Fife NHS Board 25 September 2019, 10:00 to 13:00 Staff Club, Victoria Hospital Chair - Tricia Marwick 1. CHAIRPERSON’S WELCOME AND OPENING REMARKS 10 minutes TM 2. DECLARATION

Fife NHS Board

25 September 2019, 10:00 to 13:00Staff Club, Victoria Hospital

Chair - Tricia Marwick1. CHAIRPERSON’S WELCOME AND OPENING REMARKS 10 minutes

TM

2. DECLARATION OF MEMBERS’ INTERESTSTM

3. APOLOGIES FOR ABSENCE - R LaingTM

4. MINUTES OF PREVIOUS MEETING HELD ON 31 JULY 2019

(enclosed)

TM

Item 4 - Minutes 073119.pdf (8 pages)

5. MATTERS ARISINGTM

6. CHIEF EXECUTIVE’S REPORT 20 minutes

PH

6.1. Chief Executive Up-date(verbal)

PH

6.2. Fife Integrated Performance & Quality Report Executive Summary

(enclosed)

PH

Item 6.2 - ESIPQR Sep 2019.pdf (9 pages)

7. CHAIRPERSON’S REPORT 5 minutes

7.1. Board Development Session – 28 August 2019(enclosed)

TM

Item 7.1 - Board Development Session Note 082819.pdf (1 pages)

8. WINTER PLAN 2019-20 10 minutes

(enclosed)

ER/NC

Item 8 - SBAR Winter Plan 19-20.pdf (3 pages)

Item 8 - NHS Fife Winter Plan 2019-20 v1.2.pdf (20 pages)

Item 8 - Fife Integrated Escalation Plan Winter 2019-2020 v0.7.pdf (1 pages)

Item 8 - Winter 19-20 Emergency Care Action Card v0.3.pdf (1 pages)

Item 8 - Winter 19-20 HSCP Action Card v0.2.pdf (1 pages)

Item 8 - Winter 19-20 Occupational Therapy and Physiotherapy Action Card v0.3.pdf (1 pages)

Item 8 - Winter 19-20 Pharmacy Action Card v0.3.pdf (1 pages)

Item 8 - Winter 19-20 Planned Care Action Card v0.2.pdf (1 pages)

Item 8 - Winter 19-20 Radiology and Diagnostic Action Card v0.2.pdf (1 pages)

9. ELECTIVE ORTHOPAEDIC CENTRE UPDATE 10 minutes

(enclosed)

CP

Item 9 - SBAR Ortho Project Update September 19 - updated.pdf (3 pages)

Item 9 - Ortho Appendix 1.pdf (3 pages)

Item 9 - Ortho Appendix 2.pdf (12 pages)

10. KINCARDINE & LOCHGELLY HEALTH & WELLBEING CENTRES INITIAL AGREEMENT

10 minutes

(enclosed)

NC

Item 10 - SBAR Kincardine and Lochgelly Capital Investment NHS Fife Board 250919.pdf (5 pages)

Item 10 - Kincardine IAD-refresh - draft as at 19-08-23 submitted to FCIG.pdf (45 pages)

Item 10 - Lochgelly IAD revised Aug2019 as at 2019-08-23 - submitted to FCIG.pdf (57 pages)

11. BOARD AND COMMITTEE DATES TO MARCH 2021 5 minutes

(enclosed)

CP

Item 11 - SBAR Board and Committee Dates for 2019-21.pdf (2 pages)

Item 11 - Update Committee Dates 2019-20 September - March.pdf (1 pages)

Item 11 - DRAFT Board and Committee Dates 2020-21.pdf (1 pages)

12. GOVERNANCE ARRANGEMENTS - REMUNERATION COMMITTEE

10 minutes

(enclosed)

BAN

Item 12 - SBAR Remuneration Governance Arrangements.pdf (2 pages)

Item 12 - Remuneration Committee ToRs Appendix 1.pdf (3 pages)

13. STATUTORY AND OTHER COMMITTEE MINUTES 5 minutes

13.1. Audit & Risk Committee dated 5 September 2019 (unconfirmed)

(enclosed)

MB

Item 13.1 - SBAR for Audit & Risk Committee.pdf (1 pages)

Item 13.1 - Mins Audit & Risk Committee dated 5 September 2019 unconfirmed (1).pdf (8 pages)

13.2. Clinical Governance Committee dated 4 September 2019 (unconfirmed)

(enclosed)

LB

Item 13.2 - SBAR for Clinical Governance Committee.pdf (1 pages)

Item 13.2 - Mins Clinical Governance Committee dated040919 V2 unconfirmed (1).pdf (13 pages)

13.3. Finance, Performance & Resources Committee dated 10 September 2019 (unconfirmed)

(enclosed)

RL

Item 13.3 - SBAR for Finance Performance & Resources.pdf (1 pages)

Item 13.3 - Mins Finance Performance & Resources dated 10 September 2019 unconfirmed.pdf (8 pages)

13.4. Staff Governance Committee dated 30 August 2019 (unconfirmed)

(enclosed)

MW

Item 13.4 - SBAR Staff Governance Committee.pdf (1 pages)

Item 13.4 - Mins Staff Governance Committee dated 083019 unconfirmed.pdf (7 pages)

13.5. Brexit Assurance Group dated 6 September 2019 (unconfirmed)

(enclosed)

LB

Item 13.5 - SBAR for Brexit Assurance Group 060919.pdf (1 pages)

Item 13.5 - Mins Brexit Assurance Group dated 060919unconfirmed.pdf (3 pages)

13.6. East Region Programme Board dated 24 May 2019(enclosed)

PH

Item 13.6 - SBAR East Region Programme Board.pdf (1 pages)

Item 13.6 - Mins ERPB 24.05.19 Final.pdf (8 pages)

13.7. Fife Partnership Board dated 13 August 2019 (unconfirmed)(enclosed)

DM

Item 13.7 - SBAR for Fife Partnership Board 130819.pdf (1 pages)

Item 13.7 - Mins Fife Partnership Board 130819 unconfirmed.pdf (4 pages)

14. FOR INFORMATION:

14.1. Integrated Performance Report - July 2019 and Integrated Performance & Quality Report - August 2019

(enclosed)

CP

Item 14.1 - IPR July.pdf (51 pages)

Item 14.2 - IPQR Aug 2019 v1.pdf (40 pages)

15. ANY OTHER BUSINESS

16. DATE OF NEXT MEETING: Wednesday 27 November 2019 at 10:00 am in the Staff Club, Victoria Hospital, Kirkcaldy

Fife NHS Board

File Name: Board/Minutes 073119 Issue 1 05/08/2019 Originator: Paula King Page 1 of 8 Review Date:

MINUTE OF THE MEETING OF FIFE NHS BOARD HELD ON WEDNESDAY 31 JULY 2019 AT 10.00 AM IN THE STAFF CLUB, VICTORIA HOSPITAL, KIRKCALDY Present: Dr L Bisset (Chairperson) Mrs C Cooper, Non-Executive Director Mr P Hawkins, Chief Executive Cllr D Graham, Non-Executive Director Mr M Black, Non-Executive Director Ms R Laing, Non-Executive Director Ms S Braiden, Non-Executive Director Dr C McKenna, Medical Director Mrs W Brown, Employee Director (part) Mrs C Potter, Director of Finance Mrs H Buchanan, Director of Nursing Mrs M Wells, Non-Executive Director Mr E Clarke, Non-Executive Director In Attendance: Mr A Fairgrieve, Director of Estates, Facilities & Capital Services Mr S Garden, Director of Pharmacy & Medicines Mr M Kellet, Director of Health & Social Care Ms B A Nelson, Director of Workforce Mrs E Ryabov, Chief Operating Officer (Acute) Mrs P King, Corporate Services Manager (Minutes) 55/19 CHAIRPERSON’S WELCOME AND OPENING REMARKS The Chair welcomed everyone to the Board meeting and reminded Members

that the notes are being recorded with the Echo Pen to aid production of the minutes. These recordings are also kept on file for any possible future reference. The Chair congratulated Mr Garden on his appointment as Director of Pharmacy & Medicines following interviews held earlier this month.

The Chair advised that: • the garden within Victoria Hospice has been officially opened, significantly

improving its accessibility. Patients, carers and staff have been heavily involved in the design of the new garden which has been guided by the needs of patients. The £40,000 refurbishment was funded using NHS Fife’s Endowment Fund;

• an open afternoon took place in the garden of Queen Margaret Hospice on 26 July 2019. The garden is not normally open to the public as it is set aside as a quiet place for the use of hospice patients and their families but it was on this occasion to allow people to see the improvements carried out there. Congratulations were given to the Queen Margaret Hospice Garden Group who undertake considerable work to raise funds for this area and provide a voluntary service too;

• the deadline for staff to nominate for the 2019 Achievement Awards is 1 August 2019. The ceremony will take place on the evening of 20 September 2019;

• the process to recruit a new Non-Executive Member to join the Board as a

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Whistleblowing Champion is underway and Members are asked to raise awareness of the vacancy. The closing date is midday on Monday 12 August 2019;

• Mr Kellet, Director of Health & Social Care, is leaving the Partnership today (31 July 2019) to take up a role with Scottish Government. The Chair, on behalf of the Board, recorded thanks to Mr Kellet for the work he has done to move integration forward in Fife for Health & Social Care and wished him and his family well for the future.

56/19 DECLARATION OF MEMBERS’ INTERESTS There were no declarations of interests. 57/19 APOLOGIES FOR ABSENCE Apologies for absence were received from Mrs Marwick, Ms Milne and Ms

Owens. 58/19 MINUTE OF THE PREVIOUS MEETING HELD ON 26 JUNE 2019 The Minute of the previous meeting was approved as a true record. 59/19 MATTERS ARISING There were no matters arising. 60/19 CHIEF EXECUTIVE’S REPORT .1 Chief Executive Update There was nothing to update. .2 Executive Summary - Integrated Performance Report (IPR) Mr Hawkins introduced the Executive Summary. Executive leads and

Committee Chairs highlighted areas of significance within the IPR, in particular:

Clinical Governance An update was provided in relation to Hospital Acquired Infection (HAI)

Staphylococcus Aureus Bacteraemia (SAB) rates, noting there had been a slight improvement in the month. Work continued on SABS within community services and in-depth discussion took place at the Clinical Governance Committee looking at the challenges facing this group of patients and how to make improvements in that group. Good work was also being undertaken between the Harm Reduction Team and the A&E Department and with local Pharmacies to support these patients and Dr Bisset, as Chair of the Clinical Governance Committee, was grateful to Dr Morris, Consultant Microbiologist, for his support in this area. Performance against Stage 2 complaints recovered to an extent in April but remained well below target at 47.6%; further improvement would be noted in the next Integrated Performance Report as work continued with

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staff in Acute and the Health & Social Care Partnership. This issue was being kept under review by the Clinical Governance Committee.

Finance, Performance & Resources NHS Fife Acute Division – Attention was drawn to three key targets.

Performance around the 4-Hour Emergency Access target continued to be strong at 94.7% but there was still variability due to the large volume of activity in A&E which remained higher than the average. The variability is concerning particularly out of hours and over the week-end and a Performance Improvement Team has been set up to undertake data analysis to try and identify the causes. The Cancer 62 day Referral to Treatment performance remained reasonably stable at 84.4%, the main challenge is within urology. Two new urologists have been appointed which should help with some of the more routine work and benefit the cancer pathway which was also being reviewed to try and reduce delays wherever possible. The Patient Treatment Time Guarantee was on trajectory overall for out-patients and in-patients and NHS Fife was performing well particularly relative to other Boards. The teams are working hard in this area and the waiting list funding received was helping to support recruitment. The Acute Services Division continued to be challenged around its savings plan but work was underway to get a plan in place. Members would be up-dated further in the Private Session.

Health & Social Care Partnership (H&SCP) – Improvements had been

noted in both the Smoking Cessation target, which was on track to meet target for the first time in many years, and in the levels of Delayed Discharges. Child and Adolescent Mental Health Services (CAMHS) performance was variable with performance at 77.6% at the end of June. The additional Primary Mental Health Workers, recruited as part of the Scottish Government Action 15 funding to provide early intervention, improve initial assessments and increase effectiveness of signposting, has led to a reduction in the number of referrals to CAMHS specialist services but there are still challenges in meeting the target. Services providing brief Psychological Therapies for people with less complex needs are performing well but there are still challenges to meet the target for those with more complex needs. The whole system redesign work supported by Scottish Government is on-going. The Finance, Performance & Resources Committee has requested a representative from the Service attend its next meeting to describe the challenges to enable Members to have a better understanding of the situation. In the discussion that followed further information was requested to provide: • a comparison with other Health Boards; • an update on the review of the third and voluntary sector and how that

support operates in the light of the refresh of the Mental Health Strategy to ensure the support given by these partner agencies is directed at meeting the objectives of the Strategy; and

• an update on the impact of the additional Primary Mental Health Workers.

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This information will be submitted through the appropriate Committees of the Board in the first instance.

Action: M Kellet Financial Position – At the end of month two, the overspend was

£2.004m. The most significant challenge is that facing the Acute Services Division in respect of its savings and the delivery of these. The Estates & Facilities and Corporate Directorate budgets were underspent and this is supporting the overall financial position. At this point there has been no Integration Joint Board (IJB) risk share factored into the position reflecting ongoing discussion about how this will be applied in this financial year. Reference was made to a letter from the Cabinet Secretary following a meeting with Council Leaders looking at options for the risk share. It is hoped to have an update position for the next Finance, Performance & Resources Committee in September.

The capital position for the two months to May was noted. Staff Governance Updates were provided in relation to the sickness absence rate, iMatter

and PDP/Turas. Considerable attention continued to be focused on promoting attendance overall within the Board and in certain areas and was a constant element of discussion at the Executive Directors Group in terms of how to change the approach and do things differently. In response to questions, Ms Nelson outlined some of the improvement initiatives underway particularly supporting staff health and wellbeing in relation to anxiety/stress in partnership with staff side colleagues. The improved position in respect of iMatter was noted and Members were pleased that staff in the H&SCP employed by Fife Council were also included in the iMatter engagement tool. The use of the ‘roaming’ tea trolley developed by the Communications Team had been recognised nationally and the response to this by staff was appreciated.

The Board noted the information contained within the Integrated

Performance Report Executive Summary. 61/19 CHAIRPERSON’S REPORT (a) Board Development Session – 26 June 2019 The Board noted the report on the Development Session. 62/19 WORKFORCE STRATEGY 2019-22 Ms Nelson presented the draft Workforce Strategy 2019-22 produced in line

with the new three year financial planning framework that applies to all NHS Boards. Ms Nelson explained the process gone through to produce the document and confirmed that all key stakeholders had the opportunity to input to the document that covered all NHS Fife staff, including those who work in Fife H&SCP. Whilst section 5 covered the Broad Action Themes, there was a detailed implementation plan that sat alongside the Strategy document. The

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importance of integration across the NHS and IJB was highlighted. Reference was made to the Youth Employment Strategy narrative and the approach to modern apprentices able to be employed into current vacant posts and be paid the rate for that post.

A number of questions were asked around recruitment and retention of staff,

neurodiversity in the workplace and the benefits of employing people with certain conditions and development of new roles and these were responded to. The challenges in medical recruitment were highlighted, noting in particular the need for trained medical staff to sustain services in Fife and work was underway with colleagues in Acute and the H&SCP looking at innovative ways to ease the burden on these staff. Consideration also needs to be given to linking workforce with technology, identifying what NHS Fife needs going forward and shaping the workforce accordingly to match the changing population. The change in the demographic also required to be built into discussion around funding for future years.

The Board approved the draft NHS Fife Workforce Strategy for 2019-22 and

thanked all colleagues involved in its production.

63/19 PROPERTY AND ASSET MANAGEMENT STRATEGY The document provided an up-date on the 2019 Property and Asset

Management Strategy (PAMS) as required by the State of the NHS Scotland Assets and Facilities Report Programme. The draft PAMS report was submitted in June 2019 to meet the Scottish Government’s (SG) deadline, and dispensation was received that in order to seek Board approval we need further time to follow NHS Fife’s internal governance process.

The PAMS report is a strategic document which highlights NHS Fife’s asset

needs and its investment making decisions. Good discussion took place at the Board Development Session in June 2019 and feedback would be incorporated into future PAMS documents. Detailed discussion had also taken place at the Finance, Performance & Resources Committee where it was recognised that further consideration needs to be given to the transformation work underway and how to use buildings for the future linking in with the Workforce Strategy, IT, etc. The document demonstrated the big challenge in Fife and would be scheduled as a topic at a future Board Development Session.

Action: P Hawkins/A Fairgrieve The Board noted and approved the 2019 PAMS document. 64/19 ELECTIVE ORTHOPAEDIC CENTRE UPDATE Mrs Potter spoke to the paper that outlined progress against the key milestones

in relation to the development of a new Elective Orthopaedic Centre. All the different partners had now been procured and the first round of clinical stakeholder engagement workshops had been held working on the design of the centre. The engagement of staff was essential and feedback had been positive with a real commitment to the project. Mrs Potter emphasised that governance of the project was key and the project was subject to many

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processes of external review and scrutiny. The Finance, Performance & Resources Committee and the Board would be regularly updated as the project progressed. Because the project was at the early planning stage, Internal Audit would be asked to take a view of the governance arrangements from the outset. A Communication Strategy was also being developed by the Head of Communications to keep staff and the public advised of progress.

The Board noted progress on the project to date and proposed that this be

scheduled as a topic at a future Board Development Session. Action: P Hawkins 65/19 REVIEW OF WINTER 2018-19 The Board considered a report from the Chief Operating Officer and Director of

Health & Social Care, that provided a review of winter 2018-19 in terms of what went well, what could be improved and key lessons that could be further developed for the Winter Plan 2019-20.

Good partnership working had taken place over last winter and it was essential

to maintain this going forward. There were challenges around staffing in Acute, the opening and closing of surge capacity and particular issues in social care around care at home provision. Planning for winter 2019-20 was underway and included holding a system wide meeting that would be used to pick up the day of care audit work and linking in issues around the set aside budgets. There were a number of variables that could affect performance over winter but staff continued to make every effort to plan as effectively as possible. The impact of flu also needed to be taken into account and the importance of ensuring that patients and staff are vaccinated to minimise sickness absence was emphasised. The level of attendance was also on the rise and there was a need for good liaison with Primary Care. The importance of partner contributions from the third and independent sectors particularly in relation to prevention and anticipatory care was highlighted and a proposal to explore these providers being involved in locality huddles would be considered in terms of planning for next year. The route to the Board in terms of the IJB Finance and Performance Committee would be checked.

Action: E Ryabov/M Kellet Mrs Brown left the meeting. The Board noted the Winter Review document for 2018-19, acknowledging the

challenges but also recognising the significant improvement in performance over the last few years mainly down to the efforts of staff, and noted the dates for Winter Planning 2019-20.

66/19 INTERNAL AUDIT – OPERATIONAL PLAN 2019-20 Mrs Potter presented the Internal Audit Operational Plan 2019-20, which was

part of the Strategic Audit Plan 2019-24, that set out the key areas of focus for Internal Audit in 2019-20. Attention was drawn to the IJB Strategic Audit Plan 2019-20 and Operational Audit Plan 2019-20 that was attached for information.

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The Board: • noted that the Audit & Risk Committee considered the Internal Audit

Operational Plan and recommended approval by the Board; • approved the Internal Audit Operational Plan; and • noted the Plan will remain a live document and may be subject to revision

later in the year for which approval would be sought via the Audit & Risk Committee.

67/19 2019 PRIMARY CARE IMPROVEMENT PLAN Mr Kellet introduced the Plan which is a key component of the implementation

of the new 2018 General Medical Services (GMS) Contract. The Plan is the responsibility of the IJB and was approved at its meeting on 21 June 2019. It is brought to Fife NHS Board for information because of the Board’s wider responsibility in the implementation of the GMS contract. The Plan has generated considerable successes to date, notably a Fife-wide phlebotomy service which is unique across Scotland. There are two significant issues in relation to the Primary Care Improvement Fund allocation and GP Practice sustainability which are set out in the paper. The Board will be kept appraised of progress.

Discussion took place on a number of areas of the Plan in particular the need

for further engagement with communities, the link to the Workforce Strategy for NHS Fife and the H&SCP as there are significant workforce implications that require a collaborative approach in order to sustain services across the piste, the need to look at advanced practice and new roles to see how they can feed into the contract to support GPs and funding. The complexity of general practice and the challenges facing GP colleagues in terms of recruitment and sustainability together with implementing the new contract, which is to ease the difficulties being experienced by GPs, was recognised. It is a whole scale change in the way that general practice and primary care services will be run to ensure that people have the opportunity to see the right clinician at the right time and consideration needs to be given as to how to merge the resilience for GPs and implement the new contract. An explanation of the contract position around GPs was also provided. The Plan had been discussed at length by the Clinical Governance Committee and a further report was requested due to the complexities being faced by GPs.

The Board: • noted the Fife Primary Care Improvement Plan and noted that discussions

are on-going through the Clinical Governance Committee and further updates will be provided moving forward.

68/19 STATUTORY AND OTHER COMMITTEE MINUTES The Board noted the below Minutes and the issues to be raised to the Board. .1 Audit & Risk Committee dated 20 June 2019 (unconfirmed) .2 Clinical Governance Committee dated 3 July 2019 (unconfirmed)

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.3 Finance, Performance & Resources Committee dated 16 July 2019 (unconfirmed)

.4 Staff Governance Committee dated 28 June 2019 (unconfirmed) Mrs Wells referred to the Sturrock Report and the intention to create an

additional Non Executive Director position with a particular responsibility for Whistleblowing. She reminded Members that NHS Fife already had a Whistleblowing Champion and emphasised the importance of working within existing organisational procedures as they worked well.

Committee Chairs confirmed that there was nothing formally to

raise/escalate to the Board. .5 Communities & Wellbeing Partnership dated 11 June 2019

(unconfirmed) .6 East Region Programme Board dated 29 March 2019 .7 Fife Health & Social Care Integration Joint Board dated 21 June

2019 (unconfirmed) .8 Fife Partnership Board dated 14 May 2019 (unconfirmed) 69/19 FOR INFORMATION: The Board noted the item below. .1 Integrated Performance Report – May and June 2019 .2 Health & Social Care Partnership Strategic Plan for Fife 2019-22 70/19 ANY OTHER BUSINESS None. 71/19 DATE OF NEXT MEETING: Wednesday 25 September 2019 at 10.00 am in the Staff Club, Victoria Hospital,

Kirkcaldy

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Page 1

Fife IntegratedPerformance & Quality Report

Executive Summary

Produced in September 2019

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Page 2

IntroductionThe purpose of the Executive Summary Integrated Performance and Quality Report (ESIPQR) is to provide assurance on NHS Fife’s performance relating to National LDP Standards and local Key Performance Indicators (KPI).

The ESIPQR comprises of the following sections:

I. Executive Summary

a. LDP Standards & Local Key Performance Indicators (KPI)

b. National Benchmarking

c. Indicatory Summary

d. Assessment, by Governance Committee (including Executive Lead and Committee Comments)

The baseline for the report is the previous month’s Integrated Performance and Quality Report (IPQR), which was tabled at the most recent meetings of the Standing Committees:

Clinical Governance 4th September 2019

Finance, Performance & Resources 10th September 2019

Staff Governance 30th August 2019

Any issues which the Standing Committees wish to escalate to the NHS Fife Board as a result of these meetings are specified.

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I. Executive SummaryAt each meeting, the Standing Committees of the NHS Fife Board consider targets and Standards specific to their area of remit. This section of the IPQR provides a summary of performance against LDP Standards and local Key Performance Indicators (KPI). These indicators are listed within the Indicator Summary including current and previous performance and benchmarking against other NHS Boards.

a. LDP Standards & Key Performance Indicators

The current performance status of the 28 indicators within this report is 12 (43%) classified as GREEN, 3 (11%) AMBER and 13 (46%) RED. This is based on whether current performance is exceeding standard/trajectory, within specified limits or considerably below standard/trajectory.

There are four indicators that consistently exceed the Standard performance; C Diff infection rate, IVF Treatment Waiting Times (regional service), Antenatal Access and Drugs & Alcohol Waiting Times. Other areas of success should also be noted…

Inpatients Falls with Harm, consistently below the target level, at 1.47 per 1,000 Occupied Bed Days

The SAB infection rate (measured on a rolling 3-month basis) is significantly lower than the Improvement Trajectory for 2019/20

New Outpatient Waiting Times achieved above Standard performance for third month in succession with 95.4% waiting less than 12 weeks

Patient TTG (Patients Waiting at Month End), continuing to be above the Improvement Trajectory for 2019/20

Cancer 31-Day DTT achieving the Standard in June


National Benchmarking is based on whether indicator is in upper quartile (▲), lower quartile (▼) or mid-range (◄►); based on 11 mainland NHS Boards. The current benchmarking status of the 24 indicators within this report has 5 (21%) within upper quartile, 12 (50%) in mid-range and 7 (29%) in lower quartile. There are indicators where national comparison is not available or not directly comparable.

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Page 4

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Page 5

d. Assessment

Executive Lead CommentsNo issues to highlight.

Standing Committee Meeting Issues and CommentsNo issues require to be highlighted or escalated to the NHS Fife Board.

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Page 7

Executive Lead Comments

Acute waiting times for new outpatients, Patient TTG and Diagnostics are currently performing in the upper quartile compared with other mainland Scottish NHS Boards. In terms of AOP performance, TTG is better than target but Outpatients is behind target.

Urology remains challenging for 31 and 62 day Cancer Waiting Time target. The work within Urology Improvement Group to review the pathways is expected to be completed by January 2020 as is currently on track.

Emergency Access standard remains a challenge for Fife. Improved patient flow is key to achieving 95% and review of AU1 Assessment Pathway, redevelopment of ECAS and implementation of OPAT service all underway and are due to be completed by October 2019.

Bed Days Lost to Delays has reduced to 6.8%, under 5% target for March 2020, with the number of patients in delay at census 53. A review of timeliness of social work assessments is under way and a trusted assessor’s model within VHK for patients transferring to STAR/Assessment Beds is on track for completion by October.

Mental Health Waiting Times continue to be a challenge with both CAMHS and Psychological Therapies below AOP trajectories. All improvement actions are currently on track to deliver by agreed timescales.

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Page 8

Executive Lead CommentsAs previously reported, further work is required as a matter of priority to ensure that savings are identified and deliverable for the Acute Services Division, in support of the Health Board’s statutory requirement to break even. External expertise is being provided through Deloitte LLP to robustly support and challenge the team to design and implement an effective savings programme, with a strong focus on what/when/how much in terms of specific savings proposals.

It is important to note that at this point there has been no IJB risk share factored into the year to date position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.6m to the in year overspend position (i.e. 4/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £6.8m.

We continue dialogue with colleagues in the Health Finance Directorate on the impact of any application of the risk share arrangement, on the financial consequences for the NHS Fife Board in relation to the delivery of the statutory financial requirement to break even.

In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £4.4m to a mid range overspend of £8.8m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.68m (i.e. 72% of the £6.5m gap), nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £9m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. It is important to note that the most recent forecast overspend on the IJB budget was in excess of the initial £6.5m budget gap; being more than £9m).

Within the Scottish Government reporting template we are required to highlight the level of any potential brokerage required to deliver a break even position. Board members are asked to note that we have included a funding request of £4.68m in this respect; this assumes the impact of the social care overspend would require additional external funding and the overspend on the Health Board retained budgets would be managed through local management action.

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Page 9

Standing Committee Meeting Issues and CommentsThe meeting discussed Psychological Therapies and CAMHS Waiting Times performance and the Acute Services Division Efficiency Programme, and highlighted the challenges identified around Winter Planning.

There was a useful presentation and discussion on the Scottish Capital Investment Manual.

Executive Lead CommentsWe continue to progress work in partnership with our staff representative colleagues to improve performance in this area. This includes jointly presented “myth busting sessions” which will also support the application of the newly agreed Circular dealing with this issue.

Our workshops which include discussion of best practice examples from within the Board, the art of having “Good Conversations”, supporting staff resilience and the need to be aware of and support in a timeous way any colleagues who are experiencing mental health related issues, have been extremely well received.

Standing Committee Meeting Issues and CommentsSickness Absence

Absence for June is 5.55%, a decrease of 0.11% from May 2019. Future reporting will include junior doctor absence figures which are currently showing a sickness absence level of below 1%. Targeted actions continue in all areas.

PAUL HAWKINSChief Executive18th September 2019

Prepared by:CAROL POTTERDirector of Finance and Performance

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7.1

File Name: Board Dev – 260619 Issue 1 27/06/19 Originator: Paula King Page 1 of 1

Report to the Board on 25 September 2019 BOARD DEVELOPMENT SESSION – 28 August 2019

Background 1. The bi-monthly Board Development Sessions provide an opportunity for Board

Members and senior clinicians and managers to consider key issues for NHS Fife in some detail, in order to improve Members’ understanding and knowledge of what are often very complex subjects. The format of the sessions usually consists of a briefing from the lead clinician or senior manager in question, followed by discussion and questions, or a wide-ranging discussion led by members themselves.

2. These are not intended as decision-making meetings. The Board’s Code of

Corporate Governance sets out the decision-making process, through recommendations from the Executive Directors Group and/or relevant Board Committee, and this process is strictly observed.

3. The Development Sessions can, however, assist the decision-making process

through in depth exploration and analysis of a particular issue which will at some point thereafter be the subject of a formal Board decision. These sessions also provide an opportunity for updates on ongoing key issues.

August Development Session

4. The most recent Board Development Session took place in the Staff Club, Victoria

Hospital, Kirkcaldy on Wednesday 28 August 2019. There were three main topics for discussion: Winter Planning, Elective Orthopaedic Centre and Data/Fife Integrated Performance & Quality Report. Recommendation

5. The Board is asked to note the report on the Development Session. TRICIA MARWICK Board Chairperson 29 August 2019

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Page 1 of 3

NHS Fife Board

DATE OF MEETING: 25 September 2019TITLE OF REPORT: Winter Plan 2019/20

EXECUTIVE LEAD: Ellen Rybov, Chief Operating Officer, AcuteNicky Connor, Chief Officer, H&SC

REPORTING OFFICER:Susan Fraser, Associate Director of Planning and PerformanceClaire Dobson, Divisional General ManagerAndy MacKay, Deputy Chief Operating Officer

Purpose of the Report (delete as appropriate)For Decision For Discussion For Information

Route to the Board (must be completed)

The draft Winter Plan 2019/20 has been considered at EDG (16 September), the Staff Governance Committee (30 August), Clinical Governance Committee (4 September) and the Finance, Performance & Resources Committee (10 September).

SBAR REPORTSituation

This paper provides an update to the Board on the draft Winter Plan for 2019/20.

Background

The Winter Plan aims to: Describe the arrangements in place to cope with increased demand on services over

the winter period. Describe a shared responsibility to undertake joint effective planning of capacity. Ensure that the needs of vulnerable and ill people are met in a timely and effective

manner despite increases in demand. Support a discharge model that has performance measures, a risk matrix and an

escalation process. Ensure staff and patients are well informed about winter arrangements through a robust

communications plan. Build on existing strong partnership working to deliver the plan that will be tested at

times of real pressure.

The focus will primarily be on the winter period covering October 2019 to March 2020.

Assessment

This draft of the Winter Plan 2019/20 has been agreed following a winter planning event on 22 August 2019 with H&SCP and Resilience colleagues and a follow up meeting with Acute colleagues on 23 August. A small working group has been taking forward the actions from the Winter Review 2018/19 over the summer months including actions included in the Winter Plan

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2019/20.

The top 5 planning priorities for winter 2019/2020 identified at the Winter Review workshop 18/19 are:

1. Review of the integrated escalation plan including developing a fuller understanding of the requirements of demands into social care

2. Acute bed modelling exercise to take place and review of 18/19 bed reconfiguration

3. Proactive recruitment including consideration of Hospital Ambulance Liaison Officer (HALO) to facilitate efficient discharges

4. Establish appropriate point of care testing at the front door

5. Focus on prevention of admission with further developments of High Health Gain programme, management of patients in locality huddles and identifying alternatives to GP admissions and planning timely discharges to Community Hospitals. This forms part of the Joining Up Care transformation programme.

These priority areas were the key actions for the Winter Plan 2019/20. It continues being developed as an integrated plan between with NHS Fife and Health and Social Care.

Boards are required to submit draft Winter Plans to Scottish Government by end September 2019. Draft plans have been submitted to the committees before going to the NHS Fife Board and IJB in September 2019, prior to submission of a final version of the plan to Scottish Government in October.

Weekly winter monitoring reports will commence at the beginning of October 2019 when general managers from NHS Fife and Health and Social Care Partnership will meet to review the report and take action when necessary.

Recommendation

The Board is invited to

Note and agree the draft Winter Plan 2019/20.

Objectives: (must be completed)Healthcare Standard(s): To aid delivery

HB Strategic Objectives: Supports all of the Board’s strategic objectives

Further Information:Evidence Base: N/AGlossary of Terms: N/AParties / Committees consulted prior to Health Board Meeting:

Executive Directors and Board Committees

Impact: (must be completed)Financial / Value For Money Promotes proportionate management of risk and thus

effective and efficient use of scarce resources.

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Risk / Legal: Inherent in process. Demonstrates due diligence. Provides critical supporting evidence for the Annual Governance Statement.

Quality / Patient Care: NHS Fife’s risk management system seeks to minimise risk and so support the delivery of safe, effective, person centred care.

Workforce: The system arrangements for risk management are contained within current resource. e.g.

Equality: The arrangements for managing risk apply to all patients, staff and others in contact with the Board’s services.

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CONTENTS

1 Introduction .............................................................................................................32 Key Deliverables......................................................................................................33 Planning Priorities Winter 2019/20 ........................................................................54 Winter Planning Process ........................................................................................64.1 Clear alignment between hospital, primary and social care ..................................................64.2 Appropriate levels of staffing to be in place across the whole system to facilitate consistent

discharge rates across weekends and holiday periods .........................................................74.3 Local systems to have detailed demand and capacity projections to inform their planning

assumptions ..........................................................................................................................84.4 Maximise elective activity over winter – including protecting same day surgery capacity.....94.5 Escalation plans tested with partners ..................................................................................104.6 Preparing effectively for infection control including norovirus and seasonal influenza in .......

acute and community settings .........................................................................................114.7 Delivering seasonal flu vaccination to public and staff ........................................................12

5 Summary ................................................................................................................13Appendices...................................................................................................................13

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1 Introduction

Health and Social Care providers have a key responsibility to undertake effective planning of capacity to ensure that the needs of vulnerable and ill people are met in a timely and effective manner despite increases in demand on services or a mismatch between demand and supply of services. This can happen at any time of the year but commonly in winter activity rises, there is increased risk of infection (Norovirus in particular), the weather conditions can be adverse and influenza is more likely than at other times of the year.

NHS Fife, Fife Council and the Health and Social Care Partnership (HSCP) share the challenges of managing service delivery in the context of demographic change across primary, secondary and social care. The organisations are collectively responsible for managing the local health and social care system. This includes managing information and intelligence; assessing needs and working with community partners to ensure that services are fit for purpose; they meet the needs of patients; and are cost effective despite the pressures described above. The purpose of this document is to describe the arrangements put in place by NHS Fife, Fife Council, the Health and Social Care Partnership and partner organisations throughout the year, but particularly over the winter (including the Christmas and New Year holiday).

This plan is supported by:

NHS Fife Pandemic Flu Plan NHS Fife Major Incident Plan NHS Fife Business Continuity Plan H&SCP Response and Recovery Plan

NHS Fife, Fife Council and the Health and Social Care Partnership have completed the self assessment checklist which helps to measure our readiness for winter across several domains. The checklist will be utilised as a local guide to assess the quality of winter preparations.

A detailed review of plans in these areas will apply a Red, Amber, or Green status. The self assessment checklist will be reviewed over winter to ensure that plans are in place to cope with system pressures and ensure continued delivery of care.

NHS Fife, Fife Council and the HSCP are confident that systems and processes will be in place to support demand.

2 Key Deliverables

The Fife Integrated Winter Plan takes on a whole system approach, to offer seamless transition between the Acute Hospital, Outpatient Services, Community Hospital and Community Social Care Services throughout Fife.

The Winter Plan aims to:

Describe the arrangements in place to cope with increased demand on services over the winter period.

Describe a shared responsibility to undertake joint effective planning of capacity.

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Ensure that the needs of vulnerable and ill people are met in a timely and effective manner despite increases in demand.

Support a discharge model that has performance measures, a risk matrix and an escalation process.

Ensure staff and patients are well informed about winter arrangements through a robust communications plan.

Build on existing strong partnership working to deliver the plan that will be tested at times of real pressure.

Key principles to the winter plan are:

Our workforce are key to the successful delivery of the winter plan. Engagement with staff across key stakeholders through winter plan workshops Completion of the self assessment checklist indicates that arrangements are in progress to

support the delivery of the winter plan. Resilience, severe weather, Norovirus and Flu plans are re-visited and are in place.

We will focus primarily on the winter period covering October 2019 to March 2020, but pressure due to capacity is present all year round.

There are a number of key pressures that are prevalent over the winter period which affect our ability to optimally manage flow and capacity. History and current intelligence tells us that these include:

Increased clinical acuity/complexity/dependency and increased conversion rate from Emergency Department (ED) attendance to admission

Increased attendances to the ED Increase in (medically-fit-for-discharge) patients in delay. Decreased resilience within the workforce (school holidays, bank holidays and

sickness/absence). An inability to scale-down scheduled care activity due to waiting time obligations. Having appropriate levels of community capacity to accommodate demand from across the

health and social care system. Increasing activity and demand in primary care against a background of issues with General

Practice sustainability.

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3 Planning Priorities Winter 2019/20

The review of winter 2018/19 considered performance, what went well, what went less well and helped to identify the 2019/20 planning priorities for the Acute Services Division and the HSCP.

The top 5 planning priorities for winter 2019/2020 identified at the Winter Review workshop 18/19 are:

1. Review of the integrated escalation plan including developing a fuller understanding of the requirements of demands into social care

2. Acute bed modelling exercise to take place and review of 18/19 bed reconfiguration

3. Proactive recruitment including consideration of Hospital Ambulance Liaison Officer (HALO) to facilitate efficient discharges

4. Establish appropriate point of care testing at the front door

5. Focus on prevention of admission with further developments of High Health Gain programme, management of patients in locality huddles and identifying alternatives to GP admissions and planning timely discharges to Community Hospitals. This forms part of the Joining Up Care transformation programme.

Additionally, the following actions were also identified:

Community Hospital re-design should provide community beds at the right level and in the right place

Review capacity planning ICASS, Homecare and Social Care resources throughout winter Multidisciplinary short life working groups to take actions forward across Acute and HSCP Estimated Discharge Date process to be further developed and clear instructions in place Have a discharge lead to enhance Criteria Led Discharges and get earlier discharges and

plans in place Enhance weekend discharge planning with further development of the weekend discharge

team and enhanced clinical support Consider the introduction of planned outpatient appointments for medically fit in-patients

awaiting diagnostic tests Explore a sustainable model for discharge lounge Proactive and dynamic planning that follows predicted problems with use of system watch and

better use of data Full review of how and when surge capacity is used Consideration of impact of individual decisions made which will affect the whole system Produce a winter surgical program plan that includes use of the short stay surgical unit, and

distribute the surgical programme, taking into account the periods of higher demand from emergency patients

Consider an enhanced ambulatory model for surgical and medical patients Proactive infection control and learning for Fife Care homes Continue the success of the staff flu campaign into its 3rd year Urgent Care model will be up and running by winter 2019 and implemented in a staged

approach

The planning priorities identified for 2019/20 align with a range of transformation programmes across the Acute Services Division and the HSCP. These key programmes are the Joining Up Care

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programme (HSCP) and Acute Services Transformation Programme although it should be noted that the Redesign of Community Hospitals will not take place this winter.

During the review stage, it was agreed to proactively plan for winter by establishing a short life working group (SLWG) to take forward the development of the Winter Plan and Escalation Plan.

4 Winter Planning Process

4.1 Clear alignment between hospital, primary and social care

a) Winter Review 18/19 – What happened last year

An EDD process was developed and is was in the early stages of being introduced with Acute directorate. This is currently reviewed within our daily safety huddle.

To provide intermediate care capacity in West Fife, GP cover was secured. The care home capacity to provide a single intermediate care unit is a challenge with interim placements being commissioned as required.

Over 300 High Health Gain Individuals have been assessed across HSCP and these have a care plan and care coordination in place. The rollout of this model continues.

Testing and development of pathways into a trusted assessor model for assessment beds within VHK is ongoing.

Urgent Care service delivery was agreed in line with the contingency arrangements in place for the Primary Care Emergency Service. Festive rotas and staffing were in place before during and after the festive period.

b) Winter Planning 19/20 – Actions we are going to take this year

Lead/sRefAction Timescales NHS Fife HSCP Status

1 Ensure adequate Community Hospital capacity is available supported by community hospital and intermediate care redesign

October 2019 DGM East and West

2 Review capacity planning ICASS, Homecare and Social Care resources throughout winter

August 2019 DGM West

3 Focus on prevention of admission with further developments into High Health Gain, locality huddles to look at alternatives to GP admissions

March 2020 DGM West

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4 Reduce length of stay as a winter planning group and being progressed through BAU

September 2019

GMs,DCOO, Ass Dir

PPDGM West

5 Test of Change for use of the community hub during Winter. November

2019 DGM West

6 Test of change to reconfigure STAR bed pathway. November

2019 DGM West

7 Urgent Care ED enhanced direction model November

2019 DGM West

8 Implementation of model for discharge lounge through tests of change November

2019GMs,

DCOO

9 Explore third sector transport over winter months October 2019 GMs,

DCOO

10 Weekly senior winter monitoring meeting to review winter planning metrics and take corrective action.

October 2019

GMs,DCOO,Ass Dir

PP

DGM West

4.2 Appropriate levels of staffing to be in place across the whole system to facilitate consistent discharge rates across weekends and holiday periods


There are currently informal arrangements in place to provide 7 day pharmacy service in acute with recruitment to substantive posts continuing.

Secure Social Work staffing in the Discharge Hub and community hospitals over the festive period.


Lead/sRef Action Timescales Acute HSCP Status1 Secure Social Work staffing in the

Discharge Hub and community hospitals over the festive period.

October 2019 DGM West

2 Test of change of a rota of senior decision making capacity in OOH/weekends to promote 7 day discharges

November 2019 GM EC

3 Agree Urgent Care workforce levels and secure staffing as early as possible.

October 2019 DGM West

4 Enhance Clinical Co-ordinator role November DGM West

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within the Urgent Care service. 20195 Consideration of a Hospital Ambulance

Liaison Officer (HALO) role to further plan and arrange efficient discharges

October 2019 GMsDCOO

6 Enhance weekend discharge planning with further development of the weekend discharge team

October 2019 GMsDCOO

7 Explore augmenting IAT/MSK resource at front door with a view to reducing admission rate

October 2019 GM WC

8 Proactive recruitment and a joined up workforce plan to utilise staff intelligently across the year as well as winter

October 2019 GMs,DCOO DGM West

4.3 Local systems to have detailed demand and capacity projections to inform their planning assumptions


A communication plan was put in place for the public and staff. Advanced Nurse Practitioners are in place to focus on nurse led/criteria led discharges within

GI and Respiratory. A flexible bed base was utilised within community hospitals with an additional 20 beds in use

and locum cover secured for QMH hospital. A winter placement and activity tracker for HSCP was created and monitored throughout

winter. A review of discharge transport options has taken place. An assessment of delayed discharges due to medicines has been completed. A focus on

discharge medicines being available within 2 hours to aid discharges has been implemented. A winter ready section of the website and intranet was developed and completed. Weekly meetings between Corporate, Acute and HSCP management teams. A reconfiguration of beds was complete by December 2018. A revised weekly winter planning report was devised, as well as winter plan rag status

reporting. An escalation plan for surge capacity was agreed. An acute site management structure was agreed and put in place. Daily community service huddles took place to flexibly manage demand and capacity across

community services. “Black Box” testing has been invested in for front door staff.

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Lead/sRef Action Timescales Acute HSCP Status1 Proactive and dynamic planning that

follows predicted problems with use of system watch and better use of data including Urgent Care in collaboration with NHS 24

October 2019 GMsDCOO DGM West

2 Estimated Discharge Date process to be further developed and clear instructions in place


3 Full review of how and when surge capacity is used against the escalation plan

September 2019

GMs DCOO DGM West

4 Banish boarding event to take place to reduce pressure in hospital with patients boarding in non patient wards.

September 2019

MDCOO

5 Comprehensive review of board and ward round process across Acute inpatient wards to identify and implement consistent best practice

Observation exercise Aug

2019

December 2019

DCOOAMD

6 Identify location for surge capacity (likely ward 4 & 13, but awaiting confirmation of roof repair for ward 4)

Oct 2019 DCOOGMs

7 Have a discharge lead to enhance Criteria Led Discharges and get earlier discharges and plans in place

November 2019

GMsHoN

8 Bed modelling exercise supported by SG to optimise Acute bed configuration for 19/20 including the relocation of Ward 9 to Phase 3, beside Ward 24

November 2019 GM PC

9 Intention to increase N:R ratio in AHP caseload to reduce de-conditioning in acute medical wards to reduce LoS and reduce level of support required by patients at point of discharge.

October 2019 GM WCCS

4.4 Maximise elective activity over winter – including protecting same day surgery capacity


A review of known peaks took place and a reduction in capacity took place for the festive period and January.

The surgical programme was reviewed weekly with a surgical short stay unit open from January.

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Lead/sRef Action Timescales Acute HSCP Status1 Produce a winter surgical program

plan that includes use of the short stay surgical unit, and distribute the surgical programme, taking into account the periods of higher demand from emergency patients

October 2019 GM PC

2 Review the ambulatory model for surgical and medical patients and implement any enhancements

October 2019 GM ECGM PC

3 Test the introduction of planned outpatient appointments for medically fit in-patients awaiting diagnostic tests

October 2019 GM WCCS

4 Review theatre requirements for SHDU cases to smooth activity over the week

November 2019

GM EC GM PC

4.5 Escalation plans tested with partners


Business continuity plans are under constant review however additional work has been carried out in respect of winter planning.

Tabletop exercises are regularly carried out with departments to ensure the efficacy of contingency plans.

A corporate Business Continuity Plan has been formed. An East of Scotland Winter Preparedness review has been held and attended by Public

Health, Acute and HSCP representatives. An escalation plan was agreed and triggers created. Staffing issues were also incorporated

into this plan.


Lead/sRef Action Timescales Acute HSCP Status1 A review of the integrated escalation

plan with action cards including training and testing, and agreement of the surge capacity model over winter, including opening and closing of surge beds

August 2019GMs

DCOOAss Dir PP

DGM West

2 Review and improve business continuity plans for services

September 2019

GMsDCOO DGM West

3 Tabletop exercise to be arranged to test Major Incident plans

November 2019 Ass Dir PP

4 Multi Agency meeting to discuss winter arrangements across Fife

November 2019 Ass Dir PP

5 Update Corporate Business Continuity November 2019

Ass Dir PP

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Plan and Response and Recovery Plan6 Ensure that community services have

access to 4x4 vehicles in the event of severe weather and that staff have received an appropriate level of training to drive such vehicles.

September 2019

DGM West

7 Review the full capacity protocol September 2019

GMsDCOO

Ass Dir PP

DGM West

The draft Integrated Escalation Plan can be found in Appendix 1.

4.6 Preparing effectively for infection control including norovirus and seasonal influenza in acute and community settings


A weekly winter planning meeting took place to address issues and implement improvements in a timely manner with an escalation and reporting process. This was supported by an agreed weekly winter monitoring report that allowed decisions to be

26 Norovirus education sessions were delivered with a study day “winter is coming” with attendees from all disciplines.

A tabletop exercise on the management of Norovirus outbreaks took place. A review of Norovirus preparedness planning took place through the NHS Fife Infection

Control Committee. A series of Winter 2017/18 debrief sessions have taken place.


Lead/sRef Action Timescales Acute HSCP Status

1 POCT for flu will be implemented early this year in preparation for the challenges expected from increased numbers of patients presenting with flu

October 2019

GM WCCS

2 Proactive infection control and learning for Fife Care homes

October 2019DGM West

3 POCT will also be implemented in paediatrics for RSV which will support early diagnosis (supporting winter bed pressures) and reduce requirement for unnecessary molecular testing.

October 2019

GM WCCS

4 Weekly Winter Planning Meetings to continue to monitor hospital position

October 2019 GMsAss Dir PP DGM West

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4.7 Delivering seasonal flu vaccination to public and staff


A monthly review of the seasonal flu action plan took place all winter. An information pack was developed and distributed to the independent care sector in Fife. Redesign of the staff vaccination consent form has enabled more detailed and timely data

collection against targets for monitoring. Promotion of under 65 at risk health groups for vaccination has taken place in community

networks and workplace teams. Flu/Respiratory testing at the front door as in 2017/18.


Lead/sRef Action Timescales Acute HSCP Status

1 Continue the success of the staff flu campaign into its 3rd year October 2019 GMs

DCOODGM West

ADoN2 Monthly review of progress against

seasonal flu action plan October 2019 GMsDCOO DGM West

3 Deliver staff communications campaign across Acute & HSCP, in order to achieve 60% uptake in healthcare workers (national target) and 50% uptake in social care workers (local target)


4 Develop & distribute Information pack to independent care sector in Fife, covering staff vaccination, winter preparedness and outbreak control measures


5 Redesign consent form and data collection methods to enable more detailed & timely monitoring of staff vaccination against targets


6 Promotion of community flu vaccination for <65 at-risk groups via health promotion community networks and workplace team.


7 Review and agree options for inclusion of flu vaccination messaging for at-risk groups in out-patient letter template


8 Flu/Respiratory testing at the front door as in 18/19 October 2019 GMs

DCOO DGM West

5 Summary

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The winter plan describes the arrangements in place to cope with increased demand on services over the winter period. In partnership NHS Fife, Fife Council and the HSCP have a shared responsibility to undertake effective planning of capacity.

The priority is to ensure that the needs of vulnerable and ill people are met in a timely and effective manner despite increases in demand. Our workforce are key to the successful delivery of the winter plan.

Resilience, severe weather, Norovirus and Flu plans have been re-visited and are in place.

The plan is supported by a discharge model, performance measures, a risk matrix and an escalation process.

Winter communications planning is well under way. The communication planned is both staff and public facing using recognised communications mechanisms (including social media).

The self assessment checklist when completed will indicate that arrangements are in progress to support the delivery of the winter plan.

Partnership working is essential in order to deliver the plan and will be tested at times of real pressure.

AppendicesAppendix 1: Fife Integrated Escalation PlanAppendix 2: Fife Integrated Escalation Plan: Action CardsAppendix 2: Local Procedure for Escalation Plan Level Appendix 3: HSCP Winter Discharge Model (To be added)Appendix 4: Winter Plan Financial Table (To be added)Appendix 5: Weekly Winter Monitoring ReportAppendix 6: Preparing for Winter 2018-19 Supplementary Checklist (To be added)

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Appendix 1: Fife Integrated Escalation Plan

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Appendix 2: Fife Integrated Escalation Plan: Action Cards

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Appendix 3: Local Procedure for Escalation Plan Level

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Appendix 5: Weekly Winter Monitoring Report

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Integrated NHS Fife and HSCP Escalation Plan 2019/2020 v0.7

Code Escalation at: Acute Actions H&SCP Actions Total CapacityNHS Fife and Fife Council CEO to agree actions

Extr

eme

Pres

sure

Instigate Full Capacity Protocol as follows:

All acute beds available for any patient Organisational business continuity plans invoked Move all delayed patients to other locations in Fife Surgery proceeds on a case by case basis prioritising emergency procedures and cancers in discussion with clinical team. In the event of surgery cancellation redirect available theatre staff to support inpatient activity. 10 Emergency Care Placements (HSCP)

773 Adult Acute beds

EC: 312 core beds+ 24 surge beds

PC: 167 core

HSCP: 254 core beds + 16 surge beds

10 Emergency Care Placements

COO and Director of H&SCP to agree sequence of actions dailyEmergency Care Planned Care HSCPGM Huddle at lunchtime to agree plan, to increase medical staffing at ward level to focus on discharge.

Surge Capacity(See Staffing Plan)Stage 1: Increase Ward 13 to 20 beds (6 beds)Stage 2: Increase Ward 13 to 26 beds (6 more beds)Stage 3: Surge Ward 4 open (12 beds)

Weekend plan to include 3rd on call consultant with junior doctor/ANP and AHP support.

Cancel outpatient clinics where medical staffing can support inpatient management based on specialty requirement.

Maximise use of SSSU so that inpatient surgery has no impact on hospital capacity.

Assess QMH capacity and spread of activity across the two sites. Implement staffing moves.

Surgical consultants are contacted by the PC management team to support with timely discharges and creation of flow.

Surge Capacity(See Staffing Plan)Stage 1: Increase Cameron Hospital wards to 25 rehab and to 14 Stroke (8 beds) Stage 2: Increase Glenrothes ward to 14 beds (4 beds)Stage 3: Increase QMH ward to 24 (4 beds)

Increase ICASS capacity Offering support workers additional shifts By escalating all care at home waits

Implement community capacity calls

Seve

re P

ress

ure

Review requirement for delivery of non critical services with a view to deploy staff into clinical areasCritical review of planned activities across all staff groups to focus on patient care and flow


EC: 312 core beds + 24 surge beds

PC: 167 core

HSCP: 254 core beds + 16 surge beds

Deputy COO and DGM West to agree sequence of actions dailyEmergency Care Planned Care HSCP

Mod

erat

e Pr

essu

re Every patient to be reviewed by a consultant

Expedite medically fit for discharge patients.

Activate additional support to frailty.

All wards to identify at least 1 patient for discharge pre 10:30am

Assess AHP caseload and implement staffing moves as required.

Specialty ward rounds to take place every day.

Identification of surgical patients in surgical wards and in AU2 who are near discharge and suitable for a move to SSSU. Appropriate patients would be approved by the on call consultant general surgeon.

Review boarding patients in all planned care wards to ensure plans are in place.

Urology patients admitted to the surgical assessment unit (AU2) are redirected to UDTC.


Prioritise ICASS discharges from VHK & QMH - Review caseloads / increase flow to homecare outwith normal commissioning to meet increased demand.

Prioritise discharges from VHK to STAR/ Assessment beds/home with homecare above normal commissioning levels


EC: 312 core beds

PC: 167 core beds

HSCP: 254 core beds

Plan

ned

Ope

ratio

nal

Wor

king

Management plan put in place

Huddle discussion and predictor indicates that hospital is able to accommodate both elective and emergency patients for the day

There are no patients in A&E or Admission Units awaiting admission without allocated beds

The normal flow to HSCP services is expected - 10/12 patients to exit each day

733 Adult beds

EC: 312 core beds

PC: 167 core beds

HSCP: 254 core beds

EC: 95-98% occupancy with 312 beds open

No patients awaiting admission in A&E or AU1au & AU2au

Intensive care capacity available

PC: 85-90% Occupancy with 167 beds open

H&SC: <90%% Occupancy

<10 patients clinically fit for next stage of care from VHK

No boarding patients

EC: >98% occupancy with312 beds open

< 5 patients awaiting admission in A&E or AU1au/AU2au without allocated beds


PC: >90% occupancy with 167 beds open

H&SC: >90% Occupancy

>10 patients clinically fit for next stage of care from VHK

< 10 EC patients boarding in PC Wards

EC: >=100% occupancy with 324 beds open

>10 patients awaiting admission in A&E or AU1au/AU2au for admission

No intensive care capacity available

PC: 100% occupancy with 167 beds open



>20 EC patients boarding into PC Wards & front door boarding required


EC: >=100% occupancy with 312 beds open

>5 patients awaiting admission in A&E or AU1au/AU2au without allocated beds


PC: > 95% occupancy with 167 beds open



>10 EC patients boarding in PC Wards & front door boarding required

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Emergency Care Action Card

Extreme PressureTriggers

EC: >=100% occupancy with 324 beds open >10 patients awaiting admission in A&E

or AU1au/AU2au for admission No intensive care capacity available PC: 100% occupancy with 167 beds

open H&SC: >100% Occupancy >30 patients clinically fit for next stage

of care from VHK >20 EC patients boarding into PC

Wards & front door boarding

ActionsInstigate Full Capacity Protocol as follows:

All acute beds available for any patient Organisational business continuity plans invoked Move all delayed patients to other locations in Fife Surgery proceeds on a case by case basis prioritising

emergency procedures and cancers in discussion with clinical team.

In the event of surgery cancellation redirect available theatre staff to support inpatient activity.

10 Emergency Care Placements (HSCP)

Severe PressureTriggers


or AU1au/AU2au without allocated beds Intensive care capacity available PC: > 95% occupancy with 167 beds


of care from VHK >10 EC patients boarding in PC Wards

& front door boarding required

Actions GM Huddle at lunchtime to agree plan, to increase medical

staffing at ward level to focus on discharge. Surge Capacity (See Staffing Plan)

o Stage 1: Increase Ward 13 to 20 beds (6 beds)o Stage 2: Increase Ward 13 to 26 beds (6 more beds)o Stage 3: Surge Ward 4 open (12 beds)

Weekend plan to include 3rd on call consultant with junior doctor/ANP and AHP support.

Cancel outpatient clinics where medical staffing can support inpatient management based on specialty requirement.

Review requirement for delivery of non critical services with a view to deploy staff into clinical areas

Critical review of planned activities across all staff groups to focus on patient care and flow

Moderate PressureTriggers

EC: >98% occupancy with 312 beds open < 5 patients awaiting admission in A&E

or AU1au/AU2au without allocated beds Intensive care capacity available PC: >90% occupancy with 167 beds

open H&SC: >90% Occupancy >10 patients clinically fit for next stage of care from VHK < 10 EC patients boarding in PC Wards

Actions Every patient to be reviewed by a consultant Expedite medically fit for discharge patients. Activate additional support to frailty. All wards to identify at least 1 patient for discharge pre

10:30am Assess AHP caseload and implement staffing moves as

required. Specialty ward rounds to take place every day.

Planned Operational WorkingTriggers

EC: 95-98% occupancy with 312 beds open No patients awaiting admission in A&E

or AU1au & AU2au Intensive care capacity available PC: 85-90% Occupancy with 167 beds

open H&SC: <90%% Occupancy <10 patients clinically fit for next stage

of care from VHK No boarding patients

ActionsManagement plan put in place Huddle discussion and predictor indicates that hospital is able

to accommodate both elective and emergency patients for the day


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HSCP Action Card







ActionsInstigate Full Capacity Protocol as follows: All acute beds available for any patient Organisational business continuity plans invoked Move all delayed patients to other locations in Fife Surgery proceeds on a case by case basis prioritising










Actions Surge Capacity (See Staffing Plan)

o Stage 1: Increase Cameron Hospital wards to 25 rehab and to 14 Stroke (8 beds)

o Stage 2: Increase Glenrothes ward to 14 beds (4 beds)o Stage 3: Increase QMH ward to 24 (4 beds)

Increase ICASS capacity o Offering support workers additional shiftso By escalating all care at home waits

Implement community capacity calls





Actions Prioritise ICASS discharges from VHK & QMH - Review

caseloads / increase flow to homecare outwith normal commissioning to meet increased demand.

Prioritise discharges from VHK to STAR/ Assessment beds/home with homecare above normal commissioning levels.






ActionsThe normal flow to HSCP services is expected - 10/12 patients to exit each day

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Occupational Therapy and Physiotherapy Action Card







Actions Implement staffing over establishment Cancel non-essential clinical activity and redeploy staff

accordingly







Actions Cancel non-clinical activities OT /PT Managers collaborate to maximise AHP resource and

share appropriate caseload. Occupational Therapy and Physiotherapy (OT/PT) managers

will engage with SMT throughout the day to optimise discharge pathways across the hospital

Optimise staffing levels within resource to increase clinical time utilising bank / voluntary uplift in hours

Seek authorisation to uplift staffing beyond resource including overtime and consideration of locum.





Actions OT/PT Managers review boarders lists and capacity amongst

teams in preparation for step up to level 2 Physiotherapy will activate prioritisation guidelines; respiratory

acuity, prevention of deterioration, discharges, reviews. Occupational Therapy will prioritise patients for a discharge

pathway, deferring reviews Deploy staff across specialties to meet demand






Actions Perform all inpatient activity in relation to clinical urgency,

discharge, prevention of admission and rehabilitation.. Urgency determined by clinical presentation

Attendance at safety huddles and board rounds Pursue bid to augment staffing to increase rehab capacity in

Acute and MOE medical wards to reduce LoS and reduce level of support required by patients at point of discharge

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Pharmacy Action Card







Actions Activate BCP and Major Incident plan to move pharmacy staff

from the H&SCP to Acute services to maximise service delivery.

Pharmacist Prescribers to consider use of HBPs for dispensing in community pharmacy







Actions Optimise staffing levels by moving all available non-patient

facing acute pharmacy staff into direct clinical care roles Provide pharmacy and medicines management nursing

support to ward 13 Pharmacist prescribers to support increased focus on

discharge





Actions Front door pharmacy team to link with frailty team to support

increased activity Medicines Management Nurse to support discharge lounge Review boarding patients in planned care wards to ensure

medicines availability Expedite Medically fit for discharge patients, use EDD to target

pharmacy technician support to ensure medicines availability at the bedside and prioritise pharmacist review of patients that have not been seen






ActionsCore service delivery: Maximise dispensary discharge prescription turnaround

performance; Clinical pharmacy service, focus on screening new admissions

within AU1 & AU2 and direct admission areas; follow up of high risk patients and pharmacy technician referrals; clinical pharmacist check of all compliance aid discharges; provide medicine related advice and support through clinical coordinator

Pharmacy Distribution, ward medicines top up to maintain availability of over-labelled packs

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Planned Care Action Card







ActionsInstigate Full Capacity Protocol as follows:

All acute beds available for any patient Organisational business continuity plans invoked Move all delayed patients to other locations in Fife Surgery proceeds on a case by case basis prioritising










Actions Maximise use of SSSU so that inpatient surgery has no impact

on hospital capacity. Assess QMH capacity and spread of activity across the two

sites. Implement staffing moves. Surgical consultants are contacted by the PC management

team to support with timely discharges and creation of flow. Review requirement for delivery of non critical services with a

view to deploy staff into clinical areas Critical review of planned activities across all staff groups to

focus on patient care and flow





Actions Identification of surgical patients in surgical wards and in AU2

who are near discharge and suitable for a move to SSSU. Appropriate patients would be approved by the on call consultant general surgeon.

Review boarding patients in all planned care wards to ensure plans are in place.

Urology patients admitted to the surgical assessment unit (AU2) are redirected to UDTC.







ActionsManagement plan put in place Huddle discussion and predictor indicates that hospital is able

to accommodate both elective and emergency patients for the day


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Radiology and Diagnostic Action Card







Actions Continue with previous actions Continue to review inpatient demand and accommodate

activity expect to cancel non urgent outpatient examinations.







Actions Consultant discussion to prioritise inpatients to facilitate flow

and discharge. Review requirement for routine CT inpatient activity out of

hours/weekend. Inform Everlight of expected activity increase. Expect increase in QMH inpatient requests. Review outpatient appointments to increase inpatient capacity Review outpatient appointments to increase inpatient activity.





Actions Monitor waits for inpatient examinations Inform Clinical Services Manager when waits breach longer

than 72 hours for routine request Expect urgent outpatient requests to increase as patients

discharged. Monitor requirement to increase service provision Continue to monitor inpatient waits Consultant discussion to prioritise inpatients to facilitate flow

and discharge






ActionsPerform all inpatient activity in relation to clinical urgency, urgency determined by clinical history on order comm request.

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Page 1 of 3

DATE OF MEETING: 25 September 2019TITLE OF REPORT: Orthopaedic Elective Project Progress ReportEXECUTIVE LEAD: Carol Potter, Director of Finance REPORTING OFFICER: Alan Wilson, Project Director



Finance, Performance & Resources Committee 10 September 2019


NHS Fife has instigated the next stage of the Scottish Capital Investment Manual (SCIM) process for the development of a new Elective Orthopaedic Centre. This involves the production of an Outline Business Case (OBC) for submission to the Scottish Government Capital Investment Group (CIG) by early October to meet the initial timelines as set out in the Initial Agreement Document (IAD).

Background

The new Elective Orthopaedic Centre construction project has key milestones set out in the IAD and the purpose of this report is to provide assurance to the Committee on progress against these key milestones.

Assessment

The project is progressing at pace and is meeting all current key milestones. The 1:200 scale floor plan drawings have been agreed in principal with all stakeholders at the Project Team meeting on 29th August with some further discussion on the single room ratio to be arranged.(Appendix 1).

By agreement of the floors plans this has now given the design an agreed Gross Internal Floor Area (GIFA) to allow for the initial cost plan to be developed and provide assurance on design affordability at an early stage. The design is now frozen at this stage until these assurances are confirmed.

The architect is now producing an external façade design for the approval of the project team and some proposed images are attached in (Appendix 2).

A presentation of the current proposed design and project update was given by the team to NHS Fife Board at their development session on 28 August and the feedback from the Board members was positive.

An SBAR was submitted to the NHS Fife Endowment Board of Trustees meeting on the same

NHS Board

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date to ask for their support in principle to use charitable funds to enhance the patient’s experience of the service, ranging from external facilities to the use of new technology methods. Trustees were supportive of this approach and further work will be undertaken in due course.

A communications plan has been developed to ensure targeted and timely engagement with key stakeholders including staff, patients, visitors to the Victoria Hospital as well as partner organisations and contractors leading up to and throughout the period of the Elective Orthopaedic Centre works.

The next key stage is completion of the Outline Business Case (OBC) for consideration by various groups as detailed below.

October 2019 •15th October OBC will be submitted to SG Capital Investment Group

November 2019 •5th November -NHS Fife Finance, Performance & Resources Committee to review and to recommend approval by NHS Board •6th November - NHS Fife Clinical Governance Committee, information only •12th November - SG Capital Investment Group Meeting– for review and approval (subject to confirmation of Board approval) •27th November - NHS Fife Board Meeting – for approval

Recommendation

Board members are asked to:

Note the progress made to date

Objectives: (must be completed)Healthcare Standard(s): AllHB Strategic Objectives: AllFurther Information:Evidence Base:Glossary of Terms: SCIM – Scottish Capital Investment Manual

OBC – Outline Business CaseCIG – Capital Investment GroupIAD - Initial agreement DocumentGIFA – Gross Internal Floor Area

Parties / Committees consulted prior to Board Meeting:

FCIGFP&R Committee

Impact: (must be completed)Financial / Value For Money Increase in costs/ unable to meet all service needs if costs

increase.Risk / Legal: Failure to meet key milestones causing delay in business

case process.Quality / Patient Care: Potential quality issues/ Delays leading to inadequate

facilities.Workforce: Workforce issues will be addressed through the OBC

process

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Equality: Equality issues will be addressed through the OBC process

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NHS Fife Board

DATE OF MEETING: 25 September 2019 TITLE OF REPORT: Capital Investment – Kincardine and LochgellyEXECUTIVE LEAD: Nicky Connor, Interim Director Health and Social Care REPORTING OFFICER: Claire Dobson, Divisional General Manager (West)

Purpose of the Report (delete as appropriate)For Decision

Route to the Board (must be completed)Fife Capital Investment Group – 30th August 2019 NHS Fife Clinical Governance Committee – 4th September 2019 NHS Fife Finance, Performance and Resources Committee - 10th September 2019


NHS Fife has recognised that Kincardine and Lochgelly Health Centres are facilities that do not meet all current standards and limit high quality, modern and integrated patient care.

Authorisation was given by the Capital Planning Group to begin to look at potential capital investment to meet patient and service needs. The Initial Agreement Documents (IADs) were previously submitted to Scottish Government who requested that the model of care be articulated more fully and that Fife participate in the national pathfinder programme for Local Care; to support transformational change that shifts the balance of care to community.

The Scottish Capital Investment Manual (SCIM - http://www.scim.scot.nhs.uk/) provides guidance and support in the effective delivery of infrastructure projects within NHS Scotland. There are four main stages, Strategic Assessment (SA), Initial Agreement Document (IAD), Outline Business Case (OBC) and Full Business Case (FBC).

This paper relates mainly to the IAD stage for Kincardine and Lochgelly. National and local strategies have been taken into account in preparing these IADs.

The Executive Summaries for Kincardine (Appendix 1) and Lochgelly (Appendix 2) are attached. The full IADs are embedded within the two Executive Summaries.

[Note the Capital Planning Group has now been revised and is called the Capital Investment Group (CIG)].Background

Following recognition that Kincardine and Lochgelly Health Centres do not meet current healthcare standards and limit high quality, modern and integrated patient care, Strategic Assessments (SAs) for both areas were developed in 2016 and involved engagement of key stakeholders. The SAs were presented to the Capital Planning Group in March 2016 when approval was given to move to the next stage of the planning process – preparation of the IADs.

A significant amount of work is involved in preparing an IAD, including collection of service

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http://www.scim.scot.nhs.uk/

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activity, developing data projections, developing investment objectives, undertaking an option appraisal, preparing a Benefits Register, a Risk Register and a Design Statement.

NHS Fife was successful in securing funded support from Hub East Central Scotland Limited (Hubco) to assist in the development of the IADs. The work to inform the content of the IADs commenced in May 2016 and was completed in March 2017.

A number of workshops and events were held to inform the developing IADs and involved engaging a wide group of stakeholders which included GP Practices, other healthcare professionals, Social Work and other Fife Council colleagues, Community Councils and elected members. Most of the workshops were specific to either Lochgelly or Kincardine, but when appropriate - with Stakeholder’s agreement - the workshops were combined. A summary of the engagement is included within the Executive Summaries, with full details of the process followed and the outcomes detailed in the IADs.

Subsequently the Partnership has worked with Scottish Future Trust and their consultants Carnell Farrah to develop the model of care. The Partnership attended three workshops and has drawn on learning from the initial phase of the Community Health and Wellbeing Hub implementation.

National and local strategies (including the NHS Fife Clinical Strategy and Fife Health & Social Care Partnership Strategic Plan 2016-2019), and the SCIM guidance were followed in preparing these documents.

It is worth noting that the General Practice in Kincardine is contracted to NHS Forth Valley and representatives from Forth Valley have been included in the work to date and representation / discussions will be continued throughout the business planning process. Assessment

Fife Health and Social Care Partnership is working with local communities, teams and stakeholders to support the delivery of a fully integrated 24/7 community health and social care model that ensures sustainable, safe, individual partnerships of care. New models of care will be technology enabled, recognising advancing technologies and the value that will offer in terms of less dependency on buildings, support capacity and changing population needs. Consideration is also being given to the requirements of the GMS contract and new models for primary care which involve a multi-professional approach to care with service delivered locally wherever possible. Following the IADs development process, including the non-financial option appraisal, the preferred options at this time are:

LochgellyA clearly preferred direction of travel (new build in Lochgelly to deliver the developing service model) and site option (Francis Street) along with a mandate to further explore / develop this option in the short term subject to the outcomes of formal financial appraisal.

KincardineA clearly preferred direction of travel (new build in Kincardine to deliver the developing service model) and site option (Tulliallan Primary School) along with a mandate to further explore / develop this option in the short term subject to the outcomes of formal financial appraisal.

The IAD’s highlight the stakeholder groups that have been engaged in the workshops and who

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are likely to support the preferred options, unless something radical changes.

The Scottish Health Council has confirmed that engagement to date has been in line with the Scottish Government guidance of Informing, Engaging and Consulting the Public in Developing Health and Community Care Services (CEL 4 2016).

We have assumed that any change in service provision will be through redesign and that there will be no additional revenue costs, other than through the Primary Care Investment Fund.

Indicative costs for each of the short listed options are included in the Executive Summaries and full IADs.Recommendation

For Decision

Approve the direction of travel following the non-financial option appraisal (subject to formal financial appraisal) for Kincardine and Lochgelly as outlined in the Assessment section above.

Approve submission to the Scottish Government Capital Investment Group.

Objectives: (must be completed)Healthcare Standard(s): I experience high quality care and support that i right for

me.I experience a high quality environment if the organisation provides the premises.

HB Strategic Objectives: SustainableClinically ExcellentPerson Centred

Further Information:Evidence Base: N/AGlossary of Terms: IADs - Initial Agreement DocumentsParties / Committees consulted prior to Health Board Meeting:

Fife Capital Investment GroupNHS Fife Clinical Governance Committee NHS Fife Finance, Performance and Resources Committee

Impact: (must be completed)Financial / Value For Money Indicative costs for each of the short listed options have been

prepared as per the guidance in the SCIM. These costs, along with the assumptions they are based on, are detailed in the Executive Summaries of the IADs.

Further detailed costs will be developed as the OBCs and FBCs are prepared.

An assumption has been made that there are no increased revenue costs and that any change in service provision will be through redesign.

Risk / Legal: A Risk Register has been prepared and will be reviewed at each Project Board meeting.

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Detailed planning with Estates and Facilities colleagues will ensure all legislation and guidance is complied with.

Expectations within both communities have been raised by the work to date, there may be a risk to the organisation, if these expectations are not met.

Quality / Patient Care: As summarised in the “ Summarising the need for change” section within the Executive Summaries (and full IADs):

- Improved capacity to deliver an increased range of services in an integrated way

- Potential to target health inequalities- Modern, safe and fit for purpose premises that comply

with all legislation and guidance, improving performance in clinical and estates services

- Improved accessibility- Ability to provide group work

[Note: further work with NHS Forth Valley is required to facilitate increased service provision and care]

Workforce: Significantly improved physical environment - Clinical- Care- Staff facilities- Patient group work could be undertaken- Improved education / meeting facilities

Facilities - Safer and more cost effective environment

Staff representatives have been involved in the work to date and as more detailed planning is undertaken they will be fully involved in the design of the buildings to ensure modern, fit for purpose facilities are provided.

Equality: The Board and its Committees may reject papers/proposals that do not appear to satisfy the equality duty (for information on EQIAs, click here EQIA Template click here

Has EQIA Screening been undertaken? YesBelow are the links to SIAs for Kincardine and Lochgelly that have been completed and published.

http://intranet.fife.scot.nhs.uk/Publications/index.cfm?fuseaction=publication.display&objectID=29B1AB9C-02CB-7D86-171D1B07728A9841

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https://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=2350F996-65BF-00F7-D88A727668E553A1&subjectid=5AC0DA91-914B-47DB-A964-32D811AA3B91&objectid=C7A564CE-01FC-A63A-91223A9E2008696D

https://intranet.fife.scot.nhs.uk/subjects/index.cfm?fuseaction=service.display&pageid=2350F996-65BF-00F7-D88A727668E553A1&subjectid=5AC0DA91-914B-47DB-A964-32D811AA3B91&objectid=C7A564CE-01FC-A63A-91223A9E2008696D

https://intranet.fife.scot.nhs.uk/Publications/index.cfm?fuseaction=publication.display&objectID=9C19A68C-FE95-4AA0-90E674A265233402




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http://intranet.fife.scot.nhs.uk/Publications/index.cfm?fuseaction=publication.display&objectID=29B34372-E5CC-3B6C-5AD05314B0AD6DE9

EQIA’s for both projects will be undertaken and then updated as the planning process is worked through.

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Kincardine Community Health and Wellbeing Centre ProjectInitial Agreement Document

Project Owner: Claire Dobson, Divisional General Manager, West Division Fife H&SCP

Project Sponsor: Nicky Conner, Interim Director, Fife H&SCP Date: 23/08/19

Version: 2.3Version HistoryVersion Date Author(s) Comments1 Feb 2018 CD/LE Approved by IJB2.02 16/087/2019 CD/ Updated in Line with Local Care SFT Consultant Report

and in line with SCIM guidance2.3 23/8/19 CD Updated in line with discussion with Scottish

Government Local Care Team

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Contents1. Executive Summary 3

1.1. Introduction 31.2. Organisational Overview 31.3. Strategic Direction and Context 41.4. Drivers for Change, Investment Objectives and Options Appraisal 7

2. Strategic Case: Existing Arrangements and Need for Change 102.1. Service Arrangements 102.2. Service Details 122.3. Strategic Context 142.4. Drivers for Change 192.5. Investment Objectives 202.6. Proposed Benefits 20

3. Strategic Risks, Constraints and Dependencies 223.1. Risks 223.2. Constraints and Dependencies 223.3. Critical Success Factors 23

4. Economic Case 244.1. Do Nothing / Do Minimum Option 244.2. Engagement with Stakeholders 254.3. Service Change Proposals 254.4. Indicative Costs 294.5. Options Appraisal 294.6. The Preferred Option 304.7. Design Quality Objectives 304.8. Design Statement 32

5. Commercial Case 335.1. Outline Commercial Case 33

6. The Financial Case 346.1. Capital Affordability 346.2. Revenue Affordability 35

7. The Management Case 377.1. Governance Arrangements 377.2. Proposed Project Resources 377.3. Project Plan 387.4. Stakeholder Engagement and Support 38

8. Conclusion 408.1. Review of Strategic Assessment 408.2. Preferred Option 40

Appendices 41Strategic Assessment 41Benefits Register 43Risk Log 46

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1 EXECUTIVE SUMMARY

1.1 INTRODUCTION1.1.1 Fife Health and Social Care Partnership is working with local communities, teams and

stakeholders to support the delivery of a fully integrated 24/7 community health and social care model that ensures sustainable, safe, individual partnerships of care. The purpose of this Initial Agreement (IAD) is to seek approval to develop an Outline Business Case to re-provide Kincardine Health Centre in purpose designed and built premises within Kincardine to provide the necessary infrastructure to support this goal.

1.1.2 The IAD establishes the need for investment, building on the NHS Fife and Fife Health and Social Care Partnership strategic goals to deliver a model of local care, focused on individual outcomes, supported by health and social care delivered by the right person in the right place at the right time. It describes the appraisal of a long list of options, identifies the short list, and recommends a preferred way forward, together with indicative costs, to enable the delivery of Fife’s Community Health and Wellbeing Hub model within the Kincardine community.

1.1.3 The vision for primary care and community services in NHS Fife and Fife Health and Social Care Partnership is to enable the people of Fife to live independent and healthier lives. We will deliver this by working with people to transform services to ensure these are safe, timely, effective and high quality, focused on achieving personal outcomes. This requires access to the right professional at the right time in the right place; where services can be provided within a community setting, closer to where service users live, they should be. Care should be provided in an environment that supports staff to provide an excellent experience and has modern facilities that meet the needs and expectations of service users, carers and staff well into the late 21st century.

1.1.4 The people of Fife have told NHS Fife and Fife Health and Social Care Partnership, through a wide range of engagement vehicles and the formal consultation which informed the Clinical Strategy and Joining Up Care programme that they:

would like services to be integrated, coordinated and person focused; want to reduce the duplication they experience both in sharing their

information and in service delivery; value local delivery.

1.1.5 Fifes’ Community Health and Wellbeing model is delivering prevention and early intervention by:

working with local health and social care practitioners, using local knowledge and data to identify people earlier

co-producing tailored interventions to deliver holistic assessment, outcome focused planning and care management,

maximising opportunities for local community treatment and care bringing local health and social care practitioners (including housing,

voluntary sector and local area coordinators) together to collaborate to meet people’s outcomes

enhancing rapid access to locality assessment and rehabilitation simplifying communication and information sharing for service users, carers

and staff

1.2 ORGANISATIONAL OVERVIEW 1.2.1 Kincardine Health Centre, located on the edge of the village, provides General

Medical Services through Clackmannan and Kincardine Medical Practice who are

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contracted by NHS Forth Valley, as part of a two centre practice arrangement. Community services are provided by both NHS Fife (including District Nursing, Health Visiting and Podiatry) and NHS Forth Valley (the majority) for Kincardine residents. Services are working to deliver high quality person-centred health and social care services in a way which promotes and enhances the health and wellbeing of the people of Fife.

1.2.2 The Kincardine Health Centre Practice population is circa 3,200, the locality population is predicted to grow by 9%1 in the 25 years. However the population in the older age group is projected to increase by 52%, this will see the proportion of the practice population who are frail, whom our local care model has demonstrated benefit from integrated holistic care management, grow from 4% to 5%.

1.2.3 The current facility is a 1930’s construction, originally built as a police station. Models of care have changed over time with the building considerably modified and extended throughout its lifetime. Our new model of working requires accommodation that is fit for purpose, which enables multi disciplinary and group working, which supports the community and partners to deliver collaboratively. The current building and configuration is not fit for purpose, the building does not work for modern health and social care delivery, with corridors and treatment rooms which do not meet minimum standards, areas which do not enable disabled access and no storage.

1.2.4 The development of the health and wellbeing model and delivery of the new General Medical Service Contract is constrained by structural and layout constraints. All possible reasonable changes have been made to the existing building. Kincardine Health Centre fails to meet the spatial, organisation and design standards for Primary and Community Health Care premises and has no capacity for further growth. Major improvements to address maintenance and statutory standards will not facilitate significant improvements in space utilisation to meet patient quality, staff standards and efficiency objectives.

1.3 STRATEGIC DIRECTION AND CONTEXT1.3.1 Our ambition is that from the youngest to the oldest, the fittest to the frailest the

371,910 people of Fife live well. Our aim is to join up services to provide better experiences of care, as locally as possible, by fully embedding the community health and wellbeing hub model across Fife.

1.3.2 NHS Fife Clinical Strategy sets the strategic direction with Fife Health Social Care Partnership that is focused on local early, preventative care. By working with partners to improve the health of local people and the services they receive, while ensuring that national clinical and service standards are delivered across the NHS system, we will strengthen primary care and community services. This will be achieved by working with practices to fully develop practice level multi disciplinary working, delivering local community care and treatment, maximising proactive early intervention through community teams focused on segmented populations and ensuring rapid access to complex assessment, rehabilitation and when required bed based intermediate care within localities.

1.3.3 Our vision requires a flexible and responsive model that works with people to define the outcomes they want to achieve, enabling people to maximise their health and wellbeing by utilising their own and community assets, responsively adding and adapting services to meet and sustain outcomes. Figure 1 below seeks to illustrate how we can layer services when required and adjust support and care incrementally. Our goal is to maximise opportunities for services to work together locally as soon as possible, while minimising duplication for the patient and services.

1 Local Strategic Assessment 2018, Fife Council Research Team

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1.3.4 In Fife by fully engaging with the public, people who use health and social care services and their carers, partners and staff we have developed a community health and wellbeing hub model to support independence, improve wellbeing and care. To ensure fully person responsive, integrated support for health and wellbeing Fife is redesigning mental health provision, community intermediate bed models, while embedding our community health and wellbeing hubs. Integrating with the new model for General Medical Services, services and community groups requires facilities which enable colleagues and communities to work together. If practitioners and partners are to support people as effectively as possible, by for example minimising multiple attendances and maximising the potential of local multi disciplinary working, they require facilities which support this.

1.3.5 Fife’s community health and wellbeing hub model is underpinned by early identification within Primary Care. Using practice level data to segment population needs is enabling a targeted, timely approach based on need rather than referral criteria; colleagues are proactively working in partnership with people in their local community. This approach can improve outcomes so that:

People are supported to stay at home or in a homely setting for as long as possible.

Staff are equipped to support this in terms of knowledge, skills, processes and resources.

The organisation maximises use of planned services.

1.3.6 Having worked with Scottish Futures Trust (SFT) we are able to articulate more fully how this model can be scaled up for Fife to support people and improve their outcomes. People are often referred to a number of services. The Hub model supports these services to come together, locally, to tailor their support to individual needs. This ensures people access the right service for their needs at the right time. Often people access services too late. By using local information to identify needs sooner, we can maximise people’s health and wellbeing. People can feel that their care is uncoordinated and there is duplication. By developing care management people have one person who is their main point of contact:

Proactive case finding – to maximise early intervention / complex case management / anticipatory care planning, using practice data and local clinical intelligence.

Figure 1

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Integrated earlier intervention – Practice level multi disciplinary team (MDT) working collaboratively, with co-ordinated local case management or locality level complex case management.

Where there is social complexity – locality MDT working together locally to plan and deliver integrated care focused on individual outcomes.

Where there is medical complexity – rapid assessment via local complex assessment and rehabilitation centres and if required with diagnostics at a locality level with local follow up.

The scope and develop programme to implement the model fully across Fife is in year two of three.

1.3.7 The focus is on working with people earlier to reduce the proportion of people who enter the health and social care ‘system’ at the orange to red / right-hand end of the spectrum of care in Figure 1 .This maximises people’s potential including for rehabilitation, and releases resources to support urgent care, while providing capacity for meaningful planning with people and their families. Initial test data indicates that people with frailty who receive the care management intervention are experiencing fewer unscheduled hospital admissions – the average being 5 in the 12 months pre intervention and an average of 1 in the six months post intervention. Staff describe how they are more able to collaborate and reduce referrals and timescales through the locality MDT model. The assessment and rehabilitation centre testing is supporting more timely access with reduced waiting times (17 weeks to less than a week), a reduction in Did Not Attends from 20% to 2% and combining assessments with mental and physical health.

1.3.8 Fife Health & Social Care Partnership (H&SCP hereafter) vision is being delivered by enabling integrated care that crosses the boundaries between primary, community, hospital and social care, with GPs, hospitals, health workers, social workers, social care staff and others working together as one system. This more co-ordinated approach is reducing the need for people to navigate their way through what can be a bewildering maze of specialist services. This is supporting delivery against the Partnerships (draft) revised priorities of:

Priority 1 – Working with local people and communities to address inequalities and improve health and wellbeing outcomes across Fife.

Priority 2 – Promoting mental health and wellbeing. Priority 3 – Working with communities, partners and our workforce to transform,

integrate and improve our services. Priority 4 – Living well with long term conditions. Priority 5 – Managing resources effectively while delivering quality outcomes

1.3.9 The proposal for investment into fit for purpose health and social care facilities in Kincardine will not only support the delivery of clinical services and but also enable the delivery of our community health and wellbeing model delivering these key priorities within the Kincardine area. The strategic assessment (Appendix 1) outlines how the current facility hampers this.

1.3.10 The following list identifies key national and local documents that have influenced the

development of this proposal, although this is not an exhaustive list.

1.3.11 Quality Strategy ambitions in relation to:

Person centred care - through improving access to Primary Care and providing more care closer to home;

Safe – reducing risk of infection through provision of modern fit for purpose accommodation;

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Effective – bringing together wider range of health and care services to make more effective use of resources.

1.3.12 2020 Vision aspirations are that everyone can live longer healthier lives at home, or in a homely setting with focus on improving quality of care, improving the health of the population and providing better value and sustainability. The Public Health priorities for Scotland (2018) support investment for local integrated delivery.

1.3.13 The Public Bodies (Joint Working) (Scotland) Act 2014 aims to improve outcomes for people by creating services that allow people to stay safely at home for longer with focus on prevention, anticipation and supported self-management, and to provide opportunities to co-locate health and care services working together for the local population.

1.3.14 The Scottish Government’s Nursing 2030 Vision: Promoting Confident, Competent and Collaborative Nursing for Scotland's Future (2017) sets the direction for nursing in Scotland through to 2030 and focuses on Personalising Care, preparing nurses for future needs and roles, and supporting nurses. In particular for Community Nurses the Chief Nursing Officer Directorate Transforming Nursing, Midwifery and Health Professions (NMaHP) Roles Paper Three includes shifting the balance of care from hospital to community and primary care settings at or near people’s homes. With integrated teams of Community and Practice Nurses providing seamless care.

1.3.15 Promoting the wellbeing of children is central to the work of Health Visitors and this is supported by the new Universal Health Visiting Pathway and the Named Person role conferred by Children and Young People (Scotland) Act (2014).The Universal Health Visiting Pathway sets the standard for Health Visiting and the minimum core visits that families with children aged 0-5 years can expect from their Health Visitor, regardless of where they live, this is seeing investment in the workforce to support full implementation.

1.3.16 The 2018 General Medical Services Contract in Scotland refocuses the role of General Practitioners as expert medical generalists and recognises that general practice requires collaborative working with enhanced multidisciplinary teams that are required to deliver effective care, joint working between GP practices in clusters and as part of the wider integrated health and social care landscape.

1.3.17 The Community Health and Wellbeing Hub programme in Fife has been selected to participate in a national Local Care Pathfinder Programme, together with Caithness and Ayrshire’s Garvock Valley, sponsored by the Scottish Futures Trust on behalf of the Scottish Government. The goal of the porgramme is to facilitate the shift in the balance of care to community care., The intention is to produce three projects that deliver transformational change in the provision of care from hospital based care to community based care, so people’s health and wellbeing is supported as close to home as possible. The Fife Health and Social Care Partnership is being supported by Scottish Futures Trust and Carnell Farrar (specialist health care planners) to progress the redesign.

1.4 DRIVERS FOR CHANGE, INVESTMENT OBJECTIVES AND OPTIONS APPRAISAL1.4.1 The key drivers for change and investment objectives are summarised below at

Table 1:

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Table 1Effect of the need for change on the organisation

Investment Objective

1 South West Fife is experiencing significant population growth in the older population. The Medical Practice, Community Health and Social Care services do not have the infrastructure to currently deliver the service requirements of the current population nor deliver the objectives of the new General Medical Service’s (GMS) contract and more local health and social care delivery to improve individual outcomes and minimise unscheduled hospital care.

Ensure equal access to Primary Care and Community Services for the whole population. As a national pathfinder site, the Partnership is seeking to realise key service transformation ambitions with modern, fit for purpose infrastructure to allow staff and community partners to better support local community health and wellbeing

2 Pressure on existing staff, accommodation and services will inevitably increase.

Ensure the right staff skill mix and service capacity are available to deliver strengthened and tailored local capacity to manage people’s health and care within their local community.

3 Staff facilities and accommodation are restricted with staff working in suboptimal conditions, impacting poorly on staff morale and the community’s experience of local service delivery.

Ensure appropriate workforce including increased flexibility of roles /development of new roles to support implementation of GMS (2018) and Community Health and Wellbeing Hub.

4 The facilities available, combined with significant change in population, restrict the ability to deliver a wider multi disciplinary model locally. There is no capacity in local facilities to deliver group therapy, physiotherapy and the components of care and treatment within the new GMS

Provide the infrastructure to support a more integrated seamless service across health and social care, minimising travel and multiple appointments for the community.

5 Services cannot be delivered locally based on local patient need, but instead are based on where it is more convenient/possible to deliver services.

Improve the patient and user experience - deliver services locally based on local patient need.

6 The Equalities Act 2010 compliance within the building is poor - discriminating between the experiences of service users.

Accommodation that complies with all legal standards and regulatory requirements and gives equality of access for all.

7 Some clinical rooms are very small, failing to meet current standards due to the age and design of the building. These can be very restrictive/ unsuitable for patients and staff.

To deliver safe and effective care with dignity - provide facilities which ensure the safe delivery of healthcare in line with guidelines and standards.

8 There is no scope to enhance the primary and community care services provided in the existing accommodation including transferring the right care closer to patients’ homes.

To deliver services more effectively and efficiently - facilitate better joint working to ensure right care is delivered at the right time and in the most appropriate setting. By delivering locally the community of Kincardine will be supported to timely access and reducing difficult travel arrangements for appointments in neighbouring Clackmannanshire.

1.4.2 A wide range of possible options for investment were considered using the options framework. These were reviewed and the resultant options short list (including indicative costs) is included in the table below:

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Option Description Indicative Capital Cost (£)

Option 6b New build at Feregait site in Kincardine 3,846,621

Option 6c New build at Station Road site in Kincardine 3,903,627

Option 6d New build at Tulliallan Primary School in Kincardine 3,903,627

1.4.3 An options appraisal process was completed with the community, assessing each of the options on its ability to deliver the investment objectives. Option 6d (Tulliallan) was identified as the preferred option from this analysis. Further detailed work will be undertaken during the Outline Business Case (OBC hereafter) stage to fully confirm the service scope, costs, phasing, and timescales.

1.4.4 This Initial Agreement Document, the first of three document phases, details our thinking in terms of the most important issues which shape our strategic priorities and how these align nationally and across NHS Fife/Fife Health and Social Care Partnership.

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2 STRATEGIC CASE: EXISTING ARRANGEMENTS AND NEED FOR CHANGE

2.1 SERVICE ARRANGEMENTS2.1.1 The holistic multi disciplinary primary and community care services in Kincardine are

currently delivered from the existing Kincardine Health Centre, a 1930’s constructed facility – originally built as a police station - that has been considerably modified and extended throughout its lifetime. The building is owned by NHS Fife.

2.1.2 GP services in Kincardine are delivered as part of a two centre practice, along with Clackmannan Health Centre, with each operational unit given equal standing and operating full time to meet their respective local needs. The GP Practice is contracted to NHS Forth Valley to provide General Medical Services.

2.1.3 The services delivered from the existing Kincardine Health Centre are primarily provided in support of the population needs of the people of Kincardine and surrounding areas, with 98% of the resident population registered (see figure 2- map of Kincardine interzone) with the practice. In accordance with NHS Fife’s statutory obligation to provide access to Primary Medical Services there is a requirement to continue provision of these services within this geographic area.

Figure 2

2.1.4 Aligned to the Practice there are a range of community health services provided from the current facility including District Nursing, Health Visiting, Midwifery and Podiatry. In addition there are services working with the Practice and wider community team who cannot access accommodation locally, requiring patients to travel to them, this includes Mental Health Nursing and Physiotherapy. There are dependencies with the District General Hospital at Forth Valley Royal Hospital Larbert and Local General Hospital at Queen Margaret Hospital, Dunfermline, and other hospitals in East Region for provision of diagnostic services, consultant advice, elective and unscheduled inpatient care and outpatients for a variety of specialties to meet the health care needs of their local population. The Forth Valley Primary Care Out of Hours Service and Fife’s Primary Care Emergency Service provide out of hours care from other facilities.

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2.1.5 The GPs together with the multi-disciplinary team manage the widest range of health problems; providing both systematic and opportunistic health promotion, diagnoses and risk assessments; dealing with multi-morbidity; coordinating long-term care; and addressing the physical, social and psychological aspects of patients’ wellbeing throughout their lives.

2.1.6 As figure 1 (page 5) above portrays, the GPs and multidisciplinary team are integrally involved in deciding how health and social services should be organised to deliver safe, effective and accessible care to patients in their community. Practice based multi disciplinary team working is identifying people who could benefit from a case management approach and supporting people to access the right support where there is:

Complexity in their care and support arrangements through locality multi disciplinary teams, or

Clinical complexity rapid access to assessment through the locality community health and wellbeing hub teams.

2.1.7 Kincardine Medical Practice has a current practice population of 3198 (May 2019), which has grown by 3% over the past 18 months. The current demographic of the population (based on 2011 census, 2016 SIMD datazone data and ISD practice data) are:

50.7% female: 49.3% male 24% are over the age of 65 and 13.4% are 0-15 years 9.1% of the population are income deprived, 10.8% of the population are

employment deprived and 14.4% of children (under 16) live in poverty 0.1% of the practice population live in the most deprived quintile and 0% on the

least deprived 25.9% of patients of the practice have at least one long term condition.

2.1.8 Projections for future demand for primary care and community services with Kincardine are driven by the population projections which see the older population growing by 52% by 2041. This would therefore see the practice population who have severe frailty grow from 23 to 35 and those with moderate frailty grow from 92 to 140. It is this group whom Community Nursing are seeking to work with to maintain and improve their position on the life curve through the care management intervention and the wider hub programme is seeking to support through local delivery of rehabilitation programmes.

2.1.9 The current workforce delivering services is outlined below along with potential future workforce required to deliver primary care and community services. Recent and continuing changes to the workforce are being phased in line with population growth and service model developments which take into account the requirements to implement the GMS (2018) contract and enhance the primary healthcare team, community health and social care teams and Health Visitor pathway. The Practice is also a training practice with a GP trainee and provides training placements for 5th year medical students.

Existing Provision

Recent growth

Future provision * Incl. new roles

General Practitioners 2.35 WTE 0.25 WTEAdvanced Nurse Practitioner 0.6 WTE 0.6 WTEPractice Nursing (2) 0.78 WTE 0.05 WTEPractice Phlebotomist 0.1 WTEPractice Manager (shared with 1 WTE

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Clack)Admin staff (8) 4.1 WTE 1.46 WTEDistrict Nursing Team (3 shared with High Valleyfield)

2.2 WTE Treatment room service extensionHosiery / Doppler follow up clinicsExtending the range of treatment for patients who could attend the centre

Community Phlebotomist (2) 0.12 WTE 12 sessions per month

Community Teams Admin Staff 0.2 WTEGP Trainee (1)Visiting teams WTE Sessions Future provision

* Incl. new rolesPrimary Care Pharmacist Circa 0.5wteMidwifery Team (0.1 wte) 2 per monthHealth Visiting clinic Baby weighing

0.05 wte0.05 wte

1 per monthHV also arrange ad hoc appointments

Opportunity to hold child wellbeing meetings locally

Physiotherapy 4 per month Podiatry 0.3 wte 12 per monthMental Health Nursing (Primary Care)

4 per month

Smoking Cessation specialist (0.13 wte) See patients in Clacks.

Opportunity to deliver locally

Child immunisation clinic 4 per month Potential future flu clinic

Social Workers / Social Care Workers

0 MDT time

Continence Nurse 4 per monthDermatology Nurse 4 per month

2.2 SERVICE DETAILS2.2.1 The accommodation in Kincardine(Building report at appendix 1), provided over one

level with a total floor area of 237m2, supports:

GP activity associated with the Kincardine Medical Practice (circa. 13,000 appts PA and a practice population of circa. 3,200)

Nurse activity associated with the Kincardine Medical Practice (circa. 6,400 appts PA)

Practice employed Phlebotomist activity associated with the Kincardine Medical Practice (circa. 2260 appts PA)

Community nursing treatment room activity (circa. 1,500 episodes PA) Community Phlebotomy services (circa. 1,325 episodes PA) Midwifery ante-natal clinic activity (circa. 200 appts PA) Podiatry services (circa 410 appts. PA) Health Visiting Stop Smoking sessions (circa. 200 appts PA) Mental Health Health Visiting Clinic Physiotherapist

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2.2.2 The primary care and community services have been developed as far as possible however the development of the clinical model and increasing demand for services has exacerbated the issues of an inefficient layout, internal and external envelope deterioration. Whilst the GP Practice and Health and Social Care Partnership are working collaboratively to modernise and expand services to improve outcomes and support the population growth, development is severely constrained by the existing premises.

2.2.3 Services delivered from the existing Kincardine Health Centre amount to a total of circa 25,000 attendances per annum, 96 attendances per day or around 23 patients / clinical room activity per day.

2.2.4 Patients initial experience is very poor with one small reception hatch and reception area of 40m2 (NB No separate records area now exists as all GP records are held electronically). There is one waiting area (total 22m2) with no age-specific provision. Local Politicians have indicated their concern about the fabric of the building and the constraints it places on the local delivery of integrated health and social care.

2.2.5 Clinical care is delivered through five poorly configured consulting rooms which also support administrative activity. These are distributed throughout the current facility and, for the most part, used very flexibly. With 100% utilisation of the available capacity it is clear that a lack of available space is impacting upon the provision of local care. Mixed function means sub optimal use of clinical space. The AEDET review exercise confirmed that the layout and fabric of the building place considerable limitations on effective and safe service delivery (page 29).

2.2.6 The office accommodation available for the administrative functions is well below the minimum standards and staff facilities are insufficient for the 21 staff working in the building on a daily basis as well as the wide range of visiting colleagues.

2.2.7 Although all possible reasonable changes have been made to the building Kincardine Health Centre fails to meet the spatial, organisation and design standards for Primary Health Care Premises and has no capacity for further growth. It has reached the end of its economic life as a clinical facility. Major improvements to address maintenance and statutory standards are not feasible due to structural and layout constraints.

2.2.8 A number of services are only available from the Clackmannan Health Centre because of capacity constraints. Resulting in patients from Kincardine travelling to Clackmannan to see a health professional, with best estimates indicating that this may be as many as 2,000 times per annum. People may be asked to attend Clackmannanshire for stop smoking support, physiotherapy, mental health nurse consultation, coil insertion/removal, implant insertion/removal and joint injections as well as medicals such as fostering or DVLA medicals. It is extremely difficult to put an actual figure on this, as the baseline number has not been recorded historically and there is good anecdotal evidence to suggest that Kincardine patients would rather cancel / delay an appointment rather than travel to Clackmannan – further masking the true size of the problem.

2.2.9 Local and proactive care is further confounded by problematic public transport to Clackmannan from Kincardine; there are no direct public transport (bus) routes. One appointment may take up to three hours out of a patient’s day.

2.2.10 Where services are not/cannot be delivered locally in Kincardine, patients are referred to different locations – mostly within the NHS Forth Valley Board area - that include: Clackmannan Health Centre (GP overflow activity)

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Forth Valley Royal (Out-patient activity) (unless specifically requested by patient to be referred to a Fife hospital)

NHS Fife provided services e.g. Physiotherapy provided in other Fife locations Community Nursing provide home based support for people who are not

housebound, meaning that fewer patients are being seen than could be seen within a clinic setting, with wider MDT input potential.

2.2.11 Out of Hours Primary Care is delivered from Urgent Care Centres in Fife and Forth Valley. Both Health Boards do not have current plans to extend the number of Urgent Care Centres. Kincardine Health Centre does not routinely deliver out of hours services, but offers a small number of clinics over an extended period.

2.2.12 It is not feasible to deliver evening services from the health centre.

2.2.13 The model of care is developing in line with the new GP Contract, with the Primary Care Development implementation plan progressing along with the Business Planning process. Historical re-development of the facility has meant that many areas originally designed to provide essential support functions have been lost in a drive to maximise clinical consultation space. This means that the facility no longer has any meaningful storage (with a consequential impact on consulting rooms and staff morale); does not have a clean utility room; does not have a dirty utility room; does not have a disposal hold; does not have any cleaner’s room / facilities; does not have a quiet / interview room; or an effective disabled WC.

2.2.14 This is effectively demonstrated by comparing the baseline Schedule of Accommodation of the current Kincardine Health Centre with that proposed for a replacement facility that has been developed based on the current and developing clinical model, future capacity requirements and relevant health planning guidance. Such a comparison shows that, even although the number of consulting rooms has only increased by three from the baseline (an increase of circa. 40/ 60m2 gross), the actual area now required is around 593m2 greater (833m2 as compared to 240m2).

2.3 STRATEGIC CONTEXT2.3.1 NHS Fife Clinical Strategy sets the strategic direction with Fife H&SCP that is

focused on local early, preventative care. In working with partners to improve the health of local people and the services they receive, while ensuring that national clinical and service standards are delivered across the NHS system we will strengthen primary care and community services.

2.3.2 Our vision requires a flexible and responsive model that works with people to define the outcomes they want to achieve, enabling people to maximise their health and wellbeing by utilising their own and community assets, adding and adapting services responsively to meet and sustain outcomes.

2.3.3 Our development of community health and wellbeing hubs is designed to flexibly and responsively layer services where required, adjusting support and care incrementally. In light of the changing demography this has focused on supporting people to minimise and modify the impact of frailty (including younger people frail because of long term conditions, addictions etc). Providing holistic assessment and care management, focused on individual outcomes, anticipatory planning and supporting a reduction in unscheduled care. Fife has a population of 371,910 (2018 midyear population estimates, National Registers Scotland), with slightly above the Scottish average for the over 65’s age group described in Table 2.

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Table 2

Total Population 65+ 75+ 85+Fife 371,910 20% 9% 2%Scotland 5,438,100 19% 8% 2%

2.3.4 Fife H&SCP has seven localities. Kincardine is in the South West Fife locality. The South West Fife locality sits within the West Division of the H&SCP. The H&SCP is developing a locality clinical model with GP Clusters focused on the needs of the locality population. Table 3 demonstrates the percentage of locality populations over 75.

Table 3

Population over 75 ( 75+City of Dunfermline 3928 7%Cowdenbeath 3360 8%Glenrothes 4109 8%Kirkcaldy 5549 9%Levenmouth 3560 10%North East Fife 7192 10%South West Fife 3845 8%

2.3.5 Over the next 25 years the total population within South West Fife is projected to increase by 9% by just around 4,600 by the year 2041. Most of the areas’ population growth is expected to take place in the older people age group, an increase of circa 52% which will place and increasing demand on health and social care.

Figure 3

Population - 2016 49,777Population estimate – 2041 54,400

2016 20410-15 17.1% 17.5%16-64 63% 55%65+ 19.7% 27.5%

2.3.6 The Local Development Plan indicates that housing developments will see circa 317 new homes built by 2032 (potentially an additional 790 people). The local development plan includes potential for the development of a further 259 homes within the Kincardine Health Centre catchment area.

2.3.7 The local and national goal, supported by NHS Fife’s Clinical Strategy (2016-21), NHS Forth Valley Healthcare Strategy (2016-21) and the Fife Health and Social Care Partnership’s Strategic Plan for Fife 2016-2019 (currently being revised) is to provide safe, effective and sustainable care at home or as close to home whenever possible. The model being implemented will support robust, integrated health (primary and community), social care and third sector services with a strong focus on early intervention, prevention, anticipatory care and supported self management.

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2.3.8 The proposal for investment into fit for purpose health and social care facilities in Kincardine will not only address the current strictures upon local delivery of clinical services and deficiencies in facilities at the existing Kincardine Health Centre but also enable the delivery of the above key areas within the Kincardine area.

2.3.9 The well rehearsed pressures in General Practice in Scotland can be illustrated by the following indicators: 10% of the population consults with a GP practice clinician every week. 34% of all GPs are aged 50 and over in 2015, compared with 29% in 2005. 37% increase in female GPs and 15% decrease in male GPs over the ten-year

period to 2015. 40% of female GPs leave the profession by the age of 40. 2015 – 1 in 5 GP training posts unfilled.

2.3.10 Fife’s Primary Care Improvement Plan sets out how primary care and General Practice are reshaping to implement the new GMS 2018 Contract. This is facilitating the development of GPs as expert medical generalists within expanded Primary Health Care Teams, by implementing new roles and ways of working. This is underpinned by the guiding principles of:

Contact: accessible care for individuals and communities. Comprehensiveness: holistic care of people – physical and mental health. Continuity: long term continuity of care enabling an effective therapeutic

relationship. Co-ordination: overseeing care from a range of service providers.

2.3.11 Care pathways are patient (not disease) centred to meet the challenge of shifting the balance of care, realising Realistic Medicine and enabling people to remain at or near home wherever possible. Local accessibility and the need to provide a wider range of services to people in their local communities and to develop greater local integration is being hampered by the accommodation available within the Kincardine area.

2.3.12 Local accessibility and improved joint working with other Health and Social Care Partners as part of wider whole system will facilitate integration of health and social care and enable more effective delivery of health and wellbeing outcomes. This will be underpinned by practice multi disciplinary team working, supported by responsive wider locality teams in reaching to deliver local care.

2.3.13 Key national and local documents have influenced the development of our health and care model and thereby this proposal, although this is not an exhaustive list. It should be noted that along with Caithness and Ayrshire Fife’s Community Health and Wellbeing Hub programme has been selected as a national pathfinder site to support a Once for Scotland approach to delivering the shift in the balance of care from hospital to community.

National

Commission on the Future Delivery of Public Services (The Christie Report) (June 2011).

2020 Vision for Health and Social Care (September 2011). Healthcare Quality Strategy (2012). A National Clinical Strategy for Scotland (February 2016). Health and Social Care Delivery Plan (December 2016).

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Property Asset Management Strategy (2017). NHS in Scotland 2016 – Audit Scotland Report, October. Achieving Excellence in Pharmaceutical Care: A strategy for Scotland Aug 2017. General Medical Services Contract (2018). Health and Social Care Integration – Audit Scotland November 2018. Nursing 2030 Vision: Promoting Confident, Competent and Collaborative Nursing

for Scotland's Future (2017)

Local

Health and Social Care Partnership Strategic Plan for Fife Plan (draft 2019-2022).

NHS Fife Clinical Strategy (2016-21). NHS Fife Estates Rationalisation Strategy (2017). NHS Fife Operational Delivery Plan (2018/19).

The corresponding relevant documents from Forth Valley also support integrated local working:

NHS Forth Valley Healthcare Strategy (2016-21). NHS Forth Valley ‘Our Delivery Plan’ 2018/19.

2.3.14 This proposal interacts with these key local and nation strategies in terms of:

Quality Strategy ambitions in relation to:

Person centred care - through improving access to Primary Care and providing more care closer to home;

Safe – reducing risk of infection through provision of modern fit for purpose accommodation;

Effective – bringing together a wider range of health and care services to make more effective use of resources.

2020 Vision aspirations are that everyone can live longer healthier lives at home, or in a homely setting with focus on improving quality of care, improving the health of the population and providing better value and sustainability.

Technology Enabled Care projects are being tested within the current service model to modernise primary care, support earlier identification and self management.

NHS Fife’s clinical strategy and Operational Delivery Plan are focused on delivering person centred care, closer to home where possible. The proposed development will support the local provision of health and social care services within Kincardine, facilitating person centred care and support.

The 2018 General Medical Services Contract refocuses the role of General Practitioners as expert medical generalists and recognises that general practice requires collaborative working, with enhanced multidisciplinary teams that are required to deliver effective care, joint working between GP practices in clusters and as part of the wider integrated health and social care landscape. Better care for patients will be achieved through:

Maintaining and improving access; Introducing a wider range of health professionals to support the expert medical

generalist; Enabling more time with the GP for patients when it is really needed; and Providing more information and support to patients.

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The Public Bodies (Joint Working) (Scotland) Act 2014 aims to improve outcomes for people by creating services that allow people to stay safely at home for longer with a focus on prevention, anticipation and supported self-management, and provide opportunities to co-locate health and care services working together for the local population. Fife’s local Health and Social Care Strategy describes how the nine National Outcomes for Integration can be met through prevention, local earlier integrated working focused on peoples own outcomes.

Promoting the wellbeing of children is central to the work of Health Visitors and this is supported by the new Universal Health Visiting Pathway and the Named Person role conferred by the Children and Young People (Scotland) Act (2014).The Universal Health Visiting Pathway sets the standard for Health Visiting and the minimum core visits that families with children aged 0-5 years can expect from their Health Visitor, regardless of where they live. This will require an increase in the Health Visiting establishment and new ways of working for full implementation.

The Scottish Government’s Nursing 2030 Vision: Promoting Confident, Competent and Collaborative Nursing for Scotland's Future (2017) sets the direction for nursing in Scotland through to 2030 and focuses on personalising care, preparing nurses for future needs and roles, and supporting nurses. Within this framework redesign in community nursing is supporting the implementation of the Chief Nursing Officer Directorate’s paper on Practice and Community Nursing to integrate locally to support prevention and early intervention.

Fife Health and Social Care Partnership, established on 1st April 2016, is refreshing its strategic plan, this includes revised Vision, Mission and Values. The plan is focused on delivering proactive, integrated support and, therefore, will seek to secure an outcome focused model delivered locally aimed at securing improved outcomes through early identification and intervention:

The Vision is To enable the people of Fife to live independent and healthier lives.

The Mission is “We will deliver this (vision) by working with individuals and communities, using our collective resources effectively. We will transform how we provide services to ensure these are safe, timely, effective and high quality and based on achieving personal outcomes.”

Our Values are: Person-focused - Integrity – Caring - Respectful - Inclusive - Empowering

This will support local delivery of the national outcomes for integration.

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2.4 DRIVERS FOR CHANGE2.4.1 The following is a full list of the main drivers causing the need for change, the effect

that these issues are having on the current service provision and an assessment of why it is believed action is required now.

Table 4Driver for change:

What effect is it having, or likely to have, on the organisation? Why action now:

Primary, Community and Voluntary sector services cannot provide the integrated model of care they and the community recognise is required now and for the future.

The model of care is being undermined now: preventing locally based, integrated proactive care.Time from Initial Agreement to occupation of a new facility could take circa 4 years.

Services cannot be delivered locally for local patient need; instead are based where it is possible to deliver services.

NHS Fife/Fife H&SCP will fail to deliver the GMS (2018) and community health and wellbeing hub model within Kincardine unless this is planned for.

The clinical and social care model have developed and implementation is being circumscribed.

Pressure on existing staff, accommodation and services will inevitably increase.

Sustainability of primary care is a key priority for the IJB and NHS Fife. There is a need to plan to provide a sustainable service for the future.

Existing facilities fall far below the required standards in terms of how they are configured and laid out. The Equalities Act 2010 compliance within the building is poor.

Existing facility configuration and layout presents unacceptable risks, as well as poor local performance, functional in-efficiency and suboptimal patient experience.

Premises are functionally inadequate and compromise pro-active, integrated care.

No scope exists to re-organise parts of the service to improve the experience.

Poor clinical and non clinical functionality and space restrictions in existing accommodation (configuration) Some consulting rooms are very

small and do not meet current standards. These are very restrictive / unsuitable for patients and staff.

Poor patient and staff experience. Does not meet current recommended standards.

Capacity is unable to cope with current, let alone future projections of need. Patients are required to make repeated appointment to meet with different members of their multi disciplinary team and to access healthcare out-with the local area.

Service sustainability and development is at risk and an increasing number of patients will travel from Kincardine to Clackmannan for basic Primary Care.

Clinical and social care functionality (capacity) issues

Facilities lack the number and range of support areas necessary to deliver modern, integrated, safe and effective services

A lack of essential support areas represents a real and unacceptable risk to the Board in key areas such as HAI and patient safety.

Building issues (Including statutory compliance and backlog maintenance)

Increased safety risk from outstanding maintenance and inefficient service performance

Building condition and associated risks will continue to deteriorate if action is not taken now, affecting performance.Redesign of building will allow for improved care, staff experience and financial performance.

2.5 INVESTMENT OBJECTIVES2.5.1 This section identified the ‘business need’ in relation to the current arrangements

described in section 2.1. These were discussed at the Architecture & Design

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Scotland (A&DS) facilitated workshop to develop the project design statement. A wide range of stakeholders including clinical and managerial staff along with community representatives were involved in a workshop to describe the difference between ‘where we are now’ and ‘where we want to be’.

Table 5

Effect of the need for change on the organisation:

Investment Objectives

Existing service arrangements are affected by lack of clinical support service facilities.

Ensure equal access to a patient centred approach by enabling delivery of and access to local anticipatory and preventative care for patients.

Implementation of integrated models of care is undeliverable locally in the current environment

Ensure equal access to modern integrated care with provision driven by patient need rather than limitations in physical capacity.


Ensure the right staff skill mix and service capacity are available to deliver and strengthen local capacity to manage people’s health within the local community.

The facilities available, 100% occupancy, combined with significant population change, restrict the ability of the parties to deliver the full range of integrated services locally.

Enable earlier access to proactive and anticipatory care through local delivery via integrated seamless service across health and social care.

Existing configuration, as a result of a 1930’s building, being modified and extended with a ‘best fit’ approach.Current facilities have treatment rooms below minimum acceptable standards.

Delivery of safe and effective care with dignity –by providing facilities which comply with all legal standards and regulatory requirements and gives equality of access for all.

Increased safety risk from outstanding maintenance and inefficient service performance.

Improve safety and effectiveness of accommodation by improving the physical condition, quality and functional suitability of the healthcare estate.

2.6 PROPOSED BENEFITS2.6.1 There is a clear emphasis on General Practice provision and the development of the

community health and wellbeing hub model within the IJBs’ Strategic Plans and NHS Fife and Forth Valley’s Clinical Strategies. The proposed investment in infrastructure will enable the Kincardine Medical Practice to fully participate in the required programmes of care, enable full access to the Primary Care Improvement Plan and thereby improve outcomes for individuals, experience for staff and the reputation of the organisation.

2.6.2 Benefits for each of the investment objectives described in section 2.5 above are mapped to the expected benefits in the context of the Scottish Government’s five Strategic Investment Priorities (Safe; Person-Centred; Effective Quality of Care; Health of Population; Efficient: Value and Sustainability).

2.6.3 To ensure that resources are effectively exploited and that any investment made provides agreed benefits a register has been developed. This benefits register (see appendix 2) identifies the expected benefits, indicates a baseline and target measurement and also gives a priority level to each benefit. A Benefits Realisation Plan will be developed as part of the Outline Business Case.

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Table 6Investment Objective Benefit Investment

Priority1. Ensure equal access to a patient

centred approach by enabling delivery of and access to local anticipatory and preventative care for patients.

GP Practice Multi Disciplinary Team and wider community hub team have access to accommodation to meet population needs locally

Person CentredHealth of PopulationIntegrated CareQuality of Care

2. Ensure equal access to modern integrated care with provision driven by patient need rather than limitations in capacity.

Services delivered locally based on need

Person CentredEfficientEffectiveIntegrated Care

3. Ensure the right staff skill mix and service capacity are available to deliver and strengthen local capacity to manage people’s health within the local community.

Higher staff retention levelsHigher staff morale/lower absence rates Increased flexibility of rolesCareer progressionImproved workforce planning across the health and social care pathwaySupports training, education and development

Person CentredEfficientEffectiveValue and Sustainability Integrated Care

4. Enable earlier access to proactive and anticipatory care through local delivery via integrated seamless service across health and social care.

Access to wider staff skills and experience on one siteReduces unnecessary hospital referrals / multiple appointmentsReduces patient risk

Effective Quality of CarePerson CentredIntegrated Care

5. Delivery of safe and effective care with dignity – by providing facilities which comply with all legal standards and regulatory requirements and gives equality of access for all.

Improves patient experience addressing privacy and dignity issuesImproves staff safety through provision of primary care & community services on one site allowing for available support for patients and staff.Ease of compliance with standards e.g. Equalities Act 2010, HAI Fit for purpose flexible accommodation meeting all guidelines e.g. room sizes

SafePerson CentredQuality of CareIntegrated Care

6. Improve safety and effectiveness of accommodation by improving the physical condition, quality and functional suitability of the healthcare estate.

Increased local provision and access to treatment making best use of available resources by having the infrastructure to deliver more proactive prevention and early intervention focused support, maximising MDT working to facilitate access for people and thereby reducing the call upon unscheduled care.

Effective Quality of CareEfficient: Value and Sustainability

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3 STRATEGIC RISKS, CONSTRAINTS AND DEPENDENCIES

3.1 RISKS3.1.1 Recognising that one of the main reasons when change projects are unsuccessful in

terms of cost and time overruns and/or failing to deliver the expected benefits is the failure to properly identify and manage the project risks a Project Risk Register has been developed. Risks at the Initial Agreement Stage of the Project have each been assigned an owner and mitigation action identified (appendix 3).

3.1.2 The key areas of risk relate to:

Capital envelope does not support the preferred way forward. Clinical and care models may change and not be adequately planned for The programme may be delayed : further impacting on service delivery Engagement: in terms of maintaining positive stakeholder engagement Acquisition of land: initial discussions have been held with Fife Council in relation

to the possible purchase of land.

3.1.3 These risks will then be reviewed in more detail at the Outline Business Case stage. The process of risk management will continue throughout the life of the project and then transfer to the operational management of the organisation.

3.2 CONSTRAINTS AND DEPENDENCIES3.2.1 Financial: given the current climate it is recognised that the project is likely to be

constrained financially. The affordability of the project will continue to be fully tested through each of the approval stages; this will include the development of a fully detailed revenue model within the Outline Business Case. Once the project budget is set, the project will require to be delivered within this.

3.2.2 Programme: given the risks associated with the current arrangements, there is a need to deliver the project as quickly as possible.

3.2.3 Quality: the project will require to comply with all applicable healthcare guidance and achieve the Achieving Excellence Design Evaluation Tool (AEDET) pre-defined target criteria across all categories.

3.2.4 Sustainability: as the preferred option is a new build there will be a requirement to achieve British Research Establishment Environment Assessment Method (BREEAM) ’excellent’.

3.2.5 Site: as the preferred option is a new build within a live environment, delivery of the project will be restricted and constrained. Careful planning will be required to plan how the project can be delivered efficiently and safely with minimal disturbance to surrounding services and areas.

3.2.6 Dependencies associated with the build phase will be tested in development of the OBC.

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3.3 CRITICAL SUCCESS FACTORS3.3.1 In addition to the Investment Objectives set out in section 2, the stakeholders have

identified several factors which, while not direct objectives of the investment, will be critical for the success of the project.

Table 7Requirement Description Critical Success FactorStrategic fit Meets agreed clinical

and investment objectives, related business needs and service requirements

Promotes sustainability of Primary Care provision and delivery of 2018 GMS Contract

Consistent with NHS Board’s Clinical Strategy

Supports delivery of NHS Scotland Quality Strategy

Facilitates integration of health and social care services, delivered locally

From Patient perspective:• a facility that is easily accessible,

bright, friendly and airy. • designed so that patients can be

treated with dignity particularly in terms of confidentiality.

Value for money

Maximise the return on the required investment and minimise risks

Service model maintains or reduces revenue costs in the longer term through earlier intervention

Service model enables effective decision making in allocation of resources

Building design maximises efficiency and sustainability

Potential achievability

Is likely to be delivered in relation to the required level of change

Matches the available skills required for successful delivery

The skills and resources are available to implement new ways of working

The H&SCP and the Practice are able to embed new ways of working

NHS Fife are able to deliver the programme to agreed budget and timescales

Technology enablers are available and utilised

Supply side capacity and capability

Matches the ability of service providers to deliver required services

Service providers are available with skills, materials and knowledge

The project is likely to attract market interest from credible developers

Potential affordability

Available capital and revenue resources are sufficient to support the successful delivery of the proposed facility and services

Solution is affordable to all stakeholders

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4 ECONOMIC CASE

4.1 Do Nothing/ Do Minimum option:4.1.1 It is not feasible to continue with the existing arrangements (‘Do Nothing’) as outlined

in Section 2.11, because the building is not fit for purpose. The backlog maintenance required while supporting minimum safety and supporting the building to be water tight will not make it fit for purpose. The do nothing option scored lowest throughout the option appraisal process. The building and footprint likewise mean that a do minimum option is not feasible.

Table 8Strategic Scope

Do Nothing / Do Minimum

Service Provision:

Primary Care services in Kincardine are delivered from the existing Kincardine Health Centre. This former Police Station has been considerably modified and extended throughout its lifetime.Continue with existing service provision with no changes to service provided as outlined in Section 2.11. This will result in insufficient capacity to meet future demand for treatment, restrict proactive integrated care and maintain inequity of access.

Service Arrangements:

The service arrangements will continue as existing with Kincardine Medical Practice; Primary General Medical Services being provided alongside Community, District Nursing and Children’s Services. There will be the risk of being unable to implement GMS (2018) and community health and wellbeing hub model and potential requirement for patients to register with practices outwith their catchment area.

Service Provider and workforce arrangements (at the time of the Option Appraisal):

Workforce arrangements will continue as the existing situation with GP services Community, District Nursing and Children’s Services delivered in the building. The developing integrated Mutli disciplinary mode will be circumscribed with inequity of access and travel implications for both patients and staff. Poor accommodation will continue to be managed as a risk in terms of staff health and safety.Areas originally designed to provide essential support functions have been lost in a drive to maximise clinical consultation space. The facility no longer has any meaningful storage (impacting on consulting rooms); does not have the following: a clean utility room; a dirty utility room; a disposal hold; any cleaner’s room/facilities; a quiet/interview room; or an effective disabled WC.

Supporting assets:

The building presently does not meet the required standards (particularly around spacing and access). The condition of the building will continue to deteriorate. Decant of community services may be required to support practice provision and reducing access for community services.

Public & service user expectations:

Public consultation indicates a strong desire for the delivery of effective GP & Primary Care/Community Care services in Kincardine from one building in a good central location which is all on one level.Services delivered by a wide range of professionals.Strong desire to increase targeted delivery to address inequalities.Single shared staff room.Suitable space for patients who become unwell and need transfer to acute services.

This option will not deliver this in the future and will perpetuate a poor environment with limited facilities and also reduce access to primary and community care services for local residents. It will also continue to impact negatively on confidentiality and dignity, and the organisations reputation.

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4.2 ENGAGEMENT WITH STAKEHOLDERS4.2.1 It was key to have the support of key stakeholders from health and social care staff

and leaders from the local community to define the change required and create the vision for change.

4.2.2 Stakeholders supported this through their participation in the Option Appraisal Exercises and Design Statement workshops.

4.2.3 This will ensure that the vision is shared, is communicated to all who will be impacted by the change and the support from those who have an emotional commitment to the services provided in their community.

4.2.4 Further detailed information on the engagement and involvement with stakeholders completed to date, and proposed throughout the programme is included at section 7.

4.3 SERVICE CHANGE PROPOSALS4.3.1 The initial scope for the Kincardine Health Centre project was to explore design and

scope options to provide a suitable health and social care facility in Kincardine which was of a suitable size and condition to meet with the growing needs of the existing practice and community health and social care team.

Long List

4.3.2 The theoretical long-list of options was initially generated by the NHS and Local Authority teams with the support of Hubco and its advisers, and reviewed throughout the process. This long-list was based on the cross-referencing of strategic theoretical service options available with local site / facility considerations.

4.3.3 Strategic theoretical option themes included:

Strategic Scope Summary1 Service Provision Do nothing (The status quo)

Centralise (currently separate) health care facilities in Fife (Kincardine), Forth Valley (Clackmannan) or somewhere in-between recognising that these sites are staffed by the same practice

Build entirely new and minimise any use of existing buildings (full build)

2 Service Arrangements

Don’t have any specific GP / health facilities locally

3 Service provider/ workforce

Utilise only ‘operational’ solutions to address existing problems

4 Supporting Assets Build new but also make use of existing facilities to support the overall model (reduced build)

Combine a new build or refurbishment proposal with other new / existing developments across the public sector

5 User Expectations The expectations of the public and service users

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4.3.4 The following core long-list of options, in addition to Option 1 do nothing/minimum described above at 4.1, was agreed:

Table 9Option Description Commentary2 Don’t have any

Health Centre building – use existing available public sector estate.

This option was not short-listed as it was completely incapable of delivering the preferred service model, would not deliver the community health and wellbeing hub required and result in an even more fragmented service than at present. It was also reliant upon finding existing spaces that do not exist.

Option Description Commentary3a An operational

solution utilising only the existing Health Centre

Whilst a number of operational solutions are being considered by the Board to address acute short-term crises – and this option is not ‘mutually exclusive’ – it is not capable of addressing anything other than capacity concerns in the very short-term and certainly not any of the physical/facility issues identified. It was consequently not short-listed.

3b An operational solution utilising the existing Health Centre plus space in other local facilities.

This option was assessed as a variation on option 3a), that also sought to access space in other local facilities. It was not short-listed for the same reasons.

Option Description Commentary4a Refurbish & extend

the existing Health Centre facility

This option was not deemed feasible as the current Health Centre building covers the entire curtilage meaning no options for extension or adequate refurbishment exist. It was consequently proven unfeasible and not short-listed.

4b Refurbish other existing facilities.

This option acknowledged the possibility of identifying and refurbishing another local facility however, in the event, no such facility could be found. It was consequently proven unfeasible and not short-listed.

Option Description Commentary5a Reduced new build

on existing Health Centre site (plus use of space in other facilities to be confirmed).

This option involved building a reduced new facility on the existing site that made use of space in other local buildings. It was rejected as not feasible for a number of reasons including the cost/disruption associated with decant and lack of facilities to support either the reduced new build element or decant. The option was consequently not short-listed

5b Reduced new build on land at Feregait (plus use of space in other (?) facilities)

This option was rejected as no additional suitable facilities could be identified.

5c Reduced new build on land at Station Road (plus use of space in other (?) facilities)

This option was rejected as no additional suitable facilities could be identified.

5d Reduced new build on land at Tulliallan Primary School (plus use of space in other (?) facilities)

This option was rejected as no additional suitable facilities could be identified and no way could be found to link into the existing school facility.

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Option Description Commentary6a Full new build on

existing site for Kincardine services only

This option involved a full new build on the existing site that was entirely self-contained and intended to deliver Kincardine services only. It was not short-listed as the site is too small for the required area as well as having significant cost, disruption and operational challenges associated with decant to support demolition and re-building.

6b Full new build on the Feregait site for Kincardine services only

This option involved a full (self-contained) new build on the Local Authority owned Feregait site. It was deemed feasible and consequently short-listed.

6c Full new build on the Station Road site for Kincardine services only

This option involved a full (self-contained) new build on the Local Authority owned Station Road site. It was deemed feasible and consequently short-listed.

6d Full new build on the Tulliallan School site for Kincardine services only

This option involved a full (self-contained) new build on part of the Local Authority owned Tulliallan Primary School site. It was deemed feasible and consequently short-listed

Option Description Commentary7a Full (combined) new

build on existing site for Kincardine & Clackmannan services

This option involved a full new build on the existing site that was entirely self-contained and intended to deliver the combined services currently delivered separately in Kincardine and Clackmannan by the same GP practice. It was not short-listed as any option that involved centralising existing services in any single location was not deemed acceptable by any of the stakeholders involved. This included NHS Fife and NHS Forth Valley in recognition of the fact that the practice and its delivery locations straddle both Board areas

7b Full (combined) new build at Feregait site

This option was not short-listed as any option that involved centralising existing services in any single location was not deemed acceptable by any of the stakeholders involved.

7c Full (combined) new build at Station Road site

This option was not short-listed as any option that involved centralising existing services in any single location was not deemed acceptable by any of the stakeholders involved

7d Full (combined) new build at ANOther site in Kincardine


7e Full (combined) new build at ANOther site in Clackmannan.


7f Full (combined) new build at ANOther site “between” Kincardine & Clackmannan.


4.3.5 The benefits criteria against which the long list were assessed were initially drafted by the wider planning team in light of the strictures placed upon the clinical model by

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the facility associated challenges identified. These were refined during the option appraisal events into an agreed list based on global stakeholder opinion.

4.3.6 Importantly, this list was also developed with the support of the stakeholder group reviewing options related to a similar business case being developed for Lochgelly in order to ensure that both projects, which have similar objectives and timescales, were able to benefit from each other’s work through the development of an agreed list of benefits criteria that were weighted independently.

4.3.7 In summary, the benefits criteria reflected the ability of each identified option to, noted in order of highest to lowest weighting: Deliver an optimal physical environment. Be readily accessible. Support flexibility and sustainability. Support local and national service strategies. Deliver wider community & public benefits.

4.3.8 The Partnership is committed to delivering services that are integrated and maximise opportunities for local delivery. It has been formally confirmed that there is an on-going requirement to continue to deliver GP, primary care and local clinical services separately from Kincardine and Clackmannan in recognition of population, local clinical needs and geographical considerations. Consequently all option 7s, were not taken forward to the short-list.

4.3.9 Specific site/facility considerations included: The existing NHS owned Health Centre site in Kincardine. A Local Authority owned site at Feregait. A Local Authority owned site at Station Road. Part of the Local Authority owned Tulliallan Primary School site.

4.3.10 Whilst a number of other potential sites were raised and considered, they were all excluded at this stage as they were either demonstrably too small and / or not in public sector ownership. On this latter point it was noted that a site that was not currently in the ownership of the public sector would only be considered if none of the public sector sites was deemed appropriate based on the appraisal process.

4.3.11 It was acknowledged by all concerned at the outset and throughout the appraisal process that sites are extremely limited in the Kincardine area and that this would inevitably present a significant challenge to the project.

Short List

4.3.12 The short-list was largely shaped by: A complete lack of suitability/options regarding the current site. A complete lack of facilities in the Kincardine area to present refurbishment

opportunities or additional supportive capacity for the integrated health and social care model.

A very limited range of additional sites/opportunities.

4.3.13 The short list consequently included four options:Table 10

Option Description1 Do Nothing (The Status Quo)6b New build at Feregait site in Kincardine (for Kincardine services only)6c New build at Station Road site in Kincardine (for Kincardine services only)6d New build at Tulliallan Primary School in Kincardine (for Kincardine services only)

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4.4 INDICATIVE COSTS4.4.1 Indicative costs for each of the options on the Short List have been prepared as per

guidance in the Scottish Capital Investment Manual by Hubco. The non preferred options are based on BCIS Tender Price Indices – updated to 4th quarter 2020. The preferred option is based on elemental cost/m2 from other recent health centre projects and the current Schedules of Accommodation (updated to 4th quarter 2020).

Table 11Description Capital

Costs (£) *

Whole Life Capital Costs (£)

Whole Life Operating Costs (£)

Est. NPV (£)

Est.EUV (£)

1 Do Nothing/Base - - 1,749,291 723,705 28,5202 (6c) Kincardine Stn 3,903,627 769,948 10,293,636 6,368,662 250,9793 (6b) Feregait 3,846,621 758,689 10,220,763 6,307,702 248,5774 (6d) Tulliallan School 3,903,627 769,948 10,293,636 6,368,662 250,979

4.5 OPTION APPRAISAL4.5.1 The following table outlines how the advantages and disadvantages of the short list

were assessed against the benefits criteria. This was undertaken through a process of discussion / debate within groups with the intention of seeking consensus agreement around the relative merits of each option and scores to be applied.

Table 12

Option1: Status Quo

Option 6b:Feregait

Option 6c: Station Rd

Option 6d: Tuliallan

Advantages(Strengths & Opportunities)

Established location.

Purpose built facility. Good central location.Good pedestrian and vehicle access.Secure location. Good service access.Good parking.

Relatively close to town centre.Relatively flat site, for 1 level building.Good pedestrians and vehicle access.Secure location. Good community setting.Flexibility – with potential expansion options.Ease of segregated access.

Central location.Good physical site.Good local and physical access.Community Campus opportunity.High visibility.Increased flexibility.Ability to segregate access for staff/patients/ servicing.Access from A977.

Disadvantages(Weaknesses & Threats)

Building and curtilage not suitable for further development

Potential flood risk.Site investigation required (mining?).Ground conditions make development expensive.Infrastructure issues.

Potentially too overlooked.Impacts on village green.Potential flood risk.Site investigation required (mining?).Ground conditions make development expensive.Infrastructure issues.Public transport – slight walk.Access road may not be suitable for construction traffic.

Loss of school / community amenity space.Potentially contentious road issues.Potential flood risk.Site investigation required (mining?)Ground conditions make development expensive.Infrastructure issues.

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Option1: Status

Quo

Option 6b:

Feregait

Option 6c:

Station Rd

Option 6d:

TuliallanInvestment ObjectivesEnsure equal access to Primary Care and Community Services for the whole population No Yes Yes Yes

Ensure the right staff skill mix and service capacity are available to deliver strengthened and tailored local capacity to manage people’s health within their local community.

No Yes Yes Yes

Ensure appropriate workforce including increased flexibility of roles /development of new roles to support implementation of nGMS and Community Health and Wellbeing Hub.

No Yes Yes Yes

Provide a more integrated seamless service across health and social care. No Yes Yes Yes

Improve the patient and user experience - deliver services locally based on local patient demand. No Yes Yes Yes

Accommodation that complies with all legal standards and regulatory requirements and gives equality of access for all.

No Yes Yes Yes


No Yes Yes Yes

To deliver services more effectively and efficiently - facilitate better joint working to ensure right care is delivered at the right time and in the most appropriate setting

No Yes Yes yes

Weighted score 221 539 509 739Preferred / Possible / Rejected Rejected Possible Possible Preferred

4.6 THE PREFERRED OPTION4.6.1 The preferred solution is Option 6d: A new build on the Tuliallan Primary School site,

owned by Fife Council. Option 6d represents a clearly favoured option for all stakeholders, with little to choose between options 6b and 6c for second place.

4.6.2 The proposal has the support of representative service users, carers, staff, the GP Practice and all other key stakeholders.

4.6.3 It is recommended that NHS Fife proceeds to Outline Business Case, exploring Option 6d: New build Tuliallan Primary School site in more depth.

4.7 DESIGN QUALITY OBJECTIVES4.7.1 A key part of the development of the Initial Agreement Document (IAD) was to ensure

that stakeholders were fully engaged in the NHS Scotland Design Assessment Process (NDAP).

4.7.2 There were two key strands to this work;

1) A multi-stakeholder event where the Achieving Excellence, Design Evaluation Tool (AEDET) was completed for the existing unit.

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2) An NDAP Design Statement was developed to capture the ‘non-negotiable’ points that need to be addressed by the project.

4.7.3 AEDET on Existing Property: An AEDET Workshop was held on 21 February 2017.

4.7.4 The existing unit at Kincardine was reviewed. A Benchmark Score was achieved with the resultant Target Score as below at Table 13.

Table 13

Descriptor Benchmark TargetUse 1.0 4.3

Access 1.1 4.4Functionality

Space 2.0 4.2Performance 1.3 4.4Engineering 1.4 3.4

Build Quality

Construction 0.0 4.0Character and Innovation 1.3 4.4

Form and Materials 2.1 4.4Staff and Patient Environment 1.3 4.5

Impact

Urban and Social Integration 2.6 4.3

4.7.5 NDAP Design Statement: A multi-stakeholder event was held on Friday 3 March 2017. This event was facilitated by Architecture and Design Scotland (A&DS) where

AEDET Refresh Benchmark Summary

AEDET Refresh Target Summary

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the group discussed the non-negotiables in terms of requirements from the perspective of patients, staff and visitors.

The Patients Perspective

The patient’s perspective was reviewed in terms of their initial approach to the centre through to waiting for their appointment. There was a consensus on the expectations for a facility that was easily accessible, bright, friendly and airy. It was agreed that the facility should be designed so that patients could be treated with dignity particularly in terms of confidentiality.

The Staff Members Perspective

Staff groups were clear that they would want the facility to enable different staff groups’ paths to cross. Staff want to feel safe in accessing and egressing the facility. Suitable investment in information technology and teaching facilities is also expected as well as staff change, shower and communal staff room facilities.

The Visitor/Carer Perspective

It was agreed that carer’s should be able to accompany patients and be easily accommodated in the waiting and consulting spaces with access to support information at hand.

A smaller private waiting space is required to support patients and carers who are challenged by open spaces or who themselves are exhibiting challenging behaviours.

4.8 DESIGN STATEMENT

4.8.1 The event enabled participants to clearly describe the attributes the building must possess, this will support the development of the detailed business case. The business objectives the project seeks to achieve are:

To provide current clinical service requirements locally and reduce the number of referrals to other service providers and additional attendances required.

Deliver group based activities. A key strand of NHS Fife’s Clinical Strategy is to reduce health inequalities by reconfiguring services and resources so that there is equity of access to services across Fife and across all patient groups. Care should be provided at home or as close to home as possible. Delivering services in a group environment will allow a greater number of NHS Fife residents be supported in their management of their own well-being.

To meet Outcome 3, 5 and 9 of the National Outcomes for Integration, i.e. that people who use Health and Social Care Services have positive experiences of those services, and have their dignity respected; health and social care services contribute to reducing health inequalities; and resources are used effectively and efficiently in the provision of health and social care services

Improve safety and effectiveness of accommodation by improving the physical condition and quality of the healthcare estate.

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5 COMMERCIAL CASE

5.1 OUTLINE COMMERCIAL CASE5.1.1 The indicative costs for the preferred option at this stage are £3,903,6 excluding VAT.

The current building is owned by NHS Fife, it is therefore anticipated that NHS Fife will lead on the procurement, supported by the IJB, through the Scottish Futures Trust hub initiative.

5.1.2 Hub East Central is the designated procurement vehicle for health projects in excess of £750k in the NHS Fife Board area.

5.1.3 The East Central HubCo can deliver projects through one of the following options:

Design and Build contract (or build only for projects which have already reached design development) under a capital cost option.

Design, Build, Finance and Manage under a revenue cost option.

5.1.4 Design and Build, using NHS Capital is likely to be the most suitable vehicle for this project.

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6 THE FINANCIAL CASE6.1.1 Based on the current costs and assumptions identified in Section 4.4 above, NHS

Fife considers the project to be affordable within the current available capital resources estimated within the Local Delivery Plan. This builds in a significant contingency into the scheme to cover optimism bias and other possible infrastructure and enabling costs. Should Capital costs increase over the agreed budget, the Board would require to acquire Capital funding from elsewhere within the Board’s Capital Programme.

6.1.2 Fife Health & Social Care Partnership has agreed to fund the revenue consequences; which are affordable within the revenue resources available. Should Revenue costs increase, then these additional costs would require to be funded within the Partnership’s overall revenue resource envelope.

6.1.3 In order to make this assessment an overall affordability model has been developed covering all aspects of projected costs including estimates for:

Capital costs for preferred option (including construction and equipment); Non-recurring revenue costs associated with the project; Recurring revenue costs (pay and non-pay) associated with existing

services i.e. baseline costs; Changes to revenue costs associated with service redesign as a direct

result of the development.

6.2 CAPITAL AFFORDABILITY6.2.1 The total capital cost comprises the projected construction cost, supplied by HubCo,

plus all other costs directly related to the project such as VAT and professional fees.

6.2.2 The estimated capital cost associated with each of the short listed options is detailed in the table below:

Table 14 Option 6b:

FeregaitOption 6c: Station Rd

Option 6d: Tuliallan

Construction Cost 1,993,192 2,023,192 2,023,192 Prelimenaries 358,775 364,175 364,175 Fees Stage 1 & 2 & Construction 159,455 161,855 161,855 Hubco Items 75,741 76,881 76,881 Contractor OHP 65,775 66,765 66,765 Contingency / Risk 149,489 151,739 151,739 Planning & Warrant inc Mark Ups 20,000 20,000 20,000Survey Fees 20,000 20,000 20,000 Inflation BCIS TPI 3Q19 - 4Q20 @ 347 67,078 68,073 68,073Optimum Bias 478,366 485,566 485,566Professional Fees 458,750 465,381 465,381

Total Capital Costs 3,846,621 3,903,627 3,903,627

6.2.3 To provide the above Indicative Costs at this Initial Agreement Stage, the following assumptions have been made.

1. The non preferred options are based on BCIS Tender Price Indices – updated to 4th quarter 2020. The preferred option is based on elemental cost/m2 from

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other recent health centre projects and the current Schedules of Accommodation (updated to 4th quarter 2020).

2. The optimum bias % applied is based on the Green Book recommendation of 24% for a standard build.

3. No costs identified for council requirements e.g., bus stops, crossings.4. Land will be available on a long-term lease from Fife Council, therefore, no

costs for land purchase have been included.5. No costs included for demolition as assuming Fife Council would demolish

existing buildings and clear land where appropriate with a corresponding adjustment on any lease costs.

6. Advisers’ costs (included within the Capital Cost figures) are based on Hubco calculations.

7. Discounted Cash Flow (used to calculate NPV and EUV figures) - after 30 years the discount rate adjusts to 3%.

8. Life cycle costs are based on maximum life for a new build.

6.2.4 For comparison, the present backlog maintenance costs recognised for Kincardine Health Centre are circa £99.2k. This represents the estimated cost (excl. VAT, professional fees and enabling costs) to complete all presently recognised backlog maintenance to bring the asset up to 'satisfactory condition'. It does not allow for replacing of any assets due to functionally unsuitability.

6.3 REVENUE AFFORDABILITY6.3.1 The estimated revenue cost for both the baseline (do nothing) and the short list

options are included below:

Table 15

Cost per Annum (£k)Revenue Cost Option1:

Status QuoOption 6b:Feregait


Option 6d: Tulliallan

Estates CostsNon PayEquipment 76 300Heating Fuel And Power 4,928 18320Property Maintenance 3,520 7488Property Rates 6,092 29952Water Charges 3592Facilities CostsPay: Support Services 11006 25701Non PayBedding And Linen 205 700Cleaning 150 500Equipment 0 500General Services 361 1342Post Carriage And Telephones 0 70Printing And Stationery 2 225Property Maintenance 495 1753Surgical sundries 76 150Total Estates & Facilities Costs 26,911 90,592Depreciation Charge 7,057 123,180Notes / Assumptions Actual costs 1) Revenue Costs for proposed site are based

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Cost per Annum (£k)Revenue Cost Option1:

Status QuoOption 6b:Feregait


Option 6d: Tulliallan

2018/19 on current plans of 832m2.2) One-off equipment purchases required in year 1 of £5,280.

6.3.2 The H&SCP estimates that the ability to deliver a more integrated, proactive model locally will support revenue efficiencies. It is not expected that there will be any revenue implication for overall GMS costs on NHS Fife and so has been excluded from this table.

6.3.3 Any changes GPs make to the provision of services within the GP Practice are being developed through Primary Care Improvement Fund.

6.3.4 A full affordability analysis will be undertaken at OBC stage to confirm whether the Capital and Revenue costs associated with the new facility are affordable within the available funding levels.

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7 THE MANAGEMENT CASE

7.1 GOVERNANCE ARRANGEMENTS7.1.1 Governance will be taken forward in line with the Scottish Capital Investment Manual

(SCIM) guidelines, through the NHS Fife Capital and Investment Group and Finance, Performance and Resources Committee.

7.1.2 As the estimated costs of this project are out with the Board’s delegated limited for capital expenditure of £1.5m, there is a requirement to seek the Scottish Governments approval through the Capital Investment Group (CIG).

7.1.3 Under the SCIM guidelines, approval of this Initial Agreement will lead towards developing an Outline Business Case (OBC) to enable the preferred way forward to be identified.

7.2 PROPOSED PROJECT RESOURCES7.2.1 Fife HSCP, together with NHS Fife and the Kincardine Medical Practice, will utilise a

Project Board to develop the business case and manage the process through to approval. The Project Board will comprise:

Table 16Role Individual Capability and ExperienceProject Sponsor Nicky Connor, Interim

HSCP DirectorExperience in leading and ownership of developments.

Project Owner Claire Dobson, Divisional General Manager, HSCP

Experience from delivery of range of capital redesign programmes

Clinical Services Manager, HSCP

Belinda Morgan Experience in modernisation of service delivery models in community care and in project management

Head of Estates Appointee pending Experience from delivery of range of capital redesign programmes

Facilities Manager NHS Fife

Jim Rotherham Experience in delivering similar projects such as Linburn Rd.

Finance Business Partner

Gordon Cuthbert, Finance Business Partner

Responsible for providing financial guidance and scrutiny

Capital Finance/ Planning

Individuals will be identified from a pool of staff who have experience of similar projects

NHS Fife eHealth Representatives will be invited to sit on the project team to ensure collaborative working and identification of any risks and opportunities with regard to technology.

Kincardine Medical Practice

The Partners and Practice Manager provide Primary Care expertise and have sound understanding of local community needs

Other health care professionals will be consulted/co opted as required

7.2.2 The remit of the Project Board is:

To assist the Project Sponsor and Project Owner with the decision-making process and ongoing implementation of the project.

To assist the Project Owner with preparing to meet the assurance needs of the Finance, Performance & Resources Committee, as well as any further enquiries from IJB / NHS Fife’s Board with regard to the project.

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7.2.3 The Project Team will be further developed at OBC stage when key suppliers have been procured.

7.2.4 Those individuals identified above have been heavily involved in developing this Initial Agreement Document and they will continue to be involved in leading the project through subsequent stages providing continuity and a stable environment for the project to achieve its objectives. Users of the Practice have been consulted and will continue to be involved as the project progresses.

7.2.5 A blend of resources will be utilised to deliver this project. The Project Board, Project Director, Stakeholders and Clerk of Works will be internal resources, whilst the Project Manager and Cost Advisor are likely to be procured through utilisation of external suppliers. The Board has used this blend of resource successfully on other projects and feels that it creates a good balance between control, risk transfer, capability and availability. The Board is experienced in delivering projects of this nature within the selected procurement route and is ready to move the project forward to the next stage upon IAD approval.

7.3 PROJECT PLAN7.3.1 A detailed Project Plan will be produced for the OBC. At this stage, the Project Board

is aiming to achieve the milestones shown below:

Table 17Key Milestones DateAppointment of Advisors by SFT January 2016Appointment of Local Care Consultants / Local Care Pathfinder May 2017Initial Agreement approval October 2019First Project Board December 2019Outline Business Case approval February 2020Full Business Case approval October 2020Construction Commences December 2020Construction completion May 2022Commence service July 2022

7.4 STAKEHOLDER ENGAGEMENT AND SUPPORT7.4.1 This proposal impacts on adults, children and young people and their carers who live

in Kincardine who require access to Primary Medical Services and community health and social care. It also impacts upon clinical and support staff currently working within the Health Centre, Medical Practice and locality teams who cannot currently access accommodation in Kincardine.

7.4.2 The table below details the engagement that has taken place to date and the support for the proposal, included the identified preferred solution, received from the stakeholders.

7.4.3 Further engagement with the identified stakeholders in line with SCIM guidance will be undertaken as the project progresses.

Table 18Stakeholder Group Engagement that has taken place Confirmed support for the

proposalNHS Fife Board

The Health Board is fully supportive of this proposal, with Nicky Connor, Interim HSCP Director, taking the lead role in its

The Health Board agreed priority for development in May 2017. The Initial Agreement was previously

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Stakeholder Group Engagement that has taken place Confirmed support for the

proposaldevelopment. approved by the NHS Fife

Board in May 2017.

Patients / service users

Service user and carers representatives have been informed to support their full engagement in the option appraisal. Patients have identified a range of ‘non-negotiable’ that cannot be supported from the current accommodation.

There is a preference from service users for the development to be accessible, bright, friendly and supportive of their dignity and confidentiality.

Kincardine Medical Practice

The Medical Practice deliver Primary Medical services to their Practice population under a 17J contract. The Practice manager and lead GP have been actively involved in the process of developing options and plans for the proposal.

The Practice fully supports the Initial Agreement Document and intend to continue service provision in accordance with the developments within the new GMS.

Staff / Resource

Staff affected by this proposal include: Kincardine Medical Practice Medical, Nursing and Administrative staff. Community service staff including District Nurses, Health Visitors, AHPs, admin and clerical, Social Work and staff from partner health and social care services.

There is support for the proposal from all staff groups.

General public The general public will be affected by this proposal as potential service users or by being neighbours of the existing or proposed future facility. The public were supportive of the Community Health and Wellbeing model within the Joining Up Care Consultation.A Communication and Engagement Plan is being developed to ensure ongoing Stakeholder communication.

Kincardine Community Council have been engaged and are supportive of this development

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8 CONCLUSION

8.1 REVIEW OF STRATEGIC ASSESSMENT8.1.1 The Project Team have reviewed the Strategic Assessment (completed as part of the

first stage of the process – Appendix 1) and the position in terms of the need for change, the benefits that need addressed, the links with National Investment Priorities and the prioritisation scoring, the position remains unchanged.

8.2 PREFERRED OPTION8.2.1 Overall, the non-financial option appraisal process has identified that the current

preferred strategic option is for the service to be delivered from a new build facility to support delivery of integrated health and social care for the Kincardine community.

8.2.2 All of the stakeholder groups engaged in this process:

Are likely to support Option 6d) as an overall preferred option, unless something radical changes.

Do not support the ‘do nothing’ option in any way. See little difference between the relative merits of options 6b) and 6c).

8.2.3 NHS Fife and Fife Health and Social Care Partnership have summarised the need for change in and around the facilities in Kincardine under a number of defined headings within the IAD. These are:

Integrated clinical and care functionality (capacity) issues which have been identified as those problems associated with a lack of local space (area) that is essential for safe, effective, timely and appropriately compliant service delivery, e.g., a lack of clinical support, administrative support, group, sanitary, teaching and specialist areas.

Service capacity related issues that predicate the need for change based on a lack of available physical capacity across the service delivery model that are hampering the delivery of integrated care locally.

Clinical functionality (configuration) issues that seriously challenge the delivery of safe and effective modern services, e.g., access issues, room design, sound attenuation, security, patient flow, etc.

Building and fabric issues including overall condition, suitability, statutory compliance issues and backlog maintenance.

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Appendix 1: Strategic Assessment

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Associated Buildings and Assets

Kincardine Health Centre is a facility that has been extended to around three times its original size. The building is single storey with a flat roof extension that now occupies all of the available land. The building has a baseline area of 237m2 and features a mixture of traditional GP/consulting spaces that includes:

1 x main reception area at a total of 40m2 (NB no separate records area now exists as all GP records are held electronically)

1 x waiting areas (total 22m2) with no age-specific provision

5 x (reasonably sized but poorly configured) consultant / treatment rooms that also support administrative activity and are further compromised through the late addition of cupboards that further reduce their functionality

1 x office (18m2)

Kincardine Health Centre Condition Report

NHS Fife Estates maintain records on the suitability and condition of buildings in its estate. Below is the current information relating to the Kincardine Health Centre building:

Status OccupiedGIA (m2) 235Land Value £40,000Net Book Value £105,475Tenure Owned

Overall, this current situation represents the ‘Do nothing’ option as reviewed and explored as a component of the formal option appraisal exercise conducted as a component of the Initial Agreement process. It has also informed the benchmark data in the Benefits Realisation plan.

Current configuration / layout of Kincardine Health Centre

Building Engineering Statutory FireBacklog (C and Below) £36,394 £ 37,887 £ 24,935 £0.0

Quality C (Not Satisfactory)Space Utilisation O (Overcrowded)Functional Suitability C (Not Satisfactory)

Figure used from surveys were complete in December 2012

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Appendix 2 Benefits register

Benefits Register1. Identification 2. (RAG)

Ref No. Benefit Assessment As measured by: Baseline Value Target Value Importance

Person-centred Benefits

P1Supports people in looking after and improving their own health and wellbeing

QuantitativeMaintenance of PC team consultation rate (includes GP/PN/TR) /1,000 population

6531 6531 5

P2

Ensures that people who use health and social care services have positive experiences and their dignity respected.

Qualitative

Targeted client questionnaire designed to measure overall experience of health and social care delivery

Current patient experience

questionnaires

Future patient experience

questionnaires4

P3 Improves the physical condition of the Healthcare Estate Quantitative Estate physical condition survey

assessment C A 5

P4 Improves utilisation of the Healthcare Estate Quantitative Estate utilisation assessment Over-crowded (100%

utilisation) 80% 5

P5 Improves functional suitability profile of the Healthcare Estate Quantitative Estate functional suitability

assessment C A 5

P6 Reduces the age of the Healthcare Estate Quantitative Estate age/life expectancy 87 years/<5 years <10 years/>25

years 4

P7Improves access to all clinical areas - in particular for those with mobility issues

Qualitative Measured accessibility to all patient/clinical areas

Baseline issues as identified in SA, IA and design brief

Equalities Act 2010 compliance and AEDET scores

5

P8 Improves access to age appropriate waiting areas Qualitative

Availability of a child-specific waiting area that is appropriate to the size of the facility

No child-specific waiting

Child-specific waiting available 4

P9Improves way-finding and access to a main reception point

Qualitative and Quantitative

(i) AEDET score (ii) number of receptions points (i) 1.1 (ii) 1 (i) 4.4 (ii) 1 4

P10Addresses confidentiality concerns associated with existing facility

QuantitativeAbility to hear normal volume conversations from adjacent rooms or outside with windows open

Possible to hear conversations at normal volume

Only possible to hear "raised voices" or "shouting"

5

P11 Addresses confidentiality concerns at reception Qualitative Ability to hear conversations at

reception area from waiting area

Conversations currently take place in

public at reception

Provision of private spaces for sensitive

conversations.

5

P12

Increases the number and range of services available on-site, thereby reducing "hand-off's" and additional attendances

Quantitative

(i) Access to social care services (ii) Access to social work services (iii) Access to LA services on site (iv) Access to voluntary (sign-posting) services on site (v) Access to other relevant "targeted" clinical services on site

(i) No access (ii) No access (iii) No access (iv) Minimal access (v) Minimal access

(i) Sessional access (ii) Sessional access (iii) Sessional access (iv) Sessional access (v) Sessional access

3

1. Identification 2. Prioritisation (RAG)

Ref No. Benefit Assessment As measured by: Baseline Value Target Value Relative

Importance Safety Benefits

S1 Reduces adverse harmful events Quantitative(i) Number of adverse incidents recorded (ii) Severity of adverse incidents recorded

2015-2016 (i) 1 (ii) No harm (IT / security access)

2016-2017 (i) 1 (ii) No harm (communication via NHS FV and NHS F

DN re patient discharge)2017-2018 (i) 02018-2019 (i) 0

2019/20 (i) 1 to date (ii) moderate harm (sharps incident)

Zero events relating to the building / facilities 5

S2 Increases safety of people receiving care and support

Qualitative and quantitative

Addressing baseline issues as identified in SA, IAD and design brief

Baseline issues as identified in SA, IAD and design brief All issues addressed 5

S3 Improves statutory compliance QuantitativeBacklog maintenance costs/m2 associated with statutory compliance elements

71% 100% 5

S4 Reduces backlog maintenance Quantitative Backlog maintenance costs/m2 £422.2/m2 Zero 5

S5 Reduces significant and high risk backlog maintenance Quantitative Significant and high risk backlog

maintenance costs/m2 £404.92/m2 Zero 5

S6Reduces Infections through addressing design, area, fabric and equipment issues

Quantitative (i) Domestic Monitoring Tool (ii) Compliance with local HAI audits

(i) 94% (ii) Several non-compliant issues

(i) 100% (ii) Zero non-compliant issues 5


Ref No. Benefit Assessment As measured by: Baseline Value Target Value Relative Importance

Effective Quality of Care Benefits

E1 Improves the Functional Suitability of the Healthcare Estate Quantitative Estate functional suitability assessment C A 5

E2 Increases access to group learning opportunities Quantitative

(i) The number of group work sessions held locally (ii) The number of people attending group work sessions held locally

(i) 0 (ii) 0 Discussions to realign services underway 5

E3Reduces the number of patients travelling between Kincardine & Clack's for routine appts

Quantitative (i) Reduce the number of appts offered to Kincardine patients at Clack's (i) 2000 (i) 1000

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1. Identification 2. (RAG)Ref No. Benefit Assessment As measured by: Baseline Value Target Value Relative

Importance

Health of the Population Benefits

H1Supports smoking cessation initiatives (12 weeks post quit)

Quantitative

(i) Number of smoking cessation appts delivered locally (ii) Number of clients still not smoking 12 week after session completion

(i) 200 (ii) 18 (i) 240 (ii) 20 3

H2 Supports antenatal access Quantitative(i) Number of ante-natal appointments held locally (ii) DNA rates

(i) 208 (ii) 24

(i) 250 (ii) 15 (enabling patient-led care model where more care will be delivered in the community)

4

H3 Supports child healthy weight interventions Quantitative (i) Number of child healthy

weight appts held locally PA

Zero currently provided from the HC - interventions are provided on an outreach

basis

Option available of providing

interventions from the HC

4

1. Identification 2. (RAG)


Value & Sustainability Benefits

V1 Optimises resource usage Quantitative (i) Consultations/clinical room/day (ii) Number of staffed reception points

(i) 28 (ii) 1 (i) 24 (ii) 1 4

V2 Optimises service delivery model parameters by staff group Quantitative (Overall consultation rate/1,000

population 6531 6531 4

V3 Improves accommodation space utilisation Quantitative Estate utilisation assessment Over-crowded (100%

utilisation)Optimised(80% clinical

utilisation) 5

V4 Optimises overall running cost of buildings Quantitative Facility running costs/m2 and per

appt £70.29/m2 < national average 5

V5 Optimises cleaning costs Quantitative Cleaning costs/m2 and per appt £31.99/m2 < national average 3

V6 Optimises property maintenance costs Quantitative Property maintenance costs/m2

and per appt £12.77/m2 < national average 5

V7 Optimises energy usage costs Quantitative Energy usage & associated costs/m2 and per appt (Kj & £) £25.53/m2 < national average 5

V8 Optimises FM & support services costs Quantitative FM and support services

costs/m2 Contained in V5 Contained in V5 3

V9 Optimises waste costs Quantitative Waste costs £510 per annum In line with Waste Action Plan 4

V10Reduces financial burden of backlog maintenance and/or future lifecycle replacement expenditure

Quantitative Backlog maintenance costs/m2 £422.2/m2 Zero 5

V11 Reduces carbon emissions and/or energy consumption Quantitative (i)Detailed energy/building

assessment (ii)BREEAM rating (i) G (ii) N/A (i) A (ii) "Excellent" 5

V12 Reduces local medicine/prescribing costs Quantitative (i) Medicines cost/registered

patient £186.61 work towards national average 5

1. Identification2.

Prioritisation (RAG)


Importance Wider/Social Benefits

W1 Supports wider town and community planning Qualitative Fits with Local Authority

Planning -

Actions contained within community action plan including: public accessibility networks and enhanced business / economic facilities within the town. [Charrette planned for 2017]

3

Scale / RAG Relative Importance

1 Fairly insignificant2 ↕3 Moderately important4 ↕5 Vital

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Appendix 3 Risk LogProject Risk Log

Last Revised date: July 2019

Ref # RISK DESCRIPTION FINANCIAL NON-FINANCIAL UNQUANTIFIABLE

CONSEQUENCE

LIKELIHOOD RISK SCORE PROPOSED TREATMENT ACTION TAKEN OWNER

01-May 01-May MITIGATION INDIVIDUAL TYPE

IA Stage1 May fail to identify all stakeholders. 3 2 6 All Stakeholders who need to be engaged

will be identified by the Project Board. Board will continue to ensure ongoing stakeholder engagement through a range of tailored methods.

All Stakeholders who need to be engaged have been identified.

Project Chair NHS

2 May fail to engage with Stakeholders. 4 3 12 Engagement arranged as required. All User Group Workshops to be arranged to include Key Stakeholders. Communication regarding Local Care Consultancy shared with practices and involvement in workshops.

Procedures arranged for engaging with wider stakeholders e.g. Option Appraisal and AEDET. Attendance of stakeholders monitored to ensure consistent engagement.

Clinical Services Manager

H&SCP

3 Stakeholders have different aspirations. 3 4 12 Groups arranged to ensure ongoing engagement with key stakeholders discuss aspirations. Core team to manage discussions and agree project aspirations with Project Board decision if required

All discussions facilitated to ensure stakeholder involvement with discussion on aspiration versus need.

Project Chair NHS

4 May fail to define appropriately the clinical and service needs, particularly as these change over time with specific practice sustainability and GMS contract developments.

4 3 12 Ensure clinical and other service stakeholder involvement, including representation on Project Board, to allow effective modeling of multiple scenarios resulting in an agreed Clinical Output Specification and Accommodation Schedule

Clinical and other services representation requested and delivered where necessary. Fife wide representative sought

Project Chair NHS

5 The brief/requirement may suffer from scope creep.

3 3 9 Ensure continual review of requirements/needs

Project leads monitoring development of project with project board involvement if required

Project Chair NHS

6 May fail to adequately determine the overall programme.

4 5 20 Project team to identify programme at initial stage

Initial programme dates being developed for Initial Agreement

Project Chair NHS

7 Stakeholder review / acceptance/governance timescales may affect the programme.

4 3 12 Ensure appropriate governance arrangements adhered to with realistic timescale for acceptance.

Project leads developing indicative programme that ensure governance .

Project Chair NHS

8 There may be insufficient funds to deliver the full Clinical/Service Requirement.

4 3 12 Indicative costs for options to be developed based on Schedule of Accommodation required

Costs being developed. Developing clinical model is utilising existing resources in a different way. Project Team will ensure proposal compliments GMS Contract.

Head of Finance NHS

9 NHS FV strategic objectives do not align with NHSF.

4 4 16 Ensure board to board discussion and agreement on strategic objectives

Contact made with NHS FV team Clinical Services Manager

NHS

10 Preferred site acquisition may be time consuming causing delay.

4 3 12 Ensure early engagement with Local Authority

Local authority representatives involved in workshops and meetings. Ongoing engagement with local authority colleagues.

Project Chair NHS

11 Support from the local community could change or diminish causing a reputational risk.

3 5 15 Public involvement to be secured Community representation agreed for all workshops where appropriate e.g. AEDET and NDAP. Extensive ongoing public consultation


NHS

12 Project development does not allow for future expansion of local community resulting in service delivery not being appropriate.

4 3 12 Ensure all proposed plans are flexible and allow for future expansion.

All proposed sites chosen with future expansion capability

Project Chair NHS

13 Insufficient management to lead and project support capacity support delivery of the project

4 3 12 Ensure responsibilities clearly identified. Roles and responsibilities assigned and governance structure agreed

Project Board developed. Project Chair NHS

Project Title : KINCARDINE HEALTH CENTRE

Project Manager:

Version Number: V4.1

Identification Assessment Control Monitoring

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Lochgelly Community Health and Wellbeing Centre Project

Initial Agreement Document

Project Owner: Claire Dobson, Divisional General Manager, West Division Fife H&SCPProject Sponsor: Nicky Connor, Interim Director, Fife H&SCP

Date: 23/8/19Version: 2.3

Version HistoryVersion Date Author(s) Comments1 Feb 2018 CD/LE Approved by IJB2.01 16/08/2019 CD/ Updated in Line with Local Care SFT Consultant Report

and in line with SCIM guidance2.3 19/8/19 CD Updated in line with discussion with Scottish

Government Local Care Team

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Contents

1 Executive Summary 3

2 Strategic Case: Existing Arrangements and Need for Change 102.1 Service Arrangements 102.2 Service Details 152.3 Strategic Context 172.4 Drivers for Change 212.5 Investment Objectives 232.6 Proposed Benefits 24

3 Strategic Risks, Constraints and Dependencies 263.1 Risks 263.2 Constraints and Dependencies 263.3 Critical Success Factors 27

4 Economic Case 284.1 Do Nothing/Do Minimum Option 284.2 Engagement with Stakeholders 294.3 Service Change Proposals 294.4 Indicative Costs 334.5 Option Appraisal 344.6 The Preferred Option 374.7 Design Quality Objectives 374.8 Design Statement 39

5 Commercial Case 405.1 Outline Commercial Case 40

6 The Financial Case 416.4 Capital Affordability 416.9 Revenue Affordability 42

7 The Management Case 447.1 Governance Arrangements 447.2 Proposed Project Resources 447.3 Project Plan 457.4 Stakeholder Engagement and Support 45

8 Conclusion 478.1 Review of Strategic Assessment 478.2 Preferred Option 47

Appendices 48Appendix 1 Strategic Assessment 48Appendix 2 Benefits Register 50Appendix 3 Risk Register 57

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1 EXECUTIVE SUMMARY

1.1 INTRODUCTION1.1.1 Fife Health and Social Care Partnership is working with local communities, teams

and stakeholders to support the delivery of a fully integrated 24/7 community health and social care model that ensures sustainable, safe, individual partnerships of care. The purpose of this Initial Agreement Document (IAD) is to seek approval to develop an Outline Business Case to re-provide Lochgelly Health Centre to deliver the necessary infrastructure to enable locally based, tailored, health and social care in purpose designed and built premises.

1.1.2 The IAD establishes the need for investment in light of local health and social care needs. It is fully shaped by the NHS Fife and Fife Health and Social Care Partnership strategic goals to deliver a model of local care, focused on individual outcomes, supported by health and social care delivered by the right person in the right place at the right time. It describes the appraisal of a long list of options, identifies the short list, and recommends a preferred way forward, together with indicative costs, to enable the delivery of Fife’s Community Health and Wellbeing hub model within the Lochgelly community.

1.1.3 The vision for primary care and community services in NHS Fife and Fife Health and Social Care Partnership is to enable the people of Fife to live independent and healthier lives. We will deliver this by working with people to transform services to ensure these are safe, timely, effective and high quality, focused on achieving personal outcomes. This requires access to the right professional at the right time in the right place; we know that our community health and wellbeing hub model of early proactive care can deliver this and will reduce the increasing trend in emergency hospital admissions. Where services can be provided within a community setting, closer to where service users live, they should be. Care should be provided in an environment that supports staff to provide an excellent experience and has modern facilities that meet the needs and expectations of service users, carers and staff well into the late 21st century.

1.1.4 The people of Fife have told NHS Fife and Fife Health and Social Care Partnership, through a wide range of engagement vehicles and the formal consultation which informed the Clinical Strategy and Joining Up Care programme that they:

would like services to be integrated, coordinated and person focused; want to reduce the duplication they experience both in sharing their

information and in service delivery; value local delivery.

1.1.5 Fifes’ Community Health and Wellbeing hub model is delivering prevention and early intervention by:

working with local health and social care practitioners, using local knowledge and data to identify people earlier.,

co-producing tailored interventions to deliver holistic assessment, outcome focused planning and care management,

maximising opportunities for local community treatment and care, bringing local health and social care practitioners (including housing,

voluntary sector and local area coordinators) together to collaborate to meet people’s outcomes,

enhancing rapid access to locality assessment and rehabilitation,

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simplifying communication and information sharing for service users, carers and staff.

1.2 ORGANISATIONAL OVERVIEW 1.2.1 Lochgelly Health Centre, located at the heart of the town, provides General Medical

Services to 79% of the resident population of Lochgelly and the surrounding areas of Lochgelly East, Lochgelly West & Lumphinnans, Ballingry, Cardenden and Lochore & Crosshill, through three Medical Practices based within the Health Centre. Community services are provided by NHS Fife including for example Community Nursing, Health Visiting, Mental Health, Sexual Health and Podiatry. Services work together to deliver high quality person-centred health and social care in a way which promotes and enhances the health and wellbeing of the people of the area.

1.2.2 The three Practice populations total circa 10,728 people. The practice area is in the highest income deprived deciles of Scotland and therefore faces significant health inequalities. The locality population is predicted to grow by 5%1 in the next 25 years. Most of this population growth is anticipated to be in the older people age group, circa 45%, with both children and working age populations predicted to decrease. These changes will significantly increase the level of frailty the practices are supporting within a community which has a significantly higher disease burden associated with intergenerational income inequalities (table 3 below details the communities relative disease prevalence and unscheduled care access with that of the rest of Fife)

1.2.3 The current facility is a 1970’s construction, with every effort made to modify the building to support the delivery of modern integrated health and social care. However it is no longer fit for purpose, our new model of working requires accommodation that enables the delivery of our vision of multi disciplinary and group working, which supports the community and partners to deliver collaboratively. A model which is being delivered in other communities which have access to modern facilities which do not have the same complexity of intergenerational inequalities and disease burden of the Lochgelly Community. Healthcare has been identified through local community planning as one of the major issues for the area.

1.2.4 The development of the community health and wellbeing model and delivery of the new General Medical Service Contact is being held back by structural and layout constraints. All possible reasonable changes have been made to the existing building and alternative premises accessed. Lochgelly Health Centre fails to meet the spatial, organisation and design standards for Primary and Community Health Care premises and has no capacity for further growth. Major improvements to address maintenance and statutory standards will not facilitate significant improvements in space utilisation to enable local integrated care to meet patient quality, staff standards and efficiency objectives.

1.3 STRATEGIC DIRECTION AND CONTEXT1.3.1 Our ambition is that from the youngest to the oldest, the fittest to the frailest, the

371,910 people of Fife live well. Our aim is to integrate services to provide better experiences of care, as locally as possible, by fully embedding the community health and wellbeing hub model across Fife.

1.3.2 NHS Fife Clinical Strategy sets the strategic direction with Fife Health and Social Care Partnership that is focused on local, early, preventative care. By working with

1 Local Strategic Assessment 2018, Fife Council Research Team

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partners to improve the health of local people and the services they receive, while ensuring that national clinical and service standards are delivered across the NHS system, we will strengthen primary care and community services This will be achieved by working with practices to fully develop practice level multi disciplinary working, delivering local community care and treatment, maximising proactive, tailored and targetted early intervention through community teams focused on segmented populations and ensuring rapid access to complex assessment, rehabilitation and, when required, bed based intermediate care within localities.

1.3.3 Our vision requires a flexible and responsive model that works with people to define the outcomes they want to achieve, enabling people to maximise their health and wellbeing by utilising their own and community assets, responsively adding and adapting services to meet and sustain outcomes. Figure 1 below seeks to illustrate how we can layer services when required and adjust support and care incrementally. Our goal is to maximise opportunities for services to work together locally as soon as possible, while minimising duplication for the patient and services.

1.3.4 In Fife by fully engaging with the public, people who use health and social care services and their carers, partners and staff we have developed a community health and wellbeing hub model to support independence, improve wellbeing and care. To ensure fully person responsive, integrated support for health and wellbeing Fife is redesigning mental health provision, community intermediate bed models, while embedding our community health and wellbeing hubs. Integrating with the new model for General Medical Services, services and community groups require facilities which enable colleagues and communities to work together. If practitioners and partners are to support people as effectively as possible, by for example minimising multiple attendances and maximising the potential of local multi disciplinary working, they require facilities which support this.

1.3.5 Fife’s community health and wellbeing hub model is underpinned by early identification within Primary Care. Using practice level data to segment population needs is enabling a targeted, timely approach based on need rather than referral criteria; colleagues are proactively working in partnership with people in their local community. This approach can improve outcomes so that:

People are supported to stay at home or in a homely setting for as long as possible

Staff (across all sectors) are equipped to support this in terms of knowledge, skills, processes and resources

The organisation maximises use of planned services

Figure 1

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1.3.6 Having worked with Scottish Futures Trust (SFT) we are able to articulate more fully how this model can be scaled up for Fife to support people, improve their outcomes, transforming health and wellbeing. People often find they are referred to a number of services sequentially. The hub model supports these services to integrate, locally, to tailor their support to individual needs. This ensures people access the right service for their needs at the right time. Often people access services too late. Through for example our frailty care management approach we are using local information to identify needs sooner, to maximise people’s health and wellbeing. People can feel that their care is uncoordinated and there is duplication. By developing care management people have one person who is their main point of contact. The developing integrated model elements can be summarised as:

Proactive case finding – to maximise early intervention and co-ordination / complex case management / anticipatory care planning, using Practice data and local clinical intelligence

Integrated earlier intervention – Practice level multi disciplinary team (MDT) working collaboratively, with co-ordinated local case management or locality level complex case management

Where there is social complexity – locality MDT working together locally, to plan and deliver integrated care focused on individual outcomes

Where there is medical complexity – rapid assessment via local complex needs assessment and rehabilitation centres, and if required diagnostics at a locality level with local follow up.

The scope and develop programme to implement the model fully across Fife is in year two of three.

1.3.7 The focus is on working with people earlier to reduce the proportion of people who enter the health and social care ‘system’ at the orange to red / right-hand end of the spectrum at Figure 1. This maximises people’s potential including for rehabilitation, and releases resources to support urgent care, while providing capacity for meaningful planning with people and their families. Initial test data indicates that people with frailty who receive the care management intervention are experiencing fewer unscheduled hospital admissions – the average being 5 in the 12 months pre intervention and an average of 1 in the six months post intervention. Staff describe how they are more able to collaborate and reduce referrals and timescales through the locality MDT model. The assessment and rehabilitation centre model testing is supporting more timely access with reduced waiting times (17 weeks to one week), a reduction in Did Not Attends from 20% to 2% and combining assessments for mental and physical health.

1.3.8 Fife Health & Social Care Partnership (H&SCP hereafter ) vision is being delivered by enabling integrated care that reduces the boundaries between primary, community, hospital and social care, with General Practitioners, hospitals, health workers, social workers, social care staff and others working together as one system. This more co-ordinated approach is reducing the need for people to navigate their way through what can be a bewildering maze of specialist services. This is supporting delivery against the Partnerships (draft) revised priorities of:

Priority 1 – Working with local people and communities to address inequalities and improve health and wellbeing outcomes across Fife.

Priority 2 – Promoting mental health and wellbeing. Priority 3 – Working with communities, partners and our workforce to transform,

integrate and improve our services. Priority 4 – Living well with long term conditions. Priority 5 – Managing resources effectively while delivering quality outcomes

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1.3.9 The proposal for investment into fit for purpose health and social care facilities in Lochgelly will not only support the delivery of clinical services but also enable the embedding of our community health and wellbeing model delivering these key priorities within the Lochgelly area. The strategic assessment (Appendix 1) outlines how the current facility hampers this, for example there is no capacity for complex multi disciplinary frailty assessments or for the locality multi disciplinary team to meet and plan together.

1.3.10 More pressingly the local context in Lochgelly presents immediate challenges with two of the three practices facing major sustainability issues. The significant spacial pressures are hampering the ability to implement both immediate and medium term ameliorative actions and to progress the implementation of the new GMS.

1.3.11 The following list identifies key national and local documents that have influenced the development of this proposal, although this is not an exhaustive list.

1.3.12 Quality Strategy ambitions in relation to: Person centred care - through improving access to Primary Care and providing

more care closer to home; Safe – reducing risk of infection through provision of modern fit for purpose

accommodation; Effective – bringing together wider range of health and care services to make

more effective use of resources.

1.3.13 2020 Vision aspirations are that everyone can live longer healthier lives at home, or in a homely setting with focus on improving quality of care, improving the health of the population and providing better value and sustainability. The Public Health priorities for Scotland (2018) support investment for local integrated delivery.

1.3.14 The Public Bodies (Joint Working) (Scotland) Act 2014 aims to improve outcomes for people by creating services that allow people to stay safely at home for longer with focus on prevention, anticipation and supported self-management, and to provide opportunities to co-locate health and care services working together for the local population.

1.3.15 The Scottish Government’s Nursing 2030 Vision: Promoting Confident, Competent and Collaborative Nursing for Scotland's Future (2017) sets the direction for nursing in Scotland through to 2030 and focuses on personalising care, preparing nurses for future needs and roles, and supporting nurses. In particular for community nursing the Chief Nursing Officer Directorate Transforming Nursing, Midwifery and Health Professions (NMaHP) Roles (Paper Three) includes shifting the balance of care from hospital to community and primary care settings at or near people’s homes. With integrated teams of community and practice nurses providing seamless care.

1.3.16 Promoting the wellbeing of children is central to the work of Health Visitors and this is supported by the new Universal Health Visiting Pathway and the Named Person role conferred by Children and Young People (Scotland) Act (2014).The Universal Health Visiting Pathway sets the standard for health visiting and the minimum core visits that families with children aged 0-5 years can expect from their Health Visitor, regardless of where they live, this is seeing investment in the workforce to support full implementation.

1.3.17 The 2018 General Medical Services Contract in Scotland refocuses the role of General Practitioners as expert medical generalists and recognises that General

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Practice requires collaborative working with enhanced multidisciplinary teams that are required to deliver effective care, joint working between General Practitioner Practices in clusters and as part of the wider integrated health and social care landscape.

1.3.18 The Community Health and Wellbeing Hub programme in Fife has been selected to participate in a national Local Care Pathfinder Programme, together with Caithness and and Ayrshire’s Garvock Valley, sponsored by the Scottish Futures Trust on behalf of the Scottish Government. The goal of the porgramme is to facilitate the shift in the balance of care to community care. The intention is to produce three projects that deliver transformational change in the provision of care from hospital based care to community based care, so people’s health and wellbeing is supported as close to home as possible. The Fife Health and Social Care Partnership is being supported by Scottish Futures Trust and Carnell Farrar (specialist health care planners) to progress the redesign.

1.4 DRIVERS FOR CHANGE, INVESTMENT OBJECTIVES AND OPTIONS APPRAISAL1.4.1 The key drivers for change and investment objectives are summarised below in

Table 1:Effect of the need for change on the organisation


1 The locality is experiencing population growth, with significant growth in the older population. Lochgelly experiences significant health inequalities; Lochgelly East is in Decile One of the Scottish Index of Multiple Deprivation. The GP Practices, Community Health and Social Care services do not have the required local infrastructure to support the development of local health and wellbeing focused services to meet the population’s needs.

Ensure equal access to integrated Primary Care and Community Services for the whole population. As a national pathfinder site, the Partnership is seeking to realise key service transformation ambitions with modern, fit for purpose infrastructure to allow staff and community partners to better support local community health and wellbeing.

2 Pressure on existing staff, accommodation and services will inevitably increase (current building use is at 100%- with a reserve list process in place).

Ensure the right staff skill mix and service capacity are available to deliver strengthened and tailored local capacity to manage people’s health within their local community.

3 Staff facilities and accommodation are severely restricted with staff working in suboptimal conditions, impacting poorly on staff wellbeing and morale and the community’s experience of local service delivery.

Improve place experience of people, the community and colleagues. Ensure appropriate workforce can be accommodated, including increased flexibility of roles /development of new roles to support implementation of GMS contract (2018) and Community Health and Wellbeing Hub.

4 The facilities available in the community, combined with significant change in population, restrict the ability to deliver a wider multi disciplinary model locally. There is insufficient capacity in local facilities to deliver group therapy, and the components of care and treatment within the new GMS

Provide the infrastructure to support a more integrated seamless service across health and social care, including the capacity to deliver group based activities locally. This will support timely access and minimise travel and multiple appointments for the community.

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Table 1

Effect of the need for change on the organisation


5 Services cannot be delivered locally, to meet patient need, but instead are delivered from where it is possible to deliver services.

Improve the patient and user experience - deliver services locally based on local patient need. Reducing the number of referrals to other services and the requirement for additional attendances because there is not the capacity to provide integrated care.

6 The Equality Act (2010) compliance within the building is poor - discriminating between the experiences of service users.

Accommodation that complies with all legal standards and regulatory requirements and gives equality of access for all.Support delivery locally of the National Outcomes for Integration.

7 Some clinical rooms are very small, failing to meet current standards due to the age and design of the building. These can be very restrictive/ unsuitable for patients and staff. Increased safety risk from outstanding maintenance and inefficient service performance.


8 There is no scope to enhance the primary and community care services provided in the existing accommodation including transferring the right care closer to patients’ homes.

To deliver services more effectively and efficiently through our hub model - facilitate better joint working to ensure right care is delivered at the right time and in the most appropriate setting

1.4.2 A wide range of possible options for investment were considered using the options framework. These were reviewed and the resultant options short list (including indicative costs) is included in table 2 below:

Table 2

Option Description Indicative Capital Cost (£)

Option 2 New build in Car Park 7,025,717Option 3 New Build at Jenny Grey (former care home) site 6,959,207Option 4 Refurbishment of Jenny Grey (former care home)Option 5 New Build at Francis Street 6,835,692Option 6 New Build at North School 7,244,244

NB Option4 is no longer available, having been demolished since the Option Appraisal. 1.4.3 An options appraisal process was completed with the community, assessing each of

the options on its ability to deliver the investment objective. Option 5, Francis Street, was identified as the preferred option from this analysis. Further detailed work will be undertaken during the Outline Business Case (OBC) stage to fully confirm the service scope, costs, phasing and timescales.

1.4.4 This Initial Agreement Document, the first of three document phases, details our thinking in terms of the most important issues which shape our strategic priorities and how these align nationally and across NHS Fife/Fife Health and Social Care Partnership.

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2 STRATEGIC CASE: EXISTING ARRANGEMENTS AND NEED FOR CHANGE

2.1 SERVICE ARRANGEMENTS

2.1.1 The holistic multi disciplinary primary and community care services in Lochgelly are currently delivered from the existing Lochgelly Health Centre, a 1970’s constructed facility, which has been considerably modified and extended throughout its lifetime. The building is owned by NHS Fife.

2.1.2 General Practitioner services in Lochgelly and the surrounding area are delivered by three General Practices operating full time to meet their respective Practice population needs. The General Practitioner Practices are contracted to NHS Fife to provide General Medical Services:

Lochgelly Meadows General Practitioner Practice (Primary care services) General Medical Services

Lochgelly Medical Practice (Primary care services) General Medical Services

Lochgelly (Dr Thomson) Medical Practice (Primary care services) General Medical Services

2.1.3 Aligned to the Practice there is a wide range of permanent and visiting community health services provided from the current facility. Fife Health and Social Care Partnership and NHS Fife are responsible for the provision of Community Nursing, and Managed Services (treatment room support, Primary Care Nurse, Health Visiting, Clinical Psychology, Sexual Health, Pharmacy, Allied Health Professionals, Child Health, Stop Smoking, Community Midwifery, Mental Health and Addictions, Out-Patient Services and Facility Management), detailed in table 4 below.

2.1.4 A constrained range of Voluntary Sector activity is delivered from the Health Centre, including drug and alcohol support services (supporting clinic activity etc). The constraining factor is accommodation availability.

2.1.5 The local Community Council supported by local Councillors and Members of Scottish and UK Parliament have a local campaign group to support the realisation of a new health centre. The campaign notes the need for modern infrastructure to enable the local delivery of an integrated model to meet the significant health and wellbeing needs of the community.

2.1.6 The services provided from the existing Lochgelly Health Centre are primarily provided in support of the population needs of the people of Lochgelly and surrounding areas, with 79% of the resident population registered (see figure 2 - interzone map) with the Practices. In accordance with NHS Fife’s statutory obligation to provide access to Primary Medical Services there is a formal requirement to continue provision of these services within this geographic area. Figure 2

Map of Lochgelly East, Lochgelly West, Lumphinnans, Ballingry, Lochore & Crosshill Interzones

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2.1.7 The General Practitioners together with the multi-disciplinary team manage the widest range of health problems; providing both systematic and opportunistic health promotion, diagnoses and risk assessments; dealing with multi-morbidity; coordinating long-term care; and addressing the physical, social and psychological aspects of patients’ wellbeing throughout their lives.

2.1.8 As figure 1 (page 5) above portrayed the General Practitioners and multidisciplinary team working in the hub model are integrally involved in deciding how health and social services should be organised to deliver safe, effective and accessible care to patients in their community. Practice based multi disciplinary team working is identifying people who could benefit from a case management approach and supporting people to access the right support where there is:

Complexity in their care and support arrangements through locality multi disciplinary teams, or

Clinical complexity providing rapid access to assessment through the locality community health and wellbeing hub teams.

2.1.9 The combined Practice population of 10,728 (April 2019), has grown by 1.6% over the past 18 months. The current demographics of the population (based on 2011 census, 2016 SIMD datazone data and ISD Practice data 2019) are:

50.9% female: 49.1% male

18.0% are over the age of 65 and 18.2% are 0-15 years (slightly higher than the average for Fife)

45.4% of patients live in the most deprived quintile, with 0.9% living in the least deprived quintile

20.9% of the wider locality population are income deprived, compared to the Fife average of 12.4%, 24.3% of children (under 16) live in poverty compared to the Fife average of 17.9%

27.6% of the Practice’s patients have one or more long term condition compared to Fife rate of 7.16%

Fife has the highest rate of under 18 and under 20 pregnancy rates in Scotland. The Cowdenbeath locality has the second highest rate of teenage pregnancy under 18 (three year aggregates to 2017) within Fife.

2.1.10 Table 3 below notes a range of health indicators for the Lochgelly practice population (where available, or the wider locality where not available) compared to Fife (Fife has seven localities); this demonstrates the relative poor health of the population. The health outcomes for the people supported by the Lochgelly practices are consistently lower than the rates for Fife, in a number of instances these are the highest rates / poorest outcomes in Fife.

2.1.11 The Lochgelly area populations’ experience higher rates of emergency hospital and multiple admissions. Along with higher rates of admission related to COPD, coronary heart disease and alcohol related hospital stays.

2.1.12 In SCOTPHO analysis of QoF data 2017/18 the Lochgelly area comes out in the top three in 12 of 17 measures when compared with the seven Fife localities.

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2.1.13 Mental Health is the fourth highest of the health impacts on the population of Fife (after Cancer, Cardiovascular disease and Neurological conditions); those who are socially disadvantaged have an increased probability of experiencing mental ill health. For example, in 2010/2011, there were twice as many GP consultations for anxiety in areas of deprivation than in more affluent areas in Scotland (62 consultations vs. 28 per 1,000 patients). The impact of mental health difficulties in the Lochgelly community is evidenced in the data below and the current range of services seeking to access accommodation in the health centre (detailed in table 4).

Table 3

Indicator Lochgelly area

Wider Locality

Fife Comparative notes

Premature mortality Cancer related

CHD related

337 per 100,000 180 per 100,000 70 per 100,000

(5th of 7) (2nd of 7) (2nd of 7)

Patients (65+) with multiple emergency admissions

6,087 per 100,000

(1st of 7)

New and unplanned repeat A&E attends

297.4 per 1,000.

264 per 1,000

Potentially avoidable admissions

20.2 per 100,000

(2nd of 7)

Median 11/15-5/19 Falls related admissions (65+)

2.5 per 1,000 2.05 per 1,000

(1st of 7)

Cancer rate (QOF) 3.06 2.85 2.85 (Lochgelly has the 3rd highest compared to the 7 localities)

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Indicator Lochgelly area

Wider Locality

Fife Comparative notes

CHD rate (QOF) 4.65 4.67 3.94 (Lochgelly has the 3rd highest compared to the 7 localities)

Hypertension rate (QOF)

18.45 17.54 15.36 (Lochgelly has the highest compared to the 7 localities)

Asthma Rate (QOF) 7.17 7.58 (2nd of 7) 6.94 (Lochgelly has the 3rd highest compared to the 7 localities)

COPD rate (QOF) 3.4 3.61 (2nd of 7) 2.58 (Lochgelly has the 3rd highest compared to the 7 localities)

COPD admissions (standardised rate)

Prac. 1 - 2.7Prac. 2 - 7.2Prac. 3 - 5.6

5.3 3.1 Two of the three practices are above Fife levels (Crude & standardised rates).

Diabetes rate (QOF) 7.11 6.51 (2nd of 7) 5.56 (Lochgelly has the highest compared to the 7 localities)

Alcohol related mortality

17.1 per 100,000

(3rd of 7)

Mental Health rate (QOF)


Mental Health Prevalence

5,132 per 100,000 (1st of 7)

Psychiatric Admissions (episodes)

29.7 per 1,000 (2018)

25.7 per 1,000 (2018)

24.5 per 1,000 (2018)

Lochgelly levels are above all Fife localities for both patients and episodes

Depression rate (QOF)


Dementia rate (QOF)

1.00 1.09 0.81 (Lochgelly has the 2nd highest compared to the 7 localities)

Stroke and TIA rate (QOF)

2.81 2.7 2.46 (Lochgelly has the 2nd highest compared to the 7 localities)

Developmental disorders

856 per 100,000 (2nd of 7)

2.1.14 Projections for future demand for primary care and community services with Lochgelly are driven by the population projections which see the older population growing by 45% by 2041 and by the known negative impact on health of the relative socio economic deprivation the community experiences. Housing developments are seeing the construction of circa 420 new homes by 2025 (potentially an additional 1,050 people). The local development plan includes potential for the development of a further 4070 homes within the Lochgelly Health Centre catchment area. The infrastructure is therefore required to enable services to develop the community health and wellbeing model to support the anticipated increase in the needs detailed in table 3 rather than seeking to continue to do more of the same.

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2.1.15 The current workforce delivering services, health, social and voluntary sector activity is outlined below at table 4 along with potential future workforce required to deliver integrated primary care and community services. Recent and continuing changes to the workforce are being phased in line with population growth and service model developments and are taking into account the requirements to implement the GMS (2018) contract and enhance the primary healthcare team, community health and social care teams and health visitor pathway. The Meadows Practice provides training placements for medical students.

Table 4

Existing Provision

(whole time equivalent)

Recent change

Future provision * Incl. new roles

General Practitioners (5) 4.5 - 1wteAdvanced Nurse Practitioner (2) + trainee

2 +1wte

Nurse Practitioner (1) 0.8 +0.8wtePractice Nursing (3) 1.7 -1.05wtePrimary Care Mental Health Nurse 1 +1Practice Phlebotomist (1) 0.39Practice Manager (3) 2.9 Admin staff (11) 9.6 -0.27Community Nursing Team (9+ 2 student/rotational Intermediate Care team colleague)

6.87 (+2) Redesign of Community Nursing + caseload weighting necessitate change

Community Phlebotomist (1) 0.5Community Teams Admin Staff 0.9 Medical Students 0.2Primary Care Pharmacist 1 +4 requiring an office

and access to consultation

accommodation Visiting teams Sessions per

monthFuture provision * Incl. new roles

Addiction Services 12Clinical Psychology 33Fife Intensive Rehabilitation and Substance Misuse Team

16

Phlebotomy (Bloods) 16Respiratory Nurse Base + Clinic 1 wte + 3

clinicsPaediatric Clinic 6Asthma Clinic 4Fife Forum 8Continence Clinic 4ADAPT (Alcohol and drug triage service)

4

Stop Smoking 4Psychiatry 8Health Visitors Baby Clinic 4Health Visitor Review Clinic 12

+ Wellbeing

13 staff and the full range of centre based Health Visiting activity:

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meetings when required

majority currently delivered from an adjacent smaller village

Immunisation Team 8 Potentially evening Flu clinics Midwife Clinic 12Safe Space 4Dietician 2Orthoptic Clinic 4Podiatry 16Diabetic Foot Check (DAR’s) 6Dermatology 4Minor Surgery Clinic As required

circa 2 per week

Depot Clinic (QMH Nurses) 1 hr per weekTreatment Room 20Fife Alcohol Advisory Service 4Social Workers / Social Care Workers

MDT time Child Protection meetings

Mental Health Nursing 8Contraception and Sexual Health 4Alcohol and Drug Drop in 4 (evenings)Wider voluntary sector A wider range of voluntary sector

services e.g. citizens advice supporting income maximisation

First Contact Physiotherapist 0.55wte

2.2 SERVICE DETAILS

2.2.1 The accommodation in Lochgelly (Building report at Appendix 1), provided over one level with a total floor area of 760m2, supports:

General Practitioner activity associated with the Lochgelly Meadows Practice (Circa. 19,000 appts PA and a Practice population of circa. 5,011)

Nurse activity associated with the Lochgelly Meadows Practice (Circa. 4,000 appts PA)

General Practitioner activity associated with the Lochgelly Medical Practice (Circa. 10,000 appts PA and a Practice population of circa. 3,511)

Nurse activity associated with the Lochgelly Medical Practice (Circa. 7,000 appts PA)

General Practitioner activity associated with the Lochgelly (Dr Thomson) Practice (Circa. 5,400 appts PA and a Practice population of circa. 2,206)

Nurse activity associated with the Lochgelly (Dr Thomson) Practice (Circa. 900 appts PA)

Community nursing “treatment room” activity (16 appts per day, 22 at busiest times, Circa. 4,100 appts PA), Phlebotomy provide 37 appts 4 days per week, Circa 6,500 PA) with the team visiting about 30 people at home per day.

Primary Care nursing activity (Average 30 appts per week - 1560 PA) Minor surgical procedures undertaken by a specialist General Practitioner

(Circa. 100 episodes PA) Practice Phlebotomy services (Circa. 5,500 episodes PA) Midwifery ante-natal clinic activity (Circa. 750-800 appts PA)

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Psychology out-patient services (Circa. 1000 appts PA) Targeted sexual health services for younger people (Circa. 300 appts PA) Dietetic consultations (Circa. 204 episodes PA) Podiatry services (Circa. 1010 appts PA) Stop Smoking sessions (Circa. 470 appts PA) Paediatric consultation activity (Circa. 170 appts PA) Mental Health: Nursing Psychiatry and Psychology

o West Fife Community Outreach Team (Circa. 200 appts PA).o Addictions – sessions outlined aboveo Psychiatry – sessions outlined above

Voluntary Sector services – sessions outlined above

2.2.2 General Practitioner Practices have access to a known number of consulting rooms/areas on a daily basis, with visiting services scheduled ahead as far as possible, based on room availability. This situation is complicated by a lack of inter-service flexibility and the particular challenge associated with low patient numbers in a wide range of different clinics, most notably high ‘session utilisation’ (all rooms are booked all the time they are available) but poor ‘in-session utilisation’.

2.2.3 Whilst the General Practitioner Practice and Health and Social Care Partnership are working collaboratively to modernise, integrate and expand services to improve outcomes and support the population growth, development is severely constrained by the existing premises. For example the respiratory nurse would be able to see circa three times more patients if clinic space was available, supporting more proactive case management, with medical colleagues and thereby reduce emergency admissions further.

2.2.4 In summary, baseline data indicates that services delivered from the existing Lochgelly Health Centre amount to a total of circa 70,000 attendances per annum; circa 270 attendances per day or around 15 patients / clinical room activity per day. Whilst this is considerably less than the theoretical capacity associated with these clinical spaces, this situation occurs as a result of an overall lack of administrative / support areas within the building and the resultant extensive use of consulting space for administrative and clinical support activities. For example GPs use their consulting rooms also as office space, meaning the rooms cannot be used by another clinician outwith their clinical sessions.

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2.2.5 As the Health Centre runs at 100% capacity services often double book rooms in case cancellations arise – this includes clinical services, voluntary sector support groups, teams seeking to deliver mandatory staff training and centre based teams seeking to meet together. The AEDET review exercise confirmed that the layout and fabric of the building place considerable limitations on effective and safe service delivery (page 38).

2.2.6 Where services are not / cannot be delivered locally in Lochgelly, patients are referred to different locations that include: Queen Margaret Hospital, Dunfermline; Victoria Hospital, Kirkcaldy; Rosewell Clinic, Lochore. For example the majority of Health Visiting activity including Wellbeing Meetings is delivered from Rosewell Clinic; impacting on access inequities.

2.2.7 Out of Hours Primary Care is delivered from four Urgent Care Centres in Fife. The Partnership does not have plans to extend the number of Urgent Care Centres. The Practices and Community Teams offer a small number of clinics / sessions into the evening. The restrictions of the building do not lend themselves to safe and simple access in the evening.

2.2.8 The model of care is developing in line with the new General Practitioner Contract, with the Primary Care Development implementation plan progressing along with the Business Planning process. Accommodation is not available to support the local delivery of physiotherapy, mental health nursing, primary care pharmacists, social prescribing, etc. For example the Local Area Co-ordinator (voluntary sector member of the team sign posting people to local community provision) is not able to work from Lochgelly as frequently as required. To meet the areas needs within the GMS (2018) there will be three levels of pharmacotherapy input, this will see the resource based in Lochgelly grow from 1 whole time equivalent to 5.

2.2.9 Nationally, a re-provisioning exercise is in process to replace existing GP IT systems, with suppliers having until February 2020 to complete development of their respective systems in line with NHS National Services Scotland requirements. After this, a transition exercise will commence across all boards, with Fife’s transition scheduled to commence summer 2020. This will facilitate the Lochgelly practices to be paperlite.

2.3 STRATEGIC CONTEXT

2.3.1 NHS Fife Clinical Strategy sets the strategic direction with Fife Health and Social Care Partnership that is focused on local early, preventative care. In working with partners to improve the health of local people and the services they receive, while ensuring that national clinical and service standards are delivered across the NHS system we will strengthen primary care and community services.

2.3.2 Our vision requires a flexible and responsive model that works with people to define the outcomes they want to achieve, enabling people to maximise their health and wellbeing by utilising their own and community assets, adding and adapting services responsively to meet and sustain outcomes.

2.3.3 Our development of the community health and wellbeing hub model is designed to flexibly and responsively layer services where required, adjusting support and care incrementally, as locally as possible. In light of the changing demography this has focused initially on supporting people to minimise and modify the impact of frailty and factors leading to frailty(including younger people frail because of long term conditions, addictions etc). Providing holistic assessment and care management, focused on individual outcomes, anticipatory planning and supporting a reducing in

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unscheduled care. Fife has a population of 371,910 (2018 mid year population estimates, NRS), with slightly above the Scottish average for the over 65’s age group described in Table 5.

Table 5

Total Population 65+ 75+ 85+Fife 371,910 20% 9% 2%Scotland 5,438,100 19% 8% 2%

2.3.4 Fife H&SCP has seven localities. Lochgelly is within the Cowdenbeath locality. The Cowdenbeath locality sits within the West Division of the (H&SCP. The H&SCP is developing a locality clinical model with General Practitioner Clusters focused on the needs of the locality population. Table 6 demonstrates the percentage of locality populations over 75.

Table 6

Population over 75 75+City of Dunfermline 3928 7%Cowdenbeath 3360 8%Glenrothes 4109 8%Kirkcaldy 5549 9%Levenmouth 3560 10%North East Fife 7192 10%South West Fife 3845 8%

2.3.5 Figure 3 notes the anticipated change in the localities population over the next 25 years. The total population within Cowdenbeath Locality is projected to increase by 5% by just around 2,000 by the year 2041. Most of the areas’ population growth is expected to take place in the older people age group, an increase of circa 45% which will place an increasing demand on health and social care.

Figure 3

Population - 2016 41,288Population estimate – 2041 43,300

By 20410-15 8% (600)16-64 4% (1,000)65+ 45% (3,600)

2.3.6 The local and national goal, supported by NHS Fife’s Clinical Strategy (2016-21), and the Fife Health and Social Care Partnership’s Strategic Plan for Fife 2019-2022 (draft) is to provide safe, effective and sustainable care at home or as close to home whenever possible. The integrated model being implemented will support robust, holistic health (primary and community) and social care, with third sector services having a strong focus on early intervention, prevention, anticipatory care and supported self management.

2.3.7 The proposal for investment into fit for purpose health and social care facilities in Lochgelly will not only address the current restrictions upon local delivery of clinical, community and third sector services and deficiencies in facilities at the existing

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Lochgelly Health Centre but also enable the delivery of the above integrated model within the Lochgelly area.

2.3.8 The well rehearsed pressures in General Practice in Scotland can be illustrated by the following indicators: 10% of the population consults with a GP Practice clinician every week 34% of all GPs are aged 50 and over in 2015, compared with 29% in 2005 37% increase in female General Practitioners and 15% decrease in male GPs

over the ten-year period to 2015 40% of female GPs leave the profession by the age of 40 2015 – 1 in 5 GP training posts unfilled

2.3.9 Fife’s Primary Care Improvement Plan sets out the ambitions for reshaping primary care and General Practice in implementing the new GMS 2018 Contract. This is facilitating the development of General Practitioners as expert medical generalists within expanded Primary Health Care Teams, by implementing new roles and ways of working. This is underpinned by the guiding principles of:

Contact: accessible care for individuals and communities Comprehensiveness: holistic care of people – physical and mental health Continuity: long term continuity of care enabling an effective therapeutic

relationship Co-ordination: overseeing care from a range of service providers

2.3.10 Care pathways are patient (not disease) centred to meet the challenge of shifting the balance of care, realising Realistic Medicine and enabling people to remain at or near home wherever possible. Local accessibility and the need to provide a wider range of services to people in their local communities and to develop greater local integration is being hampered by the accommodation available within the Lochgelly area. The effect of which is evidenced in the continued reliance upon the traditional medical model of relatively high acute hospital attendance and admission rates.

2.3.11 Local accessibility and improved joint working with other health and social care partners as part of a wider whole system will facilitate integration of health and social care and enable more effective delivery of health and wellbeing outcomes. This will be underpinned by Practice multi disciplinary team working, supported by responsive wider locality teams in reaching to deliver local care.

2.3.12 Key national and local documents have influenced the development of our health and care model and thereby this proposal, although this is not an exhaustive list. It should be noted that along with Caithness and Ayrshire Fife’s Community Health and Wellbeing Hub programme has been selected as a national pathfinder site to support a Once for Scotland approach to delivering the shift in the balance of care from hospital to community.

National Commission on the Future Delivery of Public Services (The Christie Report)

(June 2011) 2020 Vision for Health and Social Care (September 2011) Healthcare Quality Strategy (2012) A National Clinical Strategy for Scotland (February 2016)

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Health and Social Care Delivery Plan (December 2016) Property Asset Management Strategy (2017) NHS in Scotland 2016 – Audit Scotland Report (October 2016) Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland (August

2017) General Medical Services Contract (2018) Health and Social Care Integration – Audit Scotland (November 2018) Nursing 2030 Vision: Promoting Confident, Competent and Collaborative

Nursing for Scotland's Future (2017) Local

Health and Social Care Partnership Strategic Plan for Fife Plan (draft 2019-2022)

NHS Fife Clinical Strategy (2016-21) NHS Fife Estates Rationalisation Strategy (2017) NHS Fife Operational Delivery Plan (2018/19) Let’s really raise the bar: Fife Mental Health Strategy (draft) (2019-2023)

2.3.13 This proposal interacts with these key local and national strategies in terms of:

Quality Strategy ambitions in relation to: Person centred care - through improving access to Primary Care and providing more care

closer to home; Safe – reducing risk of infection through provision of modern fit for purpose

accommodation; Effective – bringing together a wider range of health and care services to make more

effective use of resources.

2020 Vision aspirations are that everyone can live longer healthier lives at home, or in a homely setting with focus on improving quality of care, improving the health of the population and providing better value and sustainability.

Technology Enabled Care projects are being tested within the current service model to modernise primary care, support earlier identification and self management.

NHS Fife’s Clinical Strategy and Operational Delivery Plan are focused on delivering person centred care, closer to home where possible. The proposed development will support the local provision of health and social care services within Lochgelly, facilitating person centred care and support.

The 2018 General Medical Services Contract refocuses the role of General Practitioners as expert medical generalists and recognises that general Practice requires collaborative working, with enhanced multidisciplinary teams that are required to deliver effective care, joint working between General Practitioner Practices in clusters and as part of the wider integrated health and social care landscape. Better care for patients will be achieved through:

Maintaining and improving access; Introducing a wider range of health professionals to support the expert medical

generalist; Enabling more time with the General Practitioner for patients when it is really

needed; and Providing more information and support to patients.

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The Public Bodies (Joint Working) (Scotland) Act 2014 aims to improve outcomes for people by creating services that allow people to stay safely at home for longer with a focus on prevention, anticipation and supported self-management, and provide opportunities to co-locate health and care services working together for the local population. Fife’s local Health and Social Care Strategy describes how the nine National Outcomes for Integration can be met through prevention, local earlier integrated working focused on peoples own outcomes.

Promoting the wellbeing of children is central to the work of Health Visitors and this is supported by the new Universal Health Visiting Pathway and the Named Person role conferred by the Children and Young People (Scotland) Act (2014).The Universal Health Visiting Pathway sets the standard for health visiting and the minimum core visits that families with children aged 0-5 years can expect from their Health Visitor, regardless of where they live. This will require an increase in the Health Visiting establishment and new ways of working for full implementation.

The Scottish Government’s Nursing 2030 Vision: Promoting Confident, Competent and Collaborative Nursing for Scotland's Future (2017) sets the direction for nursing in Scotland through to 2030 and focuses on personalising care, preparing nurses for future needs and roles, and supporting nurses. Within this framework redesign in community nursing is supporting the implementation of the Chief Nursing Officer Directorates paper on Practice and Community Nursing to integrate locally to support prevention and early intervention.

Fife Health and Social Care Partnership, established on 1st April 2016, is refreshing its strategic plan, this includes revised Vision, Mission and Values. The plan is focused on delivering proactive, integrated support and therefore will seek to secure an outcome focused model delivered locally aimed at securing improved outcomes through early identification and intervention:

The Vision is To enable the people of Fife to live independent and healthier lives. The Mission is “We will deliver this (vision) by working with individuals and communities,

using our collective resources effectively. We will transform how we provide services to ensure these are safe, timely, effective and high quality and based on achieving personal outcomes.”

Our Values are: Person-focused - Integrity – Caring - Respectful - Inclusive - Empowering

2.3.14 This will support local delivery of the national outcomes for integration.

2.4 DRIVERS FOR CHANGE

2.4.1 The following is a full list of the main drivers causing the need for change, the effect that these issues are having on the current service provision and an assessment of why it is believed action is required now.

Table 7

Driver for change:


The clinical and social care model have developed and implementation is being circumscribed

Primary, Community and Voluntary sector services cannot provide the integrated model of care they and the community recognise is required now and for the future.

Existing facilities lack the number and range of support areas necessary to

The model of integrated care is being undermined now: preventing locally based, proactive care.

Lack of essential support areas (e.g. clean and dirty utility areas) represents a real and unacceptable risk to the Board in key areas such as Healthcare Associated

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Driver for change:


deliver safe and effective services, the physical capacity of the building is 100% utilised and oversubscribed.

Infections and patient safety that can only be addressed through significant investment.

Time from Initial Agreement to occupation of a new facility could take circa 4 years.

Services cannot be delivered locally for local patient need; Existing physical capacity is unable to deliver essential baseline change and re-design.

Local health inequality issues will continue to be difficult to support.NHS Fife/Fife H&SCP will fail to deliver the GMS (2018) and the community health and wellbeing hub model within Lochgelly unless this is planned for.


Sustainability of primary care is a key priority for the Partnership and NHS Fife. There is a need to plan to provide a sustainable service for the future

Existing facilities fall far below the required standards in terms of how they are configured and laid out. The Equality Act (2010) compliance within the building is poor.

Existing facility configuration and layout presents unacceptable risks, as well as poor local performance, functional in-efficiency and suboptimal patient experience. Wheelchairs, mobility scooters and double buggies cannot access parts of the building, including the waiting area. The waiting areas are too small.

Premises are functionally inadequate and compromise pro-active patient care.

No scope exists to re-organise parts of the service to improve the experience.

Poor clinical and non clinical functionality and space restrictions in existing accommodation (configuration)

Some consulting rooms are very small and do not meet current standards. These are very restrictive / unsuitable for patients and staff.

Poor patient and staff experience. Does not meet current recommended standards.

Capacity is unable to cope with current, let alone future projections of need. Patients are required to make repeated appointments to meet with different members of their multi disciplinary team and to access healthcare out-with the local area.

Service sustainability and development is at risk and an increasing number of patients will travel to other venues for appointments.

Clinical and social care functionality (capacity) issues

Facilities lack the number and range of support areas necessary to deliver modern, integrated, safe and effective services

There are no rooms available to deliver training, accommodate local multi disciplinary team meetings, etc.There is no accommodation to support local access to a wider range of visiting community services to support for example income maximisation.

Building issues (Including statutory compliance and backlog maintenance)

Existing facilities fall far below the required standards in terms of how they are configured and laid out.

Physical characteristics of the building prevent safe and effective patient care: small treatment rooms below minimum standards.

Building configuration and layout present unacceptable risks as well as poor performance and functional inefficiency.

Redesign of building will allow for improved care, staff experience and financial performance.

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Driver for change:



Building condition, performance and associated risks will continue to deteriorate if action is not taken now.

2.5 INVESTMENT OBJECTIVES

2.5.1 This section identified the ‘business need’ in relation to the current arrangements described in section 2.1. These were discussed at the Architecture & Design Scotland (A&DS) facilitated workshop to develop the project design statement. A wide range of stakeholders including clinical and managerial staff along with community representatives were involved in a workshop to describe the difference between ‘where we are now’ and ‘where we want to be’.

Table 8

Effect of the need for change on the organisation:

Investment Objectives

Existing service arrangements are affected by lack of clinical support service facilities.

Ensure equal access to a patient centred approach by enabling delivery of and access to local integrated anticipatory and preventative care for patients. Secure accommodation to deliver required group based activities.

Implementation of integrated models of care is undeliverable locally in the current environment

Ensure equal access to modern integrated care with provision driven by patient need rather than limitations in capacity.


Ensure the right staff skill mix and service capacity are available to deliver and strengthen local capacity to manage people’s health within the local community.

The facilities available, 100% occupancy, combined with significant population change, restrict the ability of the parties to deliver the full range of integrated services locally.

Enable earlier access to proactive and anticipatory care through local delivery via integrated seamless service across health and social care. This will reduce referrals to other services. Care will be driven by patient need rather than limitations on capacity.

Existing configuration, as a result of a circa 1970’s building, which has been modified and extended with a ‘best fit’ approach means poor accommodation e.g. service users who rely on wheelchair access or have a mobility problem have extreme difficulty in both accessing and traversing the facility.

Delivery of safe and effective care with dignity by providing facilities which comply with all legal standards and regulatory requirements and gives equality of access for all. Improved staff wellbeing.


Improve safety and effectiveness of accommodation by improving the physical condition, quality and functional suitability of the healthcare estate.

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2.6 PROPOSED BENEFITS

2.6.1 There is a clear emphasis on General Practice provision and the development of the community health and wellbeing hub model within the Partnership’s Strategic Plan and NHS Fife Clinical Strategy. The proposed investment in infrastructure will enable the Lochgelly Medical Practices to fully participate in the required programmes of care, enable full access to the development of Primary Care Improvement Plan and thereby improve outcomes for individuals, their families and the community, experience of staff and the reputation of the organisation.

2.6.2 Benefits for each of the investment objectives described in section 2.5 above are mapped to the expected benefits in the context of the Scottish Government’s five Strategic Investment Priorities (Safe; Person-Centred; Effective Quality of Care; Health of Population; Efficient: Value and Sustainability).

2.6.3 To ensure that resources are effectively exploited and that any investment made provides agreed benefits a benefits register has been developed. This register (see appendix 3) identifies the expected benefits, indicates a baseline and target measurement and also gives a priority level to each benefit. A Benefits Realisation Plan will be developed as part of the Outline Business Case.

Table 9

Investment Objective Benefit Investment Priority

1. Ensure equal access to a patient centred approach by enabling delivery of and access to local integrated anticipatory and preventative care for patients. Secure accommodation to deliver required group based activities.

General Practitioner Practice Multi Disciplinary Team, wider community hub team and voluntary sector have access to accommodation to meet population needs locally.

Person-CentredHealth of PopulationIntegrated Care

2. Ensure equal access to modern integrated care with provision driven by patient need rather than limitations in capacity.

Services delivered locally based on need.

Person CentredEfficientEffectiveIntegrated Care

3. Ensure the right staff skill mix and service capacity are available to deliver and strengthen local capacity to manage people’s health within the local community.

Higher staff retention levels.Higher staff morale/lower absence rates. Increased flexibility of roles.Career progression.Improved workforce planning across the health and social care pathway.Supports training, education and development.Improved patient centred communication within the wider team.

Person CentredEfficientEffectiveValue and Sustainability Integrated Care

4. Enable earlier access to proactive and anticipatory care through local delivery via integrated seamless service across health and social care. This will reduce referrals to other services. Care will be driven by

Access to wider staff skills, support and experience on one site.Reduces unnecessary hospital referrals.Reduces patient risk.

Effective Quality of CarePerson CentredIntegrated Care

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patient need rather than limitations on capacity.

5. Delivery of safe and effective care with dignity – by providing facilities which comply with all legal standards and regulatory requirements and gives equality of access for all. Improved staff wellbeing.

Improves patient experience addressing privacy and dignity issues.Improves staff safety through provision of primary care & community services on one site allowing for available support for patients and staff. Ease of compliance with standards e.g. Equality Act (2010), HAI Fit for purpose flexible accommodation meeting all guidelines e.g. room sizes.

SafePerson CentredQuality of CareIntegrated Care

6. Improve safety and effectiveness of accommodation by improving the physical condition, quality and functional suitability of the healthcare estate.

Increased local provision and access to treatment making best use of available resources by having the infrastructure to deliver more proactive prevention and early intervention focused support, maximising MDT working to facilitate access for people and thereby reducing the call upon unscheduled care.

Effective Quality of CareEfficient: Value and Sustainability

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1 STRATEGIC RISKS, CONSTRAINTS AND DEPENDENCIES

1.1 RISKS

1.1.1 Recognising that one of the main reasons when change projects are unsuccessful in terms of cost and time overruns and/or failing to deliver the expected benefits is the failure to properly identify and manage the project risks, a Project Risk Register has been developed. Risks at the Initial Agreement Stage of the Project have each been assigned an owner and mitigation action identified (appendix 3).

1.1.2 The key areas of risk relate to: Capital envelope does not support the preferred way forward. Clinical and care models may change and not be adequately planned for The programme may be delayed: further impacting on service delivery Engagement: in terms of maintaining positive stakeholder engagement Acquisition of land: initial discussions have been held with Fife Council in

relation to the possible purchase of land.

1.2 CONSTRAINTS AND DEPENDENCIES

1.2.1 Financial: given the current climate it is recognised that the project is likely to be constrained financially. The affordability of the project will continue to be fully tested through each of the approval stages; this will include the development of a fully detailed revenue model within the Outline Business case. Once the project budget is set, the project will require to be delivered within this.

1.2.2 Programme: given the risks associated with the current arrangements, there is a need to deliver the project as quickly as possible.

1.2.3 Quality: the project will require to comply with all applicable healthcare guidance and achieve the Achieving Excellence Design Evaluation Tool (AEDET) pre-defined target criteria across all categories.

1.2.4 Sustainability: as the preferred option is a new build there will be a requirement to achieve British Research Establishment Environment Assessment Method (BREEAM) ’excellent’.

1.2.5 Site: as the preferred option is a new build within a built-up area delivery of the project will be restricted and constrained. Careful planning will be required to plan how the project can be delivered efficiently and safely with minimal disturbance to surrounding residents and local businesses.

1.2.6 Dependencies associated with the build phase will be tested in development of the Outline Business Case.

1.2.7 These risks will then be reviewed in more detail at the Outline Business Case stage. The process of risk management will continue throughout the life of the project and then transfer to the operational management of the organisation.

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1.3 CRITICAL SUCCESS FACTORS

1.3.1 In addition to the Investment Objectives set out in section 2, the stakeholders have identified several factors which, while not direct objectives of the investment, will be critical for the success of the project.

Table 10

Requirement Description Critical Success FactorStrategic fit Meets agreed clinical

and investment objectives, related business needs and service requirements

From Patient perspective:• a facility that is easily accessible, bright,

welcoming and airy. • designed so that patients can be treated

with dignity particularly in terms of confidentiality.

Promotes sustainability of Primary Care provision, Realistic Medicine and delivery of 2018 GMS Contract

Consistent with NHS Board’s Clinical Strategy

Supports delivery of NHS Scotland Quality Strategy

Facilitates integration of health and social care services, delivered locally

Value for money

Maximise the return on the required investment and minimise risks

Service model maintains or reduces revenue costs in the longer term through earlier intervention

Service model enables effective decision making in allocation of resources

Building design maximises efficiency and sustainability

Potential achievability

Is likely to be delivered in relation to the required level of change

Matches the available skills required for successful delivery

The skills and resources are available to implement new ways of working

The Partnership and the Practice are able to embed new ways of working

NHS Fife are able to deliver the programme to agreed budget and timescales

Technology enablers are available and utilised

Supply side capacity and capability

Matches the ability of service providers to deliver required services

Service providers are available with skills, materials and knowledge

The project is likely to attract market interest from credible developers

Potential affordability

Available capital and revenue resources are sufficient to support the successful delivery of the proposed facility and services

Solution is affordable to all stakeholders

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1 ECONOMIC CASE

1.1 DO NOTHING/ DO MINIMUM OPTION:

1.1.1 It is not feasible to continue with the existing arrangements (‘Do Nothing’) as outlined in Section 2, because the building is not fit for purpose. The do nothing option scored lowest throughout the option appraisal process. The building and footprint likewise mean that a do minimum option is not feasible.

Strategic Scope of Option

Do Nothing

Service Provision:

Primary Care services in Lochgelly are delivered from the existing Lochgelly Health Centre. The facility has previously been considerably modified and extended.

Service Arrangements:

Three separate Primary General Medical Services practices, Community Health and Voluntary Sector services

Service Provider and workforce arrangements:

For the services detailed above at section 2 the workforce arrangements will continue with General Practitioner services Community Health and Social Care and Voluntary Sector services delivered in the building. The developing integrated multi disciplinary model will be circumscribed with inequity of access and travel implications for patients. Poor accommodation will continue to be managed as a risk in terms of staff health and safety.

Supporting assets:

The existing Lochgelly Health Centre has a baseline area of 760m2 and features a mixture of traditional General Practitioner/consulting spaces that includes:4 x restricted separate reception and records areas at a total of 100m2 (Associated with the 3 x separate Practices and NHS consulting elements)

2 x waiting areas (total 26m2) with inadequate space to meet even baseline needs and no age-specific provision

17 x (reasonably sized but poorly configured) consultant/treatment rooms located throughout the facility with little/no functional relationship to each other or the different patient groups they relate to

1 x interview room 1 x group room, although this is in effect a former waiting area with no windows that is

far from fit for purpose and can consequently only be used for very short periods, therefore this has virtually no capacity for e.g. staff meetings, staff training and group work (e.g. breastfeeding support)

5 x small and disparate offices (total 74m2) 1 x staff room (23m2) servicing the whole facility and all staff groups

Clinical Functionality Capacity issues have been identified as those problems associated with a lack of local space (area) that is essential to safe, effective and appropriately compliant service delivery.Areas originally designed to provide essential support functions have been lost in a drive to maximise clinical consultation space. Whilst the facility technically has sufficient space to support baseline clinical activity, in reality it is unable to do this as a consequence of a chronic lack of storage, waiting, quiet / interview, phlebotomy, administrative and office space. In addition, the existing facility lacks any form of clean utility room, dirty utility room, disposal hold, Domestic Services Room (DSR) or clinical storage facilities. There is no dedicated teaching, group space nor consulting rooms capable of supporting a GP training function. There are no administration areas capable of supporting wider staff teaching and learning or undertaking on-line training and assessment packages.The facility has nowhere that a patient can be managed should their visit become protracted; they become unwell; and / or they require acute management prior to transfer out to another facility by ambulance. This results in delays to clinical activity as it means consultations being delayed or suspended and is compounded due to the extremely poor access to all existing clinical areas. (None of these can be accessed by a trolley through the main entrance should this be required, with the only other entrance – at the rear – only being

Table 11

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1.2 ENGAGEMENT WITH STAKEHOLDERS

1.2.1 It was key to have the support of key stakeholders from health and social care staff and also leaders from the local community to define the change required and create the vision for change.

1.2.2 Stakeholders supported this through their participation in the Option Appraisal Exercises, Achieving Excellence Design Evaluation Toolkit AEDET and Design Statement workshops.

1.2.3 This will ensure that the vision is shared, is communicated to all who will be impacted by the change and the support from those who have an emotional commitment to the services provided in their community.

1.2.4 Further detailed information on the engagement and involvement with stakeholders completed to date, and proposed throughout the programme is included at section 7.

1.3 SERVICE CHANGE PROPOSALS

1.3.1 The initial scope for the Lochgelly Health Centre project was to explore design and scope options to provide a suitable health and social care facility in Lochgelly which was of a suitable size and condition to meet with the growing needs of the existing Practices, community health and social care team and voluntary sector services.

Long List1.3.2 The theoretical long-list of options was initially generated by the NHS and Local

Authority teams with the support of Hubco and its advisers, and reviewed throughout the process. This long-list was based on the cross-referencing of strategic theoretical service options available with local site / facility considerations.

1.3.3 Strategic theoretical option themes included:Table 12

Strategic Scope Summary1 Service Provision Do nothing (The status quo)

Build entirely new, minimise any use of existing buildings (full build)2 Service Arrangements Don’t have any specific General Practitioner / health facilities locally3 Service provider/ workforce

Utilise only ‘operational’ solutions to address existing problems

4 Supporting Assets Build new but also make use of existing facilities to support the overall model (reduced build)

Combine a new build or refurbishment proposal with other new / existing developments across the public sector

Use and/or refurbish one or more existing local buildings/facilities5 User Expectations The expectations of the public and service users

accessible by a number of steps. This impacts poorly on patient dignity and confidentiality).The building configuration is poor from access, service configuration, safety and security perspectives.

Public & service user expectations:

Delivery of effective General Practitioner and Primary Care, physical and mental health services in Lochgelly from one building in a good central location which is all on one level.Services delivered by a wide range of professionals.Strong desire to increase ‘targeted’ delivery to address inequalities.Single shared staff roomAccess to adjacent car parking spaces in a free Council car park.

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1.3.4 The following core long-list of options, in addition to Option 1 do nothing/minimum described above at Table 11, was agreed:

Option Description CommentaryOption 2 Don’t have any

Health Centre building – use existing available public sector estate.

This option was not short-listed as it was completely incapable of delivering the preferred service model, would not deliver the health & social care hub required and result in an even more fragmented service than at present. It was also reliant upon making use of existing spaces that lack both the capacity and functionality to deliver any of the services being delivered now and in the future.

Option Description CommentaryOption 3a

An operational solution utilising only the existing Health Centre

Whilst a number of operational solutions are being considered by the Board to address acute short-term crises – and this option is not mutually exclusive – it is not capable of addressing anything other than capacity concerns in the very short-term and certainly not any of the physical/facility issues identified. It was consequently not short-listed.

Option 3b

An operational solution utilising the existing Health Centre plus space in the adjacent Lochgelly Centre

This option was assessed as a variation on option 3a), with space in the Lochgelly Centre providing potential additional scope to improve capacity concerns in the short-term. It was not short-listed for the same reasons.


Refurbish & extend the existing Health Centre facility

This option was originally agreed for short-listing and was subsequently developed into drawings. Unfortunately this work-up highlighted that there was insufficient space to support the required extension (which would have to be on a single level on the adjacent car park site). It was consequently proven unfeasible and not short-listed.

Option 4b

Refurbish the existing Jenny Grey facility

In contrast to the previous option, refurbishment of the Jenny Grey facility was not initially thought feasible, however architect work up developed a scheme that appeared credible with good use of space and only minimal compromise. This option was consequently short-listed.


Reduced new build on existing Health Centre site (plus use of space in existing Health Centre facility)

This option involved building a reduced new facility on the existing site that retained the existing facility. It was a theoretical option only and clearly not feasible as the existing Health Centre occupies its entire curtilage. The option was consequently not short-listed.

Option 5b

Reduced new build on existing Health Centre site (plus use of space in Lochgelly Centre)

This option involved building a reduced new facility on the existing site that also made use of space in the adjacent Lochgelly Centre. The option was not short-listed as it offered no benefits over a reduced new build on the adjacent car park site but introduced significant cost, disruption and operational challenges associated with de-cant to support demolition and re-building. The option was consequently not short-listed.

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Option 5c

Reduced new build on adjacent (car park) site (plus use of space in Lochgelly Centre)

This option involved a reduced new build on the adjacent car park site that made use of space (primarily group rooms) in the adjacent Lochgelly Centre. It was deemed feasible and consequently short-listed.

Option 5d

Reduced new build on Lochgelly North School site (plus use of space in shared new development)

This option involved a reduced new build on the existing (disused) Lochgelly North School site that would be aligned to potential (very early stage) local authority proposals relating to the construction of a pre-school nursery on the site. It was deemed feasible and consequently short-listed.

Option 5e

Reduced new build on Jenny Grey site (plus use of space in other facilities TBC)

This option involved building a reduced new facility on the existing Jenny Grey site that also made use of space in appropriate existing local facilities. In the event, no such facilities could be found and consequently the option was not short-listed


Full new build on existing site

This option involved a full new build on the existing site that was entirely self-contained. It was not short-listed as it offered no benefits over a full new build on the adjacent car park site but introduced significant cost, disruption and operational challenges associated with de-cant to support demolition and re-building

Option 6b

Full new build on adjacent car park site

This option involved a full (self-contained) new build on the adjacent car park site. It was deemed feasible and consequently short-listed.

Option 6c

Full new build at Lochgelly North School site

This option involved a full (self-contained) new build on the Lochgelly North School site. It was deemed feasible and consequently short-listed.

Option 6d

Full new build at Jenny Grey

This option involved a full (self-contained) new build on the existing Jenny Grey site. It was deemed feasible and consequently short-listed

Option 6e

Full new build at Francis Street

This option involved a full (self-contained) new build on the Francis Street site. It was deemed feasible and consequently short-listed.

1.3.5 The benefits criteria against which the long list were assessed were initially drafted by the wider planning team in light of the strictures placed upon the clinical model by the facility associated challenges identified. These were refined during the option appraisal events into an agreed list based on global stakeholder opinion.

1.3.6 Importantly, this list was also developed with the support of the stakeholder group reviewing options related to a similar business case being developed for Kincardine in order to ensure that both projects, which have similar objectives and timescales, were able to benefit from each other’s work through the development of an agreed list of benefits criteria that were weighted independently.

1.3.7 In summary, the benefits criteria reflected the ability of each identified option to, noted in order of highest to lowest weighting:

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Deliver an optimal physical environment Be readily accessible Support flexibility and sustainability Support local and national service strategies Deliver wider community & public benefits

1.3.8 The Partnership is committed to delivering services that are integrated and maximise opportunities for local delivery. It has been formally confirmed that there is an on-going requirement to continue to deliver General Practitioner, primary care and local clinical services from Lochgelly.

1.3.9 Specific site/facility considerations included:

The existing NHS owned Health Centre site in Lochgelly The adjacent Local Authority owned (car park) site in Lochgelly A site at the Local Authority owned Lochgelly North School The Jenny Grey site (A Local Authority care home recently reprovided) A Local Authority owned site at Francis Street

1.3.10 Whilst a number of other potential sites were raised and considered, they were all excluded at this stage as they were either demonstrably too small and / or not in public sector ownership. On this latter point it was noted that a site that was not currently in the ownership of the public sector would only be considered if none of the public sector sites was deemed appropriate based on the appraisal process.

Short List 1.3.11 The short list initially included Options 1, 4b, 5c, 5d, 6b, 6c, 6d and 6e.

1.3.12 In reflection of the complexity of the process and relatively early stage in the development it was however agreed to combine a number of these options. Specifically:

Option 6b was combined with option 5c for evaluation purposes, with the amended option 5c becoming new build on adjacent (car park) site plus/minus use of space in Lochgelly Centre. This combined option referenced the fact that the required land take for both options was the same, with only the volume of accommodation required on a second floor different, whilst acknowledging the significant additional work still required to understand the actual opportunities and threats associated with potentially accessing the Lochgelly Centre.

Option 6c was combined with option 5d for evaluation purposes, with the amended option 5d becoming new build on the Lochgelly North Schools site that ‘had the potential to make use of space in a shared new development’ if this is taken forward by the Local Authority. This combined option referenced the fact that the area available was capable of delivering both options whilst acknowledging that the nursery proposal was still only embryonic.

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1.3.13 The short list options finally agreed and short-listed for scoring (by location) were:

1.4 INDICATIVE COSTS

1.4.1 Indicative costs for each of the options on the Short List have been prepared as per guidance in the Scottish Capital Investment Manual by Hubco. The non preferred options are based on BCIS Tender Price Indices – updated to 4th quarter 2020. The preferred option is based on elemental cost/m2 from other recent health centre projects and the current Schedules of Accommodation (updated to 4th quarter 2020)

Description Capital Costs (£) Whole Life Capital Costs (£)

Whole Life Operating Costs (£)

Est. NPV (£)

Est.EUV (£)

1 (1) Do Nothing/Base - - 5,465,940 2,311,661 91,099

2 (5c) Car Park 7,025,717 1,639,332 19,613,953 11,871,118 467,8233 (6d) Jenny Grey 6,959,207 1,623,802 19,526,538 11,799,393 464,9964 (4b) Jenny Grey

Refurbishment - - - - -5 (6e) Francis

Street 6,835,692 1,594,962 19,364,198 11,666,192 459,7476 (5d) North School 7,244,244 1,690,358 21,488,830 12,763,618 502,995

Site Option CommentaryOption 1 Do nothing (The status quo)Current

Site/Adjacent Car Park Area: Option 5c Build a new Health Centre on the adjacent (car park) site

(plus/minus make use of space in Lochgelly Centre)

Option 4b Create a new Health Centre by refurbishing the existing Jenny Grey facility

Jenny Grey Site

Option 6d Build a new Health Centre on the Jenny Grey site by demolishing the existing facility

Lochgelly North School Site

Option 5d Build a new Health Centre on the Lochgelly North School site (with potential to make use of space in a shared new nursery development)

Francis Street Site Option 6e Option 6e) Build a new Health Centre on the Francis Street site

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1.5 OPTION APPRAISAL

1.5.2 The following table 13 outlines how the advantages and disadvantages of the short list were assessed against the benefits criteria through an Option Appraisal exercise undertaken with representatives of all stakeholder groups. Stakeholders worked in groups, and through a process of discussion / debate within groups, with the intention of seeking consensus agreement around the relative merits of each option and scores to be applied. Table 14 then summarises the options relationship to the investment objectives.

Table 13

OptionAdvantages:Strengths & Opportunities

Disadvantages:Weaknesses & Threats

Option 1:Status Quo

Established location Building and curtilage no longer fit for purpose.Not suitable for further developmentIs no longer an option.

Option 5c:

Car Park

Central, established location.Accessible site. Overlooked- supports security.Visible site.Community setting.Improves town landscape.Community setting.

Two storey.Further site investigations required due to mining.Constrained town centre site.Loss of car parking during construction.Reduced car parkingAccess roads may be unsuitable for construction traffic.Site ground conditions make development very expensive.Infrastructure issues – sewers do not support new development /network issues.

Option 4b: Refurb. Jenny Grey

Relatively close to town centre.Reuse of existing public sector estate.Space for optimum parking / site servicing. Good access.Overlooked- supports security.Potential capital savings.Community setting.Flexibility of expansion options on site.Potential complimentary use of site.Potential to have segregated staff access.

Decant costs.Possibly too overlooked. Further site investigations required due to mining. Access roads may be unsuitable for construction traffic.Does not meet more detailed briefing requirements due to restrictions of existing structure.

Option 6d: New Build Jenny Grey

Relatively close to town centre.Large flat site, optimum parking/site servicing. Good access. Overlooked- supports security.Adjacent to open amenity site.Community setting.Flexibility of expansion options on site.Potential complimentary use of site.Potential to have segregated staff access.

Overlooking could impact on patient privacy.Further site investigations required due to mining. Access roads may be unsuitable for construction traffic.Perceived impact on local amenity space.

Option 5d: North

Relatively close to town centre.Large flat site, optimum parking/site servicing.

Further site investigations required due to mining.Access roads may be unsuitable for

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OptionAdvantages:Strengths & Opportunities

Disadvantages:Weaknesses & Threats

School Good access. Overlooked - supports security. Potential complimentary use of site.Uses a site with established community functionUses infrastructure of potentially suitable capacity of site.

construction traffic.Site ground conditions make development very expensive.Infrastructure issues – sewers do not support new development /network issues.Hidden from primary routes.Demolitions required on site. Potential impact on programme/approvals from adjacent developments

Option 6e: Francis St

Central location.Accessible, ample site.Overlooked- supports security.Visible site.Community setting.Increased flexibility.Enables segregated access

Possibly too overlooked.Further site investigations required due to mining.Access roads may be unsuitable for construction traffic.Site ground conditions make development very expensive.Infrastructure issues – sewers do not support new development /network issues.

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Table 14

Investment ObjectivesOption

1: Status

Quo

Option 5c:Car Park

Option 4b:

Refurb. Jenny Grey

Option 6d:

New Build Jenny Grey

Option 5d:

North School

Option 6e:

Francis St

Ensure equal access to Primary Care and Community Services for the whole population. No Yes No Yes Yes YesEnsure the right staff skill mix and service capacity are available to deliver strengthened and tailored local capacity to manage people’s health within their local community.

No Yes No Yes Yes Yes

Ensure appropriate workforce including increased flexibility of roles /development of new roles to support implementation of GMS (2018) and Community Health and Wellbeing Hub.


Provide a more integrated seamless service across health and social care, including the capacity to deliver group based activities locally.


Improve the patient and user experience - deliver services locally based on local patient need. Reducing the number of referrals to other services and the requirement for additional attendances because there is not the capacity to provide integrated care.


Accommodation that complies with all legal standards and regulatory requirements and gives equality of access for all.Support delivery locally of the National Outcomes for Integration.




To deliver services more effectively and efficiently - facilitate better joint working to ensure right care is delivered at the right time and in the most appropriate setting.


Weighted score 256 431 435 632 431 879Preferred / Possible / Rejected Preferred

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1.6 THE PREFERRED OPTION

1.6.1 The Option 6e) (listed as Option5) New Build at Francis street, represents a clearly favoured option for all stakeholders, with 6d) a clear 2nd place.

1.6.2 The proposal has the support of representative service users, carers, staff, the General Practitioner Practice and all other key stakeholders.

1.6.3 It is recommended that NHS Fife proceeds to Outline Business Case, exploring Option 6e (option 5): New Build at Francis street site in more depth.

Figure 4

1.7 DESIGN QUALITY OBJECTIVES

1.7.1 A key part of the development of the Initial Agreement Document was to ensure that stakeholders were fully engaged in the NHS Scotland Design Assessment Process (NDAP).

1.7.2 There were two key strands to this work;

1) A multi-stakeholder event where the Achieving Excellence, Design Evaluation Tool (AEDET) was completed for the existing unit.

2) An NDAP Design Statement was developed to capture the ‘non-negotiable’ points that need to be addressed by the project.

Indicative Site Plan for New Build at Francis Street.

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1.7.3 AEDET on Existing Property: An AEDET Workshop was held on 21 February 2017.

1.7.4 The existing unit at Lochgelly was reviewed. A Benchmark Score was achieved with the resultant Target Score as below.

Table 15Descriptor Benchmark Target

Use 1.4 4.5Access 1.1 4.4

Functionality

Space 1.0 4.2Performance 1.4 4.4Engineering 1.3 3.4

Build Quality

Construction 0.0 4.0Character and Innovation 1.0 4.4

Form and Materials 1.3 4.4Staff and Patient Environment 1.1 4.3

Impact

Urban and Social Integration 1.3 4.5

AEDET Refresh Benchmark Summary

AEDET Refresh Target Summary

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1.7.5 NDAP Design Statement: A multi-stakeholder event was held on Friday 3 March 2017.

1.7.6 This event was facilitated by Architecture and Design Scotland (A&DS) where the group discussed the non-negotiable in terms of requirements from the perspective of patients, staff and visitors. These are summarised below:

The Patients Perspective

The patient’s perspective was reviewed in terms of their initial approach to the centre through to waiting for their appointment. There was a consensus on the expectations for a facility that was easily accessible, bright, friendly and airy. It was agreed that the facility should be designed so that patients could be treated with dignity particularly in terms of confidentiality.

The Staff Members Perspective

Staff groups were clear that they would want the facility to enable different staff groups’ paths to cross. Staff want to feel safe in accessing and egressing the facility. Suitable investment in information technology and teaching facilities is also expected as well as staff change, shower and communal staff room facilities.

The Visitor / Carer Perspective

It was agreed that carer’s should be able to accompany patients and be easily accommodated in the waiting and consulting spaces with access to support information at hand.

A smaller private waiting space is required to support patients and carers who are challenged by open spaces or who themselves are exhibiting challenging behaviours.

1.8 DESIGN STATEMENT

1.8.1 The event enabled participants to clearly describe the attributes the building must possess, this will support the development of the detailed business case. The business objectives the project seeks to achieve are:

To provide current clinical service requirements locally and reduce the number of referrals to other service providers and additional attendances required.

Deliver group based activities. A key strand of NHS Fife’s Clinical Strategy is to reduce health inequalities by reconfiguring services and resources so that there is equity of access to services across Fife and across all patient groups. Care should be provided at home or as close to home as possible. Delivering services in a group environment will allow a greater number of NHS Fife residents to be supported in their management of their own well-being.

To meet Outcome 3, 5 and 9 of the National Outcomes for Integration, i.e. that people who use Health and Social Care Services have positive experiences of those services, and have their dignity respected; health and social care services contribute to reducing health inequalities; and resources are used effectively and efficiently in the provision of health and social care services

Improve safety and effectiveness of accommodation by improving the physical condition and quality of the healthcare estate.

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2 COMMERCIAL CASE

2.1 OUTLINE COMMERCIAL CASE

2.1.1 The indicative costs for the preferred option at this stage are £6,835,692 excluding VAT. The current building is owned by NHS Fife, it is therefore anticipated that NHS Fife will lead on the procurement, supported by the IJB, through the Scottish Futures Trust hub initiative.

2.1.2 Hub East Central is the designated procurement vehicle for health projects in excess of £750k in the NHS Fife Board area.

2.1.3 The East Central HubCo can deliver projects through one of the following options:

Design and Build contract (or build only for projects which have already reached design development) under a capital cost option

Design, Build, Finance and Manage under a revenue cost option

2.1.4 Design and Build, using NHS Capital is likely to be the most suitable vehicle for this project.

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3 THE FINANCIAL CASE

3.1 Based on the current costs and assumptions identified in Section 4.5 below, NHS Fife considers the project to be affordable within the current available capital resources estimated within the Local Delivery Plan. This builds in a significant contingency into the scheme to cover optimism bias and other possible infrastructure and enabling costs. Should Capital costs increase over the agreed budget, the Board would require to acquire Capital funding from elsewhere within the Board’s Capital Programme.

3.2 Fife Health & Social Care Partnership has agreed to fund the revenue consequences; which are affordable within the revenue resources available. Should Revenue costs increase, then these additional costs would require to be funded within the Partnership’s overall revenue resource envelope.

3.3 In order to make this assessment an overall affordability model has been developed covering all aspects of projected costs including estimates for:

Capital costs for preferred option (including construction and equipment); Non-recurring revenue costs associated with the project; Recurring revenue costs (pay and non-pay) associated with existing services

i.e. baseline costs; Changes to revenue costs associated with service redesign as a direct result of

the development.

3.4 CAPITAL AFFORDABILITY

3.5 The total capital cost comprises the projected construction cost, supplied by HubCo, plus optimum bias and professional fees.

3.6 The estimated capital cost associated with each of the short listed options is detailed in table 16 below:

Table 16

Option 5c:

Car Park

Option 4b: Refurb.

Jenny Grey

Option 6d: New Build

Jenny Grey

Option 5d: North

School

Option 6e: Francis St

Construction Cost 3,669,025 3,634,025 681,125 3,569,025Preliminaries 660425 654,125 302,722 642,425

Fees Stage 1 & 2 & Construction

293,522 290,722 143,793 285,522

Hubco Items 139,423 138,093 124,873 135,623Contractor OHP 121,078 119,923 283,802 117,778

Contingency / Risk 275177 272,552 20,000 267,677Planning & Warrant (Inc

Mark Ups 20,000 20,000 16,000 20,000

Survey Fees (Inc Mark Ups)

16,000 16,000 126,403 16,000

Inflation BCIS TPI 3Q19 - 4Q20 @ 347

122,588 121,426 681,125 119,270

Optimum bias 880,566 872,166 908,166 856,566 Professional fees 827,913 820,175 853,335 805,806

Total capital costs 7,025,717 6,959,207 7,244,244 6,835,692

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3.7 To provide the above Indicative Costs at this Initial Agreement Stage, the following assumptions have been made:

1. The options are based on elemental cost/m2 from other recent health centre projects and the current Schedules of Accommodation (updated to 4th quarter 2020)

2. The optimum bias % applied is based on the Green Book recommendation of 24% for a standard build

3. For the Jenny Grey Refurbishment option it had been assumed that this building was at least 30 years old. Life cycle adjustments have been made downwards to reflect this.

4. No costs identified for council requirements e.g. bus stops, crossings.5. Land will be available on a long-term lease from Fife Council therefore no costs for

land purchase have been included.6. No costs included for demolition as assuming Fife Council would demolish existing

buildings and clear land where appropriate with a corresponding adjustment on any lease costs.

7. Advisers’ costs (included within the Capital Cost figures) are based on recent Hubco calculations.

8. Discounted Cash Flow (used to calculate NPV and EUV) - after 30 years the discount rate adjusts to 3%

9. Life cycle costs are based on maximum life for a new build

3.8 For comparison, the present backlog maintenance costs recognised for Lochgelly Health Centre are £255,000. This represents the estimated cost (excl. VAT, professional fees and enabling costs) to complete all presently recognised backlog maintenance to bring the asset up to 'satisfactory condition'. It does not allow for replacing of any assets due to functionally unsuitability.

3.9 REVENUE AFFORDABILITY

3.9.1 The estimated revenue cost for both the baseline (do nothing) and the short list options are included below:

Table 17Cost per Annum (£k)

Revenue CostOption1: Status

Quo

Option 5c:

Car Park

Option 4b:

Refurb. Jenny Grey

Option 6d: New

Build Jenny Grey

Option 5d:

North School

Option 6e:

Francis St

Non PayEquipment 260 1500Heating Fuel and Power 17,336 35097Property Maintenance 10,577 13518Property Rates 30,032 54072Water Charges 5132Facilities CostsPay: Support services 23,946 58256Non Pay:Bedding and Linen 710 1369Cleaning 482 929Equipment 942 1816General Services 684 1385Post Carriage and Telephones 70 142Printing and Stationery 222 449

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Cost per Annum (£k)Revenue Cost

Option1: Status

Quo

Option 5c:

Car Park

Option 4b:

Refurb. Jenny Grey

Option 6d: New

Build Jenny Grey

Option 5d:

North School

Option 6e:

Francis St

Property Maintenance 959 2034Surgical Sundries 50 256Other misc non pay 4,831Total Estates & Facilities Costs 91,099 175,956Depreciation charge 30,449 266,435

Notes/Assumptions

Actual costs 2018/19

1) Revenue Costs for proposed site are based on current plans of a two storey build of 1502m2.2) One-off equipment purchases required in year 1 of £8,400.

3.9.2 The H&SCP estimates that the ability to deliver a more integrated, proactive model locally will support revenue efficiencies. It is not expected that there will be any revenue implication for overall GMS costs on NHS Fife and so has been excluded from this table.

3.9.3 Any changes General Practitioners make to the provision of services within the General Practitioner Practice are being developed through Primary Care Improvement Fund.

3.9.4 A full affordability analysis will be undertaken at OBC stage to confirm whether the Capital and Revenue costs associated with the new facility are affordable within the available funding levels.

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4 THE MANAGEMENT CASE

4.1 GOVERNANCE ARRANGEMENTS

4.1.1 Governance will be taken forward in line with the Scottish Capital Investment Manual (SCIM) guidelines, through the NHS Fife Capital and Investment Group and Finance, Performance and Resources Committee.

4.1.2 As the estimated costs of this project are outwith the Board’s delegated limited for capital expenditure of £1.5m, there is a requirement to seek the Scottish Governments approval through the Capital Investment Group (CIG).

4.1.3 Under the SCIM guidelines, approval of this Initial Agreement will lead towards developing an Outline Business Case (OBC) to enable the preferred way forward to be identified.

4.2 PROPOSED PROJECT RESOURCES

4.2.1 Fife HSCP, together with NHS Fife and the Lochgelly Medical Practices, will utilise a Project Board to develop the business case and manage the process through to approval. The Project Board will comprise:

Table 18

Role Individual Capability and ExperienceProject Sponsor Nicky Connor, Interim HSCP

DirectorExperience in leading and ownership of developments.

Project Owner Claire Dobson, Divisional General Manager

Experience from delivery of range of capital redesign programmes

Belinda Morgan Clinical Services Manager Experience in modernisation of service delivery models in community care and in project management

Facilities Manager NHS Fife

Jim Rotherham Experience in delivering similar projects such as Linburn Rd.

Head of Estates Appointee pending Experience from delivery of range of capital redesign programmes

Finance Business Partner

Gordon Cuthbert, Finance Business Partner

Responsible for providing financial guidance and scrutiny

Capital Finance/ Planning

Individuals will be identified from a pool of staff who have experience of similar projects

NHS Fife eHealth Representatives will be invited to sit on the project team to ensure collaborative working and identification of any risks and opportunities with regard to technology.

Lochgelly Medical Practices

The Partners and Practice Managers provide Primary Care expertise and have sound understanding of local community needs

Other health care professionals will be consulted / co opted as required

4.2.2 The remit of the Project Board is: To assist the Project Sponsor and Project Owner with the decision-making

process and ongoing implementation of the project. To assist the Project Owner with preparing to meet the assurance needs of the

Finance, Performance & Resources Committee, as well as any further enquiries from IJB / NHS Fife’s Board with regard to the project.

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4.2.3 The Project Team will be further developed at OBC stage when key suppliers have been procured.

4.2.4 Those individuals identified in table 14 above have been heavily involved in developing this Initial Agreement Document and they will continue to be involved in leading the project through subsequent stages,providing continuity and a stable environment for the project to achieve its objectives. Users of the Health Centre / Practice have been consulted and will continue to be involved as the project progresses.

4.2.5 A blend of resources will be utilised to deliver this project. The Project Board, Project Director, Stakeholders and Clerk of works will be internal resources, whilst the Project Manager and Cost Advisor are likely to be procured through utilisation of external suppliers. The Board has used this blend of resource successfully on other projects and feels that it creates a good balance between control, risk transfer, capability and availability. The Board is experienced in delivering projects of this nature within the selected procurement route and is ready to move the project forward to the next stage upon IAD approval.

4.3 PROJECT PLAN

4.3.1 A detailed Project Plan will be produced for the OBC. At this stage, the Project Board is aiming to achieve the milestones shown in table 19 below:

Table 19

Key Milestones DateAppointment of Advisors by SFT January 2016Appointment of Local Care Consultants / Local Care Pathfinder May 2017Initial Agreement approval October 2019First Project Board December 2019Outline Business Case approval February 2020Full Business Case approval October 2020Construction Commences December 2020Construction completion May 2022Commence service July 2022

4.4 STAKEHOLDER ENGAGEMENT AND SUPPORT

4.4.1 This proposal impacts on adults, children and young people and their carers who live in the Lochgelly area who require access to Primary Medical Services, community health and social care and voluntary sector services. It also impacts upon clinical and support staff currently working within the Health Centre, Medical Practice and locality teams who cannot currently access accommodation in Lochgelly.

4.4.2 Table 20 below details the engagement that has taken place to date and the support for the proposal, including the identified preferred solution, received from the stakeholders.

4.4.3 Further engagement with the identified stakeholders in line with SCIM guidance will be undertaken as the project progresses.

Table 20


proposalNHS Fife The Health Board is fully supportive of this The Health Board agreed

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proposalBoard proposal, with Michael Kellet, HSCP

Director, taking the lead role in its development.

priority for development in May 2017. The Initial Agreement was previously approved by the NHS Fife Board in May 2017.

Patients / service users

Service user and carers representatives have been informed to support their full engagement in the option appraisal. Patients have identified a range of ‘non-negotiables’ that cannot be supported from the current accommodation.Ongoing engagement and specific engagement to support the development of the Clinical Strategy and through the Health and Social Care Joining Up Care Proposal consultation informed the development of the model of care.

There is a preference from service users for the development to be accessible, bright, friendly and supportive of their dignity and confidentiality.Community groups, individuals and stakeholder groups have shaped the community health and wellbeing hub model.

Medical Practices

The Medical Practices deliver Primary Medical services to their Practice population under a 17J contract. The Practice Managers and General Practitioners have been actively involved in the process of developing options and plans for the proposal.

The Practices fully support the Initial Agreement and intend to continue service provision in accordance with the developments within the new GMS.

Staff / Resource

Staff affected by this proposal include: Lochgelly Medical Practice, Meadows Practice and Dr Thompson Medical Practice, Nursing and Administrative staff. Community service staff including District Nurses, Health Visitors, AHPs, Clinical Psychology, Mental Health Nursing, Psychiatry, Pharmacy, Physiotherapy, Partner Voluntary Sector services, admin and clerical, Social Work and staff from partner health and social care services.

There is support for the proposal from all staff groups.

General public The general public will be affected by this proposal as potential service users or by being neighbours of the existing or proposed future facility. The public were supportive of the Community Health and Wellbeing model within the Joining Up Care Consultation.A Communication and Engagement Plan is being developed to ensure ongoing Stakeholder communication.

Lochgelly area Community Councils have been engaged and are supportive of this development

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5 CONCLUSION

5.1 REVIEW OF STRATEGIC ASSESSMENT

5.1.1 The Project Team have reviewed the Strategic Assessment (Appendix 1) and the position in terms of the need for change, the benefits that need addressed, the links with National Investment Priorities and the prioritisation scoring, the position remains unchanged.

5.2 PREFERRED OPTION

5.2.1 Overall, the non-financial option appraisal process has identified that the current preferred strategic option is for the service to be delivered from a new build facility.

5.2.2 All of the stakeholder groups engaged in this process:

Are likely to support Option 6e) as an overall preferred option, unless something radical changes.

Do not support the “do nothing” option in any way. See little difference between the relative merits of options 5b), 5d) and 4b).

5.2.3 NHS Fife and Fife Health and Social Care Partnership have summarised the need for change in and around the facilities in Lochgelly under a number of defined headings within the IAD. These are:

Integrated clinical and care functionality (capacity) issues which have been identified as those problems associated with a lack of local space (area) that is essential for safe, effective, timely and appropriately compliant service delivery, e.g., a lack of clinical support, administrative support, group, sanitary, teaching, group work and specialist areas

Service capacity related issues that predicate the need for change based on a lack of available physical capacity across the service delivery model that are hampering the delivery of integrated care locally

Clinical functionality (configuration) issues that seriously challenge the delivery of safe and effective modern services, e.g., access issues, room design, sound attenuation, security, patient flow, etc

Building and fabric issues including overall condition, suitability, statutory compliance issues and backlog maintenance

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Appendix 1 – Strategic Assessment

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Lochgelly Health Centre Condition Report

NHS Fife Estates maintain records on the suitability and condition of buildings in its estate. Below is the current information relating to the Lochgelly Health Centre building.

Status OccupiedGIA (m2) 779Land Value £70,200Net Book Value £560,353Tenure Owned

Current configuration / layout of Lochgelly Health Centre

Building Engineering Statutory FireBacklog (C and Below) £121,746 £0 £133,280 £0

Quality C (Not Satisfactory)Space Utilisation O (Overcrowded)Functional Suitability C (Unsatisfactory)

Figure used from surveys were complete in December 2012

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Appendix 2 - Benefits Register

Benefits Register

1. Identification2.



Importance Person-centred Benefits

P1 Supports people in looking after and improving their own health and wellbeing. Quantitative Maintenance of PC team consultation

rate/1,000 population 4852 4852 4

P2Ensures that people who use health and social care services have positive experiences and their dignity respected.

QualitativeTargeted client questionnaire designed to measure overall experience of health and social care delivery

Current patient experience questionnaires

Future patient experience

questionnaires4

P3 Improves the physical condition of the healthcare estate Quantitative Estate physical condition survey assessment C A 5

P4 Improves utilisation of the healthcare estate Quantitative Estate utilisation assessment Over-crowded (100%

utilisation) 80% 5

P5 Improves functional suitability profile of the healthcare estate Quantitative Estate functional suitability assessment C A 5

P6 Reduces the age of the Healthcare Estate Quantitative Estate age/life expectancy 77 Years/<5 Years <10 years/>25 years 4

P7 Improves access to all clinical areas - in particular for those with mobility issues Qualitative Measured accessibility to all patient/clinical

areasBaseline issues as identified in

SA, IA and design brief

Equality Act (2010) Compliance and AEDET

scores5

P8 Improves access to age appropriate waiting areas Qualitative Availability of a child-specific waiting area that

is appropriate to the size of the facility No child-specific waiting Child-specific waiting available 4

P9 Improves way-finding and access to a main reception point

Qualitative and Quantitative

(i) IA AEDET Score (ii) Number of reception points

(i) 1.1 (ii) 4

(i) 4.4 (ii) 1 4

P10Addresses confidentiality concerns related to hearing private conversations, between rooms, associated with existing facility

QuantitativeAbility to hear normal volume conversations from adjacent rooms or outside with windows open

Possible to hear conversations at normal volume

Only possible to hear raised voices or shouting 5

P11 Address confidentiality concerns at Reception Qualitative Ability to hear conversations at reception area

from waiting areaConversations currently take place in public at reception

Provision of private spaces for sensitive

conversations5

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P12

Increases the number and range of services available on-site, thereby reducing hand-off's and additional attendances

Quantitative

(i) Access to social care services on site (ii) Access to social work services on site (iii) Access to LA services on site (iv) Access to voluntary (sign-posting) services on site (v) Access to other relevant targeted clinical services on site

(i) No access (ii) No access (iii) No access (iv) Minimal access

(v) Minimal access

(i) Sessional access (ii) Sessional access (iii) Sessional access (iv)

Daily access (v) Sessional access

5

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1. Identification2.



Importance Safety Benefits

S1 Reduces adverse harmful events Quantitative

(i) Number of adverse incidents recorded on Datix(ii) Severity of adverse incidents recorded

2015/2016 (i) 3 (ii) 1 minor harm (falling ceiling tiles) 2 no harm (verbal abuse no appts; leak from skylight) 2016/2017 (i) 2 (ii) 1 no harm (verbal abuse from patient - lone

worker receptionist); 1 minor harm (IT system failure - different system to other Practices - no adequate available rooms, full day clinic cancelled)

2017/2018(i) 2 (ii) 2 no harm (2 children running around after close

and heavily pregnant colleague tripped twice on raised lino flooring within staff cupboard)

Incidents and ongoing risks practices have relayed to Project Team: Patient collapse blocking door way – no screens or

privacy (2013) Uneven flooring in Office area/Room 1 since 2016 Reception ceiling tiles fell onto PC due to water

ingress2018 Display materials fell off wall onto patient 2018

Zero events relating to the

building / facilities

5

S2Increases safety of people receiving care and support e.g. feeling safe and secure


Addressing baseline issues as identified in SA, IA and design brief

Baseline issues as identified in SA, IA and design brief All issues addressed 5

S3 Improves statutory compliance Quantitative

Backlog maintenance costs/m2 associated with statutory compliance elements

72% 100% 5

S4 Reduces backlog maintenance Quantitative Backlog maintenance £335/m2 Zero 5

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costs/m2

S5 Reduces significant and high risk backlog maintenance Quantitative

Significant and high risk backlog maintenance costs/m2

£191/m2 Zero 5

S6Reduces Infection risk through addressing design, area, fabric and equipment issues

Quantitative(i) Domestic Monitoring Tool (ii) Compliance with local HAI audits

(i) 97% (ii) Several non-compliant issues(i) 100% (ii) Zero non-compliant

issues5

S7 Increasing facility flexibility by rationalising IT systems. Quantitative

Number of different Practice-based IT systems in use

3 1 2

1. Identification2.



Effective Quality of Care Benefits

E1 Improve the capacity to deal with emergency clinical incidents


Reduces the impact of clinical emergencies by providing suitable space and equipment 0 1 4

E2 Improves the Functional Suitability of the Healthcare Estate Quantitative Estate functional suitability assessment C A 5

E3 Supports increased local access to pharmacy support. Quantitative Number of pharmacist hours available per

Practice/week 1wte 5wte 3

E4 Increases access to group opportunities. Quantitative

(i) The number of group work sessions held locally (ii) The number of people attending group work sessions held locally

(i) 0 (ii) 0 (i)10 (ii) 15 (per group) 5

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1. Identification2.



Health of the Population Benefits

H1 Supports smoking cessation initiatives (12 weeks post quit) Quantitative

(i) Number of smoking cessation appts delivered locally (ii) Number of clients still not smoking 12 week after session completion

(i)470 (ii) 40 (i)500 (ii) 50 3

H2 Supports antenatal access Quantitative (i) Number of ante-natal appointments held locally (ii) DNA rates

i) 902 ii) 100

i) 950 ii) 50 (enabling to patient-led care model where more care will be delivered in the community)

4

H3 Supports the integration of general and mental health services Quantitative Number of mental health appts held locally PA 1200 2000 4

H4 Supports child healthy weight interventions Quantitative (i) Number of child healthy weight appts held

locally PA

Zero currently provide from

the HC - interventions are provided

on an outreach basis

Option available of providing interventions from the HC 4

H5 Supports sexual health interventions Quantitative Number of sexual health appts held locally PA 300 480 4

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Ref No. Benefit Assessment As measured by: Baseline Value Target Value Relative Importance Value & Sustainability Benefits

V1 Optimises resource usage Quantitative (i) Consultations/clinical room/day (ii) Number of staffed reception points

(i) 12 (ii) 4 (i) 24 (ii) 1 4

V2 Optimises service delivery model parameters by staff group Quantitative Overall consultation rate/1,000

population 4852 4852 4

V3 Optimises overall running cost of buildings Quantitative Facility running costs/m2 and per

appt £67.44/m2 < national average 5

V4 Optimises cleaning costs Quantitative Cleaning costs/m2 and per appt £30/m2 < national average 3

V5 Optimises property maintenance costs Quantitative Property maintenance costs/m2 and

per appt £10.27/m2 < national average 5

V6 Optimises energy usage costs Quantitative Energy usage & associated costs/m2 and per appt (Kj & £) £25.92/m2 < national average 5

V7 Optimises FM & support services costs Quantitative FM and support services costs/m2 Contained in V5 Contained in V5 3

V8 Optimises waste costs Quantitative Waste costs £835 per annum In line with Waste Action Plan 4

V9Reduces financial burden of backlog maintenance and/or future lifecycle replacement expenditure

Quantitative Backlog maintenance costs/m2 £335/m2 Zero 5

V10 Reduces carbon emissions and/or energy consumption Quantitative (i)Detailed energy/building

assessment (ii)BREEAM rating (i) G (ii) N/A (i) A (ii) ‘Excellent’ 5

V11 Reduces local medicine/prescribing costs Quantitative Medicines cost/registered patient

Lochgelly: £125 Meadows: £122 Thompson: £118

Move towards the Scottish average 5

V12 Paper records storage area/capacity minimised on site Quantitative Area (m2) associated with paper

records storage 80m2 0m2 5

55/57 171/331

56 | P a g e

Wider/Social Benefits

W1 Supports wider town and community planning Fits with Local Authority planning. Zero

Actively contributes to Lochgelly Plan

within project boundaries.

3

Scale / RAG Relative Importance

1 Fairly insignificant2 ↕3 Moderately important4 ↕5 Vital

56/57 172/331

57 | P a g e

Appendix 3 Risk RegisterProject Risk Log

Last Revised date: Junly 2019

Ref # RISK DESCRIPTION FINANCIAL NON-FINANCIAL UNQUANTIFIABLE

CONSEQUENCE

LIKELIHOOD RISK SCORE PROPOSED TREATMENT ACTION TAKEN OWNER

01-May 01-May MITIGATIONINDIVIDUAL TYPE

IA Stage1 May fail to identify all stakeholders. 3 2 6 All Stakeholders who need to be engaged

will be identified by the Project Board. Board will continue to ensure ongoing stakeholder engagement through a range of tailored methods.

All Stakeholders who need to be engaged have been identified.

Project Chair NHS

2 May fail to engage with Stakeholders. 4 3 12 Engagement arranged as required. All User Group Workshops to be arranged to include Key Stakeholders. Communication regarding Local Care Consultancy shared with practices and involvement in workshops.

Procedures arranged for engaging with wider stakeholders e.g. Option Appraisal and AEDET. Attendance monitored to ensure consistent engagement.


H&SCP

3 Stakeholders have different aspirations. 3 4 12 Groups arranged to ensure key stakeholders discuss aspirations. Core team to mange discussions and agree project aspirations with Project Board decision if required

All discussions facilitated to ensure stakeholder involvement with discussion on aspiration versus need.

Project Chair NHS

4 May fail to define appropriately the clinical and service needs, particularly as these change over time with specific practice sustainability and GMS contract developments.

4 3 12 Ensure clinical and other service stakeholder involvement, including representation on Project Board, to allow effective modeling of multiple scenarios resulting in an agreed Clinical Output Specification and Accommodation Schedule

Clinical land other services representation requested and delivered where necessary. Fife wide representative sought

Project Chair NHS

5 The brief/requirement may suffer from scope creep.

3 3 9 Ensure continual review of requirements/needs

Project leads monitoring development of project with project board involvement where required.

Project Chair NHS

6 May fail to adequately determine the overall programme.

4 5 20 Project team to identify programme at initial stage

Initial programme dates being developed for Initial Agreement

Project Chair NHS

7 Stakeholder review / acceptance /governance timescales may affect the programme.

4 3 12 Ensure appropriate governance arrangements adhered to with realistic timescale for acceptance.

Project leads developing indicative programme that ensure governance structure followed.

Project Chair NHS

8 There may be insufficient funds to deliver the full Clinical / Service Requirement.

4 3 12 Indicative costs for options to be developed based on Schedule of Accommodation required

Costs being developedDeveloping clinical model is utilising existing resources in a different way. Project Team will ensure proposal compliments GMS Contract

Head of Finance NHS

9 Preferred site acquisition may be time consuming causing delay. 4 3 12 Ensure early engagement with Local

AuthorityLocal authority representatives involved in workshops and meetings. Ongoing engagement with local authority colleagues.

Project Chair NHS

10 Support from the local community could diminish causing a reputational risk. 3 2 6 Public involvement to be secured Community representation agreed

for all workshops where appropriate e.g. AEDET and NDAP. Extensive on-going public consultation.


NHS

11 Project development does not allow for future expansion of local community resulting in service delivery not being appropriate.

4 5 20 Ensure all proposed plans are flexible and allow for future expansion.

All proposed sites chosen with future expansion capability

Project Chair NHS

12 Insufficient management to lead and project support capacity support delivery of the project

4 3 12 Ensure responsibilities clearly identified. Roles and responsibilities assigned and governance structure agreed. Seeking support from HUBco Central as per originial contract for business case.

Project Board developed. Project Chair NHS

13 Project may be required to incorporate elements/all of services delivered from Rosewell Clinic resulting in increased costs and time

4 3 12 Explore possible alternative accommodation.

Tentative discussions planned Project Chair NHS

Status

Project Title: LOCHGELLY HEALTH CENTRE

Project Manager:

Version Number: V4.1

Identification Assessment Control Monitoring

57/57 173/331

NHS Fife Board Meeting

DATE OF MEETING: 25 September 2019TITLE OF REPORT: Board and Committee Dates to March 2021 EXECUTIVE LEAD: Carol Potter, Director of FinanceREPORTING OFFICER: Gillian MacIntosh, Board Secretary



Discussions over the summer have taken place with Health & Social Care Partnership staff, with a view to improving the ongoing synchronisation of NHS Fife dates with the Integration Joint Board (IJB) and IJB committee meetings in the overall scheduling of the full calendar of meetings. Each NHS Fife Board Committee has also approved their respective set of dates at the September round of meetings.


The Board is asked to note the planned dates of meetings of Fife NHS Board and its Committees from September 2019 to the end of March 2021. Dates for the Board and its Committees will be published on the Website/Intranet to alert staff and members of the public to the meeting dates.

Background

In accordance with the Code of Corporate Governance, the Board is required to meet at least six times in the year and will annually approve a forward schedule of meeting dates.

Assessment

The Board last considered the calendar of dates in January 2019. Earlier review of the calendar was planned for this year, to improve synchronisation with the IJB issuing of dates and to provide more notice to members of the overall schedule. Specifically reflected in the calendar is improvements to the future scheduling of Clinical Governance meetings, particularly the lead-in time from the IJB’s Clinical & Care Governance Committee to the Health Board’s Clinical Governance Committee, which is more aligned than was the case previously.

Members are also reminded that NHS Board dates have been set in relation to the publication/availability of performance and finance information, allowing sufficient information for the production of the Integrated Performance & Quality Report (IPQR), the circulation and consideration by the appropriate sub committees of the Board and the collation of the Executive Summary of the IPQR for the NHS Board.

1/2 174/331

Page 2 of 2

An electronic Outlook calendar has now been created, enabling diary ‘invitations’ to be sent to members for the Board and Committee meetings they participate in. Following Board approval of the attached calendar, invitations will be circulated by email and will be kept updated on an ongoing basis, to aid members’ diary management.

Recommendation

The Board is asked to approve the 2019-21 meeting dates for the Board and its committees.

2/2 175/331

Fife NHS Board and Committee Dates 2019/20 - 09.09.19Month Committee Meeting Dates

Board/Board Committees in Month APF

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

BoardCGFP&REndowment SubARIJBIJB F&PIJB DSIJB A&RIJBRemunerationIJB C&CG

25/09/1904/09/1910/09/1910/09/1905/09/1906/09/1917/09/1917/09/1920/09/1924/09/1924/09/1927/09/19

18.09.19

September

1 2 3 4CG

(2:00)

5AR

(10:00)

6IJB

7 8 9 10FP&R(9:30)

11 12Sept IPR

13 14 15 16Sept

IPR toEDG

17IJB DS

18APF

(1:30)

19 20IJB

A&R

21 22 23 24IJB AnnA/c

25BOARD(10:00)

26 27IJB

C&CG

28 29 30

Endow-mentSub

(1:00)

AR IJB F&P Remuneration(10:00)

Board DevelopmentIJB F&PIJB

30/10/1903/10/1925/10/19

October 1 2 3IJBF&P

4 5 6 7PH

8 9 10 11 12 13 14 15 16 17Oct IPR

18 19 20 21Oct

IPR toEDG

22 23 24 25IJB

26 27 28 29 30(10:00)

31

BoardSGFP&REndowment SubCGIJB F&PIJB C&CGIJB DSIJB A&R

27/11/1901/11/1905/11/1905/11/1906/11/1907/11/1908/11/1913/11/1915/11/19

20.11.19

November

1SG

(10:00)

2 3 4 5FP&R(9:30)

6CG

(2:00)

7IJBF&P

8IJB

C&CG

9 10 11 12 13IJB DS

14Nov IPR

15IJB A&R

16 17 18Nov

IPR toEDG

19 20APF

(1:30)

21 22 23 24 25 26 27BOARD(10:00)

28 29 30

Endow-mentSub(1:00)

Board DevelopmentIJBAR

18/12/1906/12/1912/12/19

December

1 2 3 4 5 6IJB

7 8 9 10 11 12Dec IPR

13 14 15 16Dec

IPR toEDG

17 18 19 20 21 22 23 24 25PH

26PH

27 28 29 30 31

AR(9:30)

BoardARIJB C&CGFP&REndowment SubCGSGRemunerationIJB DS

29/01/2009/01/2010/01/2014/01/2014/01/2016/01/2017/01/2023/01/2031/01/20

22.01.20 January

1PH

2PH

3 4 5 6 7 8 9AR

(10:00)

10IJB

C&CG

11 12 13 14FP&R(9:30)

Endow-mentSub

(1:00)

15CG

16 Jan IPR

17SG

(10:00)

18 19 20Jan

IPR toEDG

21 22APF

(1:30)

23Remuneration(10:00)

24 25 26 27 28 29BOARD(10:00)

30 31IJB DS

CG(2:00)

Board DevelopmentIJB A&RIJB F&PIJB C&CGIJB

26/02/2007/02/2011/02/2021/02/2028/02/20

February1 2 3 4 5 6 7

IJBA&R

8 9 10 11IJBF&P

12 13 Feb IPR

14 15 16 17Feb

IPR toEDG

18 19 20 21IJB

C&CG

22 23 24 25 26(10:00)

27 28IJB

29

BoardCGIJB F&PSGFP&REndowment SubARIJB A&RIJB

25/03/2004/03/2005/03/2006/03/2010/03/2010/03/2013/03/2013/03/2027/03/20

18/03/20

March

1 2 3 4CG

(2:00)

5IJBF&P

6SG

(10:00)

7 8 9 10FP&R(9:30)

11 12 March

IPR

13IJB A&R

14 15 16MarchIPR toEDG

17 18APF

(1:30)

19 20 21 22 23 24 25BOARD(10:00)

26 27IJB

28 29 30 31

Endow-mentSub

(1:00)

A&R(9:30)

A&R(9:30)

KEY: EDG Board Board Development/ Boardof Trustees Committees IJB Committees APF IPR

1/1 176/331

DRAFT Fife NHS Board and Committee Dates 2020/21 - 09.09.19Month Committee Meeting Dates

Board/Board Committees in Month APF

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

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Mon

day

Tues

day

Wed

nesd

ay

Thur

sday

Frid

ay

Satu

rday

Sund

ay

Mon

day

Tues

day

Board DevelopmentIJB C&CGIJB F&PIJB

29/04/2003/04/2007/04/2024/04/20

April

1 2WinterReviewEvent

3IJB

C&CG

4 5 6 7IJB F&P

8 9 10PH

11 12 13PH

14 15 16April IPR

17 18 19 20Apr IPRto EDG

21 22 23 24IJB

25 26 27 28 29 30

BoardSGCGFP&REndowment SubARRemunerationIJB DS

27/05/2001/05/2007/05/2012/05/2012/05/2014/05/2021/05/2029/05/20

20.05.20

May

1SG

(10:00)

2 3 4PH

5 6 7CG

(2:00)

8 9 10 11 12FP&R(09:30)

13 14May IPR

15 16 17 18May IPRto EDG

19 20APF

(1:30)

21Remuneration(10:00)

22 23 24 25 26 27BOARD(10:00)

28 29IJB DS

30 31

Endow-ment SC

(1:00)

AR(9:30)

Board/Development/BoTIJB C&CGIJB F&PEndowment SubARIJB

24/06/20

05/06/2009/06/2018/06/2018/06/2026/06/20

June

1 2 3 4 5IJB

C&CG

6 7 8 9IJB F&P

10 11 12 13 14 15 16 17June IPR(end April

data)

18Endow-ment SC

(9:30)

19 20 21 22June

IPR toEDG

23 24BOARDAnnual

A/cs(10:00)

25 26IJB

27 28 29 30

AR(10:30)

BoardSGCGRemunerationIJB A&RFP&REndowment Sub

29/07/2003/07/2008/07/2009/07/2010/07/2014/07/2014/07/20

22.07.20 July

1 2 3SG

(10:00)

4 5 6 7 8CG

(2:00)

9Remune

ration(10:00)

10IJB A&R

11 12 13 14FP&R(09:30)

Endow-ment Sub

(1:00)

15 16July IPR

17 18 19 20Jul IPRto EDG

21 22APF

(1:30)

23 24 25 26 27 28 29BOARD(10:00)

30 31

Board DevelopmentIJB C&CGIJB F&PIJB DSIJB

26/08/2007/08/2013/08/2021/08/2028/08/20

August

1 2 3 4 5 6 7IJB

C&CG

8 9 10 11 12 13August IPR

14 15 16 17Aug IPRto EDG

18 19 20 21IJB DS

22 23 24 25 26(10:00)

27 28IJB

29 30 31

IJB F&P

BoardSGCGIJB F&PFP&REndowment SubARIJB A&RIJBIJB DSIJB C&CG

30/09/2004/09/1907/09/2011/09/2015/09/2015/09/2017/09/2018/09/2025/09/20

23.09.20

September

1 2 3 4SG

(10:00)

5 6 7 8 9 10 11IJB F&P

12 13 14 15FP&R(09:30)

16 17Sept IPR

18IJB A&R

19 20 21Sept

IPR toEDG

22 23APF

(1:30)

24 25IJB

26 27 28 29 30BOARD(10:00)

CG(2:00)

Endow-ment Sub

(1:00)

AR

Board DevelopmentIJB C&CGIJB F&PIJBSGIJB F&P

28/10/2002/10/2006/10/2023/10/2030/10/20

23/10/20

October

1 2IJB

C&CG

3 4 5PH

6 7 8 9 10 11 12 13 14 15Oct IPR

16 17 18 19Oct IPRto EDG

20 21 22 23IJB

24 25 26 27 28(10:00)

29 30SG

(10:00)

31

IJB F&P

BoardCGRemunerationFP&REndowment SubIJB F&PIJB C&CGIJB A&RIJB DS

25/11/2004/11/2005/11/2010/11/2010/11/2011/11/2013/11/2020/11/2027/11/20

18.11.20

November

1 2 3 4CG

(2:00)

5Remune

ration(10:00)

6 7 8 9 10FP&R(09:30)

11IJB F&P

12Nov IPR

13IJB C&CG

14 15 16Nov IPRto EDG

17 18APF

(1:30)

19 20IJB A&R

21 22 23 24 25BOARD(10:00)

26 27IJB DS

28 29 30

Endow-ment Sub

(1:00)

Board DevelopmentIJBAR

23/12/2004/12/2017/12/20

December1 2 3 4

IJB5 6 7 8 9 10

Dec IPR11 12 13 14

Dec IPRto EDG

15 16 17AR

(9:30)

18 19 20 21 22 23(10:00)

24 25PH

26 27 28PH

29 30 31

BoardFP&REndowment SubCGSG

27/01/2112/01/2112/01/2114/01/2115/01/21

20.01.21 January

1PH

2 3 4PH

5 6 7 8 9 10 11 12FPR

(09:30)

13 14 Jan IPR

15SG

(10:00)

16 17 18Jan IPRto EDG

19 20APF

(1:30)

21 22 23 24 25 26 27BOARD(10:00)

28 29 30 31

Endow-ment Sub

(1:00)

CG (2:00)

Board DevelopmentRemuneration

24/02/2118/02/21 February

1 2 3 4 5 6 7 8 9 10 11Feb IPR

12 13 14 15Feb IPRto EDG

16 17 18Remuneratio

n (10:00)

19 20 21 22 23 24(10:00)

25 26 27 28

BoardSGCGFP&REndowment SubAR

31/03/2105/03/2111/03/2116/03/2116/03/2118/03/21

24/03/21March

1 2 3 4 5SG

(10:00)

6 7 8 9 10 11CG

(2:00)

12 13 14 15 16FP&R(09:30)

17 18 March IPR

19 20 21 22MarchIPR toEDG

23 24APF

(1:30)

25 26 27 28 29 30 31BOARD(10:00)

Endow-ment Sub

(1:00)

AR(9:30)

KEY: EDG Board Board Development/ Boardof Trustees Committees IJB Committees APF IPR

1/1 177/331

NHS Fife Board

DATE OF MEETING: 25 September 2019TITLE OF REPORT: Governance Arrangements – Remuneration CommitteeEXECUTIVE LEAD: Barbara Anne Nelson, Director of WorkforceREPORTING OFFICER: Barbara Anne Nelson, Director of Workforce



The Board has previously considered and approved (at its meeting in May 2019) the recommendation that the Remuneration Sub Committee be reconstituted as a Standing Committee of the Board, this being aligned to developing national guidance on the operation of Remuneration Committees across the NHS in Scotland. A revised remit reflecting this change was considered at the last meeting of the Remuneration Committee in July.


The provisions of the current NHS Fife Code of Corporate Governance reflected the arrangement whereby the Remuneration Sub Committee of the Board reported via the Staff Governance Committee. A revised remit requires Board approval prior to an update of the Code.

Background

The NHS Fife Board decided at its meeting on 29th May 2019 that the Remuneration Committee will operate in future as a direct committee of the Board. The Terms of Reference for the Committee therefore require minor revision to reflect this revised governance arrangement.

Assessment

The Terms of Reference for the Committee have now been amended to reflect the fact that the Committee is now constituted as a stand-alone body, separate from the Staff Governance Committee (see Appendix 1). The revised document has been initially approved by the Remuneration Committee at its meeting on 11th July 2019.

Work is being undertaken nationally to amend the reporting arrangements and terms of reference for Remuneration Committees within all Boards, as part of the Governance Blueprint work that is developing ‘Once for Scotland’ remits for mandatory committees and Board Standing Orders. The position in the future will be that Remuneration Committees will be established to report directly to the Board. We are implementing this provision in advance of the new guidance. However, the Board should note that a further iteration of the Committee’s Terms of Reference will follow, on the issue of guidance on mandatory governance committees. This is expected to clarify the role of the Committee, how it relates to the National Performance Management Committee and its reporting route to the Board.

1/2 178/331

Page 2 of 2

Recommendation

NHS Fife Board is asked to: note that the Remuneration Committee will henceforth report directly to the Board; approve the revised Remuneration Committee Terms of Reference as attached; agree that an interim update outwith the annual review cycle be made to the Code of

Corporate Governance to reflect these changes; and note that a further update will follow on the conclusion of the national work.

Objectives: (must be completed)Healthcare Standard(s): Appropriate Corporate Governance arrangements HB Strategic Objectives: Appropriate Corporate Governance arrangements

Further Information:Evidence Base: Consideration of discussion at Remuneration Committee

Workshop in addition to anticipated national guidanceGlossary of Terms: N/AParties / Committees consulted prior to Health Board Meeting:

Staff Governance Committee made aware on 3rd May 2019 of this proposed change to the Corporate Governance arrangements for the Remuneration Committee

Impact: (must be completed)Financial / Value For Money N/ARisk / Legal: Ensures that the Corporate Governance arrangements for

this Committee are appropriateQuality / Patient Care: N/AWorkforce: Ensures arrangements for the Executive and Senior

Manager Cohort are appropriate. Equality: An EQIA has not been completed locally but the

overarching arrangements for this cohort will have been EQIA assessed as part of their development.

2/2 179/331

REMUNERATION COMMITTEE

CONSTITUTION AND TERMS OF REFERENCE

Date of Approval: 25 September 2019

1. PURPOSE

1.1 To consider and agree performance objectives and performance appraisals for staff in the Executive cohort and to oversee performance arrangements for designated senior managers.

1.2 To direct the appointment process for the Chief Executive and Executive Members of the Board.

2. COMPOSITION

2.1 The membership of the Remuneration Committee will be:

Fife NHS Board Chairperson Two Non-Executive Board members Chief Executive Employee Director

2.2 The Director of Workforce shall act as Lead Officer for the Committee.

2.3 All Executive members in attendance at the Committee will leave the meeting when any discussion takes place with regard to individual Directors’ performance. The NHS Fife Chief Executive will leave the meeting when there is any discussion with regard to their own performance.

3. QUORUM

3.1 Meetings will be quorate when at least three members are present.

4 MEETINGS

4.1 The Committee shall meet as necessary, but not less than three times a year.

4.2 The Fife NHS Board Chairperson will chair the Committee. If the Chairperson is absent from the meeting, one of the other Non-Executive members will chair the meeting.

4.3 The agenda and supporting papers for each meeting will be sent out at least five clear days before the meeting.

4.4 The full minutes will be circulated to all Committee members and Lay Board members only. Minutes edited to remove all personal details will be circulated to all Board members.

1/3 180/331

5 REMIT

5.1 The remit of the Remuneration Committee is to consider:

Job descriptions for the Executive cohort; Other terms of employment which are not under Ministerial direction; To hear and determine appeals against the decisions of the Consultant

Discretionary Awards Panel; Agree performance objectives and appraisals directly for the Executive

cohort only, and oversee arrangements for designated senior managers.

Redundancy, early retiral or termination arrangement in respect of all staff in situations where there is a financial impact upon the Board (this excludes early retiral on grounds of ill health) and approve these or refer to the Board as it sees fit.

5.2 The Committee will produce an Annual Report incorporating a Statement of Assurance for submission to the Board, via the Audit & Risk Committee. The proposed Annual Report will be presented to the first Committee meeting in the new financial year or agreed with the Chairperson of the Committee by the end of May each year for presentation to the Audit & Risk Committee in June.

5.3 The Committee shall draw up and approve, before the start of each financial year, an Annual Work Plan for the Committee’s planned work during the forthcoming year.

5.4 The Committee will undertake an annual self-assessment of its work and effectiveness.

5.5 The Committee shall provide assurance to the Board on achievement and maintenance of Best Value standards, relevant to the Committee’s area of governance as set out in Audit Scotland’s baseline report “Developing Best Value Arrangements”.

6. AUTHORITY

6.1 The Committee is authorised by the Board to investigate any activity within its Terms of Reference, and in so doing, is authorised to seek any information it requires from any employee.

6.2 In order to fulfil its remit, the Remuneration Committee may obtain whatever professional advice it requires, and require Directors or other officers of the Board to attend meetings.

6.3 Delegated authority is detailed in the Board’s Standing Orders and Standing Financial Instructions and is set out in the Purpose and Remit of the Committee.

2/3 181/331

7. REPORTING ARRANGEMENTS

7.1 The Remuneration Committee reports directly to the Fife NHS Board on its work. Minutes of the Committee are presented to the Board by the Committee Chairperson, who provides a report, on an exception basis, on any particular issues which the Committee wishes to draw to the Board’s attention.

3/3 182/331

Audit & Risk Committee: Chair and Committee Comments

AUDIT & RISK COMMITTEE

(Meeting on 5 September 2019)

No issues were raised for escalation to the Board.

Audit &

Risk C

omm

ittee: Chair and C

omm

ittee Com

ments

1/1 183/331

Fife NHS BoardUNCONFIRMED

File Name: Audit 05/09/19 Issue 1Originator: Fiona McLeary Page 1 of 8 Date:

MINUTES OF THE NHS FIFE AUDIT AND RISK COMMITTEE HELD AT 10:00AM ON THURSDAY 5 SEPTEMBER 2019 IN THE STAFF CLUB, VICTORIA HOSPITAL, KIRKCALDY.

Present:Mr M Black, Non-Executive Director (Chairperson) Ms S Braiden, Non-Executive DirectorMs J Owens, Chair, Area Clinical Forum

In Attendance:Mrs H Buchanan, Director of Nursing Mr B Hudson, Regional Audit ManagerDr G MacIntosh, Head of Corporate Governance & Board SecretaryMrs C Potter, Director of Finance

ACTION44/19 APOLOGIES FOR ABSENCE

Members Cllr D Graham and Ms M Wells and attendees Mr P Hawkins, Mr T Gaskin and Ms P Tate.

45/19 DECLARATION OF MEMBERS’ INTERESTS

There were no declarations of interest.

46/19 MINUTES OF PREVIOUS MEETING HELD ON 20 JUNE 2019

The Minutes of the previous meeting held on 20 June 2019 were approved as an accurate record.

47/19 ACTION LIST

Members of the Audit and Risk Committee noted that all the outstanding actions on the Committee’s rolling Action List were complete.

48/19 MATTERS ARISING

There were no matters arising.

49/19 GOVERNANCE - GENERAL

(a) IJB Annual Assurance Statement

Dr MacIntosh advised that the IJB Assurance Statement had been through the IJB Governance Structure in July, as its timing was aligned to their annual accounts process and the budget setting timetable of the Council. The paper was largely for

1/8 184/331


ACTIONinformation, as its timing means it cannot be considered as part of the financial year-end assurance process of the Health Board.

Members noted the Statement but wished it recorded that, in members’ view, the ‘medium’ level of control identified in the report is not an accurate reflection of the IJB’s still developing systems of Corporate Governance, there being much work still to be done to improve the level of assurance in this area.

The Audit and Risk Committee:

noted the report

(b) Corporate Calendar – Future Committee Meeting Dates

Dr MacIntosh reported that she had worked in closer partnership with colleagues in the IJB and Council to ensure that dates are better aligned. The full Board Calendar will be presented to the next meeting of the NHS Fife Board for formal approval. Thereafter, she electronic calendar invitations will be issued to Members. GM


noted the proposed meeting dates to 2021.

(c) Review of Property Transactions

Mr Hudson advised that under the Property Transactions Handbook (PTH) regulations, the Audit and Risk Committee is charged with oversight of the monitoring of the process of property transactions. This is a cyclical exercise, with the Committee receiving details of the relevant property transactions annually at its May meeting. Three 2018/19 transactions were advised to the May 2019 Committee, and Internal Audit were asked to review all three to ensure the requirements of the PTH were followed. The audit report assessed each transaction at Grade A, i.e. each transaction is properly completed. The related recommendation related to the timeliness of certification sign off, which has been accepted by management. A clean property transaction return in respect of 2018/19 can therefore be submitted to the Scottish Government Health and Social Care Directorate (SGHSCD) by the 30 October 2019 deadline.

2/8 185/331


ACTIONThe Audit and Risk Committee noted:

the requirements of the Property Transactions Handbook have been complied with; and

arrangements are in place to issue the Board’s Annual Property Transactions Return to SGHSCD by the deadline of 30 October 2019, and that the return can be submitted with no significant issues identified.

50/19 GOVERNANCE - INTERNAL AUDIT

(a) Internal Audit Progress Report / Update on Follow Up Work

Mr Hudson reported that since the date of the last meeting the Internal Audit Team has continued to progress the delivery of the 2019/20 audit plan. The report shows the number of reports that have been issued since the last meeting and includes a summary their findings.

He drew attention to the Audit Follow Up update on page 36, which highlighted the possibility of using the DATIX system for future Follow Up reporting. This approach has been initially discussed with the Director of Finance.

The overall aim is to make the follow up report to this Committee a more visual product for recording the status of all internal audit report action points, with reports available from DATIX to allow regular reporting to the Audit and Risk Committee and Executive Directors.

Mr Hudson added that he had recently changed the format of the full report and had revised definitions and risk assessments. He encouraged members to have a look at the new reports and provide any feedback.

Mrs Potter reiterated that the proposed Audit Follow Up process will be a very helpful and positive step forward, using technology to enhance the way we report and give assurance to the Committee. Historically this has been very manual, people dependant and bureaucratic process. She added that it will also help to inform future audits as the information is being uploaded as evidence of an action being completed. If that provides additional assurance, that might mean that the Internal Audit team do not have to review something for a longer period; or, if it is not adequate, it gives a indication to be able to go back and look at a particular area.

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ACTIONDr MacIntosh added that the Standing Committees of the Board are now receiving relevant internal audit reports for information. She suggested that a standard S-bar cover paper should be produced to highlight that the reports are there for each Committee’s assurance only, that the actions rest with the individuals named within the report, and that the Audit and Risk Committee has general oversight that the improvement actions are being progressed.

Mrs Potter and Mr Hudson agreed to produce an S-bar to accompany the Internal Audit reports to each Standing Committee. CP/BH


noted the ongoing delivery of the 2018/19 and 2019/20 NHS Fife internal audit plan;

noted the proposed changes to the management of the Audit Follow-up-system and;

agreed to comment on the change to the reporting format and audit opinion.

(b) Internal Audit Framework

Mr Hudson reported that as the Audit and Risk Committee is responsible for all audit activities, it is important its members have oversight of the Internal Audit function and any specific requirements of Public Sector Internal Audit Standards (PSIAS). This is largely encapsulated in three documents:

Internal Audit Charter Internal Audit Services Specification NHS Fife Internal Audit Reporting Protocol

As stated in the PSIAS, an Audit Charter requires to be in place. The Charter was previously approved in September 2018. It is subject to annual review and has been updated to take account of the recent External Quality Review. The process for the updating of the Service Specification is detailed on page 42. A formal process around how this works has been approved by the FTF partnership board. There are certain documents within the service specification that require the approval by the committee e.g. the internal audit reporting audit protocol and the follow up protocol.


noted the NHS Fife Specification for Internal Audit

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ACTIONServices;

approved the updated Internal Audit Charter and; approved the updated NHS Fife Internal Audit Reporting

Protocol.

51/19 GOVERNANCE – ANNUAL ACCOUNTS

(a) Annual Accounts – Progress Update on Audit Recommendations

Mrs Potter reported that a number of recommendations had been highlighted in the respective annual reports of each auditor. The S-BAR sets out what the annual reports cover and the position for both the Chief Internal Auditor and Audit Scotland at the year end. The appendix gives a summary of the actions/findings and recommendations, along with the proposed actions and responses from the internal audit annual report and external audit.

The current status against each of the actions required to take forward was included in the report. This is first of these reports to the Audit and Risk Committee, and the same paper will also be considered by the Finance, Performance and Resources Committee. The report seeks to give the Board assurance that responsible individuals are taking forward the improvement actions.

The Audit & Risk Committee:

noted the actions taken to date; noted this update will also be considered by the Finance,

Performance & Resources Committee at its meeting on 10 September; and

requested that a regular update be given at future meetings of the Committee.

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52/19 RISK

(a) Board Assurance Framework (BAF)

Mrs Buchanan reported that the BAF identifies risks to the achievement of Fife NHS Board’s objectives, particularly (but not exclusively) related to delivery of the:

NHS Fife Strategic Framework NHS Fife Clinical Strategy Fife Health & Social Care Integration Strategic Plan

She took members through the BAF, highlighting the changes since the last meeting:

Financial Sustainability

Current Controls

The current controls have been strengthened to include a system-wide Transformation programme. Lessons will be learned from the successes of the medicines efficiency programme in terms of its approach and use of evidence based, data-driven analysis.

Additionally, where appropriate, external support has been appointed to accelerate a programme of cost improvement across Acute Services.

Mitigating Actions

Actions around engagement with Health & Social Care / Council colleagues on the risk share methodology further emphasise the need to ensure that the Executive Directors’ Group, Finance, Performance & Resources Committee and the Board are appropriately advised on the options available to manage any overspend within the IJB before applying the risk share arrangement.

Current Performance

The current score reflects the ongoing financial challenges facing Acute Services in particular, and the early stage in the delivery of efficiencies across the health budgets delegated to the Health & Social Care Partnership.

Changed in Linked Risks

Risk 1357: Financial management, planning and performance. The risk level has decreased from high to moderate.

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Environmental Sustainability There have been no changes and no changes to the linked risk.

Workforce Sustainability There are no changes to the overall BAF but there has been a change to the linked risk. The Risk has decreased from high to moderate due to the recent recruitment of rheumatology consultants.

Quality & Safety There are no changes to the overall BAF. Two linked risks have been added related to:

Temperature Monitoring Oxygen Driven Suction

These were fully discussed at the NHS Fife Clinical Governance Committee Meeting on 4 September.

Strategic PlanningThe Chief Executive now chairs the Transformation Board and the refreshed work will focus on:

Acute Transformation Programme Joining Up Care Mental Health Redesign Medicine Efficiencies

Integration Joint BoardContinuing to develop with the Health and Social Care Partnership.

eHealth BAFA proposed draft of this will be reported to the Clinical Governance Committee in November.

Mr Black asked where the Transformation group’s activities will report to in terms of the BAF.

Mrs Buchanan stated that the transformation programme will impact all the BAFs and updates would be taken forward accordingly.

Mrs Potter noted that that delivering on the transformation agenda will mitigate a lot of the risk that sit within each of the areas. However, the financial climate will continue to be challenging but we have a very robust approach across the services with an overarching forward look.

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Mrs Buchanan will make sure that the transformation components are reflected appropriately in the next round of documentation.


noted the BAF; and noted the developments to its risks and ratings.

(b) Risk Management Report

Mrs Buchanan reported that defining the Board’s Risk Appetite is being taken forward and we have agreed to:

adopt HM Treasury risk appetite definition and classification;

reviewed examples of risk appetite statements; agreed the content should be in Plain English and where

possible include info graphics; and agreed the work should be taken forward initially through

the standing committees of the Board.

After consideration at each Committee, the work to conclude Risk Appetite will go to the Board Development session in October and for approval at the NHS Fife Board thereafter. A suite of Key Performance Indicators (KPIs) have also been developed and will be taken to EDG for initial consideration.


noted the update.

53/19 OTHER BUSINESS

(a) There were no matters of escalation to the NHS Board from this meeting’s agenda.

54/19 Any Other Competent Business

There was no other competent business.

55/19 DATE OF NEXT MEETING: Thursday 9 January 2020 at 10.00am, within the Boardroom, Staff Club, Victoria Hospital, Kirkcaldy.

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Clinical Governance: Chair and Committee Comments

CLINICAL GOVERNANCE COMMITTEE


Key issues to be highlighted to the Board:

KINCARDINE & LOCHGELLY HEALTH CENTRES IADsThe Committee approved the outline clinical models being proposed for these two Centres.

DRAFT MENTAL HEALTH STRATEGYThe Committee noted the progress being made with the Strategy. Several comments have been made regarding this and once responses have been received the Committee will review the document.

COMMUNITY HOSPITALS AND INTERMEDIATE CARE BED REDESIGNThe committee noted the progress being made with this and fed back several comments. A revised document will be reviewed in due course.

Clinical G

overnance Executive Summ

aryC

linical Governance: C

hair and Com

mittee C

omm

ents

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UNCONFIRMED

Issue: V1 Date: September 2019Originator: Catriona Dziech Page 1 of 13

MINUTE OF NHS FIFE CLINICAL GOVERNANCE COMMITTEE HELD ON WEDNESDAY 4 SEPTEMBER 2019 at 2PM IN THE STAFF CLUB, VHK

Present:Dr Les Bisset, Chair Martin Black, Non Exec Committee MemberCllr David Graham, Non Exec Committee Member

Rona Laing, Non Exec Committee Member

Margaret Wells, Non Exec Committee Member John Stobbs, Patient RepresentativePaul Hawkins, Chief Executive Dr Chris McKenna, Medical DirectorDona Milne, Director of Public Health Helen Buchanan, Nurse Director

In Attendance: Lynn Campbell, ADN, ASD Nicky Connor, Interim Director of H&SCPDr Rob Cargill, AMD, ASD Dr Helen Hellewell, AMD, H&SCPGillian MacIntosh, Board Secretary Andy McKay (for Ellen Ryabov)Barbara Anne Nelson, Director of Workforce Helen Woodburn, Quality & Clinical

Governance LeadJulie Paterson, DGM H&SCP (Fife-wide) (for Item 9.1)

Frances Baty, Head of Psychology Service (for Item 9.1)

Dr Marie Boilson, Clinical Director (Fife-wide) (for Item 9.1)

Dr John Kennedy, Clinical Director (East) (for Item 9.1)

David Heaney DGM H&SCP (East) (for Item 9.2) Claire Dobson DGM H&SCP (West) (for Item 9.2)

Karen Gibb (for Item 9.2) Cllr Tim Brett (Observer)Catriona Dziech, Note Taker

MINUTEREF ITEM ACTION

060/19 APOLOGIES FOR ABSENCEAs members, Wilma Brown and Janette Owens. As attendees, Susan Fraser, Scott Garden, Elizabeth Muir, and Ellen Ryabov

061/19 DECLARATIONS OF MEMBERS’ INTERESTSRona Laing declared an interest in Item 5.9 as a current patient of Lochgelly Medical Practice.

062/19 MINUTES OF PREVIOUS MEETING HELD ON 3 JULY 2019The notes of the meeting held on 3 July 2019 were approved.

063/19 ACTION LISTAll outstanding actions are updated on separate Action List.

064/19 MATTERS ARISING5.1 Participation and Engagement Update

Helen Buchanan gave an update on the recent review to look at the role and remit of Patient Focus Public Involvement (PFPI) and the Participation & Engagement Network (PEN) groups.

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064/19 The initial review highlighted that within both groups there was duplication across their remits and a lack of consistency in the approach to public involvement across NHS Fife. We are currently looking at a model to support both. An Option Appraisal to identify the best approach is being considered within the next two weeks.

Advice is being taken from the Scottish Health Council on the preferred model and to get a steer on the best approach aligned to national developments. The proposed model to be implemented in Fife should be available for November meeting of the NHSFCGC.

Dr Bisset noted that it was very important a report / proposal is brought to the next meeting, not least since this issue was raised at the Annual Review public session last February. It was agreed we need to be ready with a refreshed model and a plan for how to take it forward.

HB

5.2 Surgical Site Infection Update – Improvement PlanHelen Buchanan reminded members that a full discussion had taken place previously with Keith Morris at the last meeting of the Committee.

Helen Buchanan advised Keith Morris has already had a conversation with Health Protection Scotland about the things we do in Fife which may be different from the rest of Scotland. One of the things we do that is not part of the pathway in Scotland is that all women come back to maternity services. There has been a lot of discussion whether this is the correct pathway or should it be the GPs who see these women who are potential SSIs. Helen Buchanan advised this is a conversation that she and Keith Morris are planning to have with the Obstetricians, Midwives and GP Services about the preferred pathway.

HB

064/19

Helen Buchanan also advised that when looking at other Health Boards in Scotland, we found that not everyone collates the data as we do in Fife. NHS Fife is very open and transparent about its data reporting. Helen Buchanan advised the Improvement Plan was ongoing without a proposed end date. Keith Morris feels this may be due to the way we count SSIs and

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how we put the data forward as opposed to the problem but we still report it and that is the correct thing to do.

Feedback from Health Protection Scotland was that GPs are the ones who see SSIs on a routine basis (not just for C Sections but for all surgical sites) and are best placed to treat instead of women coming back to Acute and being seen by Midwives post delivery.

Dr Bisset noted that it does look like NHS Fife are an outlier within the present figures, so it would be helpful to have an update paper for the November NHSFCGC with progress in determining the true picture.

HB

5.3 Transformation Programme Workshop Update and Role and Remit of Joint Strategic Transformation GroupThis paper provided the Committee with an update on the Transformation Programme in Fife, including a report on the recent Transformation Stocktake Workshop which took place on 23 July 2019.

The Committee noted the Workshop’s recommendations to:1 Establish a new system for Transformation

with a joint meeting with H&SCP and NHS Fife to establish a review of each scheme’s timelines and proposed value.

2 Disband the Joint Strategic Transformation Group and establish an Integrated Transformation Board reporting to NHS Fife Board and the IJB.

3 Established a ‘stage and gate’ process for approval and monitoring of programmes.

4 Escalation process to be used against delivery of programmes for NHS Fife and IJB.

5 Establish a workgroup to produce an integrated plan.

064/19

Paul Hawkins advised that further analysis will take place at the next meeting on 20 September to set out what the timelines look like. A paper will then be circulated to adopt the new procedures. There will be a Transformation Board which is accountable to both Clinical Governance committees of the Health Board and the IJB, in addition to the scrutiny of the Council. It is proposed, at the moment, the Chairs and a

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nominated lead from the Council would be on that Group. The idea of the Transformation Board is to have as many of the decision makers around the table right at the beginning of the conversations, to smoothly push things through and identify for the attention of the governance committees the real issues that we wish to go forward with. This should hopefully move forward within the next six weeks.

Dr Bisset clarified we are being asked to note the comments from the recent Workshop and that nothing is being approved at this stage. Paul Hawkins confirmed this and noted that the role of the governance committees in the approval process was still being considered.

The Committee noted the update and a further paper will come to the next meeting. The position of the different Committees in the overall plan will be clarified at the next meeting of the Transformation Group.

PH

5.4 Primary Care Improvement Plan – Governance arrangements and GMS contractDr Hellewell gave a verbal update on the position, stating that the scoping exercise has taken place but not all the detail was yet available for a written report to be prepared for this meeting. A report will be submitted for the next NHSFCGC in November.

HH

Dr McKenna confirmed a meeting is being held within the next few weeks as a Primary Care team to look at the governance arrangements for Primary Care and how this sits with the requirements to implement GMS. It is hoped a robust structure will be in place by the next NHSFCGC in November.

HH

5.5 Drug related Death ReportThis item was covered within the Action List update. A report will be available for NHSFCGC in November.

5.6 Update on Pharmacy input to identifying SABs

064/19

Dr Hellewell advised she has spoken to Andrea Smith and Scott Garden, who confirmed there is nothing in place currently with pharmacies to identify infections. There is development work ongoing. A new Pharmacist is coming in to post who will lead on this work. Further detail will follow in due course.

Dr Bisset asked that Dr Hellewell bring a written HH

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paper to NHSFCGC in November which sets out the position with SABs in the Community.

5.7 Feedback from HIS following OPAH/Glenrothes HAI Report Helen Buchanan advised she has spoken with Ann Gow and highlighted the concerns raised in the inconsistency of reports from the OPAH visit to VHK and the Glenrothes Hospital visit in comparison to the verbal feedback. Ann Gow has agreed to take back comments to her team and respond to Helen Buchanan. This feedback will then be brought back to the NHSFCGC.

HB

Helen Buchanan advised that with the introduction of the new Quality Framework, future reporting will look different.

Dr Bisset noted that the Committee had been concerned with the inconsistencies within the report, including whether some parts of the report actually referred to Fife, and hoped HIS had taken this on board. Dr Bisset said we should not lose sight of this and that we should expect a response from HIS. Helen Buchanan agreed to go back to Ann Gow to see what actions she has taken forward with her staff at HIS.

HB

Dr Bisset noted that a large number of the Matters Arising items were verbal updates and this was unsatisfactory. Although appreciating that verbal reports are sometimes necessary, Dr Bisset asked that members strive to bring written reports wherever possible.

ALL

5.8 Information Governance and Security Group (IGSG) – Terms of Reference Dr McKenna advised this report was for noting but highlighted the following:- Carol Potter is now the new SIRO- The key purpose of the Group is set out at

Paragraph 1.3

064/19 Gillian MacIntosh advised that, at the recent meeting of the IGSG, it was agreed that under Item 3.2, quorum of the meetings, deputies of key members would be accounted for these purposes, and thus the document would be amended accordingly.

The Committee approved the amended Terms of GMacI

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Reference, subject to the correction of a few minor typographical clarifications as suggested by Rona Laing and Margaret Wells.

5.9 Kincardine/Lochgelly – Initial Agreement documents (IADs)Nicky Connor advised these reports have been to the Capital Planning Group and officers have taken on board the previous feedback regarding the detail of the proposed model.

Authorisation was given by the Capital Planning Group to begin to look at potential capital investment to meet patient and service needs. The IADs were previously submitted to Scottish Government who requested that the model of care be articulated more fully and that Fife participate in the national pathfinder programme for Local Care, which supports transformational change that shifts the balance of care to community.

This paper relates mainly to the IAD stage for Kincardine and Lochgelly. National and local strategies have been taken into account in preparing these IADs.

The Committee: Approved the direction of travel following the

non-financial option appraisal (subject to formal financial appraisal) for Kincardine and Lochgelly as outlined in the Assessment section; and

Approved submission to the Finance, Performance and Resources Committee for approval to progress to NHS Fife Board and Scottish Government Capital Investment Group.

065/19 REQUESTED REPORTSNone scheduled for September Committee

066/19 QUALITY, PLANNING AND PERFORMANCE 7.1 Integrated Performance and Quality Report

Performance reporting to the board has been in the form of separate Integrated Performance Report and Quality Report (IPQR). A review was requested to bring these two reports together into one document.

This paper provides the committees with an overview of the changes that have been made to the reporting

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of performance and quality in NHS Fife.

The Committee noted the new Integrated Performance and Quality Report, welcoming the format changes.

Dr Bisset asked that thanks and congratulations be passed to Susan Fraser and the others who helped produce this new report.

Dr McKenna highlighted the following from the Executive Summary:- SSI – still an outlier- SABS – significant improvement

7.2 HAIRT ReportHelen Buchanan advised very little has changed to the HAIRT report and highlighted the challenges as set out in Para 1.2 for:- Caesarean Section SSI- SABs (Staphylococcus aureus Bacteraemia)- ECBs (Escherichia coli Bacteraemia)- Large Bowel Surgery SSI

Dr McKenna highlighted it may worthwhile keeping an eye on ecoli bacteraemia as there may be an emerging issue with the overuse or incorrect use of antibiotics in urinary tract infections which can result in the development of the bacteraemia. There is an emerging pattern of this group of infections coming in to Acute Services.

Helen Buchanan advised a group had been established looking at catheter associated urinary tract infection. This has been a successful multidisciplinary group and a report on the work can be brought to the NHSFCGC if desired.

066/19 7.3 Winter Plan UpdateThis paper provided the committee with an update to the draft Winter Plan for 2019/20 submitted at the last meeting, outlining arrangements being put in place to support capacity and sustainability over the winter period (focussing on the period October 2019 to March 2020).

This draft of the Winter Plan 2019/20 has been agreed following a winter planning event held on 22 August 2019 with H&SCP and Resilience colleagues and a follow up meeting with Acute

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colleagues on 23 August. A small working group has been taking forward the actions from the Winter Review 2018/19 over the summer months, including actions included in the Winter Plan 2019/20.

Nicky Connor advised some of the detail within the Appendices is still being finalised to ensure the actions in terms of escalation are smart, ready and specific. This is not included at present within this document but she assured the NHSFCGC it is actively in progress.

Claire Dobson advised the tracker versus placement document which is produced each year will be finalised shortly and then costed. Joint working has been undertaken to complete this.

The Committee noted the Winter Plan 2019/20 update.

067/19 GOVERNANCE8.1 Board Assurance Framework – Quality and Safety

The Committee noted this report is an update on the Quality and Safety BAF since the last report received on 3 July 2019.

Helen Buchanan advised there were no changes to the associated risks.

Helen Buchanan advised the Risks previously highlighted to the Committee - 1502 (3D temperature Monitoring System (South Lab)) and 1524 (Oxygen Driven Suction) – that there is mitigation with both Risks and these are being worked through.

067/19 The Committee noted the changes as set out in the Quality and Safety BAF.

8.2 Board Assurance Framework – Strategic Planning This report provides the Committee with the next version of the NHS Fife Strategic Planning BAF.

David Graham queried if the Timescale date of 31/08/2019 will be reviewed and this was confirmed.

The Committee noted the current position in relation to the Strategic Planning risk.

8.3 BrexitDr McKenna advised this is an update to the previous

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version submitted to the Committee and confirmed there has been no changes since the last report.

Dr Bisset asked that a more explicit summary other “no change” be provided for eHealth for NHSFCGC in November.

CMcK

The Committee noted the update.

8.4 Annual WorkplanHelen Woodburn advised that during May and June 2019, a short review has been undertaken of the current work plan and structure of the agenda in order to streamline information and processes for the Clinical Governance Committee. This included a comparison to other standing committees of the Board, with a view to reduce any variation between the committees and achieve standardisation in templates, work plans and agenda structure.

The Committee noted and approved the changes as set out in the report.

Dona Milne asked that Director of Public Health Annual Report be changed on the Workplan to report annually in May.

HW

8.5 Corporate Calendar Future Committee Meeting DatesThe Committee noted the proposed dates for the Committee for 2019 through to 2021.

068/19 TRANSFORMATION / REDESIGN / CLINICAL STRATEGY9.1 Community Hospital Redesign

Nicky Connor advised that Community Hospital Redesign is one of the key areas of transformation within the H&SCP and will also be part of the programme to be considered by the Transformation Board.

This report is to inform and update the Committee of progress made on the redesign of Community Hospital and Intermediate Care Beds, and to set out next steps.

David Heaney, Karen Gibb, Dr Hellewell and Dr Kennedy each gave an update on the background and work undertaken on the proposed models.

Following detailed discussion by members, the

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following of areas of concern were highlighted:- the rigour of the Public Consultation process,

particularly at the early stages of the option appraisal process;

- the Financial Planning for the proposals and how this related to the system as a whole; and

- Too much focus on beds modelling and less about the model of care.

Nicky Connor thanked the Committee for the feedback and noted the concerns raised.

In summary, Dr Bisset thanked everyone who had put a lot of hard work in to producing these papers, which are very helpful and appreciated. It is clear from the issues raised today the Committee are uncomfortable going ahead to public consultation at the moment, until further work is done to prepare the proposals. The issues raised need to be addressed through the Transformation Group arrangements described earlier in the meeting by Paul Hawkins. Going forward, the proposal would be taken through the Transformation Group to undertake the ‘stage and gate’ exercise and then make sure the final papers go to the Governance Committees of both the Health Board and IJB. In light of this, the current timetable set out in the paper for its approval will need to be changed.

The Committee noted the update on progress with the Community Hospital and Intermediate Care Redesign.

068/19 9.2 Mental Health Strategy and Board Feedback Paper Nicky Connor advised that this is another significant area of transformational change within the H&SCP. This is a progress report along with formal feedback received from the Board on the current draft of the strategy. Significant work is underway to consider these comments in consultation with clinical colleagues.

Julie Paterson advised that the H&SCP’s Finance & Performance Committee considered Fife’s draft mental health strategy at its meeting on 17 July 2019. The outcome from this meeting is that the Committee has requested financial information on how the strategy will be delivered, to be submitted to their meeting on 17 September 2019.

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At its meeting on 31 July 2019, NHS Fife Board considered the draft mental health strategy and provided a formal response for consideration in the final draft of the strategy (included as Appendix 1 in the paper).

The H&SCP’s Clinical & Care Governance Committee met on 9 August 2019 to consider the draft mental health strategy and ‘enthusiastically’ supported the document. They will meet again on 27 September 2019 to review any subsequent changes arising from feedback via NHS governance routes, with a view to final presentation to the Integrated Joint Board in October 2019.

As with the previous paper, it was agreed that consideration of this work would now fall under the remit of the Transformation Board. At present, the H&SCP’s response to the Board’s feedback was awaited, before the strategy could progress further.

Helen Hellewell assured the Committee the concerns raised were being addressed, although at this stage the response was not finalised. Dr Hellewell would ensure comments were fed back as soon as possible and hopefully in advance of the planned ‘stage and gate’ process.

HH/NC

Martin Black raised a concern that there is no link to Addictions and Learning Disability within the Mental Health Strategy. Dr McKenna advised this has been discussed previously, but highlighted these areas have their own stand-alone strategies. Nevertheless, Dr McKenna has asked for greater reference to Learning Disability and Addiction Services to be raised within the overall Mental Health Strategy.

The Committee noted the progress of the draft Mental Health Strategy for Fife.

069/19 ANNUAL REPORTS10.1 Medical Education Report

The Committee noted the report and the recommendations, commending the large amount of training and education work underway in Fife which is well-rated by participants.

Dr Bisset asked that Dr Morwenna Wood and her team should be congratulated on this report and their

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continuing hard work.

10.2 Prevention & Control of Infection Annual Report Helen Buchanan advised the Executive Summary on Page 7 of the report highlights the extensive work undertaken by the Infection Control Team.

The Board considered and accepted the Annual Report.

070/19 LINKED COMMITTEE MINUTESDr Bisset advised that all items under this section would be taken without discussion unless any particular issues were raised.

11.1 Acute Services Division Clinical Governance Committee – 24 July 2019 – c/f to November 2019Dr Cargill advised that the frequency of the meeting had been changed from four times per year to six and thus two sets of minutes will be available for the Committee in November.

11.2 Area Clinical Forum11.3 Area Drugs & Therapeutics Committee (ADTC)

Dr McKenna highlighted the issues around Safe and Secure Use of Medicine Group (SSUOMG) and Biosimilar issue around Adalimumab / Trastuzumab.

11.4 HSCP Clinical and Care Governance Committee11.5 Clinical Governance Oversight Group11.6 Fife Research Committee – 27 June 2019 – carried

forward to November 201911.7 Health and Safety Sub-Committee11.8 Integrated Joint Board11.9 Infection Control Committee11.10 Public Health Assurance Group11.11 Resilience Forum

071/19 ITEMS FOR NOTING12.1. Internal Audit Report – Information Governance &

eHealth Report No. B31&32/19The Committee noted this report, which was tabled for the Committee’s information.

072/19 ISSUES TO BE HIGHLIGHTED TO THE BOARDThe following issues to be highlighted to the Board:Community HospitalsMental Health StrategyTransformation Group

073/19 AOCBThere was no other competent business.

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074/19 DATE OF NEXT MEETINGWednesday 6 November 2019 at 2pm in Staff Club, VHK

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Finance, Performance & Resource Committee: Chair and Committee Comments

FINANCE, PERFORMANCE & RESOURCES COMMITTEE


Issue to be escalated: Challenges discussed around the Winter Plan for 2019/20

Issues to be highlighted are: Reports presented on Psychological Therapies and CAMHS Presentation and discussion on the Acute Services Division Efficiency

Programme Presentation on the Scottish Capital Investment Manual

Finance, Performance &

Resource C

omm

ittee: Chair and C

omm

ittee Com

ments

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Fife NHS BoardUnconfirmed

MINUTES OF THE FINANCE, PERFORMANCE AND RESOURCES COMMITTEE MEETING HELD ON TUESDAY 10 SEPTEMBER 2019 AT 09:30AM IN THE BOARDROOM, STAFF CLUB, VICTORIA HOSPITAL, KIRKCALDY.

Present:Ms R Laing, Non-Executive Director (Chair) Mr E Clarke, Non-Executive DirectorDr L Bisset, Non-Executive Director Mr P Hawkins, Chief ExecutiveMrs W Brown, Employee Director Ms J Owens, Non-Executive DirectorMs Sinead Braiden, Non-Executive DirectorMrs H Buchanan, Director of NursingMs D Milne, Director of Public HealthMr A Fairgrieve, Director of Estates, Facilities & Capital ServicesMrs N Connor, Interim Director of Health & Social Care

Mrs C Potter, Director of FinanceMr C McKenna, Medical DirectorMs E Ryabov, Chief Operating OfficerMr S Garden, Director of Pharmacy

In Attendance:Ms Julie Paterson, Divisional General ManagerMs Frances BatyMr Lee CowieMrs Christine Armistead, DeloitteMr Alex Deveney, DeloitteMrs K Sinclair, PA to the Director of Finance (minutes)

ACTION103/19 APOLOGIES FOR ABSENCE

Apologies were received from Gillian Macintosh, Head of Corporate Governance & Board Secretary.


Rona Laing wished to record that in relation to agenda item 7.3, she is a patient at Lochgelly Medical Practice.

105/19 MINUTE OF MEETING HELD ON 16 JULY 2019

The minute of the last meeting was agreed as an accurate record.

106/19 ACTION LIST

The Chair reviewed the action list, and asked for the Stratheden ICPU action to be changed to November 2019. Also, the PAMS conversation has been dealt with and can be removed from the Action List. The Chair noted that the other outstanding actions would be discussed under the relevant agenda items for this meeting.

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2

MATTERS ARISING

107/19

108/19

5.1 Psychological Therapies UpdateThe Committee had requested further information and clarity on a number of matters that arose from the July FP&R Committee in relation to performance within the psychological therapies service.Julie Paterson, Frances Baty and Lee Cowie provided a detailed overview and assessment of the issues outlined in the report. Following discussion, the Chair asked Julie Paterson to provide a copy of the work plan for the Re-balancing Care Group. It was agreed that Julie Paterson and Frances Baty would provide a further update in January 2020.


5.2 CAMHS UpdateNicky Connor provided an overview of the report and invited Julie Paterson to outline the key issues.

The Chair thanked Julie Paterson for the report and noted that there were some promising initiatives in progress and wanted to acknowledge that there has been an improvement in CAMHS targets and staff should be thanked for their efforts.


ACTION to be added to agenda for Jan 2020

109/19

GOVERNANCE

6.1 Board Assurance Framework – Financial SustainabilityCarol Potter advised that the BAF score has been held at high. In relation to the financial planning management performance operational risk - Carol Potter advised that this risk has now reduced from 16 to 12, and this will no longer be a linked risk on the next report.

The Committee noted and approved the current position.

110/19 6.2 Board Assurance Framework – Strategic PlanningChris McKenna advised that the BAF has already been thoroughly considered at the Clinical Governance Committee and that he had no further update.

The Committee noted the current position

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3

111/19

112/19

113/19

114/19

115/19

6.3 Board Assurance Framework – Environmental SustainabilityAndy Fairgrieve confirmed that there was no change to the risk.

The Committee noted and approved the current position.

6.4 Annual Accounts – Progress Update on Audit RecommendationsCarol Potter directed the meeting to the covering SBAR and confirmed that the report was for information and assurance. The report was considered by the Audit & Risk Committee last week but because of the financial nature it was important to share with the FP&R Committee.

The Committee noted the actions being taken to address the recommendations from internal and external audit.

6.5 Corporate Calendar – Dates for Future Committee Meetings

The Committee agreed and noted.

6.6 BrexitCarol Potter explained that there are a number of different aspects of the Brexit discussion that align to difference Governance Committees and for FP&R it is any issues around the Estate, the General Economy and Procurement and Supply Chain.

The issues highlighted in the appendices remain in line with previous discussions and these were highlighted at the Brexit Assurance Group last week.

The Committee noted the current position.

PLANNING

7.1 Orthopaedic Elective ProjectCarol Potter gave an update to the meeting advising that there was a presentation at the Board Development session, which was very well received. The project is progressing at pace, which was highlighted to Board members. The Project Team are working to the planned timeline for completion of the Outline Business Case, which will be presented to the November meeting of the FP&R Committee, in parallel with submission to Scottish Government. Carol Potter noted that Scottish Government colleagues have confirmed that they are content to accept the Outline Business Case while it is progressing through the NHS Fife internal governance processes.

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4

116/19

117/19

The Project Team are working closely with the Head of Communications on a communications strategy. This is likely to include a dedicated page on the external website, visible to the public and all stakeholders.

An update will also be presented to the NHS Board Meeting later this month, with information to follow thereafter to public and staff. The Chief Executive has suggested we share the fly through video plus some of the design images on social media.

The Committee noted the progress to date.

7.2 Scottish Capital Investment Manual (SCIM)Carol Potter introduced the presentation on the Scottish Capital Investment Manual (SCIM), confirming that the purpose of the update was to ensure that the members of the Committee were aware of the Capital Investment process.

The SCIM process is a requirement for all infrastructure projects across NHS Scotland Boards as well as any projects that the Integration Joint Board take forward which have a potential capital investment requirement and are above the Health Board’s delegated capital limit. Carol Potter offered to present to the management teams of both the Acute Services Division and Health & Social Care Partnership to ensure greater awareness and understanding of this key governance and assurance process.

The Chair thanked Carol Potter for the presentation and commented that it was very helpful and timely.

7.3 Kincardine & Lochgelly Health &Wellbeing Centres Initial AgreementsNicky Connor advised that the Board and Committee are aware that there has been recognition that the facilities at Kincardine and Lochgelly are not fit for the future, in terms of service delivery and sustainability of the infrastructure. Previous iterations of the IAs were not supported by Scottish Government and a request was made to provide further information on the clinical redesign and strategic ambition for these new facilities..Significant work has been taken forward, taking on board the feedback from Scottish Government

Eugene Clarke asked for assurance that future proofing and the impact of digitalisation in both centres was being addressed, as nothing mentioned in the report. Carol Potter explained that the final Outline Business Case would have a significant increase in detail, which would include technology.

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5

118/19

119/19

Nicky Connor confirmed that she would build into the final document and the covering SBAR, a section on technology and the impact of digitalisation.

The Chair asked for assurance on revenue affordability, and that both centres will be able to remain within the existing revenue budget. It was noted that the FP&R Committee would receive a further update on the revenue position as the projects progress to Outline Business Case stage.

The Committee approved and recommended approval to the Board.

7.4 Procurement StrategyCarol Potter explained that this was an entirely new document and has been developed through best practice and lessons learned from joint working wtih the Procurement Planning Manager for NHS Tayside and NHS Lothian. The Procurement Strategy will allow NHS Fife to formally document how we intend to approach all of our procurement activity, and our social responsibility in terms of supporting the economy and public services.

The Strategy is a 5 year document, with an annual report to be prepared for consideration by the Executive Directors Group and the FP&R Committee, which will describe the activities that the Procurement function has been undertaking, toward delivering the aspirations set out in the strategy. A Procurement Governance Board will be established with representatives from across operational service areas. The group will meet quarterly and seek to support ongoing best practice in procurement activities, as well as a forum to highlight areas for efficiency.

The Chair asked that information on social enterprise and supporting local businesses to be included in the next Annual Report.

The Committee approved the NHS Fife Procurement Strategy 2019 to 2024 and agreed the publication of the Strategy on the website to comply with the Procurement Reform Act 2014.

7.5 Winter Plan 2019/20Nicky Connor and Ellen Ryabov provided an overview of the draft Winter Plan building on the presentation provided at the recent Board Development Session.

ACTIONNicky

Connor

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6

The Plan focuses on the period October 2019 to March 2020, and has already been considered by the Clinical Governance Committee. The draft Winter Plan has to be submitted to the Scottish Government by 23 September 2019, with the final version to follow in November. Since the Plan was drafted, a letter has been received from the Scottish Government confirming an additional £320,000 as part of the Winter Readiness monies. Nicky Connor and Ellen Ryabov were asked to ensure there was clarity in the Winter Plan on how these resources would be prioritised. ER/NCEllen Ryabov explained that the letter from the Scottish Government has very clear requirements, including delivering a 4 hour performance at 95% as well as other operational performance inlcuding TTG. Ellen Ryabov also confirmed that the Plan will revised to provide greater assurance on whether the targets can actually be delivered, given current challenges in unscheduled care performance. A re-draft will provide clarity and assurance for the FP&R Committee and the Board.

The Chair suggested that the Winter Plan requires escalation to the Board, and a further discussion and a development session is required.


PERFORMANCE

120/19 8.1 Integrated Performance & Quality ReportThe Chair explained that this is the first time the FP&R Committee have seen the IPQR in its new format.

Carol Potter provided an overview of the financial position for the period to the end of July 2019, highlighting the overspend of c.£5m, noting that, this does not include any share of the overspend of the IJB position. The report provided further detail on the underlying financial issues, key risks and concerns, as well as the current forecast position to year end.

The Committee noted the following:

reported overspend of £5.228m for the year to 31 July 2019 additional overspend of £1.6m for the year to 31 July 2019

which would result if the risk share arrangement was applied to the current full year gap for the Integration Joint Board.

The potential (draft) outturn position of £9m reflecting an optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings.

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7

Carol Potter provided an update on the Capital position, confirming that the capital programme is broadly on track and the full allocation is expected to be utilised this year.

The Committee noted the capital expenditure position to 31 July 2019 of £0.653m and the forecast year end spend of the capital resource allocation of £7.394m.

Ellen Ryabov provided an update on the Acute performance.

Nicky Connor provided an update on the Health and Social Care Partnership.

The Committee noted the current position for both the Acute Division and Health and Social Care Partnership.

121/19 8.2 Acute Services Division Efficiency ProgrammeCarol Potter explained that Deloitte LLP have been working with the Acute Services management ream to provide extra support to drive forward a robust approach to the efficiency agenda..Carol introduced Christine Armistead and Alex Deveney from Deloitte who presented the output of their diagnostic work and recommended next steps.

Paul Hawkins confirmed that the update was a draft position and that a detailed report will be finalised after further discussions through EDG, to ensure all Directors have an opportunity to comment and review the data presented. The report will be submitted for consideration at the next FP&R Committee.

In response to a query from Les Bisset, with regard management capacity to deliver next steps, Ellen Ryabov acknowledged that a Programme Management Office would be advisable, to ensure a pace of change and focus on actions.. The Committee confirmed that they would support the increased additional support and recognised that this would also be beneficial if it incorporated the Health & Social Care Partnership, to provide an integrated approach to transformational change. Ellen Ryabov agreed to discuss this further with the Chief Executive.

The Chair requested that the Acute Services Division Efficiency Programme becomes a standard agenda item for the FP&R Committee going forward and possibly a Board Development Session could also be looked into.

ACTIONAddition to standard agenda

ER

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8

ITEMS FOR NOTING

122/19

123/19

124/19

9.1 Internal Audit Report B26-20 Property Transaction Monitoring

The Committee noted the report.

9.2 Minute of IJB Finance & Performance Committee, 17 July 2019

The Committee noted the minute.

ISSUES TO BE ESCALATED

1. Winter Plan

125/19 ANY OTHER BUSINESS

None.

Date of the Next Meeting: Tuesday 5 November 2019 at 9:30am, within the Boardroom, Staff Club, Victoria Hospital

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Staff Governance: Chair and Committee Comments

STAFF GOVERNANCE COMMITTEE

(Meeting on 30 August 2019)

Key issues to be raised:

1. Safe Staffing Legislation

This legislation recognises the importance of safe staffing levels relating to both nursing & midwifery and Allied Health Professions staffing. Work is underway under the direction of the Board Nurse Director to ensure that the Board meets its obligations in this area.

2. Turas

Current compliance is 51% towards a target of 80%. Whilst this is an improvement within 2019/20 it remains 9% lower than the required trajectory to achieve the 80% by the due target date. The Executive Directors Group continues to monitor performance monthly towards this target.

3. Sturrock Report

The Committee received a presentation on the Board’s response to the Sturrock Report. This outlined the common themes for future work which had been developed in partnership.

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Fife NHS BoardUnconfirmed

File Name: Board/Minutes 083019 Issue 1 04/09/2019Originator: Paula King Page 1 of 7 Review Date:

MINUTE OF THE STAFF GOVERNANCE COMMITTEE HELD ON FRIDAY 30 AUGUST 2019 AT 10.00 AM IN THE STAFF CLUB, VICTORIA HOSPITAL, KIRKCALDY

Present:Mrs M Wells, Non-Executive Director (Chairperson) Mr E Clarke, Non-Executive Director Mrs C Cooper, Non-Executive DirectorMr S Fevre, Co-Chair, Health & Social Care Partnership Local Partnership ForumMr A Verrecchia, Co-Chair, Acute Local Partnership Forum

In Attendance:Mr B Anderson, Head of Staff GovernanceMrs N Connor, Interim Director of Health & Social Care Mr A MacKay, Deputy Chief Operating OfficerDr G MacIntosh, Head of Corporate Governance & Board SecretaryMs BA Nelson, Director of WorkforceMs J Owens, Associate Director of Nursing (items 80/19 to 85/19) Mrs R Waugh, Head of HRMrs P King, Corporate Services Manager (Minutes)

80/19 CHAIRPERSON’S WELCOME AND OPENING REMARKS

The Chair welcomed everyone to the meeting, in particular Mrs Connor, Interim Director of Health & Social Care, and Mr MacKay, Deputy Chief Operating Officer. The notes are being recorded with the Echo Pen to aid production of the minutes. These recordings are also kept on file for any possible future reference.


None.

82/19 APOLOGIES FOR ABSENCE

Apologies were received from Mrs Brown, Mrs Buchanan and Mr Hawkins.

83/19 MINUTE AND ACTION LIST OF THE PREVIOUS MEETING HELD ON 28 JUNE 2019

The Minute of the previous meeting was approved.

The action list would be updated as per discussion at the meeting of the relevant agenda items.


None.

It was agreed to take agenda item 10 at this point.

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File Name: Staff Gov/Minutes 083019 Issue 1 04/09/2019Originator: Paula King Page 2 of 7 Review Date:

85/19 SAFE STAFFING LEGISLATION

Ms Owens gave a presentation on Safe Staffing Legislation, which had been brought into law in recognition of the importance of safe staffing levels on mortality. This was a major piece of work around nursing and midwifery that would be expanded into Allied Health Professions (AHPs) in due course and the legislation placed a duty on every Health Board to ensure appropriate staffing was in place at all times. Ms Owens responded to a number of questions about monitoring staffing levels in the community using the proposed compliance tools, the implications for high cost agency use and raising the issue through the Integration Joint Board. The effect on supplementary staffing was of concern particularly in Intensive Care areas and for Operating Department Practitioners, but there are other, less specialist areas where agency should not be used. Discussions are therefore taking place with areas that do have critical vacancies looking at different ways to fast track the recruitment process.

The Chair thanked Ms Owens for her useful and comprehensive presentation on safe staffing, noting the work underway in Fife to meet this obligation for nursing & midwifery and other staff, particularly AHPs.

The Committee noted the content of the presentation.

86/19 BOARD ASSURANCE FRAMEWORK (BAF) – STAFF GOVERNANCE RISKS

Ms Nelson advised that this is the routine consideration of the BAF in terms of workforce sustainability risks and any sub set risks, as submitted to every meeting. There was no change to the content of the workforce sustainability risk since the version last presented to the Committee in June 2019.

The only remaining operational risk related to the national shortage of consultant radiologists. A query had been raised at the last meeting about the level of the risk given it had been on the register for some time and whether or not this should be reduced. After internal consideration and a test of the market, confirmation had been received from the Acute Services Division that the risk should remain at a high level as the recruitment issues remained in this speciality. The date of the current management action related to this risk would be updated accordingly.

Action: A MacKay

The Committee was reminded that two additional risks had previously been added relating to Mental Health and Brexit. As workforce planning arrangements were more aligned to service planning and financial planning arrangements within the Board, Members were assured that any specific staffing risks would appear in the local risk registers and would be escalated as appropriate. Ms Nelson would consider how best to articulate the known shortage areas to provide more detail and will report back to the Committee.

Action: B A Nelson

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Mr Clarke commented that there was no reference to ‘digital readiness’ which had the potential to be a big risk for staff going forward, if technology was to be an important aspect of service delivery transformation.

The Committee noted the content of the report and approved the risk ratings of the updated workforce sustainability element of the Board Assurance Framework.

87/19 STAFF HEALTH & WELLBEING

a) Attendance Management Update

Mrs Waugh spoke to the paper that provided an update on the sickness absence statistics for April to June 2019. The NHS Fife average sickness absence rate for June 2019 was 5.55%, about 0.5% above the NHS Scotland average rate for the same period. Analysis of the statistics was set out on pages 3-6 of the report and included additional information on short and long term absence at para 2.2, as requested at the last meeting. In reference to doctors in training, NHS Lothian had provided a report on medical and dental absence that showed a sickness absence rate of below 1% and this data would form part of the report to the Committee in due course. A number of actions were ongoing and these were listed on pages 7-8 of the report.

Members were pleased to note the good work being taken forward particularly related to staff health and wellbeing across NHS Fife and the Health & Social Care Partnership. In response to a question around evaluation of the effectiveness of the actions undertaken to improve performance, Ms Nelson advised that although some activity was qualitative related to the health and wellbeing of staff and was difficult to evaluate, for certain actions the difference could be quantified and would be part of the future reporting mechanism. Useful discussion also took place on the application of policies and the need for these to be consistently applied. Consideration should be given as to whether this is a training issue about how to enable people to act in a compassionate manner, at the same time as dealing with the responsibilities of running a service.

The Committee noted the sickness absence position for the first quarter of the 2019/20 financial year, noting the small improvement in the overall position.

b) Well at Work

Mrs Waugh spoke to the update paper on the latest Well at Work (Healthy Working Lives) activity, highlighting in particular the evaluation of year 1 of Going Beyond Gold work and the year 2 plan that would be presented to the November Committee meeting. Also highlighted were the Holyrood Wellbeing Conference that key members of the team had been invited to speak at and the update to the Health and Wellbeing Strategy that would focus on smoking, alcohol, healthy eating and

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physical activity. An update on the Kindness Conference would also be provided at the next meeting in November, or earlier at the Area Partnership Forum.

Action: R Waugh

The Committee noted the ongoing activities in support of Well at Work.

88/19 FOCUS ON APPROPRIATELY TRAINED AND DEVELOPED STAFF GOVERNANCE STRAND

a) Once for Scotland Workforce Policies Update

Ms Nelson briefed Members on the content of the paper.

The Committee noted the update on revising core HR policies on a national basis, and the Board’s anticipated actions in respect of Phase 2 of this work.

b) Dignity at Work Action Plan/Sturrock Report

Ms Nelson gave a presentation on the Sturrock Report outlining the context/remit of the Sturrock review, common themes, steps taken within NHS Fife and local and national actions. An update was also provided on the first Short Life Working Group chaired by the Cabinet Secretary that would oversee how the Report’s recommendations would be met. Ms Nelson emphasised that the plan would only work if it is owned and driven by staff and it was agreed that presentations be made at the Local Partnership Forums, preferably done jointly with Fife Council and the Integration Joint Board, to inform staff appropriately. The presentation given to the Committee would be circulated to Members.

Action: B A Nelson

89/19 WORKFORCE STRATEGY 2019/22

The Committee noted the formal approval of the Workforce Strategy 2019-20 by the Board in July 2019.

90/19 TURAS UPDATE

Mr Anderson referred to the report that demonstrated performance against the recovery plan target to restore compliance to above 80% by the end of October 2019. This related to Turas PDP completion as agreed by the Executive Directors Group (EDG), along with the position for each Directorate to meet the agreed recovery plan. Whilst PDP compliance has shown an increase in performance in 2019/20, it currently sits at 51% compliance, 9% lower than the required trajectory to achieve 80% by the target date.

The importance of staff having their appraisal was emphasised, particularly as a first step in supporting staff and obtaining their views about how they feel things are going. It was agreed this tied into the discussion on sickness absence.

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There were a number of reasons why this is not happening at the rate it should, mainly linked to learning the new system, technical glitches with the new system and workload pressures.

The Committee noted the progress in relation to the recovery plan established to restore compliance to above 80%.

91/19 HR COLLABORATIVE WORKING – NATIONAL/REGIONAL

Discussed under item 83/19. Ms Nelson confirmed that elements of the regional work streams of shared services would be reported to the Executive Directors Group, Area Partnership Forum and Staff Governance Committee. It was hoped that an update on the regional collaborative work could be provided to the next Committee meeting.

Action: B A Nelson

92/19 BREXIT UPDATE

Ms Nelson informed Members that, given recent political developments, communication related to Brexit would be re-energised on a general basis and for staff that may be affected in order to support them and encourage them to apply for settled status. Some Boards have already suffered an impact in terms of workforce as people consider their life choices. The Brexit Assurance Group had arranged a meeting for 6 September 2019, where these issues would be considered further.

The Board noted the update provided.

93/19 YOUNG PEOPLE’S WORKFORCE STRATEGY

Ms Nelson spoke to the paper that provided an overview of work undertaken to date on the Board’s approach to Youth Employment and an indication of other steps that are being taken to increase engagement in this agenda. Ms Nelson thanked Mr Anderson and team for the considerable work done to increase youth employment opportunities.

Mrs Connor referred to a recent presentation by Fife Council who have a reference group of youth staff, aged 16-30, that is able to feed in and advise about the best way to engage with this age group. Mr Anderson would link in with Council colleagues, and NHS Lothian who also had a good set up around youth employment, for any further learning for NHS Fife going forward. Comment was also made about the need to identify transferrable skills into careers in the health sector and how this is actively promoted.

The Committee noted the specific actions to be taken in supporting the Youth Employment Strategy.

The Committee considered the update and noted the actions planned for 2019.

94/19 STAFF GOVERNANCE COMMITTEE - FUTURE DATES

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The Committee noted the proposed dates of future Committee meetings through to 2021.

95/19 INTEGRATED PERFORMANCE & QUALITY REPORT

The new Integrated Performance & Quality Report has been developed with input from Committee Chairs and Directors to give a simpler drill down of information. It was intended that the section on Staff Governance be expanded in future but the content needed to be meaningful and related to easily obtainable data. Members had previously discussed a paper on HR metrics and suggested including Turas and iMatter on an annual basis. The importance of the qualitative information around staff governance was emphasised, noting that this would be reported to the Board by the Chair of the Committee under the minutes section of the Fife NHS Board agenda.

The Committee noted the Integrated Performance & Quality Report and noted its content in relation to Staff Governance.

96/19 ISSUES TO BE HIGHLIGHTED TO THE BOARD:

a) From the Integrated Performance & Quality Report

The following items would be highlighted to the Board: Sickness Absence performance

b) In addition to the Integrated Performance & Quality Report

The following items would be highlighted to the Board: Safe Staffing Legislation; Turas; Sturrock Report on values and behaviours

97/19 ITEMS FOR INFORMATION/NOTING

The below-noted minutes were noted:

a) Minutes and Action List of the Area Partnership Forum (24.07.19)

b) Minutes of the Acute Services Division and Corporate Directorates Local Partnership Forum (27.06.19)

c) Minutes and Action List of Health & Social Care Local Partnership Forum (26.06.19)

98/19 ANY OTHER BUSINESS

a) Winter Planning 2019/20

The Committee acknowledged that the Winter Plan 2019/20 was in development and a helpful presentation had been given at the Board Development Session on 28 August 2019.

b) Appointment of Director of Workforce

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Ms Linda Douglas has been appointed as the new Director of Workforce and would likely take up post on 1 January 2020. Ms Douglas is the current Director of HR at the Scottish Ambulance Service and will attend the November meeting of the Staff Governance Committee as part of the handover arrangements.

c) Staff

Mr Mackay took the opportunity to highlight one of many examples whereby staff go above and beyond for patients in their care. In this example, at a time when the hospital was extremely busy and pressurised, staff had enabled a patient receiving end of life care in one of the Admissions Unit to get married.

99/19 DATE OF NEXT MEETING:

Friday 1 November 2019 at 10.00 am in the Staff Club, Victoria Hospital, Kirkcaldy

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Brexit Assurance Committee: Chair and Committee Comments

BREXIT ASSURANCE GROUP


No issues were raised for escalation to the Board

Brexit A

ssurance Com

mittee: C

hair and Com

mittee C

omm

ents

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File Name: Brexit Assurance Committee 060919

Issue 1 Date: 09/09/19

Originator: Cheryl Clifford Page 1 of 3

MINUTES OF THE BREXIT ASSURANCE GROUP HELD ON 06 SEPTEMBER 2019 AT 2PM IN COMMITTEE ROOM 3, 5TH FLOOR, FIFE HOUSE

Present:Dr Les Bisset (chair), Vice Chairman Mr Martin Black, Non Executive Committee MemberMr Scott Garden, Director of Pharmacy Ms Rona Laing, Non Executive Committee MemberMs Gillian MacIntosh, Head of Corporate Planning and Performance Ms Dona Milne, Director of Public Health Ms Barbara Anne Nelson, Director of Workforce Ms Carol Potter, Director of Finance

Apologies:Dr Chris McKenna, Medical Director Mrs Margaret Wells, Non Executive Committee Member

In Attendance:Cheryl Clifford, Office Manager, Public Health

MINUTE REF

ACTION

23/19 WELCOME AND INTRODUCTIONS Dr Bisset welcomed everyone to the meeting.

24/19 DECLARATION OF MEMBERS’ INTERESTSThere were no declarations of interest.

25/19 APOLOGIES FOR ABSENCEApologies were noted above.

26/19 MINUTES OF PREVIOUS MEETINGThe minutes of the previous meeting were accepted as an accurate record.


28/19

All matters arsing were captured on the agenda. SCOTTISH PLANNING ASSUMPTIONS The paper relating to this was circulated prior to the meeting. The template has been circulated to relevant colleagues for comment and will be tabled at the EDG meeting on 16th September for approval prior to being returned to the Scottish Government by the deadline of 20th

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Issue 1 Date 09/09/19

Originator: Cheryl Clifford Page 2 of 3 :

September. The completed template will be circulated to the group. A discussion followed on the assumed number of UK nationals returning to the UK following Brexit and the additional pressures this may bring to services in the Winter. Ms Potter agreed to bring this to the attention of the Winter Planning Group. Ms Nelson reported further communication to staff will take place regarding “Stay in Scotland” and will include extended family members. It was agreed numbers of UK nationals returning to the UK can only be estimated and the number of chronic conditions suffered by returnees is unknown.

CC

CP

29/19 EXTRACT FROM BOARD COMMITTEE MINUTES Finance Performance and Resources

The group were asked to note the extract from the above meeting. An SBAR was also provided and will be tabled at the next Finance Performance and Resources meeting due to take place on 10th September.

Staff Governance The group were asked to note the extract from the above meeting. Ms Nelson reported further communication to staff will take place regarding “Stay in Scotland” and staff will be encouraged to apply for the resettlement scheme.

Clinical Governance The group were asked to note the extract from the above meeting. A discussion followed whereby Mr Garden updated the meeting on the work being undertaken. Mr Garden agreed to forward a written update to the group.Ms Milne confirmed she had spoken to the CMO last week regarding the rumoured Flu vaccine shortage. The CMO had confirmed there was no truth in the rumour and sufficient flu vaccine was available for this year’s campaign.

SG

30/19 SELF ASSURANCE CHECKLIST FOR H&SCP Ms Milne confirmed this checklist had been given to all partners for reporting but a discussion will take place next week to confirm if this template will continue to be used. Ms Milne will give an update at the next meeting.

DM

31/19 NHS FIFE RESILIENCE FORUM MINUTES The group were asked to note the minute from the above meeting.

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Issue 1 Date 09/09/19

Originator: Cheryl Clifford Page 3 of 3 :

32/19 NATIONAL UPDATES Ms Milne reported three FOI’s had been received regarding Brexit, a response was sent back by the requested date.

33/19 AOCB There was no other competent business.

34/19 DATE OF NEXT MEETINGWednesday 25th September at 2pm in Room 52,Hayfield House

Monday 28th October at 2pm in Room 521, Hayfield House

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East Region Programme Board

EAST REGION PROGRAMME BOARD

(Meeting on 24 May 2019)

No issues were raised for escalation to the Board.

East Region Program

me B

oard

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Version: Final

Meeting: East Region ProgrammeDate: Friday 24th May 2019Location: Fettes Suite, SHSC, Crewe Road South

Present: T Davison Chief Executive, NHS Lothian/Regional Implementation Lead (Chair) P Hawkins Chief Executive, NHS Fife R Roberts Chief Executive, NHS BordersJ McClean Acting Director of Regional Planning, East Region D Phillips Regional Workforce Planning Director, East RegionS Goldsmith Director of Finance, NHS LothianA McCallum Director of Public A Joyce Employee Director, NHS LothianJ Smyth Director of Strategic Change & Performance, NHS BordersN Berry Director of Nursing, Midwifery and Acute Services, NHS BordersF Murphy Director, NSD J Stephen Head of IM & T, NHS N Waters Programme Director C Caddell Regional Admin (minute taker) In Attendance: Andrew Mackay, Deputy Chief Operating Officer, NHS Fife Sarah Tait, Regional MCN for Child Protection Manager Jane Macdonell, Clinical Lead, Regional MCN for Child Protection Peter McLoughlin, Programme Manager, NHS Lothian Yvonne Lawton, Head of Strategic Planning &Partnership James Wilkie, Regional Planning Manager, SAS Apologies for absence were received from:Carol Gillie, Cliff Sharp, John Cowie, Carol Potter, Ellen Ryabov, Christopher McKenna, Wilma Brown, Barbara Anne Nelson, Alex McMahon, Jim Crombie, Colin Briggs, Tracey Gillies, Janis Butler, Judith Mackay, Caroline Lamb, Lewis Campbell, Michael Kellet, Judith Proctor, Alison McDonald, Jim Forrest, Allister Short, Robert McCulloch

Minutes

East Region Programme Board 2019, 11am – 1pm

Fettes Suite, SHSC, Crewe Road South, Edinburgh

Chief Executive, NHS Lothian/Regional Implementation Lead (Chair) Chief Executive, NHS Fife Chief Executive, NHS Borders Acting Director of Regional Planning, East Region Regional Workforce Planning Director, East Region Director of Finance, NHS Lothian

Health, NHS Lothian Employee Director, NHS Lothian Director of Strategic Change & Performance, NHS Borders Director of Nursing, Midwifery and Acute Services, NHS Borders

Head of IM & T, NHS Borders/Regional Functional Lead eHealth/DigitalProgramme Director – Prevention and Reversal of Type 2 Diabetes, East RegionRegional Admin (minute taker)

Andrew Mackay, Deputy Chief Operating Officer, NHS Fife Sarah Tait, Regional MCN for Child Protection Manager for Item 5 Jane Macdonell, Clinical Lead, Regional MCN for Child Protection for Item 5 Peter McLoughlin, Programme Manager, NHS Lothian for Item 11 Yvonne Lawton, Head of Strategic Planning & Performance, West Lothian Health & Social Care

James Wilkie, Regional Planning Manager, SAS

Apologies for absence were received from: Carol Gillie, Cliff Sharp, John Cowie, Carol Potter, Ellen Ryabov, Christopher McKenna, Wilma

a Anne Nelson, Alex McMahon, Jim Crombie, Colin Briggs, Tracey Gillies, Janis Butler, Judith Mackay, Caroline Lamb, Lewis Campbell, Michael Kellet, Judith Proctor, Alison McDonald, Jim Forrest, Allister Short, Robert McCulloch-Graham

East Region Health & Social Care Delivery Plan Programme Programme Office Strathbrock Partnership Centre 189A West Main Street Broxburn EH52 5LH

Page: 1 of 8

Chief Executive, NHS Lothian/Regional Implementation Lead (Chair)

Director of Nursing, Midwifery and Acute Services, NHS Borders

Borders/Regional Functional Lead eHealth/Digital Prevention and Reversal of Type 2 Diabetes, East Region

West Lothian Health & Social Care

Carol Gillie, Cliff Sharp, John Cowie, Carol Potter, Ellen Ryabov, Christopher McKenna, Wilma a Anne Nelson, Alex McMahon, Jim Crombie, Colin Briggs, Tracey Gillies, Janis

Butler, Judith Mackay, Caroline Lamb, Lewis Campbell, Michael Kellet, Judith Proctor, Alison

East Region Health & Social Care

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Version: Final Page: 2 of 8

1. Welcome and Ap ologies T Davidson welcomed everyone to the meeting and apologies were noted.

2. Notes of Previous Meeting held on 29th March 2019 The Group reviewed the minutes from the previous East Region Programme Board (ERPB) meeting held on 29th March 2019 and they were agreed as an accurate record of the meeting.

3. Matters Arising National Business Systems Programme Board – East Region representative T Davison advised that R Roberts has agreed to represent the East Region on the national NHS Business Systems Programme Board.

4. Update from Preceding RCAG J McClean gave a brief update on items discussed at the preceding RCAG.

5. Regional MCN for Child Protection - Annual Report and Work Plan J Macdonell, Clinical Lead for the Regional MCN for Child Protection presented the 2017 - 2019 Bi-annual Report and the Work Plan for 2019 - 2020 to the Group for agreement. J Macdonnell provided a comprehensive overview of the key achievements of the Regional MCN including training and education of clinical teams to support confidence and competence in this challenging field; the positive benefits of established peer review; use of audit data to inform continuous service improvement and the role of the MCN in influencing and leading national work. J Macdonnell highlighted her recent 2 year secondment to NHS Fife to lead the Child Protection service, with strategic plans now in place to support service development. The ERPB agreed the Annual Report and noted the many achievements. The MCN Work Plan for 2019-20 was presented to the Board and endorsed. J McClean commented that the MCN had clearly demonstrated the value of collaborative working particularly in supporting clinical teams with education, training and peer support and reflected on the position 5 years ago when there were few clinicians willing to work in this field. J McClean advised that J Macdonell had now stepped down from her MCN Lead Clinician role and noted the significant contribution she had made to the regional MCN and in influencing national work. A process to recruit to the 2 sessions per week post is underway through the host Board, NHS Fife.

6. NHS Board Annual Operating Plans 2019 Boards draft Annual Operating Plans for 2019-20 had been circulated to Programme Board members, with Chief Executives providing an overview of respective operational plans and challenges. NHS Fife P Hawkins provided an overview of the NHS Fife draft AOP, advising that it is anticipated that circa £6.7m will be made available from Scottish Government to support delivery of Access Targets in 2019/20. In the few areas where performance standards have not been met in 2018/19, trajectories have been agreed in support of an improved position for 2019/20. P Hawkins advised that there was a proactive approach to recruitment as a way of mitigating workforce risks.

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NHS Borders R Roberts provided an overview of the draft NHS Borders AOP, advising that circa£3.8m is required from Scottish Government to fully achieve all waiting times targets by 31 March 2020, however an allocation of £2.8m is expected for 2019/20 which includes a cancer waiting times allocation. NHS Lothian T Davison provided an overview of the NHS Lothian draft AOP, advising that discussions were still ongoing with Scottish Government to agree trajectories and funding, however £10m is anticipated from Access Support with additional funding from other sources. T Davison highlighted the challenge of making inroads into the backlog of outpatients waiting which subsequently increased the number of patients subject to Treatment Time Guarantees (TTG). T Davison outlined plans to explore a number of options to increase theatre capacity, including the use of modular theatres pending the development of the NHS Lothian Elective Treatment Centre. Following discussion, Boards confirmed their commitment to ensuring that only patients requiring specialist or tertiary care should be referred to NHS Lothian. J McClean reminded the Board that detailed work had been undertaken in the Region 4/5 years ago to review cross boundary flow activity. The review highlighted that while some of the referrals to NHS Lothian where not clinically required, a large proportion of the non-Lothian referrals were made by NHS Lothian consultants to other NHS Lothian consultants. Following the review Boards strengthened local arrangements to ensure that referrals out of Board were clinically appropriate. NHS Lothian teams undertook to review the process of Consultant to Consultant referrals. T Davison suggested that NHS Lothian would look at the cross boundary flow and differentiate tertiary and secondary referrals. It was agreed to discuss this further at the forthcoming Regional Leads meeting.

TD/JMcC

7. East Region Work Programme 2019 -20 Following a more detailed presentation at the previous ERPB, J McClean presented the final version of the East Region Work Programme 2019-20 providing clarity and focus on agreed objectives for the forthcoming year. The Group noted the Work Programme and agreed that an update will be brought to ERPB at mid-year to discuss progress.

JMcC

8. East Region Transformation Fund – 6 monthly update S Goldsmith spoke to a previously circulated update on the allocation and commitment of Transformation Funds in line with the agreed reporting and management arrangements. The East Region received allocations of £2.4m in both 2017/18 and 2018/19. As at April 2019 there was an under spend of £3.6m which Scottish Government agreed could be carried forward to 2019/20. The Group noted that the position for 2019/20 allocations is still to be formally confirmed. S Goldsmith highlighted previously flagged areas for possible future investment including developing further the Artificial Intelligence programme piloted in NHS Lothian and Robotic Surgery. P Hawkins noted that further discussion was required to understand the regional benefits of these initiatives. Following discussion, T Davison commented that, as a Region, we

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needed to move some of the in-principle transformational opportunities into tangible outputs. The Board noted the paper and agreed to receive an update once the 2019/20 allocation has been confirmed. A 6 monthly update report will be provided mid-year.

SG/JMcC

9. Common Ground - Regional Planning in the East Region J McClean presented the East Region Document, Common Ground, to the Board. The electronic document sets out a comprehensive description of the East Region, including its population demographics, challenges in relation to workforce, finance and managing demand. T Davison added that this should be viewed as a stakeholder communication, setting out the work we are undertaking collaboratively across the region. Although NHS Lothian do not plan to take the document formally through local governance arrangements, the document will be circulated for information.

10. Work Programme Updates 10.1 East Region Diabetes Programme - Prevention and Reversal of T2 Diabetes N Waters spoke to a previously circulated Project Highlight Report noting that work streams are progressing. Weight Management Workstream The launch of the Counterweight service was anticipated for May and is progressing although there has been some slippage. A Clinical Lead has been appointed to support the workstream. Children and Young People Workstream The CYP work stream has seen delay in order to ensure wider discussion with agreement to establish a Board to oversee and lead this work stream. Employer Scope The Employer Scope work stream has been slower to commence however there has been agreement by the Interface Group and Partnership Group to establish a Board to oversee and progress this work stream. ‘Whole systems’ A meeting has been arranged between Early Adopter sites and the Scottish Government in June to discuss a pilot in each Board area. Following discussion it was agreed that it would be helpful to sight the Directors of Finance on the Programme and possible funding opportunities. 10.2 Laboratory Medicine In J Crombies absence, J McClean spoke to a previously circulated Project Highlight Report noting in particular the progress with work on the Managed Service contract. Challenges with job matching Project Manager job descriptions have led to delays in initiating workstreams. It was agreed to raise this issue at the next East Region Leads meeting on the 11th June 2019. 10.3 Ophthalmology The previously circulated Project Highlight report was noted. P Hawkins confirmed that he was stepping down as Chair of the Network Board and proposed that Ralph Roberts took on this role. R Roberts has agreed to chair this Group.

JMcC

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10.4 Regional Trauma Network In A McMahon’s absence, J McClean spoke to a previously circulated Project Highlight Report noting in particular the amended phasing of funding for Networks through to 2023/24, however this should not affect delivery of the East Region programme. A McCallum highlighted the importance of psychology support as part of the patient pathway. J McClean suggested that the Regional Network Manager could provide detail of the proposed regional investment in this aspect of the pathway and agreed to put her in touch. 10.5 Regional Innovation Programme In T Gillies’ absence, S Goldsmith spoke to a previously circulated Project Highlight Report on the Regional Innovation Programme. 10.6 HR/Workforce In J Butler’s absence, D Phillips spoke to a previously circulated Project Highlight Report in particular noting:

Policy & Practice Bundle A paper in relation to Cross Board Working and Retirement and Re-engagement will be brought to the August ERPB meeting. Workforce Planning An event is scheduled for the 6th June to discuss the Physician Associate role and how we implement, support and develop Physician Associates in the East. D Phillips will meet with an external consultancy to discuss potential modelling tool to understand the impact of pension taxation upon retiral decisions and reduced working patterns for senior consultants. 10.7 Finance - Payroll and Procurement S Goldsmith spoke to previously circulated Project Highlight Reports for Payroll and Procurement. The Board noted that the Payroll Project Manger will be moving post. A Procurement Project Manager has been appointed. S Goldsmith noted that NHS Borders were pulling out of both services but no formal communication has been received. R Roberts advised that this was due to a capacity issue. T Davison suggested an offline discussion to see if can help keep system engaged. 10.8 Realistic Medicine In T Gillies’ absence, J McClean spoke to a previously circulated Project Highlight Report and confirmed a half day workshop to be scheduled to agree specific areas of work to be included in the work package on realistic prescribing in the frail elderly and agree outcomes. 10.9 eHealth J Stephen spoke to a previously circulated Project Highlight Report on eHealth. The Board noted that the group was running well and a central point of contact for work streams.

JMcC

11. Surgical Robotics In T Gillies absence, P McLoughlin spoke to a previously circulated draft Business Case for Robot Assisted Surgery in the East Region, setting out the context, aspirations and benefits of introducing this regional initiative R Roberts asked for further detail on how ongoing costs would be picked up across the Region. P McLoughlin advised that it was likely that these would be picked up through the East Coast Costing Model. S Goldsmith advised

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that it was hoped that the programme could be funded through the Regional Transformational Fund for the first 2 years, however this would need to be agreed. P Hawkins commented that although the regions Medical Directors have been sighted on the development of this proposal, it was essential that Board Chief Executives had an opportunity to review the Business Case prior to any decision being made. S Goldsmith confirmed that this was the intention and that there was still time for local discussions to take place. R Roberts asked that if there was agreement in principle at this stage, there would be an expectation that costs would not change. P Hawkins suggested that it would be helpful to be informed by the experiences of the DaVinci Robot used for Urological Cancer. F Murphy advised that the National Planning Robotic Surgery Review Group is gathering evidence which could be shared with the colleagues involved in the development of the Business Case. Following discussion, the Board agreement in principle to proceed with the OBC with a request that a final Business Case is brought to the August ERPB meeting.

TG

12. Sacral Nerve Stimulation for Urinary Dysfunction - Establishment of an East Region Service J McClean reminded the Group that as agreed at the last ERPB, preparation for implementation of a regional service is now underway through NHS Lothian Urology service team, with the aim to commence in August 2019. J McClean also spoke to a previously circulated letter from NSD and noted that an outstanding issue to be resolved is management of the backlog of patients for PNE Testing from the National Service. Efforts are underway through J Campbell’s office to secure private sector capacity although it is yet to be confirmed if this is possible. P Hawkins enquired if patients could be treated in England. F Murphy noted that due to the distressing symptoms, the majority of patients requiring this type of treatment would be unlikely to travel to England. The Board noted that the impact on the emergent regional service if it were to accept these patients, would be the equivalent of 1 years activity with a conversion rate of 50% of patients requiring permanent implant. NHS Lothian Urology service has indicated that this would be a significant challenge within current workforce, capacity and financial constraints. J McClean highlighted that DoFs have confirmed that they have included costs within their respective financial plans. S Goldsmith confirmed that this has been added to the list of financial risks. Following discussion it was agreed that J McClean would work with the service team in NHS Lothian to explore options for additional capacity locally, in Boards elsewhere in Scotland and in the private sector.

JMcC

13. Regional Interface Group – Feedback from Meeting held on 3 rd May T Davison provided a brief update on the items discussed at the last Regional Interface Group discussion between Health Board, Councils and IJBs highlighting the potential for regional collaboration on mental health, in particular response to crisis situations across different agencies. There has been agreement to arrange a regional discussion involving key leads from

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Councils, IJBs and Health to share examples of models currently in place and explore further opportunities. Interest was expressed by NHS Lothian and Borders to work collaboratively on CAMHS given some of the challenges. A workshop will be organised to consider possible opportunities for collaborative working.

JMcC

14. MCN for Learning Disabilities - Bi-annual Work Plan for Noting D Phillips spoke to a previously circulated Learning Disability MCN Work plan for 2019-2021 and reminded the Board that the Regional LD MCN had agreed to complete the MCN Work Plan following the publication of the Scottish Government strategy for improving the lives of people with learning disabilities - ‘Keys to Life’ - , and ‘Coming Home’, a review of out of area placements for people with LD across Scotland. The ERPB noted the Work Plan and will feed back any comments via the Regional Planning office.

All

15. William Quarriers Scottish Epilepsy Centre – Financial Model J McClean reminded the Board of the discussion at the previous ERPB meeting, highlighting concerns that the financial model proposed by Quarriers would disadvantage the East Region Boards due to the continued decrease in referrals from the East. J McClean advised that the 3 Regional Chief Executive Leads and Regional Director of Finance Leads have agreed the principle of a 3 year rolling average financial model for 2019/20, with a stock take review in March 2020 to confirm that this approach remains appropriate for 2020/21. J McClean advised that the Directors of Finance from the 4 Boards have been sighted on this and arrangements will be put in place to implement this approach.

16. National Review of Oral Medicine - Discussion on East Region Position J McClean introduced this item, advising that a national review of Oral Medicine services had been requested by NHS Lothian due to fragility of the service due to workforce issues. The previously circulated Report had been discussed by National Specialist Services Committee (NSSC) and the National Planning Executive Group, before being passed to the Regional Planning Groups to work with the Chief Dental Officer to implement recommendations. The Board noted that the review had been unable to source robust activity data and that there was no clear model proposed for Oral Medicine services in Scotland. There remain challenges in the East of Scotland with a single handed Oral Medicine Consultant in Lothian. J McClean confirmed that she and the West of Scotland Regional Planning Director had met with a colleague from the Chief Dental Officers (CDO) office to discuss the Reviews recommendations and to seek views on the next steps, however following discussion it is understood there are not yet plans in place to take this forward. J McClean suggested that given some of the issues highlighted, there may be an opportunity to address some of these at a national level, i.e. securing robust data on activity and future demand, training and education issues. Following discussion, it was agreed that this should be an agenda item at the next Implementation Leads meeting to ascertain the views of colleagues from NES and the West and North Regions.

TD/JMcC

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17. Update from NSD including National Planning Board Update F Murphy introduced the previously circulated Quarterly Update paper from NSD for information and noting. She advised that further communication will be issued to Board Chief Executives on the recent decisions relating to TAVI provision in Scotland.

18. National Pharmacy Aseptic Dispensing (NPAD) Programme National CIVAS+ Workshop - Flash Report – For Noting J McClean spoke to a previously circulated Flash Report from the National Pharmacy Aseptic Dispensing (NPAD) Programme National CIVAS+ Workshop and confirmed that work across the region was progressing. As previously agreed Directors of Pharmacy are leading on this work for the Region with reporting through the RCAG as well as ERPB.

19. Update from Boards There were no additional issues discussed under this item

20. Date, Time and Venue of Next Meeting: Programme Board: Friday 16 th August 2019 at 11.30am, SHSC with preceding RCAG at 10.30am – 11.30am

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Fife Partnership Board: Chair and Committee Comments

FIFE PARTNERSHIP BOARD

(Meeting on 13 August 2019)

No issues were raised for escalation to the Board

Fife Partnership Board: C

hair and Com

mittee C

omm

ents

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2019.F.P.B.28

FIFE PARTNERSHIP BOARD

MINUTE OF MEETING HELD ON TUESDAY 13TH AUGUST, 2019 FIFE COUNCIL, GLENROTHES - 10.00 A.M. – 11.40 A.M.

PRESENT: Councillors David Alexander, David Ross (Chair) and Dave Dempsey; Steve Grimmond, Chief Executive, Fife Council; Dona Milne, Director of Public Health, Josie Murray, Consultant, NHS Fife; Nicky Connor, Interim Director of Fife Health & Social Care Partnership; David Crawford, Department of Work and Pensions; Jim Grieve, Interim Partnership Director, SEStran; Roddie Keith, Local Senior Officer, Scottish Fire and Rescue Service; Shirley Laing, Deputy Director, Scottish Government; Derek McEwan, Chief Superintendent, Police Scotland; Lynne Cooper, Scottish Enterprise and Kenny Murphy, Chief Executive, Fife Voluntary Action

ATTENDING: Michael Enston, Executive Director – Communities, Alan Paul, Senior

Manager, Property Services, Louise Playford, Service Manager (Asset Management and Development), Tim Kendrick, Community Manager (Development), Sharon Murphy, Community Planning Manager, Pamela Pate, Corporate Development Officer, Chloe Grayson, Development Officer and Lesley Robb, Lead Officer - Committee Services, Fife Council.

APOLOGIES FOR ABSENCE: Paul Hawkins, Chief Executive, NHS Fife; Tricia Marwick, Chair NHS Fife

Board; Elaine Morrison, Head of Partnerships East Region, Scottish Enterprise and Sue Reekie, Chief Operating Officer, Fife College.

60. MINUTES The Board considered the minute of meeting of the Fife Partnership Board of 14th May,

2019. Decision The Board:-

(1) approved the minute; and

(2) noted that arising from the minute, with reference to para. 56, Plan For Fife – One Year On, the Director of Public Health advised that further work was ongoing to develop a number of high level indices for the State of Fife Indices and an update report would be submitted to a future meeting of the Board.

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2019.F.P.B.29

61. COMMUNITY LED SERVICES THEMATIC REPORT

The Board considered a report presenting the annual progress on the Plan for Fife, Community Led Services Outcome Theme. A discussion document was previously presented to the Fife Partnership Board on 14th May 2019. This had been updated following further consideration by partners and partnership groups. Decision The Board:-

(1) considered and commented on the content of the report; and

(2) considered how their organisation and/or sector could best contribute to the planned actions.

62. THRIVING PLACES THEMATIC REPORT– DISCUSSION DOCUMENT

The Board considered a joint report by the Superintendent (Operations) Police Scotland, Executive Director, Communities and Executive Director, Enterprise and Environment, Fife Council presenting an initial discussion document on the delivery of the Thriving Places outcome theme within the Plan for Fife. Decision The Board:- (1) considered and commented on the content of the initial discussion document; (2) would seek further comments and inputs from their organisations and/or sector

on work to deliver the Thriving Places outcome theme; and (3) provided further input to the outcome theme report, which will be considered by

the Board at its meeting on 19th November 2019.

63. LOCAL COMMUNITY PLANS

The Board considered a report by Executive Director, Communities, Fife Council providing an update on the development of local community plans across Fife’s seven local community planning areas and an update on progress to date with the production of neighbourhood plans. Decision/

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2019.F.P.B.30

Decision The Board:-

(1) noted that all seven local community plans had been finalised and approved by the relevant area committee;

(2) noted that neighbourhood plans were being developed in conjunction with local communities over a three-year period; and

(3) would help to ensure that partner organisations contribute to the delivery of local community plan priorities.

64. FIFE PARTNERSHIP AGREEMENT

The Board considered a report by Community Manager (Development), Fife Council presenting an updated Fife Partnership Agreement, which reflected changes in governance arrangements, in line with the Community Empowerment (Scotland) Act 2015. Decision The Board approved the updated Fife Partnership Agreement.

65. PARTNERSHIP ASSET STRATEGY

The Board considered a report by the Senior Manager (Property Services), Fife Council providing an update of the work across the Partnership around shared use of assets and identifying opportunities to make better use of Partnership members collective resources to achieve Partnership goals and ambitions. The report requested members agreement to the formation of an Assets sub-committee and associated terms of reference to progress the work. Decision The Board:- (1) noted the ongoing work in support of shared use of assets across the

Partnership;

(2) reviewed the terms of reference for the newly formed Assets sub-committee;

(3) agreed representation of the Assets sub-committee;

(4) requested that the first meeting of the Assets sub-committee was in the form of a workshop to explore further opportunities for asset sharing; and

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2019.F.P.B.31

(5) agreed to appoint Roddie Keith, Scottish Fire and Rescue Service as chair of the sub-committee.

66. DIRECTOR OF PUBLIC HEALTH ANNUAL REPORT The Board considered a report by Director of Public Health, NHS Fife providing an overview of Fife’s population and the factors that contribute to their health and wellbeing. The report also provided highlights of some of the work undertaken by partners to address inequalities and improve health and wellbeing, in terms of the six Public Health Priorities for Scotland and the Plan for Fife. Decision The Board;-

(1) noted the contents of the report; and

(2) agreed to explore the opportunity to build on the work and strengthen links with Partnership Members, in recognition of the links between Public Health and Community Planning.

67. FIFE PARTNERSHIP BOARD – PROPOSED FORWARD WORK PROGRAMME The Board:-

(1) considered the Proposed Forward Work Programme; and

(2) agreed that following the announcement of the reopening of the Levenmouth Rail Link, further work would be required to develop a Levenmouth Blue Print, including Active Travel and noted an update report would be submitted to a future meeting of the Board.

68. NEXT MEETING

The next meeting will be held on Tuesday 19th November, 2019 at 10.00 am and the venue will be Enterprise Events Hub Fife, 1 Falkland Gate, Glenrothes, KY7 5NS.

______________

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Integrated Performance Report

Produced in July 2019

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2

Contents

Section A Overview and Executive SummaryOverview 3Performance Summary Table 4Performance Data Sources 5Executive Summary 6Performance Assessment Methodology 11

Section B:1 Clinical GovernanceExecutive Summary 13Performance Summary Table 14HAI/SABS Drill-down 15Complaints Drill-down 16

Section B:2 Finance, Performance & ResourcesExecutive Summary 18Performance Summary Table 22Performance Drill-down

NHS Acute Division4-Hour Emergency Access 23Cancer 62 Day Referral-to-Treatment 24Patient Treatment Time Guarantee 25Diagnostics Waiting Times 2618 Weeks Referral-to-Treatment 27

Health & Social Care PartnershipDelayed Discharge 28Smoking Cessation 29Child and Adolescent Mental Health Service (CAMHS) Waiting Times 30Psychological Therapies Waiting Times 31

Financial Position 32Capital Programme 43

Section B:3 Staff GovernanceExecutive Summary 47Performance Summary Table 49Sickness Absence Drill-down 50

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3

Section A: Introduction

OverviewThe purpose of the Integrated Performance Report (IPR) is to provide assurance on NHS Fife’s performance relating to National Standards, local priorities and significant risks.

The IPR comprises 4 sections:

Section A Introduction Section B:1 Clinical Governance Section B:2 Finance, Performance & Resources Section B:3 Staff Governance

The section margins are colour-coded to match those identified in the Corporate Performance Reporting, Governance Committees Responsibilities Matrix.

A summary report of the IPR is produced for the NHS Fife Board.

The IPR is undergoing a major refresh for 2019/20. Part of this exercise is the merging of the IPR and key sections of the current Quality Report, forming the Integrated Performance and Quality Report, IPQR.

The report has to be ratified by the NHS Fife Board before it is formally adopted, so we are continuing with the ‘old’ IPR until that time. The drill-down part of the IPR will not be updated as far as Improvement Actions are concerned during this period.

Overview

and Executive Summ

ary

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4

Performance Summary

Current Period Current Performance

Previous Period

Previous Performance

Direction of Travel Period Performance Rank Scotland

GR

EE

N

HAI - C Diff Safe 0.32 12 months to May 2019 0.20 12 months to

Apr 2019 0.20 ↔ 0.15 y/e Dec 2018 0.19 4th 0.27

Complaints (Stage 1 Closure Rate in Month) Person-centred 80.0% May 2019 64.0% Apr 2019 85.5% ↓ 74.8%

Complaints (Stage 2 Closure Rate in Month) Person-centred 75.0% May 2019 62.1% Apr 2019 47.6% ↑ 56.0%

HAI - SABs Safe 0.24 12 months to May 2019 0.40 12 months to

Apr 2019 0.41 ↑ 0.30 y/e Dec 2018 0.43 10th 0.33

IVF Treatment Waiting Times Person-centred 90.0% May 2019 100.0% Apr 2019 100.0% ↔ 100.0%

Outpatients Waiting Times Clinically Effective 95.0% May 2019 96.4% Apr 2019 98.0% ↓ N/A End of March 98.2% 1st 75.0%

Antenatal Access Clinically Effective 80.0% Mar 2019 90.9% Feb 2019 86.1% ↑ N/A

Drugs & Alcohol Treatment Waiting Times Clinically Effective 90.0% Mar 2019 95.0% Feb 2019 94.1% ↑ N/A q/e Mar 2019 92.6% 8th 93.2%

Alcohol Brief Interventions Clinically Effective 4,187 FY 2018/19 4,914 Apr to Dec 2018 2,873 ↑ N/A

4-Hour Emergency Access * Clinically Effective 95.0% May 2019 94.5% Apr 2019 94.7% ↓ 94.6% y/e Mar 2019 95.2% 3rd 91.2%

Cancer 31-Day DTT Clinically Effective 95.0% May 2019 93.3% Apr 2019 89.9% ↑ 91.7% q/e Mar 2019 95.2% 6th 94.9%

Diagnostics Waiting Times Clinically Effective 100.0% May 2019 99.5% Apr 2019 99.7% ↓ N/A End of March 99.9% 1st 84.0%

Dementia Post-Diagnostic Support Person-centred 100.0% 2017/18 85.3% 2016/17 88.2% ↓ N/A

Dementia Referrals Person-centred 1,327 Apr to Dec 2018 586 Apr to Sep

2018 406 ↓ 586

Cancer 62-Day RTT Clinically Effective 95.0% May 2019 86.6% Apr 2019 84.4% ↑ 85.4% q/e Mar 2019 84.8% 6th 81.4%

18 Weeks RTT Clinically Effective 90.0% May 2019 82.6% Apr 2019 80.9% ↑ 81.8% Mar-19 76.9% 7th 77.3%

Patient TTG Person-centred 100.0% May 2019 85.7% Apr 2019 87.6% ↓ 86.6% q/e Mar 2019 69.1% 6th 68.4%

Detect Cancer Early Clinically Effective 29.0% 2 years to Dec 18 25.5% 2 years to Sep

18 24.9% ↑ 27.6%

Delayed Discharge (Delays > 2 Weeks) Person-centred 0 30th May Census 37 25th Apr

Census 41 ↑ N/A 28th Mar Census 11.58 7th 9.60

Smoking Cessation Clinically Effective 490 Apr 18 to Feb 19 390 Apr 18 to Jan

19 330 ↑ 390 q/e Dec 2018 59.2% 5th 63.6%

CAMHS Waiting Times Clinically Effective 90.0% May 2019 66.7% Apr 2019 72.3% ↓ 68.9% q/e Mar 2019 72.8% 7th 73.6%

Psychological Therapies Waiting Times Clinically Effective 90.0% May 2019 66.2% Apr 2019 66.1% ↑ 66.1% q/e Mar 2019 67.6% 10th 77.4%

Sta

ff G

over

nanc

e

RE

D

Sickness Absence Clinically Effective 4.00% May 2019 5.66% Apr 2019 5.42% ↓ 5.54%

* The 4-Hour Emergency Access performance in May was 94.5% (all A&E and MIU sites) and 92.4% (VHK A&E, only)

DefinitionPerformance improved from previousPerformance worsened from previousPerformance unchanged from previous

StatusGREENAMBER

RED

DefinitionPerformance meets or exceeds the required Standard (or is on schedule to meet its annual Target)Performance is behind (but within 5% of) the Standard or Delivery TrajectoryPerformance is more than 5% behind the Standard or Delivery Trajectory

Sec

tion

RA

G

Only published annually: NHS Fife had the 4th highest sickness absence rate in FY 2018-19 (Fife performance 5.51%, Scotland performance 5.39%)

Treatment provided by Regional Centres so no comparison applicable

Standard Quality Aim Target for 2018-19

National Comparison (with other 10 Mainland Boards)FY 2019-20 to Date

Only published annually: NHS Fife was 6th for FY 2016/17

Performance Data

Direction of Travel↑

↓

↔Fi

nanc

e, P

erfo

rman

ce a

nd R

esou

rces

Clin

ical

Gov

eran

ce

RE

DA

MB

ER

Only published annually: NHS Fife was 7th for FY 2017-18

GR

EE

N

Only published annually: NHS Fife was 3rd for FY 2016/17

Only published annually: NHS Fife was 6th for 2-year period 2016 and 2017




RE

D

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5

Performance Data SourcesLDP Target / Standard / Local Target LMI / Published LMI Source Period Covered by

Published DataTime Lag in

Published DataHospital-Acquired Infection: Sabs LMI Infection Control Quarter 3 monthsHospital-Acquired Infection: C Diff LMI Infection Control Quarter 3 months

Complaints LMI DATIX (Business Objects Report) Year 6 monthsIVF Treatment Waiting Times LMI ISD Management Report Quarter 2 months

18 Weeks RTT LMI Information Services Quarter 2 months4-Hour Emergency Access LMI Information Services Month 1 month

Delayed Discharge Published (ISD) N/A Month 1 monthAlcohol Brief Interventions LMI Addiction Services Year 3 months

Drugs & Alcohol Waiting Times Published (ISD) N/A Quarter 3 monthsCAMHS Waiting Times LMI Mental Health Quarter 2 months

Psychological Therapies Waiting Times LMI Information Services Quarter 2 monthsDementia: Referrals LMI ISD Management Report Quarter 9 months

Dementia: Post-Diagnosis Support LMI ISD Management Report Quarter 9 monthsSmoking Cessation LMI Smoking Cessation Database Year 6 monthsSickness Absence LMI HR (SWISS) Year 3 months

Detect Cancer Early LMI Cancer Services 2 Years 7 monthsAntenatal Access LMI ISD Discovery N/A N/A

Cancer Waiting Times: 62-Day RTT LMI Cancer Services Quarter 3 monthsCancer Waiting Times: 31-Day DTT LMI Cancer Services Quarter 3 months

Patient TTG LMI Information Services Quarter 2 monthsOutpatient Waiting Times LMI Information Services Final Month of Quarter 2 months

Diagnostics Waiting > 6 Weeks LMI Information Services Final Month of Quarter 2 months

GREEN Local Management Information (LMI) and Published data almost always agreeAMBER LMI and Published data may have minor (insignificant) differencesRED LMI and Published data will be different due to fluidity of Patient Tracking System

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6

Executive SummaryAt each meeting, the Standing Committees of the NHS Fife Board consider targets and Standards specific to their area of remit.

This section of the IPR provides a summary of performance Standards and targets that have not been met, the challenges faced in achieving them and potential solutions. Topics are grouped under the heading of the Committee responsible for scrutiny of performance.

CLINICAL GOVERNANCE

Hospital Acquired Infection (HAI) - Staphylococcus aureus Bacteraemia (SAB) target: We will achieve a maximum rate of SAB (including MRSA) of 0.24.

During May, there were 5 Staphylococcus aureus Bacteraemias (SAB) across Fife, 3 of which were non-hospital acquired, with 2 occurring in VHK. The number of infections in the month was 4 less than in May 2018, so the annual infection rate fell to 0.40.

Assessment: There continues to be an enhanced focus on PVCs with weekly reports issued to Senior Charge Nurses when their ward has fails to achieve 90% for all PVCs being removed prior to the 72hr breach. Due to these recent results, Ward 44 has established a quality improvement group to look at improving compliance with PVC management in their ward. The ASD will also look at resurrecting the enhanced focus on PVC management and avoidable harm across the entire directorate to support an increased awareness of the risks of vascular access device use.

Complaints local target: At least 80% of Stage 1 complaints are completed within 5 working days of receipt; at least 75% of Stage 2 complaints are completed within 20 working days; 100% of Stage 2 complaints are acknowledged in writing within 3 working days.

Performance on closure of Stage 1 Complaints within time fell sharply in May, with only 48 out of 75 (64%) being closed within the target timescale The Stage 2 performance (62.1%) continued to recover, and all 29 complaints were acknowledged within 3 working days.

Assessment: The internal complaints-handling process continues to be monitored across Acute and Health and Social Care Partnership. The Patient Relations Team continues to review the quality of information within the investigation statements and the initial draft responses produced by the Patient Relation Officers. A daily review of open cases is also carried out to ensure timescales and deadline issues are escalated.

FINANCE, PERFORMANCE & RESOURCES

Acute Services Division

4-Hour Emergency Access target: At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

In May, 94.5% of patients attending A&E or MIU sites in NHS Fife waited less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

Assessment: Whilst the VHK has had increased patient levels in comparison to previous years, the % of patients treated within the target time continues to be in line with the Standard, and above the national average performance.

There has been an increasing number of patients waiting longer than 4 hours for admission to the hospital, directly linked to hospital pressure in terms of bed capacity, an increase in respiratory infections, as well as the number of frail people being admitted to hospital.

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The Unscheduled Care Improvement Coordinator commenced post in May which has allowed for in depth analysis of attendances and performance which is feeding into the PerformED working group.

Cancer 62 day Referral to Treatment target: At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days.

In May, 86.6% of patients (71 out of 82) started treatment within 62 days of an urgent suspected cancer referral, a small improvement in comparison to April. Breaches were spread across 5 specialties.

Assessment: There are continuing significant issues throughout the prostate cancer pathway; MRI before TRUS, delays to reviewing results, waits for post MDT OPA and histopathology and radiology turnaround times along with waits to surgery for renal and bladder patients. No significant delays were noted within the breast, lung and cervical pathways and breaches are attributed to the number of steps involved in the pathway.

A local Urology Improvement Group has been set up with focus on the prostate pathway. Waits to TRUS and MRI are reduced. A national SWLG for urology and colorectal to support improvement in performance and the development of a downgrading framework to ensure optimum referral and adherance to the Scottish Referral Guidelines are currently under way.

Patient Treatment Time Guarantee target: We will ensure that all eligible patients receive Inpatient or Day-case treatment within 12 weeks of such treatment being agreed.

In May, 85.7% of patients were treated within 12 weeks, slightly less than in April. The Trauma & Orthopaedics and Urology specialties recorded the highest numbers of breaches.

Assessment: Achieving the target continues to be a significant challenge for Urology due to demand exceeding available capacity and difficulties in securing sufficient levels of additional capacity to meet the gap.

Resources have been secured from the Scottish Government to deliver the Waiting Times Improvement plan for 2019/20, however there continue to be issues relating to the availability of capacity in the independent sector and staffing both locum, and within our own staff groups to undertake additional in house waiting list initiatives.

Diagnostics Waiting Times target: No patient will wait more than 6 weeks to receive one of the 8 Key Diagnostics Tests.

At the end of May, 19 patients out of 4,370 patients on the waiting list had waited more than 6 weeks, with 14 breaches being for Endoscopy tests and 5 for Imaging (MRI and CT).

Assessment: Resources have been secured from the Scottish Government to deliver the Waiting Times Improvement plan for 2019/20 and this is enabling the improvement in performance achieved in 2018/19 to be sustained in Q1 2019/20. However, there continue to be challenges in securing sufficient reporting capacity in Radiology with priority being given to reports for Cancer patients.

18 Weeks Referral-to-Treatment target: 90% of planned/elective patients to commence treatment within 18 weeks of referral.

Performance against the 18 Weeks RTT Standard improved again in May, to 82.6%, the highest since June 2017.

Assessment: The 18 weeks performance has improved in Quarter 1 2019/20 due to the improved performance in TTG and sustained outpatient and diagnostic position.

Health & Social Care Partnership

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Delayed Discharge target: No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge.

The overall number of patients in delay at the 30th May Census (excluding Code 9 patients – Adults with Incapacity) was 73, 8 more than at the April Census. Of these, 37 patients had been in delay for more than 14 days.

Assessment: The Partnership continues to rigorously monitor patient delays through a daily and weekly focus on transfers of care, flow and resources. Improvement actions have focused on earlier supported discharge and earlier transfers from our acute setting to community models of care. Close working with acute care continues in order to ensure available community resources are focused on the part of the system where most benefit can be achieved in terms of delays and flow.

Smoking Cessation target: In FY 2018/19, we will deliver a minimum of 490 post 12 weeks smoking quits in the 40% most deprived areas of Fife.

Data from the National Smoking Cessation Database shows that 390 people who attempted to stop smoking during the first 11 months of the FY (87% of the planned number at this point) had successfully quit at 12 weeks.

As expected, the number of successful quits in the post-Christmas period has increased significantly. Provisional year-end figures, to be confirmed next month, show an achievement of 451 quits, 8% below the target.

Assessment: An additional clinic in Philip Hall in Kirkcaldy has been established, and awareness sessions are being undertaken in the Mercat, Kirkcaldy during June and July to compensate for the mobile unit being out of action.

A link has been established with the Respiratory Outpatient clinic Consultant to support direct dispense of Champix, while monthly meetings have been set up to implement the routine access of NRT for patients within the Acute Services Division.

Child and Adolescent Mental Health Services (CAMHS) target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services (note: performance is measured on a 3 month average basis).

During May, 94 out of 141 children and young people (66.7%) who started treatment did so within 18 weeks of referral. Performance has dropped by 13% since March, and there has been little change in the size of the waiting list.

Assessment: Referrals to CAMHS continue to be significant. Ongoing initiatives around robust screening, positive signposting and engagement with partner agencies to increase the capacity of universal service providers has allowed specialist CAMHS to focus their provision on children and young people with complex, serious and persistent mental health needs.

Additional Primary Mental Health Workers, which will place mental health professionals alongside GPs, have been recruited as part of the SG Action 15 funding. This will provide early intervention, improve initial assessments and increase effectiveness of signposting thus reducing the overall burden on both GPs and the Tier 3 CAMH service.

Therapeutic Group programme has been established providing a rolling provision in West Fife, targeting those who have waited longest. Benefits of group provision allow larger numbers of children and young people to be supported by smaller numbers of staff.

Psychological Therapies Waiting Times target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for psychological therapies (note: performance is measured on a 3 month average basis).

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During May, 313 out of 473 patients (66.2%) who started treatment did so within 18 weeks of referral. This was virtually unchanged from the performance in April. The waiting list size is on an upward trend, as the volume of referrals continues to impact on existing capacity.

Assessment: Services providing brief therapies for people with less complex needs are meeting the RTT 100%; overall performance reflects the longer waits experienced by people with complex needs who require longer term treatment. We continue to address the needs of this population through service redesign with support from the ISD/HIS Mental Health Access Improvement Support Team.

The establishment of Community Mental Health Teams across Fife is progressing well and can be expected to contribute to the reduction of waiting times for the most complex patients once a multi-disciplinary team case management approach is fully operational.

In November 2018, the ‘AT Fife’ website was launched by the Psychology Service to facilitate self-referrals to low intensity therapy groups. This initiative will increase access to Psychological Therapies (PT) and reduce waiting times for people with mild-moderate difficulties. We anticipate that this new pathway will also free up capacity in specialist services to offer PT to people with more complex needs.

Financial Performance

Financial Position

The revenue position for the 3 months to 30 June reflects an overspend of £3.130m. This comprises an overspend of £3.301m on Health Board retained budgets; and an underspend of £0.171m aligned to the Health budgets delegated to the Integration Joint Board (IJB). The key financial challenge in this reported position is the overspend of £3.954m within the Acute Services Division (of which £1.275m overspend relates to a number of Acute services budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but remain managed by the NHS Board). The key driver of the overspend is the shortfall in the level of savings identified and delivered.

Through discussion with the Chief Executive, Chief Operating Officer and other members of the Acute Division Senior Management team, it is recognised that further work is required to ensure that savings are identified and deliverable, in support of the statutory requirement to break even. A need has been identified for immediate external expertise to robustly support and challenge the team to design and implement an effective savings programme, with a strong focus on what/when/how much in terms of specific savings proposals. Through use of a national framework contract Deloitte LLP have been engaged to work with the Acute Division Management Team on this savings programme over a 12 week period, effective from 15 July 2019. A report will be provided to the Board, through the Finance, Performance & Resources Committee, on the progress and outcome of this work.

It is important to note that at this point there has been no IJB risk share factored into the position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.1m to the in year overspend position (i.e. 3/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £4.2m. Following a recent meeting between the Cabinet Secretary for Health and the Co-Leaders of Fife Council, we are now in receipt of a letter from the Cabinet Secretary with regards the overall financial position for the IJB. We are in discussion with colleagues in the Health Finance Directorate to establish any specific direction from this letter and resultant financial consequences for the NHS Fife Board.

In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £3.8m

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to a mid range overspend of £8.1m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.68m (i.e. 72% of the £6.5m gap), nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £8.5m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. This is a draft position and will be updated following further discussion with the SGHSCD Finance team.

Capital Programme

The total Capital Resource Limit for 2019/20 is £7.394m. The capital position for the 3 months to June shows investment of £0.422m, equivalent to 5.7% of the total allocation. Plans are in place to ensure the Capital Resource Limit is utilised in full.

STAFF GOVERNANCE

Sickness Absence HEAT Standard: We will achieve and sustain a sickness absence rate of no more than 4%, measured on a rolling 12-month basis

The sickness absence rate in May was 5.66%, 0.24% higher than in April and 0.66% higher than in May 2018.

Assessment: Various improvement initiatives in the past year saw an improvement in the sickness absence rate in FY 2018/19, being 0.25% lower than FY 2017/18.

iMatter local target: We will achieve a year on year improvement in our Employee Engagement Index (EEI) score by completing at least 80% of team action plans resulting from the iMatter staff survey.

Assessment: A proactive plan has been developed to promote the 2019 iMatter cycle to support improvements in the engagement and action planning components. The process started in April, and reporting of progress/performance will be considered when the IPQR is in use.

TURAS local target: At least 80% of staff will complete an annual review with their Line Managers via the TURAS system

Assessment: Reporting of progress/performance in relation to the recovery plan agreed with EDG will be considered when the IPQR is in use. The improvement trajectory for all divisions/directorates is to achieve 80% by the end of October.

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Performance Assessment MethodologyThe Scottish Government requires Health Boards to attain a defined level of performance against a number of measures (known as Standards). NHS Fife also scrutinises its performance against a number of local targets.

Targets and Standards are grouped into three categories; those where performance consistently achieves the required target (i.e. ‘on track’), those where performance is consistently close to the Standard, and on occasion achieves it (i.e. ‘variable’) and those generally ‘not met’.

1 Targets and Standards; On TrackNHS Fife continues to meet or perform ahead of the following Standards:

In-Vitro Fertilisation (IVF) target: At least 90% of eligible patients to commence IVF treatment within 12 months of referral from Secondary CareHospital Acquired Infection (HAI), Clostridioides Difficile (C-Diff) target: We will achieve a maximum rate of C- Diff infection in the over 15 year olds of 0.32Antenatal Access target: At least 80% of pregnant women in each SIMD quintile will book for antenatal care by the 12th week of gestationAlcohol Brief Interventions target: In FY 2018/19, we will deliver a minimum of 4,187 interventions, at least 80% of which will be in priority settingsDuring FY 2018/19, NHS Fife delivered a total of 4,914 interventions in priority and wider settings. The % delivered in priority settings (i.e. Primary Care, A&E and Antenatal) was less than the notional 80% sub-target, and plans are in place to improve on this in FY 2019/20.Drug and Alcohol Waiting Times target: At least 90% of clients will wait no longer than 3 weeks from referral to treatment

2 Targets and Standards; Variable PerformanceNHS Fife has generally met or been close to the following Standards for a sustained period however performance varies from month-to-month. If performance drops significantly below the Standard for 3 consecutive months, a drill-down process is instigated.

Cancer Waiting Times: 31 Day Decision to Treat target: We will treat at least 95% of cancer patients within 31 days of decision to treatIn May, 93.3% of patients (111 out of 119) started treatment within 31 days, an improvement of 3.4% compared to April, but remaining below the Standard. The breaches were recorded in the Ovarian (1) and Urology (7) specialties.Outpatients Waiting Times target: 95% of patients to wait no longer than 12 weeks from referral to a first outpatient appointmentAt the end of May, 96.4% of patients waiting for their first outpatient appointment had waited no more than 12 weeks. While this was slightly less than in the previous 2 months, performance remained above the Standard. The specialty recording most breaches was Urology.Sustaining the performance in outpatients will be a challenge due to demand exceeding available capacity in a number of specialities. Resources have been secured from the Scottish Government to deliver the Waiting Times Improvement plan for 2019/20, however, there continue to be issues relating to staffing both locum, and within our own staff groups to undertake additional in house waiting list initiatives.Detect Cancer Early target: At least 29% of cancer patients will be diagnosed and treated in the first stage of breast, colorectal and lung cancerNHS Fife’s performance fell during 2017, with published information showing that 25% of patients were diagnosed at Stage 1 during the 2-year period from 1st January 2016 to 31st

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December 2017, the 6th highest of the 11 Mainland Health Boards. In the previous 2-year period, NHS Fife recorded a performance of 29.5%, the best in Scotland.Local figures covering up to the end of December 2018 show that the running 2-year performance has improved slightly (to 25.5%), with the figures for Q1 to Q3 of FY 2018/19 showing a performance of 27.6%.Dementia Care target: Deliver expected rates of diagnosis and ensure that all people newly diagnosed will have a minimum of a year’s worth of post-diagnostic support (PDS) coordinated by a link worker. Management information covering the period up to the end of FY 2018/19 Q3 has been made available to Health Boards, and covers Referral Rates and Completion of Post-Diagnostic Support, as well as illustrating relative waiting times. The first two measures are formal AOP Standards.During 2017/18, 711 people were referred to the Dementia PDS in NHS Fife. This is 55% of the notional target (1,289), and NHS Fife achieved the 2nd highest % of all Mainland Health Boards. In the absence of a formal target, Health Boards are looking for this % to increase year-on-year, taking into account that the notional target will increase each year to reflect the growth in the elderly population. In reality, Fife (along with most Health Boards) has seen this % reduce in 2017/18.Data for FY 2018/19 shows that 586 referrals had been made in the first 9 months of the year. This equates to 44% of the notional target (1,327), but if the rate of referral continues during Q4, the whole year achievement will be an improvement on 2017/18. For Post-Diagnostic Support, the situation is less clear due to the nature of the measure, which requires that no assessment is possible until after the 1-year support period is complete. For 2017/18, NHS Fife has so far recorded a performance of 85.3%, above the Scottish average of 83.0%; both figures, can be expected to increase by the time we have the full-year figures (in June).For 2016/17, Fife achieved 88.2% against a Scottish average of 83.5%.We have subjectively assigned an AMBER RAG status to both measures.It is worth recording that during 2017/18, NHS Fife had the highest % of all Mainland Health Boards of patients who waited less than 3 months for contact with a link worker following referral. The Scottish average was 61.9%, Fife achieved 96.2%.

3 Targets and Standards; Not Being Met - Drill-DownFor each of the Standards and targets not being met (or where performance is high-profile and key to the delivery of safe patient care), a more in-depth report is provided and is structured as follows:

A summary box, describing the measure, current performance and the latest published performance and status (Scotland)

A trend chart covering the last 12 months of local performance data

A chart showing the Recovery Trajectory (as per the Annual Operational Plan), where appropriate

A past performance box showing the last 3 data points (previous to the ‘current’ position)

An improvements/benefits box, outlining key actions being taken, expected benefits and current status.

Drill downs are located in the Clinical Governance, Finance, Performance & Resources and Staff Governance sections.

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Section B: 1 Clinical Governance

Executive Summary

Hospital Acquired Infection (HAI) - Staphylococcus aureus Bacteraemia (SAB) target: We will achieve a maximum rate of SAB (including MRSA) of 0.24.

During May, there were 5 Staphylococcus aureus Bacteraemias (SAB) across Fife, 3 of which were non-hospital acquired, with 2 occurring in VHK. The number of infections in the month was 4 less than in May 2018, so the annual infection rate fell to 0.40.

Assessment: There continues to be an enhanced focus on PVCs with weekly reports issued to Senior Charge Nurses when their ward has fails to achieve 90% for all PVCs being removed prior to the 72hr breach. Due to these recent results, Ward 44 has established a quality improvement group to look at improving compliance with PVC management in their ward. The ASD will also look at resurrecting the enhanced focus on PVC management and avoidable harm across the entire directorate to support an increased awareness of the risks of vascular access device use.

Complaints local target: At least 80% of Stage 1 complaints are completed within 5 working days of receipt; at least 75% of Stage 2 complaints are completed within 20 working days; 100% of Stage 2 complaints are acknowledged in writing within 3 working days.

Performance on closure of Stage 1 Complaints within time fell sharply in May, with only 48 out of 75 (64%) being closed within the target timescale The Stage 2 performance (62.1%) continued to recover, and all 29 complaints were acknowledged within 3 working days.

Assessment: The internal complaints-handling process continues to be monitored across Acute and Health and Social Care Partnership. The Patient Relations Team continues to review the quality of information within the investigation statements and the initial draft responses produced by the Patient Relation Officers. A daily review of open cases is also carried out to ensure timescales and deadline issues are escalated.

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Performance Summary


Previous Period



GR

EE

N

HAI - C Diff Safe 0.32 12 months to May 2019 0.20 12 months to

Apr 2019 0.20 ↔ 0.15 y/e Dec 2018 0.19 4th 0.27

Complaints (Stage 1 Closure Rate in Month) Person-centred 80.0% May 2019 64.0% Apr 2019 85.5% ↓ 74.8%

Complaints (Stage 2 Closure Rate in Month) Person-centred 75.0% May 2019 62.1% Apr 2019 47.6% ↑ 56.0%

HAI - SABs Safe 0.24 12 months to May 2019 0.40 12 months to

Apr 2019 0.41 ↑ 0.30 y/e Dec 2018 0.43 10th 0.33

Clin

ical

Gov

eran

ce



RE

D

Sec

tion

RA

G



Performance Data


↓

↔


StatusGREENAMBER

RED


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SAB

9 10 12 10 9 5 13 8 7 10 7 8 5

0

2

4

6

8

10

12

14

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

# of

Cas

es

Infe

ctio

n ra

te (p

er 1

,000

AO

BD)

12 Months Ending

SABNumber of Cases Standard NHS Fife Scotland Average (HPS)

Mar 2018 to Feb 2019 Apr 2018 to Mar 2019 May 2018 to Apr 2019Previous 3 Reporting Periods 0.42 ↔ 0.42 ↔ 0.41 ↑

Current Issues Vascular Access Device (VAD) SABContext Never met Standard

2nd highest infection rate of all Mainland Boards in Calendar Year 2018Change to HAI measures where infections are classed as ‘hospital’ or ‘non-hospital’ depending on their source is anticipated

Measure We will achieve a maximum rate of SAB (including MRSA) of 0.24

Current Performance 0.40 cases per 1,000 acute occupied bed days in period from June 2018 to May 2019

Scotland Performance 0.33 cases per 1,000 acute occupied bed days in Calendar Year 2018

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Complaints

At least 80% of Stage 1 complaints are completed within 5 working days of receipt

Measures(Local Targets)

At least 75% of Stage 2 complaints are completed within 20 working days

Current Performance 64.0% (48 out of 75) Stage 1 complaints closed in May were completed within 5 working days (or 10 working days if extension applicable)62.1% (18 out of 29) Stage 2 complaints closed in May were completed within 20 working days

Scotland Performance Stage 1 Complaints: 74.4% for 2017-18 (data published annually)Stage 2 Complaints: 52.8% for 2017-18 (data published annually)

66 67 57 66 70 80 72 54 66 89 67 76 75

0

10

20

30

40

50

60

70

80

90

100

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Stag

e 1

Com

plai

nts

Clos

ed in

Mon

th

Stag

e 1

Com

plet

ion

Rate

s

Stage 1 Complaints

Stage 1 Complaints Closed Target (Stage 1 Complaints) Stage 1 Completion Rate

38 23 55 44 38 44 35 38 36 30 26 21 29

0

10

20

30

40

50

60

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Stag

e 2

Com

plai

nts

Clos

ed in

Mon

th

Stag

e2 C

ompl

etio

n Ra

tes

Stage 2 ComplaintsStage 2 Complaints Closed Stage 2 Completion Rate

Target (Stage 2 Complaints) Stage 2 Acknowledgement Rate

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February 2019 March 2019 April 201973.0% ↓ 78.8% ↑ 85.1% ↑

Previous 3 Months Stage 1Stage 2 53.3% ↓ 34.6% ↓ 47.6% ↑

Current Issues Stage 2 Complaints: Delays in receiving medical statements continues to affect performance. There has been delay with approval within the Partnership mainly due to additional information being requested to ensure complaint points are addressed fully. Significant sickness absence within PRD has also resulted in a delay with drafting response letters. Absence has also affected the Stage 1 closure rate.

Context During the first quarter of 2019, 53 out of 92 Stage 2 Complaints (58%) were either Fully or Partially Upheld, while 25 (27%) were Not Upheld; for Stage 1 Complaints, 109 out of 222 (49%) were Fully or Partially Upheld while 85 (38%) were Not Upheld

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Section B: 2 Finance, Performance & Resources

Executive SummaryAcute Services Division

4-Hour Emergency Access target: At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

In May, 94.5% of patients attending A&E or MIU sites in NHS Fife waited less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment.

Assessment: Whilst the VHK has had increased patient levels in comparison to previous years, the % of patients treated within the target time continues to be in line with the Standard, and above the national average performance.

There has been an increasing number of patients waiting longer than 4 hours for admission to the hospital, directly linked to hospital pressure in terms of bed capacity, an increase in respiratory infections, as well as the number of frail people being admitted to hospital.

The Unscheduled Care Improvement Coordinator commenced post in May which has allowed for in depth analysis of attendances and performance which is feeding into the PerformED working group.

Cancer 62 day Referral to Treatment target: At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days.

In May, 86.6% of patients (71 out of 82) started treatment within 62 days of an urgent suspected cancer referral, a small improvement in comparison to April. Breaches were spread across 5 specialties.

Assessment: There are continuing significant issues throughout the prostate cancer pathway; MRI before TRUS, delays to reviewing results, waits for post MDT OPA and histopathology and radiology turnaround times along with waits to surgery for renal and bladder patients. No significant delays were noted within the breast, lung and cervical pathways and breaches are attributed to the number of steps involved in the pathway.

A local Urology Improvement Group has been set up with focus on the prostate pathway. Waits to TRUS and MRI are reduced. A national SWLG for urology and colorectal to support improvement in performance and the development of a downgrading framework to ensure optimum referral and adherance to the Scottish Referral Guidelines are currently under way.

Patient Treatment Time Guarantee target: We will ensure that all eligible patients receive Inpatient or Day-case treatment within 12 weeks of such treatment being agreed.

In May, 85.7% of patients were treated within 12 weeks, slightly less than in April. The Trauma & Orthopaedics and Urology specialties recorded the highest numbers of breaches.

Assessment: Achieving the target continues to be a significant challenge for Urology due to demand exceeding available capacity and difficulties in securing sufficient levels of additional capacity to meet the gap.

Resources have been secured from the Scottish Government to deliver the Waiting Times Improvement plan for 2019/20, however there continue to be issues relating to the availability of capacity in the independent sector and staffing both locum, and within our own staff groups to undertake additional in house waiting list initiatives.


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Diagnostics Waiting Times target: No patient will wait more than 6 weeks to receive one of the 8 Key Diagnostics Tests.

At the end of May, 19 patients out of 4,370 patients on the waiting list had waited more than 6 weeks, with 14 breaches being for Endoscopy tests and 5 for Imaging (MRI and CT).

Assessment: Resources have been secured from the Scottish Government to deliver the Waiting Times Improvement plan for 2019/20 and this is enabling the improvement in performance achieved in 2018/19 to be sustained in Q1 2019/20. However, there continue to be challenges in securing sufficient reporting capacity in Radiology with priority being given to reports for Cancer patients.

18 Weeks Referral-to-Treatment target: 90% of planned/elective patients to commence treatment within 18 weeks of referral.

Performance against the 18 Weeks RTT Standard improved again in May, to 82.6%, the highest since June 2017.

Assessment: The 18 weeks performance has improved in Quarter 1 2019/20 due to the improved performance in TTG and sustained outpatient and diagnostic position.

Health & Social Care Partnership

Delayed Discharge target: No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge.

The overall number of patients in delay at the 30th May Census (excluding Code 9 patients – Adults with Incapacity) was 73, 8 more than at the April Census. Of these, 37 patients had been in delay for more than 14 days.

Assessment: The Partnership continues to rigorously monitor patient delays through a daily and weekly focus on transfers of care, flow and resources. Improvement actions have focused on earlier supported discharge and earlier transfers from our acute setting to community models of care. Close working with acute care continues in order to ensure available community resources are focused on the part of the system where most benefit can be achieved in terms of delays and flow.

Smoking Cessation target: In FY 2018/19, we will deliver a minimum of 490 post 12 weeks smoking quits in the 40% most deprived areas of Fife.

Data from the National Smoking Cessation Database shows that 390 people who attempted to stop smoking during the first 11 months of the FY (87% of the planned number at this point) had successfully quit at 12 weeks.

As expected, the number of successful quits in the post-Christmas period has increased significantly. Provisional year-end figures, to be confirmed next month, show an achievement of 451 quits, 8% below the target.

Assessment: An additional clinic in Philip Hall in Kirkcaldy has been established, and awareness sessions are being undertaken in the Mercat, Kirkcaldy during June and July to compensate for the mobile unit being out of action.

A link has been established with the Respiratory Outpatient clinic Consultant to support direct dispense of Champix, while monthly meetings have been set up to implement the routine access of NRT for patients within the Acute Services Division.

Child and Adolescent Mental Health Services (CAMHS) target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services (note: performance is measured on a 3 month average basis).


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During May, 94 out of 141 children and young people (66.7%) who started treatment did so within 18 weeks of referral. Performance has dropped by 13% since March, and there has been little change in the size of the waiting list.

Assessment: Referrals to CAMHS continue to be significant. Ongoing initiatives around robust screening, positive signposting and engagement with partner agencies to increase the capacity of universal service providers has allowed specialist CAMHS to focus their provision on children and young people with complex, serious and persistent mental health needs.

Additional Primary Mental Health Workers, which will place mental health professionals alongside GPs, have been recruited as part of the SG Action 15 funding. This will provide early intervention, improve initial assessments and increase effectiveness of signposting thus reducing the overall burden on both GPs and the Tier 3 CAMH service.

Therapeutic Group programme has been established providing a rolling provision in West Fife, targeting those who have waited longest. Benefits of group provision allow larger numbers of children and young people to be supported by smaller numbers of staff.

Psychological Therapies Waiting Times target: At least 90% of clients will wait no longer than 18 weeks from referral to treatment for psychological therapies (note: performance is measured on a 3 month average basis).

During May, 313 out of 473 patients (66.2%) who started treatment did so within 18 weeks of referral. This was virtually unchanged from the performance in April. The waiting list size is on an upward trend, as the volume of referrals continues to impact on existing capacity.

Assessment: Services providing brief therapies for people with less complex needs are meeting the RTT 100%; overall performance reflects the longer waits experienced by people with complex needs who require longer term treatment. We continue to address the needs of this population through service redesign with support from the ISD/HIS Mental Health Access Improvement Support Team.

The establishment of Community Mental Health Teams across Fife is progressing well and can be expected to contribute to the reduction of waiting times for the most complex patients once a multi-disciplinary team case management approach is fully operational.

In November 2018, the ‘AT Fife’ website was launched by the Psychology Service to facilitate self-referrals to low intensity therapy groups. This initiative will increase access to Psychological Therapies (PT) and reduce waiting times for people with mild-moderate difficulties. We anticipate that this new pathway will also free up capacity in specialist services to offer PT to people with more complex needs.

Financial Performance

Financial Position

The revenue position for the 3 months to 30 June reflects an overspend of £3.130m. This comprises an overspend of £3.301m on Health Board retained budgets; and an underspend of £0.171m aligned to the Health budgets delegated to the Integration Joint Board (IJB). The key financial challenge in this reported position is the overspend of £3.954m within the Acute Services Division (of which £1.275m overspend relates to a number of Acute services budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but remain managed by the NHS Board). The key driver of the overspend is the shortfall in the level of savings identified and delivered.

Through discussion with the Chief Executive, Chief Operating Officer and other members of the Acute Division Senior Management team, it is recognised that further work is required to ensure that savings are identified and deliverable, in support of the statutory requirement to break even. A need has been identified for immediate external expertise to robustly support and challenge the team to design and implement an effective savings programme, with a


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strong focus on what/when/how much in terms of specific savings proposals. Through use of a national framework contract Deloitte LLP have been engaged to work with the Acute Division Management Team on this savings programme over a 12 week period, effective from 15 July 2019. A report will be provided to the Board, through the Finance, Performance & Resources Committee, on the progress and outcome of this work.

It is important to note that at this point there has been no IJB risk share factored into the position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.1m to the in year overspend position (i.e. 3/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £4.2m. Following a recent meeting between the Cabinet Secretary for Health and the Co-Leaders of Fife Council, we are now in receipt of a letter from the Cabinet Secretary with regards the overall financial position for the IJB. We are in discussion with colleagues in the Health Finance Directorate to establish any specific direction from this letter and resultant financial consequences for the NHS Fife Board.

In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £3.8m to a mid range overspend of £8.1m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.68m (i.e. 72% of the £6.5m gap), nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £8.5m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. This is a draft position and will be updated following further discussion with the SGHSCD Finance team.

Capital Programme

The total Capital Resource Limit for 2019/20 is £7.394m. The capital position for the 3 months to June shows investment of £0.422m, equivalent to 5.7% of the total allocation. Plans are in place to ensure the Capital Resource Limit is utilised in full.


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Performance Summary


Previous Period



IVF Treatment Waiting Times Person-centred 90.0% May 2019 100.0% Apr 2019 100.0% ↔ 100.0%

Outpatients Waiting Times Clinically Effective 95.0% May 2019 96.4% Apr 2019 98.0% ↓ N/A End of March 98.2% 1st 75.0%

Antenatal Access Clinically Effective 80.0% Mar 2019 90.9% Feb 2019 86.1% ↑ N/A

Drugs & Alcohol Treatment Waiting Times Clinically Effective 90.0% Mar 2019 95.0% Feb 2019 94.1% ↑ N/A q/e Mar 2019 92.6% 8th 93.2%

Alcohol Brief Interventions Clinically Effective 4,187 FY 2018/19 4,914 Apr to Dec 2018 2,873 ↑ N/A

4-Hour Emergency Access * Clinically Effective 95.0% May 2019 94.5% Apr 2019 94.7% ↓ 94.6% y/e Mar 2019 95.2% 3rd 91.2%

Cancer 31-Day DTT Clinically Effective 95.0% May 2019 93.3% Apr 2019 89.9% ↑ 91.7% q/e Mar 2019 95.2% 6th 94.9%

Diagnostics Waiting Times Clinically Effective 100.0% May 2019 99.5% Apr 2019 99.7% ↓ N/A End of March 99.9% 1st 84.0%

Dementia Post-Diagnostic Support Person-centred 100.0% 2017/18 85.3% 2016/17 88.2% ↓ N/A

Dementia Referrals Person-centred 1,327 Apr to Dec 2018 586 Apr to Sep

2018 406 ↓ 586

Cancer 62-Day RTT Clinically Effective 95.0% May 2019 86.6% Apr 2019 84.4% ↑ 85.4% q/e Mar 2019 84.8% 6th 81.4%

18 Weeks RTT Clinically Effective 90.0% May 2019 82.6% Apr 2019 80.9% ↑ 81.8% Mar-19 76.9% 7th 77.3%

Patient TTG Person-centred 100.0% May 2019 85.7% Apr 2019 87.6% ↓ 86.6% q/e Mar 2019 69.1% 6th 68.4%

Detect Cancer Early Clinically Effective 29.0% 2 years to Dec 18 25.5% 2 years to Sep

18 24.9% ↑ 27.6%

Delayed Discharge (Delays > 2 Weeks) Person-centred 0 30th May Census 37 25th Apr

Census 41 ↑ N/A 28th Mar Census 11.58 7th 9.60

Smoking Cessation Clinically Effective 490 Apr 18 to Feb 19 390 Apr 18 to Jan

19 330 ↑ 390 q/e Dec 2018 59.2% 5th 63.6%

CAMHS Waiting Times Clinically Effective 90.0% May 2019 66.7% Apr 2019 72.3% ↓ 68.9% q/e Mar 2019 72.8% 7th 73.6%

Psychological Therapies Waiting Times Clinically Effective 90.0% May 2019 66.2% Apr 2019 66.1% ↑ 66.1% q/e Mar 2019 67.6% 10th 77.4%

* The 4-Hour Emergency Access performance in May was 94.5% (all A&E and MIU sites) and 92.4% (VHK A&E, only)


StatusGREENAMBER

RED


Sec

tion

RA

G

Treatment provided by Regional Centres so no comparison applicable




Performance Data


↓

↔

Fina

nce,

Per

form

ance

and

Res

ourc

es

RE

DA

MB

ER

Only published annually: NHS Fife was 7th for FY 2017-18

GR

EE

N

Only published annually: NHS Fife was 3rd for FY 2016/17

Only published annually: NHS Fife was 6th for 2-year period 2016 and 2017


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Performance Drill Down – Acute Services Division

4-Hour Emergency Access

Measure At least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission, discharge or transfer for Accident and Emergency treatment

Current Performance 94.5% in MayScotland Performance 90.7% in May

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

0

100

200

300

400

500

600

700

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Perf

orm

ance

Num

ber o

f Bre

ache

s

4-Hour Emergency Access4 (less than 8) hour breaches 8 (less than 12) hour breaches 12 hour breaches

NHS Fife A&E Performance Scotland Average (ISD)

February 2019 March 2019 April 2019Previous 3 Reporting Periods 92.1% ↑ 94.5% ↑ 94.7% ↑

Current Issues Variability in delivery of the access target continues and further deep dive analysis ongoing with increased contact with the SG Unscheduled Care team for support

Context Consistently above the Scottish average3rd best Mainland Health Board performance over the whole of FY 2018/19


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Cancer Treatment Waiting Times: 62-Day RTT

Measure At least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days of urgent referral

Current Performance 86.6% of patients (71 out of 82) started treatment in May within 62 daysScotland Performance 81.1% of patients started treatment within 62 days in May

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

0

5

10

15

20

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

% P

atie

nts <

62

Days

# Pa

tient

s > 6

2 Da

ys

Cancer Waiting Times: 62 day RTTBreast Cervical ColorectalHead & Neck Lung LymphomaMelanoma Ovarian Upper GIUrological Standard NHS FifeScotland Average (DISCOVERY)

February 2019 March 2019 April 2019Previous 3 Months

85.6% ↓ 75.6% ↓ 84.4% ↑

Current Issues Challenges with Urology prostate pathway and processesWaits to surgery for bladder and renalChallenges with reporting turnaround times in radiology and histopathology Short term Consultant sickness in breast

Context Standard last achieved in October 2017Above Scotland average in 10 out of last 12 months6th best performing Mainland Health Board during final quarter of 2018/19


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Patient Treatment Time Guarantee

Measure We will ensure that all eligible patients receive Inpatient or Day Case treatment within 12 weeks of such treatment being agreed

Current Performance 224 patient breaches (out of 1,563 patients treated) in May (85.7% within the guarantee time)

Scotland Performance 68.4% of patients treated within 12 weeks in first quarter of 2019

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

-

100

200

300

400

500

600

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

% P

atie

nts <

= 12

Wee

ks

# Pa

tient

s > 1

2 W

eeks

Patient TTGEmergency ENT General SurgeryGynaecology Ophthalmology OMSPlastics T & O UrologyOther Rheumatology NHS FifeScotland Average (DISCOVERY) Standard


70.5% ↑ 78.5% ↑ 87.6% ↑

Current Issues Recurring gap in elective inpatient and daycase capacity Unable to deliver the level of additional in house waiting list and outsourced activity in Urology, Surgical Paediatrics and Orthopaedics

Context NHS Fife performance generally very close to Scottish average, though positive gap has emerged since the start of 2019


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Diagnostics Waiting Times

Measure No patient will wait more than 6 weeks to receive one of the 8 key diagnostic tests

Current Performance 99.5% of patients waiting no more than 6 weeks at end of MayScotland Performance 84.0% of patients waiting no more than 6 weeks at end of March

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0%

0

50

100

150

200

250

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

% P

atie

nt's

<= 6

Wee

ks

# Pa

tient

's >

6 W

eeks

Diagnostics Waiting > 6 WeeksUpper Endoscopy Lower Endoscopy ColonoscopyCystoscopy Magnetic Resonance Imaging Computer TomographyNon-obstetric ultrasound Barium Studies StandardNHS Fife Scotland Average (ISD)


99.5% ↑ 99.9% ↑ 99.7% ↓

Current Issues Radiology Consultant , radiographer and sonographer vacancies, increased demand for MRI, Ultrasound and specialist cardiac and colon CTReporting capacityVariable capacity for additional UltrasoundIncrease in demand from bowel screening

Context Standard last achieved in April 2016, but small breach numbers in last 4 monthsBest performing Mainland Health Board at the end of March


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18 Weeks Referral-to-Treatment

Measure 90% of planned/elective patients to commence treatment within 18 weeks of referral

Current Performance 82.6% of patients started treatment within 18 weeks in MayScotland Performance 77.3% of patients started treatment within 18 weeks in March

1,25

4

1,13

7

1,01

6

1,13

9

1,13

4

1,29

0

1,28

0

919

1,39

6

1,24

9

1,43

2

1,07

5

1,07

1

0

200

400

600

800

1,000

1,200

1,400

1,600

75.0%

77.0%

79.0%

81.0%

83.0%

85.0%

87.0%

89.0%

91.0%

93.0%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

# of

Pat

ient

s >18

Wee

ks

% o

f Pat

ient

s <

18 W

eeks

18 Weeks RTT# Patients >18 wks Standard NHS Fife Scotland Average (ISD)


77.7% ↑ 76.9% ↓ 80.9% ↑

Current Issues Performance in Outpatients is impacting on non-admitted and admitted pathway performanceThe challenges in TTG performance is impacting on admitted pathway performance

Context Standard last achieved in September 20167th out of 11 Mainland Health Boards in March


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Performance Drill Down – Health & Social Care Partnership

Delayed Discharge

Measure No patient will be delayed in hospital for more than 2 weeks after being judged fit for discharge

Current Performance 37 patients in delay for more than 14 days at May Census – this equates to 9.95 patients per 100,000 population in NHS Fife

Scotland Performance 9.60 patients per 100,000 population at March census

0

20

40

60

80

100

120

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Num

ber o

f Del

ays

Delayed Discharges

Delays 0-2 Weeks Delays 2-4 Weeks Delays 4-6 Weeks Delays Over 6 Weeks Delays Over 2 Weeks


41 ↓ 43 ↓ 41 ↑

Current Issues Increasing number of patients in delayContext Never met 14-day target

7th lowest delays over 2 weeks (per 100,000 population) of all Mainland Health Boards, at March Census


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Smoking Cessation

Measure In FY 2018/19, we will deliver a minimum of 490 post 12 weeks smoking quits in the 40% most deprived areas of Fife

Current Performance 390 successful quits in first 11 months of the year (80% of annual target)Scotland Performance 4,810 successful quits at end of Q3, 63.6% of target

0

100

200

300

400

500

600

700

800

900

Apr-

17

May

-17

Jun-

17

Jul-1

7

Aug-

17

Sep-

17

Oct

-17

Nov-

17

Dec-

17

Jan-

18

Feb-

18

Mar

-18

Apr-

18

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Num

ber o

f Qui

ts

Smoking CessationTrajectory NHS Fife

November 2018 December 2018 January 2019Previous 3 Months

267 ↓ 290 ↓ 331 ↓

Current Issues The mobile unit has been off the road for over 8 weeks and is impacting on service provision with no resolution in the immediate future. In discussion with transport there is no other available vehicle that would service our needs in the same way in the current NHS Fife fleet.

Context Lower quit target (490) has been set for FY 2018/19 by the Scottish GovernmentCurrent achievement for FY 2018/19 is behind the Scottish average


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CAMHS Waiting Times

Measure At least 90% of clients will wait no longer than 18 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services

Current Performance 66.7% of children and young people started treatment within 18 weeks in MayScotland Performance 73.6% of patients started treatment within 18 weeks during FY 2018/19 Q4

885

911

724

753

715

705

784

827

790

850

897

806

793

0

100

200

300

400

500

600

700

800

900

1,000

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

# Pa

tient

s on

Wai

ting

List

% Tr

eate

d in

18

Wee

ks

CAMHS Waiting TimesPatients Waiting Standard NHS Fife Scotland Average (ISD)

February 2019 March 2019 April 2019Previous 3 Reporting Periods 74.3% ↑ 79.8% ↑ 72.3% ↓

Current Issues Volume of referrals to service exceeds available capacityLimited resilience within the current resource to manage absence without impacting on performanceChallenges exist in addressing both longest waits and 18 week target without impacting negatively on one or the other

Context Below Standard since May 20147th out of the 11 Mainland Health Boards for the quarter ending March


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Psychological Therapies Waiting Times

Measure At least 90% of clients will wait no longer than 18 weeks from referral to treatment for Psychological Therapies (PT)

Current Performance 66.2% of patients started treatment within 18 weeks of referral in MayScotland Performance 77.4% of patients started treatment within 18 weeks during FY 2018/19 Q4

3,58

0

3,34

0

3,17

0

3,27

0

3,35

5

3,46

7

3,61

7

3,74

5

3,60

1

3,55

4

3,64

3

3,58

3

3,72

1

2,800

2,900

3,000

3,100

3,200

3,300

3,400

3,500

3,600

3,700

3,800

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

# Pa

tient

s on

Wai

ting

List

% Tr

eate

d in

18

Wee

ks

Psychological Therapies Waiting TimesPatients Waiting Standard NHS Fife Scotland Average (ISD)

February 2019 March 2019 April 2019Previous 3 Reporting Periods 68.7% ↑ 69.8% ↑ 66.1% ↓

Current Issues Delivery of PTs across services requires further integration to enhance efficiencyContext Never met Standard; monthly performance normally between 65% and 75%

10th out of the 11 Mainland Health Boards for the quarter ending March


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Performance Drill Down – Financial Performance

Revenue Expenditure

Measure Health Boards are required to work within the revenue resource limits set by the Scottish Government Health & Social Care Directorates (SGHSCD).

In year position £3.130m overspend

Outturn position Target of breakeven; potential £8.5m overspend

0

500

1,000

1,500

2,000

2,500

3,000

3,500

May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

£000

Period

Financial Performanceagainst Trajectory 2019/20

Plan Actual

Year end Outturn May 2019 June 20192018/19

Revenue Resource Limit

Actual (in year position) £0.260m underspend £2.004m overspent £3.130m overspent

Plan (in year position) Breakeven £1.139m overspent £1.708m overspent

Forecast Outturn position £0.260m underspend Breakeven( target) Target - Breakeven *Optimistic- £3.823 overspend*Mid Range £8.072m Overspend*

* Please note these figures exclude the impact of risk share

CommentaryThe revenue position for the 3 months to 30 June reflects an overspend of £3.130m. This comprises an overspend of £3.301m on Health Board retained budgets; and an underspend of £0.171m aligned to the Health budgets delegated to the Integration Joint Board (IJB). The key financial challenge in this reported position is the overspend of £3.954m within the Acute Services Division (of which £1.275m overspend relates to a number of Acute services


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budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but remain managed by the NHS Board). The key driver of the overspend is the shortfall in the level of savings identified and delivered.Through discussion with the Chief Executive, Chief Operating Officer and other members of the Acute Division Senior Management team, it is recognised that further work is required to ensure that savings are identified and deliverable, in support of the statutory requirement to break even. A need has been identified for immediate external expertise to robustly support and challenge the team to design and implement an effective savings programme, with a strong focus on what/when/how much in terms of specific savings proposals. Through use of a national framework contract Deloitte LLP have been engaged to work with the Acute Division Management Team on this savings programme over a 12 week period, effective from 15 July 2019. A report will be provided to the Board, through the Finance, Performance & Resources Committee, on the progress and outcome of this work.It is important to note that at this point there has been no IJB risk share factored into the position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.1m to the in year overspend position (i.e. 3/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £4.2m. Following a recent meeting between the Cabinet Secretary for Health and the Co-Leaders of Fife Council, we are now in receipt of a letter from the Cabinet Secretary with regards the overall financial position for the IJB. We are in discussion with colleagues in the Health Finance Directorate to establish any specific direction from this letter and resultant financial consequences for the NHS Fife Board.In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £3.8m to a mid range overspend of £8.1m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.7m (i.e. 72% of the £6.5m gap) nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £8.5m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. This is a draft position and will be updated following further discussion with the SGHSCD Finance team.

1. Financial Framework

1.1 The Financial Plan for 2019/20 was approved by the Board on 27 March 2019, with the related Annual Operational Plan approved on 29 May 2019.

2. Financial Allocations

Revenue Resource Limit (RRL)

2.1 On 1 July 2019 NHS Fife received confirmation of June core revenue and core capital allocation amounts. The revised core revenue resource limit (RRL) has been confirmed at £688.159m. A breakdown of the additional funding received in month is shown in Appendix 1 and Appendix 2 shows details of anticipated allocations expected to be received.

Non Core Revenue Resource Limit

2.2 NHS Fife also receives ‘non core’ revenue resource limit funding for technical accounting entries which do not trigger a cash payment. This includes, for example,


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depreciation or impairment of assets. The Anticipated non core RRL funding of £33,832m is detailed in Appendix 3.

Total RRL

2.3 The total current year budget at 30 June is therefore £769.950m.

3. Summary Position

3.1 At the end of June, NHS Fife is reporting an overspend of £3.130m against the revenue resource limit. Table 1 below provides a summary of the position across the constituent parts of the system: an overspend of £3.301m is attributable to Health Board retained budgets; and an underspend of £0.171m is attributable to the health budgets delegated to the Integration Joint Board.

3.2 Key points to note from Table 1 are:

3.2.1 Acute Division overspend of £3.954m, driven largely as a result of non delivery of savings (£2.394m);

3.2.2 The aforementioned Acute Division overspend includes £1.275m overspend relating to a number of Acute services budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but which remain managed by the NHS Board;

3.2.3 Underspend across Estates & Facilities; and3.2.4 Underspend of £0.176m against the Health budgets delegated to the IJB.

Table 1: Summary Financial Position for the period ended June 2019

FY CY YTD Actual Variance Variance Run Rate Savings£'000 £'000 £'000 £'000 £'000 % £'000 £'000

Health Board 422,766 428,833 98,300 101,601 3,301 3.36% 842 2,459Integration Joint Board - Health 339,002 341,117 86,129 85,958 -171 -0.20% -899 728Total 761,768 769,950 184,429 187,559 3,130 1.70% -57 3,187


Acute Services Division 190,521 194,327 50,589 54,543 3,954 7.82% 1,560 2,394IJB Non-delegated 8,195 8,225 2,177 2,134 -43 -1.98% -57 14Estates & Facilities 71,796 71,895 17,736 17,307 -429 -2.42% -452 23Board Admin & Other Services 51,982 66,557 25,040 25,129 89 0.36% 61 28Non Fife & Other Healthcare Providers 84,462 84,462 21,099 21,511 412 1.95% 412 0Financial Flexibility & Allocations 40,402 42,514 681 0 -681 -100.00% -681 0Health Board 447,358 467,980 117,322 120,624 3,302 2.81% 843 2,459

Integration Joint Board - Core 365,421 385,794 98,688 98,512 -176 -0.18% -904 728Integration Fund & Other Allocations 12,422 4,955 0 0 0 0.00% 0 0Sub total Integration Joint Board Core 377,843 390,749 98,688 98,512 -176 -0.18% -904 728IJB Risk Share Arrangement 0 0 0 0 0 0.00% 0 0Total Integration Joint Board - Health 377,843 390,749 98,688 98,512 -176 -0.18% -904 728

Total Expenditure 825,201 858,729 216,010 219,136 3,126 1.45% -61 3,187

IJB - Health -38,841 -49,632 -12,559 -12,554 5 -0.04% 5 0Health Board -24,592 -39,147 -19,022 -19,023 -1 0.01% -1 0Miscellaneous Income -63,433 -88,779 -31,581 -31,577 4 -0.01% 4 0

Net position including income 761,768 769,950 184,429 187,559 3,130 1.70% -57 3,187

MemorandumBudget Expenditure Variance split by

Budget Expenditure Variance split by

4. Operational Financial Performance for the year


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Acute Services 4.1 The Acute Services Division reports a net overspend of £3.954m for the year to

date. This reflects an overspend in operational run rate performance of £1.560m, and unmet savings of £2.394m. Within the run rate performance, pay is overspent by £1.194m. The overall position has been driven by a combination of unidentified savings and continued pressure from the use of agency locums, junior doctor banding supplements, incremental progression and nursing recruitment in line with workforce planning tool. Balancing finance and other performance targets across the Acute Services whilst seeking to identify recurring efficiency savings proved challenging. Further details of the position, by Directorate are set out below:

Table 2: Acute Division Financial Position for the period ended June 2019


Acute Services Division- Planned Care & Surgery 65,059 66,716 17,459 18,520 1,061 6.08% 187 874- Emergency Care & Medicine 71,362 72,742 19,291 20,939 1,648 8.54% 969 679- Women, Children & Clinical Services 51,600 52,263 13,427 14,446 1,019 7.59% 178 841- Acute Nursing 674 700 176 152 -24 -13.64% -24- Other 1,826 1,906 236 486 250 105.93% 250

0.00%Total 190,521 194,327 50,589 54,543 3,954 7.82% 1,560 2,394


Estates & Facilities4.2 The Estates and Facilities budgets report an under spend of £0.429m which can be

broken down into under spend of £0.452m on run rate and unmet savings of £0.023m. The run rate net under spend is generally attributable to vacancies, energy and water and property rates, and partially offset by an overspend on property maintenance.

Corporate Services4.3 Within the Board’s corporate services there is an overspend of £0.089m .This

comprises an under spend on run rate of £0.061m as offset by unmet savings of £0.028m. Further analysis of Corporate Directorates is detailed per Appendix 4.

Non Fife and Other Healthcare Providers4.4 The budget for healthcare services provided out with NHS Fife is overspent by

£0.412m. Further detail is attached at Appendix 5.

Financial Plan Reserves & Allocations4.5 Financial plan expenditure uplifts including supplies, medical supplies and drugs uplifts

were allocated to budget holders from the outset of the financial year, and therefore form part of devolved budgets. A number of residual uplifts are held in a central budget and will be subject to robust scrutiny and review each month. The detailed review of the financial plan reserves at Appendix 6 allows an assessment of financial flexibility for the year to date. As in every financial year, this ‘financial flexibility’ allows mitigation of slippage in savings delivery, and is a crucial element of the Board’s ability to deliver against the statutory financial target of a break even position against the revenue resource limit. Integration Services

4.6 The health budgets delegated to the Integration Joint Board report an underspend of £0.176m for the year to date. This position comprises an under spend in the run rate performance of £0.904m; together with unmet savings of £0.728m. The underlying drivers for the run rate under spend are vacancies in community nursing, health visiting, school nursing, community and general dental services across Fife Wide

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Division. The aforementioned under spend is partly offset by locum costs within mental health services, inpatient service costs within East and West.

Income4.7 A small under recovery in income of £0.004m is shown for the year to date.

5. Pan Fife Analysis

5.1 Analysis of the pan NHS Fife financial position by subjective heading is summarised in Table 3 below.

Table 3: Subjective Analysis for the Period ended June-19

Annual Budget

Budget Actual Net over/ (under) spend

Pan-Fife Analysis £'000 £'000 £'000 £'000Pay 352,742 91,731 91,771 40GP Prescribing 74,106 18,150 18,269 119Drugs 31,006 8,265 8,002 -263Other Non Pay 366,163 100,370 101,094 724IJB Risk Share 0 0 0 0Efficiency Savings -12,757 -3,187 0 3,187Commitments 47,469 681 0 -681Income -88,779 -31,581 -31,577 4Net underspend 769,950 184,429 187,559 3,130

Pay

5.2 The overall pay budget reflects an overspend of £0.040m. There are under spends across a number of staff groups which partly offset the overspend position within medical and dental staff; the latter being largely driven by the additional cost of supplementary staffing to cover vacancies and also nursing.

5.3 Against a total funded establishment of 7,650 wte across all staff groups, there was 7,780 wte staff in post in June.

Drugs & Prescribing 5.4 Across the system, there is a net under spend of £0.144m on medicines of which an

overspend of £0.119m is attributable to GP Prescribing and an under spend of £0.263m relating to sexual health and rheumatology drugs. The GP prescribing position is based on 2018/19 trend analysis and April 2019 actual information.

Other Non Pay5.5 Other non pay budgets across NHS Fife are collectively overspent by £0.721m.The

overspends are in purchase of healthcare and other supplies. These are offset by under spends across a number of areas including energy and other admin supplies.


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6 Financial Sustainability

6.1 The Financial Plan presented to the Board in March highlighted the requirement for £17.333m cash efficiency savings to support financial balance in 2019/20. The Plan was approved with a degree of cautious optimism and confidence that the gap would be managed in order to deliver a break even position in year 1 of the 3 year planning cycle. As reported to the Board in March, this view was entirely predicated on a robust and ambitious savings programme across Acute Services and the Health & Social Care Partnership; supported by ongoing effective grip and control on day to day expenditure and existing cost pressures; and early identification and control of non recurring financial flexibility.

6.2 The extent of the recurring / non recurring savings delivery for the year is illustrated in Table 4 below.

Table 4: Savings 2019/20

Savings 2019/20 Target Identified

& Achieved Identified

& Achieved Total Identified

& Achieved Recurring Non-Recurring to date Outstanding

£'000 £'000 £'000 £'000 £'000

Health Board 10,873 714 316 1,030 9,843

Integration Joint Board 6,460 1,435 2,111 3,546 2,914

Total Savings 17,333 2,149 2,427 4,576 12,757

7 Key Messages / Risks

7.1 As described above, the most significant financial risk is the non-delivery and identification of savings; particularly within the Acute Services Division, and the shortfall in the overall savings plan for the Health & Social Care Partnership budgets as reported to the IJB.

7.2 At this early stage in the year, it is difficult to be entirely definitive on the likely outurn for the year, however initial indications suggest the position ranges from an optimistic year end overspend of £3.8m to a mid range overspend of £8.1m. This does not include the impact of the risk share arrangement for the IJB position ie a further £4.7m, nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division.

7.3 For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £8.5m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings.

8 Recommendation

8.1 Members are invited to approach the Director of Finance or Chief Executive for any points of clarity on the position reported and are asked to:

Note the reported overspend of £3.130m for the year to 30 June 2019;

Note the additional overspend of £1.1m for the year to 30 June 2019, which would result if the risk share arrangement was applied to the current full year gap for the Integration Joint Board;


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and

Note the potential (draft) outturn position of £8.5m reflecting an optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings.


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Appendix 1 – Core Revenue Resource LimitBaselineRecurring

Earmarked Recurring

Non-Recurring Total Narrative

£'000 £'000 £'000 £'000

May-19 Opening 662,752 662,752May Adjustments -696 -229 -925

Jun-19 Realistic Medicines 30 30 Year 2 funding

Elective Activity as per AOP 5,525 5,525Waiting List first 75%and funding for Lothian Endoscopy

Best Start 360 360Funding of recommendation of report

6EA Unscheduled Care 250 250 Annual allocationHealthly Start Vitamins 28 28 Annual allocationOutcomes Framework 3,774 3,774 5% reduction on 2018/19

HNC Nursing Students 72 72Quarterly based on student numbers

Employers Pension Contribution 16,293 16,293 Cover increase in costs to 20.9%

Total Core Revenue Allocation 678,349 3,774 6,036 688,159

Appendix 2 – Anticipated Core Revenue Resource Limit Allocations£'000

CAMHS Regional post 35Distinction Awards 230Research & development 881NSS Discovery -39NDC Contribution -842Community Pharmacy Pre-Reg Training -44Patient Advice & Support Service -40New Medicine Fund 3,005Golden Jubilee SLA -24Waiting List 1,675NSD risk share -2,566Scotstar -321PAT scan -477Depreciation to Non-core -12,820Primary Medical Services 50,114Mental Health Bundle 620Primary Medical Services Bundle 1,718Salaried Dental 2,100Community Pharmacy Champions 19Capacity Building CAMHS & PT 456Mental health innovation fund 288Veterans First Point Transisition Funding 114Pharmacy Global Sum Calaculation -1,346FNP 934Men C -16Primary Care Fynd GP sub Committee 34ADP 1,157Primary Care Improvement Fund 2,520Action 15 Mental Health strategy 524Excellence in care 70Total 47,959


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Appendix 3 - Anticipated Non Core Revenue Resource Limit Allocations

£'000PFI Adjustment 3,374Donated Asset Depreciation 119Impairment 8,000AME Provision 2,000IFRS Adjustment 5,019Non-core Del 2,500Depreciation from Core allocation 12,820Total 33,832

Appendix 4 - Corporate Directorates

Cost Centre CY Budget

£'000YTD Budget

£'000YTD Actuals

£'000YTD Variance

£'000E Health Directorate 10,139 2,338 2,336 -2Nhs Fife Chief Executive 201 55 56 1Nhs Fife Finance Director 4,982 1,268 1,138 -130Nhs Fife Hr Director 2,929 756 733 -23Nhs Fife Medical Director 6,220 1,329 1,309 -20Nhs Fife Nurse Director 3,320 843 1,171 328Nhs Fife Planning Director 1,853 479 425 -54Legal Liabilities 16,010 12,984 13,033 49Public Health 2,035 518 480 -38Early Retirements & Injury Benefits 629 25 2 -23External & Internal Audit 151 38 39 1Regional Funding 162 58 58 0Depreciation 17,926 4,349 4,349 0Total 66,557 25,040 25,129 89


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Appendix 5 – Non Fife & Other Healthcare Providers

CY Budget £'000

YTD Budget £'000

YTD Actuals £'000

YTD Variance

£'000Health BoardAyrshire & Arran 93 23 14 -9Borders 43 11 12 1Dumfries & Galloway 24 6 14 8Forth Valley 3,025 756 812 56Grampian 342 86 76 -10Highland 129 32 53 21Lanarkshire 109 27 37 10Scottish Ambulance Service 96 24 26 2Lothian 30,013 7,503 7,289 -214Greater Glasgow 1,575 394 407 13Tayside 38,985 9,747 9,792 45

74,434 18,609 18,532 -77UNPACSHealth Boards 8,064 2,016 2,396 380Private Sector 1,209 302 407 105

9,273 2,318 2,803 485

OATS 690 172 176 4

Grants 65 0 0 0

Total 84,462 21,099 21,511 412


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Appendix 6 – Financial Flexibility and Allocations

Financial Flexibilty

Released to June-

19

£'000 £'000 Financial Plan

Drugs 4,432 0

Complex Weight Management 50 0

Adult Healthy Weight 104 0

Trainee Growth 0 0

National Specialist Services 333 0

Band 1's 307 77

Unitary Charge 263 15

Junior Doctor Travel 118 5

Consultant Increments 50 12

Discretionary Points 231 0

Cost pressures 4,885 536

Financial Flexibility 926 36

Subtotal Financial Plan 11,699 681

Allocations

Health Improvement 112 0

AME Impairments 8,000 0

AME Provisions 2,301 0

Pay Awards 1,398 0

Distinction Awards 37 0

Waiting List 5,678 0

Continuation of the Preoperative Anaemia Workstream 0 0

The Health and Care (Staffing) (Scotland) Bill 0 0

CAMHS Post 35 0

Realistic Medicines 0 0

Employers Pension increase 12,644 0

Best Start 360 0

6EA Unscheduled Care 250 0

Subtotal Allocations 30,815 0 Total 42,514 681


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Performance Drill Down – Capital Expenditure

Capital Expenditure

Measure Health Boards are required to work within the capital resource limits set by the Scottish Government Health & Social Care Directorates (SGHSCD).

In year position £0.422m spend at Month 3

Outturn position £7.394m spend

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

£000

Months

Capital Spend Profile 2019/20Plan Actual

CommentaryThe total Capital Resource Limit for 2019/20 is £7.394m. The capital position for the 3 months to June shows investment of £0.422m, equivalent to 5.7% of the total allocation. Plans are in place to ensure the Capital Resource Limit is utilised in full.

1. INTRODUCTION

1.1 The Capital Plan 2019/20 was approved by the NHS Board on 27 March 2019. For information, changes to the plan since its initial approval in March are reflected in Appendix 1. On 3 June 2019 NHS Fife received confirmation of initial core capital allocation amounts of £7.394m gross. NHS Fife is anticipating an additional £2m allocation for the new Elective Orthopaedic Centre.

2. CAPITAL RECEIPTS

2.1 The Board’s capital programme is partly funded through capital receipts which, once received, will be netted off against the gross allocation highlighted in 1.1 above. Work continues on asset sales with several disposals planned:

Lynebank Hospital Land (Plot 1) (North) – Under offer; Forth Park Maternity Hospital – Sale due to complete 5th August 2019; Fair Isle Clinic – Under offer;


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Skeith Land – preparing to market; and ADC – Closing date has been set 9th July 2019

2.2 The property at ADC is currently occupied and therefore not yet valued at open market value.

3. EXPENDITURE TO DATE / MAJOR SCHEME PROGRESS

3.1 Details of the expenditure position across all projects are attached as Appendix 2. Project Leads have provided an estimated spend profile against which actual expenditure is being monitored. This is based on current commitments and historic spending patterns. The expenditure to date amounts to £0.422m or 5.7% of the total allocation, in line with the plan, and as illustrated in the spend profile graph above.

3.2 The main areas of investment to date include:

Statutory Compliance £0.171mMinor Works £0.027mEquipment £0.140mE-health £0.040m

4. CAPITAL EXPENDITURE OUTTURN

4.1 At this stage of the financial year it is currently estimated that the Board will spend the Capital Resource Limit in full.

5. RECOMMENDATION


note the capital expenditure position to 30 June 2019 of £0.422m and the forecast year end spend of the capital resource allocation of £7.394m

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Appendix 1: Capital Plan - Changes to Planned Expenditure

Board CumulativeCapital Expenditure Proposals 2019/20 Approved Adj to June June

27/03/2019 May Adj Total£'000 £'000 £'000 £'000

Routine Expenditure

Community & Primary CareMinor Capital 136 137 272Capital Equipment 81 81Statutory Compliance 1,264 1,264Condemned EquipmentTotal Community & Primary Care 0 1,480 137 1,617

Acute Services DivisionCapital Equipment 1,754 193 1,947Minor Capital 118 60 178Statutory Compliance 2,205 2,205Condemned Equipment 23 71 94Total Acute Service Division 0 4,100 324 4,423

Fife WideMinor Work 498 (253) (197) 48Information Technology 1,041 1,041Backlog Maintenance/Statutory Compliance 3,569 (3,469) 100Condemned Equipment 90 (23) (67)Scheme Development 60 60Fife Wide Equipment 2,036 (1,835) (196) 5Fife Wide Contingency Balance 100 100

Total Fife Wide 7,394 (5,580) (460) 1,354

Total NHS Fife 7,394 0 0 7,394


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Appendix 2 - Capital Programme Expenditure Report

NHS FIFE - TOTAL REPORT SUMMARY 2019/20

CAPITAL PROGRAMME EXPENDITURE REPORT - JUNE 2019

CRL Total ProjectedNew Expenditure Expenditure

Funding to Date 2019/20Project £'000 £'000 £'000

COMMUNITY & PRIMARY CAREStatutory Compliance 1,264 109 1,264Capital Minor Works 272 4 272Capital Equipment 81 8 81Condemned Equipment

Total Community & Primary Care 1,617 120 1,617

ACUTE SERVICES DIVISIONCapital Equipment 1,947 132 1,947Statutory Compliance 2,205 62 2,205Minor Works 178 24 178Condemned Equipment 94 94

Total Acute Services Division 4,423 218 4,423

NHS FIFE WIDE SCHEMESInformation Technology 1,041 40 1,041Equipment Balance 5 5Scheme Development 60 44 60Contingency 100 100Statutory Compliance - Fire Compartmentation 100 100Minor Works 48 48

Total NHS Fife Wide 1,354 84 1,354

TOTAL ALLOCATION FOR 2019/20 7,394 422 7,394


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Section B:3 Staff Governance Summary

Sickness Absence HEAT Standard: We will achieve and sustain a sickness absence rate of no more than 4%, measured on a rolling 12-month basis

The sickness absence rate in May was 5.66%, 0.24% higher than in April and 0.66% higher than in May 2018.

Assessment: Various improvement initiatives in the past year saw an improvement in the sickness absence rate in FY 2018/19, being 0.25% lower than FY 2017/18.

iMatter local target: We will achieve a year on year improvement in our Employee Engagement Index (EEI) score by completing at least 80% of team action plans resulting from the iMatter staff survey.

Assessment: A proactive plan has been developed to promote the 2019 iMatter cycle to support improvements in the engagement and action planning components. The process started in April, and reporting of progress/performance will be considered when the IPQR is in use.

TURAS local target: At least 80% of staff will complete an annual review with their Line Managers via the TURAS system

Assessment: Reporting of progress/performance in relation to the recovery plan agreed with EDG will be considered when the IPQR is in use. The improvement trajectory for all divisions/directorates is to achieve 80% by the end of October.

Management Referrals local target: At least 95% of staff referred to the Staff Health & Wellbeing Service by their manager will receive an appointment within 10 working days

During Quarter 4 of FY 2018/19, 96.6% of the management referrals processed by the Staff Wellbeing & Safety Service were offered an appointment within 10 working days. This is an improvement of nearly 20% compared to Quarter 3.

Reporting of progress/performance during 2019/20 will be considered when the IPQR is in use.

Redeployment local target: At least 50% of jobs identified as possible suitable alternatives by the redeployment group will be investigated and an initial decision over their suitability will be made within 2 weeks

During Quarter 4 of FY 2018/19, 60.0% of jobs identified were investigated (with an initial decision over suitability made). This continues to be above the local target, but is a 7% reduction in comparison to Quarter 3. It has to be recognised that performance against this indicator will continue to vary, subject to the number of staff on the redeployment register and their particular circumstances.


Supplementary Staffing local target: At least 80% of supplementary staffing requests (Nursing & Midwifery) will be met by the Nurse Bank.

During Quarter 4 of FY 2018/19, 75.9% of staffing requirements were met via the Nurse Bank, 1% higher than the performance during Quarter 3.


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Pre-Employment Checks local target: At least 80% of all pre-employment checks, as detailed within the Safer Pre & Post Employment Checks NHS Scotland Policy, will be completed within 21 working days from receipt of the preferred candidate details

During Quarter 4 of FY 2018/19, nearly 300 individuals within various staff groups were offered employment throughout NHS Fife, with 82.7% of pre-employment checks being completed within 21 working days. This is an increase of 15.7% compared to Quarter 3.


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Performance SummaryNational Standards


Previous Period



Sta

ff G

over

nanc

e

RE

D

Sickness Absence Clinically Effective 4.00% May 2019 5.66% Apr 2019 5.42% ↓ 5.54%


StatusGREENAMBER

RED


Sec

tion

RA

G

Only published annually: NHS Fife had the 4th highest sickness absence rate in FY 2018-19 (Fife performance 5.51%, Scotland performance 5.39%)



Performance Data


↓

↔

Local Targets


Previous Period


Direction of Travel

Redeployment Clinically Effective 50.0% Jan to Mar 2019 60.0% Oct to Dec

2018 67.0% ↓

Pre-Employment Checks Safe 80.0% Jan to Mar 2019 82.7% Oct to Dec

2018 67.0% ↑

Management Referrals Safe 95.0% Jan to Mar 2019 96.6% Oct to Dec

2018 76.8% ↑

AM

BE

R

Supplementary Staffing Clinically Effective 80.0% Jan to Mar 2019 75.9% Oct to Dec

2018 74.9% ↑

iMatter Clinically Effective 80.0% FY 2018/19 47.0% FY 2017/18 41.0% ↑

TURAS Clinically Effective 80.0% 12 months to Apr 2019 41.0% 12 months to

Mar 2019 32.0% ↑

Sta

ff G

over

nanc

e


StatusGREENAMBER

RED

DefinitionPerformance meets or exceeds the local targetPerformance is behind (but within 5% of) the local targetPerformance is more than 5% behind the local target

Sec

tion

RA

GG

RE

EN

RE

D

Local Target Quality Aim Target for 2018-19

Performance Data


↓

↔

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Sickness Absence

Measure We will achieve and sustain a sickness absence rate of no more than 4%

Current Performance 5.66% in MayScotland Performance 5.39% for 2018/19 (data published annually)

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct

-18

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

Apr-

19

May

-19

Mon

thly

Sick

ness

Abs

ence

Rat

e

Sickness AbsenceNHS Fife Emergency Care Planned CareWomen, Children & Clinical Services HSC East HSC WestHSC Fife-Wide Standard

February 2019 March 2019 April 2019Previous 3 Reporting Periods 5.39 % ↑ 5.38% ↑ 5.42 % ↓

Current Issues The main reasons for sickness absence in FY 2018/19 were anxiety, stress and depression, other musculoskeletal problems and unknown causes / not specified.

Context NHS Fife had the 4th highest sickness absence rate in FY 2018-19 (Fife performance 5.51%, Scotland performance 5.39%)

Staff Governance

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PAUL HAWKINSChief Executive24th July 2019

Prepared by:CAROL POTTERDirector of Finance

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Fife IntegratedPerformance & Quality Report

Produced in August 2019

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IntroductionThe purpose of the Integrated Performance and Quality Report (IPQR) is to provide assurance on NHS Fife’s performance relating to National LDP Standards and local Key Performance Indicators (KPI).

The IPQR comprises of the following sections:

I. Executive Summary

a. LDP Standards & Local Key Performance Indicators (KPI)


c. Indicatory Summary

d. Assessment

II. Performance Assessment Reports

Clinical Governance

Finance, Performance & ResourcesOperational PerformanceFinance

Staff Governance

Section II provides further detail for indicators of continual focus or those that are currently underperforming. Each report contains data, displaying trends and highlighting key problem areas, as well as information on current issues with corresponding improvement actions. The latter, along with trajectories, are taken as far as possible from the 2019/20 Annual Operational Plan (AOP). For indicators outwith the scope of the AOP, improvement actions and trajectories were agreed locally following discussion with related services.

A summary report of the IPQR, the Executive Summary IPQR (ESIPR), is presented at each NHS Fife Board Meeting, while Board members are sent a courtesy copy of the IPQR each month.

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I. Executive SummaryAt each meeting, the Standing Committees of the NHS Fife Board consider targets and Standards specific to their area of remit. This section of the IPQR provides a summary of performance against LDP Standards and local Key Performance Indicators (KPI). These indicators are listed within the Indicator Summary including current and previous performance and benchmarking against other NHS Boards.

a. LDP Standards & Key Performance Indicators

The current performance status of the 28 indicators within this report is 12 (43%) classified as GREEN, 3 (11%) AMBER and 13 (46%) RED. This is based on whether current performance is exceeding standard/trajectory, within specified limits or considerably below standard/trajectory.

There are four indicators that consistently exceed the Standard performance; C Diff infection rate, IVF Treatment Waiting Times (regional service), Antenatal Access and Drugs & Alcohol Waiting Times. Other areas of success should also be noted…

Inpatients Falls with Harm, consistently below the target level, at 1.47 per 1,000 Occupied Bed Days

The SAB infection rate (measured on a rolling 3-month basis) is significantly lower than the Improvement Trajectory for 2019/20

New Outpatient Waiting Times achieved above Standard performance for third month in succession with 95.4% waiting less than 12 weeks

Patient TTG (Patients Waiting at Month End), continuing to be above the Improvement Trajectory for 2019/20

Cancer 31-Day DTT achieving the Standard in June


National Benchmarking is based on whether indicator is in upper quartile (▲), lower quartile (▼) or mid-range (◄►); based on 11 mainland NHS Boards. The current benchmarking status of the 24 indicators within this report has 5 (21%) within upper quartile, 12 (50%) in mid-range and 7 (29%) in lower quartile. There are indicators where national comparison is not available or not directly comparable.

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d. Assessment


No comments received

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Acute waiting times for new outpatients, Patient TTG and Diagnostics are currently performing in the upper quartile compared with other mainland Scottish NHS Boards. In terms of AOP performance, TTG is better than target but Outpatients is behind target.

Urology remains challenging for 31 and 62 day Cancer Waiting Time target. The work within Urology Improvement Group to review the pathways is expected to be completed by January 2020 as is currently on track.

Emergency Access standard remains a challenge for Fife. Improved patient flow is key to achieving 95% and review of AU1 Assessment Pathway, redevelopment of ECAS and implementation of OPAT service all underway and are due to be completed by October 2019.

Bed Days Lost to Delays has reduced to 6.8%, under 5% target for March 2020, with the number of patients in delay at census 53. A review of timeliness of social work assessments is under way and a trusted assessor’s model within VHK for patients transferring to STAR/Assessment Beds is on track for completion by October.

Mental Health Waiting Times continue to be a challenge with both CAMHS and Psychological Therapies below AOP trajectories. All improvement actions are currently on track to deliver by agreed timescales.

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Executive Lead CommentsAs previously reported, further work is required as a matter of priority to ensure that savings are identified and deliverable for the Acute Services Division, in support of the Health Board’s statutory requirement to break even. External expertise is being provided through Deloitte LLP to robustly support and challenge the team to design and implement an effective savings programme, with a strong focus on what/when/how much in terms of specific savings proposals. A workshop is scheduled for mid August with a formal update to the Executive Directors Group and Finance, Performance & Resources Committee in September.

It is important to note that at this point there has been no IJB risk share factored into the year to date position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.6m to the in year overspend position (i.e. 4/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £6.8m.

We continue dialogue with colleagues in the Health Finance Directorate on the impact of any application of the risk share arrangement, on the financial consequences for the NHS Fife Board in relation to the delivery of the statutory financial requirement to break even.

In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £4.4m to a mid range overspend of £8.8m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.68m (i.e. 72% of the £6.5m gap), nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £9m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. It is important to note that the most recent forecast overspend on the IJB budget was in excess of the initial £6.5m budget gap; being more than £9m).

Within the Scottish Government reporting template we are required to highlight the level of any potential brokerage required to deliver a break even position. Board members are asked to note that we have included a funding request of £4.68m in this respect; this assumes the impact of the social care overspend would require additional external funding and the overspend on the Health Board retained budgets would be managed through local management action.

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We continue to progress work in partnership with our staff representative colleagues to improve performance in this area. This includes jointly presented “myth busting sessions” which will also support the application of the newly agreed Circular dealing with this issue.

Our workshops which include discussion of best practice examples from within the Board; the art of having “Good Conversations”, supporting staff resilience and the need to be aware of and support in a timeous way any colleagues who are experiencing mental health related issues have been extremely well received

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II. Performance Exception Reports

Clinical Governance

Adverse Events 11

HSMR 12

Inpatient Falls (With Harm) 13

Pressure Ulcers 14

Caesarean Section SSI 15

Healthcare Associated Infections SAB (including MRSA) 16

Complaints – Stage 2 17

Finance, Performance & Resources – Operational Performance

4-Hour Emergency Access 18

Delayed Discharges 19

Patient Treatment Time Guarantee (TTG) 20

Cancer 62-day Referral to Treatment 21

Smoking Cessation 22

CAMHS 18 Weeks Referral to Treatment 23

Psychological Therapies 18 Weeks Referral to Treatment 24

Freedom of Information (FoI) Requests 25

Finance, Performance & Resources – Finance

Revenue Expenditure 26

Capital Expenditure 37

Staff Governance

Sickness Absence 39

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Clinical Governance

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Adverse Events

Major and Extreme Adverse Events

All Adverse Events

Commentary All Adverse Events are managed in accordance with GP/I9 NHS Fife Adverse Events Policy and there are systems in place to manage the events and take oversight within the Acute Division and the Health and Social Care Partnership

There is nothing exceptional to report.

Current Challenges

Improvement Actions Progress Timescale Status

1.

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HSMRValue is less than one, the number of deaths within 30 days of admission for this hospital is fewer than

predicted. If value is greater than one, number of is more than predicted.

Reporting Period; April 2018 to March 2019p

Crude Mortality Rate

CommentaryHSMR is a measure which promotes reflection on patient care within boards. The reference point is a value of 1, and this hould be used by Boards to reflect when a value is greater or less than this. A high value of the HSMR is not sufficient evidence on which to conclude that a poor quality or unsafe service is being provided. It should be regarded as a trigger for review and further understanding.

The provisional NHS Fife HSMR for the whole of FY 2018/19 was 1.01, which is in line with Scottish performance.

Current Challenges The QMH HSMR is significantly above the reference point

Improvement Actions Progress Timescale/Status

1. 2.3.

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Clinical Governance

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Inpatient Falls with HarmReduce Inpatient Falls With Harm rate per 100,000 Occupied Bed Days (OBD)

Improvement Target for 2019/20 = 2.16 per 100,000 OBD

Local Performance

Service Performance

CommentaryWhile falls with harm rate has been static overall, the data highlights an increase in a few areas within the ASD. Work is underway to explore the reasons for this including appropriate completion of the falls prevention and management bundle through audit, local environment assessment and patient profile, including those patients who have boarded in other wards.

Current ChallengesNeed to continue to review the performance with increased demands in in-patient settings and bed modelling within the acute setting. Bed Modelling is underway and aimed to be complete in August. – Actions 1, 2 and 3


1. Review the Falls Toolkit and Falls Flowchart

A short life working group has reviewed and refreshed the falls toolkit for NHS Fife and has also developed significant new risk assessment, care plan and flowcharts for post falls assessment and the use of bed or chair alarms. These new pieces of work have been consulted upon across the acute and community hospitals and have been approved.

Jul 2019Complete

Formal re-launch of the new toolkit is planned for 10th September but roll out is already underway across the organisation

Sep 2019On Track

2. Develop Older People’s Knowledge and Skills Framework

Framework (relevant to all clinical areas that care for older people across our acute and community hospitals) has been piloted with a number of health professionals within the acute hospital and the feedback is extremely positive.Formal launch planned for 10th September

Aug 2019On Track

3. Falls Audit A tool has been developed and tested in community in-patient beds and this will be utilised in acute settingFirst run of audit week beginning 12th August

Aug 2019On Track

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Clinical Governance

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Pressure UlcersAchieve 50% reduction in pressure ulcers (grades 2 to 4) developed in a healthcare settingImprovement Target rate (by end December 2019) = 0.42 per 1,000 Occupied Bed Days

Local Performance

Service Performance

Commentary There remains standard variation in the data with no sustained improvment in Pressure Ulcer development, with a rise in incidents from 0.55 in May to 0.58 in June. There remains continuous activity across Fife, with particular focus being on the use of comfort rounds and targeted refresher education sessions on the use of comfort rounds within HSCP.

Reducing number of pressure ulcers across all NHS Fife Wards – Actions 1 and 3

Current ChallengesReducing the random monthly variation in HSCP wards – Actions 2 and 3


1. All identified wards will undertake a weekly audit of compliance with SSKIN bundle

All wards are completing SSKIN bundle on a weekly basis, continued support to ensure consistent compliance is ongoing

Dec 2019On Track

2. Fife-wide task group commissioned to review SBAR/LAER reporting

The task group have completed the recommendation of SBAR/LAER reporting and will now follow the governance struture for approval

Oct 2019On Track

3. Improvement collaborative project extended to December 2019 across identified wards

All 10 wards continue to work within the QI programme Dec 2019On Track

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Clinical Governance

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SSI Caesarean SectionTo reduce C Section SSI incidence (per 100 procedures) for inpatients and post discharge

surveillance to day 10 by 4% by March 2020.

Local Performance

Service Performance

NHS Fife SSI Caesarean Section incidence rate still remains higher than the Scottish incidence rate – Action 1Current Challenges NHS Fife BMI rates are higher than the national rate – Action 2


1. Address ongoing and outstanding actions as set out in the SSI Implementation Group Improvement Plan

Improvement Plan updated in light of exception report received for Q1 2019New case ascertainment methodology to be adopted from October

Mar 2020On Track

2. Support an Obesity Prevention and Management Strategy for pregnant women in Fife, which will support lifestyle interventions during pregnancy and beyond

A number of strategies are in place: Family Health Team Winning By Losing Smoking CessationAnalysis of data currently ongoing to determine what impact these initiatives are having on pregnant women in Fife with a high BMI

Mar 2020On Track

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Clinical Governance

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HAI SAB (including MRSA)Rate of 0.24 cases or less per 1,000 Acute Occupied Bed Days (AOBD)

Improvement Target for 2019/20 = 0.34

Local Performance | Quarter Ending

National Benchmarking | Year Ending

Increase in number of VAD-related infections – Action 1

Increase in number of SAB in diabetic patients – Action 2Current Challenges

Increase in number of SAB in People Who Inject Drugs (PWID) – Action 3


1. Complete work mandated by Vascular Access Strategy Group

Improved systems and processes in place to manage VAD including policies, procedures, pathways, eHealth solutions and training and educationGovernance arrangements are more robust, and will provide assurance and data for improvementTeams continue to work on the reduction in the number of VAD associated SAB: incidence charts are used to support teams in QI

Mar 2020On Track

2. Design a new programme of work focusing on reducing the risk of SAB in diabetic patients

First meeting with key stakeholders to discuss SAB prevention in the diabetic community scheduled for September 2019

Mar 2021On Track

3. Reduce the number of SAB in PWIDs

First meeting with key stakeholders to discuss SAB prevention in the PWID community scheduled for September

Mar 2021On Track

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Clinical Governance

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Complaints | Stage 2At least 75% of Stage 2 complaints are completed within 20 working days

Improvement Target for 2019/20 = 65%

Local Performance

Local Performance by Directorate/Division

To improve quality of draft responses – Action 1

To improve quality of investigation statements – Action 2Current Challenges Inconsistent management of medical statements and inconsistent style of responses

within ASD – Action 3


1. Patient Relations Officers to undertake peer review

This continues and learning is being shared directly with individual Officers.Monthly meetings with ASD to discuss complaint issues and style of drafts are in place.Joint education session to be arranged to agree draft styles.

Mar 2020On Track

2. Deliver education to service to improve quality of investigation statements

Yearly education delivered to FY2 doctors and student nurses.Ad Hoc training sessions are also delivered when required.

Mar 2020On Track

3. Agree a process for managing medical statements, and a consistent style for responses

ASD to discuss with Clinical LeadsPRD raise issues at monthly meeting

Oct 2019On Track

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4-Hour Emergency AccessAt least 95% of patients (stretch target of 98%) will wait less than 4 hours from arrival to admission,

discharge or transfer for Accident and Emergency treatment Improvement Target for 2019/20 = 96%

Local Performance

National Benchmarking

Variation in 4-Hour Emergency Access Performance - Action 1Patient Flow – Action 2Current ChallengesECAS and OPAT Services and Capacity – Action 3


1. Formation of PerformED group to analyse performance trends

Group identifying trends and engagement meetings have commenced with services external to ED. Continue to revise what changes can be made internally following review of data.

Jan 2020On Track

2. Review of AU1 Assessment Pathway

AU1 attendances and admissions contribute to approximately 20% of EC admissions. New flow model providing better control of occupancy of the area and continue to revisit the ANP call handling from GPs.

Oct 2019 On Track

3. Development of services for ECAS and implementation of OPAT

Review of attendances and flow within the ECAS area and engagement with acute physicians regarding occupancy and demand. Microbiologist to support OPAT commencing September, however, nursing support continues to be assessed v budget.

Oct 2019 On Track

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Delayed DischargesWe will reduce the hospital bed days lost due to patients in delay, excluding Code 9, to 5% of the

overall beds occupiedImprovement Target for 2019/20 = 7%

Local Performance


To reduce the number of hospital bed days lost due to patients in delay – Actions 1 and 3Current ChallengesTo improve the time taken to complete social work assessments – Action 2


1. Test a trusted assessors model within VHK for patients transferring to STAR/assessment beds

Framework developed. Training and shadowing sessions for staff to be progressed.

Oct 2019On Track

2. Review timescales of social work assessments

Patients requiring single carer for homecare will now be assessed at home.Homecare assessments to be completed within 48 hours.Social work are reviewing timescales.

Sep 2019On Track

3. Moving On Policy to be implemented to support staff where families are refusing choices and/ or where there is no availability of the assessed resource

Policy to be signed off and implemented by winter Nov 2019On Track

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Patient TTGWe will ensure that all eligible patients receive Inpatient or Daycase treatment within 12 weeks of such

treatment being agreedImprovement Target for 2019/20 = 80% (Patients Waiting <= 12 Weeks at month end, as per Scottish

Government Waiting Times Plan)

Local Performance


Recurring gap in IP/DC capacity – Actions 1, 2 and 3

Difficulty in recruiting to Specialist Consultant posts – Actions 1 and 2Current ChallengesDifficulty in staffing additional in-house activity - Actions 1, 2 and 3


1. Secure resources in order to deliver waiting times improvement plan for 19/20

Letter confirming first allocation of funding received Oct 2019On Track

2. Develop and deliver Clinical Space redesign Improvement programme

Meetings established , Bed Modelling exercise underway Mar 2020On Track

3. Theatre Action Group develop and deliver plan

Monthly meetings established, action plan in place. Enabled the provision of additional theatre sessions to support new Consultant Urologist appointments.

Mar 2020On Track

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Cancer 62-Day Referral to TreatmentAt least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 days


Local Performance


Urology 62 day performance (Prostate) – Actions 1 and 2

Cancer Waiting Times ‘education’ – Action 2Delays to steps in pathways for 1st OPA, diagnostic investigations and reporting – Action 2

Current Challenges

Number of breaches in various specialties – Action 3


1. Urology Improvement Group review prostate pathway to minimise wait between each step

Improvements implemented have delivered a reduction in waits to 1st OPA, MRI, TRUS biopsy, and histopathology turnaround times. CNS coordinating bundle booking where appropriate. Completed actions implemented immediately.

Jan 2020On Track

2. Improvement in cancer governance structure and redesign of weekly PTL meeting together with organisation-wide education sessions to ensure clear focus on escalation processes and organisational expectations to improve cancer waiting times performance

Governance structure agreed.Meetings to be arranged and ToRs finalised.CWT education package under development. SOP to be reviewed.Further metrics introduced into the PTL meeting to allow services to manage cancer referral demand and capacity.There is a focus to ensure escalations are acted upon in a timeous fashion.

Oct 2019On Track

3. Robust review of timed cancer pathways to ensure up to date and with clear escalation points

Current pathways to be distributed to teams for review and specific escalation points to be agreed

Jan 2020On Track

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Smoking CessationIn 2018/19, we will deliver a minimum of 490 post 12 weeks smoking quits in the 40% most deprived

areas of FifeImprovement Target for 2019/20 = 473

Local Performance


To improve uptake in deprived communities – Action 1

To increase uptake of Champix – Action 2Current ChallengesTo increase smoking cessation in Antenatal Setting – Action 3


1. Outreach development with Gypsy Travellers in Thornton

Progress has been delayed due to unrest in the community, but we are hoping to re-engage in the next few months

Mar 2020On Track

2. Test effectiveness and efficiency of Champix prescribing at point of contact within hospital respiratory clinic

Plans in progress, monthly meetings with Respiratory Consultant to organise paperwork and process/pathways

Mar 2020On Track

3. 'Better Beginnings' class for pregnant women on Saturday mornings

Plans have progressed and Saturday provision has started - ongoing monitoring in place

Mar 2020On Track

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CAMHS 18 weeks RTTAt least 90% of clients will wait no longer than 18 weeks from referral to treatment


Local Performance


Increased referrals to service – Action 1

Pressure on existing staff – Action 2Current ChallengesImproving efficiency of workload allocation – Action 3


1. Introduction of Primary Mental Health Worker (PMHW) First Contact Appointments System and Group Therapy Programme

Started in April 2019 following SG Action 15 funding. Four additional staff were recruited on 1-year contracts.Impact has been extremely positive with significant amount of C&YP signposted following assessment to alternative service providers.New staff have since moved on to permanent posts, and recruitment has restarted. This is experiencing significant delay.Group programme under way, resulting in 158 C&YP being allocated group places between September and December.

Mar 2020On Track

2. Waiting List Additional Staffing Resource

Additional evening clinics to start in September; it is anticipated that additional C&YP will be allocated individual therapy

Sep 2019 to Feb 2020

Not Started

3. Introduction of Substantive Team Leader Role

Posts in place. Active allocation of appointments underway. Team leaders identifying patients for prioritisation and for evening clinics.

Mar 2020On Track

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Psychological Therapies 18 weeks RTTAt least 90% of clients will wait no longer than 18 weeks from referral to treatment for Psychological

TherapiesImprovement Target for 2019/20 = 82%

Local Performance


To reduce delays for patients with complex needs requiring PTs within care programme approach – Action 1To provide sufficient low-intensity PTs for mild-moderate mental health problems – Action 2To increase capacity in services offering PTs for secondary care patients – Action 3

Current Challenges

To improve triage in Primary Care to improve access to appropriate PTs – Action 4


1. Introduction of single point of access for secondary care patients via CMHT

Underway in 4 of 6 CMHTs; working with e-health to develop SCI gateway option to facilitate

Dec 2019On Track

2. Introduction of Extended Group Programme in primary care, accessible by self-referral

Group programme and self-referral introduced November 2018 via Access Therapies Fife website. Monitoring impact on capacity.

Sep 2019On Track

3. Redesign of Day Hospital provision to support CMHTs

Implementation of redesign underway. Further progress required to impact on capacity for delivery of PTs.

TBD

4. Implementation of mental health triage nurse pilot programme in Primary Care (Action 15 SG)

Staff in post in selected GP Cluster areas; service being well-utilised; evaluation underway (interim report due Sep 2019)

Oct 2019On Track

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Freedom of Information RequestsIn 2019/20, we will respond to a minimum of 85% of FoI Requests within 20 working days

Local Performance

Service Performance

Current ChallengesPerformance deteriorating and variable due to delays in the return of responses from services and pressure on corporate support for finalising responses – Actions 1, 2 and 3


1. Map pathway out and identify areas that have recurring issues with delayed responses

New spreadsheet created to improve ongoing tracking of enquiries and stages of delay

Aug 2019 Complete

2. Improve FoI case recording and monitoring of timeliness of responses

Revised spreadsheet being tested and refined Aug 2019On Track

3. Review enhanced cover arrangements for corporate administration of requests, to improve resilience

Not yet started Sep 2019

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Revenue ExpenditureNHS Boards are required to work within the revenue resource limits set by the Scottish Government

Health & Social Care Directorates (SGHSCD).

Local Performance

Commentary The revenue position for the 4 months to 31 July reflects an overspend of £5.228m. This comprises an overspend of £5.718m on Health Board retained budgets; and an underspend of £0.490m aligned to the Health budgets delegated to the Integration Joint Board (IJB). The key financial challenge in this reported position is the overspend of £5.915m within the Acute Services Division (of which £1.979m overspend relates to a number of Acute services budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but remain managed by the NHS Board). The key driver of the overspend is the shortfall in the level of savings identified and delivered.As previously reported, further work is required as a matter of priority to ensure that savings are identified and deliverable for the Acute Services Division, in support of the Health Board’s statutory requirement to break even. External expertise is being provided through Deloitte LLP to robustly support and challenge the team to design and implement an effective savings programme, with a strong focus on what/when/how much in terms of specific savings proposals. A workshop is scheduled for mid August with a formal update to the Executive Directors Group and Finance, Performance & Resources Committee in September.It is important to note that at this point there has been no IJB risk share factored into the year to date position. However, as reported through the Integration Joint Board, there is a £6.5m gap on the savings programme for 2019/20. If the risk share methodology was applied, this would add a further £1.6m to the in year overspend position (i.e. 4/12ths of 72% of the £6.5m gap), thus potentially increasing the overspend for the period to £6.8m.We continue dialogue with colleagues in the Health Finance Directorate on the impact of any application of the risk share arrangement, on the financial consequences for the NHS Fife Board in relation to the delivery of the statutory financial requirement to break even.In line with previous years, we are required to report a forecast outturn for the year, to Scottish Government, through the monthly Financial Performance Returns (FPR). At this early stage in the year, it is difficult to be entirely definitive on the likely outurn, however initial indications suggest the position ranges from an optimistic outturn overspend of £4.4m to a mid range overspend of £8.8m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.68m (i.e. 72% of the £6.5m gap), nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division. For the purposes of reporting to SGHSCD, therefore, we are proposing to escalate a potential overspend of £9m, being our

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optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings. It is important to note that the most recent forecast overspend on the IJB budget was in excess of the initial £6.5m budget gap; being more than £9m).Within the Scottish Government reporting template we are required to highlight the level of any potential brokerage required to deliver a break even position. Board members are asked to note that we have included a funding request of £4.68m in this respect; this assumes the impact of the social care overspend would require additional external funding and the overspend on the Health Board retained budgets would be managed through local management action.

1. Financial Framework

1.1 The Financial Plan for 2019/20 was approved by the Board on 27 March 2019, with the related Annual Operational Plan approved on 29 May 2019.

2. Financial Allocations

Revenue Resource Limit (RRL)2.1 On 1 August 2019 NHS Fife received confirmation of July core revenue and core

capital allocation amounts. The revised core revenue resource limit (RRL) has been confirmed at £692.701m. A breakdown of the additional funding received in month is shown in Appendix 1 and Appendix 2 shows details of anticipated allocations expected to be received.

Non Core Revenue Resource Limit2.2 NHS Fife also receives ‘non core’ revenue resource limit funding for technical

accounting entries which do not trigger a cash payment. This includes, for example, depreciation or impairment of assets. The Anticipated non core RRL funding of £33,832m is detailed in Appendix 3.

Total RRL2.3 The total current year budget at 31 July is therefore £770.903

3. Summary Position

3.1 At the end of June, NHS Fife is reporting an overspend of £5.228m against the revenue resource limit. Table 1 below provides a summary of the position across the constituent parts of the system: an overspend of £5.718m is attributable to Health Board retained budgets; and an underspend of £0.490m is attributable to the health budgets delegated to the Integration Joint Board.

3.2 Key points to note from Table 1 are:

3.2.1 Acute Division overspend of £5.915m, driven largely as a result of non delivery of savings (£3.100m);

3.2.2 The aforementioned Acute Division overspend includes £1.979m overspend relating to a number of Acute services budgets that are ‘set aside’ for inclusion in the strategic planning of the IJB, but which remain managed by the NHS Board;

3.2.3 Underspend across Estates & Facilities; and3.2.4 Underspend of £0.490m against the Health budgets delegated to the IJB.

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Table 1: Summary Financial Position for the period ended July 2019


Health Board 416,395 424,019 132,262 137,980 5,718 4.32% 2,531 3,187Integration Joint Board - Health 346,358 346,884 115,422 114,932 -490 -0.42% -1,455 965Total 762,753 770,903 247,684 252,912 5,228 2.11% 1,076 4,152


Acute Services Division 197,074 199,775 67,797 73,712 5,915 8.72% 2,815 3,100IJB Non-delegated 8,137 8,141 2,847 2,822 -25 -0.88% -43 18Estates & Facilities 72,826 72,668 23,745 23,639 -106 -0.45% -137 31Board Admin & Other Services 53,110 66,945 29,281 29,357 76 0.26% 38 38Non Fife & Other Healthcare Providers 85,946 85,946 28,627 29,408 781 2.73% 781 0Financial Flexibility & Allocations 23,894 29,614 917 0 -917 -100.00% -917 0Health Board 440,987 463,089 153,214 158,938 5,724 3.74% 2,537 3,187

Integration Joint Board - Core 371,725 393,044 131,925 131,431 -494 -0.37% -1,459 965Integration Fund & Other Allocations 13,074 3,542 0 0 0 0.00% 0 0Sub total Integration Joint Board Core 384,799 396,586 131,925 131,431 -494 -0.37% -1,459 965IJB Risk Share Arrangement 0 0 0 0 0 0.00% 0 0Total Integration Joint Board - Health 384,799 396,586 131,925 131,431 -494 -0.37% -1,459 965

Total Expenditure 825,786 859,675 285,139 290,369 5,230 1.83% 1,078 4,152

IJB - Health -38,441 -49,702 -16,503 -16,499 4 -0.02% 4 0Health Board -24,592 -39,070 -20,952 -20,958 -6 0.03% -6 0Miscellaneous Income -63,033 -88,772 -37,455 -37,457 -2 0.01% -2 0

Net position including income 762,753 770,903 247,684 252,912 5,228 2.11% 1,076 4,152

MemorandumBudget Expenditure Variance split by


4. Operational Financial Performance for the year

Acute Services 4.1 The Acute Services Division reports a net overspend of £5.915m for the year to

date. This reflects an overspend in operational run rate performance of £2.815m, and unmet savings of £3.100m. Within the run rate performance, pay is overspent by £2.106m. The overall position has been driven by a combination of unidentified savings and continued pressure from the use of agency locums, junior doctor banding supplements, incremental progression and nursing recruitment in line with workforce planning tool. Balancing finance and other performance targets across the Acute Services whilst seeking to identify recurring efficiency savings proved challenging. Further details of the position, by Directorate are set out below:

Table 2: Acute Division Financial Position for the period ended July 2019


Acute Services Division- Planned Care & Surgery 67,161 68,566 23,483 25,061 1,578 6.72% 439 1,139- Emergency Care & Medicine 73,578 74,518 25,792 28,354 2,562 9.93% 1,698 864- Women, Children & Clinical Services 53,542 53,853 17,982 19,483 1,501 8.35% 404 1,097- Acute Nursing 647 667 196 180 -16 -8.16% -16- Other 2,146 2,171 344 634 290 84.30% 290

0.00%Total 197,074 199,775 67,797 73,712 5,915 8.72% 2,815 3,100


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Estates & Facilities4.2 The Estates and Facilities budgets report an under spend of £0.106m which can be

broken down into under spend of £0.137m on run rate and unmet savings of £0.030m. The run rate net under spend is generally attributable to vacancies, energy and water and property rates, and partially offset by an overspend on property maintenance.

Corporate Services4.3 Within the Board’s corporate services there is an overspend of £0.076m .This

comprises an under spend on run rate of £0.038m as offset by unmet savings of £0.038m. Further analysis of Corporate Directorates is detailed per Appendix 4.

Non Fife and Other Healthcare Providers4.4 The budget for healthcare services provided out with NHS Fife is overspent by

£0.781m. This remains an area of increasing challenge particularly given the relative higher costs of some other Boards. Further detail is attached at Appendix 5.

Financial Plan Reserves & Allocations4.5 Financial plan expenditure uplifts including supplies, medical supplies and drugs uplifts

were allocated to budget holders from the outset of the financial year, and therefore form part of devolved budgets. A number of residual uplifts are held in a central budget and will be subject to robust scrutiny and review each month. The detailed review of the financial plan reserves at Appendix 6 allows an assessment of financial flexibility for the year to date. As in every financial year, this ‘financial flexibility’ allows mitigation of slippage in savings delivery, and is a crucial element of the Board’s ability to deliver against the statutory financial target of a break even position against the revenue resource limit. Integration Services

4.6 The health budgets delegated to the Integration Joint Board report an underspend of £0.490m for the year to date. This position comprises an under spend in the run rate performance of £1.455m; together with unmet savings of £0.965m. The underlying drivers for the run rate under spend are vacancies in community nursing, health visiting, school nursing, community and general dental services across Fife Wide Division. The aforementioned under spend is partly offset by locum costs within mental health services, inpatient service costs within East and West.

4.7 The key financial risk in relation to the Health & Social Care Partnership is the overall gap on the IJB budget of £6.5m (comprising an under delivery of £7.2m on social care and over delivery of £0.7m on delegated health budgets) and the increasing overspend on social care budgets seen in the first quarter of the year. The Integration Scheme for the IJB describes the steps required to manage any overspend:

“Process for resolving budget variances in year - Overspend

8.2.1 The Director of Health & Social Care will strive to deliver the outcomes within the total delegated resources. Where there is a forecast overspend against an element of the operational budget, the Director of Health & Social Care, the Chief Finance Officer of the Integration Joint Board, Fife Council’s Section 95 Officer and NHS Fife’s Director of Finance must agree a recovery plan to balance the total budget. The recovery plan shall be subject to the approval of the Integration Joint Board.

8.2.2 The Integration Joint Board may increase the payment to the affected body, by either:

utilising an underspend on the other arm of the operational Integrated Budget to reduce the payment to that body; and/or

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utilising the balance on the integrated general fund, if available, of the Integration Joint Board in line with the reserves policy.

8.2.3 If the recovery plan is unsuccessful and there are insufficient integrated general fund reserves to fund a year-end overspend, then the Parties with agreement of the Integration Joint Board shall have the option to:

Make additional one-off payments to the Integration Joint Board; or Provide additional resources to the Integration Joint Board which are then

recovered in future years, subject to scrutiny of the reasons for the overspend and evidence that there is a plan in place to resolve this.

8.2.4 Any remaining overspend will be funded by the Parties based on the proportion of their current year contributions to the Integration Joint Board.

4.8 In previous years, and in agreement with Fife Council colleagues, we have managed the overspend on the IJB through the risk share arrangement described at 8.2.4 of the Integration Scheme. However, as discussed and agreed through the Finance, Performance & Resources Committee in February 2019, the Annual Operational Plan for 2019/20 was predicated on the assumption that the Chief Executive and Director of Finance would actively pursue discussions with the Director of Health & Social Care and Fife Council colleagues that the risk share approach would not be the immediate option. Instead, the application of an earlier clause (ie a further recovery plan per 8.2.1, or each party to cover their own position per 8.2.3) was preferable.

Income4.9 A small over recovery in income of £0.002m is shown for the year to date.

5. Pan Fife Analysis

5.1 Analysis of the pan NHS Fife financial position by subjective heading is summarised in Table 3 below.

Table 3: Subjective Analysis for the Period ended July-19

Annual Budget

Budget Actual Net over/ (under) spend

Pan-Fife Analysis £'000 £'000 £'000 £'000Pay 366,117 122,615 123,377 762GP Prescribing 74,106 24,102 23,903 -199Drugs 30,815 10,989 10,606 -383Other Non Pay 367,951 130,668 132,483 1,815IJB Risk Share 0 0 0 0Efficiency Savings -12,470 -4,152 0 4,152Commitments 33,156 917 0 -917Income -88,772 -37,455 -37,457 -2Net underspend 770,903 247,684 252,912 5,228

Pay

5.2 The overall pay budget reflects an overspend of £1.8152m. There are under spends across a number of staff groups which partly offset the overspend position within medical and dental staff; the latter being largely driven by the additional cost of supplementary staffing to cover vacancies and also nursing.

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5.3 Against a total funded establishment of 7,669 wte across all staff groups, there was 7,713 wte staff in post in July.

Drugs & Prescribing 5.4 Across the system, there is a net under spend of £0.582m on medicines of which an

underspend of £0.199m is attributable to GP Prescribing and an under spend of £0.383m relating to sexual health and rheumatology drugs. The GP prescribing position is based on 2018/19 trend analysis and April & May 2019 actual information.

Other Non Pay5.5 Other non pay budgets across NHS Fife are collectively overspent by £1.815m.The

overspends are in purchase of healthcare, other supplies, property & hotel expenses and surgical sundries. These are offset by under spends across a number of areas including energy and diagnostic supplies.

6 Financial Sustainability

6.1 The Financial Plan presented to the Board in March highlighted the requirement for £17.333m cash efficiency savings to support financial balance in 2019/20. The Plan was approved with a degree of cautious optimism and confidence that the gap would be managed in order to deliver a break even position in year 1 of the 3 year planning cycle. As reported to the Board in March, this view was entirely predicated on a robust and ambitious savings programme across Acute Services and the Health & Social Care Partnership; supported by ongoing effective grip and control on day to day expenditure and existing cost pressures; and early identification and control of non recurring financial flexibility.

6.2 The extent of the recurring / non recurring savings delivery for the year is illustrated in Table 4 below.

Table 4: Savings 2019/20

Savings 2019/20 Target Identified

& Achieved Identified

& Achieved Total Identified

& Achieved Recurring Non-Recurring to date Outstanding

£'000 £'000 £'000 £'000 £'000

Health Board 10,873 863 438 1,301 9,572

Integration Joint Board 6,460 1,435 2,127 3,562 2,898

Total Savings 17,333 2,298 2,565 4,863 12,470

7 Key Messages / Risks

7.1 As described above, the most significant financial risk is the non-delivery and identification of savings; particularly within the Acute Services Division and the impact of the IJB overspend if the risk share arrangement is enacted.

7.2 At this early stage in the year, it is difficult to be entirely definitive on the likely outurn for the year, however initial indications suggest the position ranges from an optimistic year end overspend of £4.4m to a mid range overspend of £8.8m. This does not include the impact of the risk share arrangement for the IJB position i.e. a further £4.7m, nor does it include any beneficial impact of the work commissioned to drive savings within the Acute Services Division.

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7.3 For the purposes of reporting to SGHSCD, we are proposing to escalate a potential overspend of £9m, being our optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings.

8 Recommendation


Note the reported overspend of £5.228m for the year to 31 July 2019;

Note the additional overspend of £1.6m for the year to 31 July 2019, which would result if the risk share arrangement was applied to the current full year gap for the Integration Joint Board;

and

Note the potential (draft) outturn position of £9m reflecting an optimistic forecast (recognising the Acute position may improve) plus the risk share impact of the shortfall in the overall IJB savings.

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Appendix 1 – Core Revenue Resource Limit

BaselineRecurring

Earmarked Recurring

Non-Recurring Total Narrative

£'000 £'000 £'000 £'000

May-19 Opening 662,752 662,752May Adjustments -696 -229 -925

Jun-19 June Adjustments 16,293 3,774 6,265 26,332 Year 2 fundingJul-19 Advanced Breast Practtioner in Radiography Pilot 36 36

General Dental Services Element of Public Dental Service 2,091 2,091Annual Allocation- Salaried Dental Service

Impementation of Best Start 75 75 Additional fundingFamily Nurse Partnership 1,276 1,276 Annual Allocation

Breastfeeding PfG Year 2 78 782 year of Programme for Government

Patient Advice & Support Service -39 -39 Annual ContributionExcellence in Care 70 70 Funding for EIC Lead

Excellence in Care eHealth 20 20eHealth funding to support EIC Lead

Increase provision of Insulin pumps for adults and CGMs 162 162

3 year of funding to increase access to insulin pump therapy and increase availability of Continious Glucose Monitors

Mental Health Strategy Action 15 Workforce First Tranche 811 811 First 70% of annual allocationDiscovery -38 -38 Annual Contribution

Total Core Revenue Allocation 678,349 6,638 7,714 692,701

Appendix 2 – Anticipated Core Revenue Resource Limit Allocations

£'000CAMHS Regional post 35Distinction Awards 230Research & development 843NDC Contribution -844Community Pharmacy Pre-Reg Training -44New Medicine Fund 3,005Golden Jubilee SLA -24Waiting List 1,675NSD risk share -2,566Scotstar -321PET scan -477Depreciation to Non-core -12,820Primary Medical Services 50,114Mental Health Bundle 620Primary Medical Services Bundle 1,718Community Pharmacy Champions 19Capacity Building CAMHS & PT 456Mental health innovation fund 288Veterans First Point Transisition Funding 114Pharmacy Global Sum Calaculation -1,346Men C -16Primary Care Fund GP sub Committee 34ADP 1,157Primary Care Improvement Fund 2,520

Total 44,370

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Appendix 3 – Anticipated Non Core Revenue Resource Limit Allocations Appendix 3 - Anticipated Non Core Revenue Resource Limit Allocations

£'000PFI Adjustment 3,374Donated Asset Depreciation 119Impairment 8,000AME Provision 2,000IFRS Adjustment 5,019Non-core Del 2,500Depreciation from Core allocation 12,820Total 33,832

Appendix 4 - Corporate Directorates

Cost Centre CY Budget

£'000YTD Budget

£'000YTD Actuals

£'000YTD Variance

£'000E Health Directorate 10,430 3,317 3,340 23Nhs Fife Chief Executive 207 72 81 9Nhs Fife Finance Director 5,114 1,692 1,540 -152Nhs Fife Hr Director 3,013 1,008 977 -31Nhs Fife Medical Director 6,330 1,871 1,821 -50Nhs Fife Nurse Director 3,417 1,124 1,445 321Nhs Fife Planning Director 1,901 638 569 -69Legal Liabilities 15,519 12,828 12,922 94Public Health 2,092 686 642 -44Early Retirements & Injury Benefits 629 92 64 -28External & Internal Audit 151 50 53 3Regional Funding 217 107 107 0Depreciation 17,926 5,796 5,796 0Total 66,946 29,281 29,357 76

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Appendix 5 – Non Fife & Other Healthcare Providers

CY Budget £'000

YTD Budget £'000

YTD Actuals £'000

YTD Variance

£'000Health BoardAyrshire & Arran 95 32 19 -13Borders 43 15 17 2Dumfries & Galloway 24 8 20 12Forth Valley 3,089 1,028 1,110 82Grampian 349 116 104 -12Highland 131 44 73 29Lanarkshire 111 37 51 14Scottish Ambulance Service 98 33 35 2Lothian 30,600 10,200 9,982 -218Greater Glasgow 1,607 536 515 -21Tayside 39,772 13,257 13,380 123

75,919 25,306 25,306 0UNPACSHealth Boards 8,063 2,688 3,331 643Private Sector 1,209 403 534 131

9,272 3,091 3,865 774

OATS 690 230 237 7

Grants 65 0 0 0

Total 85,946 28,627 29,408 781

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Appendix 6 – Financial Flexibility and Allocations

Financial Flexibilty

Released to July-19

£'000 £'000 Financial Plan

Drugs 4,432 0

Complex Weight Management 50 0

Adult Healthy Weight 104 0

National Specialist Services 121 0

Band 1's 307 103

Unitary Charge 263 20

Junior Doctor Travel 118 7

Consultant Increments 50 17

Discretionary Points 231 0

Cost pressures 4,883 713

Financial Flexibility 926 57

Subtotal Financial Plan 11,485 917

Allocations

Health Improvement 112 0

AME Impairments 8,000 0

AME Provisions 2,412 0

Pay Awards 1,398 0

Distinction Awards 37 0

Waiting List 5,254 0

CAMHS Post 35 0

Best Start 414 0

6EA Unscheduled Care 250 0

Advanced Breast Practitioner Radiology 36 0

Excellence in care 20 0

Insulin Pumps & CGM 161 0

Subtotal Allocations 18,129 0 Total 29,614 917

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Capital ExpenditureNHS Boards are required to work within the capital resource limits set by the Scottish

Government Health & Social Care Directorates (SGHSCD)

Local Performance

Capital Programme Expenditure

CommentaryThe total Capital Resource Limit for 2019/20 is £7.394m. The capital position for the 4 months to July shows investment of £0.653m, equivalent to 8.83% of the total allocation. Plans are in place to ensure the Capital Resource Limit is utilised in full.

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1. INTRODUCTION

1.1 The Capital Plan 2019/20 was approved by the NHS Board on 27 March 2019. For information, changes to the plan since its initial approval in March are reflected in Appendix 1. On 3 June 2019 NHS Fife received confirmation of initial core capital allocation amounts of £7.394m gross. NHS Fife is anticipating an additional £2m allocation for the new Elective Orthopaedic Centre.

2. CAPITAL RECEIPTS

2.1 The Board’s capital programme is partly funded through capital receipts which, once received, will be netted off against the gross allocation highlighted in 1.1 above. Work continues on asset sales with several disposals planned:

Lynebank Hospital Land (Plot 1) (North) – Under offer; Forth Park Maternity Hospital – Sale completed 5th August 2019; Fair Isle Clinic – Under offer; Skeith Land – preparing to market; and ADC – Sale due to complete imminently

3. EXPENDITURE TO DATE / MAJOR SCHEME PROGRESS

3.1 Details of the expenditure position across all projects are attached as Appendix 2. Project Leads have provided an estimated spend profile against which actual expenditure is being monitored. This is based on current commitments and historic spending patterns. The expenditure to date amounts to £0.653m or 8.83% of the total allocation, in line with the plan, and as illustrated in the spend profile graph above.

3.2 The main areas of investment to date include:

Statutory Compliance £0.271mMinor Works £0.070mEquipment £0.211mE-health £0.040m

4. CAPITAL EXPENDITURE OUTTURN

4.1 At this stage of the financial year it is currently estimated that the Board will spend the Capital Resource Limit in full.

5. RECOMMENDATION


note the capital expenditure position to 31 July 2019 of £0.653m and the forecast year end spend of the capital resource allocation of £7.394m

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Staff Governance

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Sickness AbsenceTo achieve a sickness absence rate of 4% or less

Improvement Target for 2019/20 = 4.89%

Local Performance


Sickness Absence Rate Significantly Above Standard – Action 1Current Challenges

High Level of Sickness Absence Related to Mental Health – Action 2


1. Targeted Managerial, HR, OH and Well@Work input to support management of sickness absence

This is being progressed through Attendance Management Leads within their respective areas, HR Officers / Advisors, and through the trajectory reporting for each business unit and use of the RAG status reports. Plan for additional OH support being developed.

Sep 2019On Track

2. Early OH intervention for staff absent from work due to a Mental Health related reason

This has been in place since March 2019 and will be reviewed in six months

Oct 2019On Track

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PAUL HAWKINSChief Executive21st August 2019

Prepared by:CAROL POTTERDirector of Finance and Performance

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