Agenda and minutes

To note that Councillor Phil Jackson has been removed as a member of the Health Scrutiny Committee

The Committee noted that Councillor Phil Jackson had been removed as a member of the Health Scrutiny Committee

Councillor Cate Woodward

Councillor Angela Kandola

Councillor Maria Joannou

None

To confirm the minutes of the meeting held on 15 July 2021

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

Julie Attfield, Director of Mental Health and Learning Disabilities, Nottinghamshire Healthcare NHS Foundation Trust and Alison Smith, Clinical Psychologist, Step 4 County Psychology, Nottinghamshire Healthcare NHS Foundation Trust attended the meeting and gave a presentation which included information on access to psychological support and Nottinghamshire Healthcare NHS Foundation Trust’s plans for improving access to psychological support. The following information was highlighted:

a)  The Committee had previously identified a number of concerns about mental health services, including concerns about waiting times and access to Step 4 Psychotherapy and Psychological Therapies.

b)  The Step 4 Psychology Service provides psychological assessment and treatment (individual and groups) to adults with complex psychological and mental health difficulties that are unsuitable for intervention with a lower step of care. These include Post Traumatic Stress Disorder (PTSD), anxiety, depression, multiple comorbidities, on-going or recurring psychosis and attachment difficulties and complex trauma.

c)  The service offers psychological assessment and treatment (individual and groups) to adults with complex psychological/mental health difficulties and was established out of the decommissioned Health in Minds (IAPT) 2011/12.

d)  At present, there are 10.2 whole time equivalents (wte) employed, which includes Clinical Psychologists, Counselling Psychologists, Nurse Specialists and Psychotherapists.

e)  The current target (within the Service Level Agreement) is to see people for a psychological assessment within 8 weeks, which is met for the majority of people. There is a target of 26 weeks for those waiting for therapy.  The average waiting time is currently 10.5 months compared with 9 months in 2019.  There are a number of individuals waiting longer than the average, but some of these are for elective reasons.

f)  There has been a significant impact on the Service due to Covid, which resulted in the following:

·  Pause of 1:1 sessions

·  A shift from meeting face to face to conference/video calls

·  A reduction in discharges

·  Impact of staffing variations.

g)  In order to improve the waiting list management there has been recruitment of two part-time trainee psychologists and an assistant psychologist; and regular updates have been provided to those on waiting lists.

h)  The next steps in improving the Step 4 Psychology Service include:

·  extending the waiting list recovery plan into 2022;

·  increasing the frequency of group intervention programmes (through a range of delivery methods); and

·  ensuring patients are ‘therapy ready’ before accessing Step 4 treatments.

Louise Randle, Nottinghamshire Healthcare NHS Foundation Trust updated the Committee on transformation activity taking place that will impact on Step 4 Psychological Therapies.  The following information was highlighted:

i)  There is a large programme of works being undertaken in relation to Severe Mental Illness Transformation.  £975million will be invested in services by 2023-24 to treat those suffering from severe mental illness. This will benefit over 370,000 people through the following improvements:

·  expanded access to support, care and treatment

·  increased access to psychological therapies

·  removal of thresholds

·  a ‘no wrong door’ approach

·  enabling choice and flexibility

·  facilitating a multi-sector approach

·  integration between services and providers

·  a person centred and strengths based approach.

j)  National targets in the transformation programme are ambitious, for example there is a proposal for access to care and treatment to be within eight weeks.  These waiting time standards are being tested nationally.  Initially these will be targets for improvement and something for providers to work towards.

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

k)  The number of people on the Step 4 waiting list currently is approximately 74, however the number fluctuates due to some individuals no longer requiring access.

l)  The Trust assured the Committee that support is offered to individuals while they are on the waiting list.  Individuals on the waiting list are assessed initially, and phone contact is made after three months to assess how they are and whether their needs have changed.  A face to face review is offered at six months.  Individuals can opt in or out of these reviews.  Individuals will be redirected to another service if they are identified as waiting for an inappropriate service.  Individuals are kept informed about the length of waits.

m)  In response to concern raised by some Committee members about the implications of an individual receiving lower levels of care whilst waiting for specialist support, the Trust assured the Committee that if this happens an individual will not be removed from the waiting list for Step 4 services.

n)  The Trust acknowledged that there have been significant staffing shortages which has put pressure on the Service, and this has been a contributing factor in longer than ideal waiting times.  A number of agency and non-agency staff have been recruited to address staffing pressures.  The service does want to recruit and retain permanent staff but agency staff are currently being used to achieve a swifter increase in capacity of experienced staff.

o)  New referrals are being better managed, but the challenge is dealing with the current ‘bulge’ of cases that have accrued.  Due to the length of courses of therapy, it is not anticipated that there will be a significant change in waiting times for treatment until summer 2022.

p)  It is anticipated that the transformation programme will help improve access to a range of services such as behaviour therapy and counselling, as well as building capacity in the psychological support service and preventing people from becoming more mentally unwell.

q)  Consideration will be given to additional training and upskilling of other healthcare professionals to try and reduce inappropriate referrals to the service or referral of patients who are not ready for treatment.  Increasing the number of psychologists in local mental health teams, which is part of the Transformation Plan, will also help to improve understanding and the appropriateness of referrals. 

r)  Committee members suggested that in order for change delivered through transformation to be effective, it needs to be developed from a service user perspective.

The Committee remained concerned about the current length of wait for Step 4 Psychotherapy and Psychological Therapies, but welcomed the actions being taken by the Trust to reduce waiting times for treatment.  The Committee noted that the Trust said waiting times should be significantly improved by summer 2022 and decided to review the position again at that point.  The Committee welcomed assurance provided by the Trust that individuals receiving lower levels of care whilst waiting for specialist support are not removed from the waiting list for Step 4 services but felt that it would be useful to receive more detailed anonymised information on the reasons why individuals do leave the waiting list and their care destination. 

Resolved to

(1)  request that Nottinghamshire Healthcare NHS Foundation Trust provide anonymised information on the reasons why individuals leave the waiting list for Step 4 Psychotherapy and Psychological Therapies and their care destination, including those eligible for Section 117 aftercare; and

(2)  review Nottinghamshire Healthcare NHS Foundation Trust’s progress in reducing waiting times for Step Psychotherapy and Psychological Therapies and improving outcomes through transformation in summer 2022.

The Committee was reminded that the proposal to permanently reconfigure acute stroke services provided by Nottingham University Hospitals NHS Trust had been identified as a substantial variation or development of service.

Lucy Dadge, Chief Commissioning Officer, Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) and Dr Manik Arora, CCG Governing Body GP, updated the Committee on the development of proposals to reconfigure acute stroke services. The Committee noted that it was not possible for a representative of Nottingham University Hospitals NHS Trust to attend due to Covid-related restrictions.  They highlighted the following information:

a)  Nottingham University Hospitals (NUH) stroke service is the second largest stroke service in the East Midlands region. In response to the Covid-19 pandemic acute stroke services were temporarily moved to the Queens Medical Centre (QMC) campus on the 14 July 2020, where they currently remain.  The Committee was advised of this in July 2020 and further details were provided to the Committee at its meeting in September 2020.  

b)  The relocation of acute stroke services enabled NUH to comply with the national directives related to nosocomial (hospital acquired) Covid-19 infections with implementation of temporary new patient pathways with dedicated Covid and non-Covid areas on the City Hospital campus.

c)  There is also a clear clinical case for the reconfiguration of stroke services and specifically for the centralisation of hyper acute stroke services. The change is aligned to regional and national stroke strategies and is a stated ambition of the local Clinical and Community Services Strategy review for stroke services.

d)  This review was underpinned by strong patient and public involvement from stroke survivors alongside staff and clinicians.  The Stroke Association supported a number of patient engagement sessions, including with people who had been cared for previously by the service.

e)  Rapid diagnosis and treatment is essential to ensure the best possible patient outcomes. The relocation of Acute Stroke Services to the QMC site ensures that key assessments, investigations and interventions take place in a timely manner.

f)  There are three main geographical alignments that are achieved through the relocation to the QMC site that are critical to patient outcomes:

  i.  Acute Stroke Services are now geographically aligned with the CT scanner. Undertaking a CT scan for stroke patients as soon as possible after arrival at hospital is vital as it provides valuable clinical information that informs the patient pathway. When on the City campus, Acute Stroke Services and CT scanning were on two different sites resulting in additional ambulance journeys.

  ii.  Acute Stroke Services are now geographically aligned with Medical Thrombectomy Services. The Medical Thrombectomy (MT) Service at QMC delivers services for the entire East Midlands area. Prior to the move to the QMC campus, the Trust was one of only two Neurosciences Centres in the country that did not have a co-located hyper-acute stroke unit and Medical Thrombectomy Service

  iii.  Acute Stroke Services are now geographically aligned with other critical specialities such as the Emergency Department, Neurology and Neuro-surgery and the proximity to such medical specialities is key.  Some patients presenting acutely with stroke-like symptoms turn out to have an alternative diagnosis, for example, a brain tumour. As Acute Stroke Services are now co-located on QMC sites alongside the Neurology and Neuro-surgery departments, this enables ‘stroke mimic’ patients to be identified and put on the correct (non-stroke) patient pathway earlier.

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

g)  Changes to travel times are likely to have a more significant impact on patients living in the County rather than the City.  The CCG confirmed that as proposals are further developed the travel impact analysis will be updated.

h)  As the proposals relate to the hyper acute stroke phase the impact on other health and social care services is likely to be limited but the CCG confirmed that the potential impact will be explored as proposals are developed.

i)  With the reduction of Covid-19 admissions the Medicines Division is now in a position to undertake the remaining developmental work and it is anticipated that we will see a positive upward trajectory for the stroke SSNAP metrics alongside improved patient outcomes.  This information will be considered in evaluation of the proposal.

j)  Although the temporary change to configuration has already been made, if it is determined that making the change permanent is not the appropriate way forward, the CCG confirmed that it is possible for services to revert to their previous configuration. 

The Committee requested that representatives of Nottingham and Nottinghamshire Clinical Commissioning Group attend the Committee’s meeting in April 2022 to update the Committee on development of proposals for permanent reconfiguration of acute stroke services, including the findings of engagement that it is planned to carry out, to enable the Committee to consider how the proposals are responding to issues raised during engagement and whether the proposal is in the interests of local health services.

The Committee received and noted a written report from the Nottingham and Nottinghamshire Integrated Care System on the Local Covid-19 Vaccination Programme.

The Chair reported that, as agreed by the Committee in July, she had spoken with representatives of Nottingham and Nottinghamshire Clinical Commissioning Group about the independent review of maternity services provided by Nottingham University Hospitals NHS Trust to seek assurances regarding the terms of reference and process for, and publication of the review. Based on these assurances, the Committee welcomed the review but given the likely timescales of 12-18 months for its completion decided to review the Trust’s progress in making improvements to maternity services in February 2022.

The Chair drew the Committee’s attention to the report recently published by the Care Quality Commission following its inspection of Nottingham University Hospitals NHS Trust.  The report re-rated the Trust as Requires Improvement overall, with an Inadequate rating for the Well Led Domain.  The Committee was concerned by this report and agreed to invite a senior representative of the Trust to a future meeting alongside organisations including NHSE/I and the CCG, who will have an important role in support and oversight of the Trust.