Agenda and minutes

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To confirm the minutes of the meeting held on 15 October 2020.

The minutes of the meeting held on 15 October 2020 were approved as an accurate record and signed by the Chair.

The Committee was reminded that the proposal to develop an NHS Rehabilitation Centre had been identified as a substantial variation or development of service.

Hazel Buchanan, Director of Special Projects, and Lewis Etoria, Head of Insights and Engagement, Nottingham and Nottinghamshire Clinical Commissioning Group, updated the Committee on development of proposals for an NHS Rehabilitation Centre.  They highlighted the following information:

a)  Following further development of the proposals, including in response to issues raised during consultation and engagement, the proposal to be outlined in the decision making business case contains a number of changes compared with what was originally proposed in the pre-consultation business case.

b)  In the pre-consultation business case it was proposed to transfer 21 beds from Linden Lodge to the Rehabilitation Centre but, having looked at the cohort of patients, the workforce model and considered feedback from the consultation about potential challenges in maintaining the right level of care for patients in the three beds to be retained at the acute trust site, this has been reviewed and it is now proposed to transfer all 24 beds.  This will result in a bed capacity of 70 at the new Centre.  This increase in capacity will be achieved within the same capital cost. 

c)  In terms of referral criteria, in response to consultation, it has been decided to widen the cohort of patients eligible to receive care at the Rehabilitation Centre: to include deconditioned patients and not, as previously described ‘surgically deconditioned’ patients; by removing the proposed exclusion statement on ‘ongoing delirium or dementia diagnosis’ so that those with lower levels of dementia who could benefit from the rehabilitation services provided at the Centre are not excluded from doing so; and the ability for patients with progressive conditions, such as multiple sclerosis, to have top-up treatment and come back in for sessions.

d)  There was feedback in the consultation about ensuring high quality care for those not eligible to be referred to the Centre i.e. those with low or moderate needs.  There will now be a virtual clinical advice service to support those patients who don’t get treated at the Rehabilitation Centre.  This will utilise the skills and expertise of clinicians working at the Centre to support other clinicians who would like input and support in determining the most appropriate care pathways, for example, for patients who aren’t receiving specialist services.

e)  Proposals for the discharge process have been enhanced in response to feedback about the need for support after patients have left the Centre and the importance of integrating with services in the community to ensure that patient needs are met.  Discharge from the Centre will be managed by Clinical Case Managers, who will support patients from referral to post-discharge.  These managers will work as part of a wider multi-disciplinary discharge team, to include social workers and occupational health, linking up with services such as housing, which is a key area for discharge, to ensure individual needs are identified and met.  The virtual clinical advice service will also be available post-discharge for specific patient needs.

f)  There was feedback about the workforce model in the consultation feedback and the proposals have been reviewed in light of this and expanded.  The mental health resource has been strengthened to include psychologists and psychological assistants, with links to the Psychiatry Team at Nottingham University Hospitals and a partnership with Nottinghamshire Healthcare Trust.  Advanced Clinical Practitioners in nursing, occupational therapy and pharmacy are now included in the workforce model to bring specialist sector knowledge which will be important given the level of complexity of patients and level of acute care being provided.  This is in response to feedback about the need for the appropriate level of acute skills in the workforce to support patients 24 hours a day 7 days a week.

g)  A workforce training and education partnership will be developed with local universities, with both apprenticeship and degree programmes that support rehabilitation services.  This will be particularly beneficial because rehabilitation has some of the least developed training programmes.

h)  There will be two wards – one for the most complex patients and one for less complex patients.  The proposed facilities have been expanded in relation to feedback about patient need.  The wards will include facilities such as a laundry and an activities daily living suite with features such as a kitchenette to enable patients to practice carrying out everyday activities and tasks as part of their rehabilitation.  They will also be able to make themselves drinks and snacks.  Patients will have access to gardens and walking, both internally and externally, which is known to be fundamental to recovery.  Patients with the least complex needs will have access to gardens on the ground floor, while those with the most complex needs will have access to outdoor space on the first floor.  The staff will be able to have a view of patients at all times.  There will also be a multi-faith room.

i)  The number of family rooms has increased to four and there will be two rehabilitation flats where patients can live with carers and families as they normally would. 

j)  The gyms will be designed so that patients can access them outside the hours of therapy.  There will also be a ‘high street’ in the hub of the building with a small shop, bank machine etc that is accessible to patients as well as friends and families.  There is also potential for an IT suite and workshops to help build skills.

k)  It is intended that the facilities will give opportunity for social interaction and peer to peer support. 

l)  There is more work to be done in relation to the location of the Centre, but there is a commitment to consider further what can be done. There could be an opportunity to explore how to support voluntary organisations to support friends and family to be able to visit and a potential opportunity for charitable donations to support this through the Trust Charity.  One of the recommendations from the engagement work carried out by Healthwatch was to establish a shuttle bus from bus and train stations and this will be considered further through the Travel Impact Analysis, to consider whether it is viable.  The answers aren’t all there yet but there is a commitment to look at it further and this will feed into the next stages of the business case.

m)  It is important to consider how to take advantage of the benefits of the location and there was feedback about this, for example enabling patients to have real world experiences by travelling to neighbouring towns and villages.

n)  The draft decision making business case will be considered the Clinical Commissioning Group’s Governing Body in December.

During subsequent discussion and in response to questions from Committee members, the following points were raised:

o)  Having facilities to enable patients to carry out everyday tasks is important.  The kitchen facilities at Linden Lodge are limited and having proper kitchen facilities at the new Centre will making cooking and preparing food easier.  There will also be a small shop on site so that patients can buy food and other items and there will be the opportunity for rehabilitation assistants to take patients out to other shops.  The opportunities in relation to food preparation etc at the new Centre will be better than currently.

p)  There will be a canteen on site for visitors and there will also be facilities on the wards for the preparation of drinks which will be more accessible for friends and family.

q)  There will be one ward of 24 beds for patients with the most complex needs and other patients will be in the main ward.  There will be options to section off parts of the main ward if desired but it is intended that the large ward will support social interaction and peer to peer support.  In addition to the wards there will be multi-occupancy rooms and single rooms for those who need more privacy.  These rooms will also be used to meet patient need for gender specific facilities.

r)  Some Committee members spoke about the importance of retaining and building resources and expertise in the City and were informed that the intention is to develop a ‘hub and spoke’ model, that improves rehabilitation knowledge and skills across the system, and raises its profile as a profession.

s)  It is acknowledged that the location is a challenge but there is no opportunity for the Centre to be situated elsewhere.  Therefore, the issues are being taken into consideration and mitigating actions will be identified. Hazel Buchanan clarified that the current thinking in relation to the voluntary sector was about how to support the voluntary sector to provide support/ a service, not an expectation that the voluntary sector would be left to provide it themselves, but said that the Clinical Commissioning Group was open to any ideas on this issue. 

t)  The availability of land and funding presents an opportunity and the Clinical Commissioning Group is looking at how best to take advantage of this opportunity for a rehabilitation centre to provide high standards of care to a wider cohort of patients, while also building up rehabilitation across the system.  It is recognised that in their response to the consultation, some people suggested alternatives but that has never been within scope for this project.

Ajanta Biswas from Healthwatch Nottingham and Nottinghamshire commented that the proposals had come a long way since the original proposals and she felt reassured that the consultation outcomes had been taken on board, for example in relation to meeting patient needs.  She commented that the research and educational aspects were a strength of the proposal.  She felt that the location is a weakness of the proposal and, as there is already evidence of this, there should be a commitment to addressing the location challenges at this stage of the process.

Overall the Committee supported the principle of developing an NHS Rehabilitation Centre and the development of expertise and experience in rehabilitation services, including through education and training opportunities for the workforce, for the benefit of City residents.  The Committee welcomed the development of the proposals, including enhancing facilities at the Centre to better meet patient need, in response to consultation feedback.  The Committee welcomed the development of proposals to enhance discharge into the community and strengthen clinical support for patients who are not eligible for referral, however Committee members were mindful of the challenges in ensuring ongoing access to appropriate services and facilities in the community, for example suitable accommodation, and would like to see the provision of local support for patients to aid reintegration into their community as a priority within the ongoing development of the proposals. 

The Committee’s main concern related to the location of the Centre and the potential difficulties in accessing the Centre for patients, and particularly visiting friends and family.  This issue came up repeatedly in the consultation responses and the Committee considered that, given the benefits of maintaining regular meaningful contact with friends and family, it is important for the Clinical Commissioning Group to get the right resolution on this in order to make the Centre a success.  In response to comments and concerns raised by Committee members about accessibility and transport, Hazel Buchanan suggested that the Clinical Commissioning Group could carry out a really targeted piece of engagement on detailed proposals for travel and access closer to the opening date for the Centre.  Committee members commented that it was important for the transport solution to be in place before patients are admitted to the Centre. 

The Committee resolved to:

a)  overall, recognise the development of the NHS Rehabilitation Centre as a positive development for local health services;

b)  recommend that Nottingham and Nottinghamshire Clinical Commissioning Group carries out further exploration of how to address the challenges presented by the location in terms of access to the Centre by patients and visiting friends and family to ensure that there is a sustainable transport solution for patients, family and friends in place before the Centre opens.  The Committee recognises the potential opportunity for support to be given to the voluntary sector, possibly from the Nottingham Hospitals Charity, to support people with accessing the Centre, but feels that it is not appropriate to rely on this as a way of addressing something that is critical to the success of the Centre and therefore the Committee would like reassurance that there will be an appropriate transport solution in place even if the voluntary and charitable sector cannot deliver it;

c)  while recognising the strengthening of the proposals in relation to the role of Clinical Case Managers, the multi-disciplinary discharge teams and the introduction of a virtual clinical advice service, recommend that Nottingham and Nottinghamshire Clinical Commissioning Group prioritise ensuring that there are appropriate sustainable services in place to support patients in the community both post-discharge from the Centre and for patients with low and moderate needs who have not met the referral criteria for accessing the Centre;

d)  request the Clinical Commissioning Group keep the Committee regularly updated on the progress of the development of the NHS Rehabilitation Centre, particularly in relation to the accessibility and transport issues and work to ensure appropriate arrangements are in place to support patients in the community; and

e)  while acknowledging the benefits of the NHS Rehabilitation Centre, continue to ask for investment in services within the City location including locally based services to support patients with reintegrating into their own local communities.

Michelle Tilling, Locality Director - Nottingham, Nottingham and Nottinghamshire Clinical Commissioning Group and Executive Sponsor for Flu on the Integrated Care Partnership and Dr Hussein Mawji, GP and Deputy Clinical Director for the Integrated Care Partnership gave a presentation to the Committee on the local approach to delivery of the seasonal flu vaccination programme.  Mandy Clarkson, Consultant in Public Health, Nottingham City Council also attended the meeting to provide the Council perspective on delivery of the programme.  The following information was highlighted:

a)  Increasing the number of people receiving flu vaccinations is a priority for the Integrated Care Partnership (ICP) in 2020/21.  This is particularly important in the context of the Covid-19 pandemic which is placing additional pressure on health and care services and the co-circulation of Covid-19 and flu during winter.

b)  Work is being joined up across the system to identify who has been vaccinated and how to target those who haven’t been.

c)  A range of partners are involved in delivery of the programme including GPs, community pharmacies and Nottinghamshire Healthcare NHS Trust for delivery of the vaccine to school-aged children.  The Enhanced Care Response Team was established to support the response to Covid-19 and will be used to support delivery of the flu vaccination as well.

d)  For Nottingham City, the priorities are to increase uptake in those cohorts whose uptake was furthest from the target last year.  This is pregnant women (last year’s uptake was 37.6% against a target of 55%); under 65s at risk (respiratory) (last year’s uptake was 41.2% against a target of 55%) and school aged children (last year’s uptake was 39.2% against a target of 65%).

e)  The ICP has established a Flu Programme Group to understand how the City ICP approach can supplement the existing provider and vaccination delivery plans to maximise uptake in the City. 

f)  Operating under the Flu Programme Group, there is a task and finish group for each of the priority cohorts.  These task and finish groups involve a range of partners to understand that particular population and what needs to be done differently to maximise uptake by that group.  This work is held to account by the ICP Steering Group.

g)  The groups are working to understand population need, what needs to be done differently to increase uptake by that population and identifying evidence-based interventions about how to successfully improve uptake.  Population characteristics being looked at include socio-economic deprivation, non-English speakers and black, Asian and minority ethnic populations.

h)  Work is taking place through Small Steps Big Changes to target pregnant women.  Nottingham University Hospitals Trust’s antenatal teams will also be promoting the vaccine to women. 

i)  There will be harder-hitting communication messages going out about the consequences of not getting vaccinated.  It is felt that the previous softer messages do not have an impact on individuals, such as pregnant women and parents of school aged children, who are currently well.  Learning from case studies of pregnant women is also being used to inform communications.  Advertising will feature people from a range of backgrounds, such as young black men, who appear to be fit and well to try and communicate that everyone is at risk from low vaccine uptake.

j)  It is acknowledged that there are concerns by some members of the Muslim community about the porcine element of the nasal spray administered to school aged children.  However, the Muslim Council has issued a statement stating that it is acceptable and supported.  There are also challenges in getting consent from parents during the Covid pandemic.

k)  CityCare Partnership administer the vaccine to housebound individuals and have agreed to administer the vaccine to other members of the household at the same time.

l)  There are approximately 19,000 individuals in the City that fall within the under 65s at risk (respiratory) category and currently 31.3% of that cohort has been vaccinated. 

m)  So far there has been a 1% increase in the number of pregnant women vaccinated compared with the same point last year.  There are approximately 2,400 women within this category but it is a mobile cohort with individuals continually leaving and entering it so work to promote vaccinations is ongoing. 

n)  The school aged children vaccination programme is in the early stages but compared with the same point last year, there has been an increase in children vaccinated and an increase in parental consent given.  This is promising but there is a lot more work to do.

During the subsequent discussion and in response to questions from the Committee the following points were raised:

o)  There are tensions around the porcine element of the vaccine administered by nasal spray and some families choose not to have their children vaccinated as a result.  While every effort is being made to maximise uptake, it must be done in a way that families feel happy with.  The nasal spray is recommended because it is clinically the most effective and provides the best protection.  Injectable vaccine is available however, in accordance with NHS Guidance, this is prioritised for those unable to have the nasal spray for a clinical reason.  Ideally, families would be able to have the choice but there needs to be confirmation of supply before this can happen.  There may also be challenges in returning to specific children with the injectable vaccine given tight timescales for the vaccination programme and the potential impact on the wider service.  It might be possible to offer it, but the service does not want to raise expectations if it may not be possible.

p)  There are conspiracy theories and inaccurate anti-vaccination messages circulating in leaflets and on social media that could confuse people and deter them from getting vaccinated.  People are also unclear about where to access accurate information to challenge misconceptions.  This is a known issue and Communications Teams are working on providing consistent, accurate messaging about vaccination.  It is important that there is transparency for patients on risk.

q)  Work is also taking place with local faith leaders, however this has been more challenging than in previous years due to the impact of the Covid pandemic on access to places of worship and associated communities.

r)  A variety of communication routes are being used to get messages to people, particularly those who might otherwise not get vaccinated e.g. crib sheets prepared for clinical and non-clinical staff to inform meaningful conversation about vaccination.

s)  Concerns about the impact of the Covid pandemic on delivery of the flu vaccination programme are valid.  People may be concerned about accessing health premises to get the vaccine but should be reassured that GP surgeries have put a lot of infection prevention and control measures in place.  Many surgeries are holding specific vaccination days, with one GP dealing with normal cases and all other GPs and health professionals focused on getting people through the vaccination process as quickly as possible. 

The Committee will review uptake of the flu vaccine, with a particular focus on prioritised groups, later in the year.

Lucy Dadge, Chief Commissioning Officer, and Sarah Fleming, Head of Joint Commissioning, both from Nottingham and Nottinghamshire Clinical Commissioning Group and Philip Britt, Programme Director – Tomorrow’s NUH, Nottingham University Hospitals NHS Trust updated the Committee on the current position and next stages in the Tomorrow’s NUH (Nottingham University Hospitals) project.  The following information was highlighted:

a)  The timescales for developing the pre-consultation business case are challenging, but if deadlines aren’t met then the opportunity for capital investment will be lost.

b)  Work is starting to take place to firm up clinical proposals and will be discussed with the regional Clinical Senate in early December.  By January, it is expected that there will be much clearer views on what clinical services need to look like.

c)  The pre-engagement process commenced this week, to communicate that there will be some significant service reconfigurations and to get public views and thoughts.  It would be helpful if councillors could encourage their residents to engage with this.  The things that it is intended to engage the public in considering at this stage include:

  i.  consolidation of all emergency services on one site

  ii.  creation of a women and children facility

  iii.  evidence that separating urgent and emergency activity from planned activity is beneficial

  iv.  bringing cancer diagnostics, surgery and treatment together on one site

  v.  shifting services into the community where possible

d)  The pre-consultation business case will come to this Committee in spring 2021, prior to public consultation over summer 2021.

During the subsequent discussion and in response to questions from the Committee, the following points were raised:

e)  Consultation and engagement will include communities who live around the sites and not just service users.

f)  The national direction of travel is to prevent people from going into hospital unnecessarily and providing services in the community where possible, and this will be an ongoing focus regardless of the outcome of the Tomorrow’s NUH project.  There needs to be appropriate services and support in the community to enable this to happen.

g)  It is not yet known where sites will be and whether buildings will be knocked down and rebuilt.  Once it is clear what is needed, the focus will be on how to deliver that and an options appraisal will be carried out.  This will be an iterative process involving both the Clinical Commissioning Group and NUH.

h)  Work is looking at how to enable care to be provided in the right place at the right time and this is not just about the acute hospital e.g. for adults and children in mental health crisis.

The Committee thanked colleagues for the update and asked for further updates to be brought to the Committee at appropriate points in the process.

Councillor Adele Williams, Portfolio Holder for Adult Care and Local Transport, attended the meeting as part of the programme of scrutiny sessions with Portfolio Holders on progress with delivery of the Council Plan.  She gave a presentation about Council Plan performance and budget pressures within the adult social care aspects of her Portfolio, highlighting the following information:

a)  Throughout the Covid pandemic, adult social care services have continued to meet statutory duties and not had to put the permitted Care Act easements in place.  However, gaps are emerging with waiting lists across all teams.  There is also a backlog of reviews to complete, as planned reviews were put on hold.

b)  Some transformation work has also had to be put on hold due to the Covid pandemic and this will impact on the achievement of budget savings.

c)  Community Together Surgeries remain closed and this impact on early intervention work may result in increased demand for social care assessments. 

d)  A review is underway of how best to support citizens who would ordinarily attend day centres, that are currently closed.

e)  It is anticipated that safeguarding referrals may increase after the lockdown period and this is a concern.

f)  The Council Plan objective to set up a Council owned company to deliver care services is currently rated as ‘amber’ and it is expected to remain ‘amber’.  The business case for this is being looked at to ensure that it can make the most impact for citizens, taking into account the Council’s budget pressures.

g)  The Council Plan objective to further develop the Council’s commitment to being a Dementia Friendly City is currently rated as ‘amber’ but the expected outcome is ‘green’ as work is taking place on a specialised dementia offer.

h)  The Council Plan objective to reduce the number of people who feel lonely or isolated by 10% is currently rated as ‘amber’ and expected to finish as ‘red’.  The Covid pandemic has actually created a great sense of isolation for many people, but alongside this there has been a willingness from many to volunteer and support others.  In the context of the pandemic there is a lot of work to do on this issue.

i)  A mix of one off and longer term savings were agreed for 2020/21.  However there is a saving shortfall forecast, largely as a result of some agreed savings not being progressed due to the Covid pandemic.  Savings forecasting a significant shortfall include: removal of subsidy of Lunch Club meals – work is underway to look at how best to support community activity while achieving best value for the Council; introduction of Best Practice Policy – this has been delayed due to the need for further public consultation; fees and charges review; alternative accommodation options – delayed by a few months due to the Covid pandemic; and day care offer for older people, which needs further work.

j)  Additional 2020/21 budget savings were agreed by Council in October, including delivery of a more robust volunteering offer in communities, and lessons from the Covid response will be used to inform this; and a number of in-year contract reductions.

k)  Saving associated with the review and consolidation of internal day services for citizens with physical, sensory and learning disabilities will be achieved this year, but no centres have yet closed.  Work is taking place with a consultancy, including research and consultation with service users to understand service user views and what users would like the service to look like.  Prior to the Covid pandemic, the day centres were operating well under capacity and, although there is likely to always be a need for building based services, there could be scope to use resources better to support people to have greater community involvement, more involvement with voluntary and paid work, access to community leisure facilities etc.  Consultation is ongoing and there are some challenges with doing this in the context of the Covid pandemic. 

l)  Better Lives Better Outcomes/ Pathway savings have been impacted by the Covid pandemic and associated redeployment of staff.  However early implementation of the programme has progressed well against savings targets.

m)  There are a number of workstreams including: Older People Reablement; Older People Homecare; Older People Residential/ Alternative Accommodation; Mental Health Independence; Mental Health Residential to Supporting Living; Learning Disability Independence; and Learning Disability Residential to Supported Living.

n)  The Older People Reablement work is working towards a strengths-based model, focusing on how to support people on what they want to achieve in their lives.  The Temporary Emergency Support Team was established during lockdown and this has been crucial in supporting citizens being discharged from hospital to access reablement services.

o)  The Older People Homecare workstream has delivered well against the savings target and has been closed in line with the plan, now that practice has been embedded reducing the likelihood of an over-prescription of care.

p)  There have been difficulties achieving the savings associated with the Older People Residential/ Alternative Accommodation as, for many in long-term residential care, this is only achieved when they pass away and therefore significant savings are still required.  The impact of Covid is currently unclear and there are risks if costs are transferred from health to adult social care.  There have been delays in building the supported living accommodation for people with neurological needs and also delays for homecare in the external market.  This could increase the likelihood of short term care placements, create dependency and increase admissions to long term residential care.  A specific pathway for people with dementia is being developed. 

q)  In the Mental Health Independence workstream, reviews have been on hold due to a lack of resource as a result of the Covid pandemic, but are due to resume.

r)  The Mental Health Residential to Supported Living workstream delivered well against savings targets in 2019/20 but there will be a shortfall in 2020/21 and 2021/22 due to impacts from the Covid pandemic.  There is potential for a further 13 moves this year.

s)  No savings or reviews have been delivered against the Learning Disability Independence workstream as colleagues have been redeployed to support the Covid response.  Colleagues have now returned to the service and this should enable more reviews to be completed.  The Pathway Service has been suspended since March and it is not yet known when it will resume. 

t)  The Learning Disability Residential to Supported Living work has experienced the same issue as for Mental Health.  So far 5 moves have been undertaken and there is potential for a further 19 moves this year.  The focus will then shift to supported living being the first option for young people as they move into adulthood.

u)  The Adult Social Care Winter Plan is being considered by Executive Board in December.

During the subsequent discussion and in response to questions from the Committee the following points were raised:

v)  Some community groups, such as the Radford Care Group, are struggling with funding at the moment and this is affecting their ability to contribute to initiatives such as creating a Dementia-Friendly City.

w)  The Nottingham Pathways Service is a well-established model for supporting community involvement and volunteering, travel training and accessing leisure facilities etc, and through this it is hoped to reduce risks of isolation for people with learning disabilities.  Prior to the Covid pandemic, there were plans to hold an event to engage employers, community organisations and citizens in a conversation about what kind of City we want to be and how to achieve that together.  It is important to get this restarted as soon as possible.

x)  The offer at day centres for people with learning disabilities is good and there is a need to retain some day centres, but the approach isn’t right for everyone.

y)  There is a Whole Life Disability Team to try and reduce issues with transition from support as a child with a disability to being an adult.  The Team takes a strengths-based approach and this has been a positive move for the City.

The Committee noted its current work programme for 2020/21, including an additional meeting called by the Chair for 19 November 2020 10am to consider changes relating to the Platform One Practice.