Agenda for Health and Adult Social Care Scrutiny Committee on Thursday, 13th May, 2021, 10.00 am

Agenda and minutes

Venue: The Ballroom - The Council House, Old Market Square, Nottingham, NG1 2DT. View directions

Contact: Kim Pocock  Scruitny Officer

Items
No. Item

1.

Apologies for absence

Minutes:

Councillor Phil Jackson (medical appointment)

 

2.

Declarations of interest

Minutes:

Councillor Mike Edwards declared a personal interest in item 7: Platform One - Progress Towards Transition/ Dispersal Launch Date, as he is a patient currently registered with the Platform One practice.  He took no part in the discussion on this item.

 

3.

Appointment of Vice-Chair

Minutes:

Councillor Cate Woodward was elected as Vice Chair of the Health Scrutiny Committee 2021/22.

 

4.

Minutes pdf icon PDF 263 KB

To agree the minutes of the meeting held on 15 April 2021.

Minutes:

The Committee agreed the minutes of the meeting held on 15 April 2021 as an accurate record and they were signed by the Chair.

 

The Committee noted that comments, made publicly at its meeting held on 15 April 2021, stating that partner organisations had not addressed recommendations made by the Committee when it previously discussed suicide prevention were inaccurate.  No recommendations were made in relation to the suicide prevention item in January 2020 and all areas raised by the Committee in January were responded to by partners in the Committee’s meeting held on 15 April 2021.

 

5.

Health Scrutiny Committee Terms of Reference pdf icon PDF 103 KB

For noting.

Additional documents:

Minutes:

The Committee noted its terms of reference, as agreed at Council on 26 April 2021.

 

6.

Nottinghamshire Healthcare NHS Foundation Trust Strategy pdf icon PDF 185 KB

Minutes:

John Brewin, Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust and Julie Attfield, Director of Mental Health and Learning Disabilities, Nottinghamshire Healthcare NHS Foundation Trust, attended the meeting to present information on and discuss with the Committee the Trust’s strategy, which is currently being reviewed. They highlighted the following information:

 

(a)  Responding to the pandemic over the last 16 months has been challenging.  Nottinghamshire Healthcare NHS Foundation Trust (the Trust) set up a command centre, through which all services have been co-ordinated.  No service has been formally stood down (although the memory clinic did not operate for a period of time), but there have had to be adaptations to ensure Covid 19 compliance and that priority services continue to operate with the available workforce.

 

(b)  A significant proportion of the workforce was redeployed to keep key services open, for example in crisis teams, on wards and in children’s services. In addition, staff were absent due to shielding, isolating, family reasons and sickness absence. As regular lateral flow tests and vaccinations have been introduced, workforce capacity is improving. 90% of the workforce has now been vaccinated.

 

(c)  Many services require face-to-face contact, but where it has been possible, remote consultations have been held and have largely been well-received by patients.  The Trust is now operating a mixed model of service delivery.

 

(d)  Significant funding will accompany the national long-term plan to transform mental health services provision, leading to broader access.

 

(e)  Due to the pandemic, the Trust has seen loss of bed capacity and access to clinic space.  As a consequence of this, and other changes which had to be implemented to manage the impact of the pandemic, the Trust is not seeing more patients but those that it is seeing are more acutely unwell.

 

(f)  The Trust has seen the following changes in relation to Adult Mental Health referrals and access:

 

(i)  During the first lockdown, referrals to Adult Mental Health services dropped significantly as people did not contact their GPs. This is the only pathway not fully restored – all others are seeing restoration/ an increase to pre-pandemic rates.

(ii)  Crisis referrals have increased.  There have been 150 crisis calls per month since August 2020.

(iii)Intellectual Development Disability (IDD) referrals have increased since September 2020.  This is believed to be due to the impact of isolation on carers.

(iv)Face to face contact is increasing week by week in most services.

 

(g)  Child and Adolescent Mental Health Services (CAMHS) have continued throughout the pandemic, using a mix of face to face and virtual contact, including group work.

 

(h)  Key services to note in terms of access to services and waiting times are as follows:

 

(i)  Waiting times have improved for Improving Access to Psychological Therapies (IAPT), with 9 out of 10 people now seen within 6 weeks, and less than 1% of patients waiting over 18 weeks.

(ii)  Early Intervention in Psychosis (EIP) teams are delivering treatment to over 85% of patients within two weeks, significantly ahead of the national target of 60%.

(iii)  Waits for Memory Assessment Services have reduced significantly, to under 14 weeks currently, having been above 20 weeks for several months in 2020/21.

(iv)  The goal of 95% for routine and urgent treatment of young people with eating disorders has not been achieved,with 80% of patients treated within 4 weeks (routine) and 56% of patients treated in one week (urgent), over the course of 20/21.

(v)  Step 4 Psychotherapy and Psychological Therapies have been particularly disrupted by COVID, as certain therapies cannot be delivered virtually; this has led to patients commonly waiting in excess of 6 months for treatment.

(vi)  Average waiting time for treatment at a Local Mental Health Team (LMHT) is currently around 7 to 8 weeks, an improvement on waiting times for the same period last year.

(vii)  Despite COVID, access rates into Children and Adolescents Mental Health Services (CAMHS) in the community have improved by 6% year on year. The length of time a patient waits for assessment from CAMHS community services is currently around 11 - 12 weeks.

(viii)  The Trust’s Mental Health Support Teams in Schools service was the first to go live nationally and supports 112 schools across Nottinghamshire.

(ix)  Monthly performance against the 72 Hour Follow Up target has remained above target throughout 2020/2021.

(x)  The overall level of physical health checks continues to increase, driven by improved levels within Community Services, (now running at double the rate of last year).

 

(i)  Inappropriate out of area mental health placements have halved from an average of 464 bed days per month in 2019/20 to 177 for 2020/21 as a result of changes to crisis pathways and sub-contracting arrangements with service providers.  There are currently seven patients placed out of area.  The Trust aims to have no out of area placements by October 2021.

 

(j)  The Trust has higher referral acceptance rates across all services than national average rates. This is a positive challenge to the previous Trust reputation for not taking enough patient referrals.

 

(k)  During the pandemic the Care Quality Commission (CQC) has focused on Covid risk and safety inspections of specific services, rather than full inspections.  As a consequence, there has been no change to the Trust’s overall rating of ‘Requires Improvement’.  This legacy rating will not change until there is further inspection.

 

(l)  Since March 2020 the CQC has carried out focused inspections at Rampton Secure Hospital, Adult Mental Health in-patient wards, Infection Prevention and Control arrangements and Wells Road Low Secure Hospital.  Work is ongoing to address the need for improvements in some core services at Rampton and Wells Road Low Secure Service (which received a CQC warning notice) and to continue improvements on Adult Mental Health wards.  This work is monitored by Improvement Boards.

 

(m)There has been reduced patient experience feedback during the pandemic period. In lockdown #2 feedback was more critical than complimentary which does not reflect the previous trend of around equal critical/ complimentary feedback.  Themes arising from critical feedback include, access and waiting times, not feeling heard, adult mental health crisis care, communication, rules and restrictions on wards. Complimentary feedback themes include, helpful/ caring/ friendly staff, support and advice, listening.

 

(n)  The Trust has responded to critical feedback with improvements, including changes to carers’ visiting processes on inpatient wards, change of hours for activity co-ordinators for inpatients, setting up lived experience groups in the community, providing new IAPT services, setting up a virtual wellbeing group for IDD patients and yoga sessions for CAMHS inpatients.

 

(o)  National staff surveys have shown that the Trust is the most improved mental health organisation across all domains in the country after several years of increasing dissatisfaction. Despite this significant improvement, the Trust demonstrates only average satisfaction compared with its peers (eg, Northamptonshire, Leicestershire) and continues to work to improve staff satisfaction levels.

 

(p)  Transformation work in 2020 has included the following achievements:

 

(i)  The Early Intervention in Psychosis services is now NICE compliant.

(ii)  Individual Placement and Support investment to support people to get into work and/ or stay in work.

(iii)Crisis core staffing levels are now fully compliant.

(iv)The Street Triage Service has been expanded to include a day car as well as out of hours services.

(v)  The Intensive Home Treatment Team (Mental Health Services for Older People) is offering age appropriate support.

(vi)The crisis service for children and young people, introduced during the pandemic has been expanded to 24/7 and will be retained post-pandemic.

(vii)  A new Attention Deficit Hyperactivity Disorder pathway has been introduced.

 

(q)  The Trust has secured £3.1m in national bids for funding and has secured £49m of capital funds over three years to eradicate dormitories for inpatients by 2024.

 

(r)  Plans for 2021 include:

 

(i)  Improved pathways for those suffering severe mental illness, eg personality disorder community support pilot; investing in more substance misuse workers, peer support workers and transition workers (to support 18-25 year olds); placing Eating Disorder clinical leads in community teams; expanding the voluntary and community sector offer; and introducing Primary Care Mental Health Practitioners to all Primary Care Networks.

(ii)  Increased crisis support (including that for children and young people) to meet local demand and reduce waiting lists.

(iii)Further work on a new model offering specialist diagnostic and treatment support for those with Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorder.

(iv)Opening Sherwood Oaks with 14 new acute beds.

 

In response to questions from the Committee and in the subsequent discussion the following points were made:

 

(s)  Anyone waiting over six months for Step 4 Psychotherapy and Psychological Therapies will have a further review, which will look at other options available while they are waiting, for example online Cognitive Behavioural Therapy (CBT), and IAPT may also be able to give some support while a patient is waiting.  The Trust is investing this year in capacity and other forms of broader support (eg social prescribing) to provide psychotherapy and is confident that the waiting list will have come down significantly by the end of this financial year.

 

(t)  Committee members expressed concern about the length of the waiting time for psychological therapeutic support.  They were also concerned that support offered during the waiting period would not hold up the referral for specialist psychological support nor result in removing people from the waiting list (because they are receiving some form of treatment) before having the chance to access specialist psychological support.

 

(u)  Workforce sickness absence rates are at the lowest for a long period of time – 4% and the vacancy rate, at 10%, is the lowest it has been in the last two years.

 

(v)  The Trust will be piloting a Single Point of Access (SPA) in the autumn to manage the plethora of pathways to treatment, which can feel complicated to patients, especially where there are multiple referrals.  This should streamline some of the issues around access to services, although complex cases may take longer to resolve.

 

(w)The Trust is looking at the learning from the pandemic.  Many patients have preferred remote contact for support, particularly children and young people.  A mixed model will continue to be offered, ensuring face to face and remote services to enable availability and accessibility.

 

(x)  The CQC exposed a closed culture at Wells Road Low Secure Service, ie a service not open to learning from evidence and good practice.  In the light of this, the Trust is looking at its other services to see if there are pockets of closed cultures elsewhere.

 

(y)  Staff sickness absence rates at Rampton Hospital have decreased and retention rates have increased. This may have been impacted by the threat to jobs during the pandemic, but it is hoped that it is also as a result of improvements to the working environment. Recruiting more staff is a key priority for 2021/22.

 

(z)  Sherwood Oaks, near Mansfield, is a relatively new building, previously operating as a forensic facility, which the Trust is now converting into an open acute facility for the transfer of Adult Mental Health inpatient services from Millbrook Mental Health Unit, Mansfield.

 

(aa)  GPs have all been made aware of the new ADHD pathway.

 

(bb)  £16m is being invested into Nottinghamshire Mental Health Services (including the Voluntary and Community Sector as well as the Trust). This will enable significant changes, eg in the last year, the workforce has been expanded by 150 and will continue to be expanded by a further 250. Implementing changes will be challenging, but the Trust is confident that the first significant investment for many years will have a positive impact. The Trust is committed to carrying out these changes in an open and publicly accountable way.

 

(cc)  At the beginning of the pandemic, there was a high number of referrals to Local Mental Health Teams (LMHTs) and the Department of Psychiatric Medicine (DPM), and numbers were difficult to manage.  The number of referrals has now reduced.

 

(dd)  There is an urgent referral route to Eating Disorder Services, so there is no wait if immediate access is needed.  BMI (body mass index) is still used as a threshold for treatment but there is flexibility to consider other factors. Members were concerned that continuing to use BMI as a threshold for treatment meant that many people with eating disorders who do not drop below the BMI threshold have no access to treatment.

 

(ee)  Both Children and Adult Eating Disorder Services are being expanded.  In response to members’ concerns that there is no adult inpatient provision for Eating Disorder treatment in the city, the Trust responded that there is not the critical mass of patients which would justify creating this provision locally. Patients are placed in the region where possible.  The Trust agreed to provide more information to Committee members on Eating Disorder Services.

 

(ff)  The Mental Health Teams in Schools Service covers approximately one third of all schools across Nottinghamshire and will be further expanded with a second wave of funding.  There is a lead-in time as Emotional Wellbeing Practitioners take a year to train.  The Committee was particularly interested in which city schools are in receipt of this support. The Trust agreed to provide this information to Committee members.

 

(gg)  The Trust is working on how to provide female Psychiatric Intensive Care Unit services without having to place patients out of area, as there is currently no provision for this in the city.

 

(hh)  Given time constraints, the Chair asked that members with outstanding questions on this item send them to her for referral to the Trust for a response.

 

The Chair thanked the Trust’s colleagues for attending the meeting and noted that the Committee would discuss future visits to the Committee under the Work Programme item on the agenda.

 

7.

Platform One - Progress Towards Transition/ Dispersal Launch Date pdf icon PDF 279 KB

Minutes:

Joe Lunn, Associate Director of Primary Care, Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) and Lynette Daws, Head of Primary Care, CCG, attended the meeting to discuss progress towards the end of the Platform One contract for a GP practice and the start of the new contract for a GP practice on Parliament Street; and the dispersal of patients to their local practice where they live outside the new practice boundary. They highlighted the following information:

 

(a)  Plans are progressing well towards the transfer/ dispersal of patients when the contract with NEMS for the Platform One GP practice finishes at the end of June.

 

(b)  The CCG has requested the most current patient list at the end of May so that all patients can be checked to ensure that arrangements for them are correct and appropriate. Colleagues are also liaising with Primary Care Networks to capture those patients who will already have started the process of moving practice themselves.

 

(c)  Communications and engagement continue to be as robust as possible with both patients and staff who will be working with vulnerable patients.  The new Parliament Street practice now has a phone number and leaflets/ information cards are ready to go to print.

 

(d)  The Severe Multiple Deprivation (SMD) Locally Enhanced Service (LES) can now start to deliver to patients.  A good percentage of GP practices across the city and county are already signed up to the service.

 

Ajanta Biswas, who chairs the Platform One Stakeholder Task and Finish Group, added the following:

 

(e)  Feedback from the Task and Finish Group, which has all relevant stakeholders around the table now, indicates that things are progressing smoothly. The Group has influenced communications with patients to ensure that they are accessible and is now monitoring the transition, liaising with the new provider (Nottingham City GP Alliance) to mitigate risks raised in the EQIA (Equality Impact Assessment).  Patients will continue to need good communications and engagement as the transition date nears and in the months once it has passed and new arrangements embed.

 

In response to questions from the Committee and in the subsequent discussion the following points were made:

 

(f)  Contract changes always take place at a single point in time, ie the Platform One contract ceases on 30 June 2021 and the Parliament Street contract starts on 1 July 2021.  All changes, including dispersal of patients outside the boundary, will take place on 1 July. Letters will be sent to all patients during June, with full details about the new arrangements.

 

(g)  Patients have the right to choose their practice (where eligible to register with that practice) and a few patients have already contacted the CCG about where they want to go.  This will be confirmed in their letters and all patients will continue to be alerted to their right to choose, even though they will have been allocated a practice if they haven’t contacted the CCG directly.

 

(h)  Parliament Street has in hand security arrangements to address any potential issues that may arise with patients with complex needs.  As much information on patients, where there may be security concerns, will be passed on to their new practices, which will already have security in place in relation to existing patients.

 

(i)  Sofa surfers/ transient patients are difficult to track. Those patients whose current registered address is Platform One will automatically transfer to Parliament Street.  If such patients move to an address outside the boundary for Parliament Street and they alert the practice, then they will need to move to a practice based on their new address.

 

(j)  In response to concerns from Committee members that not all practices will have the specialist experience to work with vulnerable patients, the CCG noted that it is part of their contract that all GPs are skilled in dealing with patient complexity and that they are used to dealing with vulnerable people’s needs and referring them to specialist services. There are no practices rated as ‘Inadequate’ by the CQC, so they should all be equipped to manage such patients.

 

(k)  The CCG cannot track patients who move address frequently.  However, practices have ways of coding patients in clinical systems, which means that new practices are alerted to specific issues when a new patient registers with them. 

 

(l)  Patients who are transferred to Parliament Street who alert the practice that they have moved at some point in the future will be able to discuss remaining as an out of area patient with Parliament Street. 

 

(m)There will be no process for automatically allocating patients outside Covid rules.  If they notify their current practice that they have moved outside its boundary, the patient has to make a choice about which new practice to register with, local to their new address.  The Parliament Street practice and the CCG would support a patient in making that choice.  The requirement to follow up a patient to make sure that they don’t fall through the gap will sit with the receiving practice.

 

(n)  GPs are expected to check the number of patients seen and to monitor their vulnerable patients against the quality outcomes framework.  In addition, most GPs have good relationships with the voluntary and community sector providers in their area and with multi-disciplinary teams working across their area.  While a patient may not be in contact with their GP, their GP will be alerted to them if they are liaising with others.

 

(o)  While the CCG commissions a GP practice, that practice decides its own staffing complement with the skill mix required to deliver the contract. 

 

(p)  The CCG is working with the Nottinghamshire Healthcare NHS Foundation Trust to ensure that patients in the Platform One cohort who access mental health services are supported to continue to access these.  Patients will be able to stay with their current Local Mental Health Team (LMHT) until they are in a position to move.  At that point LMHTs and the new GP practice will work together to ensure all needs are taken into account, eg the need to see a female psychiatrist.

 

(q)  CCG colleagues agreed that it would be possible to arrange a visit for Committee members to the SMD LES when such visits are possible.

 

The Chair thanked the CCG colleagues for attending and detailed a number of recommendations to be forwarded to the CCG for response.

 

RESOLVED to recommend that

 

1)  all patients who are being transferred from the Platform One practice to the new Parliament Street practice, who move out of the new practice catchment area at some point in the future are

 

a)  offered the option to remain with the Parliament Street practice as an out of area patient if they choose to do so; or

b)  if they choose not to remain with the Parliament Street practice, the CCG provides information about choice of which practices are available to the patient and considers introducing automatic allocation of a practice on behalf of the patient;

 

2)  the CCG monitors Accident and Emergency attendance to identify whether there is an increase in the attendance of patients who have been transferred or dispersed from Platform One, so that they can be supported to access appropriate services;

 

3)  the CCG considers introducing a means of flagging on a patient’s record that they are vulnerable and find it difficult to engage with new services/ relate to new people in their lives and explores a range of methods of communicating with such patients, ie not relying on sending letters.

 

 

 

8.

Work Programme pdf icon PDF 130 KB

Additional documents:

Minutes:

(a)  Following the discussion with colleagues from Nottingham and Nottinghamshire Healthcare Trust, the Committee agreed to request that the Trust returns

 

(i)  as soon as possible (17 June 2021) to further discuss its management of waiting lists for Step 4 Psychotherapy and Psychological Therapies; and

(ii)  to a later meeting to further discuss Eating Disorder Services and the implications for city patients.

 

(b)  Ajanta Biswas, Healthwatch, agreed that Healthwatch would request written contributions from interested stakeholders for the Maternity Services item due to be discussed with Nottingham University NHS Hospitals at the 15 July meeting.

 

(c)  Items were agreed for the 17 June meeting as follows:

 

(i)  Integration and Innovation White Paper

To consider the implications of proposed reforms to health and care and the potential local impact

(ii)  Quality Accounts 2020/21

To note the scrutiny comments to be included in provider Quality Accounts on behalf of the Committee.

 

9.

Future Meeting Dates

To agree to meet at 10am on the following dates:

2021 – 17 June, 15 July, 16 September, 14 October, 11 November, 16 December

2022 – 13 January, 17 February, 17 March, 14 April

Minutes:

The Committee agreed to meet on the following dates in 2021/22:

 

2021 – 17 June, 15 July, 16 September, 14 October, 11 November, 16 December

2022 – 13 January, 17 February, 17 March, 14 April