Derek Leslie / Date: / 30th March 07
Director of Planning and Performance / Your Ref:
and Designated Director for PFPI / Our Ref: / FV/LM
NHS Highland
Assynt House / Enquiries to: / Highland office
BeechwoodPark / Direct Line: / 01463 723 930
Inverness, IV2 3HG / Email: /

Dear Derek

Agreed Actions on Patient Focus and Public Involvement for 2007/8

Following our recent discussions I can now confirm the agreed Patient Focus and Public Involvement actions for NHS Highland for 2007/8 which are included in the table at the end of this letter. This letter has been copied to the Scottish Executive Health Department for information.

In addition to the actions agreed locally, the Scottish Health Council recommends the following generic actions for all boards across all measures and targets:

  • All policies and procedures should be Equality Impact Assessed
  • All boards should remove abbreviations and acronyms from future self assessments and updates given to the Scottish Health Council in order to make these documents accessible to the general public
  • All targets and measures should be implemented using the National Standards for Community Engagement.

These agreed actions will now be included in the Scottish Health Council’s annual assessment report to the Minister for Health and Community Care. This report will also include a short summary taken from your self assessment of progress made so far on Patient Focus and Public Involvement around each measure and target, and a brief commentary from the Scottish Health Council. We will also include in the report progress made on the development issues recommended in the 2005/6 annual assessment report. Depending on progress on these, further actions may be advised.

We are currently developing our year round assessment and development process (or ‘portfolio assessment’) and will contact you shortly with more details on this. The first activity in the new financial year will be to carry out a qualitative evaluation of Public Partnership Forums, the findings of which will also be included in the report to the Minister.

Please do not hesitate to contact me if you have any queries about any of the above.

Yours sincerely

Fabio Villani

Regional Officer – North

Agreed Patient Focus and Public Involvement Actions for NHS Highland

Name of target/ measure / Agreed Actions for 2007/8
PFPI.01T -
Patient Experience / Actions from NHS Highland:
  • All 24 hospitals in NHS Highland Board area will have one patient experience feedback survey completed for inpatients in 2007. The same survey will be used in each hospital. In the four acute hospitals, volunteers will be used to hand out the forms (either Patients’ Council members or Highland HealthVOICES Network members.) In all the other hospitals forms will be handed out by staff.
  • Outpatient clinics will also have one patient experience feedback survey completed in 2007.
  • All four Community Health Partnerships will have at least one community-based patient feedback survey completed in 2007.
  • NHS Highland is looking at any areas where it could use a patient’s diary as an alternative means of getting feedback from patients.
  • The Stroke Managed Clinical Network will be working on an information leaflet on Case Conferences, and has already asked the families who have been involved in interview to comment on this when development starts.
  • The Coronary Heart Disease Managed Clinical Network has done ‘Hearty Voices’ training. Those patients are forming a Patient Focus subgroup which will work on issues and take them to steering group.
  • Regular joint meetings are held with Scottish Health Council where feedback on surveys is shared. Information will continue to be fed back to the Scottish Health Council on patients’ surveys undertaken in 2006 and in 2007.
  • A National Patient Experience Programme is also planned for 2007/08 by the Scottish Executive covering both acute and community healthcare areas.
  • As part of the programme of patient feedback mentioned above it is intended to get the Patients’ Council members and Highland HealthVOICES Network members to assist with the survey of the acute hospitals.
Additional actions from Scottish Health Council:
  • Equality Impact Assessment will be conducted across a range of services and functions.
  • Provide evidence of linking with the National Patient Experience Programme.
  • Ensure that staff are aware of the National Programme and how it links with their own practice.
  • Identify from its own previous surveys three examples of demonstrable improvements to patient experience.

PFPI.01T -
Public Partnership Forums / Actions from NHS Highland:
  • Continue progress with planned evaluation of Highland HealthVOICES Network, develop an action plan and implement changes depending on the findings of the surveys.
  • Carry out a further distribution of registration forms to key public contacts, supported with press releases to publicise Highland HealthVOICES Network.
  • Promote the use and application of Highland HealthVOICES Network to NHS staff, at briefings and meetings.
  • Review of Working Agreement, to include new section covering Argyll and Bute. At this point it will again be subject to an Equality Impact Assessment.
  • Implement the updated Expenses Policy.
  • Carry out by-election to fill vacant places on Community Health Partnership/Specialist Services Unit committees.
  • Promote the options for involvement/recruitment to Public Partnership Forum/Highland HealthVOICES Network throughout the Argyll and Bute area, using targeted mailouts and press releases.
  • Given the rapid growth of Highland HealthVOICES Network over the past year, NHS Highland aims to consolidate its strengths and assess future direction after the evaluation results are analysed.
  • Further developments in Argyll and Bute will follow the Public Involvement workshop on 16thFebruary 2007.
Additional actions from Scottish Health Council:
  • Agree with Scottish Health Council how the percentage of population figure is calculated
  • Ensure Public Partnership Forum members are on the Community Health Partnership
  • Demonstrate that the Public Partnership Forum has the opportunity to actively raise issues with the Community Health Partnership
  • Identify ways to demonstrate the difference Public Partnership Forums have made to date

PFPI.01T -
Ethnic Monitoring / Actions from NHS Highland:
  • The new Patient Question forms will be in use by 1st May 2007. The Board expects to see a gradual increase in the completion of the ethnic and other fields, and anticipate achieving 30% by December 2007 in both outpatients and inpatients.
  • Use the ethnic data recorded in the Patient Administration System to describe the ethnic mix of people who are using NHS services.
  • Provide the Scottish Health Council with information on percentage of ethnic field completed as at December 2007, for each hospital, and how the process of collection has progressed.
  • Identify staff training required to promote effective completion of the equality monitoring fields.

PFPI.01T -
Complaints / Actions from NHS Highland:
  • Impact Assessment will be completed on the Complaints Policy during 2007/8.
  • Consider additional ways of reporting on complaints to patients and the public.
  • Implement the “Quick Guide to Complaints Management Procedures”, which is designed to support NHS Highland staff awareness and compliance with the complaints procedures.
  • Awareness-raising sessions will take place in each locality in each Community Health Partnership (CHP), and in the Specialist Services Unit (SSU). The workshops will include information on complaints including the “Quick Guide”, complaints leaflet and complaints form. The first of these events took place on 19th January 2007.
  • Further educational and training materials are also being produced over the next few months. It is intended to have written educational materials and also to have these available on the NHS Highland Intranet. Some examples would be Complaints Investigation, Dealing with a complainant on the phone, etc. Training materials, including case studies, will also be produced. We intend to have these materials available in the first part of 2007.
  • A programme of providing education and training to specific groups of staff is also being developed.
Additional actions from Scottish Health Council:
  • Progress work to harmonise recording and reporting on complaints across NHS Highland following the assimilation of Argyll & Bute.
  • A phased implementation of the Independent Advice and Support Service will commence Spring 2007
  • A further three year Advocacy plan for NHS Highland, 2007-2010, is out for discussion prior to being sent to the Scottish Executive by the end of February.
  • Ensure that:
  • the Independent Advice and Support Service is available at the earliest possible date
  • there is equity of access to the Independent Advice and Support Service
  • information on the Independent Advice and Support Service is publicised and widely available in appropriate formats
  • there is a realistic and achievable target for improvement on the percentage of complaints ‘dealt with’ within 20 days
  • the data provided on the 20 day target is based on investigation of ‘complaints completed within 20 working days of receipt of the complaint’ as stated in the NHS Complaints Procedure not on the issue of a ‘holding letter’
  • organisational barriers to responding to complainants within 20 days are being identified and addressed
  • feedback is being used to improve services and this shared with patients, carers and the public
  • an advocacy service is available to patients if required

H.02T -
Smoking reduction / Actions from NHS Highland:
  • The NHS Highland Smoking Policy is currently undergoing an Equality Impact Assessment which may highlight action in terms of implementation. The Board will continue to have input from Highland HealthVOICES Network for any further policy development on smoking issues.
  • There will be direct user involvement in the review of these services during 2007/8 including patient/public membership on the Review Group.
Additional action from Scottish Health Council:
  • Involve patients and public in review of anti-smoking policies and in the development of the Board's Tobacco Strategy

E.04T -
CHI / Actions from NHS Highland:
  • Maintain the promotion of the use of CHI in all internal operating systems.
  • Respond to any patient feedback in respect of CHI.
Additional actionsfrom Scottish Health Council:
  • Inform Public Partnership Forum members, for example, through Network News, about use of the CHI number and invite any feedback or comment

A.01T -
48 Hour Primary Care Access / Actions from NHS Highland:
  • Continue to evaluate compliance with the measure across NHS Highland.
  • Continue to provide guidance and performance support to those practices not compliant with the measure.
  • Continue the Quality Outcomes Framework review process and ongoing review support to lay reviewers

A.08T -
Cancer waiting times / Actions from NHS Highland:
  • Intend trialling National Standards for Community Involvement in project work.
  • Plan to publicise and communicate Waiting Times Action Plan.
  • Promote use of North of Scotland Cancer Network Patient Carer Public Involvement Pack to patients and staff.
Additional action from Scottish Health Council:
  • Use existing patient groups to assess the impact on the patient experience of work carried out to achieve this target

T.01T -
Delayed Discharge / Actions from NHS Highland:
  • Maintain focus on care planning in partnership with patients and carers to deliver the best possible outcomes within the parameters set.
Additional actions from Scottish Health Council:
  • Continue with early work which is in progress to develop a joint Strategy for Older People which will include themes of inclusion, independence, and care. Development process will be underpinned by communications and engagement plans.
  • Ensure that an advocacy service is available to patients and families if required.

T.07T -
Healthcare Acquired Infection / Actions from NHS Highland:
  • NHS Highland is developing a local Plan following the national HAI (Healthcare Acquired Infection) Task Force Delivery Plan which includes:
-the development and launch of the public awareness hand hygiene campaign
-exploration of patient/public feedback mechanisms on HAI
-a commitment to public involvement in monitoring compliance with the NHSScotland National Cleaning Services Specification
-increasing public involvement in HAI-related publicity and awareness raising (eg hand hygiene and Infection Control Nurses Association infection control week).
  • NHS Highland Hand Hygiene Co-ordinators will draw up a plan on how best to carry out the local campaign, which will run until March 2008. The campaign will include awareness-raising sessions on hand washing, along with the distribution of leaflets demonstrating correct washing techniques and information packs for nurseries and primary schools.

1