APPROVED

NHS GRAMPIAN

Minute of Meeting of GRAMPIAN NHS BOARD held in Open Session

on Friday 6 June 2014 at 10.00am

in CLAN House, Westburn Road, Aberdeen

Present

/ Cllr Bill Howatson / Chairman
/ Mr David Anderson / Non-Executive Board Member
/ Mr Raymond Bisset / Non-Executive Board Member
Mr Richard Carey / Chief Executive
Cllr Barney Crockett / Non-Executive Board Member
Dr Roelf Dijkhuizen / Medical Director
Mrs Sharon Duncan / Non-Executive Board Member
Mr Alan Gray / Director of Finance
Professor Mike Greaves / Non-Executive Board Member
Mrs Linda Juroszek / Non-Executive Board Member
Mr Terry Mackie / Non-Executive Board Member
Mr Charles Muir / Non-Executive Board Member
Mr Jonathan Passmore / Non-Executive Board Member
Sir Lewis Ritchie / Director of Public Health
Cllr Anne Robertson / Non-Executive Board Member
Mrs Elinor Smith / Director of Nursing and Quality
By / Dr Angus Cooper / Consultant in Emergency Medicine (item 4 only)
Invitation / Dr Peter Gent / Divisional General Manager (item 4 only)
Mrs Laura Gray / Director of Corporate Communications/Board Secretary
Dr Jamie Hogg / Associate Medical Director (item 6.1 only)
Dr Annie Ingram / Director of Workforce
Mr Andrew Jackson / Legal Advisor (item 7.1 only)
Mr Jan Jansen / Consultant in General Surgery and Intensive Care (item 6.1 only)
Dr Izhar Khan / Chair, Area Medical Committee
Ms Kate Livock / Project Manager, Unscheduled Care (item 6.1 only)
Dr Mark Mitchelson / Consultant in Emergency Medicine (item 4 only)
Mr Graeme Smith / Director of Modernisation
Dr Pauline Strachan / Deputy Chief Executive
Attending / Miss Lesley Hall / Assistant Board Secretary
Mrs Rachael Sim / PA, Corporate Services
Item / Subject /
1 / Apologies
Apologies were received from Cllr Stewart Cree, Mrs Christine Lester, Dr Lynda Lynch, and Mr Mike Scott.
The Chairman welcomed Dr Khan, Chair of the Area Medical Committee, to the meeting, advising that in terms of the Committee’s Constitution, the chairman was invited to all meetings of the Board.
2 / Verbal Updates
·  Chairman
The Chairman reported that he had attended a good meeting with Grampian MPs and MSPs on 12 May. Items discussed had included NHS Grampian’s 2020 stroke vision, the development of the clinical services plan, and recruitment and retention issues. On 21 May he had attended a very successful Grampian Area Partnership Forum away day, the focus of which was health and social care integration.
On 22 May he had hosted a thank you event for volunteers from Woodend Hospital, the City Hospital and Roxburghe House. He reported that it was always a humbling experience to see the commitment and dedication shown by these volunteers and their contribution should not be underestimated.
On 27 May he had attended the annual Quality Day event which had been excellent and inspirational.
Finally, on 28 May he had attended the Royal College of GPs Primary Care Conference at which Paul Gray, Director General and Chief Executive of NHS Scotland, had spoken passionately about the role of primary care in a person-centred NHS.
·  Chief Executive
Mr Carey report that had attended the local Modernisation in Primary Care event on 28 and 29 April. This clinicians involved from across Grampian had shown tremendous energy and enthusiasm during the event, which had focused on solutions.
He advised that he had also visited a number of community hospitals, including Turner Hospital in Keith, Insch and Inverurie Hospitals. In the coming weeks he planned to visit Aboyne and Banchory. Although much of the Board time was focused on acute care, Mr Carey emphasised the contribution of community hospitals, both in terms of enabling patients to be rehabilitated closer to home following a stay in ARI, Woodend or Dr Gray’s, but also to avoid admission to an acute setting.
On 9 May he had been invited to attend the annual meeting of the Scottish Association of Medical Directors in Dunkeld.
Earlier this week he had attended the annual NHS Scotland Conference ‘Spreading and Sustaining Quality’. He was pleased to report that NHS Grampian had displayed 14 posters across the full range of poster themes.
Finally, he echoed the Chairman’s comments about the Quality Day. This had been a very well organised event that had become part of NHS Grampian’s annual calendar.
3 / Minute of Meeting held on 4 April 2014
The minute was agreed as an accurate record.
4 / Matters Arising
·  Emergency Department
Mr Carey reported that Medical Staffing within Emergency Departments (EDs), at consultant and training grade level, had become an increasing problem in Scotland. In response to the concerns raised by NHS Grampian’s Emergency Department consultants, he has asked the Director of Workforce to meet this staff group to help identify and address both short term and longer term issues. The key issues were highlighted in the Board Briefing paper that had been circulated.
Dr Cooper, Dr Mitchelson and Mr Gent were welcomed to the meeting for this item.
Dr Ingram reiterated that this was not just a Grampian issue but was of concern throughout the UK. She advised that since April she has been working with the consultants and members of the Divisional Operational Management Team and meeting them on a weekly basis. She explained the key challenges of workforce, workload and workflow. When the Emergency Care Centre (ECC) was developed it was underpinned by a different model of care and a number of policies were produced to support this. However, not all of these had been fully implemented, including the principles for management of patients within and from the ED. The number of people attending A&E has grown significantly and the nature of presenting patients had changed, with the medically unwell being the largest proportion.
Recruitment was of particular concern; there were currently 3 whole time equivalent (wte) vacancies within the consultant cohort of 10.4 wte staff. These were out to advert. Of particular concern were the middle grade vacancies in the department. In August 2013, there were 10 doctors at senior level who could fill this role. From August 2014 it was projected that there will only be 2 such doctors, creating a significant gap in cover.
However, over the last few weeks the group have been working to identifying international medical graduates who could potentially fill these roles. As of 30 May 2014, two doctors had been offered posts. There was ongoing dialogue with agencies to fill Training Grade posts.
Dr Cooper confirmed that the paper highlighted the ED consultants’ main concerns. He explained that the principal concern was that if appropriate solutions were not implemented by August, they would not be able to continue to provide safe care for patients. He advised that the primary role of the Emergency Department was the immediate resuscitation of, and the coordination of hospital response to, patients with life or limb threatening conditions. The secondary role was the assessment and management of acute injuries. Changes in healthcare over the past decade had meant that the ED was increasingly caring for patients outwith this primary role. Although this has been managed by the levels of medical staff within the department so far, this would not be possible from August with the anticipated staffing levels.
An important function of the ED was the ability to admit patients timeously and failure to do so can result in poor outcomes and poor experience. Dr Ingram’s paper referred to a multi-speciality improvement workshop held two days previously. Following this, an improvement programme was to be developed, aimed at improving ‘patient flow’, particularly in the ECC. The 8 weeks’ timescale for this programme was short and would be challenging for the teams and specialities involved.
Dr Mitchelson spoke about the requirement for 24 hours a day, 7 days a week presence of experienced emergency medicine (EM) clinicians – consultants, senior trainees or career grade doctors - who can provide the leadership, knowledge and skills to allow the ED to fulfil its primary role. He reiterated that retention and recruitment to Emergency Medicine had become increasingly problematic because of the changing roles already described and the related pressures. As stated in the paper, there will be gaps in the 24/7 presence of an EM specialist from August. Although recruitment efforts may contribute to the longer term staffing solutions, these may not be enough by August. Additional measures will need to include the use of locums, who are equally challenging to recruit. The timescale was very tight, but every effort must continue to ensure there would be a safe level of staffing from August.
Dr Dijkhuizen explained that the ED’s current function was very different from the past. Many people saw the ED as a safety net for the community and people who presented to the ED often did so inappropriately. In relation to recruitment, this has made the speciality less attractive to trainees. He stressed the importance of ensuring that every effort was made to seek and recruit suitable staff. He added that the system as a whole needed to support the ED, to make sure that early assessment directed patients appropriately and all specialties had to contribute to the process. The Clinical Pathways Criteria should help achieve this. Organisational determination was required to ensure the guidance was implemented.
Mr Passmore suggested that if recruitment was a national problem then help should be sought from the Government to address this.
Cllr Crocket agreed that a national solution was needed to help with recruitment pressures. He asked if the number of people presenting to the ED related to a lack of GPs. Dr Mitchelson responded that Grampian had a mobile and cosmopolitan workforce with a number of people not registered with a GP. Therefore, some chose to attend A&E when needing help. Dr Cooper added that a large number of people were directed to the ED by a variety of bodies when they could be signposted more appropriately. Dr Mitchelson highlighted that significant work was being done to facilitate redirection with some success, but further education of the public and staff was required. Mrs Juroszek offered the advisory structure’s help to raise awareness and help embed redirection.
Dr Khan noted that the issues had been clearly identified to the Board but asked whether or not acute physician resources had been best utilised or if the systems implemented for flow needed further exploration. Dr Dijkhuizen explained that this would form part of the ongoing discussions about flow.
Professor Greaves pointed out the important role of NHS Education Scotland in helping to achieve a suitable distribution of posts for the North East of Scotland.
Mrs Smith advised of options for other staff groups to assist and pointed out the important roles that nurses, Physician Assistants, Allied Health Professions and Nurse Practitioners provided. Dr Mitchelson agreed that these roles provided positive support but further input and up-skilling was needed to address workforce issues to address the potential gap in the 24/7 provision of service.
Mr Carey advised that complete reassurance could not be given at this time. Work will continue daily with a major focus on recruitment and attracting trainees to the North East. The existing models of care would be kept running until further systems for Unscheduled Care were developed. This would ensure the service was sustained and safe. It was agreed that an update paper be brought to the July Seminar then to the August Board meeting to provide assurance about the progress being made to address the workforce issues to ensure a safe and sustainable service from 1 August 2014.
The Chairman thanked Dr Cooper, Dr Mitchelson and Mr Gent for their contribution to the discussion of this very important issue.
The Board noted progress
5 / Involving our Patients, Public, Staff and Partners
·  Patient Story
Mrs Smith read out a patient story which focused on a relative’s experience when a family member had been admitted to hospital. The main issues highlighted the importance of appropriate help with orientation and relevant information, and the affect the different culture and attitude of staff had. Mrs Smith advised that the issues had been followed up and shared at staff meetings in the areas involved.
In response to a query from Cllr Robertson, Mrs Smith advised that this story related to recent events in the last three months and agreed to seek clarity on what action had been taken as a result of this feedback. She advised that feedback would always be given to patients in response to concerns raised.
Mrs Duncan commented that it was important not to take information out of context and that it might be helpful to have feedback from the ward managers to give a more balanced view and to provide information on action taken. For future patient stories Board Members requested information about outcomes and learning for specific areas or the broader organisation.
The Board noted the report.
6 / Developing High Quality Care in the Right Place
6.1 / The Development of Unscheduled Care in Grampian
Mr Smith advised that the paper submitted the NHS Grampian Local Unscheduled Care Action Plan (LUCAP) for 2014/15. The LUCAP built on the approach to unscheduled care approved by the Board in June 2013 and required approval before submission to the Scottish Government. It also provided an overview of major trauma following the Government’s announcement in April 2014 that Aberdeen Royal Infirmary (ARI) would be one of four Major Trauma Centres (MTCs) in Scotland.
Local Unscheduled Care Action Plan (LUCAP)