The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report

Chapter 2 Oversight and leadership

The report identifies not only individual failures that put patients in harm's way, but also system failures at every level, particularly with leadership, management and governance, that contributed to, and failed properly to identify, the problems at the Vale of Leven Hospital (VOLH).

The Scottish Government accepts its responsibility for these failings and apologises unreservedly for the suffering and loss caused. As a Government, we are aiming to ensure that structures are in place to avoid recurrence anywhere else in future.

This chapter sets out how we intend to achieve this for the people of Scotland by focusing on mechanisms for oversight and scrutiny of healthcare associated infection (HAI) at national level and the key issues of leadership, management and governance.

2.1 National initiatives, oversight and scrutiny

This section describes national initiatives and mechanisms that serve to provide the foundations for effective HAI practice, enable performance to be monitored nationally and locally, and ensure problematic issues are highlighted early. It relates to report recommendations: 1, 2, 3, 4, 5, 6, 17, 49, 70, 71, 74 and 75.

What the report tells us

The report finds the lack of a national hospital inspectorate system in Scotland in 2007 "regrettable" and welcomes the creation of the Healthcare Environment Inspectorate (HEI) in April 2009: indeed, it recommends extension of the HEI's powers to include the closure of wards to new admissions (recommendation 1). Following clear procedures and in consultation with relevant personnel, nurses in charge of wards should be empowered to assume "ultimate responsibility" for admission of patients to the ward or a bay where a risk of cross-infection is present, it states (recommendation 17).

While acknowledging the range of guidance on HAI available at the time of the VOLH outbreak and Scotland's reputation as a leader in infection prevention and control, the report calls for stronger strategic guidance for, and greater policing of, implementation of policy and guidance (recommendations 2 and 3). It supports the idea of NHS board-level HAI taskforces linked to the national HAI Taskforce to provide reassurance to the public that HAI is a priority in their area (recommendation 4).

The uncertainty posed by major structural change clearly affected the delivery of services at the VOLH, and the report makes recommendations to counter this (recommendations 5 and 6). It also calls for national guidance on the role of infection control managers, initially provided in February 2001 and followed-up in March 2005, to be re-issued (recommendation 49) to ensure that these crucial staff better understand their roles and responsibilities.

The report acknowledges that better monitoring of HAI-related mortality, particularly C. diff deaths, at national level might contribute to an overall reduction in death rates and sets out recommendations for action by the Government and the Crown Office & Procurator Fiscal Service (recommendations 70 and 71).

Many of the factors contributing to the situation at the VOLH might have been identified and addressed earlier if the Government and NHS board had applied the lessons of existing inquiry reports, the report suggests. It calls for timely review and implementation of relevant measures from such reports in recommendations 74 and 75.

Our current position

Wider health policy

Policies for NHSScotland are designed to support people to live longer, healthier lives and improve the quality of care they receive. Some policies are specific to particular areas (such as HAI), while others are broader. Central to the broader group are the Healthcare Quality Strategy for NHSScotland and the 2020 Vision.

The Healthcare Quality Strategy for NHSScotland was launched in May 2010 to continuously improve healthcare services for the population by delivering world-leading, person-centred, safe and effective care.

The 2020 Vision recognises the challenges and demands health and social care will face over the coming years and sets out how they will be addressed. The Route Map to the 2020 Vision for Health and Social Care describes priority areas for action across three domains - quality of care experience, population health and equity, and value and financial sustainability: we refer to these as our "Triple Aim". The Route Map is about retaining focus on improving quality and making measurable progress towards meeting the 2020 Vision aspirations.

Complementary to the 2020 Vision is Everyone Matters: 2020 Workforce Vision, the workforce strategy for NHSScotland. As the title suggests, this recognises the vital role each member of the NHS workforce plays in responding to the challenges the service faces. We know that staff who are motivated and valued deliver better quality care for patients. We are committed to all staff being empowered to influence the way they work, and being held to account for what they do and how they do it. Everyone Matters sets out values that are shared across NHSScotland - care and compassion, dignity and respect, openness, honesty and responsibility, and quality and teamwork - and asks all staff members to sign up to and reflect them in their everyday practice.

These key initiatives drive our quality, improvement and performance management structures, which are described in Chapter 3.

In January 2015, we announced our intention to develop a longer-term plan for health and social care that reflects how services will look in five, 10 and 15 years' time. Given the changing needs of Scotland's population and the expectation that NHS provision will keep pace with new medicines, treatments and technologies, the refreshed narrative for achieving the 2020 Vision will set the context for the next stage in the evolution of health care in Scotland, which is integration with social care.

Integration of health and social care

Integration is not about structural change for its own sake. It is about improving the care people receive, creating better outcomes and ensuring best use of resources.

The aim is to ensure that health and social care services work together to plan and deliver care around the needs of the "whole person", rather than being limited by traditional boundaries between the NHS and local authorities. Integration focuses on providing seamless, joined-up care that enables people to stay safe and well in their home or another homely setting for as long as is reasonably practicable. Flexibility is built in to ensure integration reflects local needs and priorities, and professionals and communities continue to be involved in planning and delivering services.

We are determined to deal with the problem of delayed discharges and are committed to ensuring that no-one has to remain in hospital any longer than is absolutely necessary. We believe integration of health and social care services will support the achievement of this aspiration.

Integrated working involving health and social care staff is already a reality. We are now collaborating closely with local authorities and NHS boards on how best to resource and deliver services with high-quality outcomes for the people of Scotland. This includes designing an integrated health and social care measurement framework that will help people to understand how information fits together and will enable us to identify and measure improvement towards the National Health and Wellbeing Outcomes.

The National Health and Wellbeing Outcomes

The National Health and Wellbeing Outcomes are high-level statements of what health and social care partners are aiming to achieve through integration and ultimately through the pursuit of quality improvement across health and social care. By working with individuals and local communities, integration authorities will support people to achieve the following outcomes. Outcome 1. People are able to look after and improve their own health and wellbeing and live in good health for longer. Outcome 2. People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. Outcome 3. People who use health and social care services have positive experiences of those services, and have their dignity respected. Outcome 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. Outcome 5. Health and social care services contribute to reducing health inequalities. Outcome 6. People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. Outcome 7. People using health and social care services are safe from harm. Outcome 8. People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide. Outcome 9. Resources are used effectively and efficiently in the provision of health and social care services.

Protecting patient safety

The acute Scottish Patient Safety Programme (SPSP) was launched in January 2008 to reduce avoidable harm to patients by improving the safety of care provided across NHSScotland. We discuss the SPSP's contribution to promoting patient safety in healthcare settings, engaging frontline staff in improvement work and building the improvement culture in NHSScotland in Chapter 3.

Listening to patients and the public

Empowering people to be at the centre of their care and listening to them, their families and carers is a strategic priority for NHSScotland and the Scottish Government. We are committed to developing a culture of openness and transparency in NHSScotland that views feedback as a tool for learning and continuous improvement.

The Patient Rights (Scotland) Act 2011 ensures that patients are at the heart of the NHS and at the centre of all decisions. The Act was introduced to improve patients' experiences of using health services and support them to become more involved in their health and health care. It defines 18 "Healthcare Principles" that underpin quality care and treatment - everyone involved in the delivery of NHS services must uphold these principles.

The Act also made provision for the Charter of Patient Rights and Responsibilities, defining what people can expect when they use NHS services in Scotland and what they should do if they believe their rights have not been met or respected. The Charter established the Patient Advice and Support Service (PASS), an independent body that provides free and confidential information to patients, carers and families in their dealings with NHSScotland. It also details patients' rights to provide feedback and comments, raise concerns and make complaints about the health care they have received.

The National Health Service Reform (Scotland) Act 2004 amended earlier legislation to require NHS boards to take action to involve patients, carers and members of the public in the planning, design and operation of healthcare services.

Patient and public involvement

Actions to increase opportunities for patients and the public to get involved in the design and delivery of local health services and ensure that NHS boards are meeting their statutory duties on involvement include: the Scottish Health Council, established in 2005 to ensure that NHS boards listen to and take account of people's views and work in partnership with patients and the public the Participation Standard, introduced in 2010 to challenge NHS boards to demonstrate their approach to patient and public participation in new ways public partnership forums, established in each NHS board to serve as the main link between local communities and health and social care services.

Budget

We are committed to protecting the health budget in Scotland. Total health spending will rise in 2015/16 to over £12 billion, an increase of £2.9 billion (£1,030.3 million in real terms) since 2006/07.

NHS boards received funding increases of 3.2% in 2014/15 and 3.8% in 2015/16, both of which are directed towards protecting frontline services.

HAI-specific initiatives

Reducing HAI is a priority for us. That is why we have put in place a wide range of measures, driven by the national HAI Taskforce, to reduce HAI and improve healthcare outcomes.^[1] The measures resulted in an 83% reduction in C. diff infection in patients aged 65 and over between 2007 and 2014. This compares favourably with the rest of the UK and Europe.

A robust HAI scrutiny regime is in place across NHSScotland and the care sector, and we are confident that this system is continuing to drive improvements in cleanliness, hygiene and infection control and prevention practices.

Structures, systems and standards

The Healthcare Associated Infection (HAI) Taskforce

The HAI Taskforce was first established in 2003 to coordinate, implement and monitor actions across NHSScotland to reduce avoidable HAIs. The HAI Delivery Plan 2011 Onwards details how the Taskforce aims to ensure the safest healthcare system in the world through creating a zero-tolerance approach to avoidable infections and improving prevention and control of HAIs.

To ensure that the HAI Taskforce continues to provide efficient, effective and targeted leadership and expert advice on the HAI agenda in Scotland, we have restructured it into a smaller, more focused group that will work with local teams and existing structures in NHS boards. A strategy for 2015 to 2020 will be developed by the national group over the summer of 2015.

The Healthcare Environment Inspectorate

The Healthcare Environment Inspectorate (HEI), part of Healthcare Improvement Scotland, was set up in April 2009 to provide independent and rigorous scrutiny and assurance of NHSScotland hospitals.

The HEI forms an essential part of the drive to tackle HAI. It carries out at least 30 inspections, most of them unannounced, every year, mostly of acute hospitals but also in community and non-acute settings. Over 200 inspections have been carried out since the HEI's inception. Reports of the inspections and any resulting NHS board improvement action plans are made public.

HEI annual reports

The HEI Chief Inspector's fifth and latest annual report (2013/14) was published in March 2015. It details how HEI carried out 51 inspections in 34 hospitals across 14 NHS boards and two special boards between October 2013 and December 2014. Forty-one visits were unannounced and 23 were follow-up inspections. Overall, 143 requirements (which set out what action is required from an NHS board to comply with national HAI standards) and 61 recommendations were made.

HEI inspectors check that hospitals are meeting national standards, guidance and best practice. Some members of the public work with them as volunteers and participate in inspections to bring a patient and public view to the HEI's work. A new inspection planning procedure has been introduced to help inspectors decide how often to visit individual hospitals, enabling a focus on those that most need to improve the quality of their cleanliness, hygiene and infection prevention and control practices.

HEI inspections at the Vale of Leven Hospital, 2011-14
HEI inspections at the VOLH since 2011 have been positive and have not raised significant concerns. The three HEI inspections have found: August 2011 - no requirements and two recommendations June 2012 - three requirements and two recommendations January 2014 - two requirements and two recommendations. HEI made no escalations[2] to the Scottish Government and no additional support needs were identified. Areas of good practice and those that required improvement were as follows.
GOOD PRACTICE	AREAS FOR IMPROVEMENT
Staff aware of responsibilities in relation to infection prevention and control	Environmental audit action plan to be improved to reflect actions taken
Education in infection prevention and control well promoted	Protocol to be developed to show who to contact when antimicrobial pharmacist unavailable
Hospital generally clean and well maintained	Cleaning and housekeeping of physiotherapy department
Ward environment and patient equipment clean	Staff and volunteer compliance with national guidance on hand hygiene
Staff dressed in accordance with national guidance	All staff to implement Standard Infection Control Precautions in relation to the safe disposal of waste
New estates reporting system introduced	Glove selection and use in line with policy

Revised HAI standards and the National Infection Prevention and Control Manual

Revised Healthcare Associated Infection (HAI) Standards were published in February 2015 by Healthcare Improvement Scotland to drive improvements across the service. Each standard details what patients and the public can expect of healthcare services in Scotland. NHS boards will adopt the standards from May 2015 (replacing the previous standards), and performance against them will form part of HEI inspections from June 2015.

The revised standards are aligned with the National Infection Prevention and Control Manual. This was introduced in January 2012 (the latest version was published in January 2015) to provide NHS boards with guidance on evidence-based practice, monitoring, quality assurance, quality improvement and scrutiny of infection prevention and control.

Healthcare organisations must adhere to both documents to ensure robust HAI practice and policy implementation.

Standard Infection Control Precautions

Standard Infection Control Precautions (SICPs) are the basic infection prevention and control measures necessary to reduce the risk of transmission of germs from recognised and unrecognised sources of infection. There are 10 SICPs:

1. Cough etiquette

2. Hand hygiene (hand washing)

3. Blood and body fluid spillages

4. Patient care equipment

5. Occupational exposure (including sharps, such as needles)

6. Patient placement in wards and bays

7. Personal protective equipment, including aprons/gowns, eye/face protection, footwear, gloves, headwear and surgical face masks

8. Routine cleaning of hospital environments

9. Safe management of linen

10. Safe management of waste in hospitals.

A SICPs campaign was launched in May 2014 to increase awareness in all healthcare settings and ensure that the SICPs influence care for "every patient, in every care setting, every time".

Hand hygiene (hand-washing) policy

A national zero-tolerance approach to non-compliance with hand hygiene policies by healthcare staff was introduced in January 2009, underpinned by a campaign aimed primarily at acute hospitals. The campaign reinforced to staff, patients and visitors the importance of washing and drying their hands on a regular basis and adhering to proper hand-washing techniques.

The hand hygiene national audit report published by Health Protection Scotland in September 2013 confirmed 96% compliance with hand-washing opportunities across Scotland. As part of the move towards more localised reporting to promote local ownership of information and improvement, NHS boards are now responsible for monitoring and reporting hand hygiene compliance and ensuring suitable quality assurance processes are in place. We nevertheless recognise the ongoing need to drive improvements in hand hygiene practice and will continue to support NHS boards in their quest for complete compliance.

Targets and guidance

We have produced targets and evidence-based guidance to drive improvement in HAI performance in NHS boards. The following have specific importance in relation to HAI generally and C. diff infection in particular.

HEAT targets (Local Delivery Plan Standards)

We agree national performance targets each year. These have been known as HEAT (standing for Health improvement, Efficiency, Access to services and Treatment) targets. NHS boards set out how they will commit to meeting the targets, which align with our national priorities and ambitions, in their annual local delivery plans (see Chapter 3).

A target specific to C. diff infection was first introduced in 2008 as part of a wider HAI target. The current target^[3] is due for delivery in 2014/15 and was met by NHS Greater Glasgow & Clyde in calendar year 2014. Results for all NHS boards for the 2014/15 period will be available later in the year.

For simplicity, we have decided that we will use the term Local Delivery Plan Standards to replace HEAT targets from April 2015. The standards will be used to describe NHS board performance, particularly in relation to timely access for patients, HAI and finance, and will describe the levels of performance expected. The 2014/15 C. diff target has been retained as a standard for 2015/16.

C. diff infection guidance and tools

Scotland's Health Protection Network published C. diff guidance for healthcare settings in September 2009, with a revision in January 2014 for all care settings, including care homes. The guidance outlines roles and responsibilities, prevention of transmission of C. diff infection to patients and staff, best practice on antimicrobial treatment and improvements in patient safety.

Supporting NHS boards to tackle C. diff infection

Additional tools to support NHS boards include: a protocol for C. diff testing (December 2012) a C. diff severe case investigation tool and guidance framework (January 2010) a C. diff "care bundle" (March 2013): a care bundle is a structured way of improving care and patient outcomes by defining a small, easily understandable set of evidence-based practices - probably no more than five - that have been proven to improve patient outcomes when performed collectively and reliably[4] a C. diff "trigger tool" (March 2014): this tool can be used if the number of C. diff infection cases on a ward reaches a defined figure to establish the extent of the problem, promptly identify any areas for improvement in patient care, the environment or antimicrobial prescribing, and create a culture and system that minimises the risk of patient susceptibility to C. diff infection and cross-transmission.

The HAI compendium

This lists all current national policy, guidance and supporting materials on HAI produced since 2001 by the Scottish Government and other stakeholders, including HAI guidance developed by the Department of Health in England and specialist advisory bodies that is applicable to NHSScotland. The compendium aims to provide NHSScotland staff with an overview of all up-to-date guidance and is indexed by subject group and publishing organisation. It is updated regularly when new policy, guidance and resources are issued or when material becomes obsolete.

Monitoring and surveillance

Point prevalence surveys

Point prevalence is a measure of the proportion of people in a population who have a disease or condition at a particular time. The most recent national point prevalence survey of HAI and antimicrobial prescribing carried out on behalf of the HAI Taskforce was published in April 2012, providing a "snapshot" of the situation in health care in Scotland.

The survey included all 42 NHS acute hospitals, all seven independent hospitals, all three NHS paediatric hospitals and 23 non-acute hospitals. It found that HAI prevalence was approximately one third lower in acute and non-acute care settings than had been reported in the first Scottish survey carried out in 2005/06. A markedly lower prevalence of gastrointestinal infection, particularly C. diff-related, was found. The report noted that the reduced prevalence of HAI was associated with implementation of targeted national interventions between the two survey periods.

The survey has been important in helping us to identify where future interventions might be targeted. The third national point prevalence survey is planned for 2016.

Surveillance

National and local surveillance data are collected across a range of areas to support and monitor HAI policy. These include data for MRSA^[5] screening, infections in surgical wounds, hand hygiene compliance, HAI outbreaks, norovirus^[6] infections and infections in intensive care units. National surveillance of C. diff infection shows slight annual reductions, although these have been levelling out over the last two years.

Antimicrobial prescribing and antimicrobial resistance

Prudent prescribing of antibiotics has a major role to play in the prevention and control of HAI, including C. diff infection. The HAI Taskforce addresses this through developing guidelines to improve prescribing practices, initially with an antimicrobial prescribing policy for Scotland and subsequently through the Scottish Management of Antimicrobial Resistance Action Plan 2014-18. The most recent version of the action plan, published in July 2014, reflects the significant progress made and sets out how antimicrobial stewardship will be further developed over the subsequent four years.

The HAI Taskforce recently established the Controlling Antimicrobial Resistance in Scotland Group to oversee activity in Scotland and support the overall UK strategy. The group will build on and maintain the momentum generated by the Scottish Management of Antimicrobial Resistance Action Plan 2014-18 to produce a delivery plan and outcome measures.

Figures from the latest report of the Scottish Antimicrobial Prescribing Group, published in January 2015, show a decrease of 5.4% in prescriptions for antibiotics in primary care settings. The use of antibiotics that are known to increase the risk of C. diff infection reduced by 12.7% in 2013 compared to 2012. These reductions build on those seen in previous years and reflect the ongoing impact of initiatives focusing on primary care services.

The Scottish Antimicrobial Prescribing Group
The Scottish Antimicrobial Prescribing Group works with NHS board antimicrobial management teams to maintain stewardship activities at national and local levels. It supports collaborative working with infection prevention, antimicrobial management, surveillance and patient safety teams nationally and locally to ensure an integrated approach to HAI.

HAI resources and funding

We provided over £65 million funding to tackle HAIs between 2008 and 2013 and continue to allocate substantial financial support for the HAI Delivery Plan 2011 Onwards. This includes nearly £2 million annually to enable NHS boards to employ key infection prevention and control personnel (including infection control managers) and over £5 million annually since 2009 to pay for hundreds of additional cleaning staff to implement the revised NHSScotland National Cleaning Services Specification.

NHSScotland National Cleaning Services Specification
The HAI Taskforce asked Health Facilities Scotland to revise the NHSScotland National Cleaning Services Specification to support the delivery of the ambition to provide safe health services for all. The revised document was published in 2009, providing guidance on cleanliness and hygiene and effectively setting minimum standards for the healthcare environment.

Over £6 million has been invested since 2007 in the Scottish Infection Research Network for HAI-related research activity. This includes funding of £4.2 million - the largest-ever single investment in HAI research in Scotland - granted to the network to establish a national research consortium known as the Scottish Healthcare Associated Infection Prevention Institute. This five-year project (commencing April 2015), which aims to investigate threats to the population of Scotland from HAI and emergent organisms, involves a number of universities working in partnership with NHS boards and industry representatives.

2.2 Leadership, management and governance

This section describes how leadership, management and governance arrangements are being taken forward across Scotland. It addresses report recommendations: 7, 8, 9, 13, 45, 46, 47, 48 and 49.

What the report tells us

The need for strong, focused and identifiable leadership and reporting lines to ensure HAI policy is effectively implemented and monitored is one of the main underpinning messages from the report. It analyses in detail the leadership, management and governance failings that occurred at the time of the dissolution of NHS Argyll & Clyde in 2007 and the integration of Clyde into NHS Greater Glasgow, emphasising the need for a due diligence process to be identified during any future major restructuring operation to identify risks to patient services (recommendation 7) and for an effective and stable management structure to be in place at board level to maintain patient safety throughout the process (recommendation 8).

The report finds that NHS Greater Glasgow & Clyde's clinical governance system in relation to infection prevention and control at the VOLH was not operating effectively and recommends that NHS boards should ensure infection prevention and control is explicitly considered at all clinical governance committee meetings (recommendation 9).

Nursing management at the VOLH is criticised for a range of failings, including being unaware of the improper patient isolation practices and inadequate care planning taking place, having a reduced presence in clinical areas and failing to assume a proactive role in care delivery. The report recommends that NHS boards ensure a clear and effective line of professional responsibility between the ward and the board (recommendation 13).

Inquiry experts criticised the lack of an operational role in the infection prevention and control service for the NHS board's infection control manager at a critical time during the events at the VOLH, suggesting that this represented a "serious gap" in the system that led to, among other things, reduced coherence in reporting lines within the board and the failure of relevant infection control committees to meet. Recommendations 45-49 focus specifically on actions to support and clarify the infection control manager role.

Our current position

Leadership and management

Leaders and managers at all levels are responsible for the quality of care patients and families experience. Effective leaders and managers impact on how organisations perform, how staff feel about their work and their motivation to deliver high-quality care, and how services are developed, delivered and improved.

Delivering high-quality services depends on an organisational culture that puts patients and families first and encourages and celebrates innovation, improvement and learning. Leaders and managers have a key role in nurturing such a culture and promoting the values it creates.

A healthy organisational culture is not about what we do, but how we do it. NHS boards will create the conditions for high-quality health and care services by developing and sustaining a healthy organisational culture. Considerable work has been carried out in NHS boards in recent years to develop values and drive behaviours that support a healthy organisational culture. The NHS National Waiting Times Centre Board, for example, has amended its recruitment and selection processes to ensure that only staff whose values reflect those of the organisation are appointed.

We are building leadership capacity in and across our systems through collaborative working locally and nationally, but we recognise that investment is needed in leadership and management at all levels. This includes investing in emerging managers and leaders, NHS board chairs and non-executive directors, all of whom have a role in leading by example and demonstrating shared values. Supporting and developing line managers, particularly in relation to their "people" skills, is a key action in the Everyone Matters: 2020 Workforce Vision action plan for 2014/15, helping to ensure that managers have the ability to manage people effectively and lead by example.

Supporting NHS board non-executive directors
It is vital to ensure that non-executive board members are able to fully discharge their governance role. We will continue to work with NHS boards and others to ensure that non-executives have access to appropriate training and development materials. In doing this, we will build on the excellent work already underway within boards across Scotland.

Work is ongoing locally and nationally to support leadership and management development though high-quality programmes, management training schemes, toolkits, resources, expert advice and consultancy support.

The Health and Social Care Leadership Advisory Board and the National Leadership Unit

The role of the Health and Social Care Leadership Advisory Board is to build on current good practice to support collaborative leadership development initiatives across health and social care services, taking account of national, local, geographic and service-specific issues. It aims to: act as a forum for sharing progress on the achievement of leadership priorities provide strategic direction for the development and implementation of policy and strategy for leadership across health and social care in Scotland set the tone and clarify the expectations and required standards for leadership and leadership development across health and social care services identify critical leadership gaps and development needs at national level to ensure sustainable service quality and delivery facilitate access to networks relevant to the aims and objectives of the programme of work ensure value for investment through organisational effectiveness and service and system improvement. The National Leadership Unit, located in NHS Education for Scotland, is responsible for delivering leadership development programmes and activities. These include "Delivering for the Future", a programme that prepares senior clinical leaders for roles at local, regional and national levels, and the "Management Trainee Scheme", a fast-track programme to develop leadership capacity and potential in NHSScotland.

Despite these and other initiatives on developing leadership and management potential and effectiveness, we realise that more needs to be done. We have been working with partners since 2014/15 to:

• develop a policy statement setting out the kind of leadership and management needed to deliver the 2020 Vision and ensure that guidance and development support for NHS board chairs and non-executive directors aligns with the statement
• create a portal for information about leadership and management support, tools and resources
• ensure that national development programmes relating to leadership, management and quality improvement reflect the leadership and management policy statement
• develop guidance and support on people-management skills for leaders and managers at all levels
• ensure the stipulation that infection control managers have direct lines of communication and accountability to the board is reinforced.
• NHS boards are contributing to this by:
• building local leadership and management capacity and capability as part of their workforce plan to deliver the 2020 Vision
• ensuring line managers at all levels are clear about their people-management responsibilities and are held to account for how they perform
• identifying the development, training and support needs of line managers at all levels, particularly in relation to people management, and ensuring these needs are met
• ensuring that leaders and managers at all levels understand and demonstrate the values and behaviours expected of them
• ensuring that leaders and managers are aware of, and abide by, national governance arrangements and structures
• ensuring that the approach to ongoing leadership and management development supports Everyone Matters: 2020 Workforce Vision and the Quality Ambitions (person-centred, safe and effective care) described in the Healthcare Quality Strategy for NHSScotland and reflects the leadership and management policy statement
• ensuring that managers and leaders identify and focus on the strategic workforce actions needed to deliver Everyone Matters.

We will build on this in 2015/16 to focus on effective leadership for change through addressing five priorities:

• promoting cross-sector working
• adopting values-driven approaches
• making space for honest dialogue to improve performance, sustain good performance and tackle poor performance
• strengthening management at all levels, focusing particularly on middle management, talent management and succession planning
• leading teams and engaging people.

The role of the infection control manager

The role of the infection control manager in NHS boards includes having overall responsibility for: coordinating prevention and control of infection throughout the NHS board area delivering the board-approved infection prevention and control programme establishing clear mechanisms for access to specialist infection prevention and control advice and support assessing the impact of all existing and new policies and plans on HAI and making recommendations for change challenging non-compliance with local and national protocols and guidance producing an annual report on the state of HAI, decontamination and cleaning in the NHS board and releasing it publicly working with the Scottish Government and other agencies on improving practice. The infection control manager is accountable directly to the chief executive and the board and is an integral member of the organisation's infection prevention control, clinical governance and risk management committees.

Clinical leadership

Medical

Promoting senior clinician engagement at all levels of management is recognised across the world as being key to success and high performance in healthcare organisations.

The 2009 Promoting Professionalism and Excellence in Scottish Medicine report highlighted the need to further enhance the role and contribution of the medical profession across NHSScotland by, among other actions, promoting better medical leadership at all levels of the service and more effective team-working. A number of very positive developments supported by NHS boards and NHS Education for Scotland have been taken forward since its publication, particularly in relation to opportunities for management and leadership training for clinicians.

Nursing

An effective nurse leader is someone who can inspire others to work in pursuit of the common goal of better patient care. The leader has a distinctive set of personal qualities and is a team player, possessing key skills such as the ability to think critically, set goals, communicate clearly and collaborate.

We published Leading Better Care, the review of the role of senior charge nurses in Scotland, in 2008. Emerging evidence in the early 2000s suggested that the senior charge nurse role was moving away from a focus on providing clinical coordination and managing patient care towards a more managerial and administrative orientation. This, we believed, was a denial of the true potential of the role.

Senior charge nurses make a vital contribution as leaders and guardians of safety and quality in their clinical areas, coordinating patient care, leading and inspiring the nursing team and advocating on patients' behalf with colleagues from other professions. That is why we have strengthened, and will continue to enhance, their role through our ongoing support for Leading Better Care.

Leading Better Care supports senior charge nurses in hospitals^[7] by providing facilitation, support and development opportunities to help them achieve high-quality, person-centred, safe and effective care for every patient, every time. It provides a template for developing the senior charge nurse role as the visible embodiment of clinical leadership in NHS settings.

Phase 2 of Leading Better Care, launched in 2010, introduced a resource to support senior charge nurses to demonstrate the impact of their role. The resource is aligned to the key components of Leading Better Care and the Quality Ambitions (person-centred, safe and effective care) described in the Healthcare Quality Strategy for NHSScotland. Phase 2 ended in March 2013 and we are now supporting a third phase, providing £3.4 million to NHS boards in 2013/14 and £3.5 million in 2014/15 to enable them to further improve the quality and experience of nursing care patients receive and to develop nurses' clinical leadership roles.

NHS board governance

NHSScotland is a complex entity made up of 22 organisations, each with its own governance structure. Each NHS board requires a diverse mix of individuals with different skills and experience. We want to focus on creating more responsive, better performing and better governed NHS boards to drive improvement in the quality of care, enhance NHSScotland's existing reputation and support our world-leading quality and safety ambitions.

We launched Governance for Quality Healthcare in Scotland - an Agreement in July 2013. The agreement reaffirms why good governance matters and recognises that everybody involved in overseeing, planning, delivering and supporting healthcare services in Scotland has a role to play in ensuring that good governance arrangements underpin service delivery. It provides an overarching national framework and uses available evidence on what makes a high-performing, effective board to ensure a consistent approach to how NHS boards are structured, populated and governed. The agreement nevertheless recognises that NHS boards need to be flexible and responsive to the needs of communities locally, regionally and nationally.

We then published a clinical and care governance framework for integrated health and social care services in December 2014, outlining the roles, responsibilities and focus required by the joint boards responsible for delivery of integrated health and social care services in Scotland.

The NHS Board Chairs' Quality Portfolio Group has agreed that it is essential to ensure all NHS boards have clear, transparent and robust local arrangements that demonstrate good governance. These arrangements should be informed by the wide range of resources and materials available to support the implementation of effective governance. Effective oversight and integration of governance strands is also necessary, and the clinical and care governance sections of integration schemes for health and social care have been reviewed to identify where implementation support should be targeted. Further support resources that take account of learning from reviews and reports from within NHSScotland (such as Healthcare Improvement Scotland reviews of NHS Lanarkshire^[8] and NHS Grampian^[9]) and other healthcare systems (including the Report of the Morecambe Bay Investigation^[10]) will be developed collaboratively with staff.