Agenda for Health and Adult Social Care Scrutiny Committee on Thursday, 22nd February, 2018, 1.30 pm

Agenda and minutes

Venue: Ground Floor Committee Room - Loxley House, Station Street, Nottingham, NG2 3NG. View directions

Contact: Jane Garrard  Senior Governance Officer

Items
No. Item

55.

Apologies for absence

Minutes:

Councillor Brian Parbutt – personal

Councillor Chris Tansley - for lateness

56.

Declarations of interest

Minutes:

None.

57.

Minutes pdf icon PDF 250 KB

To confirm the minutes of the meeting held on 18 January 2018

Minutes:

The minutes of the meeting held on 18 January 2018 were confirmed as a true record and signed by the Chair.

58.

Suicide Prevention pdf icon PDF 110 KB

Additional documents:

Minutes:

Following recommendations from the Parliamentary Health Select Committee, the Health Scrutiny Committee decided to review the implementation of Nottingham Suicide Prevention Plan, including how partners are working together to ensure its effectiveness in reducing suicide by Nottingham City citizens.

 

Information about the Nottingham and Nottinghamshire Suicide Prevention Action Plan and local progress against the Health Select Committee’s report recommendations was provided for the Committee’s consideration.

 

Members of the Suicide Prevention Steering Group, including, Jane Bethea (Consultant in Public Health), Nick Romilly (Insight Specialist, Public Health), Ian Ridley (the Samaritans), and Pamela Dowson (Nottinghamshire Police) and Adrienne Grove (Harmless) were in attendance to present the report and respond to the Committee’s questions.

 

Whilst the report is thorough and detailed, the following points were highlighted:

 

(i)  suicide is a preventable death which nationally affects approximately 48,000 people per year, including friends and family of the person who committed suicide and those who may have witnessed or responded to the suicide;

 

(ii)  the highest risk group of the population is males aged between 35 and 69 years old;

 

(iii)  the number of suicides in Nottingham City and Nottinghamshire per year is low at between 23-25 per year, which is in line with the national trend, but still considered too many;

 

(iv)  the Local Suicide Strategy is in line with the National Suicide Strategy but an understanding of local patterns of suicide is needed to enable an effective preventative response. The Public Health Team works closely with the Coroner and does in-depth analysis to consider which therapies work and if they are available to those in need;

 

(v)  regional data is gathered to try and identify clusters and patterns of suicide. It is recognised that people affected by suicide are themselves at risk of suicide;

 

(vi)  ‘Harmless’ is a user led organisation working with those affected by self-harm (a potential indicator for suicide) and their families, and runs the suicide prevention programme ‘The Tomorrow Project’. Harmless also works with other partner organisations including the Samaritans and the Police;

 

(vii)  how the media report suicide is very important. A good relationship with local and national media has been established and suicides are now often more sensitively reported as ‘incidents’;

 

(viii)  the funding period for suicide prevention training of frontline staff, provided by Harmless, has now come to an end.

 

(ix)  with current financial restrictions, there is concern as to the level of future funding available to support suicide prevention in Nottingham City and the escalation of risks which may occur if future adequate funding is not available, as set out within the report. These are summarised as:

 

1.  as suicide numbers are low in the City, a small change in suicide numbers can result in what appears to be a significant increase when viewed over a short time period;

2.  there is currently no commissioned suicide prevention training for the adult workforce since the contract expired and has not been renewed due to funding uncertainties;

3.  it remains unclear nationally how 5 Year Forward View funding for Mental Health and suicide prevention will be allocated to local areas and who will be responsible/lead for the commissioning of any service;

4.  support for those bereaved by suicide is an integral part of suicide prevention. There is no specific commissioning arrangement locally that is addressing this issue;

5.  funding for Harmless’ Tomorrow Project currently provides support to those bereaved by suicide but independent funding is required beyond March 2018.

(x)  The Samaritans offer non-judgemental support on the telephone and welcome anyone to talk to them. In addition to the telephone service, the Samaritans are also recruiting  and training prison listeners amongst inmates to provide peer support;

 

(xi)  HealthWatch welcome the suicide prevention and suicide bereavement support available, but highlight that the current system does not cater for citizens with chaotic lifestyles and often operates with waiting lists for intervention services. This needs to be addressed.

 

Committee members’ questions were responded to as follows:

 

(a)  there is a varied experience for self-harm patients presenting at accident and emergency departments. Where self-harm is suspected, the patient should undergo psychiatric assessment but this doesn’t always happen. This is being looked at with partners at a local level and work is ongoing to understand self-harm patients’ experiences. One significant concern is that patients can only be registered for health care at one address, therefore, if they move home (including students), there may be a period without support and/or treatment until they attend an initial appointment;

 

(b)  influence on Ministers by local councillors and the Health Scrutiny Committee would be welcomed with regard to ensuring that there is transparency of how much and to whom funding from Central Government (5 Year Forward View for Mental Health) will be distributed;

 

(c)  ‘The Tomorrow Project’ is unique and, so far, has been largely funded via academic routes but longer term future funding needs to be considered to ensure that work can continue and progress;

 

(d)  ‘The Tomorrow Project’ provides two pathways of support for bereavement and crisis. Initially there were very few bereavement support referrals from the Police and Coroner, but strengthened partnership working has meant that project workers are routinely informed of the details of the person who has committed suicide and their next of kin, which enables support to be offered at crucial point. Where suicide crisis occurs, ‘The Tomorrow Project’ is able to offer short-term preventative support of up to 12 sessions until the crisis is alleviated and then external help and support is sought for the longer term;

 

(e)  suicides within the City average at 23 per year. With small numbers it is difficult to gauge if any particular local ethnic group is at a higher risk unless considered over a longer period. However men with a black African background tend to be more highly represented amongst those with mental health issues. Suicide is significantly higher in men than women. The way in which suicide is recorded obviously impacts on the figures, so that there is potential that not all suicides are initially apparent;

 

(f)  statistics are collected at local and national levels and tracked, but if there were less than five individuals in any group, including ethnicity, the information cannot be publicly released as it may be possible to identify individuals within that group;

 

(g)  Nottingham City has four providers of psychological therapies with approximately two weeks waiting time to access services. Timely provision of crisis care is a national concern and methods of improvement are continuously being sought. Where someone in bereavement is referred to The Tomorrow Project, they are usually seen straight way (within 72 hours of notification), but if someone is in crisis they are usually seen immediately, including through outreach work, meaning that a waiting list does not exist;

 

(h)  the Samaritans advertise for volunteers to come forward and if they successfully meet the stringent criteria, they receive training. The Samaritans are available to call 24 hours a day;

 

(i)  drugs and alcohol are significant issues and whilst some information may be shared with partners, it is not appropriate for services to make referrals for support in these areas;

 

(j)  we can all encourage people to talk openly about mental health. We need to encourage a cultural shift in the perception of mental health.

 

Members welcomed the report and acknowledged the valuable work taking place in Nottingham, including ‘The Tomorrow Project’ but noted the increasing gap between primary and secondary care (with patients deemed to have issues too complex for primary care and not severe enough for secondary care), and expressed concern that waiting times to access some secondary care services can be lengthy.

 

In addition, there is concern at the general lack of awareness of the suicide prevention and suicide bereavement services available and that this needs to be addressed within the refreshed strategy, including consideration of information being available in other languages.

 

RESOLVED

 

(1)  to note the risks relating to suicide prevention training and bereavement support, as outlined in the report;

(2)  to note that the ‘Local Suicide Prevention Partnership’ is developing the strategy and action plan in line with the national strategy - placing a particular emphasis on self-harm as it is one of the greatest predictors of suicide risk;

(3)  to review progress in addressing identified risk areas and development of the draft refreshed Suicide Prevention Strategy and Action Plan in winter 2018;

(4)  to incorporate review of implementation of the Suicide Prevention Strategy and Action Plan in the Committee’s future work programmes;

(5)  to note that suicide and self-harm in prisons is a major issue and that partnership work is taking place to look at ways to understand the issues and minimise risk (with a specific project looking at risk factors to be developed by Public Health and Public Health England to begin in March 2018);

(6)  recommend that information about suicide prevention and suicide bereavement services is provided to all councillors to support them in their ward role.

59.

General Practice Services in Nottingham pdf icon PDF 110 KB

Additional documents:

Minutes:

Fiona Warren, Commissioning Manager for Primary Care, Greater Nottingham Clinical Commissioning Groups (CCG), and Alistair McLachlan, Corporate Medical Lead for the CCG, were in attendance to respond to:

 

1.  the Committee’s concerns regarding access to and quality of GP practices within the City;

 

2.  to contribute to the annual review of City GP services by the Committee;

 

3.  request for information about current and forthcoming changes to GP services

 

The following points were highlighted:

 

(i)  there are 54 GP practices within the City, catering for a population of nearly 380,000 registered citizens;

 

(ii)  to prevent duplication of work, Nottingham City CCG is working jointly  with Nottingham North and East CCG, Nottingham West CCG and Rushcliffe CCG as the ‘Greater Nottingham CCGs’ to undertake a GP review to identify common approaches which will increase resilience and sustainability of primary care;

 

(iii)  access to GPs is a growing issue nationally and as a result NHS England is funding Nottingham City CCG to provide the equivalent of 700 additional appointments at weekends and in the evening, to try and improve patient access and outcomes (known as GP+). The Nottingham City General Practice Alliance will provide these appointments from a central hub on Upper Parliament Street. Appointments will be available through patients’ GP practices, all 54 of which will promote the service which will launch in March 2018;

 

(iv)  the report outlines primary care commissioning changes including list closures (for new patients), practice boundary changes, providers serving notice on the contract, mergers with neighbouring surgeries and the potential closure of surgeries;

 

(v)  the CCG’s Primary Care Performance And Quality Steering Group oversees the performance and quality monitoring of primary care services. In addition, all of the GP practices have been inspected by the Care Quality Commission (CQC) – at their last inspection4 were rated as ‘outstanding’ and 39 were rated as ‘good’. Since the CCG issued draft ratings of ‘requires improvement’ for 5 practices and ‘inadequate’ ratings for a further 5 practices, there have been significant improvements to all of these practices and some are awaiting reinspection based on these improvements. Some areas where practices have been supported to improve include the availability and take up of online services, and upskilling staff to help direct patients to the right services to help reduce pressure on GPs;

 

(vi)  attracting and retaining workforce is a national problem, particularly retaining GPs within practices. International recruitment is difficult but being pursued, as it is predicted that a further 16 to 20 GPs will soon be required in Nottingham as several GPs near retirement;

 

(vii)  local and national estate challenges are apparent, particularly with regard to the premises where NHS Property Services is the landlord as some rent levels have increased significantly to market rents.  Nottingham CCG want to try and negotiate a fair proportion at the level of charges;

 

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

 

(a)  with regard to the practice list size, the list size reflects the actual headcount of patients registered, the weighted list size is the result of a national formula which takes into consideration age, deprivation and a number of other factors of citizens within a practice catchment area;

 

(b)  within some areas of the City, such as Hyson Green, the list size did not reflect the necessity of additional work such as double appointments due to translation needs. Hence the weighted list calculation ensures a fairer distribution of funding;

 

(c)  previously there were between 5-10% missed appointments. Since all GP surgeries now have facilities to text patients to remind them of their appointment and offer them the opportunity to cancel it in time for the appointment been allocated elsewhere, the numbers of missed appointments have reduced significantly;

 

(d)  the ‘Friends and Family Test’ is not the best test of patient experience and feedback.

 

The Chair acknowledged the challenges associated with a population of high deprivation and welcomed the work of NHS Nottingham City CCG to try and improve the quality of, and access to General Practice Services in the City.

 

RESOLVED to note the update and thank Fiona Warren and Alistair McLachlan for their presentation and attendance.

60.

Health Scrutiny Committee Work Programme 2017/18 pdf icon PDF 108 KB

Additional documents:

Minutes:

Following a short comfort break, the Committee reconvened.

 

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

 

Study groups were being established to consider provider Quality Accounts.  The Study Group looking at the Nottinghamshire Healthcare Trust Quality Account will now take place on 18 March 2018 at 10am with Councillors Williams, Bryan, Campbell and Morris.

 

Additional potential issues for the work programme suggested by members of the Committee included:

 

(a)  access to the Trauma Centre on Gregory Boulevard.  Councillors had heard that there is a practice of closing the patient list and only opening it only when vacancies occur, which results in an absence of a waiting list to access services;

 

(b)  clarification on cataract treatment in that it has been suggested that funding may only available for one eye when both may need treating;

 

(c)  the lack of co-ordination between primary and secondary care services, particularly around mental health, with patients having too complex issues for primary care but not severe enough to access secondary care services leaving issues unresolved.

 

RESOLVED for the following topics to be considered at the March meeting:

 

(i)  Nottingham Treatment Centre procurement process and plans for mobilisation of the new contract;

 

(ii)  Response to pressures on urgent and emergency care services in the post-Christmas period and following recent bad weather and lessons learned;

 

(iii)  Inpatient Detoxification Services;

 

(iv)  Nottingham CityCare Partnership Quality Account 2017/18;

 

(v)  Work Programme 2017/18.

 

61.

Process for dealing with substantial variations and developments to health services pdf icon PDF 109 KB

Additional documents:

Minutes:

Jane Garrard, Senior Governance Officer, presented the report which, following concerns expressed by the Committee and commissioners, details the agreed process for identifying and dealing with substantial variations or developments in health services, as is the role of the Health Scrutiny Committee.

 

It was noted that in creating the document, Nottingham City Scrutiny Officers liaised with the Nottinghamshire County Council Scrutiny Team to ensure consistency in approach, particularly as commissioners may be engaging with both local authorities on a service change.

 

RESOLVED to note the process for dealing with substantial variations or developments to health services.

 

62.

Public Health Budget Proposals pdf icon PDF 112 KB

Additional documents:

Minutes:

Councillor David Mellen, Portfolio Holder for Early Intervention and Early Years, Alison Challenger, Director of Public Health, and Councillor Nick McDonald, Portfolio Holder for Adults and Health, were in attendance to inform the Committee of the proposals for Targeted Intervention within the Council’s budget.

 

A presentation was delivered at the meeting and circulated with the initial publication of the minutes.

 

It was noted that due to financial restraints, Central Government require Nottingham City Council to make savings across the Authority of £27m by 2020 to reflect the reducing funding from Central Government. As a result, very careful consideration has been given to the statutory and non-statutory services provided by the City Council and a dedicated Intervention Team has worked closely with Councillors, partners and senior managers to soften the impact of the required reduction in funding. However, subject to the outcome of public consultations, difficult recommendations are being made to full Council on Monday 5 March 2018 regarding the budget proposals.

 

The proposals have not been made lightly and alternative models and approaches have been considered but it is vital that core services remain sustainable. It is acknowledged that if the proposals are approved by full Council, there will be a detrimental impact on the health promotion, prevention and treatment services available to citizens.

 

As outlined within the presentation, significant budget reductions of nearly £5.3m are required:

 

 

17/18 budget (£m)

Targeted Intervention

Proposed saving

% reduction

Targeted Intervention proposals are in addition to proposals put forward in Phase 1 of the budget.

In some cases proposals affect the same services.

The final column on the right shows the cumulative impact of both phases of proposal.

Phase 1 proposed saving

Total % reduction

Healthy Lifestyles

1.410

0.949*

67%

0.200

85%

Sexual Health

4.376

0.413

9%

0

9%

Children’s

11.009

0.382

3%

1.309

15%

Drugs & Alcohol

7.852

1.442

18%

0.144

20%

Staffing & Support

2.296

0.459

20%

0.077

23%

Other Services

1.394

0.850

61%

0.100

68%

Reinvestment Monies

7.07

0.634

9%

0.051

10%

£5.13**

£1.88

* Additional £115,000 saving in 18/19 only **Total of £5.29m for 18/19 with non-recurrent healthy lifestyles saving (£115k) and £50k from community protection (to replace DV proposal) 

 

The presentation provides further details within each of the above categories as to which services will be specifically impacted or withdrawn, and whilst it is anticipated that external organisations may step in to fund or facilitate continuation of some services, it is appreciated that funding for all public sector and many voluntary sector organisations is restricted.

 

The Committee’s questions were responded to as follows:

 

(a)  it is distressing that this process is dismantling a health structure which has been built over many years, but there are no other options due to the funding reductions.  A sustainable financial position needs to be established;

 

(b)  although Central Government is proposing to increase adult social care funding, the anticipated rise will still not meet the actual need of citizens. Cutting preventative work is not efficient but prevention is not a front line service, which are more difficult to reduce initially. An integrated adult social care model is essential for sustainability;

 

(c)  citizens will be impacted by not being able to access services which have previously been available and many may present directly to hospital which could have a significant impact on local NHS resources;

 

(d)  although other health care providers may not be able to take on provision of the services which will be impacted by these proposals, they will be able to provide sign-posting for patients to appropriate alternative support. This mitigation approach has been discussed with the CCG;

 

(e)  this is a dynamic consultation and the feedback from the consultation process will be carefully considered with tweaks to the proposals likely as a result. It is recognised that, within the proposals, Public Health is working to make sure it meets statutory requirements;

 

(f)  Nottingham is still, and will remain, an ‘early intervention City’ as many aspects of early intervention will remain but if approved, the proposals will have an impact on this. It is more beneficial to citizens and financially efficient to prevent issues before they arise but the sustainable funding is not available to support this;

 

(g)  there are still 18 Children’s Centres across the City and Family Support workers are still in place to help prevent crisis, but, at a broader level, alternative funding options will be required to sustain Nottingham as an ‘early intervention City’ including helping people to support themselves;

 

(h)  Nottingham has one of the worst oral health records in the country, and the decommissioning of the oral health service will have an impact but other prevention routes need to be considered such as oral health promotion by school nurses. Nottingham does have an adequate number of dentists in the City but there needs to be a better understanding of why citizens don’t take their children to the dentist, especially as there are no direct cost implications. The City Council needs to use its existing channels to promote good oral health and possibly encourage local dentists to engage with the City’s primary schools. Oral health promotion won’t stop but creative thinking will be required to ensure its continuation. One option would be to allow fluoride in the water system but there are challenges in doing this;

 

(i)  Public health funding only contributes towards part of a specialist midwifery post so that post will still exist;

 

(j)  it has been difficult to recruit school nurses to some areas of the City and vacancies remain. Public health will work with Children’s Centres workers and may further consider alternative, more flexible models including moving to engaging nurses qualified to work with 0-19 years olds and carefully consider exactly what is required from school nurses;

 

(k)  Crucial public health services need to be protected along with some developmental work, but the proposals don’t necessarily mean that services will disappear; some will continue but operate differently or be supported by partners. A comprehensive approach is required which works towards collaboration across partners;

 

(l)  across all partners there is good local provision for refugees and asylum seekers so it is not anticipated that the proposed 10% reduction in City Council funding will have a significant impact.

 

Members of the Committee commented:

 

(m)  there is an indication that discussions are taking place with the NHS and other providers to encourage them to pick up some of the services which Public Health can no longer provide. However there is concern that there are no guarantees that these negotiations will be successful;

 

(n)  it’s a concern that whilst service users and other stakeholders are asked to engage with the consultation process, the consultation closes on the same day as full Council is expected to make its final decision;

 

(o)  if Public Health is not commissioning services directly, then it cannot expect to have control of those services and therefore there will be an important role for health scrutiny is reviewing and scrutinising health service commissioning and delivery;

 

(p)  it is difficult for the Committee to scrutinise the proposals in their current form as, in many cases, there are no concrete proposals for future commissioning and provision at this time, but there is a lot of concern that where services are decommissioned, other providers will not pick them up and services will be lost.

 

Martin Gawith of HealthWatch Nottingham commented that the adults and health budget appeared to have been disproportionately impacted by the Council’s funding reductions and that this was disappointing following the valuable work already undertaken to improve citizen’s life expectancy and quality of life.

 

RESOLVED

 

(1)  to note the presentation;

 

(2)  record concern about the current position which has arisen as a result of cuts to Central Government funding and the potential impact on service users and service user outcomes;

 

(3)  for the Director of Public Health to ensure that the Committee is informed of any confirmation of proposals or variation on what has been proposed, with further details provided as they become available;

 

(4)  to identify several specific service areas affected by the Targeted Intervention budget proposals for the Committee to follow through in terms of implementation and impact.