Agenda and minutes

To note that Louise Craig has replaced Maria Ward to represent the interests of the Third Sector.

RESOLVED to note that:

(1)  Louise Craig, Nottingham CVS, has replaced Maria Ward as a member of the Board to represent the interests of the Third Sector; and

(2)  Tracy Taylor has replaced Peter Homa as the representative of Nottingham University Hospitals NHS Trust.

Helen Jones

Alison Michalska

Chris Packham

Andy Winter

None

To confirm the minutes of the meeting held on 27 September 2017

The minutes of the meeting held on 27 September 2017 were agreed as an accurate record and signed by the Chair.

RESOLVED to note the actions that have been completed since the previous meeting and the progress against outstanding actions listed on the Board’s action log.

David Pearson, Corporate Director Adult Social Care, Health and Public Protection Nottinghamshire County Council, introduced the report and gave a presentation updating on the Sustainability and Transformation Partnership (STP), with a particular focus on Nottingham, and the Accountable Care System Memorandum of Understanding.  He highlighted the following information:

(a)  The STP arose out of the NHS Five Year Forward View.

(b)  The governance structure includes a Leadership Board, Finance Group, Advisory Group, Clinical Reference Group and System Oversight Group.  A ‘political and chairs reference group’ is currently being established.

(c)  There are a mix of system-wide programmes e.g. delivering technology enabled care; and local actions and priorities for the two Transformation Boards – Mid-Nottinghamshire Alliance and Greater Nottingham Partnership.

(d)  Feedback on the Plan was sought earlier in the year and the Plan was updated in response to the feedback received and to reflect comments made during the engagement events.

(e)  An overarching aim of the Plan is to shift care closer to home.  There are already examples of where changes have been made that have improved people’s lives and been more cost effective.

(f)  The financial position is challenging.  At the time of developing the Plan there was a £3.7billion economy forecasting a financial gap of £628million by 2020/21.  Following work to identify ways of closing the gap, a shortfall of £38million remained by 2020/21. The majority of the £38million lay with local authorities.  The financial position for 2017/18 was forecast at month 5 as a £12.1million deficit with significant risk in delivering that position quantified at £41million (the majority of which related to non-delivery of savings programmes).

(g)  In the Next Steps on the NHS Five Year Forward View, 8 areas were identified as accelerator sites for developing more integrated accountable care systems.  This included Nottingham and Nottinghamshire with an early focus on Greater Nottingham.  The ‘Better Together’ programme in Mid Nottinghamshire is already delivering some benefits through an Alliance approach.  Partners in Greater Nottingham have agreed to an Accountable Care System Memorandum of Understanding and been asked to give consideration to how they can align organisational priorities with the requirements of the Memorandum of Understanding.

RESOLVED to note the update on the Nottingham and Nottinghamshire Sustainability and Transformation Partnership.

Dr Stephen Shortt, Rushcliffe Clinical Commissioning Group, gave a presentation on the Greater Nottingham Accountable Care System.  He highlighted the following information:

(a)  Accountable Care Systems (ACS) aim to deliver high quality care; improve health; moderate costs; and locally it has been agreed that it should support the workforce (including morale, recruitment and retention, new workforce roles, improve the quality of the workforce).

(b)  Under an ACS, health and social care commissioners and providers will collectively be accountable for achieving agreed aims, taking responsibility for both the quality of care and the cost.  Currently this isn’t the case and there is a lack of promotion of health prevention, a failure to deal with the whole person and a system that isn’t smart about transitioning people between different parts of the system.  Too often care is delayed, duplicated and delivered too far from home. 

(c)  Actuarial analysis had been carried out to understand the opportunities to improve the system value and it confirmed that there are opportunities to spend money differently to enhance quality of services and make significant savings.  This analysis has informed the development of the ACS for Greater Nottingham.

(d)  Phase 2 was establishing what capacity and capability is required across commissioners and providers.  The ‘ACS House’ sets out the minimum building blocks for the system, split into indirect enablers and integration functions.

(e)  There are a lot of successful Vanguards in Nottingham and Nottinghamshire, based on the principles in the ‘ACS House’ but they won’t scale up sufficiently to make enough difference.

(f)  Based on insights from Phases 1 and 2, the next phase of work is developing specifications for the ACS enablers and integration functions.  There is no experience of this within the English NHS or care system and therefore external expertise was sought.  Centene UK has been engaged on an interim basis to help design and create the system, building on experience of transforming care systems in the public sector and with disadvantaged communities in Medicare and Medicaid.  It will not be a provider of health or social care services. 

(g)  The population health management model is a new model of care, ensuring that every patient gets the right kind of care by focusing on identifying and supporting patients in greatest need; preventing progression of disease; and promoting wellness to the wider population. Historically the system has underinvested in those with emerging needs and this needs to change.

(h)  The operational and governance arrangements are a work in progress.  It is anticipated that there will be strategic commissioners (to end complexity and fragmentation in commissioning.  Statutory duties will remain with these organisations); system integration (all contracted providers will continue as autonomous organisations); and a provider partnership (the ACS will provide a partnership contract across the system to absorb risk and support management and administration).

During discussion the following points were made:

(i)  Currently the local health and social care system doesn’t have the necessary information, technology or infrastructure to design the most appropriate way of organising and aligning activity to best meet the needs of the population.  Fundamental redesign requires world-leading expertise.  Therefore a competitive process was held to appoint external expertise to help design the system, but there are very few organisations that have the required capabilities (a view supported by independent organisations such as the Kings Fund). 

(j)  NHS England provided £2.7million in 2017/18 specifically for the purpose of engaging external expertise, so it has not been funded from local operational budgets. 

(k)  The public needs to understand that people are being mis-treated and that, for example there is a negative impact of being in hospital. 

(l)  The pace of change needs to be accelerated.  While this work is taking place individual partners are dealing with significant budget pressures, including taking decisions to change/ close services that could be crucial to the success of the envisaged future health and social care system.  Once these services are gone it will be difficult to recreate them.

(m)Finance pressures are a huge challenge but compared with previous years there is greater clarity on the finances of partner organisations and a number of different methods of savings are being explored.  Finance leads are meeting to look at the position of each organisation preparing for 2018/19.

(n)  Experience of working with Centene UK so far had not felt like working with private consultants and had been a collaborative process.  They provided an opportunity to get pace into the process.

(o)  It is important to engage with the Third Sector as provider organisations and make sure the Sector is visible within discussions and governance arrangements.

(p)  Integration is important and partners need to work well together.

RESOLVED to note the update on the Greater Nottingham Accountable Care System.

Alison Challenger, Director of Public Health Nottingham City Council, reminded the Board that a Development Session had been held on 25 October 2017 to provide opportunity for Board members and Sustainability and Transformation Partnership (STP) leads to discuss the Nottinghamshire STP and Greater Nottingham Accountable Care System, and the financial pressures facing the health and social care system.  Discussions at that Session had been used to inform the report circulated as a supplement to the agenda. 

The Chair noted that there had already been significant discussion about these issues under the previous two agenda items (Sustainability and Transformation Partnerships in Nottingham and Nottinghamshire: Update to the Plan and Accountable Care System Memorandum of Understanding; and Greater Nottingham Accountable Care System), and it was important that the Board is aware of the current situation and the difficult decisions being made by partners on the Board.

Ciara Stuart, Assistant Director of Out of Hospital Care Nottingham City Clinical Commissioning Group and Nottingham City Council, introduced a report updating on the Better Care Fund 2017-2019 planning round and performance against national metrics.  She highlighted the following information:

(a)  The national Better Care Fund guidance was published in July 2017, and reduced the number of conditions from eight to four.  In addition, additional funding for social care was announced.

(b)  The budget for the Better Care Fund during 2017/18 is £36.6million and £38million for 2018/19.

(c)  Under the new national guidance the national metrics have stayed the same and all are currently on target, with the exception of delayed transfers of care.

(d)  Better Care Fund Plans were required to be submitted by September 2017.  In July, Nottingham City Council received a letter stating that there would be a ‘stock take’ of progress on reducing delayed transfers of care and that funding could be removed if sufficient progress was not made.  The City target for delayed transfers of care is very challenging and NHS England wanted it to be met by November.  Nottingham City Council felt that the target would be hard to achieve because work taking place to reduce delayed transfers of care was unlikely to impact until December/ January, and the Local Government Association provided guidance to local authorities that they should not sign up to unrealistic targets for delayed transfers of care.  Therefore the Plan was submitted with a narrative and was subsequently approved.

(e)  There is still significant focus and pressure on reducing delayed transfers of care.  Performance is regularly monitored and there has been a downward trajectory but performance is still not meeting target. 

(f)  There is a need to make savings from the Better Care Fund and all services are in the process of being reviewed.

(g)  The Better Care Fund Plan will be resubmitted once savings have been agreed by the Health and Wellbeing Board Commissioning Sub Committee.

(h)  There is potentially an opportunity to ‘graduate’ from the Better Care Fund for well-performing areas.  Nottingham City is on the shortlist for the next stage of the graduation process but due to performance on delayed transfers of care there is uncertainty about this.

During discussion the following points were made:

(i)  There are significant proposals for service change as a result of the need to make savings from the Better Care Fund, and these are all being looked at in detail.

(j)  There are risks that services important for the success of the Sustainability and Transformation Plan will be negatively impacted by budget decisions.

(k)  It is important that the system supports adult social care.

(l)  Currently there is money being spent on treating people in the wrong place.  Front line staff are willing to do things differently and therefore, if decision makers are bold, there is potential to release resource.

(m)It is important to recognise the contribution of housing to delayed transfers of care.

RESOLVED to

(1)  note the progress made in this year’s Better Care Fund Planning Round; and

(2)  note the performance of the Better Care Fund against its national metrics, including Delayed Transfers of Care.

Katy Ball, Director of Commissioning and Procurement Nottingham City Council, presented a six monthly update on the commissioning reviews undertaken by Nottingham City Council and the joint commissioning reviews undertaken in partnership with Nottingham City Clinical Commissioning Group for 2017/18.  This work was being driven by the Health and Wellbeing Board Commissioning Sub Committee.

Katy Ball also provided an update on work to respond to concerns about a disconnect between the Health and Wellbeing Board and Health and Wellbeing Board Commissioning Sub Committee.  She informed the Board that the Terms of Reference for the Commissioning Sub Committee were being reviewed and it was proposed that future meetings of the Sub Committee would directly follow Board meetings to improve links between the two; and other areas for greater co-ordination were being identified.

RESOLVED to note the progress made for each commissioning review in support of the aims of the Health and Wellbeing Strategy.

Shade Agboola, Consultant in Public Health Nottingham City Council, introduced a report updating the Board on winter pressures planning by Nottingham City Council and its partners.  She highlighted the following information:

(a)  Winter pressures planning is co-ordinated nationally by NHS England and requires joint working between organisations.

(b)  The flu vaccination programme was already underway and lots of promotion about the importance of being vaccinated had taken place.

(c)  Planning was targeting specific groups at particular vulnerability to cold weather, including older people, younger people, people with long term conditions and those whose housing or environmental circumstances put them at greater risk.

During discussion the following points were made:

(d)  Flu was a major concern this winter, following high levels of flu in Australia this year. 

(e)  Nottingham University Hospitals Trust had already seen an increase in child respiratory cases and this is usually followed by an increase in cases in adults.  Current admissions were already of very poorly individuals. 

(f)  During the winter period there is likely to be pressure on a range of areas including acute beds, social care and district nursing.  Nottingham University Hospitals Trust is reviewing its bed specifications to ensure that the appropriate level of care and resource is available.  Discharge to Assess had really helped to relieve pressure on inpatient beds but this meant that individuals being referred to social care were in poorer health than before.

(g)  Despite all the promotion activity, so far flu vaccination levels were no better than the previous year, especially amongst children and pregnant women.  Therefore it is really important that a focus on flu vaccination is maintained.  NHS England had commissioned 2 midwives at Nottingham University Hospitals Trust to focus on vaccinating pregnant women against flu.

(h)  NHS England would be visiting Nottingham in w/c 4 December 2017 to look at winter preparedness.

(i)  Communication with the public was key to success.  Extending access to GPs would only be effective in relieving pressure on other areas of the system if people are aware and then change their behaviour.  Councillor McDonald suggested exploring opportunities to use Council infrastructure to communicate key messages.

(j)  Voluntary sector organisations could help to disseminate messages to vulnerable groups.

RESOLVED to

(1)  ask Board members to ensure that they are taking appropriate steps to plan for winter pressures;

(2)  ask Board members to consider Public Health England’s Cold Weather Plan and satisfy themselves that the suggested actions and the Cold Weather Alert services are understood across their locality;

(3)  explore opportunities for closer partnership working with the voluntary and community sector because this sector can help reduce vulnerability and support the planning and response to cold weather, particularly through identifying and engaging vulnerable people;

(4)  consider the reduction of cold related harm as core business and include in Joint Strategic Needs Assessments and the Joint Health and Wellbeing Strategy; and

(5)  review progress in communicating key messages to citizens at the next Health and Wellbeing Board meeting.

John Matravers, Service Manager Safeguarding Partnerships Nottingham City Council, apologised for the absence of Chris Cook, Independent Chair of the Nottingham City Safeguarding Children Board and, in his absence, introduced the Board’s Annual Report.  He highlighted the following information:

(a)  It is a statutory requirement for the Safeguarding Children Board to produce an Annual Report.

(b)  The overall assessment of the Annual Report was that the work of the Board during 2016/17 had been compliant with its statutory and legal requirements.

(c)  During the year there had been significant progress across the Partnership.

(d)  In February 2017 there had been an Ofsted inspection of Children’s Services, which was rated as ‘good’.  The ‘voice of the child’ had been noted as a particular strength. 

(e)  Levels of deprivation in the City presented lots of different challenges for partners.

(f)  Strong links had been built between partners, for example between the Board, Nottingham City Council and NHS Nottingham City Clinical Commissioning Group.  These partners had jointly produced a well-received ‘Was Not Brought’ animation for practitioners and NHS England has agreed to fund a similar public-facing animation.

(g)  During the year over 2000 taxi drivers had received safeguarding training.

(h)  Training and awareness-raising amongst the front line staff of key partner organisations had continued through the ‘Every Colleague Matters’ programme.

(i)  Following the ‘Child J’ case, 2216 practitioners had attended related learning events.

(j)  The Children and Social Work Act 2017 had received Royal Assent and local areas now had to develop arrangements for replacing Safeguarding Children Boards.

During discussion Tracy Taylor commented that she was aware of the ‘Was Not Brought’ animation from her previous role in Birmingham and Nottingham University Hospitals NHS Trust would be embracing the concept.

The Chair thanked the Safeguarding Children Board for its important work and asked that, going forward, the Board inform the Health and Wellbeing Board if it has any concerns about health and social care during the course of its work.

RESOLVED to

(1)  note the Nottingham City Safeguarding Children Board Annual Report 2016/17; and

(2)  circulate the ‘Was Not Brought’ animation to Health and Wellbeing Board members.

Malcolm Dillon, Independent Chair of the Nottingham City Safeguarding Adults Board, presented the Board’s Annual Report 2016/17.  He highlighted the following information:

(a)  The Annual Report provides assurance about the effectiveness of local safeguarding arrangements during 2016/17.

(b)  During 2016/17 there were no major changes in patterns of safeguarding issues.  Most safeguarding incidents related to neglect, physical abuse and financial abuse. 

(c)  2016/17 was Year 1 of a three year work plan for the Board.

(d)  It is important that the implications for safeguarding are considered during service change and David Pearson, Sustainability and Transformation Partnership (STP) Lead, has agreed to give higher prominence to safeguarding issues within the STP.

(e)  Funding for the Safeguarding Adults Board is reducing and there are concerns about the ability to continue awareness-raising in the non-statutory sector e.g. supporting training for the Third Sector.

The Chair thanked the Safeguarding Adults Board for its important work and asked that, going forward, the Board inform the Health and Wellbeing Board if it has any concerns about health and social care during the course of its work.

In light of the opportunities for learning presented by both the Safeguarding Children Board and the Safeguarding Adults Board, it was suggested that the Health and Wellbeing Board focus a future Development Session on safeguarding issues.

RESOLVED to

(1)  note the Nottingham City Safeguarding Adults Board Annual Report 2016/17;

(2)  schedule a Health and Wellbeing Board Development Session on safeguarding issues.

The Chair reminded Board members that the draft Physical Activity and Nutrition Declaration had been discussed at the previous Board meeting in September 2017 and Board members had been asked to provide feedback on the draft Declaration following that meeting.

RESOLVED to

(1)  support the Physical Activity and Nutrition Declaration;

(2)  ask Board member organisations (or the organisations they represent) to sign the Physical Activity and Nutrition Declaration and develop action plans as outlined in the Declaration’s commitments; and

(3)  note that signatories and their progress towards commitments will be reported back to the Health and Wellbeing Board on an annual basis.

RESOLVED to

(1)  note the Nottingham City Pharmaceutical Needs Assessment consultation period from 13 November 2017 to 12 January 2018;

(2)  ask Board members to respond as organisations to the Nottingham City Pharmaceutical Needs Assessment consultation; and

(3)  ask Board members to distribute the consultation within their respective organisations to colleagues, patients, clients or service users.

RESOLVED to note the Health and Wellbeing Board Forward Plan.

Updates on issues of relevance to the Health and Wellbeing Board and/or delivery of the Joint Health and Wellbeing Strategy

RESOLVED to note the Board Member Updates circulated with the agenda.

RESOLVED to note the new Joint Strategic Needs Assessment Chapter on Children and Young People’s Oral Health.

RESOLVED to note the new Joint Strategic Needs Assessment Chapter on Homelessness.

RESOLVED to note the new Joint Strategic Needs Assessment Chapter on Learning Disability.

RESOLVED to note the new Joint Strategic Needs Assessment Chapter on Viral Hepatitis.

Opportunity for members of the public to ask questions relating to matters within the Health and Wellbeing Board’s remit.

The maximum amount of time allocated to questions and responses is 30 minutes.

There were no questions from the public.