admin.fifedirect.org.ukadmin.fifedirect.org.uk/.../publications/c64_AUGUST2016S… · Web viewNHS Fife Annual ReviewPage 39. 11 August 2016. ANNUAL REVIEW 11 AUGUST 2016. Self-Assessment

ANNUAL REVIEW 11 AUGUST 2016

Self-Assessment

NHS Fife Annual Review Page 111 August 2016

CONTENT

Section 1: Progress against Action Points arising from Annual Review 2015/16

3 - 4

Section 2: Everyone has the best start in life and is able to live longer, healthier lives

6 - 9

Section 3: Healthcare is safe for every person, every time 10 - 15

Section 4: Everyone has a positive experience of healthcare 16 - 22

Section 5: Best use is made of available resources 23 - 25

Section 6: Staff feel supported and engaged 26 - 31

Section 7: People are able to live well at home or in the community

32 - 39


Section 1: Progress against Action Points arising from Annual Review 2015/16

ACTION SUMMARY OF PROGRESSContinue to deliver on its key responsibilities in terms of clinical governance, risk management, quality of care and patient safety, including an effective response to the findings of Healthcare Environment Inspectorate (HEI)

The Clinical Governance Strategy 2015-17 has been revised to integrate the principles of National Care Standards to create a framework which applies to all clinical and care environments across Health and the Health and Social Care Partnership. This, in conjunction with other related strategies (e.g. Risk Management Framework), provides an integrated approach to support improving the quality and safety of care provided.

Make sustained progress in achieving smoking cessation targets

No data will be published for this measure until the latter part of 2016. Local management information shows that NHS Fife recorded 440 successful post-3 month quits in the 40% most-deprived SIMD areas in the first 11 months of 2015/16, around 80% of the target. This is below the national average, and efforts to improve performance will continue against the new, increased target in 2016/17.Fife Pharmacy performance is around the average compared to other board pharmacy services while non-pharmacy service performance is above the national average. However, our reach in the most deprived areas is less than the national average across both services.Smokers are accessing our services at similar levels to 2014/15, but service users are presenting with more complex health needs so it could be assumed that these smokers require a different level of service to support continued abstinence and reduce drop out levels.E-cigarettes remain an issue but have not significantly impacted on numbers accessing our services. Pharmacy services are experiencing data completeness issues due to the implementation of new data system but all Boards are experiencing similar issues.

Keep the Health and Social Care Directorates informed of

NHS Fife communicated regularly with the SGHSCD during 2015/16, to discuss the


ACTION SUMMARY OF PROGRESSprogress towards achieving all access standards, in particular 62-day cancer treatment, child and adolescent mental health services and psychological therapies

challenges in achieving and sustaining access standards. We have had continued success with the A&E 4-Hour Access Standard, and made good improvement on Outpatient Waiting Times. Monthly performance management meetings which have a specific focus on operational performance including Cancer Waiting Times, have been introduced in the Acute Services Division in order to improve performance further. It is recognised that continued efforts require to be made to improve performance for Cancer Waiting Times in 2016/17.Improvement against mental health waiting times has been more challenging, but various changes have been introduced in order to address increasing demand for services.Further information is provided in Sections 2, 4 and 7.

Make sustained progress against the staff sickness absence standard

The average sickness absence rate during 2015/16 was 5.05%, a 0.23% improvement on 2014/15. This sustained improvement also saw 5 of the 12 months during the year below 5%. The improvement which, is a reflection of the significant efforts made by all services, has continued in the first 2 months of 2016/17. The figures for April 2016 and May 2016 being 4.67% and 4.40% respectively.

Work with partners to reduce the number of bed days lost to delayed discharge across Fife in 2015/16

During the second half of 2015/16, there was a significant improvement in the delayed discharge position and in patient flow from the acute hospital to the community.The number of bed days lost to delayed discharge in the final quarter of the year was 8,686, against the previous two quarters of 11,316 (October to December) and 12,122 (July to September).Further information is provided in Section 4.

Continue to achieve financial in-year and recurring financial balance, and keep the Health and Social Care Directorates informed of progress in implementing the local efficiency savings programme

In-year financial balance was achieved in 2015/16, however a recurring shortfall of £11.1m is currently estimated for 2016/17, with potential in-year financial flexibility reducing this to £9.4m. Discussions are ongoing on how to close this recurring gap both internally and also with SGHSCD who have requested a plan showing


ACTION SUMMARY OF PROGRESSthe achievement of recurring financial balance over a three year period.


Section 2: Everyone has the best start in life and is able to live longer, healthier livesReducing Health Inequalities and PreventionIn October 2015, the Fife Health and Wellbeing Alliance published its health inequalities strategy for 2015-2020. It sets out three key themes – changing the way organisations work, creating healthier places and communities and supporting healthier lives for individuals and families. A checklist was produced which helps organisations to work in ways that will make progress in reducing health inequalities. In November 2015, the Fairer Fife Commission produced its report on inequalities called Fairness Matters. Work is now focused on turning these aspirations and recommendations to real change on the ground. In addition, NHS Fife is working towards the Health Promoting Health Service. Improving health and reducing inequalities requires extensive partnership working with Fife Council and other statutory partners, the third sector, families, carers and communities.

Examples of work to reduce inequalities include:Food and Health

Practical food programmes with vulnerable groups Royal Enivronmental Health Institute of Scotland (REHIS) Food and Health

accredited training Fife Community Food Champions Resource development to complement current and consistent Food & Health key

messages

Tobacco

Smoke Factor and Smokefree Class educational programmes in schools Smoke Free Homes initiative - protecting people from second hand smoke Supported the development of a Smoke Free care placements policy for Fife

Council’s Social Work Service and Looked After Children and Young People

Physical Activity

“Strength and Balance for All” DVD, with the aim of helping older people to live independently for longer by increasing confidence to keep active and reduce the risk of falls.

Seated Exercises for the Frail Older Adults course “Eat Well, Be Active” awards “Gotta Be….” campaign targeted young women at Fife College Avoid the Couch... and get Active, Physical Activity Toolkit

Mental Health

Mindfulness Colouring Books, new Mental Health resource Mental health promotion of “Are You OK” Steps for Stress road shows


Locality Work

7 Habits of Highly Effective Teenagers, people and families courses Leader in Me: Fair Isle Primary School (First ‘Leader in Me’ school in the UK to

achieve ‘Lighthouse’ status) ‘All About Me Cards’: a new communication tool helping Young People raise

concerns about their health and wellbeing with school nurses Where’s Dad?: Improving engagement of Fathers and Male Carers across Fife

Workplace Health Improvement

Raising awareness of health inequalities and good work with employers, partners and work programme providers

Support for local Small and Medium Enterprises(SME) to ensure positive health, safety and wellbeing practice is embedded in the policy, procedures and culture of the organisation.

REHIS elementary health and safety training for SME (recently rated excellent by REHIS).

Working with the Poverty Alliance, Living Wage Accreditation and local agencies to promote the benefits of paying the living wage.

Working with Fife Community Safety Partnership to raise awareness of lone working for SME

Early YearsChildrens’ services, working with children and families across NHS Fife and its partners, has a clear role to influence and support ways of working that are most likely to reduce health inequalities and poor health outcomes in children and into adulthood. Services are continually utilising evaluation and evidence to effectively maximise opportunities for prevention and early intervention within the early years.

Fife’s Partnership children and young people services were the subject of a joint inspection between August and October 2015, involving all of the key inspection agencies. The process involved the inspections team talking to a large number of staff and over 200 children, young people, parents and carers, as well as reviewing the records for a sample of 110 of our most vulnerable children and young people.

The results were published in March and saw across the indicators Fife achieving good or very good. An action plan from the inspection is being developed by the partnership and key findings are being progressed.

Highlighted within the report was our focus on prevention and early intervention and the value we place on children and young people’s views. NHS Fife as part of our improvement plan for children and young people have developed for the first time a Children and Young People’s Health and Wellbeing Strategy, which is supported by the Partnership’s Children’s Services Plan 2014-17. Our Child Health Strategy has been developed following extensive consultation with children, young people and families (355 people, 75% under 18).

A key area of work for the Partnership continues to be the commitment to and learning from the Early Years Collaborative. Several Tests of Change have been scaled up and received national recognition: increasing the reach and uptake of Healthy Start Multi-


vitamins using a non stigmatising universal approach, testing and scaling up early discussions around breastfeeding and choices of feeding with earlier referrals to the breastfeeding support team and testing and developing of the Health Visiting pathway (for example in light of the 27/30 month check data, a weaning pathway has been developed and rolled out).

The Family Nurse Partnership continues to see positive results, with the Vulnerable in Pregnancy and Family Health Team continually developing their model, ensuring effective targeted support to vulnerable families.

Building on from best practice in these core teams, a learning disability parenting pathway is in place and an attachment and confidence measure is being rolled out. The Maternity and Children Quality Improvement Collaborative within Fife has combined with the work of the Early Years Collaborative, extending beyond maternity care and into the wider community. The NHS Fife Early Years Implementation group ensures internal collaboration, bringing together NHS services to ensure a co-ordinated approach, facilitating operational and strategic change.

With our partners, NHS Fife continues to re-orientate services to prevention and early intervention, whilst promoting equity of access for all by increased targeting and engagement for those with poorest health outcomes and increased risks. This is evidenced in our joint work with partners in rolling out Fife’s Family Nurture Approach; which includes a recent development to refresh our maternal mental health and wellbeing pathway.

Our action plan for the full implementation of the Children and Young Person's Act is robust with full partnership buy in.

Health Improvement TargetsWe will deliver a minimum of 602 post 12 weeks smoking quits in the 40% most deprived areas of FifeNo data will be published for this measure until the latter part of 2016. Local Management Information shows that NHS Fife recorded 440 successful post-3 month quits in the 40% most-deprived SIMD areas in the first 11 months of 2015/16, with a projection that around 80% of the target will have been achieved by year end. We continue to refine pathways and adopt innovative ways of targeting hard-to-reach communities in order to improve performance.

Drug and Alcohol Waiting Times: at least 90% of clients will wait no longer than 3 weeks from referral to treatmentNHS Fife maintained a high performance throughout 2015/16, exceeding the standard in each quarter, with an overall annual performance of 98.4%, despite increased patient demand.

Cancer Waiting Times StandardsAt least 95% of patients urgently referred with a suspicion of cancer will start treatment within 62 daysNHS Fife faced significant challenges in sustaining the 62-Day Referral-to-Treatment standard during the year, with particular difficulties in the Lung and Urology specialties and in Radiology. There were difficulties around patient pathways, theatre capacity and


Consultant shortages. During the year, 90.6% of patients started treatment within the standard period. Weekly Waiting Times Meetings help to identify and escalate potential breaches and highlight capacity issues for resolution.

At least 95% of patients diagnosed with cancer will begin treatment within 31 days of decision to treatIn contrast to the 62-Day standard, 97.0% of patients in NHS Fife started treatment within the 31-Day Decision-to-Treat-to-Treatment standard during the year. Weekly Waiting Times Meetings help to identify and escalate potential breaches and highlight capacity issues for resolution.

Detect Cancer EarlyThe National Detect Cancer Early (DCE) initiative continued to result in improvements to Stage 1 Detection rates for Breast, Colorectal and Lung Cancers. Local management information shows that in the 2-year period covering 2014 and 2015, 28.0% of patients in these specialties were detected at Stage 1. The target was to achieve 29.0%, so we fell slightly short of this figure; however, increases against 2011 baseline figures have been notable, particularly for Lung Cancer.


Section 3: Healthcare is safe for every person, every timeClinical Governance SystemsClinical Governance (CG) systems continue to evolve and in the last year there has been particular focus on systems to deal with adverse events from reporting through review to learning from experience. Fife’s systems have been positively evaluated against NHS Healthcare Improvement Scotland (HIS) standards. The approach to CG has been influenced by a growing focus on quality and quality improvement and this is reflected within the revised CG strategy. This aims to better connect evidence, scrutiny and assurance with quality improvement. The Quality, Safety and Governance Group will take an organisational overview of the quality and safety of care and will evolve into the group which considers and prioritises key themes and issues for organisational improvement activities. This group will be key to providing the drive for improvement within the organisation. Using the strategy and other tools will enable a focused, contextualised approach.

HealthCheckOverall accountability for quality begins and ends with the Board. All Board members are individually responsible for assuring themselves that the organisation is as effective, safe, and person centred as possible. This assurance can be gathered partially from using and understanding the summary presented in HealthCheck, which is a set of key high level indicators deemed appropriate by NHS Fife to provide a summary on the quality and safety position of NHS Fife. Supportive text is provided alongside the indicators to aid understanding. With the growing focus on quality and improving quality, Fife is now at a point to reconsider the content and metrics of HealthCheck. The indicators need to be more balanced and reflective of the system in which we work, and be less acute focused. HealthCheck will therefore evolve over the coming months into a Quality Report for the Board which complements the Integrated Performance Report and provides a more balanced view of the whole spectrum of healthcare.

Patient SafetyThere are four programmes of improvement work underway to improve patient safety:

a) The Acute Adult Scottish Patient Safety Programme (SPSP)The intended outcomes of the Acute Adult SPSP is to:

1. Reduce Hospital Standardised Mortality Rate (HSMR) by 20% by December 2015

2. Ensure that 95% of people in acute adult health care are free from the three harms of the Scottish Patient Safety Indicator (SPSI 3) - Cardiac Arrest, Pressure Ulcers and Falls

The HSMR measure is being replaced in 2016 with a more accurate measure developed by ISD.

A 90 Day Review Process has been undertaken across NHSScotland to collate a national perspective and to inform the programme going forward. Three key themes appear to have evolved from this process:


Prevention, recognition and response to deterioration Medicines System enablers for safety

The Ten Essentials contained within Phase One of the programme are:

Hand hygiene Surgical Brief and Pause General ward safety brief Intensive Care Unit (ICU) Daily goals Ventilator Associated Pneumonia (VAP) bundle Early warning system Central Venous Catheter (CVC) insertion CVC maintenance Peripheral Vascular Catheter (PVC) maintenance Leadership walkrounds

These have been widely implemented and are monitored at an Operational level in conjunction with Performance Review Reports. There is less of a focus on reporting process data centrally. A dashboard is being developed to facilitate a systematic approach to measurement across NHS Fife where this is deemed appropriate e.g. hand hygiene.

In addition to the Ten Essentials there are nine specific priorities where work has already commenced, and this will continue to expand in line with NHS Fife priorities. The specific areas of work contained within the Nine Priorities are:

Deteriorating Patients Sepsis Heart Failure Pressure Ulcers Surgical Site Infections Venous Thromboembolism Catheter Associated Urinary Tract Infections Falls with harm Safer Medicines

Reducing Inpatient FallsThis has been identified as a strategic priority for NHS Fife. Some of the interventions identified in 2014 which will continue to be implemented during 2016/17 include:

Initial screening of all patients on admission to hospital Immediate implementation of “safety bundle” for those at risk Equipment review Staff training Reliable implementation of comfort rounds Review of observation policy Review of patient pathway Review of medical pathway Documentation review with a view to integration and removal of duplication


Environmental review

The Datix review group is currently addressing improved fields for reporting of incidents of falls and guidance developed to support staff around grading of incidents and review.

Further change ideas are currently being tested by Ward 15 and the Older People's Collaborative.

The Strategic Falls Prevention Steering Group has been reconvened and will meet quarterly to review learning from the Older People’s Collaborative and provide a mechanism for wider testing and potential roll out of improvement initiatives.

Senior Leaders in the organisation and operational managers have put in place processes to collect, monitor, and review data.

Pressure UlcersThe Tissue Viability Group has been set up to take forward improvement initiatives across NHS Fife with the aim of reducing the number of healthcare acquired pressure ulcers between the grades of 2 to 4. The group has prioritised a number of interventions which include:

Improving pressure ulcer recording and reducing duplication Improving the consistency of pressure ulcer assessment and wound grading Increasing capability in relation to pressure ulcer care training and education Improving co-ordination of care Improving communication Pressure area care Improving access to equipment Cluster reviews to identify themes for shared learning and improvement Casenote review to identify duplicate reporting

NHS Fife has demonstrated an increase in the number of reported pressure ulcers being reported since 2013. This increase has been witnessed in other health boards in Scotland and consideration for this rise is being attributed to an improvement in the reporting of this particular harm.

b) Mental HealthThe aims of the mental health strand of SPSP are to systematically reduce harm experienced by people receiving care from mental health services in Scotland, by supporting frontline staff to test, gather real time data and reliably implement interventions, before spreading across their NHS board area.

The work is being delivered through a four year programme, running from September 2012 to September 2016, and is centred on the five workstreams:

Risk assessment and safety planning Restraint and seclusion Safer meds management Communication at transitions Leadership and culture

A programme of Mental Health specific walkrounds started in 2015.


The multidisciplinary team in the Rehab ward have begun their medication work and an award submission has been sent to the Nursing Standard. The team has been linking with the Improvement Academy in NHS Tayside to share good practice.

c) Maternity & Children Quality Improvement Collaborative (McQIC)McQIC (Paediatric)Work is continuing on the these themes:

Serious safety events Central venous catheter blood stream infection Unplanned admission to the High Dependency Unit (HDU) Medicines harm Child protection harm

The team are focusing on medication reconciliation. The reconciliation process includes verification of medications from two independent sources, and reviewing documentation for children with complex needs to facilitate this work. The team recently set up a prescribing corner to facilitate protected prescribing for Clinicians with the aim of reducing potential prescribing errors.

McQIC (Neonatal)Work continues on these aims:

harm from mechanical ventilation harm from invasive lines high risk medicines harm from transitions of care undetected deterioration

The team has successfully embedded processes around some high risk medicines such as gentamycin and vancomycin and also embedded the safety brief process. They are also due to start improvement work around long line insertion and developing a process to ensure that families of neonatal patients have a consultation with senior members of staff within 24 hours of admission to align with the neonatal framework document.

McQIC (Maternity)Work continues to increase the percentage of women satisfied with their experience of maternity care and to reduce the incidence of avoidable harm in women and babies.

Avoidable harm is defined by the further sub aims to:

reduce stillbirths and neonatal mortality by 15% reduce severe post-partum haemorrhage (PPH) by 30% reduce the incidence of non-medically indicated elective deliveries prior to 39

weeks gestation by 30% offer all women carbon monoxide (CO) monitoring at the booking for antenatal

care appointment refer 90% of women who have raised CO levels or who are smokers to smoking

cessation services,


provide a tailored package of antenatal care to all women who continue to smoke during pregnancy.

A particular focus for the team in the next year will be around the prevention, early recognition and management of postpartum haemorrhage. The team are planning to develop tools to identify antenatal patients that are potentially at risk of PPH prior to these patients going into labour.

d) Primary CareThe aim of the Primary Care strand is to reduce the number of events which could cause avoidable harm from healthcare delivered in any primary care setting by focusing on:

Safety culture – improving patient safety through the use of learning from structured case note reviews and staff safety climate surveys

Safer medicines - including the prescribing and monitoring of high risk medications, such as warfarin and disease-modifying anti-rheumatic drugs (DMARDs), and developing reliable systems for medication reconciliation in the community.

Safety across the interface by focusing on developing reliable systems for handling written and electronic communication and implementing measures to ensure reliable care for patients.

Safe CareThe provision of safe care is determined by a combination of factors including culture, clinical practice and environment.

Patient safety is about placing an emphasis on the prevention of healthcare associated avoidable adverse events and their effects on patients, having a system which facilitates and enables learning from such events and building a culture of safety across all staff groups. To maintain or improve patient safety, we must have in place reliable systems to prevent, recover from or minimise error. This is increasingly important since while health care has become more effective, it has also become more complex, with greater use of new technologies, medicines and treatments.

NHS Fife’s strategic clinical framework has five values, including Safety First. The framework contains several objectives which relate directly to safety, and include:

Ensure there is no avoidable harm Achieve and maintain recognised quality standards Ensure NHS Fife’s environment is clean, tidy, well maintained, safe and

something to be proud of Embed patient safety consistently across all aspects of healthcare provision

A number of priorities are underway in NHS Fife, including:

Participation in the Scottish Patient Safety Programmes and SPSPi Learning from adverse events continues

Learning from patient and carer feedback and complaints Develop and enhance a measurement framework and dashboards to align

accessible data to the key safety priorities and reflect this within reporting


structures from ward to Board level. The availability of good information and data is an essential enabler to link these improvement measures at ward level to the achievement of performance targets at divisional or Board level. The mechanism of review through the performance reviews is supporting this. Progress has been made over the last 12 months to deliver a quality dashboard and good reports through the performance reviews to facilitate this.

Working with Health and Social Care Partnership to redefine and evolve local governance structures which facilitate the local scrutiny and improvement require to provide assurance of the quality and safety of care provided.

Delivery against Healthcare Associated Infection (HAI) standards continues to be monitored and supported through inspections by HEI colleagues. An action plan for hospital and community SABs, developed with continuing support from Health Protection Scotland (HPS), has proved highly effective and continues. Standard Infection Control Precautions (SICP) including Hand Hygiene have been promoted, monitored and reported throughout the year.

Healthcare Associated InfectionWe will achieve a maximum rate of staphylococcus aureas bacteraemia (including MRSA) of 0.24 per 1000 acute occupied bed daysAfter a huge improvement in the Sabs rate during 2014/15, the number of infections increased significantly this year, and the rate at the end of March was 0.43. There was a noticeable increase in hospital-acquired Sabs in the final quarter in particular, driven predominantly by vascular access device related infections. NHS Fife has identified areas where focused improvement work is required and this work is in progress.

We will achieve a maximum rate of C diff infection in the over 15s of 0.32 cases per 1000 total occupied bed daysNHS Fife has consistently exceeded the C Diff target for a number of years, and the infection rate during 2015/16 was 0.24. This reflected a small decrease in the actual number of cases in comparison to 2014/15.


Section 4: Everyone has a positive experience of healthcareAt the Bedside:In NHS Fife we have developed a strategy which outlines the Boards vision, mission and values and specifically details our person centred aspirations and objectives.

We are committed to embedding a person centred approach in all aspects of work across the Board and have been developing staff to think first and foremost about providing care from the basis of what matters to the person/carer. Our work in Fife is building on the work of the national programmes and there are tangible examples of the approach being used in every day practice. Within the Paediatric Unit for example, all rooms now have whiteboards with “What Matters To Me” displayed; meaning that staff can identify straight away what matters most to the child and engage accordingly.

As part of the Older People and Frailty work stream there are also tangible examples of staff engaging with patients/carers and families to identify what matters to them. Commonly the issue of information sharing has been raised as an area for improvement; in response to which, staff have identified ways of more pro actively engaging with patients and families and developed written information to support the process.

In our approach to Participation and Engagement:Following on from the work started last year to engage more widely with communities across Fife we have been developing a Fife wide Participation and Engagement Strategy. The values which underpin the strategy are grounded in person centred ways of working and have provided us with an opportunity to ask people within local communities what matters to them. This has also been implemented in the engagement process for NHS Fife’s Clinical Strategy and will continue throughout the process of development and implementation.

In our approach to Patient Experience:We have continued to encourage feedback by using a range of methods in response to people telling us that no one size fits all. We have encouraged staff to introduce methods that work within their own areas of practice and In the last year we have seen an increase in the number of areas actively seeking local feedback. In one of our Community Hospitals, “How are we doing” boxes have been introduced to encourage a steady flow of feedback. Changes resulting from feedback can be displayed at ward level to ensure people can see the value of providing feedback. In the last year we have seen an increase in the number of stories posted on Patient Opinion and have been developing staff at the front line to respond to the stories.

We have continued the roll out of the “Your Care Experience” questionnaire using technology to assist; however progress has been slow as a result of technical issues. The question set is based on the “Must do with me” principles and provides overall experience data as well as qualitative comments, in real time. The information is then used to drive improvements locally and is reported on from ward to Board. Whilst progress is slow, with technical issues now resolved, the commitment remains to drive this in the coming year.


We have continued to deliver patient and staff stories to the Board of NHS Fife as a means of bringing life to the data presented and keeping Board members connected to what it feels like to experience care in NHS Fife.

In our approach to Complaints:We remain committed to offering a personal approach to complaint handling and seek early dialogue with individuals raising a complaint, to ensure that we are clear about what matters to the person and then do all possible to achieve resolution. Performance against the 20 day standard has been a real challenge and as a result of poor compliance we have taken action to include complaints within our performance management reporting. The quarter 4 performance data identifies the improvements in this area which continue to be a focus for improvement in the coming year.

Improving AccessAt least 90% of planned elective patients will commence treatment within 18 weeks of referralNHS Fife performance fell below the 90% standard for most of 2015/16, but local management information suggests this is starting to recover in 2016/17. The fall in performance was mainly a result of a degradation in Outpatient Waiting Times for a number of specialties and the challenge of balancing routine and urgent (cancer) surgery.

We will ensure that all eligible patients receive inpatient or day case treatment within 12 weeks of such treatment being agreedDuring the year, NHS Fife continued to record a small number of patients who breached the 12-week guarantee each month. Consultant vacancies, the ongoing challenge to optimise theatre utilisation and the requirement to prioritise patients requiring urgent cancer treatment all contributed to breaches, but 98.5% of patients were treated within 12 weeks.

At least 95% of patients will wait less than 4 hours from arrival to admission, discharge, or transfer for accident and emergency treatmentDuring 2015/16, 96.5% of patients attending A&E were treated within 4 hours of arrival. The winter months were as always challenging, but various improvement programmes including a revised patient assessment model in Admissions Unit 1 (AU1) were introduced and proven to be effective in improving patient flow.

At least 95% of patients will have their first outpatient appointment within 12 weeks of referral. Additionally, we must eradicate waits over 16 weeks.At the start of 2015/16, the number of patients waiting over 12 weeks for an outpatient appointment had surged to over 2,000. This was largely a result of consultant vacancies and increased demand in a number of specialties. During the year, overall numbers dropped significantly as additional sessions were held and some activity was outsourced. At the end of March, 96.2% of patients had waited no more than 12 weeks with the actual number waiting over 16 weeks being under 300 although there remains a significant challenge with Neurology due to an inability to recruit to vacancies and increased demand.


Unscheduled and Emergency CareAt a workshop attended by Senior clinicians and managers NHS Fife recognised a number of key pressures in our ability to optimise flow and capacity, particularly over the winter period within our main Acute Hospital Site (VHK). These included:

Increased acuity/complexity,dependency Increased Emergency Department (ED) conversion rates Decreased resilience of staff

Building ResiliencePrevious plans to address this were reliant on our ability to “surge” capacity which in many ways exacerbated issues in managing patient flow and significantly increased the number of patient boarding from parent ward in our hospital.

A different approach was taken in 2015/16 and, in line with the six essential actions outlined in the Unscheduled Care Programme, a plan a number of changes was made to improve our patient experience and to significantly redesign our Urgent Care Services. These included:

Maximum use of 23-hour stay at QMH Surgical Unit An extended Ambulatory Care Service on the VHK Site Development of an assessment area in our Acute Admissions area Continuation of our successful huddle model and a clear move to clinically driven

capacity management New nursing documentation Significant development of our frailty team model within MOE with the addition of

discharge to assess models, including home care at the front door

These changes delivered for us:

Increased early supported discharge More patients using ambulatory care services 25% of all patients referred to the Assessment Unit within our Acute Admissions

ward going directly home the same day A number of patients going directly home from our Acute Admissions Ward with

home care services and/or through our Hospital@Home Service

Delayed DischargeA great deal of work has been ongoing to develop a number of initiatives and to redesign services to alleviate the pressure on acute and to strengthen community services. However, there is still pressure across the health and social care system.

In November 2015, a Memorandum of Understanding (MOU) was signed between NHS Fife and Fife Council to support improvement in delayed discharge performance. Funding was allocated to support additional packages of care, long term care placements and intermediate care placements against an agreed model. The model was designed using data detailing the numbers of people in delay in hospital in recent years as well the number of placements and packages of care previously funded. At the time of signing the MOU there were 138 people in delay in Fife hospitals registered on


EDISON, the model assumed that the number of people in delay should reduce and remain at 80.

Over the winter period, the number of people admitted to hospital and then placed on EDISON was significantly higher than anticipated; an additional 113 people were registered as delayed over the planned position.

Despite a reduction in the bed days lost due to delayed discharge the number of people in delay did not consistently reach or stabilise at 80. The majority of delays were within community hospitals. The Partnership and the Acute Services Division worked closely together to keep the number of patients delayed in the Victoria Hospital at a low and steady level in order to ensure that flow on the acute site could be maintained as far as possible.

Future Models linked to the National Indicator of 72-Hour Delayed DischargeFrom April 2016, there will be a new national indicator which will measure the proportion of patients experiencing a discharge delay of up to 72 hours. ISD have released planned changes, the most notable being:

Moving the census snapshot to the last Thursday of the calendar month Removing the 3 day discharge rule for the census snapshot

By removing the 3 day discharge rule it is expected that the inclusion of these delays will represent approximately a 15% increase on the monthly census figure.

In anticipation of the reduction in the target to 72 hours, the following programmes have been developed. These projects will play a significant role in supporting people to move out of hospital and reduce delay.

Front Door Discharge Model A discharge support model was developed over the winter period in partnership with Health and Social Care, acute services and an independent care provider to enable discharge from the Acute Medical Unit and Emergency Department. This model provided support at home for people that would otherwise remain in hospital for non-medical reasons. The model was successful in support over 90 people with very few people requiring ongoing care. This model will restart in early July.

START ProgrammeThe Short Term Assessment Review Team (START) programme is designed to support the 72 hour discharge target. This began in early February 2016 at VHK. The programme is designed to enable people who require a care package to return home as quickly and safely as possible. The team follow the patient/service user home and continue to review and support the person for up to 6 weeks, this allows time for the person to re-familiarise themselves with their surroundings and support the person to undertake tasks for themselves. If on-going needs are identified the care package will be move to a long term homecare service.

The START programme has proved to be successful; once home people are regaining independence and confidence and the care package has been reduced and/or stopped. While there is still some limitations to the programme, including consideration of people


with complex care needs, the plan is to work towards a fully integrated programme which will shortly be available across Fife. Work is continuing to embed this process with the Hospital Social Work Team, Integrated Community Assessment and Support Service (ICASS) and hospital staff.

Assessment UnitsPeople are often delayed in hospital whilst they are considering the most relevant long term care facility and the availability of a vacancy therein. At present Social Workers assess each individual’s requirements whilst they are in hospital; as part of new models of care this assessment will now be concluded within a care setting rather than a hospital setting. The initial assessment unit came on stream in April 2016. Based in Kirkcaldy the assessment unit will accommodate a maximum of 8 beds; discussions are ongoing with care homes to identify care establishments across Fife who may be willing to consider this model. It is anticipated that we will develop capacity for 40 assessment beds across Fife.

Assessment Units allow people to move from a hospital setting and ensure that we continue to work towards ensuring the person is supported to make the right choices at the right time for their own going needs. We recognise that this needs to be embedded across our hospitals and linked directly to a “Moving on from Hospital” policy, which is currently being refreshed.

Short Term Assessment and Re-ablement (STAR) ModelThe STAR model is an intermediate care model which offers people a period of re-ablement prior to returning home after a stay in hospital. STAR Units are based in local authority and private care homes across Fife

There are a number of developments ongoing which will enhance the journey for patients/service users including additional allied health professional and nursing support in each unit. An additional STAR development at Ostlers House in Kirkcaldy opened in April 2016, a new unit is to planned open in July in North East Fife with additional beds planned for the Dunfermline area in the autumn.

Hospital Social Work TeamAdditional resources have been allocated to the Hospital Social Work Team to increase assessment capacity. Social Workers are based alongside healthcare teams in community hospitals. This helps to facilitate the early identification of people who will require support on discharge from hospital and allow the necessary assessments and arrangement to take place as the patient’s condition improves. Alongside this a re-design of referral systems is taking place to improve discharge pathways and processes.

Management/Leadership OversightThe Health and Social Care Partnership and Acute Services Division closely monitor the delayed discharge position through a weekly Delayed Discharge Task Group overseen by the Divisional General Manager (West) and the Head of Strategic Planning, Performance and Commissioning. This group considers issues and works towards managing redesign of service provision to reduce the number of people delayed in


hospital. A Task and Control Group chaired by the NHS Fife Deputy Chief Executive, monitors the delay position and ensures that action is being taken accordingly.

Achieving a reduction in bed days occupied due to delay is challenging due to the high number of people registered as being delayed in hospital (demand) as well as issues in social work assessment and community service capacity. The Health and Social Care Partnership along with the Acute Services Division continue to develop and implement change programmes and initiatives to consider how we can collectively improve capacity and flow throughout the system. The 72-hour indicator presents a new challenge and work is well under way to address this.

Care for Multiple & Chronic IllnessesNHS Fife continues to build on the work of the Managed Clinical Networks (MCN) to provide the best quality services for Fife residents. The MCN work with varies services to improve the quality of patient care, with particular focus on Heart Failure, Diabetes, Stroke and Respiratory Disease.

Heart DiseaseThe Heart Disease MCN continues to recognise the importance of patient centred care, developing clear referral pathways and providing equitable access to services across Fife to manage heart disease.

Following the development of an Anticipatory Care Plan (ACP) for heart failure patients a more structured ACP approach is being developed for the management of heart failure patients who are entering the palliative phase of their illness. Working with Glasgow Caledonian University to develop an ACP for palliative heart failure patients is being developed. Access to the hospice for heart failure patients is now available.

Forming stronger links with the Psychology Service has produced a referral pathway to psychology services for patients with heart disease who are showing signs of anxiety and depression.

The Patient Participation Group (PPG) have worked with the MCN and the Volunteer Service to develop a peer support group (Fife Heart Buddies) to provide support to patients in the Cardiology wards who are facing heart surgery. Through continuous evaluation of the support provided, success has been identified and the plan is to expand the support out into the community allowing equitable access to this service for all heart disease patients across Fife.

DiabetesThe Diabetes MCN acknowledges the importance of ensuring people with diabetes are enabled and empowered to safely and effectively self-manage their condition by accessing consistent, high quality education and by creating mutually agreed individualised care plans. Clear referral pathways are in place providing equitable access to services to reduce the long term complications of diabetes.

Administration for Type 2 education programmes has become more centralised through the MCN, allowing for improved communication with educators and patients providing opportunity for patients to have increased choice of where they attend a programme.


A newsletter and patient information leaflet has been developed by the MCN and the PPG which has been circulated to GP practices to highlight the different programmes available for people with Type 2 diabetes.

Established education programmes (Diabetes Footsteps, X-pert Diabetes and Conversation Maps) continue to be delivered and are maintained through the Education sub group agenda.

StrokeThe National Stroke Bundle work continues to be a priority in NHS Fife as the methodology used in the patient safety programme is aligned with the reporting of the National Standards.

Neuro-Rehabilitation Outcome Management System (N-ROMS) is a collaborative project between NHS Fife and the Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP-RU). This project aims to develop an outcome management system for use in clinical practice. NHS Fife eHealth have been developing the NROMS System and are now in the process of implementing the new pilot system within the inpatient Fife Rehabilitation Service, Letham Ward and the Acute Stroke Unit.

The N-ROMS data will be used to answer a variety of questions relating to patient outcomes such as: differences in functional outcomes over time; experience of care and resources used to achieve outcomes. This information will in time assist in the continuous quality improvement and planning of service provision for patients across Fife.

RespiratoryFife Respiratory MCN aims to improve the health and wellbeing of people in Fife (children and adults) with respiratory conditions by supporting health professionals to develop and enhance skills and knowledge to facilitate accurate diagnosis; provide structured reviews and to assist patients to embrace self management.


Section 5: Best use is made of available resourcesOutturn for Financial Year 2015/16For 2015/16 NHS Fife achieved all three financial targets which were to operate within the Revenue Resource Limit (RRL), Capital Resource Limit (CRL) and meet its Cash Requirement.

Revenue Resource Limit

The Board delivered a surplus of £0.234m for 2015/16 against its core RRL of £637.451m. This surplus was after the deduction of £1.5m of 2015/16 NRAC funding which had been received in advance in 2014/15. The position also reflects a non-recurring benefit of £2.297m which was received due to a change in the funding treatment of the provisions held for early retirement and injury benefits.

Capital Resource Limit

In 2015/16, NHS Fife underspent its total core CRL of £12.552m by £0.002m.

Efficiency Savings

In line with the Scottish Government’s drive for efficiency across the public sector, the Board has an ongoing commitment to deliver 3% efficiency savings each year. During 2015/16, this was achieved through a combination of cash and non cash savings initiatives amounting to £18.012m which exceeds the 3% efficiency savings target. These savings comprise £6.516m of cash releasing efficiency and £11.496m of productivity gains and other non cash savings. Whilst the overall Efficient Government target was met, there was a shortfall in cash releasing savings of £3.627m which will result in a recurring £2.914m to be met as part of the 2016/17 savings target.

Links between Finance / Efficiency and Planned Service Change

Service delivery continues to be reviewed in Fife, to enhance the quality of patient care and to optimise efficient use of resources. The development of the Board’s new Clinical Strategy will inform the shape of services going forward, helping achieve the 2020 vision.

The continuation of the Integrated Care Fund has allowed further development of services in Fife. In particular this has allowed investment in services to prevent hospital admissions and earlier discharge from hospitals resulting in a reduction in pressure on hospital beds. The Integration Joint Board Strategic Plan was approved, which will drive the direction of travel for more integrated services.

During the year the Board has invested significantly in increasing nursing levels across acute and community hospital sites following the introduction of a Nursing Toolkit the previous financial year.

Development of Capital Programmes

During 2015/16 the Board spent £12.646m on a wide range of capital building projects and equipment. The element charged to the Capital Resource Limit is £12.550m which is the Capital Expenditure net of receipts.


Major construction projects undertaken during the year included £3.791m for the replacement of the Stratheden Hospital Intensive Psychiatric Care Unit which is due for completion in May 2016. Also £1.580m was spent on the Carnegie Unit on the Queen Margaret Hospital site, which is due for completion in July 2016. A new Pharmacy Aseptic Suite was completed on the Victoria Hospital site (£1.022m). An additional £2.624m was also spent on a variety of small building projects across the Boards sites.

New and replacement Medical Equipment purchases of £1.988m were made which included £0.839m of Radiology Equipment. Additional eHealth Technology investment of £0.982m has also been made during the year and £0.589m of investment in the new NHS Fife Telephone Replacement system which is due for completion in April 2017.

Work has now commenced on drawing up Initial Agreement Documents for submission to SGHSCD for the provision of new health centre facilities in both Kincardine and Lochgelly.

In 2015/16 NHS Fife had no major property sales, however there are currently significant property sales planned including Forth Park Maternity Hospital, Netherlea Hospital and parts of the Lynebank Hospital site. NHS Fife is working along with Scottish Futures Trust in drawing up suitable disposal plans and is also in discussion with other parties about the use Forth Park Maternity Hospital and Netherlea Hospital sites.

NHS Scotland State of the Estate ReportNHS Fife continues to make progress with various Estates & Facilities Key Performance Indicators. Significant work has also been undertaken in assisting with the NHS Fife Clinical Strategy, which dovetails with the National Clinical Strategy.

The Functional Suitability of sites has slightly improved and more than 81% of the area is now assessed as “Very Satisfactory” or “Satisfactory”. This figure increases to 97% when only the essential and occupied areas are assessed.

The Quality facet of sites has remained stable with 71% of the areas assessed being rated as “Very Satisfactory” or “Satisfactory”.

Space Utilisation of sites has improved by 4.5% with 84% of all sites being assessed as “Fully Utilised”.

As of the March 31st 2016 the risk assessed backlog maintenance figures are:

Low Risk £5.70MModerate Risk £23.50MSignificant Risk £17.30MHigh Risk £1.50M

Total £48M

This figure excludes £5.46M associated with properties that have been declared surplus.

NHS Fife are now using a risk-based methodology to reduce the backlog maintenance and the high and significant risks should drastically reduce in the next few years.


NHS Fifes statutory compliance is in the top quartile compared to other NHS Boards. This will continue to be a high priority within the Directorate, again using a risked-based methodology which will prioritise the capital funding available in order to address the highest risks. This will be embedded within the Senior Estates & Facilities Managers objectives. As the SCART monitoring tool develops and further questions are added, these figures will obviously change.

Operational indicators continue to show performance in the upper quartile for several services. Energy & Portering costs have seen a reduction of 5%, while laundry and linen costs are maintaining a downward trend for the third successive year and have been benchmarked as part of the HFS laundry review as being best in class. The drive for efficiency will see performance sustained at high levels in all of these areas with further improvements expected as a result of projects currently in construction.

A significant capital project to come on line in the last 12 months is the IPCU located at Stratheden Hospital which was opened on time and within budget.

Two parcels of land at Lynebank have been declared surplus and are currently under offer. Carnegie Clinic / Abbeyview Clinic and Townhill Clinic have all been declared surplus and are being marketed for disposal .

Two strategic assessments have been carried out on the Kincardine and Lochgelly Health Centres with the intent to seek Hub Co funding, the initial assessment document is currently being prepared.


Section 6: Staff feel supported and engagedEveryone MattersThe development of Staff Governance Action Plans for the Area Partnership Forum (APF) and the Acute and Corporate Divisions Local Partnership Forum (LPF) has been completed for 2016. The plans continue to focus on the five staff governance areas. Significant effort has been made in the previous 12 months to engage with staff from across the organisation directly in open meetings with the Chief Executive and Employee Director. The Meetings were well attended and provided the opportunity to question the Chief Executive directly regarding a range of issues.

Staff briefings in Acute Services Division are held every 6 weeks. In addition Managers provide staff with regular briefings at departmental level.

The development of the safety huddle in the Acute Division has allowed senior staff to share information and focus on improved care and safety of patients.

The safety huddles take place each morning of every weekday and allowing staff to share information on subjects such as deteriorating patients, deaths, cardiac arrests, falls, boarding against clinical advice and transfer to community hospitals after 8 pm across the Acute site followed by a description of current and planned capacity over the day.

The recognition of staff achievement has continued in Fife building on the success of the NHS Fife Staff Achievement Awards scheme launched last year. This year’s event was a great success celebrating the efforts of staff, volunteers and carers from across a range of departments, agencies and volunteer groups.

Engagement with staff remains a priority for NHS Fife. Well established staff-side representation exists across the following groups: Staff Governance Committee, APF, LPF for Acute Services Division and Corporate Directorates and the newly established Health and Social Care Local Partnership Forum.

There are staff side representatives as long standing members of the HR policy group, Well@Work Group, Health and Safety meetings and Attendance Management Group. All playing an invaluable role in the development of policies and innovation to improve the experience of staff across the organisation.

The Employee Director is a full member of the Integration Joint Board (IJB) for Health and Social Care

In response to requests from APF members for additional information regarding proposed efficiency savings in the current financial year a successful Finance Workshop was organised for the APF which provided the opportunity for extensive discussion and involvement in determining ways to address the Boards financial challenges. It has been agreed to hold further workshops throughout the year with the next one already scheduled for September.


iMatterThe implementation of iMatter has been extremely positive to date with staff embracing the process and response rates in the last cohort of 87%. This has been achieved, working in partnership with staff representatives and through ensuring the local management teams take ownership of the process. The Board report for 2016 is showing an 88% response rate from 819 staff from a possible 935. The current Employee Engagement Index score is 67%. There are a further 3000+ staff who will be participating in the survey this year. It has required significant time and effort in arranging and delivering staff awareness sessions but this has proved essential in improving engagement with the staff. The Support Services cohort increased their staff responses by 500% from previous National Staff Survey responses.

Focus continues to be on the development of team action plans which have been well received by teams where they have felt able to express their views openly and focus on positive improvement within their teams. The process remains new to staff and is at an early stage but the indications are that this is a powerful tool for improved staff involvement and engagement.

Strategic FrameworkThe Strategic Framework has been published and shared extensively with staff throughout the Board. The vision, mission, values and aspirations have been communicated directly with staff who are attending the iMatter awareness raising sessions.

Workforce Strategy The first draft of the Clinical Strategy led by the Medical Director has been published and issued for consultation. This has been developed through working with clinicians, partners, patients, carers and staff. The strategy will serve as a blueprint for the provision of healthcare services and help the Board to meet the evolving needs of the population. The Clinical Strategy will change the way healthcare is delivered. Work is underway to develop the Workforce Strategy to support the Clinical Strategy with a timescale that runs in parallel.

The Workforce Strategy will ensure the Board has the right workforce with the right skills, right shape and competences deployed in the right place at the right time. The strategy and implementation plans will be a living documents with flexibility, adaptable and responsive to change given the constant changing dynamics of service provision.

It is intended the final Workforce Strategy will be approved in late Autumn 2016.

Health & Social CareThe Health and Social Care Partnership’s Workforce and OD Strategy was approved by the IJB at their meeting in February 2016. The Strategy was developed in partnership with Staff Representatives from Fife Council and NHS Fife as well as managers from HR, OD, Learning and the Senior Leadership Team of the Partnership. The Implementation Plan has also been drafted to be presented to the IJB.

The Health and Social Care LPF has been established and is working well. Work is now underway to develop a framework for Partnership Activity for the LPF which will meet


the needs of staff across the partnership. This work is at an early stage but will seek to support the activity of the LPF in agreeing and developing actions which will enhance the staff experience. The LPF co-chairs have begun examining the best way to develop local action planning and a first draft of the LPF annual Action Plan was presented in June.

Electronic Employee Support System (eESS)The Core Module of eESS went live within the HR Directorate in March 2016. Due to problems encountered nationally with the upload of data undertaken by the central national team it was not possible to progress use of the module until early June. The iRec Module is not now being used nationally therefore fields are not populated from this module which has resulted in additional data input and workarounds being developed locally pending a replacement for iRec.

The Employment Relations Module has, however, been used successfully by the Human Resources Directorate for several months. The Oracle Learning Management (OLM) Module went live from April 2016. It has been implemented with over 80 Learning Administrators trained in its use and it is now being used as the organisation wide system to manage learning and development activity.

The next phases of the project will be roll out to Managers and Self Service but some issues need to be addressed before commencing these phases.

Staff DevelopmentThe Knowledge and Skills Framework (KSF) Personal Development Planning and Review (PDPR) process remains a key feature of the NHS Fife Learning and Development Framework. Regular monitoring reports are provided to the Staff Governance Committee, Executive Directors’ Group and Area Partnership Forum. The quality of PDP discussions is monitored through feedback from training programme participants, the outputs from Focus groups, and from the findings of relevant Internal Audit reports. The NHS Fife position at 31st March 2016 was 38% compliance (with a further 13% in the KSF pipeline). An improvement plan and recovery trajectory to achieve 80% by March 2017 has been developed and implemented.

Recognising the increasingly important role of health and social care support workers, we have recently concluded further successful ‘joint’ programmes with social work colleagues to enable staff to acquire appropriate recognised accredited SVQ qualifications. The six cohorts completed to date have provided positive feedback particularly emphasising the benefit of joint learning.

The e-learning infrastructure and provision continues to develop with over 35,000 e-learning module completions, primarily in the areas of clinical skills and “core” mandatory training, in 2015/16. Evaluation confirms e-learning provision minimises service disruption, is cost effective and provides quality learning, with self-ownership and accessibility viewed particularly positively. Access to NHS Fife e-learning for staff in relevant partner agencies has been implemented.

Compliance with the nine Core Skills (statutory and mandatory) training requirements as identified by the organisation is an organisational priority. There was an overall compliance performance outturn of 80% as at 31st March 2016. This is an increase of


17% compared to the previous year and an improvement plan is in place with a stretch target of 93-95% compliance by 31st March 2017.

Health & Social Care Academy, Work Placements & Social InclusionNHS Fife works closely with Jobcentre Plus and Fife Council to provide pre-employment opportunities. These opportunities, in the main, target young people aged 18 to 24 or those with long term health conditions impacting on their daily activities. The opportunities provide participants with a greater understanding of employment expectations within a range of Healthcare settings including Medical Records, Support Services and Corporate Services.

Current successes focus on:

Those people aged 18 to 24. This group has been targeted as part of the national ‘Get Britain Working Programme’.

A limited number of modern apprenticeships, engaged via fixed term contracts, are being supported within the Corporate Services functions.

The use of of 16 week employment placements for students studying for an SVQ in Information Technology at Fife College is also being explored.

Initial discussions have taken place to explore the feasibility of coordinating the activities undertaken across NHS Fife, Fife Council and Fife’s employability services under the context and scope of a Health and Social Care Academy led by Opportunities Fife. It is envisaged the scope of work experience opportunities available through the Health and Social Care Academy would incorporate roles in both clinical and non-clinical settings throughout NHS Fife, Fife Council and the third sector, with participating partners offering a limited number of work experience opportunities.

Management of Sickness AbsenceNHS Fife achieved the Gold Healthy Working Lives Award in May 2016 and implemented a Staff Health and Well Being Strategy and associated Action Plan for 2015 to 2017, along with a Staff Well at Work Handbook. The Board’s Well at Work initiatives are designed to improve and promote staff health and wellbeing and aim to reduce sickness absence in a proactive manner.

The May 2016 sickness absence figure produced by the Scottish Workforce Information Standard System (SWISS) for NHS Fife is 4.40%. This is a decrease of 0.27% from the April 2016 figure of 4.67%. In addition, the NHS Fife rate was slightly (0.48%) below the NHS Scotland average in May 2016 and 0.11% below the NHS Scotland average for the financial year from June 2015 to May 2016.

Reviews of the management of sickness absence is in place with regular Management of Attendance Review and Improvement Panels held within the Acute Services Division, the Health & Social Care Partnership areas and the support services staff groups. Additional managerial support is being provided to areas of concern.

NHS Fife has continued to provide a programme of Attendance management training for managers and supervisors, delivered in partnership, which take place once per month with the exception of July and are supplemented by eLearning and bespoke training sessions.


Medical WorkforceThere have been concentrated efforts during 2015 (continuing into 2016), to recruit and retain trained medical staff to sustain the Board’s medical workforce.

The Board successfully recruited new Consultants for a number of key specialties during 2015 and into 2016, including appointments within the following specialties: Acute Medicine, Anaesthetics, Care of the Elderly, Emergency Medicine, Endocrinology, ENT, Oncology, Ophthalmology, Pathology and Psychiatry. The areas of NHS Fife which continue to be affected by an inability to recruit and retain Consultant medical staff are Anaesthetics, Gastroenterology, Paediatrics and Radiology. Clinical Directors, Service Managers and the Associate Medical Directors have contingency plans in place to ensure continuity of service provision within NHS Fife.

Demographics

Mar-13 Mar-14 Mar-15 Mar-160

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

7075.2 7245.7 7338.8 7307.0

8671.0 8840.0 9010.0 8961.0

NHS Fife EstablishmentHeadcount and WTE trendline

Total WTETotal Headcount

31st March 2016

Job FamilyHeadcount WTE

Administrative Services 1,576 1,239.7

Allied Health Profession 797 634.6

Dental Support 88 72.5

Healthcare Sciences 187 166.8

Medical & Dental 646 566.6

Medical Support 39 37.7

Nursing & Midwifery 4,137 3,500.9

Other Therapeutic 282 230.4

Personal & Social Care 62 47.1

Senior Managers (Non Agenda for Change) 21 21.0

Support Services 1,126 789.8

Grand Total 8,961 7,307.1


Administrative Services17.6%

Allied Health Pro-fession8.9%

Dental Support1.0%

Healthcare Sciences

2.1%

Medical & Dental7.2%

Medical Support0.4%

Nursing & Midwifery46.2%

Other Therapeutic3.1%

Personal & Social Care0.7%

Senior Managers (Non AfC)0.2%

Support Services12.6%

NHS Fife - Job Family Distributionbased on Headcount on 31st March 2016

Count of cases during 2015/16

Type of Concern Number of CasesConduct 115Concerns 20Dignity at Work 16


Section 7: People are able to live well at home or in the communityDeveloping Primary Care ServicesThe shadow Health and Social Care Partnership began to develop wider teams, based around clusters of Practices. This decision was based on the assumptions about the changes that will be in place in the transitional year (2016/17) of the GMS contract.

As is common across Scotland, some practices in NHS Fife found it difficult to recruit GP partners, or salaried GP. Two GMS contracts were handed back to the Board and were run as Section 17J contracts. A General Practice Sustainability Group was established by the Board which offered support where required, and introduced other disciplines (Advanced Nurse Practitioners and Practice Pharmacists) into the practice teams.

We introduced additional support from Practice Pharmacists into general practices. This was a welcome addition to the practice based multidisciplinary team – both saving money for NHS Fife by improving effective and efficient prescribing and reducing workload for GP by undertaking medication reviews for patients on several medication e.g. care home patients, initiating chronic medication service, carrying out prescribing projects, reviewing acute prescriptions, carrying out chronic disease clinics, e.g. hypertension clinics etc.

A new model of Primary Care in Fife which aims to provide better, more holistic, person-centred and high quality care to people with chronic physical, emotional and/or mental health problems associated with adverse events in their childhood (whether disclosed or undisclosed) was introduced. This is part of a wider endeavour to make health and care services trauma-informed and a longer term aim to eliminate childhood abuse in Fife in this generation. The project is called Better than Well because once people overcome challenges in terms of trauma and loss, addiction, chronic disease etc. they are often able to live life more fully than before they encountered these difficulties. The project is based on the principle that people can take greater responsibility for their health, become more involved in the design of services and act as equal partners with providers.

NHS Fife participated in the Community Physician Fellowship pilot, with three Fellows recruited and a further round of recruitment expected to be completed early 2016/17. The Fellows worked together with other Services to begin to develop a Community HUB model which will allow blurring of the boundaries between Primary and Secondary Care and contribute to keeping complex and elderly patients at home and facilitating shorter admissions closer to home when admission is required.

Primary Care was a key focus of the new Fife Clinical Strategy, and GP representation was secured on each Workstream. As this develops, primary care contractors will be key to supporting implementation of the service redesign set out in the strategy.

The Report “Pulling together: transforming urgent care for the people of Scotland – The Report of the Independent Review of Primary Care Out of Hours Services” was considered by the Urgent and 24/7 Care Workstream.


The implementation of the Review is being led at executive level of the Health and Social Care Partnership and a group was convened based on the multi-disciplinary/multi-agency input to the Review, as a short term working group to look at the Recommendations. This Group is informing the Clinical Strategy. The expertise will be used to develop a blue print for an Urgent Care Resource Hub in Fife and to re-align the existing Primary Care Emergency Centres as Urgent Care Centres, taking the guiding principles of the Report into account.

e-Health DevelopmentsSwan Migration

All general practices successfully migrated from N3 to SWAN.

Remote Access

12 general practices were configured with a further 9 pending. This provided practitioners and practice management with secure real time access to practice IT systems from a remote location.

Scottish Primary Care Information Resource (SPIRE)

Two general practice pathfinders were identified, 1 x EMIS, 1 x INPS. Technical scoping is underway.

Clinical Portal

All practices had access to the clinical portal by mid 2015.

Chronic Medication Service

Work continued during 2015/16 to encourage practices to provide suitable patients with a serial prescription.

Dental

All general dental practices were sending referrals via SCI Gateway by mid 2015.

Optometry

SCI Gateway/NHS Mail was rolled out to all Optometry practices during 2015. Practices continue to use increasingly sophisticated equipment on a day to day basis. The widespread use of Digital Retinal Photography has been in place since 2010. Some practices have now moved on to Optical Coherence Tomography (OCT) which allows an even greater imaging of all the tissue of an eye. Unfortunately their use is not currently part of the NHS system and patients may have to pay privately for the service. One area that SIGN 144 recommends is a measurement of corneal thickness on patients with Ocular Hypertension or suspect Glaucoma, not all Optometric Practices have the equipment that is needed to take this measurement.

Immediate Discharge Letter/EDT

This was rolled out in phases during 2015.

The “Developing Clinical Capacity” aspect of Prescription for Excellence progressed well in Fife and Pharmacist Independent Prescribers commenced polypharmacy review clinics in 7 practices with the plan to improve this over the next year bringing more


Pharmacist Independent Prescribers on board. This is being shown already to be creating clinical capacity within these practices allowing the GPs to focus on other work but be available to clinically support the pharmacist.

Scottish Patient Safety ProgrammeNHS Fife has been part of the Scottish Patient Safety Programme in Primary Care since March 2013.

In the first year the focus was on improving the management of warfarin and supporting patients to understand the side effects and interactions of this medication.

Medicines Reconciliation was the focus of the second year and included the establishment of a cross sector group to improve medicine reconciliation at each stage of the patient journey. The development of electronic Immediate Discharge Letters has improved communication between secondary and primary care.

The third year focused on the management of disease modifying anti-rheumatic drugs (DMARDS). The GP Practices also completed Trigger Tools and Safety Climate Surveys to increase the focus on developing a patient safety culture amongst all staff in the GP Practice.

In 2014 NHS Fife were selected to be one of four boards taking part in a pilot programme in Pharmacy which also focused on warfarin in the first year. The pharmacies involved have been providing education and support to their patients who take warfarin and developing a range of resources to support the safer use of this medication. The second year of this programme is focusing on Medicines Reconciliation and looking at how pharmacies can gain access to additional information that can allow them to ensure patients receive the correct medication following discharge from hospital.

In 2015 NHS Fife became one of three health boards who are taking part in the SPSP Dental programme with a focus initially on anti-coagulants anti-platelets and bisphosponates.

Health and Social Care IntegrationFife’s amended Integration Scheme was submitted to the Scottish Government in the autumn of 2015 and eventually approved by Parliament.

The formal consultation on the Partnership’s Strategic Plan was undertaken between October 2015 and January 2016. Responses were analysed and a full report along with a final version of the Strategic Plan was considered by the Integration Joint Board (IJB) on the 10th February 2016. The Strategic Plan was subsequently approved and published.

A Governance structure was developed and approved for Fife’s Health and Social Care Partnership. Three Committees will form the main sub structure of the IJB i.e. a Finance and Performance Committee, a Clinical and Care Governance Committee and an Audit Risk Committee. Committee membership and remits have been approved by the IJB.

Fife’s Health and Social Care Partnership has been closely involved in the initial stages of developing Fife’s Clinical Strategy. The Clinical Strategy will fully take cognisance of


the IJBs Strategic Plan and with a wide range of the Partnership’s Clinical and Professional staff involved in the work streams, clear links and synergies are emerging.

Legislation requires the Health and Social Care Partnership to produce a Participation and Engagement Strategy. This will ensure that there is sufficient engagement with all communities and partners in relation to the work of the Partnership. A significant piece of work was undertaken to progress this which involved widespread engagement with stakeholders including public participation groups, service user and carer groups, communities and equality groups. The development of the Strategy has ensured a co-productive approach and will make sure that future structures meet legislative and policy requirements and the IJB’s development expectations for Locality Planning. A joint Workforce and Organisational Development Strategy has been developed and approved. This important framework will support the delivery of both the Clinical Strategy and the Partnership’s Strategic Plan. A supporting implementation plan for the Workforce and Organisational Development Strategy will be presented to the IJB in late summer 2016.

A considerable amount of focused activity has been undertaken to review and develop proposals with regard to how we can maximise the benefit of the wide range of services which sit within the Partnership in order that in terms of the whole system, including the Acute Division of NHS Fife, it is possible to increase flow and capacity and make improvements to clinical and care pathways to achieve a better balance of care for the public. A steering group has been established to progress work in this respect with an early focus on mapping current resources and service pathways within localities; gathering data and evidence on demand and service impact; engaging with a wide range of stakeholders and ensuring that developments evolve in ways which link with the formation of GP clusters across the Partnership. In addition, work has been ongoing to develop, implement, evaluate and scale-up where appropriate a range of small tests of change in order to test out very specific areas of system redesign or integrated practice which can build the foundations for larger scale change in the future.

A very successful conference and exhibition took place on the 3 rd February 2016 to launch the Fife Partnership. Shona Robison MSP, Cabinet Secretary for Health, Wellbeing and Sport delivered the keynote speech. Over 200 people from across all stakeholder groups attended to witness the launch of the Partnership, consider what local changes would be required and learn about some of the initiatives already being taken forward. Updated branding and a new mini website were also launched at the conference to mark the transition from the shadow period to full integration.

Healthcare Environment Inspectorate (HEI) / Older People in Acute Hospitals (OPAH) InspectionsHEI

NHS Fife had three unannounced HEI visits in 2015 and has had one announced HEI visit to date in 2016. The inspection visits have been to 4 different sites - VHK, QMH, Cameron Hospital and St Andrews Community Hospital.

Unannounced Visit: VHK 25-26 August 2015


This visit was described as a follow up visit reviewing the areas of concern and requirements from the previous unannounced inspection visits in December 2014.

Requirements:1. NHS Fife must ensure that the data collected and recorded from audits on the

use of personal protective equipment accurately reflects staff practices.This action refers to the SICPs audit tool in place within ASD whereby the calculation in the tool rounds up or down depending on the level of compliance. The Lanqip tool was reviewed as an alternative and it has a similar concern in relation to how it calculates percentage compliance. NHS Fife is currently working with Health Improvement Scotland (HIS) to develop and test a tool that is fit for purpose. This is being tested in Glenrothes hospital, but supported as a Fife wide development.

2. NHS Fife must ensure that all staff decontaminate their hands at the appropriate times, in accordance with the World Health Organization’s 5 moments for hand hygieneWhilst the HEI recognised significant improvement they did not feel assured that this was consistently adhered to following observations of practice during their visit. Hand Hygiene (HH) monitoring is now supported by an improvement plan to enable clinical teams identify improvement actions and deliver these, and provide a route of escalation if results remain below an accepted level. The HH Standard Operating Procedure (SOP) was updated to reflect some changes / feedback from clinical staff to support their practice. In addition the infection control team have led a NHS Fife-wide Hand Hygiene Improvement Project with a particular focus on hand hygiene which has received executive sponsorship and support.

Recommendation:1. NHS Fife should ensure that all patient toiletries are for single patient use

This was rectified at the time of visit, and there has been a change in practice in the area that was noted as a concern.

Unannounced Visit: QMH 29-30 September 2015Requirements:

1. NHS Fife must ensure that all wards complete standard infection control precautions audits in line with the NHS Fife HAI prevention and control assurance framework and the Health Protection Scotland National Infection Prevention and Control Manual for NHS Scotland (2015). Compliance with the audit programme must be monitoredThe inspectorate saw variation in practice across different in-patient wards at QMH. SICPs auditing has now been rolled out to all in-patient areas.

2. NHS Fife must ensure that domestic staff comply with the guidance for the selection and use of personal protective equipment described in Health Protection Scotland’s National Infection Prevention and Control Manual (2015).The inspectorate raised concerns about the use of marigold gloves and variation of practice observed during the visit. This is an issue that is being explored


further involving H&S, HPS, HSE, HFS and HIS to agree a way forward balancing infection control risks with H&S concerns.

3. NHS Fife must ensure that all patient equipment is clean and ready for use. This will reduce the risk of cross-infection to patients, staff and visitors.The Equipment Cleaning Schedule has been updated as a Fife wide document that is now in place across NHS Fife providing clarity regarding the agreed approach / method of decontamination required.

4. NHS Fife should demonstrate a consistent approach to mattress inspections across all wards and departments.See requirement 3 – this action has been incorporated into the Equipment Cleaning Schedule.

Unannounced Visit: Cameron Hospital 21-22 October 2015Requirements:

1. NHS Fife must implement a procedure for managing an outbreak, from prompt identification of infection through to the end of the outbreak. This must include completion of the hospital infection incident assessment tool and implementation of condition-specific care plans.This action has been addressed through updated guidance by the ICT.

2. NHS Fife must store personal protective equipment in line with the recommendations detailed in the Health Protection Scotland National Infection Prevention and Control Manual (2015).This action has been addressed and all areas across NHS fife have reviewed the storage of PPE to ensure it is compliant with National guidance.

3. NHS Fife must implement a policy and standard operating procedure for managing animal visits to the hospital. This will ensure that any animal visits are managed in line with standard infection control precautionsThis has been developed and is now in place.

Recommendation:1. NHS Fife should improve communication between the estates department and

ward staff to ensure that any estates and maintenance issues are acted on within a reasonable timescale and ward staff are kept informed of progress.There is improved communication and monitoring of estates requests made.

Announced Visit - St Andrews Community Hospital 27-28 April 2016Requirements:

1. NHS Fife must ensure compliance with Health Protection Scotland’s National Infection Prevention and Control Manual for NHS Scotland (2015) and guidance about the selection and use of gloves.The Inspectorate again raised concerns about the use of marigold gloves and variation of practice observed during the visit. This is an ongoing issue as noted above following the QMH unannounced inspection. See QMH feedback for detail.


As can be seen by the inspection activity over the past 12 months there has been significant scrutiny by HIS in relation to HAI standards across NHS Fife and the feedback in general has been very encouraging whilst recognising opportunities for ongoing improvements.

Some of the concerns have related to variation in practice between ASD and community services, and there has been collaboration to ensure a Fife wide approach to infection prevention and control.

Infection prevention and control is a key part of the bi-monthly Inspection Co-ordinating Group ensuring a Fife wide approach to delivering against the standards and reviewing ongoing risks, actions and improvement activities from external inspection and internal audit and surveillance.

OPAH

The most recent unannounced OPAH visit in February 2015 was very encouraging and whilst there were 10 areas of ongoing improvement identified there was recognition of 9 areas of strength evidenced during the visit. Progress is being made towards sustainable improvement in all aspects of care of Older People in Hospital.

To support the ongoing improvement of care in relation to older peoples care in hospital NHS Fife have a rolling programme of self assessment and update in regard to adherence to the standards.

The Board have had regular contact with the OPAH team with an updated action plan submitted in March 2016 which identifies four outstanding actions. Of the four outstanding actions, two (process to ensure patients have a cognitive assessment in ED; audit of discharge planning) are due to deliver against a July completion date. The two other actions relate to the development and roll out of delirium awareness and care and work and these have ambitious delivery targets of December 2016 and January 2017.

Mental HealthAt least 90% of clients will wait no longer than 18 Weeks from referral received to treatment for specialist child and adolescent mental Health Services (CAMHS)During 2015/16, 78.4% of patients started treatment within 18 weeks of referral. There was a gradual increase towards the Standard during the year, as a result of a Recovery Plan which, amongst other initiatives, increased the number of new cases that each CAMHS clinician saw in a month. In order to maintain improvement in 2016/17, further service re-design activity and recruitment will be undertaken, using funding provided by the Scottish Government.

At least 90% of clients will wait no longer than 18 weeks from referral received to treatment for psychological therapiesDuring 2015/16, 69.0% of patients started treatment within 18 weeks of referral. This reflected a gradual improvement during the year following a fall in 2014/15 when additional therapies (some with long lead times for specialist treatment) were added to the measure. The Recovery Plan implemented during the year has been reviewed and work will continue in 2016/17 to increase access to an enhanced range of psychological interventions and therapies within a tiered model of service delivery.


All patients diagnosed with Dementia will have a minimum of a year’s post-diagnostic support and a person centred support planDementia diagnosis increased during 2015/16, above the figure estimated for NHS Fife by the European measure of prevalence. There has been no guidance on measuring performance against the Post-Diagnostic Support (PDS) Standard, but this service faced a challenging demand during the year and this led to increased waiting times for patients having their first contact with a link worker. In order to future proof the offer of PDS in Fife we have devised a management arrangement which provides a functional level of coordination, standardisation and quality assurance, and the waiting time is reducing monthly.
