Venue: Loxley House, Station Street, Nottingham, NG2 3NG
Contact: Laura Wilson Senior Governance Officer
To note that Councillor Merlita Bryan has resigned as a member of the Committee.
The Committee noted the resignation of Councillor Merlita Bryan from the Committee.
Apologies for absence
Councillor Angela Kandola – work commitments
Councillor Anne Peach – other Council business
Councillor Cate Woodward - unwell
Declarations of interest
To confirm the minutes of the meeting held on 12 September 2019
Subject to including Councillor AJ Matsiko in the list of absent Councillors, the minutes were confirmed as a true record and signed by the Chair.
Caroline Nolan, System Delivery Director, Greater Nottingham Clinical Commissioning Group, and Lisa Kelly, Chief Operating Officer, Nottingham University Hospitals (NUH) NHS Trust, were in attendance to inform the Committee of the measures in place and proposed in preparation for the predicted rise in demand for services during the winter period.
A presentation was delivered and was circulated with the agenda. The following additional information was provided:
(a) following what was believed to be the peak of patient admissions in winter 2018, intake has remained steady without reduction with an increase in demand of 8.9%, with a day in July being the busiest so far this year. Temporary additional facilities to cope with peaked winter intake (70 escalation beds) became permanently established;
(b) NUH is taking part in the emergency medicine year-long pilot with 13 other hospitals across the country, to identify the most effective treatment model that ensures that the patient experience is smooth with efficient treatments pathways, whilst hospitals ensure the most efficient use of resources. Data from pilot hospitals is gathered and analysed, and amendments issued to procedures and policies. The pilot is due to conclude at the end of March 2020;
(c) there is an aim to assess, treat and discharge the majority of patients with planned support in place, within the same day, reducing the need for inpatient care. Most patients prefer to return home and there is evidence that their recovery time can be greatly reduced if in their own familiar environment, particularly if they have issues such as dementia;
(d) patient feedback regarding waiting times, communication, and how staff behave towards patients, continue to be areas of focus to address;
(e) significantly increased demand has resulted in some 12 hour trolley waits and longer waits for inpatient beds, particularly regarding mental health and specialist department admissions;
(f) in preparation for this coming winter, NUH have attempted to predict the potential areas of highest demand and considered how best to respond. This has included:
· additional facilities on the City Hospital site for longer term inpatients preparing to be discharged;
· additional assessment beds;
· three additional critical care adult beds and four additional critical care child beds;
· further work on improving discharge processes;
· all main primary healthcare partners have been supporting NUH to engage the public and encourage and support increased self-care;
· improved use of community bed capacity with patients advancing swiftly to the next section of their care journey;
· introduction of ‘call for care’ which provides a rapid assessment within 2 hours to establish a care package;
· promoting the ‘Significant 7’ within care homes to help identify deterioration so it can be addressed at home without the need for admittance to hospital;
(g) further work is required within the City to provide high intensity bespoke care services in the community, including at home, for more complex cases;
(h) there continues to be a focus on staff health and well-being, along with morale. There is a target of 80% of staff to have received the flu jab vaccination by the end of November 2019. Uptake so far has been good and it is anticipated that the target will be exceeded;
(i) in summary, the main challenges for NUH are currently as follows:
· system demand versus capacity;
· patient flow;
· provision of the correct number and type of community care beds.
A member of the committee expressed concern that patients had been discharged from hospital with the expectation that community services would have capacity to continue care. However, as this had not been the case, the discharge could be considered as unsafe. It is understandable that with the high demand for services and restricted budgets, that maintaining patient flow is vital, but appropriate communication and adequate resources need to be in place within the community to achieve the best results for all parties.
Questions from the Committee where responded to as follows:
(j) NUH aims to provide the best possible patient care and while targets do exist and are monitored, people care is the priority. Unfortunately, with the increasing demand and pressures on resources, the organisation doesn’t get it right all the time but tries to address areas where improvements can be made;
(k) as demand consistently increases and the resources available continues to reduce, this provides a very serious challenge. Some additional funding has been secured for resources including staff, but, with a lack of qualified people available, recruitment continues to be a problem nationally;
(l) as the cost of community beds can be lower than hospital-based beds, increasing the number of community beds available is being investigated. However, Nottingham already has a high number of community beds compared to other similar cities. As people tend to recover quicker in their own home, where possible and appropriate, this is the preferred option if a care package, potentially including wraparound care, can be provided;
(m) wrap around 24-hour care can be costly in any environment but with a focus on patient outcomes, opportunities to pool resources with other healthcare providers can be mutually beneficial;
(n) how the health system operates as a whole needs to be considered, and it is vital that primary care providers, including GP surgeries and Clusters, work closely together to be as effective as possible;
(o) Primary Care doctors (GPs) and nurses are based in A&E to address the needs of some patients who present with issues which can be resolved at this level. NUH also works closely with the 111 providers to encourage use of the alternative support and advice available. It is recognised that with initial contact, the 111 Service applies an algorithm, but 75% of calls are progressed to assessment by a clinician. Some callers are directed to A&E but there remains a focus on working with citizens to first encourage access to GPs, 111 and urgent care units prior to presenting at A&E for non-emergency issues. Patients presenting at A&E are asked which health services they had accessed or tried to access prior to presenting at A&E;
(p) with regard to care transition, assessments and discussion takes place and there is thorough consideration of which services would be most appropriate to put in place. It is important that the ‘home first’ approach is correctly managed but with the pressure on all provider resources, this continues to be a challenge;
(q) with regard to addressing concerns raised in feedback over patient communication, specific instances have been examined and where possible improvements made or action taken;
(r) mental health is receiving a greater focus and there are plans to open crisis cafes and consultation is taking place with patients to determine what patients most need and want from a psychiatric unit;
(s) listening to staff is important and there is a cultural and leadership system in place to ensure that staff can be supported as best as is possible in their work as part of the ‘Team NUH’ approach. The ‘Speak-up’ programme also encourages staff engagement to help empower staff;
(t) staff health and wellbeing is important to ensure that staff are functioning well in what can be very difficult circumstances with the additional demands and pressures in some clinical areas. Ensuring that the basic requirements of taking appropriate breaks and maintaining hydration levels are emphasised, but also adapting processes and policies to support staff, such as extending the staff car parking period to 8am to allow staff on night shift to more easily use the facilities. Appraisals are valuable for both parties and the paperwork has been amended to ensure that staff can clearly see that it is meaningful and supportive of staff development, including into different career pathways within NUH;
(u) one element of the current pilot includes reconsideration of targets to a suite of clinically relevant measures which, it is anticipated, will better engage staff. For the duration of the pilot the previous ‘4 hour waiting time’ target is not being applied as measures directed by the pilot are taking priority and changing as a result of ongoing real-time analysis by the central pilot team. There is no indication at this time that as a result of the pilot and increased demand, that any additional funding will be available.
Members of the Committee commented:
(v) promotion of the full range of careers and apprenticeships available with in the health service should be more strongly emphasised to local young people;
(w) additional pressures such as closure of and difficulty accessing appointments at GP surgeries do impact on A&E admissions so need to be addressed;
(x) time delays in providing care packages can result in patients returning to hospital which has a huge impact on the patient and also wider resources. These areas need to be further investigated and the fundamental issues addressed;
(y) patients presenting at A&E need to be made aware that the national waiting time targets of 4 hours maximum are not operating within NUH as a result of the pilot. Long waiting times in A&E are not helpful for patients with mental health issues, particularly where delay in community treatments may result in patients presenting with a range of physical injury in addition to continuing mental ill health.
The Chair thanked Caroline Nolan and Lisa Kelly for their update.
Due to the Portfolio Holder being required at an urgent meeting, this item was postponed to a future meeting, but Councillor Campbell-Clark briefly informed the Committee that the two major areas of concern within her remit were sexual health and substance misuse, both of which were under significant budgetary pressure.
Laura Wilson, Senior Governance Officer, presented the proposed work programme and informed the Committee that:
· the CCG has requested to attend the November meeting to present an updated pre-consultation Business Case for the National Rehabilitation Centre to detail the changes that have been made since it was considered by the Committee at the September meeting;
· the Targeted Intervention Services update scheduled for November has been removed from the work programme as this is now a ‘business as usual’ approach there is no update to provide.
Members had received an invite to visit Edwin House as part of the ‘Councillors on the front line’ programme and, given that the Inpatient Detoxification Service update (which is delivered at Edwin House) is scheduled for the November meeting, it would be appropriate for members of the Committee to accept the invite if they are available to attend.
RESOLVED to approve the updated work programme.