Agenda and minutes

Councillor Chris Tansley – work commitments

None.

To confirm the minutes of the meeting held on 30 June 2016

Subject to changing the reason for Councillor Ginny Klein’s absence to “unwell”, the minutes of the meeting held on 30 June 2016 were agreed and signed by the Chair.

Report of the Corporate Director for Resilience

Councillor Alex Norris, Portfolio Holder for Adults and Health, presented an update on his portfolio to the Committee, highlighting the following points:

(a)  at the last update to the Health Scrutiny Committee in 2015, 6 priorities were identified under the Adults and Health portfolio. These were:

·  Delivery of the Better Care Fund – this is a pooled budget to be spent on schemes and plans that integrate health and social care services, and these have started to be implemented in Nottingham.

·  Delivery of the Care Act Wave 2 – the government has not introduced wave 2 of the Care Act.

·  Looking After Each Other – support for this project continues to be a major theme. There is some wider work taking place around self-help, looking after each other, early interventions, and creating social networks before isolation sets in to reduce support needs in later life.

·  Health and Wellbeing Strategy 2 – it is hoped this will be agreed soon, it is currently being circulated. It is one of the most extensive consultations that has taken place for a health document in Nottingham.

·  E-cigarettes – there is a split in scientific opinion as to whether e-cigarettes are beneficial or harmful. The scientific consensus is moving more towards e-cigarettes having health benefits by helping people to stop smoking conventional cigarettes, and playing a part in helping to reduce smoking rates.

(b)  the manifesto pledges (now part of the Council Plan) for the Adults aspects of his portfolio are progressing as follows:

·  Integrate health and social care – the Council is delivering on an integration agenda, with a number of schemes to help the Council work more closely with the health partners. It is a good start, but there is growing evidence that a fully integrated health and social care system is needed. Integration should lead to improved outcomes and services that are more financially sustainable. There are national requirements to produce a Sustainability and Transformation Plan (STP) and the City Council is working with partners on development of a STP for Nottinghamshire minus Bassetlaw.  Although it is intended to be a joint plan between health and local authorities, it has a strong health focus and it will be important to ensure that risks relevant to the City Council are addressed.

·  Paying the Living Wage across all health contracts – the City Council is committed to paying the Living Wage (as set by the Living Wage Foundation) across all health contracts. It is currently paid on all except care contracts. The aim is to roll it out fully by 2019, but ideally sooner. Money has been found for the first step, which is to meet the National Living Wage as set by government. The next step will be to meet the rate paid by Nottinghamshire County (around £1 per hour more than is currently paid by the City Council), with the final step being to meet the Living Wage. This should help to recruit and retain quality care staff.

·  Extend Telecare and Telehealth – Telecare and Telehealth have been a really big success story for Nottingham. The Council has pledged to have 6,000 more people looked after in this way because it increases confidence, independence and wellbeing. There have been 2,000 more new users already in the first year.

·  Sign up to the Older Persons Charter - Older persons advocacy groups were listened to in writing the pledges for the manifesto, and the charter is now progressing. Age Friendly Nottingham have also been involved in the planning process for the new Broadmarsh Centre, and the "Take a seat" campaign (where shops make seats available for shoppers to have a rest) has been launched.

(c)  the manifesto pledges (now part of the Council Plan) for the Health aspects of his portfolio are progressing as follows:

·  Teen pregnancy reduction – the reduction targets are on track to be met, but prevention work needs to continue. New and emerging communities may have different social norms regarding teenage pregnancy, so they may become a greater focus for work.

·  Smoke free events - Splendour and the Nottingham Beach will be smoke free, as will the Winter Wonderland. There has been great success in making the city parks smoke free. If smoking is banned everywhere it will lose hearts and minds, but if limits are placed where citizens want smoking limited, there will be greater success. It is also key to break the link between generations, for example 99% of early starter smokers come from smoking households.

·  Promote high quality sex and relationship education (SRE) in schools – whilst the City Council is not performing very well feel on this objective, it is very difficult to do so, as the classes are not compulsory, and there is a wide range of ways to impart this knowledge. An SRE Charter has been developed, which so far 25 schools have signed up to. Though this objective is difficult, it is one that the City Council is committed to.

·  Reduce smoking in pregnancy by a third – the rates currently stand at just over 18%, whereas they should be at 17% to be on target. There is an effective system in place: mums-to-be are breath tested at medical appointments, and those who are found to be still smoking are referred to New Leaf on an opt-out basis. However this approach does not appear to always be implemented.  It is anticipated that if the policy is applied appropriately and consistently, then this target will likely be met.

·  Protect Drug and Alcohol services from cuts – drug and alcohol prevention costs take up a large proportion of the public health budget. However, services have been very successful, with the second best completion rate for treatment programmes of the big cities.  The service has recently been recommissioned.

(d)  the current priorities for the Adults aspects of his Portfolio are as follows:

·  Integrate health and social care – (covered elsewhere).

·  Create an internal services / providers market – The care market is a challenging environment and the City Council is often required to work with private sector providers who are failing. Providers for general care needs services are plentiful, due to the potential profit margins, but more expensive care services such as supporting adults with learning difficulties aren't as plentiful, and people sometimes have to be placed outside of Nottingham. Providers also have a problem recruiting and retaining staff for home care, as it involves a lot of travel, can be difficult work, and it is not well paid (the wage is comparable with waiting staff at chain restaurants). This can result in citizens waiting to receive care packages.  Key factors affecting recruitment and retention are pay, terms and conditions and training.  Internal services across the board are rated as good, and have been made as efficient as possible so that the hourly rate is as competitive as possible with private providers. Internal provision is currently small but important because it encourages higher standards in the market.  There is potential for it to be increased, not only to respond to failures of private providers, but also potentially to provide an ongoing City Council home care service.

·  Adult Safeguarding Board – there has been a Joint Adults and Children Safeguarding Board for a number of years. However because of the recent and ongoing pressures to focus on children’s safeguarding issues it has been difficult to place sufficient emphasis on issues affecting adults. For children everything is considered to be a risk until it's proven not to be, whereas for adults everything is considered safe until a risk occurs. The adults safeguarding aspects have now been separated out to form a dedicated Adults Safeguarding Board, which will hopefully prove more effective in addressing adult specific issues.

(d)  the current priorities for the Health aspects of his portfolio are as follows:

·  Health and Wellbeing Strategy - life expectancy continues to increase, but healthy life expectancy hasn't increased as quickly, so people have to live with health challenges for much longer. They value healthy life expectancy just as much as life expectancy, so that will be the overarching theme for the strategy with 4 key focuses: healthy lifestyle, mental wellbeing, healthy culture, and the built environment. The strategy will be signed off by the Health and Wellbeing Board on Wednesday 27 July 2016.

·  Substance misuse recommissioning, sexual health recommissioning and healthy lifestyles remodelling – there is scope to save money in the recommissioning of services and this is necessary given pressures on the public health grant. Sexual health and substance misuse services have been recommissioned. Sexual health has been re-geared as there was a need to get those services out of hospitals and into community settings. The new service is still embedding. Healthy lifestyle programmes are being remodelled and this reflects the difficult choices that are having to be made in response to budget pressures.

·  Alcohol Declaration – a Tobacco Declaration has been made previously and there is now a desire to pioneer something similar around alcohol in Nottingham. It is anticipated that the declaration will outline which interventions will be used to reduce the harm (both individual and societal) of excessive drinking. It will hopefully be taken to Full Council for consideration in November 2016.

(e)  there are some challenges for the Adults aspects of his portfolio:

·  Significant budget reductions – adult social work is needs-driven, so it is difficult to reduce costs without leading to deterioration in outcomes whilst people wait longer for the care and support they need. The only sustainable way to tackle financial pressures is to integrate adult social care with health. There are no existing UK models to base this integration work on, so there are risks.

·  Homecare market – (covered elsewhere).

·  Hospital pressures - traditionally what we would have called the winter crisis is now the new ‘normal’. More patients are presenting at hospital with greater needs and more complex long term conditions. This will continue to be a challenge nationally. There is a temptation to throw more money at the problem, but it will be more sensible to re-gear how that money is spent. Government will need to provide some transformation money so that a double service can be run during transition periods.

(f)  there are also some challenges for the Health aspects of his portfolio:

·  STP (sustainability and transformation plans) – local authorities are being asked for a radical upgrade in prevention services at the same time as their budgets are being cut dramatically. It is hard to upgrade services if budget are being reduced. During the integration phase, if the Council invests in things that are proven to work to reduce demand later, it will save money in the long term.

·  Health and wellbeing strategy – (covered elsewhere).

The following points were raised in discussion:

(g)  the focus is on integration not one organisation taking responsibility for commissioning all health and social care services;

(h)  early intervention for health continues to be very important. It is a theme of the integration work and an important part of the health and wellbeing strategy. Learning from projects implemented across the City creates an evidence base of what works and this can be used to inform future commissioning decisions. The Council has inherited responsibility for health visitors, but hasn’t made changes to the service, and has no intention of reducing the funding. Increased demand has been factored into the STP, the plan is well supported to understand the scale of the challenge, and all figures are based on reasonable projections of growing need over time;

(i)  as an indication that the integrated model is promising, American venture capitalists have been offering transitional money. This is not necessarily a route the Council would wish to pursue for funding, but it is a good sign that external companies think the model could prove profitable in the long run;

(j)  without successful interventions and prevention measures, the funding gap in the NHS may never be met. There has been some limited success around tobacco restrictions, but targets are nowhere near being met for reduced alcohol consumption. Minimum unit pricing would have helped massively;

(k)  meetings have taken place with the Community Partnership Forum to discuss culturally specific emerging health issues and health interventions. In home care and residential care patients want to maintain their independence, identity, and dignity. When services are commissioned, these cultural needs are identified through consultation;

(l)  the media tends to cover hospital pressures as "bed blocking", which may imply fault and intent on the part of the patient. Patients are often kept in hospital longer than necessary because the care services to support them when they leave can’t be arranged in time. A proper care package needs to be in place within the home before patients can be released. There is a risk that interim solutions can be put in place that patients will become dependent on, and then not be able to go back to independent living;

(m)  in terms of drugs, alcohol and tobacco prevention, schools are critical partners. There is more work to be done with schools on SRE, which calls into question how effective the entire PSHE (physical and sexual health education) programme is in general.  There is often more emphasis on targets than on creating well rounded individuals, so often PSHE suffers at the cost of getting better exam results. The Council needs to champion for young people and their parents in this respect;

(n)  progress reports on these targets can be shared;

(o)  the budget savings are unlikely to hit individual health sites at the moment and there is an opportunity with Nottingham University Hospitals Trust merging with Sherwood Forest Hospitals Trust that they could rationalise so that the same services are still being provided, but more efficiently and effectively. At some point some budgetary choices may have to be made that will be unpopular in the short term, but will ultimately benefit the system as a whole.

RESOLVED to note the information provided and thank Councillor Norris for attending the meeting.

Report of the Corporate Director for Resilience

Martin Gawith, Chair of Healthwatch Nottingham, and Pete McGavin, Chief Executive of Healthwatch Nottingham, presented the annual report to the Committee, highlighting the following points:

(a)  this report is the third Healthwatch Nottingham Annual Report, with a summary of some of the activities on page 6 of the report. Over the last year over 1,600 people's views have been collected, 43% of which came from vulnerable or seldom-heard groups, which was one of Healthwatch’s key aims. A number of volunteers donated over 500 hours of their time;

(b)  page 10 of the report contains a summary of the service user experiences Healthwatch has gathered. 55% of experiences are communicated directly face to face, but the technology is in place to enable reviews to be made either directly to Healthwatch, or to other websites such as Patient Opinion, where Healthwatch can then obtain the data regarding Nottingham services. Healthwatch also runs "talk to us" events, which are face to face stalls held in supermarkets, or as part of other group events, at locations throughout the city;

(c)  some work has also been done to engage with older people, with Healthwatch being an active participant in the Age Friendly Nottingham steering group. Some work has been carried out regarding people receiving a diagnosis of dementia, to find out what kind of experience people have with that diagnosis, including how sensitively it is handled and what support the patient is offered. A report will be produced soon, which has raised some concerns around people's experiences of their dementia diagnosis;

(d)  Healthwatch has also worked closely with the Refugee Forum, which is quite active in Nottingham. Particular issues raised include their access to GP services, and the availability of interpreters for GP, dental and optician appointments. There is a challenge in ensuring that all staff members involved in these appointments know that translation services are available if required;

(e)  for those seeking advice/ information from Healthwatch, 85% want to know about dental services, which reveals a potentially significant issue with NHS dentistry in the city. People think they are registered with a dentist, and do not realise they are not necessarily registered as a patient unless receiving on-going treatment.  There may then be an issue if, when they next seek treatment, the dentist isn't taking any new NHS patients at that time. It is a growing problem that needs to be addressed;

(f)  a mystery shopping exercise took place with agreement from the CCG, to call and visit every doctor in the city, regarding the availability of GP appointments, especially at weekends and in the evening. There were mixed findings, with some very good practice and some poor practice. This exercise helped to inform the CCGs decision making around commissioning of services from GPs. GP services are going to be one of Healthwatch’s priorities for next year;

(g)  some work has also taken place this year on residential care facilities. The Care Quality Commission and Nottingham City Council are trying to intervene with care homes that are in trouble as early as possible, to avoid provider failure and the need to move all the residents with very short notice if a home has to close;

(h)  it is anticipated that Healthwatch will contribute to the chapter on long term neurological conditions for the Joint Strategic Needs Assessment later this year, so some research has been conducted in this area;

(i)  Healthwatch sits on the board which oversees the work on the Sustainability and Transformation Plan (STP). Healthwatch will make sure that patient voices are heard, and that any issues are communicated to patients;

(j)  there are currently 33 volunteers involved with Healthwatch.  It is hoped that this volunteer base can be expanded in the future.

The following points were raised in discussion:

(k)  although not all GP surgeries provide Saturday appointments, they should be able to direct patients to alternative surgeries that do offer them. Surgeries are being commissioned to promote this service, yet it was found during the mystery shopping exercise that a lot of surgery receptions did not know about it and patients were being incorrectly advised.  Making sure all GP reception staff are aware of the correct information is important, and the service should be promoted properly;

(l)  Healthwatch meets up regularly with various complaints forums and patient and service user groups. It is difficult to engage with all such groups with such a small staff, but better analysis is being developed;

(m)  it is difficult to attract newly qualified GPs to city surgeries, as city surgeries are often less profitable than suburban ones. Factors influencing this include translation costs coming out of a GPs budget, and also because screening services and regular health checks (which GPs earn additional money for) are more likely to be taken up by suburban populations;

RESOLVED to note the information provided and thank Martin Gawith and Pete McGavin for the update.

Report of the Corporate Director for Resilience

Jane Garrard, Senior Governance Officer, updated the Committee on the Work Programme:

(a)  the report on adult social care and safeguarding, and the report on seasonal flu vaccination uptake have been moved to the September meeting;

(b)  the report on tackling health inequalities and the report on antenatal care have both been moved back.

Councillor Anne Peach then updated the Committee on a recent regional Health Scrutiny meeting, to which the East Midlands Ambulance Service (EMAS) and Hardwick CCG (lead commissioners) were invited to discuss the response to the recent Care Quality Commission inspection which found EMAS to be ‘Requires Improvement’:

(c)  staffing issues, including numbers of staff, skill mix and frontline leadership underpin many of the aspects raised by the CQC under the ‘safe’ domain.  Therefore staffing is a key focus for action;

(d)  EMAS is investing in its fleet - one third of EMAS vehicles have recently been replaced;

(e)  there has been an increase in the number of Red Calls which puts pressure on the service.  However recent analysis found that 50% of the ‘red’ referrals from NHS 111 don’t actually result in conveyance and this needs addressing.

(f)  delays in handover at Emergency Departments continue to cause problems and not only affects the quality of care for the patient waiting to be admitted but also impacts on EMAS’ ability to respond to other calls in the community.  Currently the biggest issues in Emergency Department handover are in Lincolnshire.

(g)  the 2016/17 contract is not based on meeting national response targets and national response targets will not be met this year.  Instead minimum contract standards have been set locally and commissioners expect to see continual month on month improvement in performance. So far Red 1 performance is meeting local targets but Red 2 performance is below the minimum performance trajectory.  The 2016/17 contract includes reinvestment of financial penalties and is intended to provide a year of financial stability.  Hardwick CCG is disappointed that the contract won’t deliver national response targets.

(h)  the EMAS Board had been concerned about a lack of consistency in Executive leadership in recent years.  There is now a new Acting Chief Executive (Richard Henderson) who has worked for the organisation for a number of years and a new Director of Operations at EMAS.  Hardwick CCG supports the current leadership arrangements;

(i)  A Strategic Demand, Capacity and Price Review is being carried out, looking at EMAS in the context of the whole emergency and urgent care system.  It is aiming to look at what it would cost to deliver national targets at a regional (East Midlands) level, and to understand what this means at a County level.  There is no blank cheque for implementation of the Review but there is scope for investment/ reinvestment over the 2-3 year period.  The findings of the Review should be known by October 2016 and another regional health scrutiny meeting is being scheduled to look at these findings and action being taken to implement improvement actions.

Jane Garrard then updated the Committee on current issues that may form part of health scrutiny work programmes in the future:

(j)  local concern had been raised with some councillors about changes to nursing services at Oakfield School, and other Special Schools. Further information on the decision is being sought.  The changes affect children at both City and County Schools and therefore it is within the remit of the Joint Health Scrutiny Committee;

(k)  NHS England has recently announced proposed changes to the provision of children’s heart surgery, including proposed cessation of children’s heart surgery at Glenfield Hospital, Leicester and cessation of ‘occasional and isolated specialist medical practices’ at Nottingham University Hospitals.  The major changes at Glenfield will affect Nottingham residents as it is the nearest site for children’s heart surgery.  Leicester City Council and Leicestershire County Council have already voiced their concern about the proposals and it is understood that their Health Scrutiny Committees will be considering referring the decision to the Secretary of State for Health for a number of reasons including a lack of public consultation.  The Leicester Deputy Mayor has written to Nottingham City Council asking for its Health Scrutiny Committee to support this course of action.  Councillors raised concern about the lack of specific consultation on the change and also the future of ECMO if surgery ceases.  Further information on the proposal including clarification on plans for consultation is being sought.  As the changes affect children from both the City and County it is within the remit of the Joint Health Scrutiny Committee.

RESOLVED to note the changes to the work programme and the work taking place in relation to scrutiny of EMAS.