Venue: Ground Floor Committee Room - Loxley House, Station Street, Nottingham, NG2 3NG. View directions
Contact: Jane Garrard Senior Governance Officer
Apologies for absence
Councillor Kirsty Jones – unwell
Councillor Anne Peach – other Council business
Declarations of interest
To confirm the minutes of the meeting held on 15 September 2022
The minutes of the meeting held on 15 September 2022 were confirmed as an accurate record and signed by the Chair.
Kazia Foster, Deputy Director of Local Mental Health Services, Alison Wyld, Executive Director of Finance, Louise Randle, Head of Transformation Mental Health Services, and Alison Newsham-Kent, Eating Disorders Service Manager from Nottinghamshire Healthcare NHS Foundation Trust and Alex Julian, Senior Mental Health Commissioning Manager from Nottingham and Nottinghamshire Integrated Care Board attended the meeting to speak to the Committee about access to Eating Disorder Services for adults. They gave a presentation highlighting the following information:
a) Referrals have steadily increased over the last year, in line with national trends. As expected there was a slight drop in referrals during July and August, which was due to lower numbers of students living in the City during those months. It is anticipated that the number of referrals will continue to increase.
b) The number of referrals accepted largely tracks the number of referrals received. On average 70% of referrals in the City are accepted. Those that are not accepted are either signposted to another service or offered self-help as appropriate.
c) Across the Service the average referral to treatment waiting times have steadily increased over the last year and the Service is working to reduce this. For City patients there has been a slight increase in the average waiting time to assessment over the last year. The average waiting time to treatment was in line with this for most of 2021 but has increased at a higher rate during 2022 (with the exception of April 2022 when there was a very low number of City patients and they were assessed and treated very quickly).
d) There has been investment in the Service. A review of current and expected demand was carried out. This identified capacity gaps and a new staffing model was approved. There has been a growth in staffing posts from 10 whole time equivalents to 21.2 whole time equivalents. Some of these posts have been successfully recruited to while recruitment is still ongoing for other posts.
e) The impact of investment has included an increase in the therapeutic offer including occupational therapy, art therapy and sensory assessments; increase in reflective practice to support practitioners to consider patient needs alongside wellbeing of the team; an improved group offer; more community support workers to support with shopping skills and meal preparation etc; improved carer offer; and enhanced support for professional development and training for staff.
f) The Service is participating in a national pilot programme called First Episode Rapid Early Intervention (FREED), which aims to engage patients at an early stage with phone contact within 48 hours of the referral, an assessment within two weeks and treatment starting within four weeks. The benefits of the programme include people feeling validated by getting an assessment within a short space of time and having an early indication of whether the service is appropriate for their needs or if they need to be signposted to an alternative. Feedback received so far has been positive.
g) The Eating Disorder Service is included within the wider Severe Mental Illness Transformation Programme. The early access targets for severe mental illness services include eating disorders. At a national level there are a number of key deliverables from this Programme for Adult Eating Disorder Services including expanding clinical and non-clinical capacity; having dedicated pathways across primary care, secondary care, local authorities and the community and voluntary sector; removing barriers to access; increasing the number of patients seen; reducing waiting times; and accepting self-referrals.
h) The Trust will be looking at the issue of self-referral across all services next year.
i) In terms of governance for transformation activity, there is an All Age Eating Disorder Steering Group that feeds into the Severe Mental Illness Transformation Board and three task and finish groups that have wider representation: Medical Monitoring; Disordered Eating; and Avoidant Restrictive Food Intake Disorder (which is a relatively new classification of eating disorder).
j) The priorities for transformation in 2022/23 include continuing to enhance capacity and capability, improving service user engagement in pathway developments, continuing to monitor and evaluate the FREED model and providing training and raising awareness of eating disorders across the health and social care system.
During subsequent discussion and in response to questions from the Committee the following points were made:
k) While one of the national requirements for transformation of eating disorder services is removal of barriers such as weight and body mass index (BMI), BMI is not used as a criteria for access to eating disorder services in Nottingham. The Chair cited an example of a citizen who had contacted the Committee to say that they had received a letter from the Trust referring to a ‘BMI cut off’. The Trust assured the Committee that its policy is not to use BMI as a criteria for accepting referrals and offered to look at the specific case so that it can be learnt from.
l) When the Trust spoke to the Committee in 2021 about access to the Eating Disorder Service, the Trust indicated that it expected waiting times to have reduced by summer 2022. The data shows that waits for assessment and treatment actually increased during this period. The Trust explained that, in addition to the backlog of cases, there continued to be a high level of referrals alongside staffing challenges. Although additional posts were funded, it proved challenging to recruit to them and even when individuals are appointed there is a 3-4 month lead in to them starting.
m) The Trust is unable to control demand and it is anticipated that it will increase further, especially in the child and adolescent mental health pathway.
n) Service user feedback is sought, for example when exploring how to carry out medical monitoring, but there is currently no patient voice within governance of the service. The Trust is looking at how to do this effectively, and this will be particularly important in terms of development of the Service.
o) While there has been agreement to increase the number of posts within the Service, it has been challenging to recruit to those posts. In addition, once new staff are in post it takes time to skill them appropriately. This means that it will take time for the increase in capacity to have an impact on waiting times.
p) Given the existence of the national programme for transformation, all mental health trusts are trying to recruit staff and this makes it very competitive.
q) Referrals are discussed at weekly multi-disciplinary team meetings and if an urgent case is identified then this will be escalated. People on the waiting list will be offered self-help support as part of the Waiting Well Programme. There is also a virtual offer provided by the voluntary sector called First Steps. Initial feedback is that this has not been taken up much by patients but more formal evaluation is awaited. A committee member suggested that having patient voice in development of the service would be helpful in this regard.
r) The Trust is looking at the transition from child to adult services. There has been a Transition Worker in place for a number of years working with young people from age 17. This post is currently vacant and this has prompted a review of whether this is still the right approach. People who have experienced the transition process are being consulted on this to help identify the best way forward for that aspect of the service.
s) In terms of support for students with an eating disorder, First Steps provides an eating disorder service accessible by students and the Unity Primary Care Network has mental health support for students in place. There is a practitioner who acts as a gateway to services. There are two new roles across the primary care networks and community teams and practices are skilled up to recognise signs and signpost to First Steps or refer to clinical services as appropriate.
The Committee expressed disappointed that despite assurance by the Trust in October 2021 that work was taking place to develop the service and improve accessibility, waiting times for assessment and treatment had increased during that period. The Trust and the ICB stated that they are both committed to reducing waiting times and aiming to meet the 8 week target that will be in place by the end of 2023/24, however there are significant challenges in doing so. In response to a question about when the Trust expects waiting times to reduce, the Trust cited increasing demand, which is outside of its control, and challenges in recruitment as the main reasons for increasing waiting times and said that the situation is unlikely to improve until the Service is fully staffed. Given national recruitment issues, it is not known when this will be achieved. In recognition that many providers cite recruitment challenges in relation to their services, the Committee commented on the need for the NHS as a whole to tackle recruitment and retention issues because the situation from the perspective of a patient trying to access services is not great.
Resolved to review progress by Nottinghamshire Healthcare NHS Foundation Trust in reducing times for assessment and treatment by the Adult Eating Disorder Service in 2023.
Councillor Linda Woodings, Portfolio Holder for Adults and Health, and Sara Storey, Director of Adult Health and Care, presented the report about the Adult Social Care Outcomes Framework (ASCOF) and seeking the Committee’s view on if, and how it wants to use the Framework to scrutinise care services. They highlighted the following information:
a) The ASCOF is a set of key measures collected for local authorities responsible for social care in England and is published annually. It therefore allows for benchmarking across all councils in England or for specific sub-sets, although in making comparisons there needs to be recognition that there is a level of variability in the data collection.
b) As things have changed over time, the ASCOF is not completely aligned with statutory duties and there have been some attempts to revise the framework, although this work was postponed due to the Covid pandemic. One of the aims of this work is to explicitly link it to the Care Quality Commission (CQC) assurance framework.
c) When CQC inspection is introduced, it is likely that inspectors will utilise ASCOF as one way of reviewing a local authority’s performance.
d) The national set will be published in November.
e) Discussion is taking place about how to increase the visibility, and use of the ASCOF data within the Council. This may include linking measures to other work e.g. using it to help assess the outcomes of the transformation programme; or specifically reviewing performance against similar local authorities.
During subsequent discussion and in response to questions from the Committee the following points were made:
f) It was confirmed that ASCOF data can be mapped against deprivation indices.
g) Looking at currently available ASCOF data, Nottingham is not a high performing council. However, it is encouraging that measures reported on by citizens who use services e.g. the proportion of service users that feel safe or the contribution of services to quality of life are more positive. There are lots of improvements that need to be made and transformation will need to deliver better outcomes.
h) It is important that data, such as ASCOF, is used by the organisation to learn and improve rather than just measuring performance for its own sake.
The Committee concluded that there would be benefit in using ASCOF data to inform its work, for example helping to identify areas for in-depth consideration.
(1) use Adult Social Care Outcomes Framework (ASCOF) data as a way of holding to account for performance and to inform future work programming decisions going forward; and
(2) request that when ASCOF data is reported to the Committee, the following information is provided:
a. data in the context of transformation
b. data compared with other comparative authorities in terms of indicators such as deprivation, age and ethnicity
c. what the Service is learning from the data
Alex Ball, Director of Communications and Engagement, and Mark Wightman, Director of Strategy and Reconfiguration, Nottingham and Nottinghamshire Integrated Care Board gave a presentation informing the Committee of the proposed approach to developing an Integrated Care Strategy for Nottingham and Nottinghamshire. They highlighted the following information:
a) Each Integrated Care System is required to produce an Integrated Care Strategy that is evidence based and built on an assessment of population need, and that builds upon existing work and momentum. It must be refreshed annually in line with emerging national guidance.
b) The assessed needs of the population are as articulated in the Joint Strategic Needs Assessments produced by Directors of Public Health, which also form the basis of Joint Health and Wellbeing Strategies so these strategies should be aligned. The Integrated Care Board Forward Plan has to refer back to the Integrated Care Strategy so all of these plans should be linked and working towards the same core aims and ambitions. Historically, despite the consideration given to population health management, little has been done in this regard and this will be the first time that there is a ‘golden thread’ running throughout.
c) The vision for the Strategy is that every citizen will enjoy their best possible health and wellbeing. In order to achieve this neighbourhoods, places and systems will need to seamlessly integrate to provide joined up care and therefore priorities and priorities will need to be joined up.
d) This presents opportunities to do things differently, by having an approach that defaults to working better together with shared aims and ambitions. This should support delivery of some of the difficult things that have not be tackled to date.
e) There are four strategic aims for the Strategy: improving outcomes in population health and healthcare; tackling inequalities in outcomes, experience and access; enhancing productivity and value for money; and supporting broader social and economic development.
f) The challenge is to create specificity in the deliverables and accountabilities for these aims and this is being worked on at the moment. An idea being explored is to ring-fence a proportion of annual uplift to invest in prevention.
g) Enablers are being identified to address the reasons why progress hasn’t been made before, for example having a shared common purpose that all partners pursue relentlessly.
h) The Health and Care Act 2022 requires the involvement of Local Healthwatch organisations and people who live and work in the area in development of the Strategy. This will happen through a three stage approach. The first stage will be collating what the system already knows through desk-top research so that citizens aren’t consulted about things they have already expressed their views on e.g. what do existing strategies, that have been developed with citizen input, say. Gaps in knowledge will then be identified and the second stage will be to fill those knowledge gaps. This will be done through a range of methods including public events and questionnaires. The approach to this will be proportionate given that a lot of information is already known and there is a relatively short timescale for completing the work. There will then be consultation with Health and Wellbeing Boards, wider stakeholders and interested members of the public.
During subsequent discussion and in response to questions from the Committee, the following additional points were made:
i) It is important that resources are directed to populations that most require support and preventative activity. The Strategy will recognise that some people need more than equal access and resources will need to reflect this. Discussions are taking place with local authorities on how to achieve this.
j) All providers cite the challenges of recruitment and retention, and therefore an effective workforce strategy will be essential to delivering the services necessary to support good health and wellbeing.
The Committee supported the proposed ambitions of the Strategy but sought reassurance about how success will be measured to ensure that it really makes a difference to peoples’ lives. There could be opportunities for the Committee to hold the system to account for doing this, and the Committee would welcome proposals from the Integrated Care Board on options for its involvement.
The Committee considered written information provided by Nottingham and Nottinghamshire Integrated Care Board about proposals to make changes to the configuration of acute stroke services provided by Nottingham University Hospital NHS Trust permanent. This included information about the patient and public engagement carried out and feedback from patients and carers.
The Committee did not raise any concerns about the proposal.
Resolved to support the configuration of acute stroke services provided by Nottingham University Hospitals NHS Trust being made permanent.
The Committee considered written information provided by Nottingham and Nottinghamshire Integrated Care Board about proposed changes to neonatal services provided by Nottingham University Hospital NHS Trust. This included information about the targeted engagement carried out and the feedback from that engagement.
The Committee noted the update on work to expand neonatal capacity at Nottingham University Hospital NHS Trust through the Maternity and Neonatal Redesign Programme and did not raise any concerns.
The Committee noted its work programme for the remainder of municipal year 2022/23.