Infected Blood Inquiry Report Oversight and Assurance Group minutes: October 2024

Attendees and apologies

Members

• Christine McLaughlin, Co-Director Population Health, Scottish Government (SG), Chair
• Dr Emilia Crighton, Director of Public Health, NHS Greater Glasgow and Clyde, representing Directors of Public Health
• John Dearden, Chair, Haemophilia Scotland
• Dr Tracey Gillies, Medical Director, NHS Lothian and representing the Scottish Association of Medical Directors
• Tommy Leggate, Manager, Scottish Infected Blood Forum
• Robbie Pearson, Chief Executive, Healthcare Improvement Scotland (HIS)
• Professor Nicola Steedman, Deputy Chief Medical Officer (DCMO), SG
• Professor Marc Turner, Director, Scottish National Blood Transfusion Service (SNBTS)
• Lynne Anderson, chair, Scottish National Blood Transfusion Committee (SNBTC)

Guests

• Dr Rachael Swann, Consultant in Gastroenterology and Hepatology, NHS Greater Glasgow and Clyde
• Caroline Pretty, Policy Manager, Sexual Health and Blood Borne Viruses, SG
• Rebekah Carton, Team Leader, Sexual Health, BBV and Respiratory Surveillance SG
• Annalena Winslow, Unit Head, Safety, Openness and Learning, SG (deputising for Craig White)
• Dr Lorna McLintock, Medical Director, SNBTS

Secretariat

• Sam Baker, Unit Head, Organ and Blood Donation, Infected Blood and Abortion Policy, SG
• James How, Team Leader, Blood, Organs and Tissue, SG
• Laura Mackay, Policy Manager, Blood Donation and Infected Blood, SG

Items and actions

Minutes of previous meeting and actions

The Chair welcomed attendees to the third meeting of the Oversight and Assurance Group (OAG). The Chair discussed the actions from the previous meeting, many of which would be dealt with under subsequent agenda items. Attendees were content with the draft minutes of the previous meeting. These minutes would be published on the Scottish Government (SG) website.

Progress on actions from previous meeting

Action 1: Revised version of the Terms of Reference (ToR) to be circulated for comments after the meeting (Action completed – there were no comments, and the updated ToR has now been published on SG website.).

Action 2: Provide update to OAG on dissemination of the advice, which will complete work on this recommendation (Action in progress – awaiting confirmation from three Health Boards (Lanarkshire, Fife and Shetland); this action will then be complete.).

Action 3: Proposal for a review of Scottish National Blood Transfusion Committee (SNBTC) governance (Action in progress – discussed at a meeting between Scottish National Blood Transfusion Service (SNBTS), Deputy Chief Medical Officer (DCMO) and SNBTC on 04 October (DCMO is progressing with colleagues).

Action 4: Proposal for a Short Life Working Group (SLWG) on implementation of Serious Hazards of Transfusion (SHOT) reports to be produced; the SLWG should give consideration to an NHS Scotland Delivery Plan to help ensure implementation of SHOT recommendations and other associated elements of the Infected Blood Inquiry’s (IBI) recommendation 7 (Action in progress – also discussed at the meeting between SNBTS, DCMO and SNBTC on 04 October (a further meeting will be held to agree whether a new group should be established)).

Action 5: SNBTS to take forward agreed actions to review and update their existing transfusion team strategy and work with partners to update learning materials related to transfusion (Action in progress – SNBTS taking this action forward).

Action 6: The OAG Chair to write to the five Boards with haemophilia centres, possibly at the time of the December update to the Scottish Parliament and to stakeholders, asking them to fully consider peer review recommendations. The letter should be clear this relates to both past and future reviews (Action to be progressed in future – potentially combined with other correspondence to Health Boards).

Action 7: Contact the Department of Health and Social Care/NHS England to check the position in relation to any review of the National Haemophilia database (Action complete – NHS England have confirmed a task and finish group is being created to explore the content of the database. The UK Haemophilia Centre Doctors’ Organisation will continue to have responsibility for the database).

Action 8: Communicate to Boards the OAG’s expectation that Veyvondi will be available to children (Action complete – the draft letter from the Chief Pharmaceutical Officer was expected to be issued in the week of the October OAG. Post-meeting note: Chief Pharmaceutical Officer letter issued 10 October)).

Draft OAG workplan

The OAG was asked to note the updated spreadsheet of IBI recommendations, circulated ahead of the meeting. The OAG did not raise any concerns regarding the progress on the recommendations.

The OAG was asked to note that the UK Government intended to provide an interim report on the response to the IBI recommendations to the UK Parliament in December. The OAG had agreed to provide a draft Scottish contribution for that progress report covering the areas where separate Scottish actions or decisions are being taken. This paper may be circulated for virtual comment/agreement due to timings of the report and the next meeting.

The Chair reiterated that there should be very clear reasons set out if there are cases where any recommendations are not being accepted.

Consideration of IBI recommendations

Monitoring liver damage for those with Hepatitis C – Viral Hepatitis report (recommendation 6)

The OAG received an update from Dr Swann on the report prepared by the Viral Hepatitis Strategic Group. It was noted that overall, good care and monitoring is already provided in Scotland by multi-disciplinary teams for Hepatitis C patients after they have achieved a sustained viral response.

Dr Swann noted that responding to some of the recommendations were somewhat problematic as elements of the IBI recommendations did not follow existing UK and international guidelines on monitoring for liver cancer, some elements seemed to be based on misunderstandings, for example around use of fibroscans, and the recommendations seemed to suggest monitoring should be mandatory, which was not in line with the aims of Realistic Medicine in encouraging patient choice. The OAG was asked to consider whether the recommendations should be implemented in principle with some modifications/clarifications or whether more information was required before considering the recommendations.

It was noted that some of the international guidelines for f3 fibrosis patients differed. Dr Swann clarified the guidelines and confirmed surveillance would continue for patients who had not yet achieved a sustained viral response (SVR).

It was agreed further consideration of the recommendations was required and that additional detail on the evidence available around monitoring for liver cancer for particular patient categories should be provided. There was also discussion around whether offering ongoing surveillance would in fact cause harm. It was noted that, overall, while some patients can find ongoing monitoring reassuring, for others it may cause them anxiety and so monitoring was not generally recommended for patients where their risk of liver cancer was extremely low. However, in discussion it was noted that many of those victims infected via NHS blood do want ongoing monitoring due to their particular anxiety about what has happened to them.

It was noted that the other three UK administrations were still considering these recommendations and therefore the evidence available could be considered further with them. It was suggested that there should be further discussion with the Inquiry before rejecting any of its recommendations. It was agreed that the Inquiry would be approached, although it was noted that NHS England had already requested these clarifications from the Inquiry.

It was also agreed that, whilst Hepatitis C services are not commissioned in Scotland, the Scottish Government should, in place of any commissioners, seek to take forward recommendation 6a) (vi) to seek reassurance that appropriate services and support are in place in all Health Boards.

Patient safety (recommendations 4a, b, c and e and 10a(i))

The OAG received an update from Annalena Winslow on patient safety. An informal UK-wide working group has been established to discuss how the recommendations could be progressed in a co-ordinated fashion, and how each team could work together and share thinking. Discussion had begun at a higher level on improving patient safety with the other UK nations via the existing Inter-Ministerial Group.

The OAG confirmed it was content in principle with the suggested actions in relation to recommendation 4 and 10a(i) on working with the parameters of a fuller scoping paper that will be presented at an OAG early next year, mapping the IBI recommendations to the Essentials of Safe Care, and to taking a UK-wide approach. However, the Group asked that the Scottish Government ensures the scoping work still retains a focus on the IBI recommendations.

Patient blood management – use of Tranexamic Acid and reducing the need for transfusions (recommendations 7a(ii) and (iii))

The OAG received an update from SNBTS on patient blood management and ensuring sufficient use of tranexamic acid (TXA). The paper suggested trying to gather information on the extent to which Boards are following the existing NICE Quality Standard on this to reduce the unnecessary use of blood. It was noted that this is complex as it involves many specialties and there is no central data source.

There was discussion about the best ways of establishing current practice, including the potential to encourage Health Boards to participate in NHS Blood and Transplant’s current comparative audit exercise. However, whilst the OAG agreed that participation could be encouraged, it was noted that the audit could be a significant amount of work for the smaller Health Boards and still would not provide a full picture of practice. Therefore, it was agreed that it may be better to leave it to each Health Board to establish the extent to which they are currently complying with recommendation 7(a)(ii) and the wider recommendations in the 2016 National Institute for Health and Care Excellence (NICE) Quality Standard.

It was agreed that Health Boards should be asked to provide assurance that they are complying with the NICE Quality Standard in relation to TXA and using the clinical dashboards as a quality assurance tool. They should also be informed about participation in the comparative audit.

The OAG agreed to revisit recommendation 7(a)(iii) once the new guidance from NICE was available as this is expected to include benchmarking indicators. However, it was noted that Health Boards could already be taking action now, using the SNBTS transfusion dashboard to monitor whether their use of blood was appropriate.

The Chief Medical Officer’s office were asked if they would undertake a review of Board governance processes relating to blood transfusion. However, it was noted that it was not the Chief Medical Officer’s (CMO) role to monitor Health Boards’ performance. It was noted that there would be further discussions on this to consider whether current governance processes are appropriate.

Agreement on next steps, timing of next meeting, and feedback on the meeting

The Chair confirmed that that the next meeting of the OAG was scheduled for Tuesday 19 November, between 10:00 and 11:30.  However, there could be scope to agree the Scottish contribution to the UK Parliament report by email if needed.

Any other business

No other business was raised.

Summary of action points

Monitoring liver damage for those with Hepatitis C – Viral Hepatitis report (recommendation 6)

Action 1: A fuller paper outlining the approach to services, the evidence available in relation to ongoing monitoring and what further interventions may be required will be presented at a future OAG.

Action 2: Request clarification from the Inquiry about the recommendations.

Patient safety (recommendations 4a, b, c and e and 10a(i))

Action 3: A fuller scoping paper will be presented at the January OAG meeting focussing on the recommendations of the Inquiry and demonstrating how the recommendations can be implemented.

Patient blood management – use of Tranexamic Acid (TXA) and reducing the need for transfusions (recommendations 7a(ii) and (iii))

Action 4: The OAG to write to Health Boards to ask them to take steps to ensure compliance with the TXA recommendation and to encourage further work to monitor their use of blood. Health Boards would be asked to provide confirmation that they were complying with recommendation 7(a)(ii) in particular.