - Section 2 The National Healthcare Associated Infection Reporting Template (HAIRT) - Section 3 Author of Paper Name Designation Elaine Vanhegan Head of Performance and Governance
Approved By Name Designation Jane Grant
Chief Executive
December 2013
SECTION 1 - BALANCED SCORECARD & PERFORMANCE SUMMARY Report Format As previously noted the NHS Forth Valley Performance Management Framework has been reviewed in line with the revised governance arrangements and changing management structure. The areas highlighted within this report are drawn from particular areas of note within the BSC and/or major points considered by the P&RC. This Report continues to be revised to ensure that the Board is succinctly updated on key performance issues. Balanced Scorecard Work continues in respect of developing the BSC to provide a broader range of measures and build upon the qualitative and quantitative data which will enable and support quality improvement and assurance. The local focus remains across the six dimensions of quality with a balanced approach to measurement. Format
The following templates update the position against locally developed quality indicators and HEAT targets
Progress symbols are noted as:
Improvement in period
Posit ion maintained
Deterioration in period
Where trajectories have been agreed, this will be reported as red, amber or green
R
A
G On track
Minor deviation from trajectory <5%
Off trajectory >5%
The narrative will provide contextual information and support
1
Imp RAG Imp RAG Imp RAG
EQ1 A E1 G V1 G
A E2 A G
EQ2 G E3 G A
EQ4 G E4 A -
EQ5 G E5 R V2 A
EQ6 A E6 R V3 A
EQ7 R E7 G V4 G
EQ8 R A V5 R
EQ9 A E8 A V6 R
A
Imp RAG E9 A Imp RAG
T1 12 Week Treatment Time Guarantee A E10 G P1 a) Patient Experience - Inpatient survey G
T2 G E11 R b) Patient Experience - GP survey -
A A P2 a) Complaints - responses A
T3 R E12 R - A
T4 R E13 G -
T5 G P3 A
G Imp RAG P4 G
T6 G S1 G P5 A
T7 G S2 G
T8 G S3 A -
T9 R S4 G R
S5 G A
S6 G G
G
No targeted assessment
Off trajectory >5%
Minor deviation from trajectory <5%
a) Hand hygiene - Acute
KEY
On track
Clostridium Difficile
Deterioration in period
Position maintained
Improvement in period
Person Centred
Access to Antenatal Care
Boarding
Timely
b) Daycase rate
Child Healthy Weight Bed occupancy
b) All Inpatient cancellations
a) Inpatient cancellations excluding patient cancelled
Breastfeeding rate
b) Unavailability - inpatients
a) Unavailability - outpatients
Pre-operative stay
b) Theatre efficiency - late start
Secondary Care Doctor's appraisal
Prescribing
Smoking cessation
Alcohol brief intervention Attendance management
c) Antimicrobial use - AcuteSuicide rate
b) Ethnicity recording - staff b) Antimicrobial use - Quarterly trend Primary care Non Core Staff Costs
Patients admitted to stroke unit
18 week Referral to Treatment
NHS Forth Valley Strategic Balanced Scorecard
Performance Dashboard October 2013
Equitable Efficient Effectivea) Antimicrobial use - Seasonal variation Primary Carea) Ethnicity recording - patients Finance
Hospital standardised mortality ratio
Adverse events
a) Acute Assessment Unit Cardiac arrest calls
Staphylococcus Aureus Bacteraemia
12 Week Outpatient wait
Emergency bed days >75 years
A&E attendance
Delayed discharge >2 weeks
Bed days lost due to delayed discharge
Average length of stay
Fluoride varnish
a) BADS procedures as Daycases / Outpatients
a) Theatre efficiency - under run
% Theatre utilisation
Safe
c) Complaints - themes
b) Complaints - numbersDid Not Attends
d) Reduction in Primary Care Antibiotic Use
b) Community hospital hand hygiene
Psychological Therapies
% A&E waits <4 hours
a) Cancer 31 day target
b) Cancer 62 day target
Access to drug & alcohol treatment
Access to child & adolescent mental health
Clinical quality indicators
Long Term Conditions
2
PERFORMANCE SUMMARY
NHS Forth Valley’s key performance highlights are noted below against the balanced scorecard (BSC).
EQUITABLE
Context Most areas within the Equitable section of BSC are updated on a quarterly or annual basis and are 3 to 6 months behind due to the nature of the data and its collection. In respect of Alcohol Brief Interventions, the most recent data for quarter ending September 2013 highlights that NHS Forth Valley has already exceeded the target set for delivery at the end of March 2014. The annually published statistics for Breast Feeding for year ending March 2013 highlight that NHS Forth Valley remains behind target and is Red in the Balanced Scorecard. There is a marked difference between the 3 Local Authorities. Stirling has exceeded the target with 34.8% of babies exclusively breast fed however Clackmannanshire and Falkirk are behind with 16.7% and 19.6% respectively. Sustain and embed Alcohol Brief Interventions (ABI) in primary care, A&E and antenatal, and develop delivery in wider settings
Percentage of babies exclusively Breast Feeding at 6-8 week check
Target: 3676
Ahead of target
3199 @ September 2013 ↑
Target: 27.7%
Position behind target
22.7% @ March 2013 ↓
Alcohol Brief Intervention Delivery
0
1000
2000
3000
4000
5000
6000
7000
Jun-13 Sep-13 Cumulative Total
Number of ABIs delivered Year end target
Breast Feeding
0.0%
5.0%10.0%
15.0%
20.0%
25.0%30.0%
35.0%
40.0%
2007 2008 2009 2010 2011 2012 2013
Forth Valley Exclusively BreastfedForth Valley Breastfed (includes mixed breast and formula fed)Scotland Exclusively BreastfedTrajectory
Quarter 2, July - September 2013 saw delivery of
3199 Alcohol Brief Interventions. Within the Priority settings of Antenatal, A&E and
Primary Care, 2132 ABIs were carried out, with 1067 in wider settings e.g. Mental Health, Criminal Justice.
This remains a standard measure throughout 2013/14 with the continued development of ABI delivery in wider settings.
The target remains the same in terms of numbers however a minimum 10% of that requires to be delivered in non priority settings.
NHS Forth Valley is behind the target with 22.7% of babies exclusively breastfed for year ending March 2013 against a target position of 27.7%. The previous year’s position was 23.6%.
The Scotland position for March 2013 was 26.2%. Wide variations in rates across the area due to socio-
economic factors. Each CHP group along with acute services is
working with partners to ensure focus on areas of inequality e.g. healthy start.
Breastfeeding at the 6-8 Week Review by CHP 2012-2013 Exclusive Any
breastfeeding Clackmannan 16.7% ↓ 21.5% ↓ Falkirk 19.6% ↑ 28.0% ↔ Stirling 34.8% ↑ 43.5% ↑
*Next update to March 2014 due October 2014
3
TIMELY
Context Performance under the ‘Timely’ heading remains challenging. The introduction of the Patient Rights (Scotland) Act 2011 with the 12 week Treatment Time Guarantee (TTG), delivery of 18 week Referral to Treatment (RTT) and the stage of treatment targets are demanding. TTG: There were 5 breaches of the TTG in October.
It is forecast that there will be 3 breaches in November and zero breaches expected in December. The RTT performance reduced from 81.6% in August 2013 to 80% in September 2013. At 31 October 2013 the number of patients exceeding the 12 weeks outpatient stage of treatment
standard was 3434. This is a slight improvement on the September 2013 position of 3491. Diagnostics Tests: At 31 October, 2013, there were 188 patients waiting over the 6 week target for the
8 key diagnostic tests. Inpatient and Outpatient unavailability levels remain much lower than the Scottish average.
The 4 hour A&E target remains a key focus with continued fluctuation in day to day activity. The October 2013 position has remained stable with a position of 93.3% against a trajectory of 92%. Steps are in place to support work being led nationally to aid achievement and sustainability of the standard with on-going review of progress. The cancer position remains Green in the Balanced Scorecard where NHS Forth Valley continues to deliver against the national target.
12 Week Treatment Time Guarantee (TTG) - Inpatients & Day Cases
18 week Referral to Treatment (RTT)
Target: 100% within 12 weeks
Compliance @ 27 November 2013 ↑
Target: 90%
Below target 81.0% @ September 2013 ↓
Month ending
Oct-13 Nov-13 Dec-13
Total
Numbers who waited over 12 weeks
5 3 8
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
% C
om
pli
an
ce
Month of Reporting
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
FV Performance 90.2 90.9 90.3 90.5 90.9 88.4 85.2 87.1 83.1 83.7 81.9 83.3 80.4 82.3 80.8 78.7 82.8 84.8 84.4 81.6 81.0
Trajectory 90% 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0 90.0
NHS Forth Valley All Specialties Performance RTTCompliance
Under the Patient Rights (Scotland) Act 2011, from 1 October 2012, all eligible patients will start to receive their day case or inpatient treatment within 12 weeks of the agreement to treat. There have been 8 breaches of the TTG for October 2013
to 27 November 2013. The challenge for December 2013 and beyond is to
achieve then maintain the TTG. The main challenge is in Orthopaedics.
The additional outpatient sessions will put pressure on the maintenance of the TTG with cognisance taken of this in respect of planning.
RTT compliance for September 2013 is 81.0%. Overall performance has slightly decreased from the
August position of 81.6%. The Scotland position for September 2013 was
90.9%. It is anticipated that, as the long waiting outpatient
waiting list is addressed, the RTT compliance will initially fall but will improve in due course as the waiting list returns to equilibrium.
4
TIMELY
Unavailability - inpatient
Unavailability - outpatient
Target: <5% of list
Behind target 9.4% @ October 2013 ↔
Target: <5% of list
Within target
0.4% @ October 2013 ↑
05
1015202530354045
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Forth Valley 32.3 37.4 34.6 38.7 35 25.2 5.1 10.8 6.9 6.0 5.3 7.1 8.2 8.8 8.8 8.3 9.4 9.4
Scotland 31.2 35.6 33.6 31.1 14.1 14.1 21.4
Inpatient Unavailablity
0.0
5.0
10.0
15.0
% U
navail
ab
lity
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
ForthValley 6.6 9.6 10.6 10.6 3.2 2.7 1.1 1.5 1.3 1.4 1.8 1.6 1.3 2.0 1.4 0.6 0.7 0.4
Scotland 7.4 9.5 10.1 7.5 5.1 5.4 4.8 4.6 5 4.2 4.2 4.1 4.3 4.3
Forth Valley Outpatient Unavailablity
The graph highlights the percentage of inpatient/day cases that are unavailable as a proportion of the total waiting list size.
NHS Forth Valley aims to have less than 5% of the total waiting list unavailable.
In October 2013, the Forth Valley inpatient/daycases unavailable list was 9.4% of the total waiting list.
This target will be reviewed early in 2014 to ensure that it is realistic as the Forth Valley position is significantly below the Scottish average
The graph describes the percentage of outpatients that are unavailable as a proportion of the total waiting list size.
The NHS Forth Valley intent is that the proportion of unavailability will be less than 5% of the total waiting list.
In October 2013, the Forth Valley percentage of unavailable outpatients was 0.4% of the total outpatient waiting list.
The Scotland position was 4.3% but this is only available for August 2013.
Outpatients waiting over 12 weeks 95% of patients with cancer treated within 31 days of decision to treat by December 2011
Target: Zero
Slight Improvement
3434 @ October 2013 ↑
Target: 95%
Stable position
96.4% @ June 2013 ↔
NHS Forth Valley new Outpatients Over 12 Weeks April-12 to July-13 and Monthly % Change
0
500
1000
1500
2000
2500
3000
3500
4000
Month
Nu
mb
er W
aiti
ng
-40%
-20%
0%
20%
40%
60%
80%
100%
% I
ncr
ease
Mo
nth
on
M
on
th
Number of Outpatients 469 589 823 1227 15991673 16921707 181719652253 21052537 30372481 30373751 3491
% Change 26% 40% 49% 30% 5% 1% 1% 6% 8% 15% -7% 21% 20% -18 22% 24% -7%
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
31 Day Cancer Standard
80.0%
85.0%
90.0%
95.0%
100.0%
31/03
/201
1
30/06
/201
1
30/09
/201
1
31/12
/201
1
31/03
/201
2
30/06
/201
2
30/09
/201
2
31/12
/201
2
31/03
/201
3
30/06
/201
3
Scotland Forth Valley Trajectory
The number of patients exceeding the 12 weeks stage of treatment standard at end October 2013 was 3434. This is a slight improvement from the September position of 3491 patients.
The main areas of challenge remain within Orthopaedics Gastroenterology Ophthalmology, Rheumatology, ENT, Dermatology, Neurology, and Respiratory.
Actions to improve the position on a sustainable basis are being taken forward by Unit teams.
The quarterly statistics at June 2013 show that 96.4% of patients were treated within 31 days against a 95% target, with a Scotland position of 97.7%
In October 2013 the monthly management position highlighted that 98.8% of patients were treated within 31 days.
5
TIMELY
95% of patients with suspicion of cancer treated within 62 days or less by December 2011
95% of patients will wait less than 4 hours for discharge or transfer from A&E
Target: 95% Stable position
95.4 @ June 2013 ↔
Target: 95%
Static position
93.3% @ October 2013 ↔
62 Day Cancer Standard
80.0%
85.0%
90.0%
95.0%
100.0%
31/03
/201
1
30/06
/201
1
30/09
/201
1
31/12
/201
1
31/03
/201
2
30/06
/201
2
30/09
/201
2
31/12
/201
2
31/03
/201
3
30/06
/201
3
Scotland Forth Valley Trajectory
60%
65%
70%
75%
80%
85%
90%
95%
100%
Oct-
11
No
v-1
1
Dec-1
1
Jan
-12
Feb-1
2
Mar-
12
Ap
r-12
May-1
2
Jun
-12
Jul-
12
Aug
-12
Sep
-12
Oct-
12
No
v-1
2
Dec-1
2
Jan
-13
Feb-1
3
Mar-
13
Ap
r-13
May-1
3
Jun
-13
Jul-
13
Aug
-13
Sep
-13
Oct-
13
Co
mp
lian
ce
month
Monthly Compliance of ED 4-hr Standard
ED
MIU
FV
Standard
The quarterly statistics at June 2013 highlight that 95.4%
of patients were seen within 62 days with a Scotland position of 94.5%.
The monthly management position for October 2013 is 95.5% of patients were treated within 62 days.
The October 2013 position is 93.3% which is
comparable with the September 2013 position of 93.4%.
Variability remains on a day to day basis however activity is becoming more consistent.
Forth Valley met its agreed trajectory of 92% in October and has made good progress in November towards achieving the next milestone of 95%.
Faster access to Child & Adolescent Mental Health Specialist Services (CAMHS) - 0 patients waiting > 26 weeks March 2013
Delivering 18 weeks referral to treatment for Psychological Therapies from December 2014
Target: Zero >26 weeks
Within target
100% @ September 2013 ↑
Target: Zero >18 weeks
Behind trajectory
43% @ September 2013 ↓
Child & Adolescent Mental Health Services
70
75
80
85
90
95
100
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Percentage seen within 26 weeks- Monthly Percentage seen within 18 weeks - monthly
Percentage seen within 26 weeks - quarterly Percentage seen within 18 weeks - quarterly
Trajectory against Completed Performance
5560
6575 75
8085
90
62 58.764.3
59.8
43
01020304050
60708090
100
Jan-1
3
Feb-13
Mar-13
Apr_Jun 13
July_Sep 1
3
Oct_Dec 1
3
Jan-M
ar 14
Apr_Jun 14
July_
Sep14
Oct_Dec 1
4
Jan_
Mar 15
Target Time Frames
% Trajectory
Complete Performance
The position for September 2013 is that 100% of
patients were treated within 26 weeks. This target will further reduce to 18 weeks by December
2014. The Scotland position for period July to September
2013 highlights that 94% of people seen by a CAMH service started their treatment within 26 weeks and 85% were seen within 18 weeks of being referred.
The adjusted waiting time performance for patients who had completed their waits within the quarter April 2013 to June 2013 for Forth Valley was 62% within 18 weeks. The RTT performance has dropped to 43% for
quarter ending September 2013 against a trajectory of 60%. Activity to review the position includes work to establish how people enter, move through, and leave the service, identifying the role, remit and function of each constituent service within the system and an analysis of Demand, Capacity, Activity and Queue (DCAQ) for each part of the service.
6
EFFICIENT
Context A number of areas under the ‘Efficiency’ heading continue to pose challenge despite the Amber or Green position within the balanced scorecard (BSC). The Absence Management position in the BSC is Red with a position of 5.37% for October 2013. A number of areas reported relate to overall capacity which remains a key focus within the EPQ Prioritisation Programme. Bed occupancy has previously been assessed, and remains, as Red due to high occupancy in a number of areas however the overall Emergency Inpatient Average Length of Stay remains Green with a month on month improvement. There is ongoing variability across the system with a number of acute wards/specialties continuing to experience challenge. Further work is underway to understand the key issues in this area. Inpatient cancellations that exclude those cancelled by the patient are Green in the BSC with a position of 5% for September. The total cancellations are at an Amber position with a cancellation rate of 9%. Theatre late starts previously within the 3% target are now Amber in the BSC and 3.2% for the month of September 2013. The theatre under run position remains red in the BSC with 11.3% of available allocated planned hours lost in September 2013. The number of British Association of Day Surgery (BADS) procedures carried out as day cases or outpatients at the end of August 2013 was 80.6% which is highlighted as Amber in the BSC. DNA rate has changed from Amber to Red within the BSC with a position of 9.0% in September 2013 against a target of 7.8%, an increase of 1% in month.
Attendance Management - to reduce sickness absence to 4% by March 2009
% occupancy rate
Target: 4% Deteriorated position
5.37% @ October 2013 ↓
Target: see text
Position @ October 2013 ↓
Sickness Absence
0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%
31/1
0/20
12
30/1
1/20
12
31/1
2/20
12
31/0
1/20
13
28/0
2/20
13
31/0
3/20
13
30/0
4/20
13
31/0
5/20
13
30/0
6/20
13
31/0
7/20
13
31/0
8/20
13
30/0
9/20
13
31/1
0/20
13
FV Trajectory
% Occupancy o f A vail Staff B eds by H o spital
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
FCH FVRH
The October 2013 position was 5.37%, this is an increase
against September of 0.24%. All areas showed increased absence in the month Acute
(0.22%), CHPs (0.23%) and Corporate (0.32%). Focus on attendance management continues as
challenge remains with significant management interventions on-going.
This issue continues to be discussed in detail though a variety of fora including Staff Governance with the Director of Human Resources reviewing the position.
Breakdown by hospital for October 2013 is: o Falkirk Community Hospital – 89.2% down from
93.5% in September. o Forth Valley Royal Hospital – 89.6% up slightly
from 89.5% in September. Due to continued high occupancy in a number of
areas this is flagged as Red in the BSC. Occupancy rate of acute staffed beds in Scotland
for quarter ending March 2013 was 85.4%, up 1.9% from quarter ending March 2012 (data source: ISD website).
85% occupancy for acute beds is the accepted standard and allows for optimum flow.
7
EFFICIENT
% of elective patients whose procedure is cancelled on the day of planned procedure or one day before excluding those cancelled by patient
% of elective patients whose procedure is cancelled on the day of planned procedure or one day before – this is across all specialties
Target: 5% Within target 5% @ September 2013 ↓
Target: Reduction
Reduced position
9% @ September 2013 ↓
Operations cancelled as % of theatre activity
0%
1%
2%
3%
4%
5%
6%
7%
8%
Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Cancellation Rate Excluding Patient Cancelled Target Rate
Number of Theatre Cancellations (All Specialties) by Reason
0
10
20
30
40
50
60
70
80
Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 M ar-13 Apr-13 M ay-13 Jun-13 Jul-13 Aug-13 Sep-13
Anaesthetist Cancelled Patient Cancelled Surgical/Clinical No Beds Other Reason Out of Time The September 2013 position for operations cancelled,
excluding those cancelled by the patient was 5%. There is a 5% target with no aligned trajectory. Activity excludes trauma. Further work is underway to establish the precise
reasons for these cancellations to ensure they are kept to a minimum.
The total number of cancellations for September 2013 was 95.
46 cancellations were by the patient with the remaining 49 cancelled by the hospital.
Cancellation rate was 9% for September 2013.
Reason For Cancellation August 2013
September 2013
Anaesthetist Cancelled 8 13 No Beds 0 1 Other Reason 10 7 Out of Time 11 7 Patient Cancelled 33 46 Surgical/Clinical 25 21
Total 87 95 Number of British Association of Day Surgery (BADS) procedures carried out as daycases or outpatients
Theatre late start hours as % of available (allocated planned) hours
Target: 84% Position behind target
80.6% @ August 2013 ↓
Target: 3% or less
Deteriorated target
3.2% @ September 2013 ↓
% B A D S D aycase P ro cedures
50%
60%
70%
80%
90%
FV Trajectory
Late Start Hours Lost as % of Available (Allocated Planned) Hours
3.1%
3.6%3.9% 3.8%
3.2%3.4%
2.4% 2.5%2.6%
3.1% 3.2%
2.6%
3.0%
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 M ar-13 Apr-13 M ay-13 Jun-13 Jul-13 Aug-13 Sep-13
Late-Start Hours as % of Timetabled(Allocated Planned) Hours Late-Start Trajectory
At the end of August 2013, 80.6% of BADS procedures
were carried out as daycases/outpatients against an NHS Forth Valley target of 84%.
The NHS Forth Valley performance is on average about 80% which is the national target set by the British Association of Day Surgery.
There is up to a 3 month lag time therefore activity figures are provisional and will be updated on a rolling basis monthly.
The target set by the National Theatre
Implementation Group is that 3% of hours or less will be lost through theatre sessions starting late.
A late start is recorded when theatre commences 15 minutes or more after the expected start time with the number of hours lost to late starts as a percentage of planned list hours.
The position at September 2013 is marginally behind target at 3.2%.
8
EFFICIENT
Theatre under run hours as % of available (allocated planned) hours
Reduce ‘Did Not Attend’ rates (DNA) for new outpatient appointments
Target: 5% or less
Deteriorated position
11.3% @ September 2013 ↓
Target: 7.8% Behind target
9.0% @ October 2013 ↓
Under Runs Hours Lost as % of Available (Allocated Planned) Hours
10.8%
13.2% 12.7%13.7%
11.5% 11.2%11.9%
9.7%
7.6%
9.0%
11.3%10.2%
8.4%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 M ar-13 Apr-13 M ay-13 Jun-13 Jul-13 Aug-13 Sep-13
Under-Run Hours as % of Timetabled (Allocated Planned) Hours Under-run Trajectory
% New Outpatient DNAs
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
Trajectory Actual
An under run is when a theatre session is finished early by 45 minutes or more with the number of theatre list under run hours as a percentage of planned list hours providing the measure.
This target continues to provide challenges with the BSC position currently red.
The position in August was 10.2% with an increase to 11.3% in September 2013.
This includes all theatres with work to review activity around dental and ECT which may be impacting negatively on the position.
The position for October 2013 is 9.0% which is 1.2%
behind target and an increase of 1% against the September position.
DNA’s have increased steadily from a position of 7% in April 2013.
There is ongoing active implementation and monitoring of the Patient Access Policy in respect of ‘Did Not Attend’ patients.
Emergency inpatient average length of stay in days
Target: 3.5 Improved position
3.32 @ October 2013 ↓
Emergency Inpat ients A vg Length o f Stay (days)
00.5
11.52
2.53
3.54
FV Trajectory
The provisional average length of stay for emergency inpatients for September 2013 is 3.32 days against a target of 3.5 days
All specialties are included in the data. The graph has been updated to exclude the Clinical
Assessment Unit with its length of stay of less than 24 hours.
The updated graph highlights an overall increase in the length of stay however the downward trend remains
The most up to date figure for all Scotland is 3.1 days at March 2013 (figures are updated and published annually in September).
9
SAFE
Context All but 1 of the measures within the Safe dimension of quality are Green within the BSC. The most recent Hospital Standardised Mortality Ratio (HSMR) for quarter ending June 2013 highlights that the overall change from October – December 2007 for NHS Forth Valley is (-18.0%) and for NHS Scotland is (-12.4%). The HSMR fluctuates over time and is influenced by various factors such as age and patient diagnosis, and varies between hospitals. NHS Forth Valley continues to exceed the Hand Hygiene target which remains Green in the BSC. Staphylococcus aureus bacteraemia cases continue to cause challenge with the 12 month rolling position to end October 0.38 per 1000 acute occupied bed days. The Clostridium difficile infections target continues to be achieved.
20% reduction in Hospital Standardised Mortality Ratio (HSMR) by December 2015
% of staff undertaking Hand Hygiene practice as per infection control requirements
Target: 20% Within target
0.98 @ quarter end June 2013 ↔
Target: 95% Within target
99% @ September 2013 ↑
0.0
0.5
1.0
1.5
2.0
Oct-Dec2006
Jan-Mar2007
Apr-Jun
2007
Jul-Sep
2007
Oct-Dec2007
Jan-Mar2008
Apr-Jun
2008
Jul-Sep2008
Oct-Dec2008
Jan-Mar
2009
Apr-Jun
2009
Jul-Sep2009
Oct-Dec
2009
Jan-Mar2010
Apr-Jun
2010
Jul-Sep
2010
Oct-Dec
2010
Jan-Mar2011
Apr-Jun
2011
Jul-Sep
2011
Oct-Dec2011
Jan-Mar
2012
Apr-Jun
2012
Jul-Sep2012
Oct-Dec
2012
Jan-Mar
2013
Apr-Jun
2013p
Sta
nd
ard
ised
Mo
rtal
ity
Rat
io
Standardised M ortality Ratio (SM R) Regression line
Hand Hygiene Compliance
92%
93%
94%
95%
96%
97%
98%
99%
100%
30/0
4/20
1230
/06/
2012
31/0
8/20
1231
/10/
2012
31/1
2/20
1228
/02/
2013
30/0
4/20
1330
/06/
2013
31/0
8/20
13
Per
cen
tag
e C
om
pli
ance
NHS Forth Valley Audit National Audit Target
HSMR with regression line Oct 2006 – June 2013 for NHS Forth Valley acute hospitals.
HSMR compares actual deaths with expected deaths within 30 days of admission. It fluctuates over time and is influenced by various factors such as age and diagnosis of patient. This will vary between hospitals.
HSMR is intended to monitor trends over time with a view to seeing improvements against target.
Data is published quarterly with 0.86 the Scotland position for quarter ending June 2013.
Data for quarter ending September 2013 is due for publication end February 2014.
Overall change from Oct – Dec 2007 is NHS Forth Valley (-18.0%), NHS Scotland (-12.4%).
The above graph highlights that the September 2013
Scottish Patient Safety Programme Hand hygiene compliance is 99%.
The September 2013 Health Protection Scotland (HPS) bi-monthly national audit report publication highlighted 97% compliance for NHS Forth Valley.
10
SAFE
S4: HEAT Target – Further reduce healthcare associated infections so that by March 2016 staphylococcus aureus bacteraemia cases are 0.24 or less per 1000 acute occupied bed days
S5: HEAT Target - Further reduce healthcare associated infections so that by March 2016 the rate of Clostridium difficile infections in patients aged 15 & over is 0.25 cases or less per 1000 total occupied bed days
Target: 0.24
Behind trajectory
12 month rolling position 0.38 @ October 2013 ↓ Target: 0.25 Within
target 0.2 @ October
2013 ↔
Staphylococcus aureus bacteraemia cases per 1000 acute occupied bed days
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
31-M
ay-1
2
31-Jul-1
2
30-S
ep-12
30-N
ov-12
31-Jan-
13
31-M
ar-1
3
31-M
ay-1
3
31-Jul-1
3
30-S
ep-13
Forth Valley Scotland 12 month rolling average Trajectory
Clostridium difficile cases in patients over 15 years per 1000 total occupied bed days
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Jun-1
2
Jul-1
2
Aug-12
Sep-12
Oct-
12
Nov-12
Dec-12
Jan-1
3
Feb-1
3
Mar-1
3
Apr-1
3
May-1
3
Jun-1
3
Jul-1
3
Aug-13
Sep-13
Oct-
13
Forth Valley Trajectory Scotland Forth Valley quarterly The number of patients with SABs in October was 8;
0 Hospital acquired, 5 Healthcare, 3 Community. The 12 month rolling position to October 2013 is 0.38. Community and Healthcare acquired SABs are the
biggest issue for Forth Valley. Work is on-going in an attempt to reduce numbers in
these groups and includes training given to CADs, Drug Workers, Community Pharmacists regarding recognising infected injection sites of IVDUs, and identification of all co-morbidities of those who have acquired a SAB.
The NHS Forth Valley rate of Clostridium Difficile
Infections (CDI) in October 2013 is 0.2 per 1000 total occupied bed days against a target of 0.25.
The number of patients with a CDI for October 2013 was 2 both of whom were Healthcare acquired.
Note: Changes in graph detail are as result of changes to the HEAT target for 2013/14 which have been applied from September 2013.
11
EFFECTIVE
Context The ‘Effective’ heading continues to show a variation in performance. The Delayed Discharge position for November was 14 delays over 28 days. The updated HEAT Target is that no-one will wait more than 14 days to be discharged from hospital into a more appropriate care setting once treatment is complete, from April 2015. The graph highlights progress against this trajectory with a November position of 28 against a trajectory of 16. This remains a key area of focus for NHS Forth Valley and partner organisations. There has been a sustained increase in the number of bed days lost due to delays in discharge from an August position of 255 to 1203 in November 2013, which equates to almost 50 beds at 85% occupancy.
No-one will wait more than 14 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April
Reduction in the number of bed days lost due to delays in discharge
Target: 0 Behind target 28 @ November 2013 ↓
Target: Reduction
Deteriorated position
1203 @ November 2013 ↓
Delayed Discharge over 14 days
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13
Nu
mb
er o
f D
elay
s
Clacks FalkirkStirlng Total Delays over 14 daysForth Valley trajectory
Total Bed Days Lost to Delayed Discharge
0
100
200
300
400
500
600
700
800
900
1000
1100
1200
1300
Jan-
13
Feb-1
3
Mar
-13
Apr-1
3
May
-13
Jun-
13
Jul-1
3
Aug-1
3
Sep-1
3
Oct-
13
Nov-1
3
Clackmannanshire Falkirk Stirling Total
The November 2013 census position was 28
delays over 2 weeks in NHS Forth Valley. This is against a trajectory of 16.
The position for delays over 4 weeks is 14 against a zero target.
Weekly monitoring and micro management meetings are on-going reviewing the position over 4 and 2 weeks.
Choice remains an issue however work is ongoing, linking with Local Authorities to identify suitable patients to transfer into Intermediate Care Facilities, also to identify appropriate vacancies earlier.
Note: Graph highlighting delays over 2 weeks
Total bed days occupied by delayed discharges at
November 2013 is 1203, an increase of 241 from the October position of 962.
Breakdown by Local Authority is Clacks 156, a reduction from October of 29; Falkirk 727, an increase of 197; Stirling 320, an increase of 73.
Weekly meetings continue, focussing on individual patient needs to ensure appropriate movement and placement.
W eekly position noted in table
21st November 2013 Over 2 wks
Over 4 wks
Clacks 2 2 Falkirk 28 12 Stirling 7 5 TOTAL 37 19
12
PERSON CENTRED
Context The BSC position in respect of admissions of stroke patients directly to the Stroke Unit is Amber at October 2013 with a position of 87% against a 90% target. This is a marked improvement on the previous 2 months. All stroke patients however are cared for appropriately under the auspices of the Stroke Team in the hospital.
Scottish Stroke Care Standard - all patients admitted with a diagnosis of Stroke will be admitted to a stroke unit within 1 day of admission Target: 90% Behind
target 87% @ October
2013 ↑
Admission to Stroke Unit within 1 day
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
30/0
4/201
2
30/0
6/201
2
31/0
8/201
2
31/1
0/201
2
31/1
2/201
2
28/0
2/201
3
30/0
4/201
3
30/0
6/201
3
31/0
8/201
3
31/1
0/201
3
FV monthly Quarterly position Trajectory Scotland
The monthly data highlights a position of 87% at October 2013 against a 90% trajectory point, an improvement of 14% against the September position of 73%.
The quarterly performance to September 2013 is 70%.
The HEAT target end point at March 2013 for all Scotland was 79.7% for same day admissions to stroke units.
*Patients discharged prior to spending 2 nights in hospital excluded
13
SECTION 2 - CORPORATE RISKS Corporate Risks Summary – December 2013 The Corporate Risk Register contains risks the organisation faces at a strategic level and should include risks escalated from the Unit or CHP Risk Registers where controls are no longer effective and the risk owner cannot manage the risk within their available resources. The Performance and Resources Committee maintains an overview of the Corporate Risk Register and considers risks that require to be reported to the NHS Board. Corporate Risks continue to be reviewed on a monthly basis.
Insufficient available capacity with resulting impact on patient flows - admission transfer, discharge and boarding of patients. Current control measures include: reduce demand for acute in-patient capacity e.g. through use of rapid access frailty unit; improve efficiency of inpatient stay and reduce variability e.g. through daily real time demand capacity meetings and improve outflow form acute services and ensure clear pathways to community e.g. through discharge beat & monitoring. Additional winter capacity planning also in place. Regular updates and monitoring via weekly Chief Executive’s Operational meeting
Delayed discharge from hospital and increased bed days. Control
measures in place include: discharge policies and seasonal pressures/discharge plans, delayed discharge steering group and activity through Reshaping Care for Older People Fund. Position reviewed at CEO level through Joint Executive Group. Regular updates and monitoring via weekly Chief Executive’s Operational meeting
Provision of healthcare management for patients managed via
Health MAPPA and non-health MAPPA. Range of control measures include staff access to existing systems/procedures and appropriate training within the Mental Health Services e.g. Health and Safety, Risk Management and Occupational Health, MAPPA awareness. Following review, the forensic mental health service has submitted a proposal to reduce the organisational risk. This proposal has recently been supported and work is underway to increase clinical forensic psychology, forensic CPN sessional time and administrative support. This will result in increased capacity for both Health MAPPA and MAPPA offence related risk assessment/management; offence focussed psychological interventions, consultative work with MAPPA partners and improved input to interagency MAPPA working with sex offenders in the community.
Inability to meet Waiting Times targets in outpatients. Outpatient waits of 12 weeks remain a challenge in a number of specialties. A four phased plan has been developed to improve the position going forward
1
2
Absence. All areas showing increased absence. Control measures
include: focus group meeting to continually address issues at operational level, with particular attention on specific staff groups as approved by Staff Governance Committee. Review and discussion at Strategic Management Team.
Achievement of year on year financial balance whilst maintaining
target delivery and below NRAC share Financial projections and risks updated monthly and reported through all governance processes. Robust monitoring of financial performance continues. Residual risk reduced to high (orange).
SECTION 3 - HEALTHCARE ASSOCIATED INFECTION REPORTING TEMPLATE (HAIRT)
Section 1 – Board Wide Issues
This section of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual hospitals, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2. A report card summarising Board wide statistics can be found at the end of section 1
Key Healthcare Associated Infection Headlines for October 2013
Staphylococcus aureus Bacteraemias (SABs)
Total number of SABs this month = 8 Total number of SABs (Apr – date) = 48
Hospital acquired = 0
Healthcare acquired = 5
Community acquired = 3
Clostridium difficile Infections (CDIs)
Total number of CDIs this month = 2 Total number of CDIs (Apr – date) = 20
Hospital acquired = 0 Healthcare acquired = 2
Device Associated Bacteraemias (incl Staph aureus) (DABs)
Total number of DABs this month = 7 Total number of DABs (Apr – date) = 34
Hospital acquired = 3 (A31 - urinary catheter, B31 - CVC & Urinary Catheter) Healthcare = 4
Ward specific SAB/CDI graphs can be found using the following link: http://staffnet.fv.scot.nhs.uk/index.php/a-z/infection-control/monthly-ward-reports/ HAI related deaths
There were no HAI related deaths this month. Outbreak and incident management
There were no incidence or outbreaks reported this month. Ward visit programme Total number of non compliances this month was 92 which is a DECREASE compared to the previous month of 104 non compliances. Predominant non-compliances include PPE use, use of Vernacare tape on cleaned equipment, sharps boxes and inappropriate storage on floors.
The full report can be found by following this link: http://staffnet.fv.scot.nhs.uk/index.php/a-z/infection-control/monthly-ward-reports/
The following pages contain information and links to national reports relevant to our HEAT targets, hand hygiene, cleaning and various data tables. Relevant graphs are contained in Annex 1,2 & 3 of this report.
Staphylococcus aureus (including MRSA)
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
Clostridium difficile
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 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
Hand Hygiene
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 in section 2. Information on national hand hygiene monitoring can be found at:
http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx
Cleaning and the Healthcare Environment
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 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
Additional information – Infection Control News
New member of the Infection Prevention & Control Team In September Diane Williamson joined the team as Infection Control Support Nurse; Diane previously worked in the Radiology Department in FVRH. Diane will be taking on ward responsibilities and a patient caseload next month. SLWG HEI readiness in the Community Hospitals Following the last Area Prevention & Control of Infection Committee meeting, a short life working group has been set up to ensure adequate preparation for the impending HEI inspection to our Community Hospitals. HAI training to Student Nurses In October, the Infection Control Team started training to first year students to embed hand hygiene and standard infection control precautions (SICPs) across Forth Valley. Ward Safety Briefs New to this month, the Infection Control Team will now attend ward safety briefs to discuss issues identified around SABs, DABs and CDIs that have been isolated in the ward. Assessors Study Day The Infection Control Team provided training at the annual Clinical Skills Assessors Study Day on the 6th November for senior staff in the acute sector. We provided HAI updates on the new SICPS auditing tool, MDROs and up and coming Quality Improvement projects including the new CAUTI bundle. The training will be repeated on the 29th November for Community staff.
Healthcare Associated Infection Reporting Template (HAIRT)
Section 2 – Healthcare Associated Infection Report Cards
The following section is a series of ‘Report Cards’ that provide information, for each acute hospital and key community hospitals in the Board, on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. 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 Numbers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). 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§ionID=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§ionID=1
For each hospital the total number of 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. Targets There are national targets associated with reductions in C.diff and SABs. More information on these can be found on the Scotland Performs website: http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance Understanding the Report Cards – Hand Hygiene Compliance Hospitals carry out regular audits of how well their staff are complying with hand hygiene. Each hospital report card presents the combined percentage of hand hygiene compliance with both opportunity taken and technique used broken down by staff group. Understanding the Report Cards – Cleaning Compliance Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates 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/ Understanding the Report Cards – ‘Out of Hospital Infections’ Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries and care homes and. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital.
NHS FORTH VALLEY BOARD REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
MRSA 1 1 0 1 0 2 0 0 0 2 0 1 MSSA 7 6 7 3 5 4 10 8 3 6 5 7 Total SABS 8 7 7 4 5 6 10 8 3 8 5 8 Clostridium difficile infection monthly case numbers
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Ages 15-64 1 1 1 4 0 1 0 1 1 2 2 0 Ages 65 plus 0 2 0 6 0 2 2 2 1 2 2 2 Ages 15 plus 1 3 1 10 0 3 2 3 2 4 4 2 Hand Hygiene Monitoring Compliance (%)
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Board Total 98 99 99 98 98 99 99 99 99 99 99 99 Note. The next edition will all contain a breakdown of the staff groups.
Cleaning Compliance (%)
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Board Total 97 96 97 97 97 97 97 97 97 97 97 97 Estates Monitoring Compliance (%)
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Board Total 95 94 98 98 97 98 97 98 98 99 94 96
FORTH VALLEY ROYAL HOSPITAL REPORT CARD
Staphylococcus aureus bacteraemia monthly case numbers
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
MRSA 0 1 0 0 0 0 0 0 0 1 0 0 MSSA 0 2 2 0 1 0 1 2 0 0 1 0 Total SABS 0 3 2 0 1 0 1 2 0 1 1 0 Clostridium difficile infection monthly case numbers
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Ages 15-64 0 0 0 0 0 0 0 0 0 1 0 0 Ages 65 plus 0 1 0 1 0 1 0 0 0 1 0 0 Ages 15 plus 0 1 0 1 0 1 0 0 0 2 0 0 Cleaning Compliance (%)
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Board Total 97 98 98 98 97 96 97 97 97 98 98 97 Estates Monitoring Compliance (%)
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Board Total 100 100 100 100 100 100 100 100 100 100 100 100
NHS COMMUNITY HOSPITALS REPORT CARD
The community hospitals covered in this report card include: Stirling Community Hospital Falkirk Community Hospital Clackmannanshire Community Hospital
Staphylococcus aureus bacteraemia monthly case numbers Nov
2012 Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
MRSA 0 0 0 0 0 0 0 0 0 0 0 0 MSSA 0 0 0 0 0 0 0 1 0 0 0 0 Total SABS 0 0 0 0 0 0 0 1 0 0 0 0 Clostridium difficile infection monthly case numbers Nov
2012 Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Ages 15-64 0 0 1 0 0 0 0 0 0 0 0 0 Ages 65 plus 0 0 0 1 0 0 0 0 0 0 0 0 Ages 15 plus 0 0 1 1 0 0 0 0 0 0 0 0
NHS OUT OF HOSPITAL REPORT CARD Staphylococcus aureus bacteraemia monthly case numbers Nov
2012 Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
MRSA 1 0 0 1 0 2 0 0 0 1 0 1 MSSA 7 5 5 3 4 4 9 5 3 6 4 7 Total SABS 8 5 5 4 4 6 9 5 3 7 4 8 Clostridium difficile infection monthly case numbers Nov
2012 Dec 2012
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
Jun 2013
Jul 2013
Aug 2013
Sept 2013
Oct 2013
Ages 15-64 1 0 0 3 0 1 0 1 1 1 2 0 Ages 65 plus 0 2 0 5 0 1 2 2 1 1 2 2 Ages 15 plus 1 2 0 8 0 2 2 3 2 2 4 2
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
1 3 1 10 0 3 2 3 2 4 4 2 8 7 7 4 5 6 10 8 3 8 5 8
Clostridium difficile Cases (ages 15 and over) Total Staphylococcus aureus Bacteraemia Cases
The following report cards provide graphs that are no longer included in the new reporting template.
The graphs below detail board wide totals of SAB and CDI infections.
ANNEX 1. BOARD WIDE SAB & CDI TOTALS
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0 1 0 1 0 1 0 0 0 2 0 0 0 3 2 0 1 0 1 2 0 1 1 0
Clostridium difficile Cases (ages 15 and over) Total Staphylococcus aureus Bacteraemia Cases
This report card details the SAB (MRSA & MSSA) & CDI totals for Forth Valley Royal Hospital.
ANNEX 2. HOSPITAL ACQUIRED SABS & CDIs
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-136 3 4 2 1 2 5 2 2 2 3 5 1 2 0 8 0 2 1 3 2 2 4 2
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
2 1 1 2 3 4 4 3 1 5 1 3 0 0 0 0 0 0 1 0 0 0 0 0
Community Acquired CDI Cases
ANNEX 3. Healthcare & Community acquired Infections
Healthcare Acquired CDI Cases
Community SAB Cases
Healthcare SAB Cases
Healthcare acquired SABs are infections that can be associated and attributed to previous healthcare interventions; this group is an area where the Infection Control team actively investigate and if it is suspected the infection has arisen from a previous hospital admission, it is treated as a hospital acquired SAB; although due to the strict HPS definitions of acquisition type it is classified as out of hospital.
Community acquired SABs are those that have not had any healthcare contact or intervention and as such are outwith our control to reduce these infections.
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
20
40
60
80
100
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
1 2 7 1 2 1 3 5 4 7 7 7
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0 0 6 0 0 0 2 4 2 3 1 3 1 2 1 0 2 1 1 1 2 4 6 4
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-130 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ANNEX 4. Device Associated Bacteraemias Total Device Associated Bacteraemia Cases
Nursing Home Device Associated Bacteraemia Cases
Hospital Device Associated Bacteraemia Cases
In addition to reporting Staph aureus bacteraemia, the Infection Control Team also monitor all device associated bacteraemias (DABs) to enable a more accurate and appropriate targeted approach rather than concentrating on an organism specific infection.
The graphs below highlight all DABs (including Staph aureus) across NHS Forth Valley.
Healthcare Device Associated Bacteraemia Cases
Community Hospital Device Associated Bacteraemia Cases
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
0
2
4
6
8
10
12
14
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13
FORTH VALLEY NHS BOARD 10TH DECEMBER 2013 This report relates to Item 6.2 on the agenda
Finance Report to end 31st October 2013
(Paper presented by Fiona Ramsay, Director of Finance)
For Noting
2
3
1. Executive Summary
This report provides a summary of the financial position for NHS Forth Valley to 31st October 2013.
There is a statutory requirement for NHS Boards to ensure expenditure is within the
Revenue Resource Limit (RRL) and Capital Resource Limit (CRL) set by the Scottish Government Health and Social Care Directorate.
The Table below provides a summary of the out-turn position :-
Annual Budget Actual Variance
Budget To date To date Over/ (under)
£’m £’m £’m £’m
Community Health Partnerships 92.406 51.454 51.754 0.300 Specialist and Ambulatory Care 76.402 45.511 45.854 0.343 Emergency and Inpatient Services 70.370 41.019 41.636 0.617 Women & Children 22.369 12.980 12.901 -0.079 Projects and Facilities 76.445 43.333 43.711 0.378 Primary Care Prescribing 55.017 30.842 30.777 -0.065 Cross Boundary Flow 43.132 25.027 24.785 -0.242 Primary Medical Services 40.374 21.827 21.826 -0.001
Area-wide Corporate Services 29.662 15.748 15.408 -0.340 Funding yet to be distributed 12.841 0.932 0.000 -0.932 inc. Contingency Income -20.748 -12.366 -12.345 0.021
Total 498.270 276.307 276.307 0.000
Family Health Services 30.110 17.297 17.297 0.000
Main points to note are as follows :- A balanced financial position is reported to the end of October 2013 and a
balanced financial position is projected for the year end. Individual Unit
4
projections are reviewed monthly and will be incorporated for the November Report. Key issues on Unit positions are detailed in the Unit Summary Section.
Cash Savings requirements are fully reflected in the Unit and Corporate Financial
positions. The main focus of work continues to be ensuring underlying sustainability of the
financial position including management of financial pressures and delivery of savings on a recurrent basis.
Non-recurrent funding has been allocated to Units as agreed for the winter period covering staffing to support additional bed capacity, additional community nursing and AHPs (Allied Health Professionals).
Projections are being updated to reflect additional capacity required to meet 18 week RTT (referral to treat) performance and improve outpatient waiting times. This capacity will be met through a combination of local waiting list initiatives, agreed capacity with the Golden Jubilee and use of the private sector ensuring these are within the parameters if the local Access Policy. Financially this is not presenting a risk and is covered from a combination of local funds remaining from the budget approved at the start of the year for this purpose augmented by funding from the National Access Team.
The draft Scottish budget was announced in September. Information regarding the Health Budget and NHS FV position was provided to the Board Seminar on 20 September 2013.
Work is in progress to update the five year Financial Plan to reflect the draft Scottish Budget / local Strategy discussions and estimates for pay / prices and prescribing changes.
2. Unit Summary
Annex 1 provides graphical highlighting the cumulative trend for each Unit month by month Community Health Partnership The Community Health Partnership which covers the two CHP Partnerships and a range of services including Learning Disability, Mental Health and Prison
Services is reporting an overspend of £0.300m to 31st October 2013. As previously reported the overspend is broadly in Specialist Mental Health Services and in Prisons and Specialist Community Services with spending on complex care cases a continuing risk. The Unit is focussing on achieving in-month financial balance.
Specialist and Ambulatory Care This Unit which covers a range of services including day surgery, cancer
services, theatres and diagnostic services (laboratories and radiology) is reporting
5
an overspend of £0.343m. The overspend remains broadly attributable to theatre supplies, diagnostics and medical physics. This Unit presented its financial management, pressures and savings to the November Performance and Resources Committee.
Funding continues to be held centrally for Access and distributed monthly until
Specialty Sustainability Plans are actioned on a recurrent basis i.e. predominantly when consultants are recruited and in post. As previously indicated work on matching activity changes with demands on supplies such as theatres is in progress and will be concluded in line with the Sustainability Plan Review.
Emergency and Inpatient Services This Unit which covers all inpatient services in both Forth Valley Royal and in
Community Hospitals, Out of Hours and Accident and Emergency Services is reporting an overspend of £0.617m. A proportion of the overspend to date continues to be as a result of ‘contingency’ beds being opened beyond that planned at the start of the year. Funding for additional capacity over the winter period has been agreed including these contingency beds and therefore this overspend should cease from October 2013 to the end of the year.
This Unit presented on its financial management, pressures and savings plans at
the October Performance and Resources Committee. The Capacity and Flow Project continues to focus on a variety of actions to improve capacity/flexibility within the overall care system which will in turn reduce reliance on contingency beds/arrangements and consequentially support improvement of the financial position on a longer term basis.
Women and Childrens This Unit covers Women and Childrens Services and Sexual Health Services and
remains broadly in a balanced financial position and Savings Plan in place. This Unit presented on its financial management, pressures and savings plans at
the September Performance and Resources Committee. Work remains particularly focussed on medical workforce for Obstetrics and Gynaecology.
Projects and Facilities This Unit which covers estates, maintenance, transport and domestic services
other than those covered by the FVRH Contract, management of the FVRH and Clackmannanshire Health Facility Contract and Capital Projects is reporting an overspend of £0.378m to the end of October 2013. This overspend is broadly attributable to corporate costs such as taxis and postages and a number of workforce issues as the Unit works towards its Workforce Plan and delivery of its remaining savings targets where savings areas identified will take a longer timeframe to deliver e.g. energy savings schemes for FVRH.
The Unit is scheduled to present its financial management, pressures and savings plans at a future Performance and Resources Committee.
6
Primary Care Prescribing Primary Care prescribing is reporting a small underspend of £0.065m with no
new issues to report at present. Entering the winter period a watchful eye is being kept for any emerging trends or pressures. Regular dialogue with primary care contractors ensures an early alert to any issues.
The next phase of the Savings Programme is in place with a new incentive scheme planned and with specific focus on practices whose prescribing spend is an outlier from both local and national patterns.
Cross Boundary Flow The summary position combines both patients travelling outwith NHS Forth
Valley for their treatment and those from other areas receiving their treatment within Forth Valley. The position to the end of October is an underspend of £0.242m with a broadly similar outturn projected.
Formal confirmation of expected increase in funding has been received from
Glasgow – this is £0.450m in line with anticipated and can be accommodated within the overall financial position. Regarding NHS Lothian, activity has reduced in certain areas but information is not available yet on relative case mix. It is likely that there will be a reduction in spend with NHS Lothian.
Area Wide Services Whilst there are some differential variances across the Departments overall area-
wide services are reporting a £0.340m underspend with Savings Plans in place and with a corresponding underspend anticipated at the year end.
Funding Not Yet Distributed This balance will continue to reduce over the year as changes are implemented and resources transferred to the relevant service. The main areas where funding is held are as follows with a collection of smaller allocations making up the balance:- Access Funding £4.5m : this funding is transferred on a month by month basis at present with individual service funding fully transferred as sustainable plans are implemented e.g. when Consultant appointments are in post. Auto-Enrolment £0.5m : initial funds transferred in July which was NHS Forth Valley implementation date ; this funding balance is required on an ongoing basis as the costs incurred this year only reflect a part year Utilities £0.5m : to be transferred to Facilities on conclusion of current year
projections. Contingency £1.1m : factored into out-turn to offset financial pressures.
Immunisation Programme Funding £0.831m
Capital to Revenue Transfer £1.268m
3. Savings
The following table provides a summary of progress with savings delivery against plan as reported to SGHSCD reflecting the categories of reporting required. This indicates that to the end of October 2013 £6.120m savings had been delivered (ahead of target of £5.003m) which is 46% of the total of £13.167m and ahead of plan/trajectory submitted as part of the LDP (Local Delivery Plan). This means savings have been delivered ahead of schedule rather than additional recurrent savings although some additional “non-recurrent” savings have been identified.
Achieved savings to
October
Forecast Year end Outturn
Efficiency and productivity workstreams
£’m £’m
Service Productivity 2.134 6.032 Drugs and Prescribing 0.991 1.588 Procurement 0.347 0.596 Workforce 1.302 2.644 Support Services (non-clinical) 0.564 0.966 Estates and Facilities 0.782 1.341
Total efficiency savings 6.120 13.167 Each month one of the Operational Units has delivered a presentation to the Performance and Resources Committee covering their Unit Plan including service issues, financial pressures and savings plans. To date four Units have presented and the final Unit is scheduled for December.
4. Temporary Workforce Spend
One of the measures included in the Board Balanced Scorecard is temporary workforce spend – this covers the use of bank and agency staff across all services, overtime and premia costs currently used in a number of areas to meet access targets. Whilst the use of such staff provides flexibility to the care system and provides temporary cover for vacancies and staff absence it is important to ensure controls are in place and that the trends and patterns are managed and monitored closely. Across all categories including overtime and on-call there has been an increase of 9.3% (approx. £0.7m) compared to the same period last year. Annex 2 provides graphical information for Bank and Agency Nursing (only a very small proportion relates to the use of Agency Staff), for Bank/Agency Medical Staff and for Locum Medical Staff
7
There has been an in-month increase in the cost of bank nursing and the overall spend remains ahead of the same period last year. Spend is predominantly in the Emergency and Inpatient Services and Community Health Partnership Units. As highlighted additional staff have been recruited to cover the winter period and this should reduce reliance on nurse bank staff. The increased spend on Medical Agency remains attributable to increases in Gastroenterology Costs (vacancy cover during recruitment period), junior medical cover in surgery (covering vacancies and maternity leave), orthopaedics (vacancy cover during recruitment period) and gynaecology (combination of vacancies, maternity leave and sick leave. This is under review to identify any areas where work is required on an exit strategy.
5. Capital
Annex 3 provides a summary of the Capital Position to the end of October 2013 and projected to the year end. There are four main areas where spend is forecast for the remaining months of the year : additional car parking at Forth Valley Royal Hospital, demolitions / decommissioning, Stirling Community Hospital site and work on Statutory Standards. There has been no change to property proceeds and brokerage repayment schedules since the September report.
6. Financial Risk
The financial risk for 2013/14 remains at ‘high’ in the Corporate Risk register but remains ‘very high’ regarding future years. 7. Conclusion
The Performance and Resources Committee are asked to note: the balanced revenue position to 31st October 2013 and the projected financial
balance for the year end. the balanced capital position to 31st October 2013 and the projected financial
balance for the year end. Fiona Ramsay Director of Finance 3rd December 2013
8
Annex 1 Unit Trend
9
Annex 2 Temporary Workforce Spend
10
ANNEX 3
NHS FORTH VALLEYCAPITAL RESOURCE LIMIT Plan Actual Variance Plan Forecast VarianceAs at 31st October 2013 £ £ £ £ £ £
SOURCES OF CORE FUNDINGScottish Executive Funding - General Allocation 2,029 2,029 0 5,422 5,422 0SGHD - Pfi Reversionary Interest 0 0 0 -4,610 -4,610 0SGHD - Pfi Reversionary Interest Assumed Allocation 0 0 0 4,610 4,610 0SGHD - HUB Initiative 115 115 0 416 416 0SGHD - Primary & Community Care Modernisation Programme Underspend 120 120 0 500 500 0SGHD - HUB DB Capital Doune HC 15 15 0 200 200 0SGHD - Detecting Cancer Early 106 106 0 106 106 0SGHD - Additional Capital 13/14 0 0 0 400 400 0SGHD - Capital Grants 0 0 0 -194 -194 0SGHD - Capital to Revenue Transfers 0 0 0 -1,268 -1,268 0Total Core Income 2,385 2,385 0 5,582 5,582 0
Planned Core Expenditure
Regional PrioritiesHUB Initiative 115 115 0 416 416 0Total 115 115 0 416 416 0Strategic PrioritiesNew Acute Hospital - Signage 11 11 0 55 55 0New Acute Hospital - Additional Car Parking 0 0 0 740 740 0Section 75 - A9 Larbert 0 0 0 52 52 0Demolitions / Decommissioning 119 119 0 700 700 0Ward 16 - Winter Beds 0 0 0 250 250 0Total 130 130 0 1,797 1,797 0Primary & Community Care Modernisation ProgrammeSCH / GP Premises 42 42 0 800 800 0Orchard House Health Centre 0 0 0 18 18 0Tullibody Health Centre 23 23 0 50 50 0CSD Refurbishment 40 40 0 40 40 0Lochview Pool Area 15 15 0 19 19 0Doune HC Modular 0 0 0 20 20 0GP Immunisation Programme 0 0 0 17 17 0P&CCMP General 0 0 0 36 36 0Total 120 120 0 1,000 1,000 0Community HospitalsFalkirk Community Hospital 273 273 0 300 300 0Stirling Community Hospital 190 190 0 275 275 0FCH Wards 18 & 19 0 0 0 400 400 0FCH - Remedial Works 204 204 0 375 375 0Total 667 667 0 1,350 1,350 0Area Wide ExpenditureIM & T Strategy 426 426 0 567 567 0IM & T Strategy (2) 0 0 0 500 500 0Medical Equipment Replacement Programme 712 712 0 750 750 0Detect Cancer Early Equipment 106 106 0 106 106 0Total 1,244 1,244 0 1,923 1,923 0Area Wide Other ExpenditureFire Safety / Statutory Standards 29 29 0 375 375 0Property Maintenance 0 0 0 3 3 0GIS Surveys 9 9 0 10 10 0GP Premises Grants 7 7 0 20 20 0HUB DB Capital Doune HC 14 14 0 100 100 0FVRH Mental Health Unit CG 50 50 0 50 50 0Capital Grants Transferred to RRL 0 0 0 -194 -194 0Capital to Revenue Transfers 0 0 0 -1,268 -1,268 0Total 109 109 0 -904 -904 0
Total Direct Core Expenditure 2,385 2,385 0 5,582 5,582 0
Savings/(Excess ) Against Capital Resource Limit 0 0 0 0 0 0
Forecast Property SalesBellsdyke Land Development 0 0 0 1,580 1,580 0Larbert House 0 0 0 1,175 1,175 0Clackmannan Hospital 260 260 0 260 260 0Bo'ness Hospital Land 0 0 0 50 50 0Total Forecast Property Sales 260 260 0 3,065 3,065 0
Position at 31st October 2013 Year end -Forecast
Performance and Resources Committee
29 November 2013
This report relates to Item 3 on the agenda
Minute of the Performance and Resources Committee held on 5 November 2013
For Noting
1
NHS FORTH VALLEY PERFORMANCE & RESOURCES COMMITTEE DRAFT Minute of the Performance & Resources Committee meeting held on Tuesday 5 November 2013 at 9.30am in the Boardroom, NHS Forth Valley, Carseview House, Castle Business Park, Stirling, FK9 4SW Present: Dr Vicki Nash, Non Executive Board Member (Chair) Ms Jane Grant, Chief Executive Mr Brendan Clark, Non Executive Board Member Professor Angela Wallace, Director of Nursing Dr Peter Murdoch, Medical Director Dr Stuart Cumming, Non Executive Board Member Mrs Helen Kelly, Director of Human Resources Mr Tom Steele, Director of Strategic Projects and Facilities Dr Graham Foster, Interim Director of Public Health Ms Fiona Gavine, Non Executive Board Member In Attendance Ms Elaine Vanhegan, Head of Performance Ms Julia Swann, Non executive Board Member Ms Jann Gardner, EPQ Programme Lead Mr Scott Urquhart, Assistant Director of Finance Ms Elsbeth Campbell, Head of Communications Mr David McPherson, General Manager Surgical and Cancer Services Unit Ms Marjolein Don, General Management Trainee Ms Maxine Michie, Senior Finance Manager – FVF and Falkirk CHP Ms Monika Johnson, Corporate Services Assistant / PA (Minute) 1/ APOLOGIES FOR ABSENCE Apologies for absence were intimated on behalf of Mrs Fiona Ramsay, Mr Charles Forbes, Mr Jim King
and Mr Alex Linkston 2/ DECLARATIONS OF INTEREST There were no declarations of interest. 3/ MINUTE OF PERFORMANCE & RESOURCES COMMITTEE MEETING HELD ON 1 OCTOBER 2013 The Performance & Resources Committee approved the minute of the meeting held on Tuesday 1
October 2013. 4/ MATTERS ARISING GP Issues Ms Grant gave an update on GP issues stating that Dr Stuart Cumming, Mr Derrick Douglas and Ms
Evelyn Hadden had been in dialogue with the two Medical Practices involved, and that an updated position paper would be produced. Ms Grant agreed to review the actions and will keep Performance & Resources Committee updated on a regular basis.
ACTION: JG
2
3
Dr Nash indicated that she would be keen to ensure primary and community care issues were being considered at the Committee and it was agreed that a paper would be produced for the January meeting outlining the current position.
ACTION: JG/SC Stirling Care Village Dr Nash highlighted that the Stirling Care Village would be part of the Board Seminar on 19 November
2013 and this would be discussed then. Mr Steele stated that he would give an update on Capital Projects under the review of the Core Performance Report during the meeting.
5/ URGENT BUSINESS Media Coverage Ms Grant and Dr Murdoch reported to the Performance and Resources Committee that there had been
an article in the local press regarding a patient who had been in the Accident and Emergency Department at Forth Valley Royal Hospital. The patient had fallen whilst in the Department. Dr Murdoch stated that the family had been given a verbal apology and that there was a full investigation underway, and that a meeting had been arranged. Dr Murdoch also informed the Committee that once the full investigation had taken place then a formal apology will be offered to the patient and the family in writing. Professor Angela Wallace supported Dr Murdoch and stated that the investigation into this incident was almost complete.
Dr Nash asked if the family had contacted NHS Forth Valley in the first instance regarding the incident
or if they had gone straight to the press. Professor Wallace stated that the family had contacted NHS Forth Valley first and then had contacted the press.
ACTION: PM/AW The Performance and Resources Committee noted the position. 6/ FINANCIAL AND PERFORMANCE ISSUES
6.1 Core Performance The Performance and Resources Committee considered the paper “Core Performance” presented by Ms Grant. Ms Grant gave a detailed overview of the paper and highlighted the key issues which were noted as: Accident and Emergency Performance – the pattern of variable performance against the 4hr
target had improved over the past 2 to 3 weeks however work was still required to ensure consistent delivery.
18 Week RTT – there were significant challenges for the Board regarding 18 Week RTT with Forth Valley being the lowest performing Board in Scotland. The current position was 81.6% which needs to increase by 10% to achieve the target
Outpatient stage of treatment targets – noted as also very challenging area as the waiting list size is increasing. The inevitable rate of conversion to inpatients and day cases added to the challenge during the winter period has increased significantly over the summer,
4
particularly in relation to those waiting over 12 weeks. It was noted that this would take many months to overcome but detailed work was underway.
TTG – an improved position with diminishing breaches indicating there would be none from December onwards.
The fact that the unavailability is very low in Forth Valley was noted as being positive although the 5% target was hard to achieve and perhaps required review.
Ms Grant offered assurance to the Performance and Resources Committee that these challenges were being tackled and that a clear position regarding progress and delivery would be required ahead of the Annual Review with the Scottish Government on 9 December 2013. It was also reported that a review of base efficiency was underway to maximise the current resource. Some of this action may not impact until well into next year. Dr Nash stated that there was a mixed picture being presented however there was positive action underway.
Stroke Unit Admission – Availability of beds had improved from 46% to 73% in month
however the trend required to continue. Key work continues to improve the capacity and flow within the service.
Delayed Discharges – There was a notable rise in delayed discharges and occupied bed days lost from 255 in August to 962 in October. Ms Grant reported that from a patient point of view this was less than ideal. Ms Margaret Duffy, Director of Integration was working on this issue. Further discussions between Ms Grant and the Local Authority Chief Executives were planned.
ACTION: JG Absence Management – The rise in absence from 4.88% to 5.1% was noted. Mrs Kelly
indicated that there were 2 Operational Units that had maintained a 4% absence rate which was a significant achievement. It was noted that Corporate Services Department’s absence rate had increased during September, impacted by small numbers of staff.
ACTION: HK Cancer Targets – ongoing delivery of the 31 and 62 day targets but not without significant
effort and challenge.
Ms Grant summarised the key issues over the next period relating to the need to ensure sustainability in relation to the 4 Hour A&E wait, while balancing the need to address significant elective waiting times pressures during the winter months. Detailed planning is underway to ensure performance is maintained and enhanced during this period.
Dr Nash went through the full report section by section seeking comment. Equitable
Breast Feeding was noted to be a continuing issue with performance lower than the rest of Scotland. Professor Angela Wallace reported that there was a working group within Forth Valley that is currently raising awareness on breast feeding and it is anticipated that this would have a positive outcome with further work being undertaken not just within the Hospital setting but also out in the community. The Baby Friendly award was noted as positive.
ACTION: AW Efficient
Inpatient length of stay was considered with it being noted that the Balanced Scorecard was at green but there was significant variation within ward areas with high occupancy rates. It was agreed that the format of the report would be reconsidered to ensure speciality based LOS data was available.
ACTION: EV
5
Effective The Delayed Discharge issues were discussed and the real need to reduce the number of
bed days lost as this was impacting on the flow through the organisation. The difficulties of working through options with patients and their families with regard to choice were highlighted. The planned action was again noted.
Timely The diagnostic position was summarised by Ms Grant indicating that there were a number of
patients breaching the 6 week target and that further work was underway to review how this could be addressed.
ACTION: JG Ms Fiona Gavine enquired as to when a credible plan would come forward with regards to delivery against the challenges highlighted. Ms Grant indicated that taking a number of issues into account around volume, reviewing the base efficiency, conversion to inpatients and treating the long waiting patients, a full recovery may not be seen until the summer. Work was being taken forward with GPs to review demand profiles in key specialties. Ms Grant indicated that the content of the overall Core Performance Report would be reviewed to allow greater focus on current issues and perhaps report on some topics less frequently where there was no material difference within on month, allowing greater focus on the areas of concern. The Major Capital Projects Summary was also considered. Mr Tom Steele highlighted the following points: Additional capacity in Ward 16 Stirling Community Hospital - Mr Steele indicated that there
had been a full review of options across the Forth Valley estate to provide additional beds over the winter period and that the only feasible option was to utilise Ward 16 on the SCH site. It was noted that capacity last winter was a significant challenge across Scotland and it would be prudent to ensure Forth Valley were well positioned to cope with both emergency and elective demand. Ward 16 would provide 22 beds which were key to supporting the overall surge capacity and delivery of key access targets. There would be at a capital cost of £0.250m and the ward would provide a facility over two winters and also a decant area for work required over the summer in wards 1- 4. There was a discussion over the potentially short life span of the ward but it was agreed that as it was the only available option to increase bed capacity in the short term the scheme should be supported.
The Performance and Resources Committee were requested to approve the plan noting the following: To ensure delivery within required timescales, SFIs (Standing Financial Instructions) would
be waived with assurance regarding value for money. The capacity for winter was required and that capital monies of £0.250m were available. Associated revenue costs were in place with recruitment for winter staffing underway.
ACTION: TS The Performance and Resources Committee approved the plan. Mr Steele went on to summarise the position around the Doune development, indicating the final position would be presented to the Board in December 2013. HUBCO was reported as the
6
preferred procurement model for the development of wards 18 and 19 on the Falkirk Community Hospital site.
6.2 Finance Report
The Performance and Resources Committee considered the paper “Finance Report for the Period Ending 30 September 2013 presented by Mr Scott Urquhart.
Mr Urquhart reported a balanced financial position for revenue and capital and confirmed a projected break even position for the 2013/14 year end, highlighting the requirement for a continued focus on managing cost pressures over the winter period to deliver the planned outturn.
Referring to funds yet to be distributed, Mr Urquhart explained that budget would be released in October in respect of incremental pay costs, support for additional capacity over winter months totalling over £1.0M, and a number of other reserves. Mr Urquhart further explained that the winter monies would span a six month period and included resources for community nursing, Allied Health Professionals, medical staffing and additional bed capacity.
Mr Urquhart highlighted a potential risk in relation to CNORIS (Clinical Negligence and Other Risks Insurance Scheme) contributions in the current financial year, with some uncertainty over the timing and settlement basis of two high value cases within NHS Scotland.
In relation to the capital position, Mr Urquhart reported expenditure to September of approx £2M, with a projected spend of £6.5M by year end. Three schemes will be progressed between now and March; additional car parking at Forth Valley Royal Hospital, demolitions and decommissioning works, and work at Stirling Community Hospital. Mr Urquhart also clarified that resources have been identified for the development of Ward 16 in the current financial year.
Following discussion the Committee noted the balanced revenue and capital position to 30th September and the projected financial balance for the 2013/14 year end.
6.3 Unit Financial Performance
Mr McPherson and Ms Michie gave a presentation on “Unit Financial Performance” to the Performance and Resources Committee. Mr McPherson highlighted the following: Unit Structure Unit Objectives and Priorities Developments around the Covalent Scorecard Pressures and Challenges Budget and Finance Approach and Efficiency Ongoing Challenges Patient Pathways
Dr Nash thanked Mr McPherson for his presentation and asked about his Unit’s absence rate being below 4% and how he had managed to achieve this very positive position. Mr McPherson
7
responded that it was continued hard work with staff being made aware of the process that any issues were worked through in a meticulous way. Professor Angela Wallace stated that strong leadership and a fairness and consistent approach had supported the position. Further discussion took place with regard to the Savings Plan for the Unit with it being emphasised that a review of contracts and improved ways of working were being considered. Mr McPherson stated that non core staffing costs (i.e. usage of Bank Staff) are continually reviewed in an attempt to make savings. Mr McPherson reported that there were a few issues being taken forward such as NETCALL, which is a patient reminder service that will be extended across the Outpatient Departments.
ACTION: DMcP In terms of procurement, it was highlighted that work with the Orthopaedic Surgeons had resulted in a consistency of the use of a specific type of prosthetic joint as opposed to a variation amongst surgeons. This resulted in a significant saving. A number of areas of financial pressure were noted around medical physics with it being reported that a lot of equipment purchased for the FVRH site was coming to the end of its warranty period and a review of the options was underway. It was noted that Oncology and Dermatology patients requiring wigs were causing a significant pressure on the Unit’s budget with a recent change in NHS guidelines. The Performance and Resources Committee noted the presentation.
7/ STRATEGIC PRIORITIES/BALANCED SCORECARD ISSUES
7.1 Francis Enquiry Update on Action
Dr Peter Murdoch presented the paper supported by a presentation and gave a background to the work undertaken across the organisation reviewing the Francis Enquiry Report. It was noted that the process had been agreed through the Performance and Resources Committee and that it was likely to be an iterative process. The main themes from Francis required to be central to the Board’s strategic direction moving forward. Dr Murdoch went onto give further detail within his presentation. Dr Murdoch highlighted that there had been a very useful session with the patient
representative groups during September where some very powerful graphic illustrations had been created. These were used through the presentation highlighting the key issues.
Since the incidents within Mid Staffordshire, there had been a number of actions taken locally and indeed a number of other reports published (e.g. Keogh) as detailed within the paper. It was also noted that the report into the Vale of Leven was due to be published in the spring of next year and there is no room for complacency.
There were 6 main themes from the Report – Values and Culture, Fundamental Care, Openness Transparency and Candour, Compassionate Caring and Committed Staff, Strong Patient centred Leadership and accurate, useful and relevant information.
The importance of patient stories and learning was stressed. Local Context and action was essential. Quality and Safety Resource to be a strategic and operational priority
o “Quality Assurance In Forth Valley’’ – Clinical Governance Risk Management Strategy o Extended remit of P&R committee o Strategic Management Team increased clinical involvement o EPQ Programme
8
o Quality Improvement Framework o Dashboards scorecards on all 6 dimensions of quality o OPAC, SPSP & Person Centred Care
Committee Review - Area Clinical Forum, Area Medical Committee, Operational Units and Nursing and Midwifery Council have reviewed the Report with key themes developed.
Dr Murdoch reported that key high level actions from this work revolved around the following points: • Systematic approach at all levels and across sectors • Consistency, clarity and cohesion • Visibility of people and information • Confidence that lessons are being learned and that action is being taken • Communication Dr Murdoch indicated that the outcome of the work presented had been reviewed by the SMT and that it had been agreed to establish a Sub Group under his Chairmanship to add further detail to the Action Plan presented. It was suggested that an update be brought quarterly to the Performance & Resources Committee.
ACTION: PM Dr Nash thanked Dr Murdoch for his update and presentation. Dr Nash stated that it was very useful. Ms Gavine supported Dr Murdoch’s presentation stating that it lets the NHS Board see what needs to be done differently. Ms Grant highlighted that in the Francis Report one of the key issues was governance and that the right information needs to be given to the Board in all aspects of business and patient care. The progress and changes made to date were noted. The Performance and Resource Committee were asked to: Consider the findings of the work to date, the outline action plan and the suggested way
forward utilising SMT to finalise detail and report to Performance & Resources Committee quarterly.
Consider the way in which the Performance & Resources Committee report back to the Board and ensure ongoing discussion keeping the themes from Francis at the centre of strategic development.
The Performance & Resources Committee agreed with the planned action to be updated quarterly and to update the Board. The focus on Francis and the key themes required to be part of the strategic agenda moving forward. It was agreed that the development of actions from the Francis Enquiry be discussed again at Performance and Resources Committee in February / March 2014.
ACTION: PM
7.2 Annual Review 2013
Ms Vanhegan gave the Performance and Resources Committee a verbal update on the “Annual Review 2013”.
9
Ms Vanhegan reported that the Annual Review would be taking place on Monday 9 December 2013 in Forth Valley Royal Hospital highlighting a different format form previous years and attendance by the Cabinet Secretary. Ms Vanhegan outlined the programme for the Annual Review which was noted as: Meet and welcome the Cabinet Secretary 1 Hour meetings to be had with ACF, AMC, APF and Patient Partners 1 hour visit and photo opportunity within the Women and Children’s Unit 1 hour meeting held in public with a presentation from the Chairman, response by the
Cabinet Secretary and Q & A Session for the public present. Private meeting and session with the full NHS Board.
Ms Vanhegan indicated that it was planned to use the Performance and Resources Committee meeting scheduled for the end of November 2013 for the full Board as a briefing session for the Annual Review.
The Performance and Resources Committee agreed to this suggestion.
8/ FORTH VALLEY ROYAL SUPPORTED BUS SERVICES
The Performance and Resources Committee received a verbal update on “Forth Valley Royal Supported Bus Services” from Mr Steele. Mr Steele reported that H1 and H2 Bus Services updating the Committee on the recent consultation process. Mr Steele highlighted that there were ongoing discussions with the Local Authority and other stakeholders. There had been a fruitful meeting with MSP Keith Brown the previous week. A further meeting with the Council Leader and CEO of Clackmannanshire, the Chairman and Ms Jane Grant was being scheduled.
ACTION: ALL & JG Dr Nash thanked Mr Steele for his update and asked if information about the supported bus services and planning would be available on the website. Mr Steele responded that information was being assimilated and would be made available to the public shortly.
ACTION: TS The Performance and Resources Committee noted the update.
9/ ANY OTHER COMPETENT BUSINESS CHKS Data Benchmarking
Ms Jane Grant summarised the national use of the CHKS benchmarking system. She indicated that there had been some issues raised at a national level as regards Information Governance and patient identifiable data. It was noted that this system had been operational in England for many years and successfully used in Tayside for the past 3-4 years with no issue noted. Ms Grant further indicated that the Scottish Government had already signed up to the system. Ms Grant wished to highlight the issue to the Committee but also give reassurance that all due process through Caldicott Guardians had been followed and that NHS Forth Valley would wish to be among another 12 Boards who would be moving forward in using the system with the benefits clear for the organisation. The Committee agreed with that course of action.
10
There being no further competent business the Performance and Resources Committee Meeting closed at 12.05pm.
10/ DATE OF NEXT MEETING
Friday 29 November 2013 at 09.30am in the Boardroom, Carseview House, Castle Business Park, Stirling FK9 4SW. – This Meeting will be in order to make preparation for the Annual Review on 9 December 2013.
Forth Valley NHS Board 10 December 2013 This report relates to Item 7.2 on the agenda
Minute of Forth Valley NHS Audit Committee held on 18 October 2013
(For Noting)
AUDIT COMMITTEE DRAFT Minute of the NHS Forth Valley Audit Committee meeting held on Friday 18th October 2013 in the Board Room, Carseview, Stirling. Present: Mr James King (Chair) Mrs Fiona Gavine In Attendance: Mrs Fiona Ramsay, Director of Finance, (Executive Lead) Mr Tony Gaskin, FTF Audit Services Mr Jim Rundell, Audit Scotland Mrs Fiona Mitchell-Knight, Audit Scotland
Mr Fraser Paterson, Counter Fraud Services Mr Graeme Bowden, Capital Accountant 1/ APOLOGIES
Apologies were received from Mr Alex Linkston, Mrs Jane Grant, Mr Charles Forbes and Mr Tom Hart.
2/ DECLARATIONS OF INTEREST
Mr King recorded his Non Executive Director position at National Services Scotland which is the organisation responsible for Counter Fraud Services (Agenda Item 5.1)
3/ MINUTES OF PREVIOUS MEETING
The Minute of the Audit Committee meeting held on 7th June 2013 was approved as a correct record.
4/ MATTERS ARISING
4.1 National Shared Services Review Mrs Ramsay provided an update on the National Shared Services Review and asked the Committee to note that the benchmarking statistics return last provided in 2010 was in the process of being updated with information to be provided by the end of October. Mrs Ramsay also indicated that the five Boards who used the asset management system CARS were testing the RAM (Real Asset Management) to ensure that full functionality provided by CARS was provided by RAM. NHS Ayrshire and Arran were leading this process and results would be provided to the Committee in due course. Mrs Gavine queried what type of information was being provided within the benchmarking return and Mrs Ramsay advised that it related to finance
departments covering processing statistics such as accounts payable, payroll and ledger transaction processing and staff costs including management accounting. Mrs Ramsay also highlighted that NHS Forth Valley had benchmarked well in 2010 and had made significant savings and improvements since that date. The information would be utilised to identify areas where further improvements could be made. The Committee noted the update on the National Shared Services Review.
5/ COUNTER FRAUD SERVICES 5.1 The Role of Counter Fraud Services
Mr Paterson from Counter Fraud Services made a presentation to the Committee on the Role of Counter Fraud Services. He outlined the Scottish Government’s Strategy to combating fraud and summarised the areas within the 4 “D” Approach targeted to counter fraud. Mr Paterson also updated the Committee on the main topics within CEL 11 (2013) issued to highlight the considerable amount of work that has been undertaken by Counter Fraud Services, in conjunction with NHS Bodies and professional organisations to combat fraud and financial crime. Mr Paterson indicated that the general levels of awareness on fraud matters, and counter-measures to defeat it, are now considerably more developed across the service. Mr Paterson highlighted the positive work with Mr Archibald NHS Forth Valley Fraud Liaison Officer. Mrs Gavine queried what type of areas were targeted within the NHS and Mr Paterson indicated that the type of areas included, staff working in other jobs while off sick, and fraud resulting from primary care practitioners falsifying data. Mrs Ramsay also highlighted the importance of culture within the the organisation to promote prevention of fraud and that NHS Forth Valley’s Counter Fraud Champion was the Employee Director who in line with the guidance issued within CEL 11 (2013) continually worked to promote a safe environment for staff who report, or are witnesses in, any fraud investigations. Mr King thanked Mr Paterson for attending the meeting and the Committee noted the presentation on The Role of Counter Fraud Services. 5.2 Counter Fraud Services Quarterly Report
Quarter ending 30th June 2013
Mr Gaskin presented the Counter Fraud Services National Quarterly Report for period ending 30th June 2013 and indicated that there had been no new referrals made directly by NHS Forth Valley. There had been four referrals received from outside sources however Mr Gaskin indicated that none of these had resulted in full investigations. Mrs Ramsay highlighted that across Scotland there were a number of referrals from the Home Office regarding elgibility for NHS treatment. Mr Gaskin also indicated that there had been three Intelligence Alerts issued during the quarter and also highlighted that the report summarised two operations that had concluded with a criminal outcome. The Committee were informed that the Counter Fraud Services Annual Conference was being held on 19th November and the intended attendees were the Fraud Liaison Manager and the Counter Fraud Champion however Mr Paterson indicated that all were welcome.
Mr King queried the low number of cases reported by NHS Forth Valley however Mrs Ramsay advised that, many issues were discussed with CFS but were referred back as they were considered not to merit a referral and that these were not recorded within the statistics – similar points had been raised by other Boards. Mrs Gavine queried the process for National Whistleblowing Line within NHS Forth Valley and if there had been any issues reported by staff. Mrs Ramsay advised that to date there had not been any local issues reported. Processes were in place to manage and report – in the case of any reports of potential fraud these would be actioned through our Fraud Policy. It was noted that there was a national Fraud Line which was currently being managed via Crimestoppers for a trial period. The Committee noted the Counter Fraud Services Quarterly report. 5.3 Local Cases Update Mr Gaskin presented an update paper to the Committee on local Counter Fraud Services cases and summarised the three ongoing reactive cases. In addition, Mr Gaskin also highlighted another national case relating to the Minor Ailment Service that NHS Forth Valley were involved in and which had previously been highlighted to the Committee. The Committee noted the Counter Fraud Services Local Cases Update report. At this point Mr King thanked Mr Paterson for attending the meeting and providing an informative presentation and input on the Counter Fraud Services section of the agenda.
6/ INTERNAL AUDIT 6.1 Internal Audit Progress Report
Mr Gaskin presented the Internal Audit Progress Report and informed the Committee that seven reports had been finalised and issued since the last meeting, and a further five draft reports were with management for comment. There were also active ongoing assignments in another ten areas. Mr Gaskin also highlighted that the Internal Audit department was now fully staffed and he anticipated that the full plan would be delivered in line with agreed timescales. Mrs Gavine queried whether there could be a method defined for making it clear about any issues arising within “non-scored” reports, in a similar fashion to the ranking system used for the definition of assurance categories and recommendation priorities within Internal Audit reports. Mr Gaskin indicated he would liaise with the Regional Audit Manager on the issue. The Committee noted the Internal Audit Progress Report.
7/ EXTERNAL AUDIT
7.1 External Audit Progress Update
Mr Rundell presented the External Audit Update paper that highlighted progress made against the External Audit 2012/13 Plan that was presented to the Committee at the February 2013 meeting. Mr Rundell informed the Committee that the plan had been delivered successfully within the agreed timescales and thanked NHS Forth Valley staff for their cooperation and input. Mr Rundell also provided a summary of the Audit Scotland reports issued since the last meeting in June and areas from where performance reports will be issued in the coming months. Mr Rundell indicated work was already under way with the 2013/14 audit plan the progress of which would be reported to the Committee at future meetings. The Committee noted the External Audit Progress Update paper. 7.2 Annual Report on the 2012/13 Audit Mrs Mitchell-Knight presented the External Audit Annual Report on the 2012/13 Audit and highlighted that overall the report was very positive and the Board had met its challenges effectively. Mrs Mitchell-Knight commented on some of the key messages within the report including: NHS Forth Valley have been issued with an unqualified opinion on the
2012/13 financial statements and the Board achieved all of its financial targets;
The Board had received non-recurring brokerage from the Scottish Government Health and Social Care Directorates (SGHSCD) during 2011/12 that was used to support the transitional costs associated with the implementation of the Board’s Healthcare Strategy and that this was in process of being repaid;
The Board had sound governance arrangements in place during 2012/13 which included a number of standing Committees overseeing key aspects of governance;
The Board has a well developed framework in place for monitoring and reporting performance and Board members are provided with monthly reports that provide assurance of the overall performance of NHS Forth Valley; and
During 2012/13 the Board met or exceeded a number of performance targets set by the Scottish Government however it had not achieved its performance targets in some areas including Access Referral to Treatments targets.
Mrs Mitchell-Knight concluded by highlighting that the report indicated the Board in common with other agencies faced very challenging times ahead and will be required to prioritise its use of resources. The Committee noted the External Audit Annual Report on the 2012/13 Audit. 7.3 Scotland’s Public Finances Follow-Up Audit Mr Rundell presented NHS Forth Valley’s Scotland’s Public Finances Follow-up Audit report and highlighted that the purpose of the report was to expand on the
annual report and assess how NHS Forth Valley is responding to the challenges of public sector budget constraints and its efforts to achieve financial sustainability. The work focused on two key questions in assessing the Board’s position on: Does the Board have sustainable financial plans which reflect a strategic
approach to cost reduction? Do senior officials, elected members and non-executive directors
demonstrate ownership of financial plans and are they subject to scrutiny before approval?
Mr Rundell asked the Committee to note that Audit Scotland had concluded that NHS Forth Valley does have sustainable financial plans that reflect a strategic approach and that both senior officers and Board Members demonstrate ownership of plans that are subject to scrutiny prior to approval. Mr Rundell also advised that an action plan had been agreed with management to address risk areas identified during the review. Mrs Ramsay indicated that management had agreed to review the Board’s approach to benchmarking to ensure standardisation and achievement of best value. The Committee noted NHS Forth Valley’s Scotland’s Public Finances Follow-up Audit report. 7.4 NHS Financial Performance 2012/13 Mrs Mitchell-Knight presented the NHS Financial Performance 2012/13 report and highlighted that the report had indicated that during 2012/13, the NHS managed its overall finances well and NHS Boards had also achieved their financial targets. Across the NHS as a whole, there had been a small overall surplus equating to 0.16% of the total Revenue and Capital budgets. Savings targets in line with Scottish Government targets had also been achieved. Mrs Mitchell-Knight did indicate the report highlighted that the savings targets will become more difficult to achieve in future years as it becomes more difficult to identify further areas to make significant savings. The report highlighted that the NHS in Scotland had made good progress in improving outcomes for patients during a period where demand for healthcare is rising and indeed signs of pressure areas were identified during the 2012/13 review. It was also noted that not all Boards had met their waiting times targets, vacancy rates for consultants and nursing staff had increased, and Boards increased their use of agency and bank staff and their spending on private sector healthcare. Mrs Mitchell-Knight highlighted the significant challenges facing the NHS and also summarised the key recommendations and target areas for review made within the report. The Committee were also asked to note that the report highlighted that NHS Forth Valley were consistent with the national picture in regard to the pressure areas and challenges the Board will face moving forward. The Committee noted the NHS Financial Performance 2012/13 report. 7.5 Audit Scotland Reports Mrs Ramsay presented a summary paper for information on one national performance report issued by Audit Scotland regarding:
7.51 Developing Financial Reporting in Scotland
The report was drafted as a contribution towards preparations for new financial powers as a result of the Scotland Act 2012 being implemented over the next three years. The changing financial environment provides an opportunity for the Scottish Government to consider where financial reporting can be developed further and the report highlighted areas that should be subject to particular consideration during this development process.
The Committee noted the summary paper on the Audit Scotland report issued since the last meeting.
8/ AUDIT FOLLOW-UP
8.1 Internal Audit Follow-Up Report Mr Bowden presented the Internal Audit Follow-Up Report and indicated that there were currently no recommendations fully outstanding, and since the last meeting, one Priority 2 recommendation had been completed relating to the Corporate Risk Register. Mr Bowden asked the Committee to note that he had been informed by the Senior Planning Manager that three recommendations emanating from the Business Continuity report previously reported as cleared, still required further review to reflect changing guidance. New completion dates had been agreed with Internal Audit. The Committee noted the Internal Audit Follow-Up Report. 8.2 External Audit Follow-Up Report Mr Bowden presented the External Audit Follow-Up Report and indicated that to date no recommendations currently due for a response remained outstanding and there had been no new recommendations raised by External Audit since the last meeting. Mr Bowden asked the Committee to note that the follow-up process would commence on recommendations made within reports presented at today’s meeting. The Committee noted the External Audit Follow-Up Report. 8.3 Progress against Audit Recommendations – Waiting Times
Mrs Ramsay presented the paper to update the Committee on progress against actions regarding audit recommendations for waiting times. Mrs Ramsay highlighted that the paper included information that had been submitted to the Scottish Government Health and Social Care Directorate at the end of September 21013 and included:
Response to Public Audit Committee recommendations; Response to Audit Scotland recommendations; and Response to Internal Audit recommendations.
Mrs Ramsay indicated that there were a couple of areas where national work had been awaited to ensure completion of recommendations so the report would be updated once these areas were finalised. Mrs Ramsay also highlighted that Boards were required to provide a final report on Audit Recommendations on Waiting Times by mid December 2013 however, as the next Audit Committee meeting was not due to be held until January 2014, a draft response would be circulated to members electronically for comment and delegated authority was approved to the Audit Committee Chair to agree the response prior to submission to the Scottish Government Health and Social Care Directorate. The Committee noted the Progress against Audit Recommendation – Waiting Time update paper.
9/ FINANCIAL & PERFORMANCE ISSUES
9.1 Consolidation of NHS Endowment Accounts Mrs Ramsay presented a paper that summarised the requirement to consolidate NHS Endowment Accounts into host Board’s Statutory Accounts with effect from financial year 2013/14. NHS Boards will also be required to restate prior-year comparative balances within Statutory Board Accounts within financial year 2013/14. Mrs Ramsay added that there are a number of areas that Boards will need to consider and discuss with External Audit including the accounts production timetable, consistency of accounting policies, materiality and technical accounting entries required. Mrs Ramsay highlighted that, with regard to the production timetable, NHS Forth Valley was in a good position as the timetables for both Endowment and Statutory Accounts are already aligned. Mrs Ramsay also asked the Committee to note that a meeting had already been arranged between Audit Scotland and Senior Finance officers to discuss the requirements of the NHS Endowment Accounts consolidation process. The Committee noted the paper on the Consolidation of NHS Endowment Accounts.
10/ ANY OTHER COMPETENT BUSINESS
10.1 Post Transaction Monitoring Mrs Ramsay advised the Committee that to comply with the NHS Scotland Property Transaction Handbook, NHS Forth Valley are required to draft an annual report on property transactions completed during the previous financial year and present it to the Audit Committee. Mrs Ramsay highlighted that during 2012/13 there had been one property purchased and two sales transacted the details of which were attached to the report. Mr Gaskin presented the Post Transaction Monitoring Internal Audit Report and advised the Committee that the transactions within NHS Forth Valley’s Post Transaction Monitoring process had merited a Category “B” audit opinion. The opinion indicated that there were adequate and effective systems of control and governance in place, although minor weaknesses were evident. Mr Gaskin also summarised the recommendations made by Internal Audit within the report’s
Action Plan and highlighted that actions had been agreed with management. Appropriate record keeping had been raised as an issue and Mrs Ramsay advised that there was a standard checklist within the NHS Scotland Property Transaction Handbook which would be further developed with Internal Audit support for use within the Property Department. The Committee noted the Post Transaction Monitoring Reports. 10.2 Payment Verification Protocol – Primary Medical Services Mrs Ramsay advised the Committee that a letter had been issued by the Scottish Government Directorate of Finance, eHealth and Pharmaceuticals notifying NHS Bodies that amendments had been made to the protocol issued on Payment Verification Procedures for Primary Medical Services and that NHS Forth Valley was aware of the changes in advance of receipt of the circular. The Committee were advised that copies of the full document could be obtained from the Scotland’s Health on the Web (SHOW) website or on request from the Audit Committee Coordinator. The Committee noted the update to the Payment Verification Protocol – Primary Medical Services. There being no further business the meeting closed at 11.30am.
11/ DATE OF NEXT MEETING
The next meeting of the NHS Forth Valley Audit Committee will take place on Friday 17th January 2014 in the Board Room, Carseview, Stirling commencing at 9.30am.
Forth Valley NHS Board 10 December 2013 This report relates to Item 7.3 on the agenda
Minute of Forth Valley NHS Board Endowment Committee Held on 18 October 2013
(For Noting)
1
ENDOWMENT COMMITTEE
Draft Minute of the Forth Valley NHS Board Endowment Committee meeting held on Friday 18th October 2013 in the Forth Valley NHS Board Headquarters, Carseview House, Castle Business Park, Stirling. Present: Mr. James King, Chair of NHS Forth Valley Endowment Committee
(Trustee) Mrs. Fiona Ramsay, Director of Finance, NHS Forth Valley (Trustee) Mr. Charlie Forbes, Non-Executive Member (Trustee)
In attendance: Mr. Jonathan Procter, IM&T Director/E-health Lead, NHS Forth Valley (Lead Director) Mr. Garry Wells, Treasury Services Manager Ms. Babs McCool, Arts and Wellbeing Co-ordinator Mr. Russell Crichton, Investment Advisor, Speirs & Jeffrey, Stockbrokers Mr. Stephen Hall, Investment Advisor, Speirs & Jeffrey, Stockbrokers
1/ APOLOGIES FOR ABSENCE
Apologies were received from Mr. Tom Hart, (Employee Director), Mr. Alex Linkston, Chair of Forth Valley NHS Board (Trustee) and Mrs. Jane Grant, Chief Executive, NHS Forth Valley (Trustee).
2/ DECLARATION OF INTEREST There were no declarations of interest.
3/ MINUTE OF THE FORTH VALLEY NHS BOARD ENDOWMENT COMMITTEE
MEETING HELD ON 7TH JUNE 2013 The Committee approved the minute of the Forth Valley NHS Board Endowment Committee held on 7th June2013 as a correct record.
4/ MATTERS ARISING 4.1 Artlink Service Level Agreement
This matter was considered in item 6 of the Agenda 4.2 Investing in Health
This matter was considered in item 8 of the Agenda 4.3 Royal Voluntary Service gifting of funds
This matter was considered in item 9 of the Agenda
6/ ARTLINK SERVICE LEVEL AGREEMENT
2
Ms McCool presented a paper “Artlink Service Level Agreement”. Ms McCool submitted a proposal for a three year Service Level Agreement (SLA) between Artlink and the Endowment Fund that incorporated the recommendations and revisions requested by the committee at the previous meeting on the 7th of June. Ms McCool also advised the committee that the agreement currently contained three different funding options for considerations and asked that the committee determine the final contract value to be included in the SLA. Following a brief discussion the committee agreed that the following levels of funding be included in the agreement.
Year ending 31st March 2014 - £75,700 (current level) Year ending 31st March 2015 - £50,719 (guaranteed minimum) Year ending 31st March 2016 - £50,719 (guaranteed minimum)
The committee also agreed that the guaranteed minimum levels of funding for the years ending 31st March 2015 and 2016 would be subject to review and that additional top-up funding may be considered. The Committee asked Ms McCool to incorporate these final adjustments into the SLA and to submit the final version to the next meeting of the committee for approval. Having concluded her report, Ms. McCool left the meeting at this time
5/ INVESTMENT PERFORMANCE & MONITORING REPORT
Mr. Russell Crichton presented to the committee the quarterly Investment Performance Report to 30th September 2013 and highlighted the following issues: 5.1 Performance of Portfolio Mr. Crichton asked the committee to note that the portfolio had achieved a return on investments of 4.7% during the three months to September 2013, and 10% during the last five years to September 2013. Mr. Crichton further advised that the performance of the portfolio continued to exceed comparable benchmarks within the charities financial sector and that the higher returns achieved by the FTSE all-share index reflected the defensive investment strategy adopted by the committee. 5 .2 Market issues
Mr. Crichton updated the Committee on market issues, with particular reference to the on-going political impasse in America relating to the agreement of their debt ceiling and to the risk to the recovery of the UK economy due to doubt over the sustainability of the current low interest rates. 5.3 Transactions carried out in period Mr. Crichton provided the Committee with a report of the acquisitions and disposals of investments carried out during the 3 months ended 30th September 2013. The Committee noted that these transactions were carried out in accordance with the terms of the discretionary portfolio management agreement.
3
5.4 Risk category of the Endowment Fund Mr. Crichton advised the committee that Speirs & Jeffrey were currently reviewing the risk classification of their clients and that the endowment fund portfolio is currently classed as “Medium/High” risk based on the 80/20 split between equity holdings and fixed interest holdings. Mr. Crichton recommended that the endowment fund portfolio remain in this classification and agreed to provide further information in support of this recommendation for consideration by the committee. Following a brief discussion the Committee thanked Mr. Crichton and Mr. Hall for their contribution and approved the Investment and Performance Monitoring Report for the three months ended 30th September 2013. Having concluded their report, Mr. Crichton and Mr. Hall left the meeting at this time
7/ FINANCIAL REPORT FOR THE 6 MONTHS ENDED 30TH SEPTEMBER 2013
Mr. Wells reported that the receipt and disbursements of funds during the period were in accordance with anticipated levels. Mr. Wells also asked the committee to note the receipt of a windfall legacy during the period of £36,771. Mr. Wells then provided additional information on the transactions relating to the activities funded from Grants, Legacies and the Royal Voluntary Service. Mr. Wells also advised the committee that in accordance with the decision taken at the June 2013 meeting, £250,000 had been disinvested from the investment portfolio in order to provide sufficient cash resources for the six months to September 2013. Mr. Wells confirmed that a revised cash forecast indicated that at least a further £50,000 will be required to be disinvested in order to fund the activities for the remaining six months up to March 2013. Mr. Wells also asked the Committee to note the continued improvement in the performance of the investment portfolio Following a brief discussion during which Mr. Wells answered a number of questions from Committee members, the Committee thanked Mr. Wells for his contribution and approved the Financial Report for the 6 months ended 30th September 2013.
8/ INVESTING IN HEALTH
i) Small Grants Mr. Wells presented a paper “Investing in Health Priorities 2013/14 – Small Grants”. Mr. Wells submitted to the committee for consideration a number of grant applications requesting funding from the Investing in Health Small Grants Fund. The committee considered each application in turn and approved the following sums:
4
Sum Sum Requested by Description of bid requested approved
Lorna Dougans Healthy living advice & exercise groups £2,100 £2,100 Physiotherapist
Dawn Gleeson Equipment to allow patients to carry £1,500 £1,500 AHP Co-ordinator out independent exercise programmes
Lee Kelso Postural Stability Instructor Training £1,950
Further info.
required Falkirk Community Trust
Ewan Jack Improving the surgical patient £800 £800
Consultant Anaesthetist experience whilst minimising sedation
Sandra Garner Samaritans Group £4,000 £4,000
Samaritans Promotional Literature & Activities
Wee County Walkers Training & promotional costs for £5,000 not
approved
exercise and fitness project
Dr. Roger Alcock A&E dept. - Kids Kart £4,500 £4,500
Consultant (A&E Paed.)
Karen McMain Artwork for X-Ray Dept. £700 not
approved
Unit Administrator
Babs McCool Artwork for waiting & learning spaces £2,600 not
approved Arts & Wellbeing Co-ordinator
Dr. Bridget McCalister "Driving Force" charity - update their £500 £500
The Driving Force web site
Total £23,650 £13,400
5
8/ INVESTING IN HEALTH
i) Large Grants Mr. Procter presented a paper “Investing in Health Priorities 2013/14 – Large Grants”. After a brief discussion the committee agreed that due to the large number and value of grant applications received there would be insufficient time to consider the applications at this meeting and agreed that a special meeting of the committee be convened at the earliest opportunity to consider and approve the applications.
9/ ROYAL VOLUNTARY SERVICE GIVING Mr. Procter presented a paper “Royal Voluntary Service Gifting” Mr. Procter advised the committee that following recent discussions with the Royal Voluntary Service (RVS) the gifting amount for 2013 was confirmed as £23,489. Mr. Procter also advised that discussions with the RVS had identified the following activities as suitable projects for the utilisation of the funds:
Way finding at Forth Valley Royal Hospital. Improved Trolley Service at Forth Valley Royal Hospital. On ward services at Forth Valley Royal Hospital.
Mr. Procter further advised that in accordance with existing arrangements with the RVS, the committee is now required to send a Letter of Intent to the RVS indicating which of these projects are to benefit from the gifting of funds.
Following a brief discussion the committee agreed that the Letter of Intent indicate that the funding will be utilised to provide a “Way Finding” service that includes all appropriate NHS Forth Valley sites.
10/ CHARITABLE DEVELOPMENT GROUP ANNUAL REPORT 2012-13
Mr. Procter presented a paper “Charitable Development Group Annual Report 2012-13” Following a brief discussion the Committee approved the Annual Report for the year ended 31st March 2013.
11/ REPORT ON SUB-COMMITTEES - CHARITABLE DEVELOPMENT GROUP
Mr. Procter presented a paper “Report on sub-committees – Charitable Development Group” 1) Mr. Procter presented the Charitable Development Group Forward Plan 2013/14 for noting.
6
7
Mr. Procter advised the committee that this report outlines the timetable for the submission of reports and presentations to the Charitable Development Group from June 2013 through to March 2014. The committee noted this report.
2) Mr. Procter presented the “Fundraising Action Plan” for 2013/14 for noting.
Mr Procter advised the committee that this report outlined the activities to be undertaken by the Fundraising Manager over the course of the next 12 months. Mr. Procter also advised that the Fundraising Action Plan had been approved by the Charitable Development Group at its meeting of 10th September 2013. The committee noted this report.
3) The Committee also noted the minutes of the Charitable Development Group held on 21st
June 2013 and the draft minutes of the meeting held on the 10th September 2013.
12/ CONSOLODATION OF ACCOUNTS
Mrs. Ramsay reported that at the Directors of Finance meeting on 1 August 2013, Boards were informed that the Endowment Fund’s annual accounts will require to be consolidated into the Host Board accounts with effect from 2013-14. A meeting between both teams of external auditors is planned to discuss the timetable, consolidation requirements and the technical accounting entries required. Further updates will be provided at subsequent meetings. The committee noted this report.
13/ ANY OTHER COMPETENT BUSINESS
There being no other competent business the Chair closed the meeting at 12:50 p.m.
DATE OF NEXT MEETING
There will be a Special Endowment Committee meeting arranged over the next month to consider the “Investing in Health Proposals and members will be consulted on a suitable date. The next full meeting of the Forth Valley NHS Board Endowment Committee is to be held on Friday 17th January 2014 at the Forth Valley NHS Board Headquarters, Carseview House, Castle Business Park, Stirling. The meeting is to commence at approximately 11.30am, following the conclusion of the business of Audit Committee.
Forth Valley NHS Board 10 December 2013 This report relates to Item 7.4 on the agenda
Minute of Forth Valley NHS Clinical Governance Committee Held on 11 October 2013
(For Noting)
DRAFT Minute of the Forth Valley NHS Board Clinical Governance Committee meeting held on Friday 11 October 2013 at 9.30 am in the Boardroom, Carseview House Present: Ms Fiona Gavine, Non Executive Board Member (Chair) Dr Allan Bridges, Chair of Area Clinical Forum Mrs Evelyn Crosbie, NHS Forth Valley Public Partnership Forum
Mr Charlie Forbes, Non Executive Board Member Mrs Helen McGuire, Patient Public Panel Representative Ms Vicki Nash, Non Executive Board Member
In Attendance: Mrs Gail Caldwell, Pharmacy Director Dr Stuart Cumming, Chair of Community Health Partnership Professional Committee
Mrs Irene Graham, Personal Assistant (Minute) Ms Jane Grant, Chief Executive Mr Jonathan Horwood, Infection Control Manager
Mrs Monica Inglis, Head of Clinical Governance Dr Peter Murdoch, Interim Medical Director
Professor Angela Wallace, Director of Nursing 1/ APOLOGIES FOR ABSENCE Apologies for absence were intimated on behalf of Mr Alex Linkston, Dr Graham Foster, Ms Elaine Vanhegan and Mrs Alison Richmond-Ferns. Ms Gavine welcomed Jane Grant to her first meeting as Chief Executive. 2/ DECLARATIONS OF INTEREST There were no declarations of interest. 3/ MINUTE OF NHS FORTH VALLEY CLINICAL GOVERNANCE COMMITTEE
MEETING HELD ON 16 AUGUST 2013 The minute of the Clinical Governance Committee meeting held on 16 August 2013 was approved as a correct record with the following amendments: Page 4, Item 6.2, sixth bullet point should read: Mortality rates - showed a 10% rise for weekend admissions but thought largely due to different case mix Page 8, Item 12 - Any other competent business
Dr Murdoch gave an update on the Ombudsman’s report which was highly critical about aspects of service and shortfalls in NHS Forth Valley which had now been published. An apology had been made to the family and all recommendations had either been acted upon or were in the process of being implemented. A report would be submitted to the next Clinical Governance Working Group and thereafter would come to this Committee.
ACTION: Dr Murdoch to add to next agenda With reference to the Clinical Governance Terms of Reference which had been circulated with the minute, the following amendment was agreed: Page 2, Item 2.3 - Attendance REMOVE - Chief Operating Officer 4/ MATTERS ARISING 4.1 Review of Actions The Committee considered the actions from the previous meeting and noted the progress made to date. 16 August 2013 Item 8.1 Professor Wallace advised that a table showing trends had been
incorporated into the Clinical Governance Complaints Performance Report.
5/ CLINICAL GOVERNANCE: STRATEGY AND OBJECTIVES 5.1 CEL 19 (2013) - Next Steps for Acute Adult Safety: Patient Safety Essentials & Safety Priorities The Committee received a presentation from Mrs Monica Inglis, Head of Clinical Governance. Mrs Inglis gave an overview of the current programme and the future approach for the Acute Adult Programme which describes 10 patient safety essentials:
Hand washing PVC (Peripheral various cannula) bundle Surgical brief and pause Ventilator Acquired Pneumonia (VAP) bundle CVC (Central various catheter) bundle CVC maintenance General ward safety brief Early warning score Intensive Care Unit (ICU) Daily Goals
Leadership walk rounds
Actions required were:
Shift from testing and spread towards sustainable implementation as standard work in all clinical areas
Local monitoring within operational delivery mechanisms and form part of governance arrangements
Local assurance mechanisms to ensure sustainable and sustained maintenance of the 10 essentials
National reporting through annual review process
9 points of care interventions had been identified:
Deteriorating patients Sepsis Heart failure Pressure ulcers Surgical site infections Venous thromboembolism Catheter associated urinary tract infection (UTI) Falls with harms Safer use of medicine-revised definitions, goals and measures
Mrs Inglis stated that we were continuing to refine the measures, which would be included in the balanced scorecard. The Committee thanked Mrs Inglis for her presentation and looked forward to an update at a future meeting. 6 ASSURANCE AND IMPROVEMENT 6.1 Sexual Health and Blood Borne Virus Managed Care Network Accreditation The Committee received a paper from Mr Jonathan Horwood, Infection Control Manager in the absence of Dr Graham Foster, Interim Director of Public Health. Mr Horwood explained that the Sexual Health and Blood Borne Virus Managed Care Network had been formed at the request of the Scottish Government and had previously reported annually to them. This was highlighted as an issue during the annual Scottish Government visit to NHS Forth Valley in 2012 and as a result it was agreed to change the reporting structure to a local level. This paper sought approval to change the governance arrangements to align with the other NHS Forth Valley Managed Clinical Networks who report to this Committee. After discussion on the value of Managed Clinical Networks, the Committee approved this change. 6.2 NHS Forth Valley Healthcare Associated Infection (HAI) Quarterly Report
The Committee received a paper from Mr Jonathan Horwood, Infection Control Manager in the absence of Dr Graham Foster, Interim Director of Public Health. Mr Horwood stated that the report covered the period April to June 2013 and he summarised the report as follows:
Staphylococcus Aureus Bacteraemias (SABs) - total of 23 cases, 3 of which were hospital attributed and were device associated. NHS Forth Valley failed to achieve the SAB HEAT target
Clostridium difficile Infections (CDIs) - total of 8 cases, 1 was hospital attributed. CDI HEAT target was achieved and work was being undertaken in the community to reduce these numbers
Device Associated Bacteraemias (DABs) - total of 6 cases, 4 of which were hospital attributed. Numbers were increasing but this was due to improved data capture.
Healthcare Associated Infections (HAI) related deaths - total of 1 Meticillin Sensitive Staphylococcus aureus (MSSA) related death, no Clostridium difficile infection related deaths this quarter
Outbreak and incident management - 7 wards had outbreaks of diarrhoea and vomiting with 6 areas confirmed as Norovirus. No wards had been closed over the period.
Mr Horwood highlighted work being carried out in the community to reduce SABS with IV drug users being a particular challenge. Ms Gavine commented that the 98% compliance figure for hand hygiene opportunities should not have been reported as being “top marks”. The Committee noted the report. 6.3 Clinical Governance Balanced Scorecard The Committee received a paper from Mrs Monica Inglis, Head of Clinical Governance in the absence of Ms Elaine Vanhegan, Head of Performance Management. Mrs Inglis highlighted the following key points:
All indicators within Safe dimension of quality are now Green, except two where measures are being reviewed nationally.
During a review of the methodology for calculating incidence for the Clostridium difficile surveillance programme it was identified that nationally there had been double counting of Geriatric Medicine hospital activity data. Measures had been taken by Health Protection Scotland to correct this and it was noted that new figures published would show a higher rate for all Health Boards.
Fluoride varnishing remains Red Target not met for patients with diagnosis of stroke admitted to Stroke Unit on day of
admission. Wider capacity problems were impacting on this figure.
It was recognised that the above challenges would be focussed on by the Performance & Resources Committee.
Mrs McGuire questioned whether the Patient Public Panel should be involved in the capacity flow chart. Professor Wallace would discuss this with the Patient Public Panel.
ACTION: Professor Wallace to take forward with Patient Public Panel The Committee noted the report 6.4 Update on Quality Improvement Strategic Workplan The Committee received a presentation from Mrs Monica Inglis, Head of Clinical Governance. Mrs Inglis gave a snapshop of the progress on implementation and outcomes which included:
Quality improvement strategic framework: the aim, strategic imperative and drivers, underpinning principles and quality improvement priorities
Key area’s of work included
Strategic imperatives and drivers Underpinning principles Quality improvement priorities Safe care: Improve safety and reduce avoidable harm Monitoring progress: balanced approach to measurement Reporting: from case to ward to Board Adverse event rate: target 30% reduction Ventilator acquired pneumonia (VAP) rate: target zero rate or 300 day as between
events Reliable rescue: Early warning score (EWS) assessment: target 95% reliable with
EWS observations Staphylococcus Aureus Bacteraemias (SAB) general ward: Scottish Patient Safety
Programme target zero rate or 300 days between events Clean clinical environment Healthcare acquired infection monthly executive report Deliver patient centred services and improve patient and family experience of care Transforming and improving care at the bedside: the senior charge nurse balanced
scorecard Breakdown of patient questionnaires Improve clinical effectiveness and demonstrate delivery of best outcomes of care Hospital Surgical Mortality Rate: target 20% reduction by December 2015 Diabetes care balanced scorecard % compliance with heart failure bundle: target >95% reliability sustained Infrastructure to support improvement
Progress is being monitored via the Clinical Governance Working Group and achievements will be detailed in the Clinical Governance Working Group annual report from Units/CHP. There followed detailed discussion on the presentation around quality improvement training. Dr Murdoch commented that we were supporting units and wards and taking a complete cohesive approach to give necessary assurance to enable promotion of good practise at grass roots
The Committee thanked Mrs Inglis for her presentation. 6.5 Update on Francis Report The Committee received a verbal update from Dr Peter Murdoch, Interim Medical Director. Dr Murdoch reported that a number of robust debates had been taking place with a lot of commonality being identified. We were already beginning to see things changing. A comprehensive report was being produced which would go to the next Performance & Resources Committee and then to the Board. The Committee noted this update. 6.6 Healthcare Improvement Scotland - Older People’s Acute Care The Committee received a verbal report from Professor Angela Wallace, Director of Nursing. Professor Wallace updated the Committee on the positive feedback from Healthcare Improvement Scotland on the self assessment; an action plan had been signed off and implemented. The Cabinet Secretary had issued a press release to all staff congratulating them on their good work. The Person Centred Care launch would take place on 1 November which incorporated older people’s acute care. The Committee were assured and recognised the improvement actions being taken forward. 7/ PERSON CENTRED CARE 7.1 NHS Forth Valley Complaints Performance Report The Committee received a paper from Professor Angela Wallace, Director of Nursing. Professor Wallace stated that the total number of complaints received for July was 89, with the percentage of complaints showing an upward trajectory, especially prison complaints. Improving response times was an ongoing challenge but work was being carried out with colleagues to improve this, additional staff had been brought in to assist. An appendix showing a detailed analysis of complaint themes had been included with this report, in future this would be included quarterly.
The Committee found the complaint themes very helpful and noted the report. 8/ SAFE CARE 8.1 Serious Adverse Incident Report The Committee received a paper from Mrs Monica Inglis, Head of Clinical Governance.
Mrs Inglis stated that this was an evolving report which was discussed in detail at the Clinical Governance Working Group. The Committee was asked to note:
The development of a pilot to test a systemic process to review falls to identify any learning and themes and to support the identification of those incidents that require a more detailed level of review
The review of the process of investigation of the first 4 incidents reported under the new procedures to identify any learning points
The planned review of ‘orange’ and ‘red’ incidents reported from January 2013 The Committee noted the report 8.2 NHS Forth Valley Risk Register - Clinical Risks The Committee received a paper from Mrs Gail Caldwell, Director of Pharmacy. Mrs Caldwell highlighted:
Inability to meet waiting times targets/referral to treatment (RTT) and 12 week legal guarantee for treatment - focused action continues to improve performance in referral to treatment.
Capacity and winter challenge - challenges in capacity across the system with resulting impact on patient flows, Emergency Department wait and timely discharge. Key factors are being considered and presentation going to October Performance & Resources Committee.
Delayed discharge - local focus continues based on work with the Joint Improvement Team will help form a basis of tactical approach for 2013 to 2015.
Multi-Agency Public Protection Arrangements (MAPPA) - following review, a proposal to reduce the organisational risk had recently been supported and work was underway to increase clinical forensic psychology, forensic Community Psychiatric Nurse sessional time and administrative support.
Provision of out of hours radiology services - the Clinical Governance Working Group agreed to remove this risk
Safe care - the Clinical Governance Working Group agreed to remove this risk Following discussion Mrs Caldwell agreed to reflect on the report in terms of Equality and Diversity.
ACTION: Mrs Caldwell to reflect The Committee noted the report. 9/ EFFECTIVE CARE 9.1 Standards and Reviews Report The Committee received a paper from Mrs Monica Inglis, Head of Clinical Governance. Mrs Inglis highlighted the following publication/guidance:
NHS National Services Scotland - MSK (Musculoskeletal) Audit of Care Pathways for Hip Fracture Patients in Scotland
The Committee considered and noted the report. 10/ REPORTS FROM ASSOCIATED CLINICAL GOVERNANCE GROUPS 10.1 Draft Minute of the Area Prevention and Control of Infection Committee held on 13 August 2013 The Committee noted the draft minute of the Area Prevention and Control of Infection Committee as presented by Mr Jonathan Horwood, Infection Control Manager in the absence of Dr Graham Foster, Interim Director of Public Health. In response to a question from Ms Gavine on why bi-monthly hand hygiene audits had stopped, Mr Horwood responded that the Scottish Government now used Scottish Patient Safety Programme data. In response to a further question from Ms Gavine on an unusual type of MRSA identified within the Neo-Natal Unit, Mr Horwood stated that Microbiology were monitoring the situation but no infections with this strain had occurred. 10.2 Child Protection Action Group Quarterly Report The Committee noted the Child Protection Action Group Quarterly Report as presented by Professor Angela Wallace, Director of Nursing. In response to a question from Ms Nash on training, Professor Wallace responded that child protection training was now available on LearnPro and there had been a good uptake from staff. 10.3 Draft Minute of the Joint Clinical Governance Working Group held on 9 July
2013 The Committee noted the draft minute of the Joint Clinical Governance Working Group as presented by Mrs Monica Inglis, Head of Clinical Governance. 10.4 Draft Minute of the Organ Donation Committee The Committee noted the draft minute of the Organ Donation Committee as presented by Dr Peter Murdoch, Interim Medical Director. 10.5 Minute of the Ethics Committee No meeting had taken place. 11/ ANY OTHER COMPETENT BUSINESS
Mrs Crosbie put forward a request by the Research & Development Group to give a presentation to this Committee. This request would be put on the forward planner for future consideration. Mr Forbes queried whether it was standard for all Board Committees to have a key issues cover page. Dr Murdoch agreed to make enquiries regarding the standard.
ACTION: Dr Murdoch to confirm standard for Board Committee papers 12/ DATE AND TIME OF FUTURE MEETINGS The next meeting of the NHS Forth Valley Clinical Governance Committee would be held on Friday, 13 December 2013 at 9.30am in the Boardroom, Carseview House, Stirling. 2014 dates were as follows: 21 February 2014 11 April 2014 There being no further business, the Chair closed the meeting at 12 noon.
Forth Valley NHS Board
10 December 2013
This report relates to
Item 7.5 on the agenda
Minute of Forth Valley NHS Staff Governance Committee held on 22 November 2013
(For Noting)
DRAFT Minute Staff Governance Committee meeting held on Friday 22 November 2013 in the Board Room, Carseview House, Castle Business Park, Stirling.
Present:- Mr Brendan Clark, Non Executive Director (chair) Mr Alex Linkston, Chairman, NHS Forth Valley Mr Charlie Forbes, Non Executive Director Mr Tom Hart, Employee Director Ms Janett Sneddon, Staff Side Co-Chair, Acute Partnership Forum Mr George Kerr, Staff Side, Co-Chair, CHP Partnership Forum
In Attendance:- Mrs Helen Kelly, Director of Human Resources Mrs Jane Grant, Chief Executive Mr Tom Steele, Director of Strategic Projects & Facilities
Mrs Alison Richmond-Ferns, Associate Director of Human Resources Mrs Morag McLaren, Associate Director of Human Resources
Ms Linda Donaldson, Associate Director of Human Resources Ms Marian Smith, PA to Director of Human Resources (note)
1/ Apologies for Absence Apologies for absence were intimated on behalf of Professor Angela Wallace 2/ Declarations of Interest There were no declarations of interest to note. 3/ Minute of Meetings 3.1 Minute of Staff Governance Committee meeting held on Tuesday 24 September 2013 The minute of the Staff Governance Committee meeting held on Tuesday 24 September 2013 was approved as a correct record. 3.2 Minute of Staff Governance Remuneration Sub Committee meeting held on Tuesday 24 September 2013. The Staff Governance Committee noted the minute of the Remuneration Sub Committee meeting held on Tuesday 24 September 2013. 4/ Matters Arising Staff Survey Update Mrs Kelly advised that publication of the results of the National Staff Survey had been delayed and the revised timeline, of week beginning 9 December 2013, was subject to agreement by the Cabinet Secretary.
The Information Services Division had been commissioned to carry out the 2013 staff survey, and to produce reports of findings. All Boards will have sight of reports, on an embargoed basis, in advance of publication. The exact timing of this will depend on the date of publication which will be confirmed to Boards as soon as possible.
Mr Hart advised that the Cabinet Secretary would be in attendance at the Employee Directors meeting scheduled for 11 December 2013. 5/ STAFF GOVERNANCE 5.1 Health and Safety Quarterly Report Consideration was given to a paper ‘Health and Safety Quarterly Report’ presented by Mr Tom Steele, Director of Strategic Projects and Facilities. Mr Steele highlighted the following as detailed in the paper:- Identification of department leads for fire safety issues Violence and Aggression Audit Manual Handling Trainers Skin Health Education Package Incident reporting Mr Steele advised that a report identifying equipment needs and replacement costs had been produced. This had been submitted to the Equipment Group and Health and Safety Committee and agreement reached on the way forward. Orders had been placed and work was ongoing with the General Managers to ensure a system was in place to address any future challenges. He further advised that meetings had been held with NHS Fife Laundry Service regarding damage to equipment during the laundering process. An assurance had been given by NHS Fife that it was the material the slings were made of and not the laundry process which affected the durability. An internal alert notice had been issued. Mr Steele highlighted a recent visit by the Health and Safety Executive (HSE) to Trystpark following a recent incident. The initial feedback received had been positive, however, discussions were ongoing with Mental Health Services Colleagues on one of the recommendations. Feedback on the official report would be provided at a future Staff Governance Committee. The Staff Governance Committee discussed having a detailed analysis of incidents reported, comparing the number of incidents recorded across a period of time and NHS Boards, the recording of medication incidents and the context. Mr Steele would consider this further and provide appropriate advice to the Committee at the next meeting. There was a further detailed discussion on the wording of the Equality Declaration section of the Summary Report. Following the discussion, Mrs Kelly agreed to seek a review of the wording. Action Mrs Kelly The Staff Governance Committee noted the Health and Safety Quarterly Report.
5.2 Attendance Management Consideration was given to a paper ‘Attendance Management’, presented by Mrs Alison Richmond-Ferns, Associate Director of Human Resources. Mrs Richmond-Ferns reported on the September 2013 figures. The September report showed an absence rate of 5.13% which was as slight increase of 0.25% however, this compared favourably to the rate of 5.34% in September 2012. Mrs Richmond-Ferns highlighted the absence rate by Management Unit, by headcount, monthly comparisons over the last three years, and the national comparators and long term absence management monitoring as detailed in the paper. She further reported on the World Café Events focus groups held in October 2013. The three areas of focus were highlighted as:- Training on attendance management Support for fit slips and phased return Keep staff well Feedback from these sessions would be collated and taken forward by the Human Resources Directors Absence Group. The Staff Governance Committee discussed the additional trigger to the short term absence procedure, the Winter Keep Well Campaign, the article on staff wellbeing in the next edition of the Staff News and the encouraging and continued progress made towards meeting the HEAT standard of 4%. Mrs Kelly advised that she had been attending Unit Case Management meetings to ensure consistency of approach and compliance, across NHS Forth Valley, with the attendance management policy. The agreed pilot of the new trigger for short term absence would address the short term absence rates. Regular progress reports on this pilot would be submitted to the Staff Governance Committee. Following discussion the Staff Governance Committee noted the:- update on absence for July to September current priorities and work on Attendance Management 6/ Reshaping the Workforce Consideration was given to a paper ‘Reshaping the Workforce’, presented by Ms Linda Donaldson, Associate Director of Human Resources. Ms Donaldson advised that the Workforce Plan, as discussed at the last Staff Governance Committee meeting had now been approved and published on the NHS Forth Valley website. She further advised that future reports to the Committee would focus on the progress against the Annual Plan, Unit Plans and the Local Unscheduled Care Action Plan (LUCAP). Ms Donaldson highlighted the following as detailed in the paper:- LUCAP (including the Winter Plan)
Nursing Recruitments Medical Workforce Recruitment Clinical Leadership – including the appointment of speciality leads Trained medical staff Job planning Agenda for change of description reviews KSF, including Internal Audit Work. It was noted that progress against the HEAT Standard in relation to eKSF would be discussed at Unit Review meetings. The Staff Governance Committee discussed the challenges associated with consultant recruitment, funding for Nurse recruitment, the changes and implications of tax legislation, integration of Health and Social Care and the future plans for Health Visitors. Mrs Grant acknowledged the work to date to progress the Winter Plan to ensure NHS Forth Valley was appropriately staffed. The Staff Governance Committee noted the paper. 7/ RISK MANAGEMENT 7.1 Corporate Risk Register – Workforce Issues Consideration was given to a paper ‘NHS Forth Valley Risk Register (Staffing Risks)’ presented by Mrs Helen Kelly, Director of Human Resources. Mrs Kelly advised the Staff Governance Committee that risks categorised as staffing in the Corporate Risk Register remained as detailed in the paper and formed a significant part of the Committee agenda. Mrs Kelly highlighted the following risks:- failure to meet 4% HEAT Standard on attendance management affordable workforce plan Mrs Kelly further advised that the risk associated with Modernising Medical Careers and the delivery of Paediatric Services had been removed from the Corporate Risk Register and the risks associated with eKSF would be added. In response to a question from Mr Clark regarding Equal Pay, Mrs Kelly advised that discussions were ongoing at a national level. The Staff Governance Committee noted the corporate staffing risks. 8 REPORTS 8.1 Human Resources Policy Consideration was given to a paper ‘Human Resources Policy’, presented by Ms Alison Richmond-Ferns, Associate Director of Human Resources. Ms Richmond-Ferns advised that the Area Policy Steering Group had reviewed the Dignity at Work Policy against the national PiN Policy on Bullying and Harassment. The revised
policy would be called the Policy on Dignity and Respect at Work. The links to the recent values work by the Organisational Development Team and learning from recent case reviews would be incorporated into the revised policy. The review is nearing completion and would be consulted on prior to being submitted to the Area Partnership Forum. Ms Richmond-Ferns reported that the PiN Policy on Supporting the Work-Life Balance had been received. The Scottish Government had requested comments be submitted by 31 January 2014. Comments would be sought from Staff Side colleagues through the Partnership Fora, the Area Policy Steering Group, General Managers and HR colleagues. Ms Richmond-Ferns highlighted the policies being reviewed as:- Alcohol and Drugs Study Support Learning and Training Retirement Tobacco Uniform She further advised that the current local financial challenges were significant in relation to the policies which resulted in additional staff leave and subsequent back fill arrangements. This was relevant to the Retirement Policy and Parental Leave Policy which were currently being reviewed at the request of the Chief Executives Operational Group. The Staff Governance Committee noted the current portfolio of work. 8.2 Update on Organisational Development Framework Priorities, including Learning, Education and Training Update Consideration was given to a paper ‘Update on Organisational Development Framework Priorities, including Learning, Education and Training Update’, presented by Mrs Morag McLaren, Associate Director of Human Resources. Mrs McLaren reported on the Organisation Development Framework Priorities including Learning, Education and Training and highlighted the following priority actions as detailed in the paper:-
NHS Forth Valley Staff Experience, Engagement and Involvement Framework Recognising our People: a proposal to develop a Staff Recognition Scheme Everyone Matters – NHS Scotland 2020 Workforce Vision Leadership Development Plan 2014 – 2017 Induction Programme Supporting KSF Reviews and Personal Development Planning Joint Executive Group/Partnership Board Development Performance Management Process and Procedures for the Executive Cohort Mrs Kelly advised that actions highlighted at the Staff Governance Remuneration Sub Committee in relation to Executive Cohort objectives would be included in the process and procedures for 2014/15. The Staff Governance Committee noted the paper.
9/ REPORTS FROM SUB COMMITTEES 9.1 Minute of Acute Services Partnership Forum meeting held on 10 September
2013 The Staff Governance Committee considered the minute of the Acute Services Partnership Forum meeting held on 10 September 2013. Ms Sneddon highlighted the following:- Integration of Adult Health and Social Care Presentation The Staff Governance Committee noted the minute of the Acute Services Partnership Forum meeting held on 16 July 2013. 9.2 Minute of Health and Safety Committee meeting held on 14 August 2013 The Staff Governance Committee noted the minute of the Health and Safety Committee meeting held on 14 August 2013 . 9.3 Minute of the Area Partnership Forum meeting held on 25 October 2013 The Staff Governance Committee considered the minute of the Area Partnership Forum meeting held on 25 October 2013. Vehicle Telematics System Mr Hart advised that following the Area Partnership Forum meeting discussions had been held with staff side representatives to discuss the issues raised, at the meeting, in relation to the proposed Vehicle Telematics System pilot scheme. These meetings had been well attended with no further issues raised. Mr Hart confirmed that the 12 month pilot scheme would be implemented within the agreed timescales. During the discussions it had been confirmed that this scheme should be referred to as Ingenium Dynamics Vehicle Risk Management System. Mr Hart had requested that an update paper on the Ingenium Driver Safety scheme be submitted to the Area Partnership Forum meeting scheduled for 13 December 2013. Mrs Kelly thanked all those involved in bringing this matter to a satisfactory conclusion. The Staff Governance Committee noted the minute of the Area Partnership Forum meeting held on 25 October 2013. 9.4 Minute of CHP Partnership Forum meeting held on 3 September 2013 The Staff Governance Committee noted the minute of the meeting of the CHP Partnership Forum held on 3 September 2013. 10/ STAFF GOVERNANCE COMMITTEE PROPOSED MEETING DATES 2014 The Staff Governance Committee discussed the proposed meeting dates and noted these may be subject to change. Action Ms Smith
11/ ANY OTHER COMPETENT BUSINESS Board Summary Template Mr Forbes highlighted the summary paper attached to the Health and Safety Quarterly Report and suggested that use of the Board Summary report would ensure consistency of presentation. It was agreed that use of the Board Summary template would be adopted for future Staff Governance Committee meetings. There being no other competent business the Chair closed the meeting at 3.15 pm
Forth Valley NHS Board
10th December 2013 This report relates to Item 8 on the agenda
Equality and Diversity Update
(Paper Presented by Angela Wallace, Director of Nursing)
For Noting
SUMMARY
1. TITLE : TAKING FORWARD THE EQUALITY AND DIVERSITY AGENDA IN NHS FORTH VALLEY 2. PURPOSE OF PAPER
The purpose of this paper is to provide NHS Forth Valley Board members with an update on progress with our Equality and Diversity outcomes as well as any other equality activities within NHS Forth Valley. Achievements against key priorities to date are reflected within the enclosed report to meet our Equality Act 2010 Public Sector Duties.
3. KEY ISSUES
Equality Duty 2010
The Equality Act 2010 harmonises and replaces previous equalities legislation. It includes a new public sector general equality duty, in three parts, which replaces the previous separate duties relating to race, disability and gender equality. As per our legislative requirements we published the following NHS Forth Valley Equality Delivery Reports 2013-17 on 30th April 2013: NHS Forth Valley Mainstreaming Report
o Award criteria and conditions in relation to public procurement o Mainstreaming Appendices Report including evidence collated and hyperlinks to
additional information used to inform our equality outcomes and evidence from involvement activities
o Evidence of systems in place to Equality Impact Assess policies, functions and services.
NHS Forth Valley Mainstreaming Report (Employees) o Workforce Diversity Monitoring o Gender Pay Gap Comparisons o Equal Pay Statement
NHS Forth Valley key areas identified within the Report:
o NHS Forth Valley Equality Outcomes Progress report in place o Proposal for NHS Forth Valley Board to have an update on the new Scotland’s
National Public Bodies Action Plan for Human Rights during early 2014 o Launch of the NHS Forth Valley Young Carers Person Centred DVD ‘Nothing about
ME without ME’ o Improving collection of ethnicity monitoring o Equality Impact Assessment Activities o Single Point of Contact Translation and Interpretation Service delivery o Action taken regarding Gender Based Violence (GBV) including actions taken to date
to enhance awareness of GBV as well as identification of current gaps in service provision
o Progress made to date in ‘Keep Well’ programme. o Appendix 1: Breakdown of population within NHS Forth Valley based on Scottish
Census 2011
The biggest challenge we continue to face is securing engagement in making a reality our commitment to advancing equality. Equality needs to be embedded in our day-to- day business, not only to meet our legal obligations, but to ensure that we achieve our commitment to delivering high quality person centred care.
For some, equality is seen as ‘not an issue’ , others take the view that we already ‘automatically’ consider equality in our day to day work and that it is a bureaucratic burden to evidence that we do so. The hard evidence, and the testimony of people in Forth Valley who experience inequalities, indicates otherwise.
4. FINANCIAL IMPLICATIONS
There should be no direct financial governance issues associated with this work. The delivery of agreed outcomes will ultimately reduce costs by improving access (e.g. reducing DNAs) and improving health.
5. WORKFORCE IMPLICATIONS The NHS Forth Valley workforce is central to the delivery of the Equality and Diversity agenda both in terms of delivering services for our population which are fair for all, but also as recipients of our work to promote equality of opportunity for all staff.
6. RISK ASSESSMENT AND IMPLICATIONS
This paper outlines progress and highlights any issues associated with taking forward the Equality & Diversity agenda within NHS Forth Valley. Failure to comply with obligations arising from Equality and Human Rights legislation (EHRC) may result in breaches of law, possible complaints of unfair discrimination in employment, & service delivery as well as interventions from the EHRC. Ideally, every service should be in a position to confidently demonstrate compliance through the Equality Impact Assessments completed on their service area or within financial or service delivery reports completed.
7. RELEVANCE TO STRATEGIC PRIORITIES
Equality and Diversity work streams form an integral part of NHS Forth Valley’s Local Delivery Plan and Patient Focus, Public Involvement Framework. It also evidences our commitment to the Equality Act 2010 Public Sector Duty requirements.
8. EQUALITY DECLARATION The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.
Further to an evaluation it is noted that: (please tick relevant box) □ Paper is not relevant to Equality and Diversity X Screening completed - no discrimination noted □ Full Equality Impact Assessment completed – report available on request. Impact Assessment: - The E&D Progress report is a factual summary of actions completed in relation to equality and diversity and as such does not require an impact assessment.
9. CONSULTATION PROCESS Main findings within this report have been discussed at the NHS Forth Valley Fair for All
Development Group and the NHS Forth Valley Clinical Governance Working Group meetings prior to submission to the Board
10. RECOMMENDATION(S) FOR DECISION
The Forth Valley NHS Board is asked to: - Note the content of this report
11. AUTHOR OF PAPER/REPORT:
Name: Designation:
Lynn Waddell Equality & Diversity Project Manager and Gender Based Violence Operational Lead
Approved by: Name: Designation: Prof. Angela Wallace Director of Nursing
1 TAKING FORWARD THE EQUALITY & DIVERSITY AGENDA IN NHS FORTH
VALLEY
2 PURPOSE OF PAPER
The purpose of this paper is to provide Board members with an update on progress with the Equality and Diversity outcomes as well as any other equality activities within NHS Forth Valley. Achievements against key priorities to date are reflected within the enclosed report to meet our Equality Act 2010 Public Sector Duties
Within 2013 NHS Forth Valley has taken significant steps to ensure that the Equality Duty 2010 Specific Duties become mainstreamed into our work as service providers and employers. We will continue to monitor our performance against equality and diversity criteria through the Fair for All Development Group; Chaired by Angela Wallace and Dr Abu Arafeh Fair for All Development group Lay Advisor and supported by Non Executive Director Mr Charles Forbes as well as submission to Clinical Governance.
.KEY ISSUES
3.1 Equality Duty 2010 The public sector equality duty in the Equality Act 2010 came into force in April 2011 - this is often referred to as the general duty. Scottish public authorities must have 'due regard' to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations.
As per our legislative requirements we published the following reports on 30th April 2013
NHS Forth Valley Equality Delivery Reports 2013 - 17 These reports include: How NHS Forth Valley are mainstreaming the equality duty Award criteria and conditions in relation to public procurement Separate Mainstreaming Appendices Report, which includes evidence collated and
hyperlinks to additional information used to inform our equality outcomes Evidence from involvement activities completed How we complete ongoing assessment and review of policies and practices
NHS Forth Valley Mainstreaming Report 2013 - 17 Employee's We published as per required: NHS Forth Valley Mainstreaming Report (Employees) & Workforce Diversity
Monitoring Gender Pay Gap Comparisons Equal Pay Statement
Easy Read Version - This information is currently under development by the Disability Service and will be made available in the near future. All documents as above are available on the NHS Forth Valley Equality and Diversity Web Page.
3.1.1 Equality & Human Rights Commission (EHRC) The EHRC Scotland Directorate commissioned a team of researchers to carry out a more in-depth review of listed public authorities’ equality outcomes. The EHRC also carried out its own analysis of the themes emerging from the equality outcomes published by Local Authorities, Education Authorities, Health Boards and Further and Higher Education institutions.
The information collated will also enable the EHRC to identify and promote good practice and make recommendations to the Scottish Government on actions to meet the Scottish Ministers Duty to “publish proposals for activity to enable a listed authority to better perform its equality duty” in December 2013. NHS Forth Valley Equality Manager has been part of the discussions with NHS Boards to identify barriers and best practice in relation to the development of NHS Equality reports and equality outcomes etc as per the Public Sector Duties. This information will be used to inform the Scottish Government in relation to their specific public sector duties.
3.1.2 Summary of findings regarding equality profile of NHS Forth Valley residents from
2011 Census attached - Appendix 1 3.2 Highlights from NHS Forth Valley Equality Outcomes Progress Report 2013-17
Relevance to NHS Forth Valley Equality Outcomes identified within brackets. A Balanced Scorecard tool is currently under development. An indication of progress made as identified beside subject title. Full progress report on actions taken to date regarding respective outcomes is available from: [email protected]
3.2.1 NHS Forth Valley Equality and Diversity Board Seminar (NHSFV Mainstreaming
Report 2013-17) It is proposed that one of the Board seminars during 2014 could focus on the Human Rights Act and the new Scotland’s National Action Plan for Human Rights. Recommendations from recent consultations are due in mid December 2013 outlining actions to be taken by Public Bodies including Health.
3.2.2 NHS Forth Valley ‘Young People Making a Difference Nationally and Locally’ (Equality Outcome 2.1a) We have continued throughout the summer period to work with young carers on the development of a training resource for NHS Forth Valley Staff on the needs of young carers. This online resource will provide advice for staff on the considerations they may require when working with this group of young people.
The format of this resource is based on the 5 values of person centred care, which fits in well with their particular needs as well as that of the cared for person.
We have received significant support from NHS Forth Valley Chairman Alex Linkston, and Michael Matheson MSP who both appear on the resource as well as from Angela Wallace Director of Nursing embedding this resource within the Person Centred Care agenda. Alison Richmond Ferns is working with Lynn Waddell to develop a note for the young people identifying the practical support and advice they have given to NHS Forth Valley to influence practice. This information would support the young people as evidence for their personal portfolio either for school or in applications for employment. Other Health Boards have expressed an interest in this work. This resource is available as NHS You-tube resource. http://www.youtube.com/watch?v=geIr1GXrxaA Resource launched at NHS Forth Valley Person Centred Care event on 1st November 2013.
3.2.3 Improving collection of Ethnicity Information as of August 2013 (Eq Outcome 2.b
Significant improvements have been made in relation to ethnicity data collection. Although we still remain below the national average (our percentage of completed fields
has increased and this has been noted within the recent Information Services Division Report August 2013.
NHSFV SMR 01 (2013 - National NHS Scotland Average 76.8%) 2011 16.4% 2012 45.5% 2013 65.9 (increase 49.5%) NHSFV SMR00 (2013 -National NHS Scotland Average 64.3%)
2011 7.7% 2012 30.4% 2013 57.6% (increase 49.9%)
Actions to be completed by Service Leads to ensure we know the full equality profile of people accessing our services. This is not just in relation to ethnicity, but to all the other protected characteristics for both service users and staff to inform our current and future work. Discussions to be held with service leads, I.T Services on how this will be completed, fields required within IT systems as well as work with the communications team on informing the public about the benefits of disclosing same.
3.2.4 E&D Training (within NHS Forth Valley Employment Mainstreaming Report) Equality and Diversity induction training has now incorporated Person Centred Care within its session. This has been piloted with a couple of staff groups including new NHS Forth Valley staff in general, as well as incorporated into Nurse Induction. To date the inclusion of this work has evaluated exceptionally well.
3.2.5 Equality Impact Assessments (EQIA) (Equality Outcome 2.3b) EQIA continued to be completed although not by all areas and not evident within several ongoing projects and changes to service delivery within NHS Forth Valley.
A new on line Screening tool has been developed which supports those areas impact assessed where no discrimination is noted or where the area being EQIA’d has no significant impact on service delivery or equality etc.
Due to limited numbers of staff attending EQIA Training, this has been stopped for the foreseeable future. However support can be given on a 1:1 basis if requested. This however may have an impact on the quality of EQIA’s submitted or completed.
3.2.6 NHS Forth Valley Interpreter and Translation Provision (Equality Outcome 2.4a) From 1 of September 2013st ALL enquiries and bookings relating to Community Language Interpreters, Translation and British Sign Language will be managed, via a single contact point within NHS Forth Valley Disability Services. The responsibility to book this service and ensure access for service users will remain with individual teams and services.
3.2.7 NHS Forth Valley Gender Based Violence (NHSFV Equality Outcome 3.b)
a) NHS Forth Valley Multi Agency Risk Assessment Conferences (MARAC) Police Scotland Forth Division commenced the MARAC (Multi Agency Risk Assessment Conference) in August 2013. MARAC’s are recognised nationally as best practice for addressing cases of domestic abuse that are categorised as high risk. During Jan – Dec ’13 there were 3500 domestic abuse cases reported to Police Scotland Forth Division
An SBAR report was submitted by NHS Forth Valley Gender Based Violence Leads (GBV) to Anne Marie Wallace NHS Forth Valley Executive Lead for GBV which set out the actions required to enable NHS Forth Valley to be a full partner in the MARAC conferences. The paper identified the corporate risks of implementing a MARAC process
without a whole systems approach to data collation and reporting from services in relation to domestic abuse as well as the risk to service users.
If the structures are put in place MARAC could provide NHS Forth Valley with an effective model for responding to a major health problem and offers a practical, multi-agency response to domestic abuse which involves engaging with those identified as being at most risk of harm and provides a method of intervening with both victims and perpetrators. As a process, MARAC accords with the WHO approach and the Scottish Government’s commitment to encourage a multi-agency approach as the most effective response to domestic abuse and to the general strategic direction for NHS Scotland.
At present NHS Forth Valley are unable to support this work. Discussions were held in October with Dr Graham Foster about our current position; further discussions to be held. b) Gender Based Violence Referral from Police to GP Practices Proposal developed by Lynn Waddell in which people who have reported Domestic Abuse to the police and are seen to be at risk, can have a letter with the patient’s permission sent to their GP in forming them that an incident has taken place. This strategy was supported by the GP sub committee in 2012 – this is currently on hold due to capacity issues.
c) NHS Forth Valley Emergency Department Gender Based Violence Actions – Falkirk Women’s Aid and NHS Forth Valley submitted a proposal to the ‘Investing in Health Large Grant Application’ to have a Domestic Abuse worker available within the Emergency Department Friday/Saturday evenings and during the festive season to deal with crisis situations for those experiencing abuse.
This is only one initiative which would support the work completed by health in relation to adult support and protection and if successful could have been expanded to other areas within NHS Forth Valley. Unfortunately the project was unsuccessful in its submission. A review is to be completed by NHS Forth Valley regarding actions to be taken during the festive season which is known to be a high risk period for women experiencing abuse.
d) 16 days of Action 25th November – 10th December 2013 The elimination of violence against women is the subject of international attention for a specific 16-day period every year. NHS Forth Valley hosted the opening event for the Forth Valley Gender Based Violence Partnership at Stirling Community Hospital on the 25th November 2013. The seminar focused on ‘What is happening nationally and locally in the area of Gender Based Violence’. Sir Stephen House Chief Constable for Scotland was the key note speaker at this event. The key message from his presentation was: The assurance of Police Scotland and the Government that Domestic Abuse is a high
priority. The focus is on keeping people safe and to encourage more people to come forward
and report these crimes Working with partners to ensure victims and their families are getting the right support
and the perpetrators are dealt with appropriately. To make real progress in bringing these issues out from behind closed doors and
make a real difference in keeping people safe.”
A formal report of the day and other activities taking place will be compiled by Lynn Waddell and partner agencies and presented in February 2014.
3.2.8 Keep Well (NHSFV Equality Outcome 3d) The programme currently delivers about 3000 health assessments per year. (Equivalent to 2.3% of the population aged 40-65) with 85% of those undergoing a health assessment are experiencing deprivation. The health assessment is greatly appreciated
by the clients. It invariably identifies some opportunity for improvement, and often leads to health gains in a variety of ways. This can be described as ‘co-production through a human therapeutic encounter’.
An Annual Report has been developed by Dr Oliver Harding Public Health Consultant on actions and outcomes to date.
Summary of Outcomes achieved: Keep well has been successful in identifying people at high risk of developing
cardiovascular disease (1 in 10 people having an ASSIGN score of 20 or above) Significant health gains are reported by those who attend, including earlier detection
of disease, e.g. our data suggest that in a year we identify some 123 people with high blood pressure, 43 with CHD, and 18 with diabetes (plus smaller numbers of other conditions including: COPD, depression, breast lumps including cancer, BPH, lupus, fibromyalga, thyroid disease, diverticulitis, chronic pain, gastro-intestinal conditions, IBS, hernia etc.)
At a community level, Keep well contributes significantly to capacity building for health improvement in regeneration areas and with vulnerable groups by a joined up agency approach e.g. walks, fruit barrow, galas, other community events, drop-ins, smoke free homes, resource development, volunteering, access to information i.e. welfare reform.
Health is jointly managed (clients/patients are supported by services that are better integrated and co-ordinated) and joint ownership of the health inequalities agenda can be demonstrated.
Individuals can access person centred services that meet their needs. Increasing numbers of care service staff are providing holistic person centred care. Sustained behaviour change is being evidenced.
Appendix 1 NHS Forth Valley Equality Profile of Population Census 2011 Summary (developed October 2013) All People All People Males Females Lives in a
household Lives in a communal Establishment
Schoolchild or full-time student aged 4 and over at their non term-time address
Scotland 5,295,403
2,567,444
2,727,959
5,196,386
99,017
41,551
NHS Forth Valley 297,636
144,475
153,161
290,421
7,215
2,414
Age Profile All 0-4 5-7 8-9 10-14 15 16-17 18-19 20-24 25-29 30-44 45-59 60-64 65-74 75-84 85-89 90+ Scotland 5,295,403
292,821
164,246
105,371
291,615
62,278
126,266
142,282
363,940
345,632
1,056,449
1,117,647
336,522
481,792
302,639
71,507
34,396
NHS Forth Valley
297,636
16,683
9,774
6,135
17,510
3,630
7,256
8,277
18,895
17,082
60,925
62,995
19,431
27,462
16,138
3,703
1,740
Long Terms Health Problem or Disability
All people Day-to-day activities limited a lot
Day-to-day activities limited a little Day-to-day activities not limited
Scotland 5,295,403 505,863 534,508 4,255,032 NHS Forth Valley 297,636 27,492 29,964 240,180
Gender
All people Males Females Scotland 5,295,403 2,567,444 2,727,959 NHS Forth Valley 297,636 144,475 153,161
11
Marriage and Civil Partnership status All people aged 16
and over
Single (never married or never registered a same-sex civil partnership)
Married
In a registered same-sex civil partnership
Separated (but still legally married or still legally in a same-sex civil partnership)
Divorced or formerly in a same-sex civil partnership which is now legally dissolved
Widowed or surviving partner from a same-sex civil partnership
Scotland 4,379,072
1,549,492
1,981,516
7,150
140,954
359,704
340,256
NHS Forth Valley 243,904
78,287
118,678
341
7,959
20,240
18,399
Sexual Orientation The Census completed in 2011 did not ask question relating to Sexual Orientation, however the following information has been devolved from the Integrated Household Survey, April 2011 to March 2012 Release
1.5 per cent of adults in the UK identified themselves as Gay, Lesbian or Bisexual,
2.7 per cent of 16 to 24 year olds in the UK identified themselves as Gay, Lesbian or Bisexual compared with 0.4 per cent of 65 year olds and over,
Across the UK, 78 per cent of men and 75 per cent of women reported that they perceived themselves to be ‘in good health’,
Of the constituent countries of the UK, for the third successive year Wales has reported the lowest rate of perceived good health,
In the UK, those aged 18 to 24 and who currently smoke are over twice as likely to have reported to be ‘not in good health’ compared with those that have never smoked.
Further information can be found on: http://www.ons.gov.uk/ons/dcp171778_280451.pdf
12
Ethnic Group
All people White White: Scottish
White: Other British
White: Irish
White: Gypsy/ Traveller
White: Polish
White: Other White
Mixed or multiple ethnic groups
Asian, Asian Scottish or Asian British
Asian, Asian Scottish or Asian British: PakistaniPakistani Scottish or Pakistani British
Asian, Asian Scottish or Asian British: Indian, Indian Scottish or Indian British
Scotland 5,295,403 5,084,407 4,445,678 417,109 54,090 4,212 61,201 102,117 19,815 140,678 49,381 32,706
Forth Valley 297,636 291,033 261,772 20,584 2,014 281 2,157 4,225 785 4,670 1,759 842
Ethnic Group cont…
Asian, Asian Scottish or Asian British: Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Asian, Asian Scottish or Asian British: Chinese, Chinese Scottish or Chinese British
Asian, Asian Scottish or Asian British: Other Asian African
African: African, African Scottish or African British
African: Other African
Caribbean or Black
Caribbean or Black: CaribbeanCaribbean Scottish or Caribbean British
Caribbean or Black: Black, Black Scottish or Black British
Caribbean or Black: Other Caribbean or Black
Other ethnic groups
Other ethnic groups: Arab, Arab Scottish or Arab British
Other ethnic groups: Other ethnic group
Scotland 3,788 33,706 21,097 29,638 29,186 452 6,540 3,430 2,380 730 14,325 9,366 4,959 NHS Forth Valley 37 1,315 717 480 474 6 221 152 46 23 447 195 252
13
Language people aged 3 years +
All people aged 3 and over
Proficiency in spoken English: Speaks well or very well
Proficiency in spoken English: Does not speak well
Proficiency in spoken English: Does not speak at all
Gaelic: Can speak Gaelic
Scots: Can speak Scots
Language other than English used at home: English only
Language other than English used at home: Gaelic
Language other than English used at home: Scots
Language other than English used at home: British Sign Language
Language other than English used at home: Polish
Language other than English used at home: Other
Scotland 5,118,223 5,044,683 62,128 11,412 57,602 1,541,693 4,740,547 24,974 55,817 12,533 54,186
230,166
NHS Forth Valley 287,616 284,418 2,718 480 1,721 93,411 274,107 383 2,160 654
1905 8,407
Gaelic Language Skills
All people aged 3
and over
Understands but does not speak, read
or write Gaelic
Speaks, reads
and writes Gaelic
Speaks but
does not
read or write
GaelicSpeaks and reads but does not write Gaelic
Reads but does not speak or write Gaelic
Other combination of skills in Gaelic
No skills in Gaelic
Scotland 5,118,223 23,357 32,191 18,966 6218 4,646 1,678 5,031,167 NHS Forth Valley 287,616 1,029 836 707 163 221 77 284,583
English Language Skills – people aged 3 years +
All people aged 3 and over
Understands but does not speak, read or write English
Speaks, reads and writes English
Speaks but does not read or write English
Speaks and reads but does not write English
Reads but does not speak or write English
Other combination of skills in English
No skills in English
Scotland 5,118,223 98,320 4,799,106 154,559 33,968 1,854 21,801 8,615 NHS Forth Valley 287,616 5,025 270,707 8,434 1,850 72 1,207 321
14
15
Religion
All people
Church of Scotland
Roman Catholic
Other Christian Buddhist Hindu Jewish Muslim Sikh
Other religion
No religion
Religion not stated
Scotland 5,295,403 1,717,871 841,053 291,275 12,795 16,379 5,887 76,737 9,055 15,196 1,941,116 368,039
NHS Forth Valley 297,636 106,259 35,127 14,508 549 401 120 2,327 239 789 117,284 20,033
Health and Provision of unpaid care
All people
Long-term health problem or disability: Day-to-day activities limited a lot
Long-term health problem or disability: Day-to-day activities limited a little
Long-term health problem or disability: Day-to-day activities not limited
Long-term health problem or disability: Day-to-day activities limited a lot: Aged 16 to 64
Long-term health problem or disability: Day-to-day activities limited a little: Aged 16 to 64
Scotland 5,295,403 505,863 534,508 4,255,032 244,427 278,496 NHS Forth Valley 297,636 27,492 29,964 240,180 13,231 15,649
Health and Provision of unpaid care cont…
Long-term health problem or disability: Day-to-day activities limited a little: Aged 16 to 64
Long-term health problem or disability: Day-to-day activities not limited: Aged 16 to 64 General health: Very good
General health: Good General health: Fair
Scotland 278,496 2,965,815 2,778,481 1,575,000 644,881 NHS Forth Valley 15,649 165,981 155,353 90,610 36,065
Health and Provision of unpaid care cont…
General health: Bad
General health: Very bad
Provision of unpaid care: No unpaid care
Provision of unpaid care: 1 to 19 hours a week
Provision of unpaid care: 20 to 49 hours a week
Provision of unpaid care: 50 or more hours a week
Scotland 226,154 70,887 4,803,172 273,333 86,816 132,082 Forth Valley 12,132 3,476 269,628 15,526 5,012 7,470
For further information on variables, see www.scotlandscensus.gov.uk/variables
1
Forth Valley NHS Board 10 December 2013 This report relates to Item 9 on the agenda
Stirling Care Village Outline Business Case
(Presented by Mr Tom Steele, Director of Strategic
Projects & Facilities)
For Approval
2
3
SUMMARY 1. STIRLING CARE VILLAGE OUTLINE BUSINESS CASE
2. PURPOSE OF PAPER
To present the Outline Business Case for Stirling Care Village for approval. 3. KEY ISSUES
An important milestone in the Stirling Care Village project has been reached with completion of the Outline Business Case (OBC).
The project is being progressed jointly between Stirling Council, NHS Forth Valley and the Scottish Ambulance Service supported by Forth Valley College. The proposed development is being taken forward as a Design Build Finance and Maintain (DBFM) project through hub East Central Scotland Ltd (hubco) in which the Council, NHS Forth Valley and Scottish Ambulance Service are Participants
The second stage in the business case process, the Initial Agreement was approved by Scottish Government in September 2012, the OBC re-iterates the case for change and detailed option appraisal resulting in a preferred way forward for the development of services within the Care Village.
The preferred way forward will see a step change in the provision of Older People’s Services with the creation of the Care Hub: a 116 place facility with a focus on integrated care provision and short stays enabling older people to remain in or go back to their own homes, avoiding long term residential care as far as possible. The care hub is one of the key elements within Stirling’s wider plan for reshaping the care of older people. Also to be provided will be Primary and Unscheduled Care Services in a new building along with Diagnostic Services and a base for the Scottish Ambulance Service. A separate facility will also be constructed for the Ambulance Service who propose to relocate their workshop facility from Falkirk.
A significant amount of work has been carried out since approval of the Initial Agreement and in partnership with hubco, from masterplanning of the site through to initial design of the individual facilities and outline construction methodology. This has culminated in the provision of the formal Stage 1 report which sets out the various design and cost proposals from hubco in meeting the requirements of the partners’’ brief. This information has formed the basis of the cost calculations within the OBC.
The Stage 1 Report forms part of the information required in Scottish Futures Trust’s (SFT) Key Stage Review, a critical assurance process that is mandatory within hub DBFM projects. At the time of writing, this review has not been completed, therefore, it is proposed that the Board remits satisfactory completion of this process prior to formal submission of the OBC to the Capital Investment Group to the Chief Executive, assisted by the Director of Strategic Projects & Facilities.
Further, in accordance with the Scottish Capital Investment Manual (SCIM) the project requires at key stages to undergo a Design Assessment. This process was commenced at Initial Agreement stage with the preparation and approval of the Design Statement and a review of the emerging design against the parameters set out in that Statement requires to be completed at OBC stage. Consultation has taken place with Architecture & Design Scotland and Health Facilities Scotland and interim feedback obtained, however, at the time of writing the assessment process is not complete. It is anticipated that progress in this regard will be available for the NHS Board meeting. It is proposed that successful completion of this process also be remitted to the Chief Executive and Director of Strategic Projects & Facilities as part of finalising arrangements for formal submission of the OBC.
New to the national project approvals process is the recently issued metric and value for money scorecard to be applied to primary care premises, developed by SFT. This is a tool based on area and cost to be used with immediate effect and submitted with business cases to the Scottish Government. This has come late in the process for the Care Village project, however, a scorecard has been completed and will be submitted with the OBC. The analysis has been applied to the whole of the Primary and
4
Unscheduled Care building, including the Ambulance Service base accommodation and at this stage shows an area of 22% over the metric and total project cost of 12% over. With regard to the latter it should be noted that the metric has been developed based on completed projects and the amount of risk within the Care Village costs at present will account for some of this difference. Further, the preliminary costs (prelims) in East Central Territory are higher than that elsewhere and this will also require to be taken into account. It is unknown how the scorecard will be received by the Capital Investment Group and it is highly likely that it will figure in their feedback in relation to the OBC. In the interim, further dialogue will take place with SFT in relation to completion of the scorecard and interpretation of the results
A major risk to the project remains, noted in Section 6 below, in relation to affordability for all of the partners and the ability to access revenue funding support from Scottish Government. Approval of the OBC by the Scottish Government and confirmation of both the fact and level of such support for the project will be key to allowing it to progress, from a budgetary perspective.
It is still proposed, therefore, that no approval will be given to progress to Stage 2 (detailed design and final costing) until the OBC (and the funding position) has achieved final sign off (Stage 2 involving incurring significantly increased design fees).
4. FINANCIAL IMPLICATIONS
Detailed capital and revenue funding calculations are as included in the Outline Business Case, based on the estimated construction cost presented by hubco in their Stage 1 Report and adjusted for inflation, a sum of {Redact} (excluding VAT and client costs such as equipment).
Significant work has been undertaken on behalf of all of the partners to understand the cost implications of progressing through the Outline Business Case stage and into the detailed design of the Care Village. An affordability model has been constructed, based on the anticipated future service and running costs of the Care Village including detailed workforce models and including the Unitary Charge that will be incurred from East Central Scotland Hubco. This has been compared with the existing service and running costs that the partners currently incur in running existing services which will no longer be required should the Care Village progress
Estimates of costs for partners in the venture including Stirling Council, the Scottish Ambulance Service and the GP practices have been provided and the partners requested to formally confirm that the venture is affordable to them. At the time of writing, responses are awaited.
A summary affordability statement is provided at Appendix I. This illustrates that the project is affordable based on the following key assumptions:
Detailed and costed workforce planning for the care hub.
Scottish Government revenue support for {Redact}% of the unitary charge for the project in its entirety.
Recovery for VAT on the unitary charge is allowable.
Costs for Soft Facilities Management (FM) services, retained Facilities Management responsibilities, Utilities, Rates and Insurance are in line with estimates made.
5. WORKFORCE IMPLICATIONS
As identified in the Outline Business Case. The main implications for workforce will be within the Care Hub as the NHS and the Local Authority implement fully integrated working.
The key issues for the integrated workforce model are:
Integrating social care and healthcare support worker roles including training.
Reduction in the number of registered nurses required.
Developing more advanced specialist health roles e.g. advanced nurse practitioners
Sustaining some posts currently supported through the Reshaping Care for Older Peoples Change Fund.
5
Investing in enhanced capacity in community services (particularly nursing and Allied Health Professionals) to support the wider care model.
6. RISK ASSESSMENT AND IMPLICATIONS
A detailed risk assessment has been undertaken and Risk Register developed in association with hubco. Joint and separate risks have been identified and costed and included in the financial analyses within the OBC.
Major or high cost public sector risks are in relation to funding, specifically revenue funding support from Scottish Government, recovery of VAT on the Unitary Charge, unfavourable market conditions and off-site infrastructure requirements determined via the Planning Consent process.
‘Red’ risks post mitigation for the public sector organisations are as follows: Off site works required as conditions of Planning Permission The project becomes unaffordable to one or all organisations The funding support for the hub revenue financed model is not available to all partner organisations and affects affordability
Estimated costs have been allocated to the risks, related to their overall rating. Those risks which could affect (increase) the construction cost and thus have an impact on the Unitary Charge amount to {Redact} and those more operational/financial risks (in the main the above mentioned VAT and market conditions risks) amount to {Redact}. At the time of writing, discussions are ongoing about the appropriate treatment of these risks as all will have a revenue consequence for the public sector.
It is anticipated the majority of risk will be closed out, mitigated or dealt with in some other way during the next stage of the project with a much reduced amount of residual risk in the Full Business Case.
7. RELEVANCE TO STRATEGIC PRIORITIES
The project is in accordance with the Integrated Healthcare Strategy as well as in line with current national drivers such as the 20:20 Vision and Health and Social Care Integration.
With regard to asset management, the project is in line with the Board’s Property & Asset Management Strategy and also represents best practice in terms of co-location of public sector organisations and rationalisation of the estate.
8. EQUALITY DECLARATION
The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.
Further to an evaluation it is noted that: (please tick relevant box) √ Paper is not relevant to Equality and Diversity □ Screening completed - no discrimination noted
□ Full Equality Impact Assessment completed – report available on request.
NB Whilst not directly relevant to the paper, it is acknowledged that equality of access to services and to premises is paramount. Further work will be undertaken in this regard to confirm any assessment requirements.
9. CONSULTATION PROCESS
Extensive consultation has taken place during the development of the OBC and the developing design of the facilities. This has been with internal and external stakeholders including service representatives, members of the public, the Local Authority, Scottish Futures Trust, Architecture & Design Scotland and Health Facilities Scotland. Briefings have also been held with elected members of Stirling Council and members of the NHS Board.
6
10. RECOMMENDATION(S) FOR DECISION
The NHS Board is asked to: -
Approve the Outline Business Case for Stirling Care Village, subject to key assurances being in place (Key Stage Review and Design Assessment) prior to submission to the Capital Investment Group.
Remit obtaining the above assurances and submission of the document to the Chief Executive with assistance from the Director of Strategic Projects & Facilities
10. AUTHOR OF PAPER/REPORT
Name: Designation:
Morag Farquhar Programme Director
Approved by:
Name: Designation:
Tom Steele Director of Strategic Projects & Facilities
Appendix 1 STIRLING CARE VILLAGE
AFFORDABILITY STATEMENT
ESTIMATED COSTS £
Direct Service Costs
Care Staffing Model Redact
Scottish Ambulance Services Redact
Primary Care & Urgent Care Redact
Sub-Total Redact
Soft FM & Energy Costs
Soft FM Redact
Transport Redact
Energy Redact
Sub-Total Redact
Unitary Charge, Capital Charges, Rates and Property Cost Reimbursements
Unitary Charge Redact
Capital Charges Redact
Rates Redact
Insurance Redact
Other Costs and Contingencies Redact
Sub-Total Redact
Income
Client Income Redact
Other Income Redact
Sub-Total Redact
TOTAL COSTS Redact
FINANCED BY
Existing Budgets Redact Net Investment in Service Provision (SAS) Redact
Less : Provision for Respite Capacity Redact Less: Amounts Released for Savings or Reinvestment Redact
Assumed Revenue Support for Unitary Charge from Scottish Government Redact
TOTAL RESOURCES AVAILABLE Redact
Forth Valley NHS Board 10 December 2013 This report relates to Item 10 on the agenda
Innovation Stock Take
(Paper presented by Jane Grant, Chief Executive)
For Approval
NHS Forth Valley Innovation & Health Stocktake
November 2013
Purpose
This paper is in response to a letter from the former Director General for Health & Social care dated 30th July 2013. The letter notes that Innovation is one of the 12 Priority Areas in A Route Map to 2020 Vision for Heath and Social Care and asks Boards to undertake 2 key tasks to drive this agenda forward. The first is to identify a Board Innovation Champion responsible to the Chief Executive and the second is to complete a short paper for consideration by the Board providing a general ‘stock-take’ of current position and future planning to enable innovation.
This paper provides an summary of NHS Forth Valley’s approach to promoting innovation and describes how this can be driven forward. Following discussion of this paper with NHS Forth Valley’s Board a finalised paper will be returned to the Director General’s office by Monday 16th December 2013.
1. NHS Forth Valley Innovation Lead/Champion
The role of the Board Innovation Champion is to contribute at a National level to the development of priority areas for innovation work. The National Leads will work collectively to harness the opportunity of partnership working across Boards and Local Authorities and work in an evolving way with academia and the Life Sciences Industry to accelerate the development and implementation of innovative solutions.
Locally the Innovation Lead/Champion is required to have an understanding of the local strategic objectives and key networks to enable appropriate connection with the National workplan. It is recognised that this area of work will evolve over coming months. At this time Jann Gardner, Lead for the EPQ (Efficiency, Productivity and Quality) Programme has been nominated as the NHS Forth Valley Innovation Lead.
2. Innovation Stocktake.
Outlined below are the key questions posed within the former Director Generals letter with a draft response from NHS Forth Valley.
2.1 What are seen as the current FV Board strengths in innovation - in terms of invention, adoption and spread
NHS Forth Valley has a commitment to continuous improvement demonstrated by the work carried out across a number of key National initiatives including Scottish Patient Safety Programme, Person Centred Care, Older people in Acute Care and the Early Years Collaborative. In addition the Board has shown through many pieces of work in recent years that it firmly invests and supports innovative ways of working with technology and eHealth. Examples of this are the development of the electronic inpatient system/smart board system (eWard), the implementation of the pharmacy robotics system and the establishment of the Clinical Simulation Training Centre which was developed in conjunction with NES. NHS FV has undertaken a number of pieces of partnership and preventative work including campaigns with local authority colleagues around childhood obesity, asset based work and community based approaches to improve fitness.
In addition a local Innovation and Improvement Programme has been established in the form of the EPQ Programme with a remit to identify, develop and support Whole System improvement work. To enable improvement, NHS Forth Valley has developed local capacity through it’s investment in IHI fellows and training of staff in improvement techniques such as lean and queuing theory.
Through further development of the local Innovation and Improvement Programme there is a potential to utilise this capacity in a more cohesive way to address the Boards key priorities and further accelerate all phases of innovation- invention, adoption and diffusion.
2.2 Are there gaps in skills, knowledge and experience that limit the ability to create, design and apply different ways of delivering services , and how collective working across Boards or in partnership with others help to address these?
There is considerable local skill, knowledge and experience in improvement techniques however the key for NHS Forth Valley lies in harnessing this resource to the Programme priorities to deliver more innovative solutions. There is however a more significant opportunity to link with other Boards and/or Local Authorities to work collaboratively to develop iterative, progressive ideas/developments which could accelerate the ‘invention’ phase to a robust service/system/product. NHS Forth Valley actively promotes partnership working with NES, NHS 24, SAS and local authorities. This programme of work is seen as an extension of that approach. More importantly, following formal validation and assessment these developments could be accelerated through adoption and diffusion phases also giving NHS Scotland collective benefit.
2.3 What are the issues and services that the Board regards would most benefit from a greater emphasis on innovation?
Key Priorities would be:
a. Demand for inpatient hospitalisation – potential for solutions which further support promote effective community based and ambulatory modelled care and result in a reduction in avoidable hospitalised bed days
b. Standardised, value added care – solutions which support standardised processes, reduced variability and improved efficiency across health care systems to reduce waste and improve care outcomes
c. Improve Integrated Working for Frail/Elderly – develop innovative solutions across care interfaces to improve care and outcomes for frail elderly patients and improve their ability to remain at home.
d. Effective community based pathways – consider potential improvements which could better support patient flow to community based services and back to their home environment.
e. Efficient Use of Outpatient based services – develop innovative solutions which enable patients to be assessed and reviewed in an ambulatory manner which optimises value added care delivery.
2.4 What is currently in place to bring staff together to work on a collective basis to share the best ideas and practice to develop innovative solutions (and how should this be developed)?
There is good practice across a number of key workstreams including Patient Centred Care, SPSP and RCOP. In addition the current EPQ Programme provides a structure to pull together improvement work, maximise synergy and minimise duplication.
Further development of this Innovation and Improvement Programme would provide supporting resource and a more cohesive future approach which could co-ordinate and drive a prioritised workplan.
2.5 What is currently in place to give staff time and recognition in their job plan/objectives to undertake work on innovation (and how this might be developed)?
As part of the EPQ Programme and SPSP initiatives there are a number of good examples where time/role has been build into job plans. A few examples are given below:
• Ward based senior Charge Nurses are non-case holding to allow them sufficient time to undertake leadership, improvement and governance related work
• EPQ Programme has specific resource associated with the leadership and support of innovative working
• Many improvements projects will identify and design into a role time to drive forward innovation e.g. Frailty Clinic development and Cardiology service development.
There is still a great deal of service development carried out within services without nominated time and there is opportunity to develop the Innovation and Improvement Programme to develop a structured approach to the development of service based ‘Champions’ who could support and accelerated co-ordinated approach to innovation.
2.6 What would the Board regard as a success from pursuing a greater emphasis on innovation? (This might include generic measures and relate to processes such as pace of adoption.)
Success could be measured in a number of ways:
• Adoption and diffusion of Nationally developed and tested initiatives with associated improvement outcome measures
• Pace of adoption with acknowledgement where pace has been drive/improved by collegiate working
• Measurement of both transformational and improvement projects with associated outcome measures
• Measurement of key outcomes associated with system capacity, capability, quality and resilience
• Ability to demonstrate from balancing measures no detriment to system for innovative developments
2.7 Are there any existing national or local change programmes that give suggestions about how to achieve success with being more innovative?
Successful acceleration of innovation will be achieved through National collaboration between Boards and from new partnership working with academia and industry. Each Board will require a co-ordinated Programme of work with integral improvement resource to enable organisational development.
While there are examples of success in SPSP and through academic/NHS collaborations we feel this is a unique opportunity to move forward into a more proactive phase of innovative development.
Local Structure
The local Innovation and Improvement Programme would be integral to Unit and Annual Planning and would support the strategic objectives of NHS Forth Valley. The work of the local Programme will be overseen by an NHS FV Programme Board for Innovation and Improvement which reports to the SMT and onwards to the P&R Committee. It is envisaged that each Board will be required to develop a local Health and Innovation plan with associated workplan and outcome measures which will be monitored and will form pat of the future Annual Review process.
Conclusion
The NHS Board is asked to:
1. Note and endorse the proposed approach to Innovation
2. Agree to receive updates from the Innovation and Improvement Programme
Forth Valley NHS Board 10th December 2013 This report relates to Item 11 on the agenda
NHS Scotland Waiting Times Audit Forth Valley Response
(Presented by Fiona Ramsay, Director of Finance)
For Noting
1
SUMMARY 1. TITLE
NHS Scotland Waiting Times Audit Forth Valley Response 2. PURPOSE OF PAPER
The Acting Director General Health and Social Care requested that all NHS Boards confirm that all audit points have been actioned in connection with the management of NHS Waiting Times
3. KEY ISSUES
The Audit Committee received an update of actions at its October meeting including a copy of the NHS Forth Valley submission to the Scottish Government Health and Social Care Directorate at the end of September. This covered recommendations contained in the Audit Scotland Report, the Public Audit Committee and the local Internal Audit Report. There are no issues to highlight.
In accordance with national guidance Internal Audit have completed a follow-up audit to
confirm that actions have been taken as reported. This report is attached for information and will be submitted as part of the response to the Acting Director Generals letter. This confirms that actions have been taken as reported.
The remaining issue for NHS Forth Valley is the migration from two patient
management systems (one for outpatients and one for inpatients) to a single patient management system. This is on track for completion by March 2014.
4. FINANCIAL IMPLICATIONS
There are no specific financial implications arising from this report The business case for the move to single Patient Management System confirms affordability and the preferred option identifies recurrent savings of £ 0.060m
5. WORKFORCE IMPLICATIONS
There are no specific workforce implications arising from this report but the importance of training in systems and processes and ongoing feedback to staff is stressed
6. RISK ASSESSMENT AND IMPLICATIONS
There are no risks to highlight from this specific report 7. RELEVANCE TO STRATEGIC PRIORITIES
Completion of actions supports delivery of 12 week Treatment Time Guarantee and the 18 week Referral to Treat Target
2
3
8. RELEVANCE TO DIVERSITY AND / OR EQUALITY ISSUES There are no specific equality and diversity issues to highlight 9. CONSULTATION PROCESS
Managers responsible for specific areas referred to in relevant reports have been directly involved. These include the lead General Manager for Access, the Head of Health Records and the Head of Patient Access 10. RECOMMENDATION(S) FOR DECISION
The Forth Valley NHS Board is asked to note the confirmation from Internal Audit that actions have been completed and to note the response to the Scottish Government Health and Social Care Directorate.
11. AUTHOR OF PAPER/REPORT:
Name: Designation:
Approved by: Name: Designation: Fiona Ramsay Director of Finance
DRAFT REPORT
NHS FORTH VALLEY INTERNAL AUDIT SERVICE
AUDIT FOLLOW UP - WAITING TIMES
REPORT NO. A09B/14
Issued To: [J Grant, Chief Executive] F Ramsay, Director of Finance
D McPherson, General Manager, Specialist and Ambulatory Care Services A Rankin, Head of Patient Access
[G Bowden, Follow-Up Coordinator and distribution to:]
[Audit Committee] [External Audit] Date Draft Issued: 29 November 2013 Target Audit Committee Date: 17 January 2014
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
INTRODUCTION & SCOPE
1. On 4 October 2013 the Acting Director-General Health & Social Care and Acting Chief Executive NHS Scotland wrote to all NHS Board Chief Executives requesting a formal report on all audit action points in relation to the management of waiting times. This return is expected to be agreed by the Board or a committee of the Board. The scope of this review, as agreed at the NHS Scotland Directors of Finance meeting of 1 August 2013, is that this exercise will not be on the same scale as the original investigation and should be a follow up review of the internal audit recommendations. This report
OBJECTIVES
2. Our audit work was designed to evaluate whether appropriate systems were in place to ensure effective delivery on the key national targets for waiting times and Referral to Treatment (RTT) targets.
RISKS
3. The following risks could prevent the achievement of the above objectives and were identified as within scope for this audit.
Responses provided to the Waiting Times Report A42/13, produced by internal audit, by responsible officers may not accurately reflect the implementation status of each audit recommendation.
AUDIT OPINION AND FINDINGS
4. Due to the limited nature of the review undertaken we have not provided a full audit opinion. This review concentrated on confirming the status of agreed actions on the recommendations contained in internal audit report A42/13 – ‘NHS Forth Valley Waiting Times Arrangements’, which was issued on 30 November 2012. This report supplements the previous updates provided by the Board to SGHSCD and confirms the accuracy of the progress report submitted by the Director of Finance to the 22 March 2013 meeting of the Audit Committee. From the follow up work conducted, we can conclude that NHS Forth Valley has taken appropriate action in response to all internal audit recommendations and that action is progressing in implementing the new national controls framework and audit methodology. Our detailed findings are set out below:
5. All of the nine original recommendations have been completed. In examining the progress made to implement the agreed recommendations from the internal audit report A42/13, we did identify some minor issues which are outlined in the narrative below.
6. Action point 1 in report A42/13 recommended that the Board should review and record the process through which the Performance & Resources Committee (P&RC) receives assurance and undertakes detailed scrutiny on Waiting Times and highlights strategic aspects, such as impact on finance, staffing and
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
performance management to the Board. This included considering the level of detail required at each level and any escalation procedures prompted by KPIs covering unavailability and breaches. This action has been completed with the enhancement of the ‘Core Performance’ reports, which are presented to each meeting of the P&RC.
7. The enhanced ‘Core Performance’ reports now specifically identify and evaluate unavailability and breaches in more detail, including financial and staffing impacts. The performance management framework, which was presented to the P&RC in April 2013, also defines waiting times as a key priority and outlines the reporting and accountability lines for general performance management throughout the Board. Aspects of this framework, particularly in relation to unit reviews and balanced scorecards, continue to be developed.
8. Action point 2 in report A42/13 highlighted the need for absolute clarity from the Scottish Government, in relation to inclusion of vascular surgery figures within general surgery figures in the Monthly Monitoring Information (MMI) return, in advance of distribution of the procedure note to all relevant staff. This action has now been completed and we can confirm that vascular surgery is now included in general surgery figures within the MMI returns submitted.
9. Action point 3 in report A42/13 identified the need for the outcomes of ongoing national discussions with Scottish Government, on the application of waiting times guidance, to be incorporated into a revised Patient Access Policy which should be approved by the Board. The NHS Forth Valley Access Policy has been revised and version 2.5 was noted and approved at the NHS Forth Valley Board meeting on 19 February 2013. The introduction to the policy held under General Policies on the NHS Forth Valley intranet states that version 2.5 of the policy “….was approved by the Board in an open session and is available on the intranet”.
10. Action point 4 in report A42/13 recommended a movement to a risk based approach in regard to supervisory checks covering inpatients and also outpatients, as well as consideration of how the outputs from this process could be used to provide assurance. A revised process for sampling unavailability and checking for reasonableness has been implemented which covers inpatient and outpatients. Problems identified through this process are then followed up and rectified. Capacity issues are discussed and actions decided at weekly Acute Waiting Times meetings chaired by the General Manager for Specialist Ambulatory Care Services (SACS). In addition, the General Manager for Emergency and Inpatient-based Services (EIS) also chairs Unit Board meetings, which cover any waiting times and capacity issues arising within EIS.
11. Action point 5 in report A42/13 recommended that the outpatient system, TOPAS, be reviewed to avoid staff using workarounds to create periods of unavailability (POU) for patients who had breached in order to fast track the patient through to appointment. The implementation of system modifications to the outpatient system in July 2013, have addressed the original action point. The system changes now require staff to select types of unavailability from a preset drop down list creating more control around the criteria required for entering unavailability for outpatient appointments. In addition, a letter is now issued to patients outlining any adjustments to their waiting times which involve the use of
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
POU. Enhancements could be made around future systems modifications by ensuring that UAT testing is collated, evaluated and retained to demonstrate that adjustments made to the systems are fit for purpose and operating in line with expectations.
12. Action point 6 in report A42/13 highlighted the need to consider a feasibility review for pursuing a single patient administration system (PAS), which would replace the two separate systems, TOPAS and HELIX, for the outpatient and inpatient elements of the patient journey. This single PAS would allow consideration of the 18 week RTT target when booking patients and would address the issues arising from the internal audit review of the TOPAS and HELIX systems, which were passed to management during the internal audit review A42/13. This action has been completed with the single PAS concept being considered in early 2013. The project implementation phase is currently progressing to migrate inpatient data from HELIX to the TOPAS system, which will be used for outpatient and inpatient administration in future.
13. Action point 7 in report A42/13 recommended that the procedure for identifying, investigating and correcting errors relating to the submission of NHS Forth Valley data to the ISD National New Ways data warehouse should be documented. There are now Standard Operating Procedures (SOPS) developed to deal with all submissions relating to waiting times. This includes specific SOPS for error reporting, which document the process which should be followed for error investigation.
14. Action point 8 in report A42/13 identified that the feasibility of including check totals within TOPAS and HELIX to confirm that all referrals are accounted for within the system should be discussed with the system suppliers. This action is now complete and a dashboard approach showing totals is being explored as an integral part of the move to a single PAS.
15. Action point 9 in report A42/13 recommended that an authorisation process should be established for permitting and revoking direct access to the database tables for TOPAS and HELIX, with regular review of permission levels and removal of permissions for those staff no longer requiring this access. Report A42/13 also highlighted the need for a log to be maintained detailing the reason for each access to the database tables for TOPAS and HELIX and recommended that a proportionate approach to streamline access roles and defined user groups on each system should be undertaken to allow better control over access permissions. This action is now complete as the Board has an Access Policy that details the authorisation process for users accessing the system and a separate Information Security Policy, on Access to Systems, that covers reporting access.
16. Access to the data warehouse is administered by the Information Management Team (IMT) and approved by the Information Systems Manager. Only members of the IMT are provided with access to the data warehouse. Access to the warehouse is monitored on an “as needs basis” by the system administrators, who are also supervisors and briefed on staff movements and access requirements. There is no logging of reasons for access, as this is considered as part of the approval process. Approval of access rights to IMT staff to run reports from the HELIX and TOPAS systems are dealt with under the Information
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
Security Policy, on Access to Systems, and also approved by the Information Systems Manager.
17. Our follow up work identified the need for improvements in the way that HELIX and TOPAZ system administrators are currently informed when users leave the organisation. Information Governance staff have already recognised this issue and a leavers checklist has been developed to act as a prompt for managers to inform system administrators when staff with TOPAZ or HELIX access leave the organisation. This leavers checklist is currently awaiting approval and will be disseminated to all relevant managers with a reminder of their responsibilities to ensure that all relevant staff leavers and staff role changes should be communicated timeously to the relevant system administrator to ensure that access to patient identifiable information is adequately protected.
ACTION
18. All of the original recommendations from internal audit report A42/13 have been completed and therefore no action plan is required.
ACKNOWLEDGEMENT
19. We would like to thank all members of staff for the help and co-operation received during the course of the audit.
David Archibald BAcc CPFA Regional Audit Manager
NHS Forth Valley Internal Audit Service
Audit Follow up - Waiting Times Report No A09b/14
Please do not print unless absolutely necessary Help your organisation reduce its carbon footprint
DEFINITION OF ASSURANCE CATEGORIES AND RECOMMENDATION PRIORITIES
Categories of Assurance:
A Good There is an adequate and effective system of risk management, control and governance to address risks to the achievement of objectives.
B Broadly Satisfactory There is an adequate and effective system of risk management, control and governance to address risks to the achievement of objectives, although minor weaknesses are present.
C Adequate Business objectives are likely to be achieved. However, improvements are required to enhance the adequacy/ effectiveness of risk management, control and governance.
D Inadequate There is increased risk that objectives may not be achieved. Improvements are required to enhance the adequacy and/or effectiveness of risk management, control and governance.
E Unsatisfactory There is considerable risk that the system will fail to meet its objectives. Significant improvements are required to improve the adequacy and effectiveness of risk management, control and governance and to place reliance on the system for corporate governance assurance.
F Unacceptable The system has failed or there is a real and substantial risk that the system will fail to meet its objectives. Immediate action is required to improve the adequacy and effectiveness or risk management, control and governance.
The priorities relating to Internal Audit recommendations are defined as follows: Priority 1 recommendations relate to critical issues, which will feature in our evaluation of the Statement on Internal Control. These are significant matters relating to factors critical to the success of the organisation. The weakness may also give rise to material loss or error or seriously impact on the reputation of the organisation and require urgent attention by a Director. Priority 2 recommendations relate to important issues that require the attention of senior management and may also give rise to material financial loss or error. Priority 1 and 2 recommendations are highlighted to the Audit Committee and included in the main body of the report within the Audit Opinion and Findings Priority 3 recommendations are usually matters that can be corrected through line management action or improvements to the efficiency and effectiveness of controls. Priority 4 recommendations these are recommendations that improve the efficiency and effectiveness of controls operated mainly at supervisory level. The weaknesses highlighted do not affect the ability of the controls to meet their objectives in any significant way.
Chairman Alex Linkston CBE Chief Executive Jane Grant
Forth Valley NHS Board is the common name for Forth Valley Health Board Registered Office: Carseview House, Castle Business Park, Stirling, FK9 4SW
www.nhsforthvalley.com
NHS Forth Valley
Carseview House Castle Business Park Stirling FK9 4SW Telephone: Fax:
Date 3rd December 2013 Your Ref Our Ref Enquiries to Mrs F Ramsay Extension
Mr P Gray Director-General Health and Social Care and Chief Executive NHS Scotland St Andrew’s House Regent Road Edinburgh EH1 3DG
Direct Line 01786 457245
Dear Paul Management of NHS Waiting Times I write with reference to Mr Connaghan’s letter of 4th October 2013 requesting confirmation that all recommendations have been successfully implemented in respect of the management of NHS Waiting Times NHS Forth Valley Audit Committee considered and reviewed at its October meeting the detailed response submitted by NHS Forth Valley at the end of September. This covered the recommendations contained in the Audit Scotland report and the Public Audit Committee together with a summary of progress in respect of Internal Audit recommendations. The final requirement was for Internal Audit to review actions taken in respect of their report of December 2012. Internal Audit have concluded their review and have confirmed that actions have been completed in accordance with the report. I have attached a copy of their report for information. As highlighted in this report NHS Forth Valley is moving to a single Patient Management System which will support improvement and eliminate issues arising from separate systems being used for outpatients and inpatients. This system change is on track for completion in March 2014. I note the positive work of the Board Waiting Times Executive Leads to develop a controls framework and can confirm the controls assurance matrix and audit methodology is now part of the Board’s internal control framework and that monitoring of this will be taken forward through the Board’s governance arrangements. In conclusion I can confirm that all recommendations have been actioned and that this response together with the Internal Audit Report has been reviewed at the Board Meeting of 10th December 2013. Yours sincerely Jane Grant Chief Executive
