Infected Blood Oversight and Assurance Group minutes: April 2025

Attendees and apologies

• Christine McLaughlin, Co-Director, Population Health, Scottish Government (SG), OAG Chair
• Dr Lynne Anderson, Chair, Scottish National Blood Transfusion Committee (SNBTC)
• Emilia Crighton, Directors of Public Health
• John Dearden, Chair, Haemophilia Scotland (HS)
• Dr Tracey Gillies, Medical Director, NHS Lothian and representing the Scottish Association of Medical Directors (SAMD)
• Tommy Leggate, Manager, Scottish Infected Blood Forum (SIBF)
•  Professor Marc Turner, Director, Scottish National Blood Transfusion Service (SNBTS)
• Dr Emma Watson, Medical Director, NHS Education for Scotland (NES)

In attendance

• Alistair Hodgson, Digital Health Care, SG
• Dr Simon Watson, Medical Director, Healthcare Improvement Scotland (HIS) (representing Robbie Pearson)

Secretariat

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

Apologies

• Professor Nicola Steedman, Deputy Chief Medical Officer, SG
• Robbie Pearson, Chief Executive, HIS

Items and actions

Minutes of previous meeting and actions

The Chair welcomed attendees to the sixth meeting of the OAG and asked if the draft minutes of the previous meeting on 26 February could be agreed.

HS asked for clarity on the “cohort” referred to in paragraph 27 and action 5 of the minutes. SG confirmed that this was those who had chronic hepatitis C who are likely to have been treated with infected blood and who have since achieved a sustained viral response. This will be clarified in the minutes.

Action 1: It was agreed the minutes of the OAG meeting on 26 February would be updated before publication. (Secretariat)

The Chair then ran through the actions from the previous meeting:

• update Scottish Ministers on outcomes of the Department of Health and Social Care’s (DHSC’s) consultation on regulation of managers and revert to the OAG for the opportunity to comment on final advice on the way forward. As noted at the February OAG, we are still awaiting the outcome of the DHSC consultation. Once details of the consultation responses have been received, SG will update the OAG on next steps
• provide a further assurance update on whether the QMS (Quality Management System) would be adopted across Scotland. HIS noted that the QMS would not be compulsory. However, HIS will be encouraging its use and Boards have so far shown themselves to be actively keen to use it. HIS also updated that they are working to ensure alignment between the processes of the Health Services Safety Investigations Body in England and the QMS in Scotland, via a proposal for a Memorandum of Understanding to ensure equivalence of approach 
• consider how the role of Care Opinion should be publicised more widely. Various options are being considered, including publicity via the statutory patient feedback mechanism re-procurement and a coordinated national effort to publicise the patient feedback mechanism using local and national channels via the national NHS Scotland Board Communicators Group
• separate discussions would be arranged with those most interested in recommendations 6a(ii) and 6a(iii) on liver monitoring. The Chair and DCMO had chaired the requested meeting with HS on 12 March and the Scottish Government is following up the agreed actions. A note of the meeting has been sent to HS. SG has responded to a letter following the meeting, from HS. SIBF have also been offered a meeting with DCMO. Action 2: SG to send the note of the meeting with Haemophilia Scotland on 12 March concerning recommendation 6 to the wider OAG (Secretariat)
• clinical leads to provide assurance that all patients in the cohort have received an assessment of liver scarring to provide reassurance to the OAG. This is being taken forward with relevant clinical leads through the Scottish Health Protection Network’s Viral Hepatitis Strategic Leads Group. We expect this to be done by the summer
• those clinical guidelines on hepatitis C which are due (or overdue) to be updated should be reviewed and updated as soon as is practicable.  Public Health Scotland (PHS) to be asked what is involved in a data linkage exercise including timescales, quality of data and what the output would be to allow the OAG to make a decision. The guidelines are expected to be updated by the summer. SG is exploring a light touch review of current service provision similar to that in NHS England. SG has also sought advice from PHS on a potential data linkage exercise. PHS have reported that they can do this work, although there are some issues with the data which means it won’t give a full picture of the current status of all the infected blood cohort of patients. On this basis, we are formally asking PHS to scope out the work

Consideration of IBI recommendations

Patient records (recommendation 4d(i))

Alistair Hodgson briefed the OAG that the 'audit' aspect of this recommendation will be formally progressed via the existing Digital Maturity process for health and social care. The Digital Maturity Assessment Platform is SG’s standardised digital transformation management tool for health and social care. Each participating organisation, which includes all Health Boards, is requested to submit an update by the end of July of each year. SG is now in the process of updating the questions to be used in this process, to make sure we gather the right information based on advice from experts. The aim will be to improve access to digital records.

Further information was requested about the mention in the paper of an online app for health and social care to be rolled out initially in Lanarkshire. When will this be rolled out more widely? Alistair confirmed that this was being reviewed at the moment, with a plan to be ready by this summer to set out timescales for the roll out to the whole country. The plan would then be for the app to be rolled out gradually, with additional capabilities to be added as we go along. 

The OAG confirmed that it was in agreement with the proposed approach.

Action 3: SG would produce a formal communication seeking nominations for Subject Matter Experts to be involved in developing the question set for the update Digital Maturity questionnaire (Alistair Hodgson).

Blood transfusions (recommendations 7f(i) and (ii))

Marc Turner briefed the OAG that the current Account for Blood (AfB) system has been in place for some years and has allowed SNBTS and Health Boards to analyse blood usage data on a population basis. However, information technology has moved on greatly over the past decade and the system now needs upgrading to remove some limitations. A business case has been put to SG to refresh and upgrade the system. This will allow for a much better handle to be produced on blood usage and outcomes across Scotland, and for more active surveillance going forward. It was noted that SG is providing funding for SNBTS which will enable them to take this work forward.

The OAG confirmed that it was content that the proposed developments of the AfB system will fulfil IBI recommendations 7f(i) and (ii).

Safety of transfusions (recommendation 7e) 

Sam Baker briefed that a short life working group (SLWG) had been established to agree how best to ask Health Boards to put in place a mechanism for ensuring implementation of Serious Hazards of Transfusion (SHOT) standards and recommendations. The group included involvement from SNBTS, SNBTC, SHOT, HIS, Hospital Transfusion Committee (HTC) Chairs, HaTS (Haematology and Transfusion Scotland network) and SAMD. 

The SLWG agreed that Boards should remain responsible for how to respond to these reports, albeit with guidance from SG. The SLWG agreed that the OAG should write to Health Boards in July, when the next SHOT report is due to be received, asking them to ensure they are meeting this recommendation on an ongoing basis. It is clear that Boards have different governance processes, so they should be given flexibility to work out the best way forward to fit their circumstances. It was also agreed that SG should carry out an initial period of external assurance to ensure Boards put in place an increased focus on this work to improve the processes and adherence to SHOT standards/recommendations. Boards would be asked to set out any improvement plans being put in place and to complete a template return to SG within six months. If was noted that if there are requests in SHOT reports for large-scale digitisation projects, then Boards would only need to report at this stage on what they are already doing or planning to do, pending further discussions with SG.

In discussions, it was noted that there were differences of practice across Boards and that ongoing external assurance processes would not promote internal ownership of these processes. For that reason, the recommendations of the SLWG had tried to strike a balance. It was also noted that there were ongoing concerns about the capacity of those working in this area to deliver further work without additional resources. As a result, some form of assurance was welcome in order to ensure Boards were encouraged to give the staff involved time to deliver this work. The OAG letter as a result will say that Boards need to nominate an agreed senior lead for this work and to give HTCs the capacity, resources and support to do this work.

The OAG confirmed that it was content with the proposed approach that Health Boards would be asked to follow, as well as the proposed arrangements for a temporary period of external assurance. The OAG agreed that these proposals and the rationale for Boards placing an increased focus on this work in 2025-26 should be discussed with SAMD and with Scottish Executive Nurse Directors (SEND) before the OAG writes to Health Boards setting these out the arrangements. Finally, the OAG confirmed that it was content for the SG to progress this work with SNBTS, HIS, and Health Boards, and to update OAG on progress.

Action 4: SG to write to Boards in April with a general update on progress on the IBI recommendations, including flagging that a further letter will be sent in July in relation to recommendation 7e (Secretariat)

Action 5: Discussions on recommendation 7e to be scheduled with SEND (Secretariat) and SAMD (Tracey Gillies).

Tranexamic acid (TXA) and patient blood management – recommendation 7(a)(ii)

Sam Baker briefed the OAG that, since the papers were issued, NHS Orkney has also responded to the request for information on this recommendation. So all Boards have now provided views and all have confirmed that they are using TXA. All Boards also confirmed that the SNBTS Clinical Transfusion dashboard is being utilised to benchmark and improve transfusion practice. 

Some Boards raised questions about the scope of the ‘eligible surgeries’ during which TXA should be used. Discussions on this issue, in relation to the current National Institute for Health and Care Excellence (NICE) guidelines, are being held, drawing in advice from the Royal Colleges. A request is therefore planned to be made to NICE to consider updating their guidance on which elective surgeries TXA should be offered before. 

Action 6: SG will write to Health Boards once any new clinical guidance in relation to recommendation 7(a)(ii) is issued, drawing attention to the implications for implementation of this recommendation (Secretariat)

In discussions, it was noted that consideration also needs to be given to what other medicines patients are being given and how they might interact with TXA. The detailed clinical context always needs to be considered. It was agreed the SG would continue to ensure any communications sent to Boards were clear that Boards were only encouraged to use TXA where appropriate for the individual patient. Similarly, Marc Turner noted that the benchmarking dashboard only gives indications and prompts rather than individual advice. 

The OAG confirmed that it was content with the responses of the Boards in terms of their use of TXA and with the assurance of the Boards that they are using the SNBTS Clinical Transfusion Dashboard to benchmark and improve transfusion practice fulfils the IBI recommendation 7a(iii).

OAG workplan and UK report on implementation of the IBI recommendations

OAG workplan

Sam Baker noted that a copy of the updated spreadsheet workplan of recommendations had been circulated. This has been revised to include next steps and an expected implementation date for most of the recommendations, making the progress of each recommendation easier to monitor. 

On the memorial to the victims of infected blood, there have been good discussions with HS and the City of Edinburgh about the planning and other stages that will need to be gone through before a memorial can be erected.  A proposal will be considered by the City of Edinburgh Council’s Public Art Panel in the autumn, which will hopefully agree a preferred location. On recommendation 7c on blood bank staffing, further discussions are needed with SG’s Planning and Delivery Board once the existing Task and Finish groups have completed their work on ensuring sustainability of services and there is also ongoing work at UK level on producing guidance for staffing levels.

Emma Watson updated on recommendations 3 and 7d on staff training and education. A new SLWG has been convened to consider implementation of these recommendations in Scotland. An initial meeting had taken place and a scoping brief has been produced, for discussion with SG, looking at how these recommendations can best be delivered using existing skills from NES and SNBTS. This initial work should take six months to deliver and further updates can be provided to the OAG in future.

UK report on implementation of the IBI’s recommendations

In line with recommendation 12 of the IBI, it was noted that UKG plans to publish a second update report on progress on implementation of the IBI’s recommendations by May, one year on from the publication of the IBI’s report. This will make clear whether the UK nations are accepting each of the recommendations, or not. The report will take the form of an update to the first report published in December 2024. As per the December report, SG is feeding in Scottish contributions to the report. 

As per discussions in the OAG, a way forward has been agreed in response to the vast majority of the recommendations. However, in a number of areas work is still ongoing and this will be recorded in the report.  

• recommendation 4(a)v, regulation of managers - SG is awaiting DHSC’s findings from its consultation before making further progress
• recommendation 5, SG is awaiting the introduction of the planned duty of candour UK legislation (known informally as the Hillsborough Bill)
• recommendation 6, liver monitoring for patients whose hepatitis C has been successfully treated - SG is continuing to consider clinical and patient views before taking a final position
• recommendation 7f iii, digitisation of transfusion processes - SG is working with SNBTS and National Services Scotland to help them to take forward work to analyse the level of current and planned digitisation in each Board and then develop an outline business case setting out options. However, this will take time, as well as needing buy in from all the Health Boards. Therefore it’s not possible to set out specific commitments yet for how this recommendation will be delivered

Action 7:  As per the December report, the OAG will be provided with a draft of the Scottish contributions to the UK report on progress on IBI recommendations for information ahead of publication in May (Secretariat).

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

Following the publication of the May UK IBI progress report, the Chair suggested that we should not need as many OAG meetings in future. The Chair suggested one more OAG this year, in the autumn, to maintain information on progress on implementing the recommendations. Updates will also be given by correspondence if needed. The SG would also be happy to convene further meetings before autumn if needed. This was agreed.

Any other business

There was no other business.

Summary of action points 

Action 1: It was agreed the minutes of the OAG meeting on 26 February would be updated before publication. (Secretariat) [Action completed. The minutes were published on the Scottish Government (SG) website on 17 April 2025]

Action 2: SG to send the note of the meeting with Haemophilia Scotland on 12 March concerning recommendation 6 to the wider OAG (Secretariat) [Action completed. The note of the meeting was circulated to members for awareness]

Action 3: SG would produce a formal communication seeking nominations for Subject Matter Experts to be involved in developing the question set for the update Digital Maturity questionnaire (Alistair Hodgson).

Action 4: SG to write to Boards in April with a general update on progress on the IBI recommendations, including flagging that a further letter will be sent in July in relation to recommendation 7e (Secretariat) [Post-meeting note - Action completed. A letter was issued to all Board Chief Executives on 13 May 2025]

Action 5: Discussions on recommendation 7e to be scheduled with SEND (Secretariat) and SAMD (Tracey Gillies). [Post-meeting note - A discussion with SEND has been scheduled for June]

Action 6: SG will write to Health Boards once any new clinical guidance in relation to recommendation 7(a)(ii) is issued, drawing attention to the implications for implementation of this recommendation (Secretariat)

Action 7:  As per the December report, the OAG will be provided with a draft of the Scottish contributions to the UK report on progress on IBI recommendations for information ahead of publication in May (Secretariat). [Post-meeting note - Action completed. The UK report was published on 14 May 2025]