Agenda and minutes

To note that Councillor Matt Shannon has replaced Councillor Farzanna Mahmood as a member of the Committee

The Committee noted that Councillor Matt Shannon had replaced Councillor Farzanna Mahmood as a member of the Committee.

None

None

Minutes of the meeting held on 11 July 2024, for confirmation

The Minutes of the meeting held on 11 July 2024 were confirmed as a true record and were signed by the Chair.

Report of the Statutory Scrutiny Officer

Ifti Majid, Chief Executive, Jan Sensier, Executive Director for Partnerships and Strategy, and Dianne Hull, Chief Nurse at the Nottinghamshire Healthcare NHS Foundation Trust (NHT); and Rosa Waddingham, Chief Nurse at the NHS Nottingham and Nottinghamshire Integrated Care Board, presented a report on the delivery of NHT’s Integrated Improvement Plan. The following points were raised:

a)  A rapid ‘Section 48’ review of mental healthcare services was commissioned by the Secretary of State in January 2024 and the initial outcomes of this were published on 26 March, with a second part to the report released on 13 August. Four main areas of focus for improvement emerged from the review, constituting NHT’s discharge processes, risk management, care planning and family engagement. Eight specific recommendations were made to NHT as part of the review, and these have now been built into the overall Integrated Improvement Plan. NHT is now in a period of national oversight, and seven transition criteria have been agreed with NHS England that must be met before this period of monitoring can end. The criteria cover key areas such as organisational culture, finance and safety. Currently, work is underway to achieve an exit date of March 2026.

b)  NHT is now using data differently throughout the organisation. A new approach called ‘safe now’ has been developed, which represents a detailed data dashboard that shows key indicators across inpatient and community services to determine safety. It is used at a service level and concerns can now be raised in a more timely way with the Executive team and the NHT Board. There is a new telephony system in the Crisis Response Team that has improved response times. However, there remains more work to be done in terms of continuing that improvement. There has also been a reduction in waiting times for access to Local Mental Health Teams. Reliance on the use of agency staff has reduced, but this still remains higher than desired, meaning that it can be harder to monitor the quality of care and reduce the length of stay.

c)  There has been a significant change in enhancing the clinical leadership voice and staff engagement. A great deal of work is needed to deliver change sustainably and at pace, without improvement progress plateauing. Many people are staying in inpatient services for longer than is needed, so there is a focus on reducing the length of stay where appropriate. NHT’s Crisis Response Team also has further work to do to ensure that people in crisis can be assessed on a 24/7 basis. Over 700 NHT colleagues have been engaged with across a variety of sessions, with patients, carers, and the independent and voluntary sectors also involved. Nominees have been made for a colleague reference group, which seeks to improve governance arrangements throughout the improvement journey.

d)  Whilst internal assurance is being strengthened, there is also external scrutiny through meetings of the Improvement and Assurance Oversight Group, NHS England’s Regional Executive Team and Care Quality Commission inspections. NHT is moving to data-driven assurance rather than narrative assurance processes, which has been welcomed by partners and those holding NHT to account. NHT accepts the findings of the recent reports and that there have been failings for Nottingham’s communities, so it is focussed on achieving sustainable change and a genuineness in its improvement journey.

The Committee raised the following points in discussion:

e)  The Committee asked how NHT was reaching out to communities to inform them of the identified failings and the improvement journey being done to bring change. It was explained that NHT is waiting on the outcomes of an Independent Homicide Review before conducting wider media interviews, however, there is an upcoming open annual meeting taking place at which these issues are due to be discussed. Wide-ranging engagement with communities has taken place, which has included the holding of some difficult conversations. NHT will continue to seek to develop its community engagement in a proactive way. The Committee noted that NHT should to as much as possible to ensure that its annual open meetings are as accessible as possible in terms of location, venue and time.

f)  The Committee asked how NHT’s annual Quality Accounts would be used to demonstrate the issues and the needed improvements effectively. It was reported that the 2024/25 Quality Accounts will show a very different picture and tone to the 2023/24 document, and there will be active engagement with the Committee as part of the development of its formal written statement. NHT is currently reaching out to communities to gather the full extent of the service impacts so that the upcoming Quality Accounts can be fully reflective of everything that has happened in the organisation.

g)  The Committee asked how more opportunities would be taken to accept reports of poor practice and instigate change. It was explained that many of the issues faced by NHT had arisen from not listening to external feedback, responding defensively to criticism and being internally focussed – which had resulted in missed opportunities to identify failings and make the appropriate improvements. A new Executive team was put in place towards the end of 2022 and has begun to identify the issues and seek to deliver change. The focus has been on achieving rapid improvements to the safety and quality of care, and implementing cultural improvement within NHT.

h)  The Committee asked what mechanisms were in place to ensure that the feedback from the established engagement groups was given proper weight and consideration. It was set out that all comments and issues raised had been recorded and broken down by service area, and had been passed on to programme leads where a formal response had been requested and the appropriate the action taken. The work carried out in response to the input given is then reported back to the various groups within six months.

i)  The Committee asked how the outcomes of improvements in patient experience were monitored. It was explained that NHT’s improvement journey is closely focussed on developing patient experience, particularly for the most vulnerable – with a shift in culture to be more accountable to the communities that NHT serves. The ‘safe now’ dashboard is an example of how patient need is now better understood within the organisation, and that leaders know exactly what is happening within NHT and the impacts on service users. A ‘waiting well’ process is in place as a safeguard for patients waiting for services and it includes a patient tracker, a risk assessment and a safety plan. This process is monitored weekly on the ‘safe now’ dashboard, with processes in place if a patient is at risk of entering crisis.

j)  The Committee asked how staffing issues were being managed and their current impact on services. It was reported that staff turnover was at its lowest level for several years, but that the staffing situation was complex and NHT is currently carrying out a review into services to ascertain not only if staffing levels are appropriate, but also if they contain the right mix of professionals. NHT is also working closely with the local universities to take on newly qualified nurses, a number of which are now starting work.

k)  The Committee asked how NHT supports people who are homeless or rough sleeping. It was set out that a Street Triage Team engages closely with community partners and the Police, and is working in Nottingham to help support people who are homelessness or rough sleeping with mental health needs.

l)  The Committee queried whether the Turning Point Access Line was operating effectively. It was explained that there is a review of the service planned as a significant part of the Improvement Plan. The timescale has not yet been confirmed, but the expectation is that there will be a new model in place and the implementation plan and timeline is being finalised.

m)  The Committee asked what work was being done to support patients after discharge from an in-patient setting. It was clarified that there had been a policy change at NHT, which has a responsibility to seek to engage as effectively as possible with the follow-up needs of discharged patients. No patients are discharged without a face-to-face, multi-disciplinary meeting, and there is a clear process in place as to what conversations should be taking place. Details of these sessions are recorded and audited, and are also uploaded onto the ‘safe now’ dashboard.

n)  The Committee considered that it is vital that NHT listens to complaints and learns from them effectively. It was set out that NHT is currently compiling complaints so they are not reviewed in isolation, and is grouping them together by theme so that they can be used to inform service reviews.

Resolved:

1)  To request that the NHS Nottinghamshire Healthcare NHS Foundation Trust (NHT) feeds back on the outcomes of its staffing establishment reviews, when appropriate, to set out how it will ensure that the right resourcing is in place to deliver services and improvement safely and effectively.

2)  To request that further information is provided on the current performance of the new Turning Point Crisis Line, and the outcomes of its current review as part of the ‘Safe Now’ process.

3)  To request an appropriate stakeholder digest on the outcomes of the ‘Safe Now’ process is provided on a periodic basis, for the purposes of ongoing assurance as to patient safety.

4)  To recommend that NHT implements a clear public voice to patients through accessible communications channels to set out what the failures in services have been and how NHT is now striving to address them.

5)  To recommend that all possible activity is carried out to communicate a clear vision of how outcomes for service users will be improved, and how NHT is working hard to embed a strong culture of openness.

6)  To recommend that NHT reviews the levels of its mental health street outreach provision, to ensure that there is an effective and sustainable degree of coverage on the basis of the current need.

7)  To recommend that NHT considers how information can be shared with communities to demonstrate how services have been improved as a result of information received directly from patients through complaints processes.

Report of the Statutory Scrutiny Officer

Amanda Sullivan, Chief Executive, Maria Principe, Interim Executive Director of Delivery and Operations, Rosa Waddingham, Chief Nurse, and Alex Ball, Director of Communications and Engagement at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB), presented a report on the work underway to achieve financial sustainability in the local NHS. The following points were raised:

a)  The ICB has increased levels of funding this year to sustain the local NHS healthcare system but, due to service pressures, there has been a significant overspend. The ICB has agreed a £100 million overspend with NHS England for 2024/25, but there is a 6% saving in costs that must now be delivered. By the end of 2025/26, the ICB must be in a balanced and sustainable financial position, so a savings programme is being developed that will be phased over a two-year period.

b)  The savings programme is focussed on delivering efficiency savings while minimising the impacts on frontline services wherever possible. The programme will be prioritising schemes that enhance efficiency and productivity, as well as reviewing contractual arrangements and value for money in the services that are currently provided; maximising efficiencies in non-patient-facing areas and enhancing financial controls across the system; ensuring compliance with existing NHS funding policies; deferring some investment in services; and concluding pilot activities where clear benefits have not been identified.

c)  There is an established process to assess the impact on quality and equality of saving plans where services are proposed to be changed or ceased. An impact screening process will be completed for all schemes to identify whether a full Equality Impact Assessment is needed, and the ICB and providers must complete the tool for all proposals that are being considered as part of the financial sustainability proposals across the system.

The Committee raised the following points in discussion:

d)  The Committee asked what the timetable for the implementation of the savings proposals was currently projected to be. It was reported that it is expected that there will be a list of initial proposals that would result in frontline service change produced by the end of October. These will be developed throughout the remainder of this financial year, for implementation during 2025/26. Meanwhile, the work to deliver efficiency savings is currently underway.

e)  The Committee asked how the initial 2024/25 cost savings would be achieved. It was explained that work was being done to drive efficiencies, reduce procurement costs, ensure that proper referrals were made and ensure best value from providers to bring costs down. A great deal of work is being done in this area to deliver best value in a way that does not impact on patient services. A focus of achieving financial sustainability is to ensure the full control of finances in a way that has not been possible since the Coronavirus pandemic. The majority of the savings in the first year will come from cost efficiencies, and national benchmarking data is being used to assess how clinical facilities can be used most efficiently to maximise the impact on reducing waiting lists. However, delivering savings in 2025/26 will be more challenging, and this will have more of an impact on certain frontline services.

f)  The Committee asked what work was being done to ensure the quality of care in private settings – particularly as there was currently high levels of expenditure on private mental health in-patient beds. It was reported that overall mental health spend and investment is protected, though individual services could be affected. Work is underway to ensure that there is proper quality assurance for external provision and, although there are no current plans to commission a dedicated Psychiatric Intensive Care Unit for women, the overall in-patient need is being kept under review. Discharge processes are also being monitored closely to develop a greater level of transfer to local community settings to support healthy and independent lives.

g)  The Committee asked how people would be supported in any changes to the provision of medication. It was set out that individual medication reviews will be carried out to ensure that patients receive what they need at best value, and proper account will be taken of exceptional circumstances. A great deal of work is underway to ensure that there is effective supply of the right medication.

h)  The Committee asked what work was being done to ensure that joint care packages were appropriate. It was reported that work is underway to ensure that care packages are properly benchmarked, in consultation with frontline clinical staff. Engagement is underway with social care partners, including the Council, to ensure appropriate discharge with an effective and proportionate package of care in place.

i)  The Committee asked how the voice of clinical leaders would be used in the development of the proposals. It was explained that many of the savings have been reviewed as part of a wider programme of service transformation and, as part of this process, the experience of clinical leaders has been used to shape the service reviews. Expert clinicians will be involved both in the development of proposals and the following implementation planning.

j)  The Committee asked how the outcomes and impacts of the savings proposals would be monitored, and what learning had been taken from previous service transformation programmes. It was reported that it is vital for the impacts of the proposals to be monitored effectively to assess whether they are achieving the intended outcomes and are not resulting in unintended consequences. An outcomes dashboard is in place and this will be reviewed regularly to actively monitor outcomes and impacts.

k)  The Committee queried how the savings proposals aligned to the aims and objectives of the current Integrated Care Strategy, including the development of prevention activity through the joint Better Care Fund (BCF). It was explained that savings proposed within the BCF would not decrease the current service offer – but would decrease the rate of the BCF’s growth. Currently, the ICB must focus on funding core activity, and will seek to increase investment again in the future once the system’s financial position has stabilised. The ICB will develop its sustainability proposals with regard to the Integrated Care Strategy across a multi-year period, reviewing the position year-on-year.

Resolved:

1)  To request that, when appropriate, the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB) confirms what proposals for service change it will be working to take forward, which proposals it has identified where a full Equality and Quality Impact Assessment will be required, and the target timeline for when these service changes need to be implemented to achieve the required savings.

2)  To request that a general indication is provided as to what extent that the 6% in budget savings for both 2024/25 and 2025/26 could be achieved thorough operational efficiencies, and what proportion will need to be made through service changes that will have a more direct impact on patients.

3)  To recommend that the ICB reviews whether the current commissioning need for inpatient beds is being met effectively (particularly in the context of mental health beds and whether a dedicated, in-area Psychiatric Intensive Care Unit for women is required), given the potential challenges in assuring the quality of care in private settings.

4)  To recommend that the ICB works as closely as possible with its partners in a clear, collaborative space to ensure that the review of joint care packages results in future packages that are appropriate to the needs of the patient, represent best value and are implemented within a timeframe that is sensitive to the needs and circumstances of the patient.

5)  To recommend that the ICB gives full consideration to how the agreed objectives of the Integrated Care Strategy could be delivered within its current timeframe, in the context of the existing financial position, in close engagement with the Nottingham and Nottinghamshire Integrated Care Partnership – particularly in the context of how investment in the Better Care Fund can be both sustained and grown.

To note the responses received to the Committee's recommendations to the Council’s Executive

The Chair presented the latest responses received from the Council’s Executive to recommendations made to it previously by the Committee.

The Committee noted the responses to its recommendations.

Report of the Statutory Scrutiny Officer

The Chair presented the Committee’s current Work Programme for the 2024/25 municipal year.

The Committee noted the Work Programme.