Agenda and minutes

Councillor Saj Ahmed  -  personal reasons

Councillor Eunice Regan  -   personal reasons

Sarah Collis  -  Chair, Healthwatch Nottingham and

Nottinghamshire

In the interests of transparency in relation to item 5 (Mental Health Crisis Services Transformation), Councillor Georgia Power declared a sensitive connection in relation to the Nottinghamshire Healthcare NHS Foundation Trust (NHT), of which NHT has been made aware.

Minutes of the meeting held on 15 February 2024, for confirmation

The Committee confirmed the minutes of the meeting held on 15 February 2024 as a correct record and they were signed by the Chair.

Report of the Statutory Scrutiny Officer

Rose-Marie Lynch and Liz Gundel, Senior Commissioning Manager and Head of Primary Care for the East Midlands at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB); and Dr Pavni Lakhani, Chair of the Nottinghamshire Local Dental Network (LDN), presented a report on the approaches being taken to improve access to NHS dental services. The following points were raised:

a)  In April 2023, responsibility for commissioning NHS dental services moved from NHS England to the ICB. A new governance structure was developed to ensure a smooth transition of services and to enable appropriate decision-making and commissioning functions to be carried out for the local area. To help inform commissioning activity going forward, a full Oral Health Needs Assessment for Nottinghamshire is being developed to better understand the needs of people across the city and this is due to be completed by the end of March.

b)  The collected data shows that, in November 2022, the monthly delivery of dental services to contract in Nottingham was at 86.1%, compared to a national average of 98.8%. This has dipped to 83.6% as of February 2024, compared to a national average of 89.1%. Locally, this fall in performance can be attributed to a number of factors including a reduction in the available workforce, sickness and issues with recruitment. Work is underway to assess the underlying causes to achieve a better understanding of how to increase delivery.

c)  In early February, the NHS and the Department of Health and Social Care launched a joint Dental Recovery Plan, which has three aims:

·  To expand access for patients via the introduction of a new patient premium and an uplift to the Units of Dental Activity (UDA) value. The enhanced UDA value will allow those with the least complex dental needs to go longer between regular check-ups where appropriate and increase the number of appointments available for those requiring active treatment. Those patients with the most complex dental needs will also attract a further uplift to the UDA.

·  To encourage good dental health in children and young people with the launch of the ‘Smile for Life’ campaign, which will be rolled out across all Early Years settings, Family Hubs and outreach projects.

·  To support and develop the dental health workforce to deliver an increase over the medium to long-term. This includes facilitating internationally qualified dentists to practice in the UK and increasing the skillset of all dental health professionals with an aim of providing more than 500 training places by 2031/32.

d)  A number of initiatives aimed at improving access to dental care in Nottingham have been ongoing since November 2022. These include community dental services, dedicated urgent care appointments and work with the most vulnerable groups with mobile vans. Activity is currently underway to fully develop access to dental services by children in care by linking related services together more closely to ensure better access to dental treatment. The ‘Getting it Right First Time’ network enables the sharing of best practice, with a particular focus on achieving recovery following the Coronavirus pandemic.

e)  Consultants in Dental Public Health are carrying out a strategic review to help identify targeted approaches to specific local issues. The decoupling of NHS dentistry commissioning from the Public Sector Procurement Regulations will allow a more flexible and pragmatic approach to competitive tendering for dental services across the city. This, linked with the other work taking place across Nottingham and Nottinghamshire, will help to improve opportunities for practices and access for patients.

The Committee raised the following points in discussion:

f)  The Committee asked how the increase to the UDA value would help to ensure better access. It was explained that, in October 2023, the UDA value was set at £23. The uplift will ensure a minimum UDA value of £28, with an additional premium if a patient has not been seen by a dentist for two or more years, and for patients with a very high level of need. This is intended to incentivise practices to take on new patients, reducing the regularity of routing check-ups where clinically appropriate to free up more time for other appointments. However, these measures aim to incentivise those practices already treating NHS patients, rather than to encourage fully private practices to start taking on NHS patients – which will required additional work.

g)  The Committee queried whether the contract targets established by the ICB were fully deliverable by dental practices. It was set out that there are a number of factors that impact on a practice’s ability to deliver on a contract, with staffing levels and difficulties with recruitment and retention being main reasons. Since the Coronavirus pandemic, there has been a shift in working patterns with more people working less conventional hour, which can make private practice more attractive in terms of wages. working hours and reduced pressures. The national recovery plan is designed to reduce the pressure on NHS practices and make it a more attractive option to dental professionals.

h)  The Committee asked how Nottingham compared to the wider East Midlands region in terms of access to NHS dental services. It was reported that, when compared to Nottingham’s most local neighbours, there is a lower delivery rate that is primarily due to workforce issues, resulting in fewer patients being seen. The ICB is working to understand the reasons behind this lower rate in Nottingham and is looking at commissioning work to offer incentives to practices. Engagement with the LDN is underway to understand what local practices need in terms of commissioning activity to help encourage an uplift in the number of patients that can be seen.

i)  The Committee asked what learning the ICB was accessing at the national level to improve delivery in Nottingham. It was explained that local ICB colleagues are part of both regional and national networks, which enable the collation of best practice and learning from other areas. This has been fed into the work around planning commissioning, alongside the outcomes of the local rapid needs assessment completed during March. Learning from areas with a stronger delivery rate, it is clear that tackling issues around the workforce has been key to achieving better results. Local improvements should become apparent over the next 12 months, but training and workforce development takes time to mature, so it is hoped that there will an improved picture of dental care in Nottingham within three to four years.

j)  The Committee queried how the ICB was responding to the patient backlog resulting from the Coronavirus pandemic. It was report that, during the pandemic, dental practices had been closed, so patients with dental problems were unable to access treatment easily. Many patients became worse and now have complex needs, but there are now fewer dentist trying to treat these greater requirements. This, alongside the national dental contract being less appealing than private practice, has caused a significant backlog of patients. An increased call-back time for routine check-ups, based on clinical need, has been introduced to help alleviate the pressure on practices, as has the reform of the national dental contract. Pathways to meet urgent clinical need are in place, including the availability of high needs premiums.

k)  The Committee asked what support was available to practises with staff wanting more flexible or part-time working hours. It was set out that specific working arrangements are a matter for a given practice and its employees. However, engagement is being carried out with practices on how viable contract targets can be set and delivered, alongside growing workforce plans to enhance training and professional development.

l)  The Committee asked whether the ICB liaised with the Council during its commissioning processes to establish where areas of future population growth would be, to ensure that the future clinical need can be met effectively. It was explained that this can be included as part of a place-based commissioning process to help future-proof services and ensure that practices are located where they are easily accessible to citizens.

The Chair thanked the representatives of the ICB and the LDN 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 conclusions of the Oral Health Needs Assessment for Nottinghamshire following its completion during March 2024, in the context of the specific local needs for access to dentistry identified within Nottingham that will be used to inform the commissioning and procurement planning to improve patient outcomes, going forward.

2)  To request that that information is provided, when available, on the outcomes of the review into the opportunities for flexible commissioning within primary care dentistry once it has been completed towards the end of 2024, to explore how additional dental access could be commissioned in this way.

3)  To recommend that an indicative timeline is established for the planned recovery of access to NHS dental services, with indicators to show what progress towards recovery looks like and how it has been measured, and what current recovery initiatives have achieved to date.

4)  To recommend that the NHS Nottingham and Nottinghamshire Integrated Care Board engages with the Council in its role as a Local Planning Authority to consider where new housing is being developed in Nottingham, as part of informing dental service commissioning and procurement planning in the context of where future population growth within the city is projected to be.

5)  To recommend that consideration is given to whether there is the potential or capacity for more dentists to be trained in the local area.

Report of the Statutory Scrutiny Officer

Paula Vaughan, Benjamin Lomas and Jan Sensier, Director of the Mental Health Care Group, Consultant Psychiatrist and Executive Director for Partnerships and Strategy at the Nottinghamshire Healthcare NHS Foundation Trust (NHT); and Lucy Anderson and Kate Burley, Head of Mental Health Commissioning, Contracting and Performance and Deputy Head of Mental Health Commissioning at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB), presented a report on the mental health crisis service offer to Nottingham residents. The following points were raised:

a)  When the Mental Health Crisis Team was initially established it had a fairly narrow scope, but has since been expanded to work with people with a wide range of support needs. Since 2015, there have been a number of changes and developments that have improved the service, and there are now more staff in place – including a wider range of professionals such as psychologists and social workers working alongside psychiatrists.

b)  Since the service redesign, Crisis Resolution and Home Treatment Teams are in place, along with a short-term residential Crisis House and Crisis Sanctuaries to provide safe spaces across the city. There are also mental health crisis professionals working within the East Midlands Ambulance Service and with street teams to improve triage. However, further improvement work is still being carried out in relation to improving access, the safety and quality of care, and using effective co-production to inform service planning and delivery.

c)  In 2019 the NHS Long Term-Plan for mental health was published, setting out the requirements for services with ambitious targets for provision. Mental health crisis services have been redesigned to include hospital liaison, crisis resolution in the home for face-to-face assessments, 24-hour helplines, 24-hour text support, a 5-bed crisis residential home and crisis sanctuaries. Progress has been made in the transformation of local services, with 11 of the 19 identified areas of improvement against the Core Fidelity Standards having been addressed. However, demand for services is growing, creating a more challenging operating environment with increasing pressure on budgets and resources. Focuses for additional improvement include further joint work with partners to understand the changes in emotional need through different communities, co-production of services and service delivery, and improving links with different services through the health care system.

The Committee raised the following points in discussion:

d)  The Committee asked what the current waiting times to access mental health services were, and what support was available for those people waiting for assessment. It was reported that the current waiting times for crisis support were around one hour, but a response within the the four-hour standard for patients requiring emergency face-to-face support is only being achieved in 80% of cases, so there is a strong focus on driving improvement here. People are contacted regularly as part of a ‘wating well’ process, but appropriate checking and signposting measures need to be developed further.

e)  The Committee asked how a mental health ‘crisis’ was defined in terms of providing the right service response. It was explained that the clinical definition of crisis could be very narrow and relate to the most extreme presentations of certain conditions, but now encompasses a much wider range of mental health needs. Interpretation of what level of needs represents a mental health crisis can be subjective and vary from practitioner to practitioner. The team tends to work with those people who would otherwise be admitted to hospital, but also engages with people who are potentially not in crisis currently – but are likely to become so (and be admitted to hospital as a result) if action is not taken. Around 80% of the referrals to crisis services are taken on by the team, but when a person self-refers and is not considered to be in crisis, the team will provide support in finding and accessing the right service for their needs. The challenges in this area are significant, as calls to the crisis line have doubled in the last 12 months. Ultimately, it is important that a range of services are joined up and focused on meeting individual need in the most appropriate service area.

f)  The Committee asked how NHT has learned from other providers and how examples of best practice are applied. It was set out that, although each provider across the country delivers mental health support services differently as required by their communities, there are still opportunities to use examples of best practice and apply them to Nottingham with local adaptations. These include using a ‘hub’-type support service, clinical assessment processes and models to maximise team capacity. Team members are part of the East Midlands Best Practice Forum and there are regular discussions around improvement. Within the existing team, the staffing has been relatively stable and, with the recent addition of phycological services, the support offer is well-rounded with new, alternative pathways for support available to service users.

g)  The Committee queried how effective the Nottinghamshire Mental Health Crisis and Turning Point telephone helplines were in terms of timeliness of access and response. It was explained that the current helpline is being entirely revamped and a new system is being introduced that will be far more user-friendly. The operators answering the calls will have access to clinical staff for timely triage, if necessary. The system will give regular updates to those people on hold detailing where in the queue they are and will provide the services with far more complete data around calls. This will allow additional activity to take place to optimise staffing for busiest times. Work can then take place to track outcomes for service users.

h)  The Committee asked how rising demand for services was being addressed in the context of the backlog created by the Coronavirus pandemic, and how parity of access to services was ensured across NHT’s whole area. It was explained that open, face-to-face support sessions are being introduced and work is underway to expand the use of Social Prescribing to offer support to people in need. However, managing and meeting demand continues to be extremely challenging in the current environment. Transformation to services has been rolled out across Nottingham and Nottinghamshire areas on a phased basis, and work is being carried out to ensure equity of access – which will be supported by the launch of the new telephone helpline system.

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 information is provided, when available, on the performance of the new combined Mental Health Clinical Access Line once it has been launched during March 2024, particularly in terms of whether it has improved ease of access, reduced waiting times for assessment and care, and achieved better outcomes for people presenting for support.

2)  To request that assurance is provided that there is equity in mental health service provision and resourcing for residents of both Nottingham and Nottinghamshire, relative to their respective levels of population and service demand.

3)  To request that information is provided on how provision within Family Hubs (Sure Start) has affected the levels of demand for adult mental health services.

4)  To recommend that full consideration is given to developing a whole-system approach to the provision of joined-up mental health services, to ensure that a person presenting at any point within the wider system is supported in accessing the help that they need through the most appropriate pathway.

5)  To recommend that full consideration is given to how to achieve an overall approach that ensures that a person presenting to one service in the system is not directed to another service simply to then be directed on again (which could result in a person in crisis being inadvertently excluded from the system as a whole), and that there is connectivity between different services in delivering the right support centred around the specific needs of the individual.

6)  To recommend that the Nottinghamshire Healthcare NHS Foundation Trust works as closely as possible with other partners both regionally and nationally to generate and apply learning in a systematic and planned way to improve the delivery of effective mental health crisis services for people in Nottingham and improve their care outcomes.

Report of the Statutory Scrutiny Officer

The Chair presented the Committee’s current Work Programme. The following points

were discussed:

a)  In April, at its final meeting of the current municipal year, the Committee is scheduled to review the outcomes of the recent Care Quality Commission assessments of mental health services provided by the Nottinghamshire Healthcare NHS Foundation Trust, and to consider the work being done to reduce ambulance waiting times in the city.

The Committee noted the work programme.