Mid Highland Community Health Partnership
General Manager’s Overview -February 2010
Introduction
This report will provide the Committee with an overview of key and emerging issues and will highlight aspects of the work of the CHP contained in other reports.
The financial position and service improvement planning continues to be the main focus of management attention. The financial position is giving cause for concern as there is still an overspend and the efficiency schemes have not delivered on a recurrent basis. Although a considerable amount of work has been done, the time taken to bring about redesign and the delays due to angst and opposition to change, mean that we have relied on non-recurrent savings. This adds to our problem next year when we will have an additional cash releasing savings target. The Management Team is considering schemes that could release funding but these will inevitably lead to changes in the way we deliver some services.
Overview
Winter Pressures
During the severe and prolonged winter weather, most services were maintained and Staff and Practices are to be commended for their enormous efforts, sometimes above and beyond the call of duty, to ensure that patient care was delivered and services supported. This was an immense achievement.
H1N1 Pandemic Influenza Preparedness
The incidence of ‘flu has greatly reduced and, in keeping with NHS Highland Pandemic ‘Flu Committee, the Mid Highland CHP Incident Management Team has been stood down for the time being. A review meeting will be held in March. The learning and opportunity to develop and hone contingency plans has been extremely useful.
Financial Position
As can be seen in the Finance Report, the CHP is continuing to forecast an overspend at the end of the financial year due to the additional tranche of cash releasing savings targets allocated in September. NHS Highland has made it clear that break-even is expected and the Management Team continues to attempt to find ways of making the savings required. This is leading to concern amongst teams and some of this angst has been reflected in media coverage.
Skye and Lochalsh Engagement Exercise
The workshop will be held on 12th February in the Dunollie Hotel, Broadford. Pennie Taylor, Journalist and Broadcaster, will facilitate the event and delegates will hear feedback from the engagement exercise as well as information from the national and Highland perspectives. The event will focus on identifying priorities for action that will deliver the outcomes described in the national policies.
Invites have gone out to all Community Councils, Local Members, MSPs, MPs, Partners in the statutory and voluntary sectors, local Clinicians and Managers.
The event will be filmed to allow for the production of a DVD for use by the Community Councils.
The cost of this event in the current financial climate has been understandably questioned by some but it is important that the delegate list includes a wide representation and no Health or Local Authority venue is large enough. The possibility of asking delegates to bring their own lunch was considered but thought not to be conducive to a successful event. Given the public interest and previous criticism, independent facilitation is considered to be essential.
Targets
Waiting Times
The waiting times targets within the responsibility of the CHP were met.
Belford continues to achieve all inpatient and outpatient waiting times. The increase in waiting time is a direct result of undertaking additional elective work from Raigmore. This work continues, as does the endoscopy work. There are meetings arranged to discuss the implementation of a new Highland-wide Endoscopy Service.
Delayed Discharge
The position remains challenging withawaiting assessment, care packages, care home funding and placements the main reasons for delay.
Due to the current financial and staffing position within Highland Council, I am still unable to provide Committee with any assurance that we will be able to improve the position or meet the target of 0 patients delayed over six weeks in the near future. A report and additional supporting information on bed days lost is contained in the pack.
Augmented Care At Home (East Ross) - The team continues to have difficulties accessing Care at Home Services leaving the support workers at full capacity most of the time. During December two patients required evening input which could not be supplied by Care at Home and existing staff worked extra hours to cover this. This has now been resolved. The lack of Care at Home results in the inability to take patients who require input from the support workers leading to the risk of avoidable admissions and delays in discharge. Following a review of activity since the reduction in beds in Ward 2c, the evening service will be provided on an as needs basis.
Smoking Cessation
There is a steady improvement but we are still a long way from trajectory. A paper detailing plans to improve the situation is contained in the pack.
Alcohol Brief Intervention
Again, considerable effort is required to ensure that the new trajectory is met. Although most Practices have signed up for the Enhanced Service, many have not recorded any activity. This is being addressed with individual Practices. A paper is contained in the pack.
Day Case Rates
Recording of day case activity is the main reason for not making this target as we are aware of considerably more activity than is being credited. This has been acknowledged and is being addressed; more information is contained in the paper in the pack.
Work surrounding the demand and capacity for day case surgery specific to the provision being based on a unit with one theatre is currently being undertaken.
Changing for the Better – Health 2012
As previously reported, the NHS Highland Board approved the following as broad areas for service improvement and best value review:-
•Redesign of Corporate Services
•Maximise use of technology
•Prescribing
•Maximise use of current bed stock
•Clinical variation
•Access payments
•Out of Hours
•Review of non-essential services
•Tertiary referrals and income generation
•Nursing and AHP contribution to long term conditions
•Workforce efficiency and effectiveness
Mid Highland CHP is making a contribution in most of these areas and Committee receives reports on progress.
The current activity includes:-
Realignment of Skye, Lochalsh, Ross, Cromarty and West Ness Localities
The next phase of the leadership and management review is ongoing. The Management Team considered a proposal for the structure at its meeting in early February but decision was deferred until March to allow the discussion at the Workshop to be taken into account.
Prescribing
As well as the ongoing work supported by the Prescribing Support Pharmacists, the CHP, together with South East Highland CHP, is supporting a Quality Prescribing initiative that will be taken forward by the Limited Liability Partnerships of GP Practices that have formed in Inverness, Badenoch and Strathspey and Ross and Cromarty. This is aimed at improving both quality and cost effectiveness.
Maximise use of current bed stock
Work is continuing in all of our hospitals to review the bed numbers and to ensure that beds are used to best effect. Length of stay continues to receive attention in order to ensure that beds are used appropriately and effectively.
Belford Redesign
The Combined Assessment Unit continues to work well and activity is in the process of being audited. Over the festive period the CAU offered a flexible service which enabled the hospital to cope with extreme weather, outbreak of infection issues and emergencies.
The redesign of the CAU has enabled the final stages of the Belford Hospital@Night Service to be implemented. There will be a full handover from the NNP and Junior Doctors at the beginning and end of each shift to the multidisciplinary team.
The new Cardiac Exercise Room is almost complete and the surgicalsecretaries’ new office is also almost ready.
Work continues to progress review of OOH GP provision including potential implementation of GP Service Level Agreement and more integrated working between OOH and A&E.
Step Down, Reablement and Intermediate Care
Discussions have been undertaken with Social Services regarding the plans to pilot a step-down service for Palliative Care patients from Belford. Meetings will be held on a monthly basis to make local changes to practice and integrate services.
Intermediate Care Nurses have been invaluable in supporting early discharge from CAU and in providing interventions in the community which have helped avoid GP referrals to CAU. This role is subject to ongoing review to ensure the most effective use of a scarce resource.
The Intermediate Care beds in Abbeyfield are now open and are being utilised.
Reablement
Catherine Kelly, Mid CHP Management Student, is undertaking the first part of her placement with Lochaber and is currently spending time meeting community staff prior to reviewing the Reablement action plan. Ms Kelly will then lead implementation of the plan.
An AHP engagement meeting took place in December 2009 and it was agreed at the meeting that this would be followed up by LEAN mapping workshop. The AHP group present at the meeting took the opportunity to highlight their priorities and pressures and constructive discussion took place about future development of AHP and Reablement services.
Implementing the Rehabilitation Framework in RC&WN, S&L
A meeting was held on 21 January with representatives from across the relevant professions to start to look at service mapping and redesign in order to bring together a more robust, unified approach, clarify service delivery and make better use of overall health resource.
This group will provide a steering role for work around rehabilitation in RCWN & S&L, meeting when required. Various pieces of work will be carried out with the involvement of some group members to support implementation of the 5 Key Impact areas of the Rehabilitation Framework. Margaret Moss, Lead AHP, will develop a Rehabilitation action plan for the CHP and include the work of this group in any planned actions agreed.
As an initial step Mrs Moss will lead a piece of work to review the existing Rehab Service in RCWN. This includes Augmented Care at Home and the community in general. A mapping event will be held within the next few weeks. Staff from across professions, locality and representatives from the Highland Council will be invited to participate in the event.
The aim of this meeting will be to look at existing case examples involving Rehab e.g. how things currently work. This will be compared with the model where a single joint Health and Social Care pathway is established with a single point of access. Thus gaps in service/patient needs will be teased out. The plan will then be to identify key challenging areas, drill down to detail and find solutions.
Brian Robertson, Area Community Care Manager Inverness, currently seconded to review Care at Home Services, will provide an introduction to the event to bring local staff up to speed with plans for Care at Home and joint working across Health and Social Care.
In Skye & Lochalsh, staff are continuing with their Rehabilitation Services and have identified two members as Falls Prevention Co-ordinators. A Rehabilitation meeting has been organised for later this month to revisit the protocols and service. A training area has been identified in PortreeHospital for staff/carers and patients to access telecare equipment to enable them to feel confident in its use before discharge home. This is in partnership with the Community Stores Team, District and Hospital Nurses and Occupational Therapists. This is now up and running with positive results.
Skye Hospitals
Committee Members will be aware of a campaign in the media and on Facebook aimed at saving PortreeHospital. Some of the statements made in the course of this campaign are inaccurate, while others are misleading and damaging.
It must be stressed that there is no intention to close either of the Skye Hospitals. They need to work more closely together and complement each other and, in common with all services in the CHP, will be required to make efficiency savings, but it is our intention to retain both facilities as neither is in a position to deliver the services currently available in the other.
It is acknowledged that there is a hope that a new hospital or hospitals will be built in Skye but, in the current economic climate, this is not likely to come to fruition for many years. The CHP will commit to carrying out a feasibility study including needs assessment to enable the inclusion of the resultant proposal in NHS Highland future planning.
Nurse contracts have been changed to reflect the need to work across both sites and this has not been received well by some staff. There are increased sickness levels in Portree Hospital with 4 WTE RGNs off sick and 2 Nursing Auxiliaries; this has an impact on the capacity in both hospitals leaving many gaps in the off duty rota. It has been agreed to look at the community staff supporting the hospitals but this would need to be on an agreed basis and can only be temporary. Short notice notification of absence is particularly difficult to manage. A meeting was held in early February with HR and Staff Side to look at the issues associated with staffing. Promoting attendance is being followed, but the repeated cancellation of meetings by some staff is delaying progress. Other suggestions being explored are around a shuttle service between the sites and staff transferring their primary base. A risk assessment has been completed and a contingency plan will be developed.
Environment
The general maintenance work in Mackinnon Memorial has now being undertaken and it is hoped that the tender for the new front porch will be agreed soon. Recent environmental audits show a significant improvement (95%) which is excellent. A meeting with Estates, Hospital Management, Infection Control, Lead Nurse and Health and Safety was held to consider improved space utilisation, identification of areas that additional toilet facilities could be put in and consideration of dedicated day case areas where bed spacing is a problem. A paper detailing the options has been submitted to the CHP and Estates have now developed this further. A short-life working group will take forward the bed spacing and utilisation of the space in the hospital based on this document.
Older Adults Mental Health
A workshop event was held in November 2009 led by Dr Cameron Stark, Clinical Lead for the Mental Health Collaborative, which looked at current services/processes. A small working group has been convened to look at issues around immediate/ongoing support and this was reported back at a meeting on 29 January.
The Unit has been facing extreme staffing problems and was in danger of closing over the festive period. The situation remains fragile and a verbal update will be given to Committee.
Highland Rheumatology Unit
Following the submission of the risk assessment completed by the HRU Team in November, further pieces of work have been identified and it is planned to explore these further with the team using the PDSA creative problem-solving approach. This approach will enable the identification of actions that could be taken to reduce the risks recognised by the HRU Team as inherent within the alternative service options discussed as part of the wider review of Rheumatology Services.
Independently of the redesign plans and as part of NHS Highland’s request that all elective work is reviewed, the Highland Rheumatology Unit had discussions with the clinical team. As a result of this the bed complement was reduced on 11th January and will remain at 10 beds until at least 31st March 2010. By this time further discussions on the longer term configuration of service will have been held. This has been the subject of considerable public and media interest.
RossMemorialHospital
RMH Patient Pathway - Following on from the workshop held in October to understand length of stay in the Ross Memorial work is being carried out to revisit referral processes and admission criteria for the hospital.
Planning
NHS Highland Strategic Framework 2010/11
NHS Highland Board considered a paper by the Chief Executive outlining the above framework at its meeting in February. Committee will have the opportunity to discuss this and the implications for the CHP. The draft Delivery Plan has been included in the pack to assist this discussion.
Chairman
At the same meeting of the Board, the roles and responsibilities of the Non Executive Directors was considered and agreed. Mr Okain McLennan, currently Non Executive member of the Mid Highland Governance Committee has been appointed as Chairman. Mrs Bethune, who is not seeking re appointment to the Board, will remain as Non Executive Member until September when her term of office will be complete.
I take the opportunity to thank Mrs Bethune for her guidance, support and encouragement, to welcome Mr McLennan to his new role and to wish both well for the future.
Gill McVicar
General Manager
9th February 2010