Agenda and minutes

To note that Councillor Power has been appointed as a member of the Health Scrutiny Committee.

RESOLVED to note that Councillor Georgia Power has been appointed to the Health Scrutiny Committee.

Councillor Carol Jones – personal

Councillor Corall Jenkins – personal

Councillor Jackie Morris -unwell

Councillor Jim Armstrong - personal

Councillor Eunice Campbell - unwell

Cllr Brian Parbutt -personal

Cllr Merlita Bryan - unwell

None.

To confirm the minutes of the last meeting held on 21 September 2017.

The minutes of the meeting held on 21 September 2017 were confirmed as a true record and signed by the Chair.

Rebecca Larder (South Nottinghamshire Director of Transformation), Dr Stephen Shortt (Clinical Lead), and Steve Thorne (Communications Lead), were in attendance and delivered a presentation to accompany the report in updating the Committee on progress of the Greater Nottingham and Nottinghamshire Sustainability and Transformation Partnership (STP) and development of a Greater Nottinghamshire Accountable Care System (ACS), since the previous update to the Committee in June.

It was noted that 730,000 citizens have access to services which work within a budget of £1.4 billion to provide health and social care services, including over 100 GP surgeries across Nottingham and Nottinghamshire. All of these services need to fully engage and contribute to the development of an ACS.

The following areas of progress were highlighted:

o  It is recognised that breakdowns in care continuity and communication between service and organisational boundaries do exist and that this needs to be addressed. Co-ordination of services is successfully being developed in other parts of the world such as Sweden, Spain, New Zealand and America with savings ranging between 5% and 29% of the overall budget. Each healthcare structure is different but advice has been sought and provided, and following a procurement exercise approved by NHS England, Capita and Centene have been awarded the contract to support the development of an ACS;

o  Citizens, service users and colleagues have been consulted and contribute to the development of the STP which includes the aim to focus on prevention and self-help (which will reduce the need for treatments), and improved co-ordination between providers, including increased partnership working;

o  The updated STP was published in July 2017 and identifies the challenges ahead and how those challenges are intended to be addressed;

o  The ACS Memorandum of Understanding, including development of locally integrated services with the Greater Nottinghamshire  ACS, focuses on integrated commissioning, integrated provision and identifies the need for interim support whilst the system is establishing;

o  The financial pressures up to 2020/21, including a £3-4m gap in funding, are identified in the report, added to which one-off investments will be required to support the transition and continued adherement to statutory requirements, but in the longer term, there is a potential for approximately £600m of savings;

o  Developing the next phase of the ACS will include consideration of how partner organisations could support elements of the work in future.

The Committee’s comments and questions were responded to as follows:

(a)  The local authority social care funding short-fall is included within the £3-4 m funding gap across the partnership of the 3 Health Authorities of Greater Nottingham. Further funding for Social Care is required and lobbying of Central Government continues;

(b)  Patient groups are engaged in the consultations but as there appears to be a common membership, further outreach consultation will be undertaken to ensure that the broader community is involved;

(c)  The health care needs of communities vary significantly between areas within the partnership so addressing local priorities may focus on very different self-care and prevention methods but with a holistic approach;

(d)  Specialist services, such as congenital heart disease services  provided at University Hospitals of Leicester NHS Trust’s Glenfield site, will continue to be commissioned separately to the ACS but it is possible that in future, consideration may be given to commissioning these services more locally;

The Committee should be assured that the contract tender for advising and supporting the Partnership through transition, was undertaken through a proper process via the NHS Procurement Framework which has been evaluated and approved by NHS England.  It is understood that there is a relationship between Centene and Practice Group but there is no possibility that Centene will be involved in delivering services now or in the future.

At this point, the meeting was adjourned for a total of 7 minutes due to disruption caused by a protester who was escorted from the room.

(e)  Physical assets, such as estate, remain the property of the Health and Social Care estate.

The Chair requested that as part of the next update, colleagues provide information on how challenges around the lack of integrated data and therefore how progress is evidenced, are being addressed

Councillors discussed that it was important for the Committee to receive regular updates on the STP and ACS given their significance for the whole health and social care system and that there was an important role for the Committee in providing democratic oversight of the decisions being taken.

RESOLVED for a further update to be provided to the Committee at the next key milestone point.

Paul Smeeton (Executive Director Local Partnerships), Dr David Rhinds (Consultant Addiction Psychiatrist) both from the Nottinghamshire Healthcare Trust, Ian Bentley (Strategy and Commissioning Manager, Crime and Drugs Partnership), Councillor Nick McDonald (Portfolio Holder for Adults and Health), and Christine Oliver (Head of Commissioning, Nottingham City Council) were in attendance to respond to Committee members’ questions and queries about future provision of inpatient detoxification services for Nottingham residents.

Nottinghamshire Healthcare Trust is undertaking a review which will include consultation on the possible closing of The Woodlands inpatient detoxification unit and exploring options for a new service model that is more financially sustainable. Commissioners are aware of the position with The Woodlands and a summary of current commissioning arrangements, the potential impact of closure of The Woodlands and initial investigations into possible alternative provision is included within the report.

Representations have been received from Double Impact and the Local Medical Committee, both stating that the facility must not be lost and the detrimental impact to service users and the wider health care system if that happened.

In addition to the report, the following points were made and responses given to questions from the Committee:

(a)  Paul Smeeton acknowledged that although a service to be proud of, it is significantly loss-making since the withdrawal by Nottinghamshire County Council from the contract to provide services to County citizens. Efforts to expand the service, including contracts with a number of other commissioners, have not generated the required income so options for the future of the unit have to be considered;

(b)  Christine Oliver commented that the unit is one of the services which the City Council commissions and is a crucial and successful part of the pathway for citizens who are unable to safely detox in the community;

(c)  Councillor Nick McDonald did not believe that closure of the unit was a good idea and it would be a great loss to the community as there is a proven need and while it is acknowledged that there are on-going cuts to budgets, alternatives to closing the unit should be sought whilst appreciating the position of partners. The current cost of maintaining a unit which does not financially support itself must be viewed realistically but all possibilities must be investigated for making the unit viable and sustainable;

(d)  Dr David Rhinds commented that this is an important, highly specialised service, a regional centre of excellence for acute substance misuse and must not be closed.  To allow closure would be a false economy which would result in significant social and health care resource implications when specialist services, knowledge and advice would not be available but existing services, including A&E, would be expected to respond and provide care. Other regional substance misuse inpatient services do not maintain the same level of expertise required for the level of complex cases received at Woodlands, added to which, some level of the service would still need to be commissioned. Patients would be reluctant to travel to other specialist units away from their support networks (the nearest unit similar to Woodlands is in Liverpool) so would be likely to end up in A&E. Even some of the private facilities do not meet the standards of Woodlands, as confirmed by the Inspector of Hospitals;

(e)  With regard to the services currently provided to pregnant women at Woodlands, if the unit were to close, the current specialist trained midwives would still be available but there would still be an impact on other services and may well result in a death of a patient;

(f)  The Woodlands Unit provides a first class service and must not be lost. The unit is working with commissioners to investigate alternatives to closure;

(g)  This is a very expensive service and although valued, the cost of supporting it in its current position would result in funding reductions to other services provided by Nottinghamshire Healthcare Trust so action must be taken;

(h)  The Trust has already given notice on some contracts held by other commissioners. If the service is to continue, existing contracts would need to be re-negotiated to ensure an appropriate charge as initially the pricing of these contracts was too low to sustain the unit without the previous level of service uptake;

(i)  If the unit is closed, the cost to other services and Local Authorities will not be initially obvious as the impact will be spread amongst a variety of health, social and community organisations, but it is inevitably higher than if the patient were appropriately treated at the existing facility;

(j)  As suggested by members of the committee, commercialism is being investigated but there is only a short timeframe of 3-4 months until a decision must be made. Private organisations have indeed taken over failing services in the past and made them financially viable. The development of a revised, more commercial service model is being explored and whilst there may be an impact on staffing numbers, employees are fully aware of the circumstances and engaged in consultation.

Members of the Committee agreed that as the information available does not confirm that The Woodlands will definitely close or set out a clear proposal for future provision if that happens, at this stage it is difficult to assess whether the change will constitute a substantial variation of the service; but there is a need for the high quality specialist service and closure of the unit is not desirable and therefore alternative options must be thoroughly investigated as a matter of urgency.

RESOLVED to

(1)  ask  the provider and commissioners to work together to explore ways of maintaining inpatient detoxification services at The Woodlands Unit, or, if this is not possible, to develop a proposal for continued access to inpatient detoxification services by Nottingham residents; and

(2)  request that commissioners and providers come back to the January meeting of the Committee, before Nottinghamshire Healthcare NHS Foundation Trust Board makes a decision regarding The Woodlands, with a proposal for future commissioning and provision of inpatient detoxification services. At this point the Committee will determine whether the proposal is a substantial variation of service and if so, whether the proposals have taken into account the public interest through appropriate patient and public involvement and whether the proposal is in the interests of the local health service.

David Johns (Registrar Public Health, Nottingham City Council), Laura Burns (Contract Manager, NHS England), Rose Lynch (Primary Care Support Officer, NHS England) and Sandra Whisten (Public Health England) were in attendance to respond to the Committee’s questions.

Although there is adequate NHS dental care available in Nottingham, the perception is that there is a shortage, as is the case in other parts of the country.  The Committee wanted to explore whether this mis-conception may be contributing the historic poor dental health of Nottingham citizens, which is particularly evident in pre-school children.

The report provides details of the commissioning of dental services in Nottingham, the responsibilities of the oral health function of the City Council within the Public Health remit, and the disappointing statistical information regarding the oral health of citizens.

David Johns delivered a brief presentation on the work undertaken by Public Health, mainly focusing on dental health promotion in nurseries and schools in neighbourhoods where children experience the poorest dental health in the City.

Initiatives include:

•  Supervised Tooth Brushing Programme.

•  Training of key health, social care and education professionals

•  Distribution of Oral Health Resources

•  Participation in national oral health awareness campaigns

Committee members’ questions and comments were responded to as follows:

(a)  Special Care Dentistry Services are available (by referral) for special needs patients, including children with autism and learning difficulties, who may need additional support and time. The Disability Partnership is aware of the service and promotes it to partners;

(b)  The Dental Health Team is working on sustainability plans with partners. The ‘Starting Well’ campaign will be launched in April 2018, to encourage families to attend dental surgeries proactively before dental issues develop;

(c)  A lot of the local dental health promotions are aimed at children rather than adults. However, adults are included in the national campaigns which possibly don’t attract the same media attention as child targeted campaigns;

(d)  As dental surgeries are private businesses, unless additional funding is made available as an incentive, it is not possible to direct dentists to set up in areas where there may be fewer surgeries, or regarding the surgery arrangements such as multiple dentist practices;

(e)  Comprehensive health needs assessments are being undertaken and the results will used to identify what the areas of greatest dental need are and what can be done. The success of different engagement approaches, including Health Visitor and other Health Care Professional promotion/support, will then be considered;

(f)  Statistics show that dental health is improving and the work of the Dental Health Team is having a positive impact, but further work is required;

(g)  Emergency dental care is available but it’s far more beneficial if citizens register at a dentist and receive treatment before the problems become an emergency. The ‘NHS 111’ telephone service data shows that the majority of callers requiring dental services can be booked into a dental surgery for non-urgent care;

(h)  Poor dental health can exacerbate or even cause other heath conditions and result in time off work, either to attend the dentist or take a child to the dentist, and affect mood and mental health;

(i)  Limited outreach dental services are available to assist homeless people and those who are transitory. Further details will be collated and provided to the Committee following the meeting.

The Chair commented that it was encouraging that progress is being made to improve dental health and commended the community engagement work but recommended that  communication directly to citizens regarding the availability of specialist dental services, for example for people with autism should be improved, for example with an enhanced web presence

RESOLVED to

(1)  recommend that NHS England engage with providers of specialist dental services, for example services for people with autism, to explore how information about those services can be made more easily and directly available to current and potential services users; and

(2)  request that further information be provided in a written briefing on the commissioning and provision of outreach dental services for communities who are transitory, homeless etc.

Mark Sheppard (Director of Contract Delivery) and Tracey Duggan (Head of Commissioning), both representing Greater Nottingham Clinical Commissioning Groups, were in attendance to present the report on the Nottingham Treatment Centre services procurement, as the current contract expires at the end of July 2018.

The report outlines the provision and arrangements within the current contract, the proposed work process, the governance structure which will include the four Nottingham and south Nottinghamshire clinical commissioning groups, and predicted timeframes.

Although the procurement involves many different services, the Chair highlighted that this included the dermatology service which had previously been a concern of the Joint City and County Health Scrutiny Committee as there had been some significant issues arising from the previous commissioning of the service, and it was important that lessons were learnt from this.  This included a recommendation from the 2015 Independent Review of Nottingham Dermatology Services that development of a longer term strategy for dermatology services is considered.

The British Association of Dermatologists (BAD) had made a representation to the Committee with regard to the commissioning process, including development of the service specification, suggesting that concerns about standards of care and risks to patients identified by the Independent Review should be addressed in the retendering of the whole service including inpatient services.

Dr Tanya Bleiker, Clinical Vice President, British Association of Dermatologists was invited by the Chair to briefly address the Committee and commissioners and in summary made the following points:

o  The service specification should be shared to ensure it can be scrutinised, to make sure that services are safe and appropriate;

o  There is currently a lack of inpatient care and this needs to be addressed in the commissioned specification;

o  It is important that both clinical and patient concerns with the service current model are heard and addressed in formulating new service specifications.

Other representations received and presented via the Chair included the following comments:

o  Paediatric and adult dermatology need to work together.  Apart from this being good practice, there are important reasons - the joint agreeing of a pathway for children with chronic conditions transitioning to adult services; availability of specialist skin cancer service access for children with rare skin cancers;

o  Adult dermatology needs to offer combined clinics with other potentially linked services such as gynaecology or rheumatology.

Mark Shepherd and Tracy Duggan responded that learning from the previous tender process has resulted in market testing and looking at what specialist provision is needed. Commissioners are working closely with NHS Commissioning and are/intend to consult patient groups and engage specialists to advise on the specifications for the service; the BAD may well be invited to assist.

Although new contracts will need to be in place and ready to commence by the end of July 2018, the timescales for development of service specifications have been extended and the points raised today will be taken into consideration. Every effort will be made to ensure a smooth transition between providers.

The Committee’s comments and questions were responded to as follows:

(a)  With regard to after-care following Treatment Centre procedures, care is taken not to arrange unnecessary follow-up appointments but there is usually a consultant appointment at three months. The Treatment Centre is commissioned to undertake the procedures, and patients’ GPs will be able to advise on, or refer for, any further after-care, should it be necessary;

(b)  It is a concern that the patient leaflet issued by the current Treatment Centre provider, Circle Health, asks patients whether they can afford the operation, as this could be misleading to NHS patients and it is agreed it may possibly cause confusion and distress to some patients so will be investigated further;

(c)  Concerns that the needs and aspirations of staff should also be taken into account prior to the commissioning process to ensure that staff can be retained and don’t move on, will be taken into account. Staff members are already engaged regarding the STP and the HR Organisation and Development Group.

The Chair emphasised that if the specifications for some services are due to change substantially, the Committee will need to scrutinise and ensure that these changes are in the best interests of citizens, as evidence through appropriate patient and public involvement, and that gaps and risks are recognised and  addressed in the commissioning process.

The Committee wanted particular reassurance about the development of the specification for the dermatology service, including what expertise has been sought and the process for engagement and consultation; and how the specification has taken into account the recommendations of clinical experts and the interests of service users.  Due to the timescales involved and associated pressures, it is suggested that the commissioners provide a written submission to the Committee and subject to that briefing providing sufficient assurance, not ask commissioners to attend a meeting.

RESOLVED to ask commissioners to provide a written briefing for the Committee regarding development of the specification for the dermatology service, including what expertise has been sought and the process for engagement and consultation; and how the specification has taken into account the recommendations of clinical experts and services users.

Jane Garrard, Senior Governance Officer, introduced the report regarding the Committee’s work programme for 2017/18.

Recent announcements by Wellspring GP Practice about the financial challenges that they are facing and that this may lead to closure were discussed.  Councillors noted that it was intended to invite Nottingham City Clinical Commissioning Group to the January meeting to discuss access to GP services and it was suggested that the position of Wellspring Practice could be a focus for that session.

RESOLVED

(1)  for the commissioning and provision of inpatient detoxification services to be scheduled for the January meeting

(2)  to make the transition from child and adolescent mental health services to adult mental health services a key line of enquiry of work looking at improving child and adolescent mental health services in December;

(3)  to consider speaking to  ‘The Tomorrow Project’ as part of the work looking at suicide prevention in February 2018;

(4)  to establish  a study group to explore how commitments to adult mental health are being maintained in current decision making to manage budget pressures and appoint Councillors Peach, Power and Williams to sit on that study group; and

(5)  for the remaining proposed schedule of topics to be noted.