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					                                          North Highland
                                          Community Health Partnership
                                          Caithness General Hospital
                                          Bankhead Road
                                          Wick KW1 5NS
                                          Telephone: 01955 605050
                                          Fax: 01955 604606
                                          www.nhshighland.scot.nhs.uk


     MINUTE of MEETING of the
     CHP MANAGEMENT TEAM                                9 February 2010 – 10.00 am
 The Environmental Research Institute,
              Thurso

Present              Mrs Sheena Craig, General Manager, (Chair)
                     Mrs Renee Bain, Staff Side Representative(representing Janette McQuiston)
                     Mrs Doreen Bell, Lead Nurse
                     Mrs Mary Burnside, Lead Midwife
                     Mr Ivor Campbell, Estates Officer
                     Mrs Lorraine Coe, Clinical Nurse Manager - Sutherland
                     Mrs Pauline Craw, Locality Manager-Caithness
                     Mrs Fiona Duff, Primary Care Manager
                     Dr Bobby Echavarren, Clinical Lead, Caithness
                     Dr Moray Fraser, Clinical Director
                     Mrs Georgia Haire, Locality Manager-Sutherland
                     Mr Duncan Hardiman, Health & Safety Manager
                     Dr Andreas Herfurt, Clinical Lead, North and West Sutherland
                     Mr Mark Kerr, Personnel Manager
                     Mr Ross MacKenzie, Head of Finance
                     Mrs Clare Morrison, Lead Pharmacist
                     Mrs Christine Tait, GP Practice Managers’ Representative
                     Mrs Margaret Taylor, Hotel Services Manager
                     Dr Natasha Usher, GP Sub Group Committee Representative
                     Ms Claire Wood, Lead AHP Representative
                     Dr Alan Woodall, Clinical Lead, East Sutherland

In Attendance        Mrs Liesel Boshoff, Service Planning Analyst, NHS Highland
                     Miss Christian Goskirk, Long Terms Conditions Manager
                     Ms Kay Oswald, CHP Support Manager

Sheena Craig welcomed everyone to the meeting and gave a special welcome to Liesel Boshoff,
Service Planning Analyst who had been assigned to the North Highland and Mid Highland CHPs.
A particular welcome was also extended to Renee Bain who was present on behalf of Janette
McQuiston. Introductions of all present were made.

1.    APOLOGIES

Apologies had been received from Mr Paul Fisher, Mrs Pam Garbe, Ms Teresa Green, Mrs Rachel
Hill, Mrs Janette McQuiston, Mr Alan Miller and Dr Cameron Stark.


2.     MINUTES OF MEETING HELD ON 12 JANUARY 2010

It was agreed that in future only confirmed minutes of the Management Team should be uploaded
to the NHS Highland website with the North Highland CHP Committee papers.

The following changes to the minutes of the meeting held on 12 January 2010 were agreed:-


                 Working with you to make Highland the healthy place to be
   Page 2, Agenda Item 3.1 Older Adults Services in Sutherland – 2nd paragraph – amend to
    “Lawson Memorial Hospital where a high level of activity has been experienced recently.”
 Page 3, Agenda Item 3.2 Maternity/Obstetric Services Update – 7th bullet point from the top of
    the page – amend to “It was agreed that there is a difficulty in sustaining the service with the
    current midwifery staffing model which needs to be reviewed.”
 Page 5, Agenda Item 5.4 Service Redesign – West Caithness – 3rd paragraph, 3rd bullet point –
    amend to “5 bed option to meet the absolute standards of HAI SCRIBE.”
 Page 7, Agenda Item 8 Sickness Absence – amend to “sickness absence remains the highest
    within NHS Highland.”
Following these amendments the minutes of the meeting held on 12 January 2010 were agreed as
a true record of business.

The Team:

     Agreed the minutes of the meeting.



3.       MATTERS ARISING

3.1      Older Adults Services in Sutherland

Georgia Haire reported that the rebuild of Migdale is continuing with the sod cutting ceremony
taking place the previous week and being reported by the media. Other areas highlighted:-
 The opening of the Bluebell Bed at Caladh Sona has been delayed until 12 February 2010 to
    allow staff training to be completed.
 The pilot project from Dornoch is being evaluated and is being rolled out to Goslpie.
 Following the open day at Cambusavie Unit, Lorraine Coe and Christian Goskirk were invited
    to the Community Council meeting to give a presentation on the work being undertaken at
    Cambusavie and the services in East Sutherland.

The Team:

     Noted the information provided.


3.2      Maternity Services Update

An update report from Mary Burnside was distributed for information. The following issues were
highlighted:
   Midwifery staffing continues to be a problem with recruitment difficulties and sick leave.
   Urgency to revisit staffing model which was reviewed in 2007 – move towards on call system
    with one midwife and an auxiliary/assistant covering the unit from 5 pm until 10 pm and a
    second midwife on call from home. Meetings with Human Resources and union representation
    are planned. The review in 2007 indicated that this type of service model should be
    considered in future planning and current staffing problems have hastened the need to
    review/progress this way of working.
   Low risk inductions of labour continue to be transferred to Raigmore. This will be revisited
    when the substantive consultant vacancy has been appointed to and midwifery staffing
    stabilises.
   A meeting to discuss the challenges around provision of double duty District Nurse/Midwife
    role in Sutherland has been arranged for 23 February. Mary apologised to Andreas Herfurt for
    lack of communication over this and it was agreed that in future Clinical leads should be
    advised of local meetings to enable them to contribute to discussions for their areas.
   Service contingency/continuity plan is being developed and this will include a staffing plan and
    identification of core service functions in the event of reduced staff numbers.


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     Cost pressures and long term impact on service provision and staff development are
      recognised.

During discussion the following issues were highlighted:-
   In Sutherland the Primary Care Emergency Centre (PCEC) is not staffed with GPs with intra
    partum care skills and the GPs should not form part of contingency plans to cover the lack of
    Out of Hours (OOH) midwifery on call cover. The principle should be established that any
    emergency birth beyond normal cannot be dealt with by the GPs and this information needs to
    be reinforced to the public and the SAS. It was acknowledged that GPs have a duty of care to
    provide immediate emergency care up to their level of competence and would not refuse to
    assist but should not be expected to be first line of call.
   If staffing problems continue will need to reconsider some of the services currently being
    provided by midwives eg aqua natal classes; baby massage classes. The risk in stopping
    educational, health promotion type classes, was acknowledged.
   Risks associated with unplanned home births were highlighted and also the pressure that
    planned home births puts on the midwifery service.
   Deskilling of GPs is taking place as ante natal care is being covered by midwives.
    Recommendation from Maternity review was that ALSO and ALS training be made available to
    GPs – problem over GPs being able to attend.
   Support from Management Team was acknowledged.
   It was agreed that accuracy of documentation was vital and information to women with
    explanations of risks being advised and being recorded at time of happening.

The Management Team acknowledged that the midwifery services were becoming difficult to
sustain. Alternative model now needed to come to full fruition as the need to move to a more
sustainable service was crucial.

The Team:
 Noted the updated information.
 Agreed that Clinical Leads be involved in management discussions regarding their areas.



4.      Prescribing Issues

4.1     Prescribing Report

Clare Morrison had distributed a report for January 2010 which had been produced for the three
LHP meetings in the North Highland CHP. The report gave the forecasted position for each of the
GP practices for 2009/10 and highlighted the therapeutic areas where the CHP’s spend is
significantly different from the rest of NHS Highland and Scotland. The report highlighted a
continuing improvement in the overspend position which was particularly heartening given the
increase seen in prescribing volume. It was agreed that it would be useful if the information
provided in the table could also show the comparison figures from the previous year and the actual
amounts spent. It was agreed the same report should continue to be sent to the Local Health
Partnerships.

4.2     Chronic Medication Service

A report by Clare Morrison outlining the Chronic Medication Service (CMS) of the new community
pharmacy contract had been distributed for information. The pharmacy contract comprises of four
core services: Public Health Service, Minor Ailment Service, Acute Medication Service and Chronic
Medication Service. CMS is the final service to be put in place and is scheduled to start in April
2010. Clare confirmed that the aim of the service is to improve patients’ understanding of their
medicines and maximise the outcomes from these medicines. A medication review will take place
with the pharmacist using a nationally approved template.



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4.3      Self Care Strategy

A paper on the North Highland CHP Self Care Strategy which had been developed during 2009
had been distributed for information. The paper gave a background to Self Care and the aim to
encourage individuals to adopt self care and improve health outcomes. The paper confirmed that
the North CHP will run two campaigns each year to promote self care and highlighted Campaign 1:
Antibiotics for sore throat. The aims of the campaign are to reduce the use of antibiotics for sore
throats and improve public awareness of why antibiotics should not be used for self-limiting
respiratory tract infections. A protocol for prescribers for managing sore throats has been
developed and a patient information leaflet for the Management Team to consider was included.

Following discussion the Management Team agreed that the strategy should be taken forward. It
was agreed that the next steps would be to take the strategy to GP and Pharmacy bodies for
support. Some changes to the information leaflet were suggested and it was agreed that work with
rural shops should be taken forward to ensure stocks of required medicines are available.

Clare advised that she had applied for National funding to support the pilot to enable data to be
collected for evaluation of the intervention.

The Team:

     Noted the information provided.
     Agreed that comparative figures of prescribing spending and actual amounts spent be shown
      on the prescribing report.
     Endorsed the Self Care Strategy and agreed changes to the patient information leaflet be
      made and liaison with local shops take place re stocking of medicines.



5.       FINANCIAL PLANNING

5.1      Financial Position as at 31 December 2009

The Finance Report for the period to 31 December 2009 had been distributed for information.
Ross Mackenzie confirmed that the forecasted year end position for the CHP is an overspend of
£249k. The prescribing overspend of £249k was highlighted. It was noted that the CRS had been
achieved but on a non-recurring basis and savings need to be delivered on a recurring basis.
Risks regarding locum costs to cover Consultants was highlighted. It was noted that NHS
Highland are continuing to forecast a breakeven position for the year end.

During discussion the focus of savings on GMS contacts was highlighted and it was suggested that
GPs are being asked to do more work for less money. Ross confirmed that the vast majority of the
GMS funding was contractually assigned and would not be affected.


5.2      CHP Savings Plan: Areas of Focus

The CHP Savings Plan for 2010/11 had been distributed for information and discussion. Sheena
Craig confirmed that a paper from the CHP was required for presenting to Roger Gibbins
identifying how the CHP was going to achieve its required £1.2m in savings. Discussion around
the areas of focus took place and actions were agreed :-
 Review of Board Administered Funds - This will be discussed with the CHP Clinical Director
    and the Clinical Leads prior to any changes being implemented. It was agreed that the
    agreement be revisited to check the regulations and confirm agreement with the Clinical Leads.
 Development of Dunbar Hospital - Looking at reconfiguring services at Dunbar Hospital and
    developing an Anticipatory care /rehabilitation centre.
 Impact of HAI Scribe requirements; HFS/QIS inspection report and future HAI
    inspections on CHP bed numbers – Risk Assessment tool is being developed for use in NHS
                                                4
      Highland which will ensure consistency of application re bed spacing. May be looking at two
      levels of applications – reasonable application (minimum reduction in beds) and absolute
      application. Currently considering the impact on services of both levels.
     Town & County Hospital – looking at review of service provision. Reviewing types of patients
      and whether can be cared for elsewhere. Dementia and Palliative care services across the
      CHP are being reviewed.
     Review of Leadership Structure – Some posts are statute and cannot be removed. Two
      unfunded Management posts are considered to be necessary.
     Enhanced Services Review – proposing to introduce a three year block contract for a basket
      of services to improve value for money. Following discussion support for enforcing the block
      contract was agreed. (see note below)
     Review of Migdale – skill mix and establishment figures being revisited to make potential
      savings.
     Acute Adult Tool Establishment review – following the implementation of this National
      validated workforce tool potential changes to the establishment figures in three wards at
      Caithness General Hospital have been identified.
     Review of community staffing structures – review is complete and team leaders are in
      place. Potential savings have been identified.
     Review of Allied Health Professionals – no ratified workforce tool is available but work is
      ongoing to support service redesign. Staff establishment figures continue to be revisited.
      Recognition has been made of the reduction in funding for Speech & Language Services by
      Highland Council.

During discussion it was agreed that a review of Obstetric/Gynaecology Services should be added
to the list of focus areas in the CHP Savings Plans for consideration. Sheena Craig asked that any
further suggestions be emailed to her for inclusion.

Note
Dr Alan Woodall requested that the following statement be included in the minutes:-
“While I accept the Management Team overall decision to progress with the proposals for the block
contract for a number of enhanced services and support this process in principle, I would like to
record formally my personal concerns that the method of establishing baseline contract allocation
(on 2008/09 year activity) could be disadvantageous to a number of practices if extenuating
circumstances which adversely affected the practice enhanced service activity for that year
occurred, and that there should be the right to appeal or contest these allocations built into the
process”.


5.3      Enhanced Services

It was agreed that this had been fully discussed during the Savings Plan discussion.

5.4      Service Redesign – West Caithness

A paper by Pauline Craw giving an update on the progress of the Stakeholder Group meetings and
outlining various options for consideration had been distributed. Pauline asked the Management
Team to consider the option appraisal and give views on whether to take one or more of the
options forward.

During discussion the following issues were highlighted:-
 The stakeholder meetings were proving challenging to manage with lack of progress identified.
 The concept of the Bluebell bed as developed and progressed in Sutherland has not been
   supported by some stakeholders.
 PCEC data had shown value to retaining a service during hours of peak activity.
 Value of providing palliative care in local setting acknowledged.
 A suggestion by a member of the Management team that an option to close the whole building
   should be considered was discounted.
 Significant capital costs of retaining beds would be an issue as not in the Board’s Capital plan.
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Following discussion the Management Team agreed that the option of providing care with no
inpatient beds, retaining the PCEC during 08.00 hours and 20.00 hours and developing a Long
Terms Condition Management and Rehabilitation Centre should be worked up.                  It was
acknowledged that this option may lead to public consultation and advice on the next steps should
be sought.

The Team:

 Noted the financial position as at 31 December 2009.
 Noted the information provided.
 Agreed that agreement re Board Administered Funds be revisited to check regulations and
  agreement confirmed with Clinical Leads.
 Agreed that block contract for enhanced services be implemented using 2008/09 as baseline
  year.
 Agreed that review of Obstetric/Gynaecology Services be added to list of areas of focus to be
  considered.
 Agreed that option to close all inpatient beds, reduce operating hours of PCEC and develop
  anticipatory care unit be worked up at Dunbar Hospital. Advice on public consultation to be
  sought.



6.     Falls Prevention and Bone Health Strategy

A draft Falls Prevention and Bone Health Strategy and Action Plan by Claire Wood, based on the
QIS Pathway for Falls Prevention and Bone Health had been distributed for information and
consideration. The pathway sets out a four-stage approach to these issues:
        Stage 1 – Self Management Population approach
        Stage 2 – Identification of those at risk of falling
        Stage 3 – Intervention for those who have had a fall
        Stage 4 – Co-ordinated management and specialist interventions.

Implementation of the strategy is expected to bring a shift in the balance of care with areas who
have already introduced it indicating the biggest impact on Orthopaedics. It was acknowledged
that we would be unable to deliver this strategy within the current provision and will need to
reconfigure and change service delivery but prevention is the way forward. It was indicated that
the proposed changes to Dunbar Hospital would give the opportunity to start delivering the
strategy.

The Team:
 Noted the information provided.



7.     Rehabilitation Framework

A report by Claire Wood outlining the Adult Rehabilitation Framework had been distributed for
information. The report was a condensed version of the framework produced by the Scottish
Government in 2007 and focussed on the core principles of rehabilitation. The five high impact
changes developed by the National Implementation Group were specified and the work
programmes currently taking place in NHS Highland to address these were highlighted:-
 Musculo-skeletal Redesign
 Falls Prevention
 Innovative Vocational Rehabilitation.

It was acknowledged that there are a number of initiatives/services delivered within the North
Highland CHP that already support delivery of the rehabilitation framework. Cost implications for

                                               6
the North CHP regarding workforce; training and education and facilities were highlighted. The
adult rehabilitation framework consensus event planned for the North CHP on 17 March 2010 at
the Marine Hotel, Brora was promoted.

The Team:
 Noted the information provided.



8.      Scottish Ambulance Services

A report by Alan Miller had been distributed for information. The content of the report was
discussed and it was agreed that some of the data was difficult to assess due to the low numbers
involved. It was noted that the GPs are continuing to assist with the achievement of the Category
“A” and “B” calls as they are being called out as BASICS attenders and are first on the scene.
Sheena Craig confirmed that she had the data available regarding these call outs for the next
Senior Executive meeting she would be attending. It was agreed that more information on dual
response call outs would be appreciated. Sheena Craig agreed she would discuss format of report
with Alan Miller.

The Team:

    Noted the information provided
    Agreed that Sheena Craig would discuss format of reports with Alan Miller.



9.      INFECTION CONTROL REPORT

The Infection Control Report by Doreen Bell had been distributed for information. The following
issues were highlighted:-
 HFS recommendations re bed spacing – on hold until risk assessment tool for NHS Highland
   developed
 Cost of improving hand washing facilities has been estimated at £28k.
 Cost of overcladding of window sills has been estimated at £8k
 Now 14 CDiff cases identified from 1 April 09 until 25 January 10 – 4 within CGH and 10 in the
   community.
 One surgical site infection reported following Caesarean section since April 2009.
 Hand hygiene results – performed well at national audit but still work do be done re technique.
 Environmental Cleaning – actions to be progressed following audits.
 Control of Infection policies have been removed from the ward areas – updated folders are only
   available in specified areas and shortcut links have been added to Ward computers.
 Shared learning will take place following the Healthcare Environment Inspectorate (HEI) visit to
   Raigmore. Heidi May, Lead Nurse and Charge Nurses from Raigmore will visit CGH to
   feedback on their audit and assist in preparation of audits scheduled for CGH in July 2010.

During discussion the issue of patients/visitors continuing to smoke outside the building and
causing a build up of cigarette ends was raised. Any solutions to the problem would be
appreciated.

The Team:

 Noted the information provided.




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10.    ANY OTHER COMPETENT BUSINESS

No other business was raised.


11.    DATE OF MEXT MEETING

The next meeting will be held on Tuesday 9 March 2010 at 10.00 am in the Seminar Room at
Caithness General Hospital, Wick.




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