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1 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
CMO (2015) 19 letter: HPHS Reporting Guidance 2015/16
This document provides guidance for staff reporting on the actions and associated activities within CMO (2015) 19 letter. This includes:
General guidance on completion of your annual report
Topic specific reporting submission requirements
Please review these guidance notes in order to complete your 2015/16 Annual Report
Hospital Settings
NHS Boards are reminded that the CMO (2015) 19 letter encompasses policy requirements for all hospital settings. This includes acute, community, maternity, paediatric, and mental health hospitals.
Boards are required to specify ALL settings and sites that are represented within their annual report submissions and which of these five categories they each represent. Boards are also required to specify which hospital sites are not represented within their annual report submission and a brief rationale for this (e.g. if you are taking a staggered approach to implementation across sites).
2015/16 Reporting Timeframe
All annual report evidence submissions should report on actions undertaken between 1st April 2015 - 31st March 2016. Scottish Government requires all NHS Boards to submit their 2015/16 Annual reports for the CMO (2015) 19 letter on or by Friday September 30th 2016 to:
nhs.HealthScotland-hphsadmin@nhs.net
Quality Assurance
NHS Boards are responsible for ensuring that all relevant managerial, clinical and/or topic leads for each of the policy areas are involved in their annual reporting process. Each section within the annual report template requires a lead contributor to be named including their job title. Additional contributors can be named in appendix A of the reporting template.
Contributors should note where quantitative data is required and ensure that this is expressed in the correct format. Data submitted in the incorrect format will not be included within local or national analysis. Therefore the evidence submission for this section will be considered incomplete, unless clarified in mitigation. Where narrative responses are requested, contributors should ensure the suggested themes are included, where possible, and the word count of 500 words/1 page is adhered to.
Programmes may operate across the whole population, but where appropriate, the scale and intensity of those actions should be proportionate to need or disadvantage. This is reflected in places where information is requested on tailored initiatives or priority settings.
Local quality assurance mechanisms should be applied in advance of your submission.
2 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Further Support Visit the HPHS pages on the Knowledge Network for a wide range of information and support on health improvement and inequalities in hospital settings:
www.hphs.co.uk
Summary Questions – reflecting 2015 / 16 delivery
Provide a brief description of what went well in the delivery of HPHS and provide examples e.g. developing a strategic approach to delivering training or local campaigns, building capacity for health improvement across the board, having strong leadership in place.
Provide a brief description of any barriers to progressing the delivery of HPHS and describe how you have, or plan to, overcome them e.g. improving data collection, developing capacity to embed and strengthen the HPHS ethos of health improvement in hospital settings.
Describe how you have built on activity reported in previous years.
Practical guidance
The reissued Annual Report: Reporting Measures for 2015 – 18 (v2 aligned with
reporting template February 2016) has minor alterations to some required evidence
questions and numbering. These alterations have been made to clarify evidence
requirements and does not change the overall performance measures.
The CMO (2015) 19 reporting template has undergone revisions from the format previously
used. The excel format has been replaced by a word template in order to improve the
accuracy of the reporting and support those providing the required data.
The list of content pages in this document contains hyperlinks to navigate to each of the 12
sections (A - L).
All fields in the reporting template shaded in light yellow should be completed with the
requested evidence.
All Annual Reports with incomplete evidence sections must provide exception reports in
the separate exception table at the end of each section.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no need to attach these as part of your narrative assessment unless requested.
Any attachments that NHS Boards include should be referenced within the “evidence” response
as labelled appendices. These appendices should be included as attachments to the email
accompanying the submission to NHS Health Scotland.
The analysis of the annual reports will refer to the indicators in the table below:
Delivery analysis Indicator description
↔ delivery Delivery has continued as reported in Year 3 CEL (2014/15)
↑ progress Improvements in delivery have been reported from Year 3
No progress No change has been reported from the Year 3 report
- Comparison cannot be made
Data was not submitted (at all/in same format) in Year 3 CEL report
* Development
phase
Delivery impacted by delay issuing CMO measures OR new performance measure
3 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Contents Page
Section A: Strategic Actions 4
Section B: Smoking 6
Section C: Alcohol 8
Section D: Maternity 9
Section E: Food and Health 11
Section F: Staff Health and Wellbeing 15
Section G: Reproductive Health 17
Section H: Physical Activity and Active Travel 19
Section I: Managed Clinical Networks – NEW 22
Section J: Inequalities and person-centred care – NEW 23
Section K: Mental Health – NEW 25
Section L: Innovative and Emerging Practice 27
4 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section A: Strategic Actions
Action 1
A. Provide the name and role for the executive lead responsible for implementation and
governance of the actions within the CMO (2015) 19 letter.
B. Provide details of relevant meetings to determine plans or developments with Health
and Social Care Integration Boards i.e. name meeting group (e.g. the Board), provide
date(s) of meeting inputs, name of briefing document/agenda item and
agreements/outcomes.
Attachments of minutes or equivalent are not required to be submitted.
C. Enter the name of the Health Facilities Lead(s) identified to support measures for vending,
catering, and the provision of green space developed to enable physical activity within the
NHS estate for staff, patients and visitors.
Action 2 Evidence submissions can represent all professional development programmes that
include topic-specific or generic health improvement and inequalities competencies. This
is to account for the range of locally determined relevant professional development
opportunities.
The proportion of staff should be described in relation to the total number of hospital-based
clinical staff eligible to complete related courses and should reflect staff training within
2015/16.
Name and describe each course, method of delivery and the number of attendees, along
with their roles.
Please ensure any duplicate reporting on staff training in relation to specific evidence
requirements for physical activity and mental health are referenced within the submission.
Note: if you have all the above information on training already collated on a separate sheet
for your NHS Board, you can attach this as your evidence. Ensure your attachment is
documented on the reporting template and covers all the requested areas.
NHS Health Scotland will distribute data to each NHS Board (in April / May 2016)
indicating staff who have completed modules on the NHS Heath Scotland Virtual Learning
Environment (VLE) for the following modules:
Health Behaviour Change module 1
Health Behaviour Change module 2
Raising the issue modules: Alcohol, Physical Activity, Smoking Health Inequalities: Awareness raising * Tackling health inequalities in health & social care *
Please note that unless staff have indicated on the VLE registration data that they work in
the acute setting, they will not be identified as such and therefore the data returned may be
incomplete.
* Note: these modules will be launched end February/early March 2016.
5 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Action 3 A. As per evidence requirement. Provide details on the role and clinical areas where
clinical and medical leadership for health improvement delivery has been demonstrated.
Additionally, identify successes and challenges in gaining clinical and medical leadership?
B. Evidence of sustained health improvement practice by clinicians could include a
description of how clinicians have been delivering health improvement practice as part of
their role.
Action 4 – overall suggested word count of 600 words
A. Evidence of the impact of strategic actions could include current status of programme,
reflection on service improvement, local action plans and evidence of outcomes across
patient services, staff health and wellbeing and the hospital environment over the lifetime of
HPHS CEL (1) 2012 and current CMO (2015) 19 letter.
B. Provide a brief description of the intended and unintended consequences of the
programme in relation to your response in 4A.
C. Provide a brief description of your plans for sustaining implementation of HPHS and
inequalities focus in hospital settings.
D. Provide a brief description of your plans indicating where and how HPHS activity is being
included in the commissioning and planning for health and social care integration.
Note: Action 5 has been removed to reduce repeated reporting.
This has resulted in the numbering being altered throughout the guidance for the
remaining performance measures. The numbering on the reissued Annual Report:
Reporting Measures for 2015 – 18 (v2 aligned with reporting template February 2016)
has also been updated.
6 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section B: Smoking
Action 5
Specific settings to be targeted for identification of smokers and referral pathways have been
included to reflect the potential areas where referrals can be made from, including: respiratory;
vascular; cardiac; diabetes; mental health; maternity and cancer.
A. (i) Note which system is used to record the smoking status for each patient and the role of
the person who records this information.
(ii) Where known, record the number of smokers supported with Nicotine Replacement
Therapy (NRT) while in hospital. If this number is not known, note the number of
prescriptions issued for NRT products.
(iii) In order to indicate engagement with smoking cessation services while a smoker is in hospital,
record the number of smokers who set a quit date while still in hospital. The emphasis is on a quit
date being set, which can include dates following the hospital stay. Where possible, provide this
figure as a proportion of all smokers recorded in a hospital setting. If quit dates are set for when a
patient who smokes return home, indicate how they will be supported once they are home.
B. List all pathways in place or being developed, naming the setting, whether it is a targeted
setting and if aligned to a Managed Clinical Network. Note if an opt-out scheme is in operation
and if the pathway is integrated with primary care. Where possible, also provide brief details on
how the pathway/s have impacted on patient-centred care through referral to, and uptake of,
smoking cessation support.
Attachment of a local pathway is not required to be submitted.
Action 6
A. (i) Provide a brief description of your progress on tobacco policies relating to shared sites.
Shared sites are defined as NHS, and any other local authority or private estate.
(ii) Provide brief details on how the NHS Smoke-free grounds policy is communicated to staff, patients and visitors. Note all channels here e.g. online reminders, admission letters, signage, staff induction and training.
(iii) Provide brief details on how the NHS Smoke-free grounds policy is implemented (only on NHS grounds where you have full control). Compliance and adherence with the policy should include details on training staff to be more confident to approach smokers and encouraging staff to be advocates for smoke-free grounds with both patients and visitors, in addition to the aspect of staff behaviour and role modelling.
Action 7
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and
the hospital environment.
7 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
A. Your assessment of the impact of smoking actions since their introduction in 2012 should
include the following themes where applicable and appropriate:
Progress made on the NHS smoke-free grounds policy, including if the messages are
being adopted and is compliance acceptable
Any progress on supporting smoking cessation for staff, particularly in light of smoke-
free grounds
Any examples of progress e.g. in the targeted settings, partnership working, pathways,
what’s working and any shared learning.
Note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
8 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section C: Alcohol
Action 8
The narrative response is intended to give you the opportunity to reflect on progress and note any
areas for improvement, assessed in relation to your NHS Board strategic plan for Alcohol Brief
Intervention (ABI) delivery.
The response should be kept succinct and only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, and if appropriate, also the
impact on staff health and wellbeing and the hospital environment.
A. Your assessment of the impact of alcohol actions since their introduction in 2012, should
include brief details on the following themes where applicable and appropriate:
Measuring impact and indicators of success
mechanisms in place to measure impact / how you capture indicators of success
integration of services, embedding of ABI delivery and mechanisms for local
partnership working
process evaluation, service evaluation or follow up
Workforce
strategic workforce development approach and workforce planning
frontline A&E and/or wider reach of ABI delivery
whole population approach or targeted work on patient / staff health and wellbeing
Support
Indicate what issues or areas of support require either national, local or peer level
support.
Note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
Note: examples of alcohol brief intervention delivery in hospital settings can be provided
in Section L: Innovative and Emerging practice.
9 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section D: Maternity
This section has been amended to reflect the measures for breastfeeding actions in
maternity and wider hospital settings.
Action 9
This section builds upon the work that hospitals are undertaking to meet UNICEF Baby
Friendly Initiative accreditation, taking elements of the WHO International Code of Marketing
of Breast-milk Substitutes. UNICEF has developed guidance for the code. N.B. The Code
covers the wider hospital-setting.
http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/guide_int_code_health_profes
sionals.pdf
A. This evidence is looking for an outline of the mechanism or plans for local NHS Board
monitoring of WHO Code compliance. Including the mechanism to monitor compliance, who
monitors the Code, how staff are informed of the Code and the process for reporting
breaches locally.
Action 10
A. This evidence is looking for a description of the process in place to support breastfeeding
mothers who are admitted to hospital settings, out with the maternity unit, to continue
breastfeeding. The description should outline how each area is addressed, and any other
initiatives that support breastfeeding in the wider settings, for example referral routes, care
pathways, dedicated breastfeeding contact.
Responses should include (i) ensuring that procedures and drugs have as little impact on
breastfeeding as possible, (ii) how staff enable mothers to express and store milk, (iii) do
mothers have the infant in their room.
B. This evidence is looking for a description of the system or pathway in place to support
breastfeeding mothers of preterm or sick babies or those mothers encountering
breastfeeding problems to continue breastfeeding. Examples could include policies,
training, breast pump loan schemes, expressing logs and other local activities.
Action 11
A. This evidence is looking for a description of the process for how attrition (drop off) rates
are calculated using local and national data. If common causes for attrition are identified,
what actions have been taken to address these? Data collected at 5 days, 10 days and 6-8
weeks can be used to work out attrition rates.
Data sources:
Guthrie Inborn Errors Screening data
ISD - http://www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/
Infant Feeding Survey - http://www.hscic.gov.uk/catalogue/PUB08694
Local Baby Friendly audit data
B. Suggested links: Early Years Collaborative – Using the model for improvement
http://www.gov.scot/Resource/0044/00446639.pdf
10 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
EYC website - http://www.gov.scot/Topics/People/Young-People/early-years/early-years-
collaborative
Action 12
A. The evidence is looking for details of the NHS Board infant feeding policy for staff
returning to work. For example, the governance arrangements for the policy, how the policy
is communicated to staff and how it is implemented.
B. A brief description is required of the facilities available to support mothers to continue to
breastfeed and /or express their breast milk on returning to work.
Action 13
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and
the hospital environment.
A. This evidence is looking for a narrative on what difference the inclusion of breastfeeding measures within the HPHS CEL / CMO letter has made since their introduction in 2012.
Brief details on the following themes could be included where applicable and appropriate:
what changes have occurred
can the impact of changes be demonstrated
identify strengths and challenges
links to local action plans
highlight quality improvement work undertaken
note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
11 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section E: Food and Health
Action 14
Provide the name of the individual(s) who has strategic responsibility for oversight of all non-
patient food provision (catering, retail, vending and trolley services). This may be the same
individual(s) noted in strategic action 1 C.
Action 15
All catering outlets in healthcare settings must meet the Healthyliving Award Plus (HLA+) by 31 March 2017 (or, for private sector directly operated catering outlets, at the point of contract (re)negotiation). All Catering outlets with the standard Healthyliving Award will be accepted for 2015/16 reporting, and should be working towards HLA+ by 31 March 2017.
All vending machines in healthcare settings must be aligned to HLA+ vending criteria by 31
March 2017 (or for privately operated vending machines, at the point of contract
(re)negotiation).
The information being requested this year on vending machines has been split into:
vending machines within catering contracts (generally those located within or near a
catering outlet) as these are included within HLA assessments
all other vending machines (generally located separately in corridors or foyer areas)
as these are out with catering contracts
This is to provide a baseline of vending provision which will be reviewed for future reporting.
If you are unable to report for separate vending machines as categorised above, please note
this.
Further information can be found below:
Healthy Living Award Plus:
http://www.healthylivingaward.co.uk/index
enquiries@healthylivingaward.co.uk
15 A - F. Complete the reporting table with the number of catering outlets operated and the
number of HLA assessed vending machines (within a catering contract). Record the
numbers with HLA and HLA+ assessment and the total number in operation. The columns
indicate those operated by NHS Boards, voluntary sector and private sector organisations.
Example table indicating reporting number format:
Number operated by the Health Board
Number operated by voluntary sector organisations (VSO)
Number operated by private sector organisations
Total number operating
HLA HLA+ HLA HLA+ HLA HLA+
Catering outlets 1 3 1 2 2 2 11
Vending machines within catering contract
1 2 1 1 2 2 9
12 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
There is a second table under Action 15 to report all vending machines located out with
catering outlets and not covered by catering contracts. E.g. foyer, corridor etc.
If the number of vending machines out with a catering outlet is known, please note this in the
reporting template. If the number is not known, please indicate this in the template.
Note: The guidance below provides information on the criteria for healthy vending within
healthcare settings for NHS Boards.
Guidance for vending within healthcare settings
Drinks vending
• A drinks vending machine must contain water, unsweetened fruit juice and/or low-fat
milk.
• Healthyliving drinks must be prominently positioned, for example at eye level in glass-
fronted machines or listed first in product lists.
• 70% of soft drinks (by both volume and brand) must be sugar-free (less than < 0.5g of
sugar per 100ml). Soft drinks include flavoured waters.
• Sugar-free soft drinks must be prominently positioned
Snack/confectionery vending
• At least 30% of the product range must meet the healthyliving bought-in specifications
outlined in What do I need to do?
• At least one healthyliving item must be available for each type of product, for example
crisps and confectionery.
• Healthyliving items must be prominently positioned, for example at eye level, and should
be priced competitively with other products.
Refrigerated food vending
• 70% of the product range must meet the healthyliving bought-in specifications.
• At least one healthyliving item must be available for each type of product.
• Healthyliving items must be prominently positioned and should be priced competitively
with other products.
Action 16
All retail outlets and retail trolley services operated in healthcare settings must meet the
Healthcare Retail Standard (HRS) by the 31 March 2017 (or, for private sector directly
operated outlets and trolley services, at the point of contract (re)negotiation).
Further information can be found below:
Scottish Grocers Federation Healthy Living Programme:
http://www.scottishshop.org.uk/healthy-living
healthylivingaccounts@scotgrocersfed.co.uk
Criteria for the Healthcare Retail Standard: http://www.gov.scot/Publications/2015/09/7885
16 A – F. Complete the reporting table with the number of retail outlets and retail trolley
services operated, out of each total in operation for each column.
13 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Note: It is acceptable not to have reached the HRS in the CMO 2015/16 data reporting
period. However, the data will provide a baseline for future reporting.
Example table indicating reporting number format:
Number meeting
the HRS
operated by the
Health Board out
of the total
Number meeting the
HRS operated by
voluntary sector
organisations out of
the total
Number meeting
the HRS operated
by private sector
organisations out of
the total
Total number operating
Retail outlets 1/5 1/3 0/2 2/10
Retail trolley
services
0/2 1/5 0/2 1/9
Additionally, record any issues or challenges you have had to overcome (or are in the
process of overcoming) to achieve the Healthcare Retail Standard (HRS).
Action 17
A. Provide both the number of sites with community food co-ops and /or other social
enterprises achieving the Healthcare Retail Standard (HRS) and the total number in
operation. For those with the HRS, provide a brief description of the products and service
offered.
Previous reporting has indicated challenges in accessing local community food co-ops or
local providers of fruit and vegetables. If you have experienced any difficulties, the National
Development Officer on the NHS Health Scotland Community Food & Health Programme,
Anne Gibson, can be approached for further support and information: anne.gibson5@nhs.net
Action 18
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and
the hospital environment.
A. Your assessment of the impact that the food and health performance measures have had
since their introduction in 2012 should include brief details on the following themes where
applicable and appropriate:
the increase in provision and availability of healthier food for staff
work with retailers to meet new standards
how the CEL measures have influenced new builds through lease contract
negotiations, build design etc.
note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
14 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
15 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section F: Staff Health and Wellbeing
Action 19
A. Provide the name of the individual(s) who has strategic responsibility for the delivery of
the staff safety, health and wellbeing strategy.
It is expected that this lead will be in either the HR or Occupational Health department,
however, to make this clear please also note the position and department.
If your NHS Board operates under a different structure, or there is no identified strategy, note
this also. This information will help to identify links for collaborative working.
B. Provide the Healthy Working Lives (HWL) Award status for all hospital and community
hospital sites to indicate achievement towards the performance measure targets.
The reporting boxes are split for individual hospitals to be named where possible and the
information requested should be inserted under the following headings of achievement:
Bronze
Silver
Gold
continuing to work towards (indicate which level)
maintaining (indicate which level)
C. Provide a brief description of interventions which support the mental and physical health
and wellbeing of all NHS staff.
Evidencing targeted work to indicate how you provide support for areas such as
engagement, health literacy, fair work and financial inclusion is particularly encouraged.
Therefore, for responses (i) – (iv), brief details on the following should also be included
where appropriate or applicable:
how interventions have been tailored for any of the topics or settings
how interventions are tailored to meet the needs of different demographic staff groups
if the initiative is new or continuing
whether model operates on universal provision
which staff access the initiative
what works well
The interventions should be reported as categorised below (i – iv), and brief details of
examples can be included (as indicated in i – iv) which can demonstrate an impact:
(i) Supporting the mental health and wellbeing of staff. Up to 3 examples may be included:
strengthening resilience; stress risk management; mindfulness, access to self-help or
Cognitive Behavioural Therapy.
Note: You should include details of the organisational approach to stress risk management
(specifically how you meet the legal requirements under the Health and Safety at Work Act
1974 and Management of Health and Safety at Work Regulations 1999). This description
should include the responsible department and also the process in place e.g. stress risk
assessment is carried out a ward/service level and recorded in a health and safety log book.
16 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
(ii) Supporting the physical health of staff. Up to 3 examples may be included: weight
management; smoking cessation; physical activity, occupational health referral (e.g. specific
pathway/referral for musculoskeletal problems)
(iii) Promotion of health screening. Provide evidence on how you raise awareness of the
national screening programme to staff. A minimum of 1 example should be provided from
the following: cervical; breast; bowel; diabetic retinopathy and pregnancy screening. Provide
brief details on any local campaigns or connections with national awareness campaigns.
Refer to the national website for further information on health screening:
www.nhsinform.co.uk/screening/
(iv) Promotion of immunisation. Provide evidence on how you raise awareness of the
national immunisation programme to staff and specifically, promotion of staff sessions for
seasonal flu vaccination. A minimum of 1 example should be provided.
Provide brief details on any local campaigns or connections with national awareness
campaigns.
Refer to the national website for further information on immunisation:
www.immunisationscotland.org.uk
Related documentation is not required to be submitted.
Action 20
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on staff health and wellbeing, and if appropriate,
hospital environment and patient-centred care.
A. Your assessment of the impact that the staff health and wellbeing performance measures
have had since their introduction in 2012 should include brief details on the following themes
where applicable and appropriate:
the performance measures and indicators in place to identify impact and
improvement of staff health and wellbeing
the approach taken to collating and monitoring measurements
indicate where cross directorate collaboration takes place
any impact on patient care as a result of staff health and wellbeing interventions
note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
17 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section G: Reproductive Health
Action 21
A. For evidence of impact on numbers of repeat terminations, submit information which
indicates in what direction the trend is moving and what your contribution has been to any
reduction of the trend. Data from ISD can be included to support your submission.
Note: The ISD data on repeat terminations does not include any measure of the timeframe
between the terminations. If you have the data available, particular reference could be made
to rapid repeat terminations (e.g. women returning within 1 or 2 years) as part of your
assessment of impact.
ISD termination data can be accessed via the link below:
http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/index.asp#1396
In previous ISD published data, repeat terminations have been presented as a proportion of
all terminations. The total number of all terminations has decreased markedly in recent years
but the number of repeat terminations has shown less of a reduction. This may be because
repeat terminations tend to occur in an older age group than first terminations and the recent
fall in termination rates is more pronounced in younger women. The result of these trends is
that the proportion of repeat terminations of all terminations appears to be rising however the
rate, expressed as a proportion of all women of reproductive age, is fairly static. This latter
rate is likely to be a more useful reflection of the overall frequency of repeat terminations and
this revised methodology has been adopted this year.
B. Submit a description of how you define vulnerable women, how you identify vulnerable
women in your area and how you collate termination information on this group.
Provide a brief description of the support provided for vulnerable women within both maternity
and termination services. Include who has these contraceptive conversations with the patient.
Space has been provided for separate reporting for maternity and termination services. If
your support process and structure is the same in both settings, please indicate this in the
response box.
Complete the exception report if you are unable to provide this information and describe your
plans to identify and capture this data locally.
To support your description, ISD LARC data can be accessed via the link below:
http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/index.asp#1523
C. The description of maternity and termination services role in the delivery of the Sexual Health and Blood Borne Virus (BBV) Framework 2015 – 2020 update should include the following:
what you are starting to do at a strategic level
where does this work report to
is any training being delivered
The reporting template allows you to report separately for maternity and termination settings.
18 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
A link to the Sexual Health and Blood Borne Virus Framework 2015 – 2020 update can be accessed below: http://www.gov.scot/Resource/0048/00484414.pdf
P17 contains the actions around LARC
Action 22
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, and where appropriate, staff
health and wellbeing and the hospital environment.
A. Your assessment of the impact that the reproductive health performance measures have
had since their introduction in 2012 should include brief details on the following themes
where applicable and appropriate:
what drivers are in place to reduce the number of repeat terminations and
unintended pregnancies and how services are achieving this.
how services have improved the culture for LARC provision through wider strategic
activities.
the support offered and the conversations undertaken
note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
19 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section H: Physical Activity and Active Travel
The required evidence has been re-structured to offer the opportunity to provide a
more comprehensive picture of delivery and interventions for physical activity and
active travel. Amendments have also been made to the required order of evidence for
action 24. Please respond to all areas where possible.
The physical activity interventions requested in the performance measures must be evidence
based and or evidence informed. This includes interventions designed to maximise the use of
the NHS outdoor estate and facilities, the integration of physical activity for patients as part of
a clinical pathway or initiatives planned to enhance the health and wellbeing of NHS staff in
the workplace.
It is recommended that NICE Guidance PH44, PH54, PH41 and PH8 (links below) is applied
in a local context where possible to inform the design and delivery of such interventions.
These may include the NHS Physical Activity Pathway, cycling or walking schemes, the use of
pedometers, the promotion of physical activity in the workplace and the use of the built and
natural environment.
Brief advice for adults in primary care: http://www.nice.org.uk/guidance/ph44
Exercise referral schemes: http://www.nice.org.uk/guidance/ph54
Walking & cycling: http://www.nice.org.uk/guidance/ph41
Physical activity and the environment: http://www.nice.org.uk/guidance/ph8
Physical activity in the workplace: http://www.nice.org.uk/guidance/ph13
Action 23
Physical activity interventions should be routinely embedded into hospital settings. NHS
Boards should focus on the priority settings of: cardiology; pulmonary rehab; mental health;
diabetes; paediatrics; oncology; orthopaedics; care of the elderly; pre-assessment and
outpatient clinics.
A. Teams or departments within NHS Boards who have revised documentation should be
named, including which settings. Please specify what information is being recorded i.e.
current physical activity levels, whether an intervention has occurred and the outcome of an
intervention (e.g. provided with written material, signpost to support, referral). Or detail the
plans in place to update documentation to record physical activity status.
Related documents (e.g. admission documents and other forms where smoking/alcohol status
is recorded) to support the evidence submission should be provided where possible.
B. Evidence of a development plan or assessment of impact of physical activity interventions
in one or more of the priority settings is requested that demonstrates a targeted, phased
approach across your NHS Board that will increase spread over time. Responses should
indicate which of the above priority setting(s) you have been able to develop and what
system or process is in place to assess the delivery and impact of the physical activity
intervention in that setting(s).
A brief summary is also required to describe the intervention in more detail and could include
the following:
which staff were trained
20 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
who delivers the intervention
which patients were targeted
how practitioner practice has changed as a result of the intervention
what made the intervention work
what were the main challenges and how were these overcome.
Note1: The impact on patient activity levels or health outcomes are not required.
Note 2: It is acceptable initially to focus interventions in one or more of the priority settings
with the intention of widening this number over the next two years.
Note 3: Insert further rows if required for additional examples. [Right click to insert another
row, or hover cursor at left edge of table to see + sign & click to insert new row]
If you are unable to report progress in at least one of the priority settings, ensure this is noted
in the exception table and detail what the challenges / barriers have been in progressing
activity.
Action 24
A. Provide specific examples of hospital based physical activity support and / or services
targeting individuals and or populations experiencing inequalities such as: those with long
term conditions; disabilities; in receipt of benefits; carers or living in areas of deprivation.
Detail (i) the system for referral to formal services, (ii) the system for signposting to local
physical activity opportunities and (iii) assessment of use, including where possible number
of staff referring, number of staff signposting, total number of staff who could refer/signpost,
uptake of referrals (access to feedback data via third parties) and any known impact of the
intervention / service on patients, staff and / or visitors where known.
B. Boards should evidence how hospital based services are partnering with community
based organisations, third sector groups, local leisure trusts, local authorities and /or other
physical activity providers to develop an infrastructure which supports signposting to, and
enables uptake of physical activity opportunities. The response should list the partners’
name, briefly detail the partnership action implemented.
C. Provide details on how improving access and use of the outdoor NHS estate for physical
activity is planned for staff, patients and the local community. Name any schemes and
initiatives in place to improve access to the outdoor estate and contribute to promoting and
enabling active travel. Detail the availability e.g. which sites are involved or if board wide, as
appropriate. Include areas such as green exercise and active travel plans in your response
along with any additional information.
Action 25
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
21 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and
the hospital environment.
A. Your assessment of the impact of physical activity and active travel actions, since their
introduction in 2012 could include the following themes where applicable and appropriate:
Progress on active travel plan development, implementation and monitoring for staff,
patients and visitors, including partnership working with SUSTRANS and Local
Authorities.
Evaluation / impact of physical activity interventions in clinical settings (include which
setting).
Where known, provide the number of staff conducting physical activity screening,
staff providing brief advice and staff providing brief interventions (as a proportion of all
staff involved in implementing the pathway). Also note the number of staff
signposting, staff referring, patients referred, patient uptake and staff active travel
participation. Note that numbers of staff completing training is requested in Strategic
Action 2.
Physical environment / greenspace. How CEL measures have been used as leverage
for the planning / development of new builds and redevelopment /retrofit of existing
sites to create greenspace and increase access to physical activity opportunities.
Clinical settings utilising the NHS outdoor estate or indoor facilities to enable patients
to be physically active.
Updating of patient documentation to record physical activity status. How CEL has
supported this, challenges, barriers and successes.
note any challenges to implementation of CEL/CMO actions and how they are
being addressed.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
There is no requirement to submit related documentation, however documents can be
submitted as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
22 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section I: Managed Clinical Networks
Action 26
A. Evidence should be submitted to indicate the Managed Clinical Networks (MCNs) in
operation in your NHS Board which are aligned to HPHS and promote the use of health
improvement pathways amongst clinical staff, with appropriate support.
Provide a brief summary of MCN improvement plans with specific reference to embedding
health improvement within clinical pathways in at least one of the following:
(i) smoking cessation
(ii) physical activity
(iii) weight management
(iv) routine enquiry to identify patients vulnerable to financial stress, homelessness or
other social or environmental factors.
If you wish to provide an example in an additional setting, please add this to the other box.
The brief description should also indicate who monitors MCN improvement plans.
Note: It is acceptable initially to only have made an impact on one or more of the priority
settings (above) with the intention of widening this number over the next two years.
Action 27
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and the hospital environment. The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken. A. Your assessment of the impact of Managed Clinical Networks on patient-centred care,
and if appropriate, also the impact on staff health and wellbeing and the hospital
environments should include details on the following themes where applicable and
appropriate:
How well the pathway works and an indication of referral numbers
Any quality improvement methodology in place to measure outcomes
note any challenges to implementation of CMO actions and how they are
being addressed.
Note: If you are unable to report on any MCNs already in place, submit information on activity and plans to develop MCNs. Include the setting, who is involved and a timescale for becoming operational.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix. Any appendices should be included as attachments to the
email accompanying the submission to NHS Health Scotland.
23 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section J: Inequalities and person-centred care
Action 28
This performance measure has been included to ensure that all NHS Boards will plan and
deliver hospital services that ensure routine enquiry identifies vulnerability and support is
built into person-centred care. Ensuring access to services for vulnerable groups is also
key for addressing inequalities in health outcomes. Consideration and reflection of
inequalities sensitive practice can also be noted here.
Efforts should initially be focussed on the priority settings of: paediatrics, maternity,
neurology, cancer, cardiology, mental health, respiratory and/ or HIV and Hepatitis C.
A. Provide a description and examples of any inequalities sensitive practice in hospital
settings.
Include any routine enquiry in assessment of vulnerability through:
Asking patients if they have money worries and offering a direct referral to advice
services
Support for patients who are, or are at risk of, homelessness
Support in access to services for vulnerable groups / examples of hospital based
inequalities sensitive practice (established or emerging)
Note: Each NHS Board should work to their own definition of who are targeted as
vulnerable groups and include how they define this in their response.
Additional information should also be included covering: the nature of services provided,
whether services are delivered on-site or externally; the departments / hospitals involved;
partners or agencies you are working with; which services receive onward referrals and
how services are funded.
If you are unable to provide any examples, please give brief details on any hospital based
initiatives currently being planned to build this area of activity, or note in the exception
table if no work is currently being undertaken in this area.
B. Provide a brief summary to indicate the actions within your health inequalities strategy
and/ or community planning structures which demonstrate to what extent inequalities
sensitive practice is implemented in the hospital sector.
Your response should be framed in terms of how the actions in your inequalities strategy
are interpreted for the hospital sector and could include if hospital services are designed
and delivered in relation to the needs of vulnerable groups or in proportion to need.
Note: If your NHS Board does not have, or is in the process of developing an inequalities
strategy and / or a Health Inequalities Action Plan, this should also be noted. You may find
relevant actions within your local outcome focussed plan to mitigate the impact of welfare
reform on health and health services in the document accessed by the link below:
http://www.gov.scot/Resource/0044/00448578.pdf
24 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Action 29
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, staff health and wellbeing and
the hospital environment.
A. Your assessment of the impact of inequalities and person-centred care could include the
following themes where applicable and appropriate to demonstrate impact:
financial gains identified
use of welfare, housing and advice services
use of advice services delivered in clinical settings
warmer homes as a result of interventions
a decrease in foodbank use
evaluation of services
note any challenges to implementation of CMO actions and how they are
being addressed.
The above list is not exhaustive. Details on measures in place and how indicators of
success were identified should also be included.
If unable to assess impact, please note this, along with brief details of plans to build this area
of activity.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
There is no requirement to submit related documentation, however documents can be
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
25 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section K: Mental Health
Action 30
Actions 30 and 31 relate to those accessing hospital services with a diagnosis of experiencing severe and enduring mental illness. Access the Mental Health Strategy 2012-2015 via the link below: Refer to page 43 for information on Health Improvement for People with Severe and Enduring Mental illness. http://www.gov.scot/Publications/2012/08/9714 The Scottish Government is due to publish a new Mental Health strategy later in 2016 to build on the 2012-2015 Strategy.
A. Provide the name of the lead(s) with responsibility for progressing the physical Health and wellbeing of patients in hospital mental health services at both a strategic and operational level. Include their professional role by NHS Board or hospital site as appropriate.
B. Provide the total number of staff working in hospital mental health settings who have received training to promote physical health. Enter the total number trained as requested for those (i) undertaking physical health assessments and (ii) those who are developing action plans to support mental health improvement. Indicate the number trained who have responsibility for (iii) both the assessments and action plans in the space provided as a separate number to negate numbers being double reported. For reporting these numbers in Strategic Action 2, ensure these are reported as pertaining to Action 30. Additionally, where known, report the following details to provide a complete picture of all the training undertaken:
name of course or module [enter all applicable, see example courses coded below]
format of course or module
role of staff completing training for each course or module you list
Training can include:
Raising the issue of physical activity – for ease, enter code RiPA
Raising the issue of smoking - for ease, enter code RiS
Raising the issue of alcohol - for ease, enter code RiA
Alcohol Brief Intervention - for ease, enter code ABI
Health behaviour Change (levels 1 or 2) - for ease, enter code HBC1 / HBC2
Other – please state details. Include relevant weight management training
If your NHS Board has been involved in the Scottish Government pilot for Distress Brief Intervention (which is operating in the hospital setting), insert DBI in the name of course box.
C. Note if relevant patient admission documentation has been revised to record the physical
health status and action plans for health improvement.
Teams or departments within NHS Boards who have revised documentation should be
named. If the information is available to you, please specify what is being recorded i.e.
current physical activity levels, whether an intervention has occurred, the outcome of an
intervention (e.g. signpost to support, referral).
26 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
If documentation has not been revised, note what work is in progress to achieve this.
Related documents (e.g. admission documents) to support the evidence submission are not
required to be submitted.
Action 31
The narrative response is intended to give you the opportunity to expand on your feedback, reflect
on progress and note any areas for improvement. The response should be kept succinct and
only be around 500 words / 1 page.
Frame your narrative to reflect impact on patient-centred care, and if appropriate, also any
impact on staff health and wellbeing and the hospital environment.
A. Your assessment of the impact of mental health actions could include any work being
planned or undertaken to assess impact of service improvements to promote physical health
and wellbeing in mental health patients.
note any challenges to implementation of CMO actions and how they are
being addressed.
Note: If unable to assess impact, please report activity underway to build this area.
The narrative could be presented in the context of a performance story or the outcome of any evaluation that has been undertaken.
Supporting documents developed as part of measuring impact can be referred to, however,
there is no requirement to attach documents as part of your narrative assessment.
If you do choose to submit documentation, please ensure this is referenced within the “evidence”
response as a labelled appendix.
Any appendices should be included as attachments to the email accompanying the submission to
NHS Health Scotland.
27 HPHS CMO (2015) 19 letter – Reporting Guidance for 2015-16
Section L: Innovative and Emerging Practice
Note: The information required in this section has been amended from the previous reporting
format.
Once the report analysis has been completed, all the examples reported for innovative and
emerging practice will be shared with the HPHS National Network in the form of a brief
summary and local contacts for further information. Therefore, the information you provide
should be brief.
Innovative practice should be interpreted as being a completely original project for your NHS
Board e.g. either a new approach or adopting / testing new quality improvement methodology
in the area.
A minimum of one example is required for numbers 1 – 2 below:
1. Development and piloting of opt-out services for smoking cessation services
2. Alcohol Brief Intervention delivery in a hospital setting
Enter an example for number 3 if applicable to your NHS Board:
3. Development of staff and/or patient weight management service(s)
Provide brief information for each example provided in 1 - 3, which includes: the name of the
project; setting; format, any targeting, any collaborative working and outcomes. A local
contact is also required.
Insert further rows if you wish to report additional examples. [Right click to insert another
row, or hover cursor at left edge of table to see + sign & click to insert new row]
Additional examples can also be submitted with brief details on the name of the project;
setting; format; targeting; collaborative work, and why this is innovative in your NHS
Board. These examples may include updated evidence from previous projects reported
in former CEL annual reports, if there is any further development to report or an
assessment of impact. However, it must be stated if this is an update as opposed to a
new project.
The examples should be aligned to one of the three core themes below:
Person-centred care
Staff health and wellbeing
Hospital environment
Examples are encouraged that demonstrate:
effective partnership working and collaboration
specific actions to advance equality and/or address health inequalities
mental health benefits to patients, relatives and staff.
Recommended