Agenda and draft minutes

Councillor Saj Ahmad  -  personal reasons

Sarah Collis  -  Chair, Healthwatch Nottingham and

Nottinghamshire

In the interests of transparency in relation to item 5 (Nottinghamshire Healthcare NHS Foundation Trust - Care Quality Commission Assessment Outcomes), Councillor Georgia Power stated that she had been a patient of a service provided by the Nottinghamshire Healthcare NHS Foundation Trust in the past, and that the Care Quality Commission had contacted her about her experience of the service as a patient as part of its assessment activity.

Minutes of the meeting held on 14 March 2024, for confirmation

The Committee confirmed the minutes of the meeting held on 14 March 2024 as a correct record and they were signed by the Chair.

Report of the Statutory Scrutiny Officer

Gemma Whysall, System Delivery Director for Urgent Care at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB); Greg Cox, General Manager at the East Midlands Ambulance Service NHS Trust (EMAS); and Lisa Kelly, Chief Operating Officer at the Nottingham University Hospitals NHS Trust (NUH), presented a report on the current waiting times for an ambulance and the system-wide approaches being taken to improve these. The following points were raised:

a)  There was a great deal of disruption to ambulance services across the winter period (contributed to by industrial action, business continuity issues and severe weather), which had knock-on impacts on the overall ambulance waiting time levels. Patient handover times at NUH hospitals increased over the last 12 months as attempts to prevent overcrowding in Accident and Emergency departments meant that ambulance crews needed to wait with patients for longer periods of time. However, over the last three months, NUH has improved the handover process by increasing the use of waiting areas and moving patients from Accident and Emergency to an appropriate ward more quickly. This has helped to reduce waiting times for ambulances outside Accident and Emergency and, following a peak in December, these waiting times are now reducing.

b)  NUH has carried out a significant level of activity across its hospitals, working alongside the ICB, to improve admissions and discharge to reduce the pressures on urgent and emergency care. Measures include the use of ‘virtual wards’ where patients can remain at home but still under the care of the hospital (and with a named consultant), improved frailty pathways to address care for the oldest patients most at risk of impact by long delays waiting for an ambulance, and alternative triage methods for initial assessment so that patients can be referred to the right place.

c)  In terms of ambulance response times, the national expectation for a response to an emergency call has been set at 30 minutes. Currently, EMAS’ target average response time for emergency calls is 39 minutes and 49 seconds. Due to the geography of Nottingham and Nottinghamshire, the response times within the city are usually faster than average, though handover times at the Sherwood Forest Hospitals NHS Foundation Trust may be shorter than those at NUH.

The Committee raised the following points in discussion:

d)  The Committee asked how NUH was learning from other NHS hospital trusts to improve the waiting times for patient handover from ambulances. It was reported that NUH has recently been visited by the national ‘Get it Right First Time’ team from NHS England, which has helped to formulate an action plan based on best practice from other comparable hospital trusts. There is a strong focus on areas identified as needing work to improve flow and capacity with the aim of reducing ambulance handover waiting times. Ultimately, this work forms a collaborative plan including NUH, the ICB and EMAS.

e)  The Committee considered that the phrase ‘virtual ward’ suggested a focus on systems rather than a focus on care and queried whether a more patient-orientated term could be used. It was explained that the phrase ‘virtual ward’ is the national NHS terminology, but that NUH could consider a potential alternative local term (such as ‘care in your own home’) to make it clearer that a ‘virtual ward’ represents hospital care within your own home.

f)  The Committee asked how NUH would assess the actual impact of the improvements being made, and how these changes would be evaluated to manage risk effectively. It was set out that one of the most significant developments to have taken place recently was to the EMAS telephone triage system, which now has more of a focus on identifying urgent care needs and signposting callers to the most appropriate care pathways for them. This has led to a reduction of callers ultimately needing an ambulance. Improvement initiatives within NUH are assessed using multiple data streams, outcome measures across periods of time and patient feedback, with the detail then fed into its Quality Assurance Board. As a result of this work, small changes made have resulted in important improvements, such an increasing the number of porters to move patients from Accident and Emergency to ward settings more quickly, or redesigning the use of physical space to improve waiting conditions.

g)  The Committee asked what work was being done to engage with staff on the changes being made to improve ambulance handover times at hospital. It was explained that both EMAS and NUH have worked hard to engage both staff and patients when developing improvements. It has been clear that both staff and patient experience deteriorated as the waiting times for patient handover at hospital increased, so it has been vital to learn from the experiences of staff and patients in bringing about improvement.

h)  The Committee noted that the waiting times for an ambulance had increased significantly where local performance had previously been strong, and asked what the major causes of this were. It was reported that there had been an increasing demand for ambulance services, compounded by critical incidents being declared within local healthcare services, a number of cases of industrial action and a reduced flow of patients through hospitals (contributed to by delays in discharge). This increased demand and reduced flow has acted together to cause a bottleneck at crowded Accident and Emergency departments that has impacted on the handover time for ambulance crews. A programme of work is underway to overcome this bottleneck, improve the patient handover time and release ambulances back to respond to calls. Triage systems are in place to direct people calling for an ambulance to a more appropriate service where applicable. As a result, improvement has been seen between January and March 2024, but there is still more work to be done.

i)  The Committee asked what improvement targets were currently in place, and what the anticipated timetable for meeting them was. It was explained that the ultimate target was to bring ambulance waiting times back to within 30 minutes, but that planning was taking place over the next six weeks to establish deliverable targets and timelines.

j)  The Committee asked how care provision within communities, such as through Social Prescribing, might help to reduce the need for hospital emergency care. It was set out that there is more that could be done to link the care carried out via ‘virtual wards’ to locally provided community care, so further work in this area will be explored.

k)  The Committee asked to what extent people in mental health crisis were referred to hospital Accident and Emergency, and how it was ensured that these patients received the right care in the right place. It was set out that there has been new funding to support mental health care needs within EMAS, with mental health specialists being recruited to the control rooms to work with other medical professionals and ambulance crews to ensure the appropriate support for patients. Within the hospital Accident and Emergency departments, partnership working is in place with the Nottinghamshire Healthcare NHS Foundation Trust (NHT) to ensure that wraparound mental health care is in place. Section 136 suites are available in hospitals, and NUH and NHT work together to ensure people in mental health crisis are supported in the right safe spaces.

The Chair thanked the representatives of the ICB, EMAS and NUH for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To request that information is provided, when available, on the plans to be put in place to deliver an average wait time for an ambulance of under 30 minutes, and the projected timeline for when this is intended to be achieved.

2)  To recommend that a local terminology is developed for services to put a greater emphasis on the care being delivered.

3)  To recommend that all possible action is taken in partnership to ensure that patients can be handed over from ambulances to hospital Accident and Emergency Departments as quickly and safely as possible, and then transferred on to the right department within the hospital swiftly and effectively.

4)  To recommend that all appropriate methods are developed in partnership to ensure that people who call for an ambulance gain access to the right pathway for the appropriate urgent and emergency care for their needs from the triage stage – particularly in the context of someone experiencing mental health crisis.

5)  To recommend that consideration is given to how ‘care in your own home’ services can also be supported by local communities themselves, particularly in the context of Social Prescribing.

Report of the Statutory Scrutiny Officer

Dr Susan Elcock, Jan Sensier and Dianne Hull, Executive Medical Director and Deputy Chief Executive, Executive Director for Partnerships and Strategy, and Chief Nurse at the Nottinghamshire Healthcare NHS Foundation Trust (NHT); and Maxine Bunn, Service Delivery Director for Mental Health and Children at the NHS Nottingham and Nottinghamshire Integrated Care Board (IBC), presented a report on the outcomes of the recent Care Quality Commission (CQC) assessments of NHT’s provision of mental health services and the improvement activity proposed in response. The following points were raised:

a)  As a result of the latest CQC assessment outcomes, NHT has been placed into an oversight framework to help manage and improve the significant and complex issues in its delivery of mental health services. A number of actions have been taken across a variety of services and, while various improvements can be made quickly, many will required longer-term development to deliver. Alongside the needed service improvements identified by the CQC, there are also financial challenges that NHT must address. An Integrated Improvement Plan is being drafted to improve issues around safety, people and the organisation being well-led. The draft plan has been submitted for comment and the NHT Board aims to sign off a final version by the end of April 2024.

b)  Since the CQC’s reports have been issued, there has been a focus on ensuring safer staffing on adult wards, and most staff posts have now been recruited to. Work has been done to strengthen nursing leadership within teams to ensure that the right expertise is in place. A range of training is underway throughout induction for new staff, with refresher training for existing staff.

c)  Extensive work has been undertaken to improve therapeutic observations, and a full audit of all observations has taken place. The risk assessment process used by the Mental Health Crisis team has been fully audited and the triage process has been strengthened to ensure service users are clear what to expect from the service, with dedicated leadership now in place to oversee this. A ‘waiting well’ policy has been developed and fully implemented to ensure that those waiting for services have support in the interim and know how to access help before they receive an appointment.

d)  Work is also taking place to review how NHT listens to patients and uses their provided feedback to drive improvement and ensure quality. Both a staff and carer reference group have been established to ensure that feedback is heard from a wide range of people involved in care, as well as from service users, allowing these experiences to be embedded in the improvement plan.

The Chair made a detailed statement setting out how the Committee had sought to engage with NHT in the past on the issues identified by the latest CQC assessments and the Coroner’s Reports to Prevent Future Deaths, which is appended to the minutes. The Committee then raised the following points in discussion:

e)  The Committee asked how mental health capacity assessments where carried out to help determine support needs. It was explained that the mental health capacity assessments are generally done by the most appropriate clinician depending on the particular context and service being used. The assessment of mental health capacity is a specific skill and it is essential that those completing the assessments are skilled and qualified to do it, so all proper training is in place.

f)  The Committee asked how services were commissioned across the city to ensure equity of access. It was reported that there could be uneven pockets of service provision, so work is underway to remove barriers and ensure access for everyone. Where services have been historically commissioned to be area-based, systems are being put in place to prioritise requirement over location to ensure that those most in need of services can receive them easily. Measures are being set to ensure that staff are in the right roles and that people entering the system seeking support are able to follow an accessible and straightforward process that has clear start and end points.

g)  The Committee asked whether there were other mental healthcare providers currently operating within an improvement framework, and what lessons were being taken from those that had been in a similar position. It was set out that NHT has started to engage with other providers that have been through a similar process and is working towards establishing what best practice looks like. NHT is also liaising with the Nottingham University Hospitals NHS Trust on how it is progressing its significant transformation and improvement journey to establish good ways of working and how best to engage with staff and patients. There are regional and national network groups that NUH is participating in to help improvement, and it is talking to a range of third-sector providers to enhance learning and establish a range of techniques for best practice.

h)  The Committee asked what work was being done to ensure that change was embedded across all services, particularly in the context of listening to the voice of patients and staff. It was explained that listening to service user experience would form a significant part of NHT’s transformation work, including taking a more robust approach to reviewing complaints and using them to inform service improvement. Work on a new complaints process in underway to ensure that the correct information is captured, and that similar complaints are recognised as a group, rather than each one being dealt with as an isolated incident. Work is also underway to amplify the patient voice and capture more feedback on services through communication with all patients. Improvements made include creating a participation structure with previous and current service users, and the delivery of a series of co-produced training programmes to enhance staff learning. Ensuring diversity and listening to a wide selection of different voices is at the heart of the improvement programme for gathering feedback.

i)  The Committee asked what immediate next steps were planned, and how NHT would work to rebuild trust with Nottingham people. It was reported that the initial aim is for an Integrated Improvement Programme to be signed off by the end of April. This will then inform activity to establish projects, work programmes and exit criteria that will all be used to monitor the delivery of improvement. Work around co-production will begin in May, with a particular focus on regaining the trust of the public and patients, and on rebuilding relationships.

The Chair thanked the representatives of NHT and the ICB for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To request that the Committee is briefed on the Nottinghamshire Healthcare NHS Foundation Trust’s (NHT’s) completed Integrated Improvement Plan for addressing the full scope of the challenges faced by the organisation, including in the areas of patient safety, quality, people and culture, finances and leadership.

2)  To recommend that everything possible is done to ensure that a diverse and representative range of voices of both patients and frontline staff are heard, amplified and listened to as a vital component in improving services through effective co-production, and that past complaints from patients are fully reviewed as part of this process.

3)  To recommend that an effective communications strategy is developed and delivered in partnership to ensure that people are aware of what is being done by NHT as part of its improvement process, to seek to rebuild trust with both current and past patients, and with future service users – particularly in the context of reaching past patients who may be reluctant to re-engage with NHT due to their past experiences.

Report of the Statutory Scrutiny Officer

The Chair presented the Committee’s completed work programme and the proposed approach to its consideration of the 2023/24 Quality Accounts of local NHS healthcare providers. The following points were discussed:

a)  The development of the Committee’s 2024/25 work programme is underway. It is proposed that the draft Quality Accounts will be considered by working groups of Committee members during the last week of April (before the upcoming local elections on 2 May), which will then report back to the next appropriate meeting of the full Committee.

Resolved to agree the proposed approach to the engagement with the Nottingham University Hospitals NHS Trust, the Nottinghamshire Healthcare NHS Foundation Trust, the East Midlands Ambulance Service and the Nottingham CityCare Partnership on the production of their Quality Accounts for 2023/24.