Agenda and minutes

Councillor Maria Joannou  -  on leave

Councillor Sajid Mohammed  -  unwell

None

Minutes of the meeting held on 13 June 2024, for confirmation

The minutes of the meeting held on 16 June 2024 were confirmed as a true record and were signed by the Chair.

Report of the Statutory Scrutiny Officer

Councillor Pavlos Kotsonis, Executive Member for Adults Social Care and Health, Helen Johnston, Public Health Registrar, and Tammy Coles, Public Health Principal at Nottingham City Council; Kate Burley, Deputy Head of Mental Health Commissioning at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB); Louise Randle, Head of Transformation for Mental Health Services, and SallyAnn Summers, Service Manager at the Nottinghamshire Healthcare NHS Foundation Trust (NHT); Apollos Clifton-Brown, Director of Health and Social Care at the Framework Housing Association; and Habib Akhtar and Ruth Squire from Change Grow Live Nottinghamshire, presented a report on the progress of the work to improve the co-existing mental health and substance use pathways accessible to Nottingham people. The following points were raised:

a)  The work to address co-existing substance use and mental health needs represents a strong example of partnership activity, with several organisations working together for the delivery of a range of complex interlinked services and support. Extensive work has been undertaken to align resources to offer a comprehensive support pathway. Since this partnership provision was last discussed with the Committee in June 2022, there has been a comprehensive assessment to understand population need within Nottingham, looking at three different settings: primary care within GP practices, secondary care within specialist mental health services and substance misuse services.

b)  Following the outcome of the needs assessment, four pathways were developed:

·  mental health workers from NHT embedded into community substance use services;

·  substance use workers embedded into community mental health teams;

·  substance use workers embedded into inpatient mental health services; and

·  peer support workers with lived experience of substance use working in substance use and community mental health services.

c)  Early evaluation has found that patient and staff experiences were positive, that the pathways developed had filled gaps in services, that the pathways were functioning as effective primary care rather than as conduits to other services, and that patients were connected to the right services. There is a developing parity between substance use and mental health services, with a similar spread of delivery across the services, and there are now links into homelessness support teams as well.

d)  There are two sources of funding for the partnership’s work – a recurrent stream from the ICB and a non-recurrent fund through the national Supplementary Substance Misuse Treatment and Recovery Grant, which is a fixed-term grant from the Office of Health Improvement and Disparities that ends in March 2025, with no confirmation of continuation beyond that time. Work to consider services from April 2025 will take place once it is clear what funding will be available.

e)  The programme is under constant review and there are a number of workstreams that are being developed further. Activity is underway to embed substance use workers in the Mental Health Crisis team, to improve access to the Talking Therapies service for those with substance use issues, extend the pathway in communities for older adults, develop services alongside Child and Adolescent Mental Health Services to help support young people with complex mental health needs and substance use issues transition into adult services, and work across the partnership to develop training, knowledge-sharing and best practice.

The Committee raised the following points in discussion:

f)  The Committee noted that the majority of people accessing services were men in early middle age and asked whether this was an accurate reflection of the full range of need, or whether women or other age groups were not being identified and connected with. It was explained that the development of the pathways has encouraged a widening of reach into the culturally diverse groups within the city, with a focus on targeting support to those living with severe multiple disadvantage (SMD). Prevention services are important and have been recommissioned and brought into the Council’s Public Health workstreams, with funding committed to them.

g)  The Committee asked how effective the support pathways were in engaging with people who were homeless. It was reported that the services within the partnership are designed to meet the needs of those who are hardest to reach. There are outreach workers who are able to go out into the community and prescribe, and work with people with SMD and start to build relationships with them. For treatment to be most effective, however, a stable place to live is necessary, so work centres on helping people maintain a secure residence. There are strong support services in place around people who are homeless and activity has been effective, but it is a lengthy process and takes time to deliver lasting outcomes, and waiting lists can be long. In terms of the pathways, there are now dedicated mental health workers working alongside substance use workers with people who are homeless. Support now needs to be built around supported living accommodation and ensuring its availability.

h)  The partnership has facilitated GP registration for a significant number of people who are homeless, leading to better physical health. There are fewer gaps in services due to the new support pathways, so mental health needs and substance use needs are being addressed in tandem. Work is taking place on the Council’s Local Plan to increase the available supported accommodation, in addition to the additional bed spaces becoming available in the near future. Unmet need is a national issue, with a particular impact in Nottingham. However, progress has been made in understanding the needs of the local population and the support pathways are a robust start in addressing the larger challenges.

i)  The Committee asked how the partnership worked together in a strategic way and the governance systems that it had in place. It was set out that good governance has been recognised as an important foundation of the partnership to ensure accountability, strength and alignment across services. All partners are independent organisations with their own individual systems in place. Formal governance of the partnership as a whole is delivered through the ICB and its Mental Health Board. The partnership also reports to the Safety Partnership Board, so there are plans in place to fully realise a robust governance structure through the NHS Nottingham and Nottinghamshire Integrated Care System Board.

j)  The Committee asked how the Council compared to neighbouring Local Authorities in terms of the number of people in need of and accessing the partnership’s services. It was explained that there are currently no comparable models to allow for comparison. The partnership is an innovation developed in Nottingham and other Local Authorities nationally are looking at the model with interest. Members from the partnership have been invited to webinars to share the practice model both regionally and nationally.

k)  The Committee asked if there were measurable targets set around delivery and how outcomes were being measured. It was reported that the partnership is in the process of assessing and setting challenging and ambitious targets whilst still remaining mindful of the demand on services, and that the pathways are still in their infancy. In general terms, measures the partnership will be exploring are achieving a greater reach and higher numbers of people completing treatments, and how to identify and address unmet need.

l)  The Committee asked what the most significant challenges were that the partnership faced. It was set out that the people the partnership aims to help have very complex multiple needs, alongside SMD. These vulnerable people can often fall between the gaps in traditional services and it is not always easy to identify those in the most need. Their care pathways will often have been complex, and measuring the outcomes of the different services that they have been involved with is difficult. Another issue has been an increase in demand for services across the board, with far more complex cases in recent years than seen previously, and with a wider range of co-existing issues.

m)  The Committee asked whether access to the Sure Start programme had mitigated against people needing to access the partnership’s services later in life. It was reported that there is published evidence that shows the effectiveness of the Sure Start programme, and how adversity and childhood experiences impact later life. Many adults with complex needs experienced childhood trauma, which is why the preventative services provided for children and young people are so important in reducing need for support later in life.

n)  The Committee asked how the partnership engaged with service users and those with lived experience to shape the planning and delivery of services. It was explained that, during the development of the pathways and the services behind them, there was engagement with people who had used services before and had experience of needing and accessing support, including with their families and carers. The commissioning process was supported by peer mentors and co-designed alongside expert panels, and responses to tenders were developed with input from people who would use the services to ensure that they fit the need effectively. Another listening exercise is due to take place soon now that the pathways have been established. Care will be taken to seek to engage further with those people who cannot currently access the services and how this can be improved.

o)  The Committee asked what had been done to improve communications with GPs on what services people with coexisting needs were accessing. It was reported that, through work with the Nottingham Recovery Network (NRN), a more proactive relationships with GPs has been established, leading to better information sharing. There has been a joint training event with GPs and service providers around communication and information sharing, and to inform GPs of the different pathways available for support. One issue often highlighted is access to patient records for GPs where a person presents as homeless. Links into primary care clinics are improving where the most people with SMD are registered or seek treatment. The NRN processes around communication are robust and letters are sent to GPs when assessments take place and treatment plans agreed with the patient. Where services become aware of someone who is not registered with a GP, they are encouraged and supported to register with one of the practices close to the city centre where links with the NRN are strongest. However, there will always be room for improvement and services across the partnership are working to facilitate better communication.

p)  The Committee asked what work was being done to develop services for young people transitioning to adult services. It was set out that some transition services have been in place for some time and that the partnership is aiming to build on these, reviewing best practice and using joint training to ensure consistency. Many services now offer support to young people beyond 18 so that the transition is gradual to the age of 25. There is a strong commitment to supporting young people onto the most appreciate pathway for them to adult services to ensure equity of access.

The Chair thanked the wide range of partnership colleagues from the City Council, the ICB, NHT, the Framework Housing Association and Change Grow Live Nottinghamshire for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To recommend that partnership work continues to seek to identify the groups of people and communities that have co-existing care needs that are not currently being met, and that careful consideration is given to how people with unmet care needs could be engaged in the co-production and design of the services to support them.

2)  To recommend that close partnership work is carried out to ensure that people with co-existing care needs who have entered one service are actively linked to the right provision for needs supported by a different service.

3)  To recommend that there is a close partnership focus on street outreach to ensure that people who have co-existing substance use and mental health needs and are also homeless or sleeping rough have as much support as possible while waiting for permanent accommodation, and that the urgent need to ensure permanent accommodation for them is advocated by the partnership to Nottingham City Council, to help inform the Council’s development of its new Housing Strategy and Local Plan.

4)  To recommend that the partnership engages with the NHS Nottingham and Nottinghamshire Integrated Care Board to give further consideration to how it can be ensured that people with co-existing substance use and mental health needs without a permanent address have access to a GP, and that their GPs are communicated with effectively on the related treatment that they are receiving.

5)  To recommend that consideration is given by the partnership as to what key performance indicators could be established to demonstrate the outcomes for Nottingham people as a result of the service improvements being made.

Report of the Statutory Scrutiny Officer

Lucy Dagde, Director of Integration, Alex Ball, Director of Communication and Engagement, and Sarah Fleming, Programme Director for System Development at the NHS Nottingham and Nottinghamshire Integrated Care Board (ICB), presented a report on the current financial position in the local NHS and the plans to achieve financial stability over the next two years. The following points were raised:

a)  The ICB has a duty to plan to provide services to meet the local healthcare needs, but these must be deliverable within the available financial envelope. To do this, there is ongoing assessment of the effectiveness and efficiency of services, so that interventions can be targeted to best improve outcomes. There are inevitably many pressures within the system but, regardless of these, funding for services has increase year on year, which is reflected in the annual growth of the ICB’s budget. However, the local healthcare system is now in a position where significant savings need to be made for it to be sustainable, going forward.

b)  To ensure best value, reviews regularly take place to consider the existing pathways and ensure that they represent the most effective and efficient use of funds. The ICB has taken a systematic approach to ensuring that commissioning is effective and offers value for money. These reviews have been done early in the financial year to allow proactive engagement with the public, partner organisation and statutory providers to ensure services fit the need of Nottingham people.

c)  Many of the budget savings proposals being put forward represent business as usual processes across services in both Nottingham and Nottinghamshire to ensure good value for money and financial sustainability. No formal decisions on potential service changes have yet been taken. Formal engagement will need to take place around proposed changes prior to final decisions are made. Decisions need to be reached with a shared view from partners, with the proposals outlined represent opportunities for achieving savings and efficiencies within the local healthcare system.

d)  The ICB is considering savings opportunities in services across Nottingham and Nottinghamshire, and the following proposals may have implications for people in the city:

·  a review of historical Discharge Care Packages to ensure the appropriateness of existing care;

·  a review of a variety of prescription and medication management policies;

·  a review of Section 117 aftercare process and policies for appropriateness and need following a mental healthcare intervention;

·  a review to ensure the best use of the Better Care Fund to achieve safe discharge from hospital;

·  formalising a joint funding policy to establish more timely joint assessment by a nurse and a social worker to determine need, with directly commissioned services and a review of existing cases;

·  a review of all cases of one-to-one care both old and new to ensure appropriate levels of care are provided;

·  a review of all adult healthcare packages to ensure they are still in line with policy;

·  a review of all children’s care packages to ensure they are tailored to the needs of the child and offer value for money;

·  a review of the structure of fast-track services to provide consistency across the area and reduce inappropriate referrals;

·  carrying out robust case management for high-cost care packages, alongside a review to ensure the continued appropriateness of care and services provided and to consider how they could be delivered more efficiently; and

·  discontinuing a non-statutory transport service for people with Continuing Healthcare needs to day services and respite care as part of care packages.

The Committee raised the following points in discussion:

e)  The Committee emphasised that, ultimately, it was vital to ensure equity of outcomes across the healthcare system, with resources targeted effectively to the areas of greatest need – particularly in the context of prevention. It was explained that the ICB will have a clear focus on prevention work and would not close related services – though prevention activity may need to be carried out differently. A great deal of work is being done to reduce the need for high-cost hospital interventions and increase community care, including through GPs. All consideration of delivering cost-effectiveness will be done in the context of achieving equity of outcomes for patients.

f)  The Committee noted that it had raised concerns with the ICB around the proposed early closure of the Fracture Liaison Services (FLS), as this would have a significant impact on likely frail and vulnerable patients. It was confirmed that the FLS would now continue to operate for the full period of its current contract whilst a review of the service was undertaken.

g)  The Committee raised concerns regarding the discontinuation of certain transport to care services, as this would reduce equity of access. It was reported that the ICB was proposing to stop transport services to day and respite care where these were not a statutory duty – but transport needs might form an element of individual care packages, and transport services to hospital outpatient appointments will be unaffected.

h)  The Committee asked how the ICB was using, or considering using, advances in Artificial Intelligence (AI) technology to improve the delivery of care. It was set out that AI offers a number of opportunities. For example, AI programmes are quicker at reading breast screening scan imagery, which frees up radiographers to do other work. AI can also be used to predict the care needs of changing populations and can be used to make longer-term care plans. However, this is an emerging field and more work needs to be done before AI could be introduced widely across the ICB.

i)  The Committee asked what assessment of impact of the proposals on the services provided by partner organisations had been done, including on services provided jointly with the Council.  The Committee was concerned that the proposal to delay the further roll-out of virtual wards, for example, might have a significant knock-on impact on hospital and ambulance services. It was explained that the ICB is liaising with leads from across the system around the proposals and how they may impact partner services. In terms of the virtual ward proposal, there will be no reduction in the provision – but the service will not be further rolled out or extended for the time being. A review will take place to ensure that the current provision is properly utilised and that the existing capacity is being used fully before growing the service further.

j)  The Committee asked for more details on the considerations given to proposals affecting Pathway One hospital discharges. It was reported that the ICB’s proposals do not reduce the amount of support available for discharge, but look at how the additional support needed can be provided more efficiently and in the most cost effective way. The proposals do not seek to reduce care, but to work with the market to be more effective, so options are being worked through with providers to establish a collaborative provision. Care will still be in place, but will be delivered differently, and there is no intention to remove Pathway One care for those that need it, or to pass costs on to social care services.

k)  The Committee asked why budgeted pilot schemes were listed in the savings proposals and raised concerns that their appeared to be an appreciable impact on preventative services. It was explained that no pilot schemes are being stopped, but they may be paused or not rolled out further so that a full review can take place on each one to ensure that the funding is being used for the most benefit. The ICB is seeking to focus on getting the core functions right and working efficiently, and will then look to the additional services that can be provided.

l)  The Committee asked how consultation with service users would take place and asked for examples of successful consultation that the ICB had undertaken recently. It was reported that consultation around changes to the Newark Hospital Urgent Treatment Centre had included public meetings at various times of the day (including evening), local councillors had been involved and made recommendations around community groups for the ICB to approach and engage with, and written information was provided in a variety of formats and languages.

m)  The Committee asked for additional details around the proposals affecting Section 117 aftercare services. It was explained that the review here will focus on the outcomes for patients and consider service redesign to improve these, with targeted future commissioning moving forward. Packages will be reviewed in consultation with patients on a case-by-case basis to stop inappropriate or unneeded care, with a greater focus on effective case management. If, when reviewed, it is clear that care is still needed to prevent crisis, then it will remain in place. There would be an appeals process if patients felt that care had been reduced but was still required.

n)  The Committee asked for more details on the proposals around children’s care packages. It was set out that children’s care packages are often complex and are individually tailored to each child. Each package will be carefully reviewed to ensure that the level of care is provided according to the required need.

o)  The Committee sought assurance that appropriate investment in mental health services would continue. It was reported that the Mental Health Investment Standard would be maintained, with work done to assess what is being invested and the outcomes this is achieving, to identify any service re-design needs.

p)  The Committee queried what the ICB’s timelines for delivering savings were and when they could expect additional information on the likely impact of the proposals on current and future service users, and how staff and patients would be engaged in effective consultation. It was set out that a process is underway to identify which proposals will require full Equality Impact Assessments (EQIA), and this information will be shared when it is available. Clinicians will be involved in the review processes to ensure that service delivery remains appropriate and, if significant service change is required, formal consultation processes will then be carried out as needed.

q)  The Committee considered that meaningful consultation with people with lived experience would be fundamental to establishing sustainable services for the future. Healthwatch will be well-placed to broker conversations with patient groups to ensure consultation engages with those most affected, and there must be open and ongoing conversations with clinicians around medicine reviews so that any changes are applied in a properly managed way.

r)  The Committee noted that it had met on 16 May 2024 to review the psychological therapy services that could be accessed by Nottingham residents. During those discussions, the Committee became concerned regarding information that the Centre for Trauma, Resilience and Growth (CTRG) service had been discontinued as of 8 May 2023 – and, although related services were now being delivered through the wider Secondary Care Psychological Therapies Pathway via Step 4, this provision did not appear to be substantively the same as that which had been available through the CTRG.

s)  The Committee had neither been informed of nor consulted on this change of service by either the Nottinghamshire Healthcare NHS Foundation Trust (NHT) as the provider or by the ICB as the commissioner, so was of the opinion that, fundamentally, the closure of the CTRG represented a tangible change to the NHS services delivered to Nottingham people – rather than a simple streamlining of pathways to deliver substantively the same services in a more efficient way. As a result, the Committee considered that it should refer this matter to the Secretary of State, subject to any further action by the ICB to seek to address this issue locally.

The Chair thanked the Director of Integration, the Director of Communication and Engagement, and the Programme Director for System Development at the ICB for attending the meeting to present the report and answer the Committee’s questions.

Resolved:

1)  To request further detail on:

a)  the NHS Nottingham and Nottinghamshire Integrated Care Board’s (ICB’s) assessment of the likely impacts of its current proposals on Nottingham people;

b)  the ICB’s view as to the relative severity of these impacts;

c)  the evidence base that the ICB has used to form these conclusions; and

d)  whether the ICB considers that it needs do any further evidence gathering or engagement to ensure that its proposals for the delivery of a sustainable local healthcare system are fully informed and have the lowest possible negative impact on service users.

2)  To request the results of the ICB’s current Equality Impact Assessment screening exercise, once it has been completed.

3)  To request further information on how investment for prevention in relation to both mental and physical healthcare services will be sustained going forward, in the context of the ICB’s proposals.

4)  To request confirmation of the general parameters to be applied by the ICB against which care packages will be reviewed in order to identify savings opportunities.

5)  To refer the closure of the Centre for Trauma, Resilience and Growth to the Secretary of State on the grounds that a significant change to a NHS-commissioned service had been carried out without proper consultation, subject to any new action by the ICB to seek to address this issue locally.

6)  To recommend that the ICB engages closely with partner organisations, including the Council, on the potential cost impacts of the proposed changes to the funding of joint care packages.

Report of the Statutory Scrutiny Officer

The Chair presented the Committee’s current Work Programme.

The Committee noted the Work Programme.