Agenda and minutes

To note that Councillor Corall Jenkins has resigned as a member of the Health Scrutiny Committee.

RESOLVED to note that Councillor Corall Jenkins has resigned as a member of the Health Scrutiny Committee.

Councillor Eunice Campbell – personal

Councillor Jackie Morris – other Council business

Councillor Georgia Power – ill health

None.

To confirm the minutes of the meeting held on 22 February 2018

The minutes of the meeting held on 22 February 2018 were confirmed as a true record and signed by the Chair.

Lucy Putland (Strategy and Commissioning Manager) and Christine Oliver (Head of Commissioning), both of Nottingham City Council, Dr David Rhinds (Consultant Addiction Psychiatrist), Nottinghamshire Healthcare Trust, and Apollos Clifton-Brown (Clinical Lead for Substance Misuse Services) at Framework, were in attendance to update the Committee on the current position regarding the provision of inpatient detoxification services.

At the November and January meetings of the Committee, members had been informed that the Woodlands Unit, provided by Nottinghamshire Healthcare Trust, was no longer financially viable under current arrangements and was facing closure. Members of the Committee were concerned that if there was no other option than for the unit to close, it was vital that an alternative local NHS-supported provision of the service is secured. 

In January Nottinghamshire Healthcare Trust took the decision not to seek to renew or further extend contracts for specialist inpatient detoxification services run at The Woodlands beyond 31 May 2018.

Whilst the City Council’s contract for the Woodlands Unit has been extended to the end of May 2018 (from March 2018), there is not enough time to undertake a full procurement process. As such, commissioning officers and medical specialists have been working together to identify an interim arrangement. The outcome of which is that Framework, the lead provider of local community drug and alcohol services, has agreed to a 10 month contract to provide inpatient detoxification beds and professional support (including transfer of many staff from Woodlands) at Framework’s recently refurbished drug and alcohol unit at Edwin House in Radford.  Framework has also secured a contract to provide inpatient detoxification services for Leicester, Leicestershire and Rutland.  A full procurement for services in Nottingham will take place during 2018.

The following points were highlighted by Lucy Putland:

a)  it is important to maintain a local inpatient detox service, particularly with the recognised aging cohort of opiate users in and around the City and the complexity of need;

b)  service users and their families were consulted on what they felt was most important to them. Responses included:

c)  timely access from community services;

d)  provision and effective management of male/female accommodation (three quarters of patients are male);

e)  several possible models were considered such as completely decommissioning the service (patients and their families would have to travel out of county to access services), procuring a new service, or purchasing bed space from another provider;

f)  Framework (a charity and housing association dedicated to helping homeless people, preventing homelessness, and promoting opportunities for vulnerable and excluded people), has recently refurbished a former care home and provides drug and alcohol treatment services, so is well positioned to expand their current provision. Commissioners and the NHS are working closely with Framework to ensure everything required is in place and ready for the service transition from Woodlands to Edwin House when the contract starts on 1 June 2018;

g)  the Committee are assured that as patients for whom community detox has not been successful, are usually inpatients for a period of 8-10 days, there is no expectation that inpatients will be moved between sites during their detox.

Apollos Clifton-Brown, Framework’s Clinical Lead for Substance Misuse Services added:

h)  the Care Quality Commission (CQC) registration is in place for patients, appropriate staffing is in place and it is anticipated that the service at Edwin House will be provided much as it was at Woodlands but with minor changes to include:

i)  delivery of pharmacy services which will be audited by NHCT and provided from a community pharmacist, rather than operated on-site;

j)  whilst the staff numbers and cover will remain the same, the required qualifications mix of staff will be different, for example having nurses and an occupational therapist at Edwin House in addition to mental health nurses;

k)  the service will operate under a difference governance structure through the Nottingham Recovery Network governance structure, which will enable improved monitoring of risk and sharing of information with partners;

l)  with community and inpatient services operated by the same provider, this will enable closer working and improved transfers and pre/post planning.

Dr David Rhinds commented that:

m)  there will be medical cover of 2 sessions provided by the Consultant Psychiatrist and 2 trainee doctors at Edwin House, which is the same as at The Woodlands.  Out of Hours provision will be slightly different and be through alliances with GPs;

n)  the approval of the General Medical Council (GMC) is required to engage trainee doctors but as this will be with the intention of retaining those doctors, it is not anticipated that there will be any objection.

Questions from members of the Committee were responded to as follows:

o)  the Framework service will offer facilities to citizens referred by Nottingham City, Leicester City, Leicestershire, Rutland and South Yorkshire Local Authorities but is keen to ensure that patients from Nottingham will need not go elsewhere;

p)  the £99,000 saving on inpatient detoxification services agreed as part of the Council’s budget process will be achieved due to the use of a different business model  and a lower occupational bed day rate. Some staff will be on Framework contracts rather than NHS contracts, which has slightly different terms and conditions. Whilst this may potentially impact on recruitment, it isn’t a problem for current staff working for Framework;

q)  treatment regimes will be the same at Edwin House as at The Woodlands;

r)  consultation was advertised widely across the NHCT and to service users. As white males account for 75% of opiate users in the City, it was to be expected that the majority of consultation responses were from white males, but for a further session next week there has been a focus on engaging Black, Asian, Minority, Ethnic (BAME) responses. The information gathered through consultation will also contribute to the tender process;

s)  with regard to the sustainability of the service provided by Framework, Derby and Derbyshire appear to rarely use inpatient detox services, but they may require services in future. Leicester, Leicestershire and Rutland already commission the service from Framework;

t)  transition of the service will be closely monitored, as will the provision at Edwin House as quality monitoring is a requirement of provision.

Members of the Committee commented as follows:

u)  this positive initial outcome is very much welcomed for service users, citizens of Nottingham and the transferred staff;

v)  all parties should be congratulated for an excellent example of how partnership working can be successful;

w)  further information on the outreach work of Framework would be welcomed, possibly in conjunction with a future update to the Committee.

RESOLVED

(1)  to note that the Committee welcomed the proposals and does not consider the transition of inpatient detoxification services from Woodlands, provided by Nottinghamshire Healthcare Trust, to Edwin House, provided by Framework, as a substantial variation of services;

(2)  for the Committee to determine at a later date whether a review of provision inpatient detoxification services is required.

Caroline Shaw, Chief Operating Officer and Deputy CEO at Nottingham University Hospitals Trust (NUHT), Nikki Pownall, Lead for Urgent and Emergency Care at Nottingham City Clinical Commissioning Group (NCCCG), Greg Cox, Nottinghamshire General Manager and Keith Sharpe Nottinghamshire Ambulance Operations Manager, both from East Midlands Ambulance Service, were in attendance to update the Committee on the extreme and sustained pressures experienced by urgent and emergency care services up to, during and following the Christmas period and well into the New Year.

Whilst a rise in emergency admissions is anticipated during the winter period, this year’s demand on services has been substantially higher, as outlined in the report.

In addition to the report and presentation in the agenda, the following points were highlighted:

a)  the pressure of massive demand on services impacted not only on NUH, but across healthcare services in Nottinghamshire and nationally ;

b)  the Accident and Emergency Delivery Board, consisting of local emergency service managers, meets regularly to ensure a co-ordinated approach, but during the sustained rise in admissions, it met daily to try and arrange appropriate responses to the consistently high demand which is only just now, 3 months later, subsiding; 

c)  the telephone service ‘NHS 111’ received 37% more calls than anticipated;

d)  patients being admitted to hospital were significantly sicker than usual, many with breathing difficulties and there was a higher proportion of older and frailer patients than usual;

e)  30% more GP appointments were made available at weekends and in the evening but this still did not meet demand;

f)  extraordinary actions were taken, including reorganisation of staff within services to help meet demand and the whole of the NHS was told to free-up staff to assist;

g)  nationally NHS England asked all hospitals to consider cancelling outpatient and routine operations to alleviate pressure and locally 410 operations and 640 outpatient appointments were cancelled by NUH;

h)  in addition to increasing hospital admissions, the flu also impacted on staff sickness levels, adding further pressures;

i)  although previously suggested, there wasn’t enough spare capacity in the system to cut bed numbers and an unprecedented 93 additional community beds were temporarily made available alongside 34 additional hospital beds. ;

j)  many staff agreed to work additional shifts;

k)  GPs were based at the front of A&E all day, every day to deal with non-urgent presentations ensuring that A&E staff were free to deal with emergency cases;

l)  the financial impact of this period will be substantial across the Health and Social Care economy. It is estimated that the financial impact to NUHT was in the region of £500,000 per week;

m)  in spite of the pressures, there were no 12 hour trolley breaches, ambulance turn-around times (which have improved significantly during the past year)  were maintained, and feedback on patient experience remained positive;

n)  EMAS  attended an average of an additional1,200 incidents per month in Nottingham compared to the same period last year;

o)  whilst the wider health community plan for a winter peak in demand, there was no way that this level of demand, which is equivalent to responding to a major incident, could have been anticipated;

p)  staff are weary now and unable to sustain additional shifts/overtime, which is recognised by NUHT which is trying to work with and support staff;

q)  the large number of cancelled operations and procedures has resulted in  a cost of approximately £2m and will have a knock-on effect, particularly for those patients affected;

r)  it has been a very challenging few months.

Questions from the Committee were responded to as follows:

s)  initially, when GPs were introduced to the ‘front door’ of A&E, A&E consultants were sceptical but soon realised the value of this additional support, particularly as patients were arriving at A&E from other routes, including the respiratory unit;

t)  it was noticeable that the age of patients is increasing as many patients were presenting in their 90’s and 100’s, with more complex issues;

u)  vaccination of staff against the flu is not mandatory but there was approximately a 65% take-up of the offer. It is now being considered if vaccination should be mandatory in future, although there is an indication that the strain of flu which was most prevalent this year, was not included in the vaccination, so further work needs to be done in this area;

v)  previously the configuration of and admission processes in A&E had been identified as hindering the smooth and timely hand-over of patients. However, following a revision of admission processes, improved staff ownership of roles, along with some physical changes to A&E lay-out to provide more cubicles and staff, patient hand-over time from EMAS to A&E  has improved significantly, along with time saving measures established by EMAS;

w)  Queens Medical Centre Emergency Department is already accepting up to 650 patients in a building designed for 350. A new Emergency Department is needed;

x)  there are clear precautions in place regarding Norovirus and preventing its spread within the Trust’s premises. As soon as any symptoms are identified, the area is closed and thoroughly cleaned. Management is much harder for community beds (in nursing/care homes) which often struggle to attain the cleaning standards required due to the environment being more homely with soft furnishings and often having communal areas which provided further challenges. When patients are discharged from NUH they often still have care needs and it was a struggle to find community beds, but overall nursing homes worked well with the CCG during the period of extreme demand;

y)  there are several areas of learning which will be taken from the experience of the past few months. The new NUHT Chief Executive has stated that the Trust can’t close beds at this time, there will be an examination of admission and discharge turnaround, the future needs of an aging population will be further investigated and consideration will be given to developing a different framework for community beds.

It is noted that the Committee is scheduled to consider flu vaccination and up-take at a future meeting.

Members of the Committee congratulated and expressed their gratitude to NHS staff in all areas that had successfully supported the system during a very difficult and extended period.

RESOLVED

(1)  to note the update and gratefully acknowledge the hard work and dedication of urgent and emergency care staff and partners during a period of exceptionally high demand;

(2)  for consideration of future winter planning for 2018/19 to be added to the Committee’s work programme.

Helen Woodiwiss, Assistant Director of Clinical Services, Kate Whittaker, Head of Patient and Public Involvement, and Jo Powell, Communications, all from Nottingham CityCare Partnership, were in attendance to provide an interim update to the Committee on the progress against current quality improvement priorities, and proposals for CityCare’s quality improvement priorities for 2018/19, with regard to the Quality Account. The final draft Quality Account will be submitted to the Committee in May 2018, for comment.

The Quality Account is a document prepared by health providers to illustrate how they have performed in meeting the quality domains of patient safety, clinical effectiveness and patient experience.

Current priorities for 2017/18 for which the CityCare Partnership will illustrate they have identified areas for improvement and then addressed include:

o  promoting prevention;

o  more integrated seamless care;

o  reducing avoidable harm;

The proposed priorities for 2018/19 are:

o  promoting prevention;

o  reducing avoidable harm;

o  supporting our staff;

o  safe and effective discharge;

The presentation outlined what has been achieved so far:

(i)  in promoting prevention;

(ii)  with more integration;

(iii)  learning from incidents

(iv)  recognition of the deteriorating patient;

(v)  safeguarding;

Also included was a summary of patient and service user feedback on the quality of services with suggestions on what further improvements could be made.

Questions from the Committee were responded to as follows:

a)  with regard to mental health service demand and whether the needs of  patients can be met, the Partnership is working closely with patients and in addition to the current provision for children and young people, the new contract will include a dementia outreach team which is considered important in an aging population;

b)  CityCare regularly considers its aims and outcomes and makes adjustments where they are needed;

c)  the Basic Care Team is very proactive and has Community Matrons to help support work in the community, but work is ongoing with regards preventing the need for hospital admissions from the community;

d)  CityCare is unwilling to discharge patients home unless they are as healthy as possible so, having assessed the patient in hospital, works to a three stage discharge pathway:

·  discharge to their own home;

·  discharge temporarily to community beds, including re-enablement centres like Connect House;

·  discharge to long term care for support of long-term health conditions.

e)  during the recent increased demands on services, an additional 52 community beds were spot-purchased to support hospital discharges.

RESOLVED to note the provisional update and note that the Quality Account will be presented to the Committee in May 2018.

Jane Garrard, Senior Governance Officer, presented the work programme schedule and requested the Committee’s comments and suggestions.

In reference to the previously agreed topic of carer support services, during National Carers Week on 12 June 2018, 4-6pm in the Council House, there will be a Carers Event to which 5-6 members of the Committee are invited to meet with and discuss carer’s perspectives as part of evidence gathering for this review.

RESOLVED that April’s meeting of the Committee should include consideration of:

  i.  progress against the City Council priority of reducing unplanned teenage pregnancy, particularly in wards such as Aspley and Bulwell where rates of unplanned teenage pregnancy have been consistently high over many years;

  ii.  year-end review of the activity of the Portfolio for Adults and Health;

  iii.  update on Nottinghamshire Sustainability and Transformation Partnership and development of a Greater Nottingham Accountable Care System;

4. review of 2017/18 and work programme 2018/19.