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                                      NHS GRAMPIAN
                  Note of the Performance Governance Committee held on
      Thursday 21 January 2010 at 10.30am in the Conference Room, Summerfield House


David Cameron (Chair), Non-Executive Board Member, NHS Grampian
Gordon Stephen, Non-Executive Board Member, NHS Grampian
Charles Muir, Non-Executive Board Member, NHS Grampian

In Attendance:

Richard Carey, Chief Executive
Pauline Strachan, Deputy Medical Director
Alan Gall. Director of Finance
Laura Gray, Director of Corporate Communications (items 5.2.1 and 5.2.2 only)
Ewan Robertson, Director of Performance Improvement/Board Secretary
Anne Ross, Head of Performance and Quality Improvement
Lesley Wilkie, Director of Public Health (item 5.1.1 only)
Gillian Lewis, Public Health Specialist – Health Improvement Strategy (item 5.1.1 only)
Glenys Wells, Personal Assistant - Minuting Secretary

Item    Subject                                                                           Action
 1.     Apologies
        Apologies were received from Bill Howatson, Val Maehle and Elizabeth
        McDade. As this meeting was inquorate, the November 2009 minute would
        require to be submitted to the March meeting for approval. The note of the
        inquorate meeting would be circulated to all members.

 2.     Healthstat
        The Healthstat section of the meeting was covered in a separate paper

 3.     Minute of Meeting held on 19 November 2009 and Matters Arising
        Deferred to March meeting.

        3.1   CHP Committee Objectives and Work plan - update
              Dr Cameron reported that he had met with CHP chairs in December
              2009 and work was ongoing to update objectives and produce

 4.     Assurance Framework
        4.1  Reports from Governance Committees and PGC Feedback:

              4.1.1    Staff Governance Committee

                                           Page 1 of 7
Item   Subject                                                                     Action
                    Mr Stephen reported a positive response to the Face2Face
                    sessions which had been attended by around 500 staff. It
                    had been agreed to continue these twice per year and more
                    sessions were being arranged for April and the autumn.
                    The Health and Safety structure was continuing to be
                    developed and covered both staff and patients. Roelf
                    Dijkhuizen had asked that HAI be incorporated and this was
                    being taken forward. It was expected to have the structure
                    in place by the end of March.
                    Sickness absence rates had been fluctuating and this was
                    thought to be a consequence of seasonal changes as well
                    as the Occupational Health Service’s (OHS) focus on the flu
                    vaccination programme. Grampian’s rate compared
                    favourably with others but there was always scope for
                    improvement. Richard Carey suggested that rates may
                    increase given the increasing challenges within the working
                    environment. The comprehensive data produced by OHS
                    was noted.

            4.1.2   Clinical Governance Committee
                    Mr Muir reported that CGC had received the full HEI report
                    and action plan which had given the Committee assurance
                    on progress to deliver improvements.
                    There was improvement towards meeting the cDiff target
                    and comprehensive information on antibiotic prescribing
                    which gave significant assurance.
                    Dr Dijkhuizen had identified an issue in relation to hand
                    hygiene related to throughput of people and this was being
                    The CGC had been advised that the Child protection action
                    plan was being implemented and updated. Mr Carey
                    confirmed that there was a common agreement on this
                    across public sector organisations.
                    Mr Robertson asked that future reports include completion of
                    the agreed actions column.

            4.1.3   Patient Focus and Public Involvement
                    Mr Carey advised that a virtual network was to be
                    established for the Wheelchair Users Group as attending
                    meetings had sometimes proved difficult.
                    Charles Muir advised that the consultation exercise relating
                    to health services for children with complex needs in
                    Aberdeen City was progressing and would be presented to
                    the Board in due course. The variety of views made the
                    process complex and lengthy.

            4.1.4   Aberdeenshire CHP
                    David Cameron presented Val Maehle’s report in her
                                        Page 2 of 7
Item   Subject                                                                       Action
                      absence. He stressed the importance of the ongoing work
                      around Single Outcome Agreements. Richard Carey
                      reported that he believed that the outcome from the national
                      review of CHPs was imminent but did not know what it was
                      likely to recommend.

             4.1.5    Moray
                      Mr Muir reported on the Committee’s recent meeting which
                      had included a good discussion on adult protection and a
                      presentation on the Health Plan.
                      The committee continued to monitor progress following the
                      HAI outbreak. Mr Carey confirmed the robust surveillance
                      arrangements put in place by Dr Dijkhuizen following the
                      HEI report and reminded members that each CHP had its
                      own specific action plan in relation to these. The CHP
                      General Manager was aware of and addressing the red
                      areas and would be expected to report on these to the
                      Committee. There would be an announced HMIE inspection
                      in May.
                      The Committee continued to track progress with the HMEI
                      report on Child Protection.
                      The CHSP had held a very positive workshop which was
                      well attended and areas of common interest with the Local
                      Authority would be taken forward. Richard Carey welcomed
                      that the local authorities appeared more supportive of the
                      Joint Future agenda.

       4.2   Review of Performance Governance Committee’s role in Risk
             Mr Robertson introduced his paper. The 2009 QIS report had raised
             issues about the role of Performance Governance Committee and the
             Audit Committee concerning risk management. He believed that
             roles were clear in that the Audit Committee was to provide
             independent assurance around the risk management process through
             the SSRC. PGC provided assurance around performance and
             strategic objectives at risk. There was perhaps a need to more
             formally review the Strategic and Operational Risk Control Plans at
             PGC and/or when agenda setting. This had been identified as a gap
             by a recent review by Bannisdale Consulting. Charles Muir said the
             report was helpful and the proposals made risk ownership more

 5.    Overall Performance ‘At A Glance’
       Anne Ross advised that the ‘At a Glance’ report circulated with the papers
       covered only the HEAT measures. The more substantial overall
       performance report continued to be produced monthly and was considered
       in full at Cross System Performance Reviews. Her report drew on the fuller
       report. She highlighted:-
                                          Page 3 of 7
Item   Subject                                                                         Action
       Cardiovascular health checks in areas of deprivation –performance
       remained under trajectory (which had already been revised downwards).
       Electronic management of referrals – well ahead of trajectory
       Cancer Waiting Times - urgent referral within 62 days had bee above the
       95% target for 3 quarters in a row. Performance against the new cancer
       target of decision to treat to treatment within 31 days was improving but
       below trajectory.
       Access times were slightly off trajectory but Richard Carey confirmed that he
       believed the 9 weeks would be delivered by the end of march 10.
       4 hour A&E wait was below 98% in October. Performance had fallen further
       at Dr Grays relating to the ward upgradings but was expected to be back on
       track by March. The ARI position was much more positive and believed to
       be above target on a sustainable position.

       Mr Carey commended this report and suggested it be used for the
       forthcoming mid year review.

       5.1   Improving the Public's Health and Reducing Inequalities 12.20
             5.1.1    Report on addressing ‘H’ Measures
                      Dr Wilkie introduced a report prepared in response to an
                      action agreed at the Annual Review in November.
                      Performance against some H targets were below
                      trajectory and the Cabinet Secretary had sought an
                      improvement plan by the end of January to show what
                      action was to be taken.

                       Mrs Lewis advised that a more detailed report covering all
                       H measures would be presented to the February Cross
                       System Performance Review. The report for the Cabinet
                       Secretary related only to those targets and initiatives
                       which she had raised. The reports would assist in
                       preparations for the 2010/11 Local Delivery Plan by
                       highlighting what could be delivered by when.

                       H3 – Child Healthy Weight Interventions - this was an
                       extremely challenging target to meet and the reported
                       performance against the target itself did not show the
                       considerable development and preparatory work that had
                       already been done to prepare for its delivery. Scottish
                       Government had asked all Boards to review their
                       trajectories for 2009/10 as Grampian was not alone at
                       being behind schedule. Discussions were ongoing
                       nationally about acceptable approaches on intervention
                       such as the Forth Valley class based model.

                       H4 – Alcohol Brief Interventions - detailed plans were in
                       place, posts had been filled and previous issues about
                       access to training had been resolved. There was
                                           Page 4 of 7
Item   Subject                                                                      Action
                      however a data recording issue as not all primary care
                      activity was being captured. This was being addressed
                      and the true position was expected to be reflected in
                      official reporting soon.

                      H6 – Smoking cessation – there had been data capture
                      issues associated with this target but these had now been
                      resolved and delivery was expected to be back on track
                      by the end of March.

                      Counterweight – the Cabinet Secretary had asked
                      specifically about this initiative in Grampian. Some
                      national funding had been received to take it forward in
                      primary care but progress had been slow due to other
                      pressures such as H1N1. Activity was now picking up

                      Mr Carey commended the report and felt that it would be
                      helpful to have a greater degree of specificity on what
                      could be delivered by when. Mrs Lewis confirmed that
                      this information would be contained within the report
                      being presented to February’s Cross System
                      Performance Review.

       5.2   Delivering safe, effective and timely care in the right place
             5.2.1     Media Performance Report
                       Mrs Gray reported that the previous 2 month period had
                       been dominated by the HEI report with a total of 420
                       stories. This was a significant increase from the previous
                       period and meant a high level of negative coverage.
                       There were other stories however including alcohol
                       minimum pricing and executive salaries. Members were
                       reminded that this report did not take into account
                       broadcast or online media.

             5.2.2    Communication and Media Management of HEI Report:
                      Mrs Gray advised that this had been a major issue for the
                      organisation and the communications function. Given the
                      high level of media coverage, it was important to reflect
                      and consider whether things could have been done
                      differently or more effectively and to identify any lessons
                      to be learned. The report provided the timeline of
                      events. Mrs Gray reminded members that the
                      organisation had seen the HEI report prior to publication
                      so the media and public reaction could have been
                      predicted. Various courses of action had been discussed
                      prior to publication but none taken forward which may or
                      may not have been the correct course of action. In
                                          Page 5 of 7
Item   Subject                                                                        Action
                       addition to the media management there was also a lot of
                       work involved in communicating with staff and Scottish
                       Government. Dr Cameron and Mr Muir were very
                       supportive of the extraordinary efforts of Mrs Gray and
                       her team under these extreme circumstances.

             5.2.3     Access Times

                       This had been discussed earlier in the meeting. Mr Carey
                       advised that discussions were ongoing with Scottish
                       Government about additional resource for theatre

       5.3   Improving Efficiency, Productivity and Sustainability

             5.3.1     End November 2009 Financial Report and December oral
                       Mr Alan Gall provided an oral update on the financial
                       position as at the end of December 2009. Pay costs were
                       being kept under control by budget holders with a £300K
                       underspend being reported for the month and a number
                       of sectors were showing an improving budget position.
                       However unexpected retrospective charges relating to
                       cross border prescribing meant the net result for
                       December was £458K over budget. The report forecast a
                       year end breakeven which meant a £3.6m deficit had to
                       be recovered over the remaining 3 months through
                       rigorous pay control, elimination of discretionary spend
                       and delay in earmarked spending. Prescribing costs and
                       earmarked funding expenditure were identified as high
                       risks in the last 3 months of the financial year.
                       Capital spending was no longer identified as a significant
                       risk but much work remained for project managers..
                       The overall financial position including plans for 2010/11
                       and beyond would be discussed in full at the March Board

 6.    CSI Performance Report

       Ms Ross presented the monthly CSI performance report which included
       performance traffic lights submitted by each programme. Where reds were
       reported, a short narrative was provided to the CSI Leadership Group.
       December’s report was disappointing given the increased number of reds
       being reported, however the January report, currently being pulled together,
       would show an improved position.

 7.    Annual Review letter and effectiveness of arrangements
                                           Page 6 of 7
Item   Subject                                                                        Action
       Dr Cameron reported a satisfactory outcome and commended Ms Ross and
       Mrs Gray for the work involved in the late change of arrangements. Mr
       Carey confirmed that all the action points were being taken forward.
       Generally it was agreed that the process had been satisfactory.

 8.    Annual Report
       Ms Ross reminded PGC that they had seen the draft Annual report and had
       had the opportunity to make contributions. The report was later than usual
       because of the late Annual Review. The report would be presented at the
       February Board meeting but in the meantime was approved by PGC.

 9.    2010/11 Local Delivery Plan (LDP) update
       Ms Ross advised that the first draft of the LDP was being produced and
       would be submitted to Scottish Government by 19 February, A major issue
       was the viability of the financial plan. The LDP would be refined over the
       next 2-3 weeks and circulated to the Executive Team and OMT prior to
       submission. There would be a presentation on the main issues at the
       March Board Seminar with final submission of the LDP on 19 March. The
       final version would also be available for PGC on 18 March and thereafter the
       April Board meeting.

10.    PGC Evaluation Plan 2009/2010
       PGC reviewed the action plan and noted that all the actions for 2009/10 had
       been completed. A 2010/11 plan would be presented at the next meeting.
       The Committee self evaluation would be deferred until later in 2010.

11.    To consider content of February 2010 Board Report

             Finance
             Assurance framework – generic statement on topics
             H measures
             Annual Report – (on Board agenda as a separate item)
             Access times – update
             At a Glance report

12.    AOCB
13.    Date of Next Meeting
       18 March 2010, 10.30am – 1pm, Conference Room, Summerfield House

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