Venue: Ground Floor Committee Room - Loxley House, Station Street, Nottingham, NG2 3NG. View directions
Contact: Jane Garrard Senior Governance Officer
APPOINTMENT OF CHAIR FOR THE MEETING
In the absence of the Councillor Anne Peach as Chair at the start of the meeting due to personal reasons, and Councillor Merlita Bryan as Vice-Chair, Councillor Brian Parbutt was appointed Chair for the meeting.
Apologies for absence
Councillor Georgina Power – personal
Councillor Chris Tansey – ill health
Councillor Anne Peach – late, personal
Sarah Collis (Chair, Nottingham and Nottinghamshire Healthwatch)
Declarations of interest
To confirm the minutes of the meeting held 18 October 2018
The minutes of the meeting held on 18 October 2018 were confirmed as a true record and signed by the Chair.
Report of the Head of Legal and Governance
Doctor Mark Simmonds, Deputy Divisional Director for Medicine and Consultant in Acute Critical Care at Nottingham University Hospitals (NUH) NHS Trust, delivered a presentation (which is included in the agenda) on the progress to date and scheduled for the Emergency Pathways Transformation.
The following points were highlighted and responses provided to the Committee’s questions:
(a) The transformation schedule has been developed as a multi-faceted change programme in response to the increasing demands on the Emergency Department (ED);
(b) NUH regularly does not meet the national requirement for 95% of patients to pass through the ED within 4 hours and attainment against this target has been declining. This is a result of multiple and often unique factors including the City’s rapidly growing population of 1.2million being served by only one ED (when most other similar sized cities have more than one), having a Major Trauma Unit and Neurosurgery Section which attract patients from further afield, and the national factor of an aging population;
(c) Last winter proved an exceptional challenge nationally with a significant increase in complex presentations. NUH reached 99.8% capacity which proved a serious strain on services and staff, so increased and more in-depth planning with partners for this winter started during the spring;
(d) Challenges continue to increase and since April 2018, there have been 7.6% more emergency admissions and 3.9% more citizens presenting at ED than planned for;
(e) The Queens Medical Centre main building is now 48 years old. In 2000 the ED was designed to facilitate 350-400 patients per day, but in 2018 regularly sees 600-650 patients per day. The construction methods used for the building has made it difficult to expand, but further physical ED capacity was required;
(f) Having consulted staff, patients and other citizens, NUH compiled a business case to expand the ED by 50% by reconfiguring the existing space allocation within the building. Funding of £4.5m was approved from Central Government to undertake this work but in addition to the physical changes, cultural and process changes, including improved ICT, were required to enable patients to move more quickly through ED, either to discharge or to move to the appropriate onward support. The improvement programme is scheduled to take 18 months and is currently at the 6 month point and is on schedule with the new ED anticipated to be opened on 19 December 2018;
(g) The whole ‘front door’ to ‘back door’ patient pathway and experience was closely examined and largely reconfigured to include integrated discharge and discharge to assess, to remove and prevent unnecessary delays, reduce the length of time patients spend in hospital (to a maximum of 3 weeks) and release bed space wherever appropriate. This has included enabling appropriate nurses to discharge patients;
(h) NUH achieves the best ambulance handover times in the region and maintains a good relationship with East Midlands Ambulance Service (EMAS). However, in addition to the specialist units within the hospital, it is believed that this efficiency results in a further increase in ambulance admissions;
(i) Several areas of individual interventions have been introduced such as the ‘EDFit2Sit’, ‘EndPJParalysis’, ‘Red2Green’, and ‘SAFER’, some of which were devised within NUH and have since been adopted by hospitals nationally;
(j) Clinical staff recruitment and retention is an issue nationally but NUH is actively encouraging culture change which will benefit patients, resources and also staff by improving the working environment. NUH is considered a fairly attractive employer within the region due to the additional specialist units and the prestige that this offers. Approximately 150 existing staff have been involved in a working group to help identify what changes NUH could make to provide an environment in which people want to work. One of the highest priorities identified was a ‘calm and controlled environment’, which is what NUH is aspiring to;
(k) The longer-term plan is for QMC to only have a single ‘front door’ for rapid access to urgent care through the Urgent Care Centre, to replace the 7 different admission units on site. This will include the ED but the ED will not necessarily be the initial contact;
(l) A full review of the services and use of the City Hospital site is also being undertaken to examine how underutilisation and duplication of services can be prevented and ensure that the greatest efficiency across both sites is achieved;
(m) For the extension of the ED, neighbouring physical space was released by services, including the fracture clinic, being moved elsewhere so that work was not taking place around patients; although there are hoardings up in some areas. Some members of the Committee had accepted the offer to tour the ED development work and were pleased with progress;
(n) Delays in discharge have consistently been blamed on the slow issuing of medication by the Pharmacy Section, but this has been scrutinised and it has been found that once the information is received by the pharmacy, the turn-around for issuing medications is reasonable. The delay can be attributed to the time taken in registering the medication request and the IT systems processing that information before it appears at the pharmacy. There is significant investment in NUH’s ICT, but not all upgrades and system replacements can take place at the same time and so have to be carefully plotted and co-ordinated;
(o) Front door mental health specialist services are the subject of complex commissioning arrangements and whilst changes to the way of working have been requested, with a lack of funding and capacity, these changes are not likely to be achieved in the immediate future. There have been 10 ‘treatment within 12 hours’ breaches since January 2018 and 9 of these were due to primary or additional mental health issues which require assessment by mental health professionals who, due to capacity, were not able to respond promptly .
Members of the Committee welcomed the progress of the Emergency Pathways Transformation programme, the achievements to date and particularly the opportunity to tour the building.
(1) formally record the thanks of the Committee to Dr Simmonds for his thorough presentation;
(2) note the progress of the Emergency Pathways Transformation;
(3) request an update presentation to the May 2019 Committee meeting.
Report of the Head of Legal and Governance
Kazia Foster, Service Improvement and Development Manager, was accompanied by Sandra Crawford, Associate Director of Transformation, and Debbie Dolan, Local Partnerships - Mental Health, all from Nottinghamshire Healthcare NHS Foundation Trust, to present the report which provides information on the current work to review and develop Adult Mental Health Services across Nottinghamshire.
A briefing note from Nottingham City Clinical Commissioning Group is also included in the agenda.
The following points were highlighted and questions from Committee members responded to:
(a) Adult Mental Health Services include:
o Acute Mental Health Inpatient Care
o Psychiatric Intensive Care Inpatient Facilities.
o S136 Places Of Safety
o Community Mental Health Services.
o Mental Health Crisis Services
o A&E Liaison Services
o Psychology and Psychotherapy
o Recovery College
(b) By 2021/22 mental health service proviers need to have developed a broad system to support patients across the whole pathway;
(c) As awareness of mental health rises, so too does the demand on services at a time when budgets need to be tightened. Therefore, new approaches need to be considered to ensure pathways are effective and efficient and with some previously used facilities now considered unsuitable, the potential for an purpose built facility;
(d) Since last year, it is anticipated that the cost of additional demands for mental health beds has significantly contributed to the increase mental health costs from £6m to £10m. Current facilities do not have the capacity to cope with the additional demand and so it has been necessary to place patients ‘out of area’ until local beds become available. This is not beneficial to the patient or their family, but currently there are no other alternative options, particularly as within the last few years 42 acute care beds and 60 rehab beds have been withdrawn within the City. This shortfall of facilities against the rising demand needs to be addressed;
(e) The four key areas identified for transformation are:
o Local Inpatient Beds Provision
o Crisis and Home Treatment Transformation
o Admission, Stay and Discharge – Patient Flow
o Local Mental Health Teams Development (Community Pathways)
(f) A business case will be presented to the Trust’s Board in December, recommending the increase in beds and facilities. If approved, a financial case will be put before the Board in March 2019, which if approved, will aim to have the additional capacity in place locally within 18 months;
(g) Work Stream Leaders will ensure that all clinical staff will have the opportunity to be involved in the development of a transformation plan along with service users and carers. It is important that everyone engages;
(h) The Trust is planning to recruit more staff and aims to be an attractive employer. A key part of this is to achieve the national standards and high quality care in a high quality environment in which people want to work. Staff turnover is currently closely monitored with leavers asked for the reasons why they are leaving;
(i) Currently the Trust is in partnership with private operators to ensure that as many patients as possible are able to be placed locally, and those placed out of area are moved back within 20 days. Part of the rise in the cost of the care is due to the reliance on private beds which obviously have a higher cost;
(j) If the approval is given and funding obtained for a purpose built facility, possibly on the Highbury Hospital site, it is intended that it will be built to cater for a higher number of patients than the current demand as a future-proofing measure and to ensure that the need to remain locally can be met for all local patients;
(k) There was an increase of investment in community mental health services, partly as a direct result of beds being withdrawn, but further focus is required to help support citizens in the community and prevent the need for admission to hospital. The profile of service users is becoming broader and more complex with more complex needs so services need to adapt to remain relevant and effective;
(l) It is vital that community mental health services are able to provide a 24 hour service with face-to-face gate keeping, robust in-reach for inpatients and home treatments where necessary. Changes are due to be made to crisis provision. As the City and County Mental Health Teams have different levels of resourcing, there will be a comprehensive examination of the services offered with the aim to provide cost effective community services and meet the Mental Health 5 year plan target by 2020;
(m) Although the number of rehabilitation beds has been reduced, there has been a huge amount of work to ensure that the majority of service users are able to live within the community and feel supported to rehabilitate in their own communities. Care doesn’t have to be attached to beds and all areas of the pathway will be reviewed with the aim to increase early intervention and reduce the need for rehabilitation beds;
(n) Ensuring that citizens can access appropriate support at an early stage is core to the aims of the Trust in its review, with patients receiving the right service in the right way and at the right time, including urgent care. However, this requires services to have appropriate resources available to prevent escalations to urgent care;
(o) Community based social prescribing would be massively beneficial and work is underway to identify what form this should take by examining existing successful models, but it is reassuring that all relevant agencies are already engaged with each other. However, it is historically very difficult to obtain funding for preventative work and existing budgets have already been reduced;
(p) The review is at a very early stage but the Trust was keen to engage with the Committee at this time and can bring further proposals to the Committee at a later stage to gain member’s views prior to progressing.
The Chair thanked Kazia Foster, Sandra Crawford and Debbie Dolan for their attendance and interesting and encouraging presentation.
(1) note the intentions in the review of Adult Mental Health Services;
(2) request that the Committee is informed (via Zena West, Senior Governance Officer) of any significant changes develop from the information provided today.
Report of the Head of Legal and Governance
Zena West, Senior Governance Officer, presented the revised proposed work programme for the remainder of the municipal year and a list of topics yet to be scheduled.
RESOLVED to note the work programme and that there will not be a meeting held in April 2019 due to the local elections being held on 2 May 2019.