COMMUNITY HEALTH PARTNERSHIP +

A MODEL FOR SHETLAND

Draft Scheme of Establishment

December 2004

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Contents

Page

1.0 Introduction: 5

Process of Developing the CHP 5

2.0 Aims 7

3.0 Improving Services: 8

Improving Outcomes 8

Range of Services 9

Service Planning 12

2020 Vision 12

Joint Future 14

Children‟s Services 16

Drug and Alcohol Services 18

Service Redesign 19

4.0 Improving Health: 20

Joint Health Improvement Plan 20

5.0 Organisational Arrangements: 22

CHP Committee 22

CHP Management Arrangements 24

Board-wide Services 25

Commissioning Team 27

LHCC Professional Committee 27

Locality Arrangements 28

6.0 Working in Partnership: 33

Patient Focus Public Involvement 33

Public Partnership Forum 35

Linking Clinical and Care Teams 36

Clinical Governance 37

Involving Staff 39

Voluntary Sector 40

7.0 Building Workforce Capacity: 41

Developing Roles 41

Workforce Development 41

Development Plans 42

8.0 Finance and Accountability: 43

Local Partnership Agreement 44

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List of Tables: Page

Table 1 - CHP Range of Services 10

List of Figures: Page

Figure 1 - Strategic Planning Group Framework 13

Figure 2 - Pyramid of Service Provision 14

Figure 3 - Joint Future Specialist Services 15

Figure 4 - Joint Future Generic Services 16

Figure 5 - Childrens Services Groups 17

Figure 6 - Joint Health Improvement Framework 21

Figure 7 - Shetland NHS Board Committee Structure 22

Figure 8 - CHP Committee Membership 23

Figure 9 - CHP Management Structure 24

Figure 10 - Shetland NHS Board Organisational Structure 26

Figure 11 - Stage One Locality Organisational Arrangements 30

Figure 12 - Stage Two Locality Organisational Arrangements 31

Figure 13 - Shetland NHS Board PFPI Structure 33

Figure 14 - Shetland NHS Board Clinical Governance Structure

37

Figure 15 - Links Between Staff and Shetland NHS Board 39

List of Appendices: Appendix A - CHP Development Summary

Appendix B - Health Targets

Appendix C - CHP Development Plan

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List of Abbreviations Used

ADPS Assistant Director of Patient Services

AHP Allied Health Professional

CADO Chief Area Dental Officer

CGCG Clinical Governance Co-ordinating Group

CGST Clinical Governance Support Team

CHD Coronary Heart Disease

CHP Community Health Partnership

CHP GM Community Health Partnership General Manager

DPH Director of Public Health

DPS Director of Patient Services

ELPA Extended Local Partnership Agreement

GDP General Dental Practitioner

GP General Practitioner

HR Human Resources

JFIG Joint Future Implementation Group

JHiMP Joint Health Improvement Plan

JPIF Joint Performance Information and Assessment Framework

LHC Local Health Council

LHCC Local Health Care Cooperative

LPF Local Partnership Forum

MCN Managed Clinical Network

MSM Medical Services Manager

NHS National Health Service

PAF Performance Assessment Framework

PFPI Patient Focus Public Involvement

PPF Public Participation Forum

QIS Quality Improvement Scotland

SADAT Shetland Alcohol & Drugs Action Team

SEHD Scottish Executive Health Department

SIC Shetland Islands Council

SMT Senior Management Team

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1. INTRODUCTION

1.1 Community Health Partnerships (CHP) are a key part of the Scottish

Executive‟s plans for improving health and health services. Section 2 of the National Health Service Reform (Scotland) Act 2004, which came into force in full on 30th September 2004, inserted a new section 4A and 4B into the National Health Service (Scotland) Act 1978 and provides for the establishment of CHPs by all Health Boards in Scotland.

1.2 The background to the development of CHPs is contained in the Scottish

Health White Paper ‘Partnership for Care’ (February 2003). It stated that Local Health Care Co-operatives (LHCCs) should evolve into CHPs, which would have a new and more consistent role in service planning and delivery, working as part of a decentralised but integrated health and social care system. The White Paper stated that CHPs would:

ensure that patients, carers and the full range of healthcare professionals are fully involved;

establish a substantive partnership with local authority services;

have a greater responsibility and influence in the deployment of resources by the NHS Board;

play a central role in service redesign locally;

focus on integrating primary and specialist health services at local level;

play a pivotal role in delivering health improvement for their local communities.

1.3 The establishment and development of the CHP is one of the key building

blocks for the modernisation of the NHS in Shetland. It also has to be set within a wider context, including the better integration of services across the NHS, more effective partnership working with the local authority and other local agencies including the independent (voluntary and not-for-profit) sector as part of community planning and Joint Future and greater public, patient, carer and staff involvement. All of this is aimed at making a direct impact on improving the health of local communities, which is a responsibility of all public sector agencies, and to provide high quality, accessible and “joined up” services. The development of the CHP in Shetland must be seen as part of the ongoing programme of development and modernisation in public services.

The Process of Developing the CHP 1.4 Shetland NHS Board is a unified Board and has not had to go through the

organisational changes that Health Board areas in mainland Scotland have faced over the last few years. Serving a population of approximately 22,000 people, health service boundaries are co-terminous with Shetland Islands Council (SIC), a unitary local authority. For these reasons some significant progress has been made in recent years in terms of the integration of services and the development of partnership working both within the health service, with the local authority and partner agencies and with patients, users, carers and local communities. There is still however much to be done and the

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development of the CHP will be integral in taking forward the health and social care agenda in Shetland over the next few years.

1.5 Over the last 12 months Shetland NHS Board has been actively working to

consider the development of the CHP. In considering the CHP, the process has been one of looking at and building upon what we have in place in Shetland. This process aimed to be as inclusive as possible and looked to provide through various different forums, opportunities for individuals, groups of staff, different organisations and agencies and members of the public to contribute to the development of the CHP. A summary of the activity undertaken over the last 12 months is outlined in Appendix A.

1.6 A formal consultation paper on the proposed development of the CHP was

widely distributed in August 2004. The consultation paper sought feedback on a range of questions about the development of the CHP and responses were sought by 30th September 2004. Opportunities were provided for different staff and patient groups during the consultation period to meet to discuss the development of the CHP. A wide variety of responses to the consultation paper were received and these comments have been incorporated into the Scheme of Establishment.

1.7 At its meeting in July 2004 the Community Planning Board agreed to support

the establishment of a short-life CHP Steering Group to oversee the work that will be involved in establishing the CHP prior to April 2005. Membership of this Steering Group is as follows:

2 x Community Planning Board members (one of which to be chair) – Executive Director SIC Community Services & Chief Executive Shetland Enterprise;

LHCC Manager;

Community Care Manager;

Senior Nurse – Community;

Area Clinical Forum members (2 GPs, 1 pharmacist, 1 nurse, 1 dentist, 1 AHP);

Head of Service – Community Development, SIC;

Community Learning & Development Manager, SIC;

Head of Environment, SIC

Voluntary Sector representative;

Patient/User representative.

1.8 The draft Scheme of Establishment was presented to the SIC Services

Committee on 2nd December and then to the Shetland NHS Board meeting on 7th December for formal approval prior to submission to the Scottish Executive.

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2. AIMS 2.1 The Statutory guidance produced by the Scottish Executive Health

Department (SEHD) in October 2004 sets out what CHPs are expected to do as follows:

deliver services more innovatively and effectively by bringing together those who provide community based health and social care services;

shape services to meet local needs by directly influencing NHS Board level planning, priority setting and resource allocation;

integrate health services, both within the community and with specialist services, underpinned by service redesign and clinical networks, and by appropriate contractual, financial and planning mechanisms;

improve the health of local communities, tackle inequalities and promote policies that address poverty and deprivation by working within community planning frameworks;

be the main NHS agent through which the Joint Future agenda is delivered in partnership with local authorities and the voluntary sector;

be the main NHS agent through which the recommendations of For Scotland’s Children are implemented in partnership with local authorities;

be the principal NHS partner in Integrated Community and Health Promoting Schools;

lead the implementation and monitoring of child health surveillance and relevant aspects of screening of children;

promote involvement of, and partnership with, staff whether employed by or contracted to the NHS; and

secure effective public, patient and carer involvement by building on existing or developing new mechanisms.

2.2 The following sections of the Scheme of Establishment outline how the CHP

will be established, implemented and developed in Shetland to meet the aims highlighted above, whilst also ensuring that the key elements contained with the CHP Statutory guidance are evidenced.

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3. IMPROVING SERVICES

Improving Outcomes 3.1 One of the key themes and expectations from the outset of the CHP will be to

improve outcomes. During the development of the CHP, a key point to emerge from the local consultation was the need for there to be demonstrable gains for patients, users, carers, staff and communities. With that in mind, it was important from the outset of the CHP that there was a process to highlight the outcomes for the CHP.

3.2 There are already a wide range of performance and outcome measures

available, whether solely within NHS Shetland and the SIC or jointly between the two agencies. There are also performance and outcome measures across Community Planning.

3.3 The future development of the CHP Performance Assessment Framework

(PAF) by the Scottish Executive will ultimately strongly influence the key targets and outcome measures for the CHP. Until such time as the CHP PAF is developed, rather than look to put in place additional or new performance/outcome measures, it is proposed from the outset that the CHP will take a greater enhanced local role in the achievement of the current performance and outcome measures. Examples of this are outlined below:

Within the joint Health and Community Care Plan, there are a range of targets across a series of national and local priorities. The CHP will have an impact on the achievement of these targets across the priority areas.

The CHP will have a positive overall influence on the NHS Board‟s waiting times by developing services in primary care and influencing demand.

The CHP will have an impact on the achievement of national and local health improvement targets (further detail in paragraph 4.2 on page 20).

The CHP will work with the SIC to set, monitor and review the Local Improvement Targets for Joint Future.

There are Quality Improvement Scotland (QIS) standards around a series of specific disease groups and services, for example diabetic retinopathy screening, acute care for stroke. As part of the managed clinical network (MCN) quality assurance framework, the range of services shall be monitored and assessed against these standards, which will include measurable indicators to highlight progress and improvement. The development of MCNs has a substantial primary care base and will be a key focus for the CHP concerning linking clinical and care teams (refer to page 36).

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Range of Services 3.4 The LHCC in Shetland was established in October 2001. It has, to date,

concentrated on developing and managing primary medical and community nursing services. Functional links and partnership working rather than formal line management arrangements have characterised its evolvement. This approach, given the size of Shetland NHS Board and positive working relationships has successfully supported developments.

3.5 In order to manage the transition from the „voluntary‟ medical and nursing

focussed LHCC into the statutory CHP, the function, range of services, structure and linkages to other parts of the NHS Board and other agencies has been considered. These discussions have been influenced by a range of factors from the statutory guidance, to key messages that have arisen from the consultation on the development of the CHP. Some of the common themes that emerged during the consultation were the need to build on the existing work of the LHCC, the need to not lose but ultimately build on the current good partnership working, the need to not create additional bureaucracy and the desire to not change things for the sake of change i.e. „if it isn‟t broke no need to fix it‟. This does not mean that change is not necessary and there are a number of areas where it is believed that change is required and that the advent of the CHP will look to develop and improve services.

3.6 If all the services recommended within the statutory national guidance are

wholly transferred to the CHP, it would likely create imbalances within Shetland NHS Board, leading to the introduction of changes which would not add value to patient care and introduce potential change in areas of service that are currently working well. In examining the range of services that will be devolved to the CHP, it has been agreed to initially create a system of structural and functional relationships leading to increased matrix working as opposed to introducing a complete new structure within the NHS Board.

3.7 There will a single CHP for Shetland and the catchment area shall be the

existing NHS Board and local authority area. The initial range of services that will be devolved to the CHP from 1st April 2005 is outlined in Table 1 on page 10. This highlights the services which the CHP will directly manage or provide or have a lead role co-ordinating as well as how the CHP will through the functional relationship have some influence on the delivery of a particular service.

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Table 1 – CHP Range of Services

Service Inclusion in CHP

Management Link Representation on CHP Committee

Primary medical services

Core CHP General Manager (GM) and Clinical Lead

GP

General dental services

Core Functional link - CADO/GDPs to CHP GM

Chief Administrative Dental Officer

Community pharmaceutical services

Core Function link -

Chief Pharmacist to CHP GM

Community Pharmacist

General ophthalmic services

Core CHP GM Optometrist

Community nursing, midwifery & health visiting

Core CHP Lead Nurse CHP Lead Nurse

Chiropody / podiatry Core

CHP GM Assistant Director of Patient Services / AHP

Allied health professionals

Functional link

ADPS link to CHP GM Assistant Director of Patient Services / AHP

Mental health and psychological services

Core

CHP GM Consultant Psychiatrist

Community child health services

Core CHP Lead Nurse CHP Lead Nurse

Relevant aspects of child and adolescent mental health services

Core CHP GM Consultant Psychiatrist

School health services

Core CHP Lead Nurse CHP Lead Nurse / DPH

Home based services for children with complex needs

Functional link

CHP Lead Nurse link to DPH

CHP Lead Nurse /

DPH

Services for vulnerable groups of children

Functional link

CHP Lead Nurse link to DPH

CHP Lead Nurse /

DPH

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Service Inclusion in CHP

Management Link Representation on CHP Committee

Family Support Services

Functional link

CHP Lead Nurse link to DPH

CHP Lead Nurse /

DPH

Drug and Alcohol Services

Functional link

CHP GM link to DPH DPH as Chair of SADAT

Sexual and Reproductive Health Services

Core Clinical Lead / CHP Lead Nurse

CHP Lead Nurse / GP / DPH for health promotion aspects

Oral Health Action Teams

Core Functional link -

CADO to CHP GM

CADO

Joint Learning Disability Service

Core Community Care Manager

Community Care Manager

Services for people with sensory and/or physical disabilities

Core Community Care Manager

Community Care Manager

Respite or short break services for all client groups

Core Community Care Manager

Community Care Manager

Joint health and social care for older people

Core Community Care Manager

Community Care Manager

Community assessment, rehabilitation and palliative care

Core Community Care Manager

Community Care Manager

Community based health promotion and health protection functions

Function link (core for primary care health promotion and protection)

Functional link to CHP GM and clinical lead through DPH/Health Promotion Manager and Public Health Nurse

DPH

Support to community based services provided by the voluntary sector

Functional link

Link through CHP GM Voluntary services representative on CHP

Community based unscheduled care

Core CHP GM CHP GM

3.8 The CHP will need time to establish itself and as the CHP evolves, the range

of services will be reviewed and where it is deemed appropriate in terms of adding value to patient care and/or organisational benefits can be accrued, the range of services within the CHP may change.

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Service Planning 3.9 In Shetland there is a well established framework of strategic planning, which

looks to integrate service planning and partnership initiatives, particularly between Shetland NHS Board and Shetland Islands Council. This strategic planning framework sees a number of strategic planning groups for the main national and local strategic priorities (refer to Figure 1 on page 13) comprising key stakeholders from service commissioners, service providers as well as users and carers. These strategic planning groups provide the focus for the development of proposals and take a lead in the development of the strategy for that particular area of service for inclusion in the joint Health and Community Care Plan between the NHS Board and the SIC. Members of the CHP will play an active role in all the Board‟s strategic planning groups.

3.10 The CHP General Manager (GM) will be a full member of the Board‟s Senior

Management Team and will also be a full member of the Board‟s Capital Management Forum, where capital planning is undertaken. The CHP will influence the Community Planning Board through the Director of Public Health (DPH) and the Executive Director - Community Services. How the CHP will evolve as part of the Community Planning framework is outlined in Figure 12 on page 31.

2020 Vision 3.11 2020 Vision is a NHS Shetland led project that is considering future health

and care services across all agencies, beyond current 3 – 5 year plans, to recognise long terms goals for healthcare in Shetland. Looking to the future, consideration is given to issues that we know we will face (e.g. an ageing population, rising public expectations) while taking advantage of ways that we can improve what we do now (by incorporating new technology, making the most of working with other agencies, working across professional boundaries). This will help build a sustainable health and care service for Shetland to suit the future population health and care needs and their expectations.

3.12 Change over the next 20 years is inevitable and will be influenced by factors

such as statutory guidance on working hours, rising patient expectations, an ageing population, shortage of healthcare professionals and rising professional standards. One size doesn‟t fit all – as a remote and rural area, Shetland services are delivered in the context of local challenges and must suit the local population. 2020 Vision is giving the Board a chance to look for at how these issues might affect Shetland. With knowledge of specific local issues such as transport (both within and out-with Shetland) and more general factors such as the local economy and environment, the Board and partner agencies are perfectly placed to do this.

3.13 2020 Vision will outline a framework within which the Board and other partner

agencies will build future health and care services for Shetland. The establishment and development of the CHP will play a crucial part in delivering the vision within the local communities of Shetland and is an essential consideration as part of the project.

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Figure 1 – Strategic Planning Group Framework

Shetland NHS

Board

Shetland Islands Council

Shetland Enterprise Association

of Community

Councils

Northern Constabulary

Users Carers

Voluntary Sector General Public

Health Action Team Social Forum Older Peoples Strategy Group Ensuring Equal Opportunities Group Mental Health Strategy Group Children & Young People‟s Services Disability Strategy Group Planning Group (CYPSPG) Alcohol & Drugs Action Team Health & Homelessness Strategy Group Taskforce on Cancer & Palliative Care CHD Strategy Group Stroke Strategy Group Local Diabetic Services Advisory Group Dental Health Strategy Group

COMMUNITY

PLANNING

BOARD

Community Health Partnership

Responsibility for development of jointly

managed services

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Joint Future 3.14 The Joint Future Implementation Group (JFIG) is the existing mechanism

through which Shetland NHS Board and the SIC oversee the range of Joint Future services. It is proposed that from 1st April 2005, JFIG would be subsumed into the CHP. The Joint Future management model is outlined in Figure 3 on page 15.

Figure 2 – Pyramid of Service Provision

3.15 Figure 2 represents a simple model outlining the range of services provided. Those people with the most complex and profound needs are at the apex of the pyramid and those with less complex needs are at the base. The aim is to get the care that people need as close to the generic services end as possible, whilst recognising that people will span across the range of services provided depending on the complexity of care and input that they require.

3.16 The Joint Future management model outlined in Figure 3 outlines the organisational structure for the range of specialist services. Each strategy group would link with one or more multi-agency, multi-disciplinary operational management teams. The strategies they produce inform and drive the work of the management teams. Each management team would have a team leader who sits on the Joint Future Management Team chaired by the Community Care Manager, who is jointly employed by the Board and the SIC as the lead officer for Joint Future locally. The post holder will be responsible through the Executive Director - Community Services and the CHP General Manager for the planning, provision and quality of all joint community care services provided or commissioned by SIC and the Board.

spec

iali

st

generi

c

1. Very specialised services;

often off-Shetland

2. Specialised services:

e.g. by care group

3. Generic services;

Available in most localities

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Figure 3 – Joint Future Specialist Services

3.17 The strategy group for mental health services will become the local Mental

Health Partnership and will provide a single over-arching strategic approach in the planning, resourcing and the development of integrated mental health services. The Partnership will have the key steering role in the implementation of the Joint Local Implementation Plan (JLIP).

3.18 The operational management teams would each have an action plan derived

from the strategy for their locality or specialist service area/care group. The action plans would be consistent with Joint Future/CHP aims and objectives.

3.19 Operational teams would be free to act within broad guidelines and delegated

pooled/aligned budgets. 3.20 The team leader would be responsible for ensuring that performance and

expenditure is monitored and reported regularly to the Joint Future Management Team.

Older People’s

Strategy Group

Disability Strategy

Group

Mental Health

Strategy Group Housing Strategy

Group

Older People’s

Services Team

Learning

Disability

Team

Physical Disability

& Sensory

Impairment Team

Mental Health

Team

Supported

Accommodation

Team

Joint Future

Management Team

Joint Future Implementation

Group (JFIG)

CHP from 1/04/05

Joint Future Joint Staff

Forum

Training

Forum HR, Training

& OD Team

Local partnership

Finance Team

Single Shared

Assessment & Care

management

OT

Discharge

Planning Group

SADAT

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3.21 The teams would provide the support structure for frontline practitioners/professionals who would be able to act independently to meet needs in their locality or field of expertise.

3.22 The Joint Future Management Team would lead on overarching pieces of

work e.g. independent advocacy, services for carers. Figure 4 - Joint Future Generic Services

3.23 Figure 4 outlines the organisational arrangements for the range of generic services across Joint Future. Each locality-based Service Delivery Group would include a wide range of service users, representatives of the local community council and the councillor for the area. The operational management team would bring together professionals from agencies operating in each locality. The detailed model at this level is outlined in Figure 12 on page 31.

3.24 The CHP will assume overall responsibility for implementing the Joint Future

Extended Local Partnership Agreement (refer to page 44). The CHP will work with the local authority to set, monitor and review Local Improvement Targets and it will also take a lead in meeting the requirements of the Joint Performance Information and Assessment Framework (JPIAF).

Children’s Services 3.25 Planning for children‟s health care currently happens within the joint agency

partnership represented by the Children‟s and Young People Strategy Group. The Board‟s Child Health Strategy Group sits as a sub-group of the Planning Group and takes a lead in the development of the Child Health Strategy. Figure 5 on page 17 describes where the Child Health Strategy Group sits within children‟s services planning.

Locality-based Service Delivery

Group

Locality based, Multi-agency,

Multi-disciplinary Health & Care Team

x 10; one for each local health centre area.

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Figure 5 - Children Services Groups

Other sub-groups are formed and report to the Child Health Strategy Group as appropriate.

Community Plan

Shetland NHS Board

Children’s & Young People’s Services Planning

Group (CYPSPG)

(Education, Health, Social Care, Housing,

Children’s Rights, Voluntary Sector, etc

Shetland Islands Council

Child Health Strategy Group

(representatives from all areas of Child Health Services + Vulnerable Children, Social Care and Integrating Children’s Services)

Child Safety Group Childcare Partnership

Food Forum

Sexual Health

Physical Activity

Drugs & Alcohol

SIGN Guidelines on Obesity Implementation Group

Mental Health

Health

Education

Working

Group

Health Promoting Schools Steering Group

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3.26 The Child Health Strategy is based on a template provided by the Scottish Executive‟s Child Health Support Group. It takes account of the needs of children on a continuum from healthy children through to those with special and complex needs. The strategy contains plans for children who are well and for those who are ill, for the promotion of health and well-being and for the prevention of ill-health. It has been developed by a multi-agency and multi-professional group and seeks to link strongly to policies on social care, social justice, social inclusion, education, childcare provision and community safety.

3.27 The development of the integrated Children‟s Services Plan across all the

local agencies from April 2005 will be the focus for outlining the planning and delivery across services for children and young people. Within this plan there shall be a range of priorities and outcomes that will be assessed and monitored. The CHP will play a role in the strategic planning of children‟s services and the delivery of children‟s services (refer to Table 1 on page 10), with CHP members being part of the of the Child Health Strategy Group.

Drug and Alcohol Services 3.28 The Shetland Alcohol and Drugs Action Team (SADAT) has been in place

since 1995 and was set up with the aim of bringing together all the representatives of local agencies involved in addressing the misuse of drugs, and laterally alcohol, in order to adapt national strategies to local circumstances. SADAT is chaired by the NHS Board‟s Director of Public Health, with the other members of SADAT being at the moment, the Chief Inspector of Police, the Head of Social Work or Head of Housing and Head of Education or Head of Community Development, the Chair and Manager of Shetland Community Drugs Team, the Manager of the local Alcohol Advice Centre and two of the SIC Elected Members. The current support staff – an Alcohol and Drug Development Officer and an assistant are part of the Board‟s Health Promotion Department.

3.29 SADAT is a strategic body, with its primary purpose being to draw up an

action plan for tackling drug and alcohol misuse locally and thereafter driving and monitoring its delivery. Supporting the work of SADAT, in Shetland there are well developed Alcohol and Drugs Forums. These comprise a broad membership that includes representatives from user groups, local campaigning bodies, Shetland‟s churches, youth services and the Licensing Board as well as service providers and employees of statutory services such as health, police, social work and housing.

3.30 The CHP General Manager will take a responsibility for engaging with the

both the Board‟s Director of Public Health and the alcohol and drug support staff not only in the strategic planning of drug and alcohol services, but also in the development of local services.

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Service Redesign 3.31 The White Paper, „Partnership for Care’, outlined proposals for a major

programme of service redesign across the NHS in Scotland. Each NHS Board is required to produce and submit an annual Change and Innovation Plan, which outlines the proposed range of redesign projects. Also to ensure that service redesign plays a major role in the work of the Board, each Board was required to establish a Service Redesign Committee.

3.32 The Service Redesign Committee was established in July 2003 and

membership of the Committee included primary care representation from the outset. The process of establishing the CHP will be a seamless transfer, with the CHP Lead Clinician and the CHP General Manager having a key input to the Board‟s Service Redesign Committee ensuring that the CHP is central to the Board‟s service redesign decisions and resource allocation.

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4. IMPROVING HEALTH 4.1 Health improvement is about rationally bringing together a set of wide

interventions to improve health. It involves an array of disciplines, professions and agencies and seeks to find ways of preventing ill health, protecting good health and promoting better health.

4.2 National health targets for cancer ischaemic heart disease, stroke, teenage

pregnancy, dental health, smoking, alcohol misuse, diet and physical activity are outlined in Appendix B. Local baseline information and position in relation to these targets is shown where there is data available. Individual staff providing health and care services have a key role and make a significant contribution to the health and health improvement of the local communities that they serve. The CHP will look to build on the work of individual practitioners, working closely across agencies and with local communities to improve health to ensure that the health targets are met for Shetland.

Joint Health Improvement Plan 4.3 The Joint Health Improvement Plan (JHiMP) is produced on behalf of the

Community Planning Board, partner organisations and the strategic planning groups outlined in Figure 1 on page 13, to inform and formalise roles and responsibilities in order to co-ordinate activities in delivering health improvements.

4.4 To carry forward the actions of the health improvement agenda, a multi-

agency Health Action Team in is place. Membership of the Team consists of key staff from Shetland NHS Board and SIC with links to Shetland Enterprise, Northern Constabulary and the voluntary sector. The Health Action Team is tasked with:

Formulating and reviewing Shetland‟s Joint Health Improvement Plan annually in order to deliver on the Community Planning Board‟s Priority of improving health and reducing health inequalities;

Providing Community Planning Board Members with relevant information on health improvements and health inequalities to help to inform their decision making processes;

Formulating and ensuring delivery on specific points for action;

Liaising between strategy groups to highlight areas of shared responsibility;

Ensuring that all reporting mechanisms and feedback loops within Health Improvement function effectively and efficiently;

Acting as a vehicle for potential policy change;

Formulating proposals for building health improvement capacity within community planning partner organisations; and

Continuing to provide a support for all health improvement activity

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4.5 Figure 6 indicates the relationships between the Community Planning Board, Health Action Team, strategic planning groups and communities, including the reporting mechanisms and feedback loops, which have been initiated.

Figure 6 – Joint Health Improvement Framework

COMMUNITY PLANNING BOARD

HEALTH ACTION TEAM

STRATEGIC PLANNING GROUPS / CHP

4.6 Building on the existing framework that is in place, the CHP will influence the

development of the JHiMP through the functional link between the CHP GM and Health Promotion Manager, with input from the Director of Public Health as required. Also through the CHPs role in the strategic planning group framework outlined in paragraph 3.9, this will also influence the development of the JHiMP.

4.7 Specialist public health expertise will be provided to the CHP through the

Board‟s Public Health Department. The organisational arrangements are outlined in Figure 10 on page 26.

4.8 The CHP will have a role to play in addressing inequalities in local

communities through the development of locality arrangements (refer to page 28) and the CHP will work to contribute to the health improvement targets.

Report on targets against outcomes, areas of good practice and areas requiring assistance – 6 monthly

Report on targets against outcomes, areas of good practice – 3 monthly

Sponsorship, assistance

Sponsorship, assistance

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5. ORGANISATIONAL ARRANGEMENTS 5.1 The NHS Board remains as the Board of governance within which all

organisational arrangements must fit. In examining the organisational arrangements for the development of the CHP, it was important that this was developed in a manner that does not create imbalances within Shetland NHS Board.

CHP Committee 5.2 In line with the statutory guidance, the NHS Board is required to establish the

CHP as a formal Board Committee following Ministerial approval of the scheme of establishment. The establishment of the CHP Committee will allow the NHS Board to devolve functions and powers to the CHP Committee within a clear accountability framework. Figure 7 outlines the Shetland NHS Board committee structure.

Figure 7 – Shetland NHS Board Committee Structure 5.3 The statutory guidance has been quite prescriptive as to who has to be

members of the CHP Committee. It is proposed that a Non-Executive Board member chair the Committee, with the membership of the CHP Committee shown in Figure 8 on page 23.

5.4 The links to the local authority shall be principally through the Executive

Director – Community Services and the Community Care Manager. There is also a place on the Committee for either an elected SIC member or another SIC officer to be decided.

5.5 The links to the Community Planning Board shall be through the DPH and the

Executive Director – Community Services.

Shetland NHS Board

Standing Committees

Special Committees

Audit

CHP

Clinical Governance

Service Redesign

Staff Governance

Endowments

General Medical

Practitioners

Reference

23

Figure 8 - CHP Committee Membership

Board Chairman and Chief Executive should be invited in attendance.

CHP Clinical Lead

Member of the Voluntary Sector

CHP General Manager

Community Care Manager

CHP Lead Nurse

Member or Officer of the

Local Authority

CADO

Member of the Public Partnership

Forum (to be established)

Optometrist

Assistant Director of Patient Services / Allied Health Professional

General Practitioner

DPH

Clinician from Acute/Specialist

sector

either MSM or nomination from

Consultants Group

Consultant Psychiatrist

Staff representative

from LPF

Chair (Non-Executive NHS

Board member)

Community Pharmacist

SIC Executive Director –

Community Services

24

5.6 Where an individual is not identified on the CHP Committee, for example a Community Pharmacist, the process for selecting the members of the CHP Committee shall be to seek nominations through the Area Professional Committee. Where an Area Professional Committee does not exist, for example for optometrists, then discussions will need to held with the relevant professionals about seeking representation on the CHP Committee.

CHP Management Team 5.7 The development of the CHP has allowed the Board to look at the way in how

the „operational‟ management of the Board‟s activity works. It is proposed to create two operational management teams and this will see the establishment of the CHP Management Team and the further development of the Hospital Management Team.

5.8 The CHP Management Team who will lead day-to-day operational

management of the CHP will comprise the following:

CHP Clinical Lead;

CHP General Manager;

CHP Lead Nurse;

Community Care Manager;

Managed Clinical Network Co-ordinator;

Assistant CHP General Manager.

5.9 Figure 9 outlines the proposed management structure for the CHP:

Figure 9 – CHP Management Structure

CHP General Manager

Independent Contractors

MCN Co-ordinator

CHP Lead Nurse Community

Care Manager

CHP Clinical Lead

CHP Chairman

DPH

Board-wide

Services

Assistant CHP Manager

Chief Executive

: Line management responsibility : Functional links

Chairman

25

5.10 The CHP Clinical Lead role will be a GP and this post will be advertised prior to April 2005. The CHP Clinical lead shall look to lead, coordinate and support the organisation (including planning and redesign), quality and effectiveness of all clinical services within the CHP. The role will require innovative and effective clinical leadership and skills, in creating a vision for the development of high quality health services, in conjunction with staff and independent practitioners, local communities, and partner agencies and facilitating the delivery of that vision to improve health and health care across Shetland.

5.11 To support the work of the work of the CHP Management Team and to reflect

the increasing range of services within the CHP it is proposed to establish one new post, an Assistant CHP Manager post. A new Primary Care Facilitator post is already planned. The Assistant CHP Manager post will support the CHP Management Team to foster and facilitate the development of services, staff and communities across the CHP. The Primary Care Facilitator post will specifically support the CHP Management Team in the facilitation of clinical governance programmes across the CHP for services relating to chronic disease management (e.g. coronary heart disease, stroke, diabetes and cancer etc), ensuring appropriate links with CGST (refer to page 35). The post will also support the co-ordination of strategic planning group activity so as to ensure that services are developed, which meet local requirements and reflect nationally defined standards, ensuring that patient views are included in the development and strategic planning of patient centred services.

5.12 All members of the CHP Management Team will be delegated certain lead

roles for which they will have specific portfolio responsibility within the CHP. 5.13 One of the key aims of the CHP will be for it to be a vehicle for integrating

primary care with specialist and acute services and with social care. The Community Care Manager will act as the key link with social care services and the local authority. The continued development of functional links and professional working relationships between the CHP Management Team and the Hospital Management Team will be one of the key mechanisms for linking primary and secondary care services.

Board-wide Services 5.14 Working across both the CHP and the Hospital Management Teams and

taking a lead role in their respective areas shall be the Finance Department, the Human Resources Department and the Public Health Department. The head of each department along with the Board‟s Chief Executive and Medical Services Manager will constitute the Board‟s Senior Management Team (SMT). As the operational management teams evolve, SMT will look to take a more strategic focus and have an overall overview of service. Figure 10 on page 26 outlines the overall Shetland NHS Board organisational structure.

5.15 A range of support functions will be required to develop and ultimately support the CHP and these will include finance input; human resources input; pharmacy input; needs assessment through the Public Health Nurse; IT support provided from the Board‟s IT Department and Estates and Capital input.

26

Figure 10 - Shetland NHS Board Organisational Structure

Chief Executive

Shetland NHS Board

CHP General Manager

CHP Management

Team

CHP Services

Operational

Nursing Development

Officer

Assistant DPS

Assistant DPS - Nursing

Head Pharmacist

Quality

CADO

Medical Services Manager

Director of Patient Services

Allied health professionals & Healthcare

Scientists

Medical Records

Consultant Medical Staff

Senior Nursing staff

General Services Manager

Director of Public Health

Health Promotion

Public Health

Planning

Director of Finance

Head of Human

Resources

Finance

Information

Information Technology

Capital & Estates

Personnel

Staff Develop-

ment

Board-wide Services

SMT Members

27

Commissioning Team 5.16 One of the key providers of healthcare for Shetland patients is NHS

Grampian, with patients travelling to Grampian for treatment and care and a range of visiting consultants from Grampian visiting Shetland on a regular basis to provide out-patient clinics as well as in-patient and day-case surgery to supplement the service provided locally.

5.17 To oversee the current arrangements, contracts and agreements with NHS

Grampian and other external providers of specialist health care, the NHS Board currently has in place a Commissioning Team consisting of the Director of Finance (chair), Director of Patient Services and the Medical Services Manager.

5.18 The arrangements for the Commissioning Team have been reviewed and it

has been agreed that its main remit should be to take a more active role in monitoring the agreements with mainland providers, particularly with NHS Grampian. The remit of the Team will be:

Agreeing updated and revised Service Level Agreements with providers, including those for visiting services;

Actively monitoring Service Level Agreements, including activity levels;

Monitoring waiting times for mainland providers;

Monitoring visiting services;

Negotiating with mainland providers over new services / service redesign projects in which they are involved.

5.19 To undertake this remit more effectively the Commissioning Team needs to

be strengthened and it is proposed to expand the Commissioning Team to include the Director of Public Health, CHP Lead Clinician and the Information Officer.

LHCC Professional Committee 5.20 Due to the establishment of the CHP Committee, the need for the LHCC

Professional Committee in a Shetland context becomes unnecessary. Due to the small size and the professionals involved at a local level, the LHCC Professional Committee is a duplication of effort. It is therefore proposed that the LHCC Professional Committee cease.

5.21 One of the issues that this causes is that a the moment the Chairman of the

LHCC Professional Committee is appointed as a stakeholder/ex-officio non-executive member of the NHS Board. It is agreed that the CHP needs to have this level of representation at NHS Board level. It is therefore proposed that the CHP Lead Clinician be appointed to the NHS Board in this capacity. The implications for NHS Board appointments will however be considered and reviewed by the Scottish Executive as it becomes clearer what NHS Board

28

areas across Scotland consider to be the best way forward for LHCC Professional Committees and CHPs.

5.22 Until such time as the Scottish Executive provides formal guidance on LHCC

Professional Committees, then in the interim the LHCC Professional Committee arrangements will continue to exist.

Locality Arrangements 5.23 One of the key aims of the CHP is to ensure that all staff are fully engaged

and involved in the work of the CHP. One of the changes that is being proposed as part of the establishment of the CHP will be the development of „locality-based‟ teams centred around the existing 10 Health Centre areas. This is not an entirely new concept as teams are already used to working as part of a „practice‟ team; what it is being proposed is formalising these arrangements under the CHP.

5.24 Locality-based arrangements will bring together all professionals and their

partners within the CHP, to provide a focus for matching their knowledge of patient and public needs, lifestyles and life circumstances with the opportunity to provide services that address both individual and community needs. Improving these links will hopefully result in more effective practitioner interventions, support and care, leading to a decrease, over time, in preventable diseases. Locality arrangements also aim to promote genuine community engagement in developing and prioritising local services.

5.25 It is proposed that locality arrangements be progressively developed, with

there being a two stage approach:

Stage One: Health and Care Team with links to Public Participation Forum;

Stage Two: Health and Care Team with links to Public Participation Forum and a Locality Services Delivery Group.

5.26 These arrangements are integral to genuinely achieving the „joined-up model‟

Shetland is aspiring to. As stated in paragraph 2.1, the development of “integrated community and health-promoting schools” needs to complement this model and vice versa.

Stage One - Health and Care Team with links to Public Participation Forum 5.27 It is proposed that the Health and Care Team in each locality consist of the

following individuals:

GP(s)

Practice Nurse representative

Practice Staff representative

Community Nursing/Midwifery/Health Visitor representative

29

Allied Health Professional link

Mental Health link

Practice Counsellor

Pharmacist

Dental representative

Health Promotion input

Care at Home representative

Social Worker

5.28 The core role of the Health & Care team shall be to co-ordinate for that

particular locality health and care services. Figure 11 on page 30 outlines the stage one locality organisational arrangements.

Stage Two - Health and Care Team, Public Participation Forum and Locality Services Delivery Group 5.29 This stage would be a natural development of stage one with the addition of a

proposed Locality Services Delivery Group in each locality. This is the „+‟ element of the development of the CHP and agreement in principle has been gained by all key agencies through community planning mechanisms. The Locality Services Delivery Group shall consist of the following individuals:

GP

Community Nursing/Midwifery/Health Visitor representative

Social worker

Locality Co-ordinator

Community Learning and Development Officer

Local Economic Forum Officer

Local Education representative

Local Housing representative

Transport and/or Environment representative

Local Northern Constabulary representative

Public Participation Forum representative

Local Community Councillor

Local Voluntary Services representative(s)

Local SIC Councillor(s) invited in attendance

5.30 The core role of the locality services delivery group shall be to determine

locality based priorities and plans and support developments – with links to the CHP and Community Planning Board. In the fullness of time, it is envisaged that all public sector services would be integrated within the local services delivery group. Figure 12 on page 31 outlines the stage two locality organisational arrangements.

30

Figure 11 – Stage One Locality Organisational Arrangements

Shetland NHS Board

CHP Committee

CHP Management

Team

CHP Management / Representative Group + Locality leads + Invited attendees

Locality x (10)

Health and Care Team

Public Participation Forum

Shetland Islands Council

Joint Future

Line Management Accountability

Functional Links

31

Figure 12 – Stage Two Locality Organisational Arrangements

______ : Line management

accountability ----------- : Functional links

Shetland NHS Board

CHP Committee

Community Planning Board

CHP Management

Team

CHP Management / Representative Group

+ Locality leads + Invited attendees

Health and Care Team

Public Participation Forum

Locality Services Delivery Group

Shetland Islands Council

Northern Constabulary

Shetland Enterprise

32

5.31 In each locality there will be a Locality Co-ordinator to take a lead role in co-ordinating work and representing the locality. It is envisaged this will be a different professional according to arrangements within the locality and should not be dictated beyond specifying the co-ordinator role, which will be an additional role for a current locality-based professional. In each option, a locality based Public Participation Forum will be established (refer to paragraph 6.10).

5.32 The progression towards locality-based arrangements will feel like a large

step for some local areas. In some areas practice and extended „partner‟ teams meet already on a regular basis and the idea of the health and care team will be a natural progression and next step. In other areas, there will have to be some thought given and support provided from the CHP Management team to progress locality arrangements.

5.33 To ensure that there remains a forum for discussion of issues, developments,

etc. across the CHP it is proposed to establish a CHP Representative Group. This forum will allow the CHP Management Team to meet with a wider representative group that may consist of the following individuals:

CHP Management Team;

Representative of each Locality – Locality Co-ordinator;

Other independent contractors;

Pharmacy input;

Allied Health Professionals;

Public Participation Forum membership;

Health Promotion input;

Staff representative;

Voluntary services representative. 5.34 The role of the representative group would be to agree the strategic direction

of the CHP and priorities for development, taking account of locality issues, to take forward to the CHP Committee.

5.35 Stage two is a progression from Stage one and is the wider Community

Planning model. The individuals outlined within the locality services delivery group does not see the creation of new posts, it is rather a meeting of all professionals and interested local individuals working within a local community to try to look at taking a more co-ordinated approach to the delivery and planning of services.

5.36 It would be proposed for all areas to progress forward with the concept of

Stage one from April 2005, with Stage two being piloted during 2005/06 in a minimum of two localities across Shetland to assess it‟s effectiveness before full implementation.

5.37 In the fullness of time, it is envisaged that all public sector services would be

integrated within the local services delivery group.

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6. WORKING IN PARTNERSHIP 6.1 The CHP will be required to maintain an effective and formal dialogue with

their local communities through the development of a Public Partnership Forum (PPF). There will be 3 main roles for the PPF:

Ensure local people are informed about the range and location of services and information which the CHP is responsible for;

To engage local service users, carers and the public in discussion about how to improve services to enable the CHP to respond to the needs, concerns and experiences of patients, carers and families.

Support the wider public involvement and to seek to make services more responsive and accountable to local communities.

6.2 Whilst the PPF will be a mechanism by which the CHP maintains this formal

dialogue, it is important that this links in with existing mechanisms through which the NHS Board and other partner agencies look to engage local communities.

Patient Focus Public Involvement 6.3 Shetland NHS Board established a Patient Focus Public Involvement (PFPI)

Steering Group in October 2003. The Boards unified status has meant that it has been able to develop a PFPI structure that has allowed from the outset an integrated organisational-wide approach. Further more the move towards joint community planning has further bolstered the development of PFPI across a number of agency boundaries. The current structure is detailed in Figure 13.

Figure 13 - Shetland NHS Board PFPI Structure

Patients, Users and Members of the Public

Health Care Practitioners and all Board Employees

PFPI Steering Group

Clinical Governance Support Team

Clinical Governance Coordinating Group

NHS Senior Management Team External Agencies

34

6.4 The PFPI Steering Group is the Boards main group for developing and coordinating the principles of PFPI as well as being a source of advice for members of staff who require it. The group has the following remit;

To help foster a culture whereby the principles and spirit of PFPI are communicated to and adopted by all staff delivering NHS services;

To ensure that the principles of PFPI are integrated appropriately into Redesign Projects;

To ensure the principles and spirit of PFPI are communicated to the people of Shetland in a practical and understandable way;

To ensure that anyone in Shetland with an interest in developing the PFPI agenda is involved in this process as active partners with all staff delivering NHS services;

To work with the Shetland Islands Council and other agencies to ensure that PFPI is an integral part of joint working and sharing of best practice is encouraged;

To work with the external agencies to ensure that policy requirements of the Scottish Executive Health Department are met appropriately;

To work with the Board‟s Staff Development Section to ensure the training needs of all stakeholders are met in relation to the delivery of the PFPI agenda;

To give guidance and support to the Board‟s Groups, Committees and Forums on how to deliver the principles of PFPI;

To assist key staff in monitoring the impact of PFPI initiatives.

6.5 The PFPI Steering Group consists of the following members;

Director of Patient Services (Vice Chair);

Assistant Director of Patient Services (Chair);

Nursing Development Officer;

Assistant Director of Patient Services (Nursing);

General Services Manager;

Area Clinical Forum representative;

Managed Clinical Network Coordinator;

Staff Development Manager;

Area Nursing Midwifery Advisory Committee representative;

Consultants Group Representative;

Three Lay Representatives;

Member of NHS Shetland 100;

Local Partnership Forum Representative;

Shetland NHS Board Member;

Shetland Islands Council Representative. 6.6 The MCN Co-ordinator will represent the CHP on the Steering Group. It is

proposed as the PPFs become established that some PPF members also become members of the PFPI Steering Group.

35

6.7 The Board‟s PFPI structure is designed to be as inclusive as possible with the ultimate aim being to provide a patient focused care model that is also fully inclusive of the population when planning services.

6.8 All Board employees especially those at the fore of health care delivery are

supported by the Clinical Governance Support Team (CGST) Clinical Governance Coordinating Group (CGCG) and the PFPI steering group in ensuring the Boards PFPI Strategy is delivered.

CGST: The CGST provide practical support on all areas of Clinical Governance to all Board employees and works in partnership with primary care health care practitioners. CGST provides specific advice and support relating to the PFPI agenda around the design of patient surveys and the provision of patient information. The CGST is a resource used by both Primary and Secondary Care and the same arrangement will be retained with the development of the CHP.

CGCG: The role of the CGCG set out in detail in paragraph 6.25. 6.9 The Board‟s PFPI structure is fluid and will support and complement the new

CHP structure. This will see the CGST linking in with and supporting the locality-based PPFs.

Public Partnership Forum 6.10 As outlined in figures 11 and 12 on pages 30 and 31 respectively, it is

proposed to establish a Public Partnership Forum for each locality. Rather than the PPFs be a fixed formal body, it is proposed that it will be a „virtual‟ grouping that will bring together existing local groups and networks of patients groups, voluntary organisations, interested individuals and others with the key role of considering and informing the CHP on specific issues. For example this will involve individuals from existing local groups such as Community Councils, and current NHS Board and local authority patient/user representative groups such as NHS Shetland 100 and Your Voice.

6.11 In order to establish and encourage the initial development of the PPFs,

support will be provided to the localities to build on current patient/public involvement activity as different communities across Shetland are at different stages. Different groups of staff will have a key role to play for example, the locality co-ordinators and Community Learning and Development workers.

6.12 The representatives from the PPFs may also need support and training,

depending on their skills and experience, to allow them to participate effectively in this group. This will be supported through the Board‟s PFPI Steering Group.

6.13 The process of seeking individuals to participate and be involved in the

locality PPFs shall be through a number of different means. First of all it will to look at existing NHS Board and SIC patient/user representative groups such as NHS Shetland 100 and Your Voice and from these groups identify individuals who are resident from that particular locality. The individuals will

36

then be contacted about the PPF and invited to attend the „PPF Development Seminar‟.

6.14 Working in conjunction with the SIC Community Services Department, it is

also proposed to identify existing local community groups, voluntary organisations and other interested individuals within each locality, and as above contact these groups about the establishment of the PPF.

6.15 Once all interested individuals and groups have been contacted, the process

for establishing the PPF shall be for the CHP to facilitate a PPF Development Seminar. A seminar will be held in each locality and the purpose of the seminar shall be for all the identified individuals from the above process to come together to discuss and agree the establishment of the locality PPF.

6.16 The CHP will have a place on the Board CHP Committee for a public

partnership forum member, which will be filled following a fair and open appointment process, taking advice from the Scottish Health Council.

Linking Clinical and Care Teams 6.17 The development of locality arrangements will be the key focus for bringing

together clinical and care teams. This will look to involve all health and care professionals within a locality working together to share any service delivery problems, make decisions on solutions and implement those decisions at a local level.

6.18 In looking at services across Shetland, the Board is working towards

establishing formal networks for a whole host of health and social care services including coronary heart disease (CHD), stroke, diabetes and cancer. As outlined in paragraph 3.9 on page 12, a number of steering groups have been established which are responsible for the strategic planning of these services. These groups are focussed on ensuring that patients, users and health and social care staff are involving in planning, reviewing and developing services collaboratively.

6.19 The purpose of the strategic groups is to ensure that Shetland NHS Board

and partner agencies delivers high quality services that are well co-ordinated and patient/user centred. The ways in which the planning groups are ensuring that co-ordinated, high quality services are being developed include:

Evaluating staff training requirements and providing all staff with the

opportunity to access the training and skills updates that are required to

offer high quality services.

Developing evidence based guidelines, protocols, policies and

procedures to ensure that services are clinically effective.

Consulting with patients, carers and the wider community wherever

possible so that pathways of care are developed collaboratively.

37

Monitoring services against local and national standards (e.g. national

programmes of review of quality such as QIS, risk management such as

CNORIS and clinical guidelines for practice such as SIGN etc).

Investing in new clinical roles (e.g. senior nurses, therapists and pharmacists), new equipment and technology (e.g. video linking suites, diagnostic equipment) to reduce patient waiting times for investigation and to make access to consultations easier.

6.20 In 2003, the Scottish Executive pledged funding to NHS Boards to develop

managed clinical networks. In October 2003, a Managed Clinical Network (MCN) Co-ordinator was recruited to assist in the establishment of formal clinical networks and this post was placed within the LHCC. This post will continue to be within the CHP and will take a key role in the ongoing development of clinical and care networks, ensuring that key linkages are made at locality level, across the CHP, between the CHP and specialist services and with the Service Redesign Committee.

Clinical Governance 6.21 The unified status of the Board has meant that it has been able to develop an

integrated clinical governance structure. The current structure is detailed in Figure 14.

Figure 14 - Shetland NHS Board Clinical Governance Structure

Chief Executive

Clinical Governance Committee

Director of Patient Services & Medical Services Manager (joint responsibility for

implementing clinical governance)

Clinical Governance Co-ordinating Group

NHS Senior Management Team

Shetland NHS Board

Everyone engaged in the provision of healthcare for and on behalf of Shetland NHS Board

38

6.22 The Board ultimately oversees the delivery of Clinical Governance throughout NHS Shetland. Activity is monitored via minutes from the Clinical Governance Committee, a committee of the Board which oversees all Clinical Governance activities. It ultimately ensures that the systems and process in place are working. It receives a quarterly report from CGCG detailing all activity throughout the Board.

6.23 The Board‟s Chief Executive has overall statutory responsibility for quality of

clinical care and the performance of individuals and teams who provide the service. The Director of Patient Services and Medical Services Manager hold joint organisational responsibility for delivery of Clinical Governance and ensuring that clinical quality and effectiveness measures are developed and maintained. The Senior Management Team (SMT) provide high-level support to the Board‟s Managers and staff to enable them to deliver on the pillars of governance. As outlined earlier the CHP General Manager will be a member of SMT and along with the CHP clinical lead will be the accountable for clinical governance across the CHP.

6.24 The main group through which clinical governance activity is discussed is the

Clinical Governance Coordinating Group. (CGCG), a multi professional group representing primary and secondary care services. Membership of CGCG is by individuals at Head of Service level and also includes members of SMT.

6.25 CGCG‟s function is to address issues around the practical delivery of all

aspects of Clinical Governance. CGCG is also the formal risk management group for the Board. The Clinical Governance Support Team (CGST) led by the Clinical Governance Coordinator supports the work of CGCG and all Board staff as resources and priorities allow. The CGST is a joint resource which works across both primary and secondary care settings. It also has close functional links to the Managed Clinical Network team.

6.26 The CHP will report directly through CGCG for all its clinical governance

activity, with the CHP General Manager, CHP Lead Clinician and MCN Co-ordinator being members of CGCG. These individuals will bring clinical governance issues to this group for discussion and action.

6.27 It is proposed that a local governance framework be established within the

CHP to manage all pillars of governance impacting on the CHP. The CHP will utilise the Boards existing structures and processes within the NHS Board which are designed to develop, manage and deliver outcomes around key areas of Clinical Governance including risk management and its associated incident reporting system, Patient Focus and Public Involvement Activity, Research, Education and Clinical Effectiveness activity including guideline development and Clinical Audit.

6.28 The Governance programme within the CHP will be based on the

requirements needed to safely deliver managed care networking across the CHP with existing quality programmes. The key staff facilitating the governance programme in the CHP will include the Primary Care Facilitator, Assistant CHP GM, the MCN Co-ordinator and the locality co-ordintators.

39

Involving Staff 6.29 The formal arrangements for the involvement of staff within the work of the

CHP will be again through the development of locality arrangements outlined in paragraph 5.23. CHP staff will also be involved in the wide range of strategic planning groups.

6.30 The CHP General Manager will be a member of the Board‟s Local Partnership

Forum (LPF). An accredited staff representative from the LPF shall be a member of the Board‟s CHP Committee and the process of selecting the LPF member has been agreed with the LPF at its meeting in November 2003.

6.31 Staff Governance is a system of corporate accountability for the fair and

effective management of all staff. Similar to PFPI and Clinical Governance, the CHP will link into the existing NHS Board arrangements for staff governance. The current structure is detailed in Figure 15.

6.32 The Staff Governance Committee is a standing committee of Shetland NHS

Board and its remit is to support the creation of a culture within the health system, where, the delivery of the highest standard possible of staff management is understood to be the responsibility of everyone working within the system and is built upon partnership and collaboration. The Staff Governance Committee consists of members from both the LPF and Shetland NHS Board.

Figure 15 – Links Between Staff and Shetland NHS Board

Staff

Local Partnership Forum

Staff Governance Committee

Shetland NHS Board

40

6.33 The responsibility and accountability for performance against the Staff Governance Standard lies ultimately with Shetland NHS Board. The Board is expected to demonstrate achievement and progress towards the standard through:

Qualitative information collected during the self-assessment audit, which is conducted by the Local Partnership Forum (LPF). This is audited externally;

The annual staff survey results, from which the Local Partnership Forum (LPF) formulates the Staff Governance Action Plan. This action plan is submitted to the Staff Governance Committee;

Statistical returns provide the quantitative information required to measure progress.

6.34 The Human Resources Department shall work with and support the CHP to

ensure that the principles of staff governance are adhered to and delivered across the CHP.

6.35 There are existing established links between the LPF and the Joint Future

staff forum, with members of the LPF being on the Joint Future staff forum. It is proposed that this continues to be the existing link between the CHP and the Joint Future staff forum, with the key management link for the CHP being the Head of Human Resources.

Voluntary Sector 6.36 The voluntary sector has an important role to play in the delivery of local

services within Shetland. The development of the stage 2 locality arrangements outlined in Figure 12 on page 31 will be the process through which the voluntary sector will become involved in the work of the CHP.

6.37 Early work is underway across Shetland to look at developing a single

voluntary sector forum. This forum will become the key link between the voluntary sector with not only the CHP, but also other public sector agencies, local communities, patient/user groups and individuals. The Scottish Executive has developed a „Scottish Compact‟, which is an agreement on how public sector agencies and the voluntary sector should work together. As work progresses on the development of single voluntary sector forum across Shetland, it is likely that agreement along the lines of the Scottish Compact will be developed.

41

7. BUILDING WORKFORCE CAPACITY 7.1 There is already an evolving culture based on partnership and team working

across Shetland NHS Board, the local authority, partner agencies and the voluntary sector. There is still much to be done and it is hoped that the development of the CHP and the proposed locality arrangements through the CHP can strengthen and build on the culture and develop a truly shared culture.

Developing Roles 7.2 The development of the range of skills and roles across the CHP will be a key

area of development, building on ongoing work and systems already in place. Shetland NHS Board have developed close working relationships with the local authority and voluntary agencies in the delivery of training and development. This process is agreed through the development of an annual joint training and development plan. This enables joint training/briefing sessions for both public and voluntary organisations on a variety of inter-agency topics. This joint future working will continue and the CHP will become a key part of this process.

7.3 The CHP General Manager and the CHP Lead Nurse will be members on the

NHS Board‟s Agenda for Change Project Team and will work with the Team on ensuring that Agenda for Change is implemented across the CHP.

7.4 The CHP will have devolved responsibility for implementing and supporting all

aspects of the new Primary Medical Services arrangements. This will include an overall lead role for the NHS Board for the ongoing implementation and development of unscheduled care arrangements.

7.5 The CHP along with the Head Pharmacist will take a lead role in considering

the opportunities arising from the proposed new Pharmacy Contract for developing new ways of working and redesigning services. Similarly the CHP will work the Board‟s CADO to consider the opportunities that will arise from the proposed new Dental Contract.

Workforce Development 7.6 To ensure that the CHP delivers sustainable and patient focused healthcare it

is important to develop a robust workforce. 'Partnership for Care' identified the necessity of redesign in the developing of more sustainable services. To enable the CHP to provide improved health and healthcare to deliver integrated services around the needs of patients, appropriately trained staff are needed in the right place at the right time that will deliver the most appropriate healthcare to meet these needs. As part of the North of Scotland Workforce Planning Group, Shetland NHS Board are looking at models which integrate workforce planning, service planning, redesign, education, development and training, recruitment and retention and the whole pay modernisation agenda to plan how many of our professionals and with what skills and competencies we will require to deliver responsive and sustainable

42

services. The Head of Human Resources is leading this work on behalf of the NHS Board and will ensure appropriate links are made for staff within the CHP.

Leadership Capability 7.7 Shetland NHS Board and partner organisations are already involved in

consultation on the Leadership Development Framework. Part of this consultation focuses on outcomes to ensure that 'our leaders' are fit for purpose and demonstrate both the right qualities and behaviours to provide effective leadership for wide ranging staffing groups in complex local social, economic and political environments. This national programme will ensure that our leaders have clarity of purpose, to deliver community based health improvement, and effective service planning and redesign to meet the needs of patients, users and carers and can build in a culture of collaboration and involvement with the public and patients into the very essence of the CHP. The development programme for leadership will be linked to the Knowledge and Skills Framework (KSF) to ensure ongoing personal and organisational development of the individuals. The Head of Human Resources is leading this work on behalf of the NHS Board and will ensure appropriate links are made for staff within the CHP.

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8. FINANCE AND ACCOUNTABILITY 8.1 Throughout the Scheme of Establishment the services, staff and resources

the Board will devolve to the CHP has been outlined. The accountability framework and decision making process have also been quite clearly defined. The NHS Board is ultimately accountable to the Scottish Ministers for the provision and delivery of health services within the area and the Board‟s Senior Management Team provide the day-to-day overview of the service, with ultimately the CHP General Manager responsible to the Chief Executive who is the Board‟s Accountable Officer.

8.2 The principles of devolution and delegation of decision making will be

developed over time as the proposed locality arrangements within the CHP become established.

8.3 The NHS Board has an agreed set of Standing Financial Instructions which

identify financial responsibilities which apply to Board members and staff. The Board‟s Chief Executive is accountable for ensuring that the Board meets its obligations within available resources and has overall executive responsibility for the Board's activities. In accordance with the Board‟s Scheme of Delegation, the Chief Executive may delegate responsibility for budgets. The budgets that will be initially devolved to the CHP are as follows:

CHP staff and other associated budgets;

All funding associated with Primary Medical Services;

Primary Care Investment Funds;

Managed Clinical Network funding;

Board‟s Prescribing budget;

Unscheduled Care budget;

Joint Future budgets;

8.4 The CHP will have devolved responsibility for managing the Board‟s Prescribing budget along with appropriate support and input from the Head Pharmacist.

8.5 The overall total of the NHS Board‟s allocation devolved to the CHP is

£12,149,000 or 35.5%. The level of resource transfer devolved from the NHS Board to the local authority is £1,006,000.

8.6 The administrative process of attributing resources in terms of departmental

and individual time has not been done on a financial basis because the CHP in Shetland is integral as part of the overall Board set-up and has been developed with the principles of functional relationships and building partnerships. If the exercise of allocating both departmental and individual time to the CHP were undertaken, then the overall total of the NHS Board‟s allocation devolved to the CHP would be increased.

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8.7 The Board‟s process for deciding about development funding is decided through the strategic planning group framework, with the NHS Board‟s Senior Management maintaining overall responsibility for managing the process. This culminates in the production of a joint Health & Community Care Plan between NHS Shetland and Shetland Islands Council that is led by the Director of Public Health. This plan enables Shetland NHS Board to set out clearly its overall strategic direction and financial position. The plan is set out according to national guidance, and covers the national priorities as well as presenting local priorities which are the particular concerns of the local services and the people of Shetland. Each section spells out relevant national and local targets, summarises local service provision, and sets out objectives and actions for the coming year(s) as proposed service developments. The CHP involvement in the strategic planning group has been outlined in paragraph 3.9.

8.8 For 2005/06, the CHP Development Plan will be part of the Health &

Community Care Plan. Local Partnership Agreement 8.9 The Extended Local Partnership Agreement (ELPA) is a comprehensive

agreement, which describes the Joint Future agenda. The different sections included in the LPA have been prepared by staff from both Shetland NHS Board and the SIC working through the Joint Staff Forum and JFIG and comprises the following sections.

Vision, Aims and Objectives;

Joint Management Arrangements;

Joint Resourcing Framework;

Joint Development Priorities and Targets;

Extension of Joint Resourcing and Joint Management;

Joint Governance and Accountability;

Joint Performance Management Framework;

Local Partnership Working;

Human Resources;

Communications and Consultation;

Single Shared Assessment.

8.10 The ELPA will outline the accountability, financial and governance

arrangements across between the CHP and the SIC. 8.11 Each section of the ELPA will be revised as part of the on-going work of the

Joint Staff Forum and the CHP to reflect progress made with the implementation of the Joint Future agenda in Shetland.

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Appendix A

CHP Development Schedule Summary

Date Action & Summary

August 2003 Initial one day externally facilitated away day the LHCC Management Team, NHS Senior Management Team and the Executive Director - Community Services of the local authority.

February 2004 A workshop for NHS Shetland 100, one of the Board‟s public consultation bodies.

March 2004 A Board sponsored CHP seminar, which included participants from a range of Board, LHCC, Local Health Council, primary care, secondary care and Local Authority staff.

May 2004

Brainstorming workshop for LHCC Management Team, NHS Senior Management Team and representatives from local authority and Community Care Manager.

Update to the Local Partnership Forum.

Update to the Area Clinical Forum.

June 2004 Commence programme of meetings with various individual members of staff, departments, groups of staff and strategic planning groups. These are ongoing throughout the remainder of the year.

Update to the LHCC Representative meeting.

Meeting with key staff from Community Planning Board partners.

Meetings with the Area Dental Committee, Area Pharmaceutical Committee and Optometrists.

July 2004 Update to informal Shetland NHS Board meeting.

Paper presented to Community Planning Board to provide members with an update on the progress being made with the development of the CHP and to seek the views of members on the future of the CHP in Shetland.

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Date Action & Summary

August 2004 Formal CHP consultation paper launched. Consultation paper distributed widely within the NHS, local authority, local enterprise company, police, Local Health Council, NHS Shetland 100, Voluntary Sector and to Community Councils.

Update to LHCC Representative meeting.

September 2004 CHP Steering Group established.

End of CHP formal consultation.

November 2004 Update to Local Partnership Forum.

Update on CHP progress to Community Planning Board.

A one-day externally facilitated away day the LHCC Management Team and NHS Senior Management Team.

Update to LHCC Representative meeting.

CHP Steering Group meeting.

December 2004 Draft Scheme of Establishment to SIC Services Committee.

Draft Scheme of Establishment to Shetland NHS Board.

Submission of Scheme of Establishment to Scottish Executive Health Department.

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Appendix B

Health Targets

Baseline

Current Position (2001)

Target

Cancer 20% reduction in the directly standardised death rate from cancer in people aged under 75 (baseline 1995, target 2010) 1

143.8

128.2

115.0

IHD 50% reduction in the directly standardised death rate from ischaemic heart disease in people aged under 75 (baseline 1995, target 2010) 1

116.4

49.4

58.2

Stroke 50% reduction in the directly standardised death rate from stroke in people aged under 75 (baseline 1995, target 2010) 1

43.0

35.8

21.5

Teenage

Pregnancy

20% in teenage pregnancies amongst those aged 13-15 (baseline 1995, target 2010) 1

9.9 2.2 7.9

Dental

Health

60% of 5 year old children to have no cavities, fillings or extractions by 20101

55.3 59.1 60

Smoking

Reduce smoking among young people to 11%2

No baseline figures available. 9% or 13 yr olds 18% of 15 yr olds smoke regularly

(at least once per week)

10% reduction in women who smoke during pregnancy (baseline 1995, target 2010)

No baseline or current figures available

Reduce smoking among adults aged 16-64 to 31% (target 2010) 3

Local baseline figures: 29% for men and 20% for men as

current smoking rate

Alcohol Misuse

Reduce incidence of adults aged 16-64 exceeding weekly alcohol limits to 29% for males and to 11% for females by 20103

Local baseline figure: 25%

males and 14% females

Reduce frequency & level of drinking in young people2

No baseline figures available 22% of 13 yr olds 44% of 15 yr olds

drink regularly (at least once per week)

Diet Increase consumption of fruit and vegetables 3 Local baseline figures: 30% of population eat 5 portions of

fruit/vegetables a day

Physical Activity

18% increase of 11-15 year olds taking vigorous exercise (baseline 1994, target 2010) 3

No local figures available – awaiting national young

peoples lifestyle survey results

60% of men and 50% of women aged 16-64 taking moderate exercise each week (baseline 1995, target 2010) 3

Local baseline figures: 27% of men &

23% women meeting target

Notes: Sources: 1 Skipper (Rates are per 100,000 population per annum), 2 SALSUS, 3 1999 Health & Lifestyle Survey used to provide local baseline information. Teenage Pregnancies are rated per 1,000 female population per annum

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APPENDIX C

CHP Development Plan

Strategic Objective – Improving Services

Task Responsibility Timescale Outcomes

To be added

Strategic Objective – Improving Health

Task Responsibility Timescale Outcomes

To be added

Strategic Objective – Organisational Arrangements

Task Responsibility Timescale Outcomes

To be added

Strategic Objective – Working in Partnership

Task Responsibility Timescale Outcomes

To be added

Strategic Objective – Building Workforce Capacity

Task Responsibility Timescale Outcomes

To be added

Strategic Objective – Finance and Accountability

Task Responsibility Timescale Outcomes

To be added