NHS Greater Glasgow and Clyde Oversight Board: terms of reference

Authority

The Oversight Board (OB) for Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children (RHC), NHS GGC (hereinafter, “the Oversight Board”) is convened at the direction of the Scottish Government Director General for Health and Social Care and Chief Executive of NHSScotland, further to his letter of 22 November 2019 to the Chairman and Chief Executive of NHS GGC. These terms of reference have been set by the Director General, further to consultation with the members of the OB.

Purpose and role of the group

The  purpose of the OB is to support NHS GGC in determining what steps are necessary to ensure the delivery of and increase public confidence in safe, accessible, high-quality, person-centred care at the QEUH and RHC, and to advise the Director General that such steps have been taken. In particular, the OB will seek to:

• ensure appropriate governance is in place in relation to infection prevention, management and control;
• strengthen practice to mitigate avoidable harms, particularly with respect to infection prevention, management and control;
• improve how families with children being cared for or monitored by the haemato-oncology service have received relevant information and been engaged with;
• confirm that relevant environments at the QEUH and RHC are and continue to be safe;
• oversee and consider recommendations for action further to  the review of relevant cases, including cases of infection;
• provide oversight on connected issues that emerge;
• consider the lessons learned that could be shared across NHS Scotland; and
• provide advice to the Director General about potential de-escalation of the NHS GGC Board from Stage 4.

Background

In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement issues, the Director General for Health & Social Care and Chief Executive of NHSScotland has concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and therefore that for this specific issue the Board will be escalated to Stage 4 of the Performance Framework. This stage is defined as ‘significant risks to delivery, quality, financial performance or safety; senior level external transformational support required’.

Approach

The OB will agree a programme of work to pursue the objectives described above. In this, it will establish sub-groups with necessary experts and other participants. The remit of the sub-groups will be set by the chair of the Oversight Board, in consultation with Board members. The Board will receive reports and consider recommendations from the sub-groups.

In line with the NHSScotland escalation process, NHS GGC will work with the OB to construct required plans and to take responsibility for delivery. The NHS GGC Chief Executive as Accountable Officer continues to be responsible for matters of resource allocation connected to delivering actions agreed by the OB.

The OB will take a values-based approach in line with the Scottish Government’s overarching National Performance Framework (NPF) and the values of NHSScotland. 

The NPF values inform the behaviours people in Scotland should see in everyday life, forming part of our commitment to improving individual and collective wellbeing, and will inform the behaviours of the OB individually and collectively:

• to treat all our people with kindness, dignity and compassion;
• to respect the rule of law; and
• to act in an open and transparent way.

The values of NHSScotland are:

• care and compassion;
• dignity and respect;
• openness, honesty and responsibility; and
• quality and teamwork.

The OB Members will endeavour to adopt the NPF and NHSScotland values in their delivery of their work and in their interaction with all stakeholders.

The OB’s work will also be informed by engagement work undertaken with other stakeholder groups, in particular family members/patient representatives and also NHS GGC staff.

The OB is focused on improvement. OB members, and sub-group members, will ensure a lessons-learned approach underpins their work in order that learning is captured and shared locally and nationally.

Meetings

The OB will meet weekly for the first four weeks and thereafter meet fortnightly. Video-conferencing and tele-conferencing will be provided.

Full administrative support will be provided by officials from CNOD. The circulation list for meeting details/agendas/papers/action notes will comprise OB members, their PAs and relevant CNOD staff. The Chairman and Chief Executive of NHS Greater Glasgow and Clyde will also receive copies of the papers.

Objectives, deliverables and milestones

The objectives for the Oversight OB are to:

• improve the provision of responses, information and support to patients and their families;

• if identified, support any improvements in the delivery of effective clinical governance and assurance within the Directorates identified;
• provide specific support for infection prevention and control, if required;
• provide specific support for communications and engagement; and
• oversee progress on the refurbishment of Wards 2A/B and any related estates and facilities issues as they pertain to haemato-oncology services.

Matters that are not related to the issues that gave rise to escalation are assumed not to be in scope, unless OB work establishes a significant link to the issues set out above.

In order to meet these objectives, the OB will retrospectively assess issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and RHC and the associated communication and public engagement; having identified these issues, produce a gap analysis and work with NHS GGC to seek assurance that they have already been resolved or that action is being taken to resolve them; compare systems, processes and governance with national standards, and make recommendations for improvement and how to share lessons learned across NHSScotland. The issues will be assessed with regards to the information available at the particular point in time and relevant standards that were extant at that point in time. Consideration will also be given to any subsequent information or knowledge gained from further investigations and the lessons learned reported.

Governance

The OB will be chaired by the Chief Nursing Officer, Professor Fiona McQueen, and will report to the Director General for Health & Social Care.

Member	Job Title
Professor Fiona McQueen (Chair)	Chief Nursing Officer, CNOD, Scottish Government
Keith Morris (Deputy Chair)	Medical Advisor, CNOD, Scottish Government
Professor Hazel Borland	Executive Director of Nursing, Midwifery and Allied Health Professionals & Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran
Professor Craig White	Divisional Clinical Lead, Healthcare Quality and Improvement Directorate, Scottish Government
Dr Andrew Murray	Medical Director, NHS Forth Valley and Co-chair of Managed Service Network for Children & Young People with Cancer (MSN CYPC)
Professor John Cuddihy	Families representative
Lesley Shepherd	Professional Advisor, CNOD, Scottish Government
Alan Morrison	Health Finance Directorate, Scottish Government
Sandra Aitkenhead	CNOD, Scottish Government (secondee)
Greig Chalmers	Interim Deputy Director, Queen Elizabeth University Hospital Support, CNOD, Scottish Government
Calum Henderson (Secretariat)	Queen Elizabeth University Hospital Support Unit, CNOD, Scottish Government

The Co-chair of Area Partnership Forum and the Chair of the Area Clinical Forum will be in attendance at the meetings. In addition to these members, other attendees may be present at meetings based on agenda items, as observers: senior executives and Board Members from NHS GGC including, Medical Director, Nurse Director, Director of Estates and Facilities, Director of Communications, Board Chair and Chief Executive; and representatives from HPS, HFS, HIS, HEI and HSE.

Stakeholders

The OB recognises that a broad range of stakeholder groups have an interest in their work, and will seek to ensure their views are represented and considered. These stakeholders include:

• Patients, service users and their families
• The general public
• The Scottish Parliament
• Scottish Government, particularly the Health and Social Care Management Board
• The Board of NHS GGC and the senior leadership team of NHS GGC
• The staff of NHS GGC and Trade Unions

Special focus will be given to patients of the haemato-oncology service and their families, as highlighted by their direct involvement in the Communications & Engagement sub-group.