Venue: Ground Floor Committee Room - Loxley House, Station Street, Nottingham, NG2 3NG. View directions
Contact: Zena West Senior Governance Officer
Apologies for absence
Councillor Merlita Bryan - personal
Councillor Eunice Campbell-Clark - personal
Councillor Andrew Rule - work commitments
Councillor Chris Tansley - unwell
Councillor Cate Woodward - unwell
Declarations of interest
Minutes of the meeting held 24 January 2019 (for confirmation)
The minutes of the meeting held on 24 January 2019 were confirmed as a true record and signed by the Chair.
Report of the Head of Legal and Governance
Hazel Buchanan and Dr Hugh Porter, from the Nottingham City Clinical Commissioning Group (CCG), attended to update the Committee on the work taking place to ensure that all citizens had access to good quality General Practice (GP) services now and in the future.
Hazel Buchanan reported that there were 53 GP practices in the City of Nottingham of a mix of sizes, but that the number of practices with only 1 GP had reduced to 9 following a scheme of mergers. While 1 practice had closed in the last 12 months, this was due to its joining with another practice.
The following points on the circulated Nottingham City CCG Primary Care update were highlighted:
(a) section 3 set out the extra funding going into Primary Care, with a focus on improving access to GPs. As part of this, the GP Alliance was identified as a group of practices that had come together in the City to provide good collective support. The Alliance was providing extended hours (representing 700 additional appointments per week), which had been well-booked and attended, and opened an additional 700 appointments for December 2018 and January 2019 during normal opening hours, which relieved pressure on hospital Accident and Emergency units. The Alliance aimed to establish a multi-disciplinary team (including pharmacists and healthy lifestyle specialists) to find the right skills mix to give the right service to patients;
(b) the Primary Care Patient Offer launched in 2016 focused on increasing access to GPs, with more same-day urgent appointments, bookings for nurse appointments available 4 weeks in advance and more GPs available for video consultations. Longer, interpreter-assisted appointments are available at 13 practices, to better support the City’s diverse population;
(c) in the City, there have been 2 boundary reductions to improve access and 1 practice list has been closed (with permission from the CCG), for a 6-month period;
(d) the Care Quality Commission (CQC) has inspected all 53 GP practices, with 4 rated ‘outstanding’, 42 ‘good’, 6 ‘requires improvement’ and 1 ‘inadequate’. The 6 practices requiring improvement have been re-inspected and the majority are progressing to ‘good’, with the CQC offering support in the delivery of action plans for improvement;
(e) the GP Alliance will be taking over the ‘inadequate’ Bilborough practice from 1 April 2019 as the contractors, as they have done before at South Lake, where the practice was turned around within 6 months;
(f) there is variation in the workload between practices, with extra funding injected to bolster reception and clerical staff, with more active signposting of patients towards other services that they might need. Workforce numbers are a serious concern at both the local and national level and the international recruitment drive resulted in only 1 applicant for the area. However, there has been an increase in GPs coming into Nottingham to train and there are opportunities to keep these people and their skills, as well as introducing pharmacists into GP practices;
(g) Dr Hugh Porter reported that the GP Forward View seeks to align with the NHS Long Term Plan, improving access and quality for patients and resilience in the workforce. The Plan aims to reorient the NHS to respond better to cost pressures and changing demographics and expectations. There will be a move away from competition and towards Primary Care Networks, which will focus on individual populations and their health needs. The new 5-year GP contracts will encourage practices to collaborate at the Network level and engage with other partners to react to community needs and address other health-related issues, such as loneliness, more effectively;
(h) the Government aimed to increase GP numbers by 5000, but numbers are lower currently than they were in 2016. More support is being built through GP+, with funding for further access to social prescribing, physiotherapists and pharmacists, to support GPs. Positively, the current GP training cohorts have been filled, with the new 5-year contract designed to provide stability and resilience, and the opportunity to develop holistic thinking for the quality of care to be provided to communities.
Following further discussion and questions from the Committee, additional information was provided:
(i) With regards to how citizens who moved between practice catchment areas frequently (particularly those with a high level of vulnerability) would maintain easy access to referred services such as mental health, Dr Hugh Porter explained that practices are linked to a national contract, which includes the establishment of a CCG-agreed catchment area where GPs will be able to carry out home visits when needed. Other options exist and are being trialled, but practices have full discretion to decide whether they will continue to offer services to patients who have left their catchment, or not. To make movement between practices more straightforward, an electronic system for transferring patient records has been put in place. Provision has also been made at a local level for supporting patients of no fixed address, while access to mental health services is provided though two areas across the City. It is intended that, by 2021, more practices will be able to carry out consultations for patients outside their catchment areas;
(j) practices are able to both offer interpreter options in advance and when a patient arrives at a practice without forewarning, as this is a legal requirement. Funding beyond the core standards is being given to practices in the most diverse areas so that they can manage the longer appointment slots needed for patients who required interpreters;
(k) that the decision whether to have drop in surgeries to ease appointment waiting time is a decision made at the discretion of the individual practice, but there are required response times for routine and emergency appointments. As there has been a huge increase in demand over the last 5 years, the GP Alliance aims to bring practices together to offer support and share effective practice;
(l) support is being offered to practices struggling with estates issues, as these could have a negative impact on morale and recruitment;
(m)the CCG has a major focus on the homeless, who are clearly very vulnerable people. Practices in areas where homeless people frequent have been provided with extra support to build expertise and create homelessness hubs, working closely with homelessness teams;
(n) the number of single-handed practices is shrinking and experience suggests that the younger generations of doctors prefer to work in larger teams. It is a challenge for a practices to achieve a large size, but this offers the benefits of being able to provide a wide range of services and strong staff resilience. However, it is considered important to establish practices of a manageable size that will be locally responsive and maintain a good continuity of care;
(o) the new contacts will be put in place on a tight national timeframe, with the Primary Care Networks to be identified by the end of May 2019. The needed cultural change will follow more slowly after the structural reorganisation, with support to help practices ease into the new system;
(p) progress is being made in meeting the action plan for improvement at the Bilborough practice rated as ‘inadequate’, and the CQC will inspect the practice again after the GP Alliance has taken over management from 1 April 2019.
1) thank the representatives of the Nottingham City Clinical Commissioning Group for their presentation and note the contents;
2) note that positive progress has been made in enabling access to GPs; and
3) request further update on the progress of the GP Forward View in 6 months’ time.
Report of the Head of Legal and Governance
Colin Monckton, Director of Strategy and Policy, attended to brief Councillors on the implications of the NHS Long Term Plan for Nottingham, highlighting the following points:
(a) the Plan was published on 7 January 2019 and sets out the NHS direction over the next 10 years, with £20.5bn to be spent over 5 years with the priorities of better integration of health and social care, improving prevention and early intervention, and addressing health inequalities. There will be a commitment to mental health, children and young people, with changes to make procurement processes more efficient and further investment in community teams, to help Local Authorities (LAs) take on more responsibility for good performance;
(b) as part of the plan, systems will be:
(i) restructured, with the clear expectation that LAs will aim to participate in their local Integrated Care Systems (ICS). ICSs will have partnership boards to include LAs with accountability and performance frameworks. There will be a stronger role for the NHS in commissioning preventative health services and the NHS will support local approaches to blending health and social care budgets where councils and CCGs agree;
(ii) redesigned, with a comprehensive rollout of personalised care and personal health budgets. Where outpatients and testing move from acute into community care, LAs will work in partnership with hospitals with major Accident & Emergency departments to reduce delayed transfers of care. New commitments will be in place for reablement and community care to an age-appropriate model;
(iii) reoriented, to create a service design aim that will avoid preventable hospitalisation and tackle the wider underlying factors of mental and physical ill-health. It will tackle health inequalities and include place-based prevention, early intervention and a focus on wider lifestyle, and facilitate the rollout of social prescribing;
(iv) refurbished, so that data management will be improved. The property estate will be maximised, teams and targets will change with the new NHS workforce implementation plan later this year, with community two-hour crisis teams, two-day access to reablement and clinical support for care homes; and the improvement of technology over the next 10 years;
(c) the Plan will be implemented alongside the Adult Social Care Green Paper due in early 2019, the publication of Local Plans for 2019/2020 by April 2019, the publication of local 5-year plans by Autumn 2019, the National Implementation Programme spending review of decisions on social care and Public Health, the Green Paper on prevention and proposed changes to legislation on competition in procurement;
(d) for funding, every area in England will receive a cash increase of at least 17% over the next 5 years, including a minimum rise of 4.4% in 2019/20, with £1bn a year distributed according to greatest need. NHS England will introduce a more accurate assessment of need to ensure the allocations formulae is more responsive to the greatest health inequalities and unmet need from April 2019;
(e) the primary risks include: a potential lack of detail, with the NHS planning guidance still to follow; that the ICS plan will not take a sufficiently place-based approach; that funding is used to fill the holes rather than to create change; that the NHS simply adds a new community function, rather than transforming its general approach; that the commissioning culture does not improve; and that the workforce does not exist to deliver the aims.
Following questions and comments from the Committee, some additional information was provided by Colin Monckton, Serena Broughton and by Dr Hugh Porter:
(f) 111 is a free number to help patients of all needs navigate to the right service, but it also has a clinical function and is able to make appointments for patients at GPs with electronic booking systems. A major objective of the system is to ensure that patients are not forwarded to multiple different points of contact before they reach the service that they need;
(g) the current situation with regards to tackling issues such as gambling addiction is being assessed to develop a collaborative approach to this and related issues;
(h) achieving joined-up, cost-effective decision-making is a major objective, and carers could be given access to the details of a patient’s course of treatment to support them in following it;
(i) currently, the areas of greatest financial need are identified using a formula-driven process lead by the Accounting and Corporate Regulatory Authority (ACRA). It is anticipated that the formula will be financially positive for the City, but it is not yet clear to what degree;
(j) there is a national requirement for the provision of 24/7 mental health crisis services by 2021, with more funding being allocated to help meet the challenge of recruiting and retaining a suitable workforce. A significant effort will be made to improve home resolution and to ensure that patients are not moved outside their community for treatment. A major focus will be on helping people to not reach the crisis point, with more guidance to be issued as part of the Long Term Plan;
(k) a local and collaborative response on commissioning of services is required to avoid perverse incentives encouraging one body to seek to pass costs to another under the pressure of the demands of regulators, rather than aligning resources to being the greatest benefit.
1) thank the Director of Strategy and Policy for sharing the initial information on the NHS Long Term Plan; and
2) consider the NHS Long Term Plan in more detail at the next meeting.
Report of the Head of Legal and Governance
Alison Challenger, Director of Public Health, attended to update Councillors on the progress in implementing the changes to Targeted Intervention services agreed as part of the Council’s budget in March 2018 and on the strategic approach to fulfilling Public Health responsibilities and improving the wellbeing of citizens, highlighting the following points:
(a) LAs have been given a statutory responsibility for improving the health of the local population and reducing health inequalities for the last 6 years (including delivering the National Child Measurement Programme, universal health visitor reviews, sexual health services, NHS Health checks, drug and alcohol treatment services, health protection and public health advice for NHS commissioners), with the aim of achieving healthier local populations;
(b) the ring-fenced Public Health Grant for delivery has reduced by 2.6% per year since 2015/16, resulting in a £32,937m budget for 2019/20. As such, ensuring that NHS services are commissioned for best value and delivered to the areas of greatest local need is of primary importance, and it is vital to also invest in other areas to increase the potential for good health, such as parks, good quality safe housing and better air quality. The main health and wellbeing priorities are to engage with obesity, smoking, alcohol related harm, mental health, dementia, loneliness, sexual health and teenage pregnancy, support in the early years, and dental health;
(c) a system-wide approach (with a major focus on the most vulnerable) is being built, in partnership with the GP Alliance, to help people stop smoking. This includes creating smoke-free hospitals, with specialist advisors and services available on site – particularly to those people most at risk. A weight management app has been developed and a weight-loss programme commissioned from a major provider, but current funding levels are extremely limited. It is hoped that the NHS Long Term Plan will make engaging with these issues much more routine for clinicians;
(d) NHS Health check invites saw a 64% increase in quarters 1-3 of 2018/19 (compared to the same period in 2017/18). External funding was secured (in conjunction with partners) to reduce physical inactivity, Nottingham’s Time to Change Hub was launched with more than 70 local champions recruited, and arrangements have been made with the CCG to sustain the Knowledge & Resource function;
(e) the City’s policies aim to maximise the contribution to public health outcomes across its wider services and functions, incorporate health considerations into decision-making across sectors and policy areas, and utilise the unique position of LAs to address the social determinants of health, with an initial focus on training the wider Council workforce to talk to citizens about healthy lifestyle behaviours. This supports the national November 2018 policy context of positive recognition of the importance of prevention, the NHS Long Term Plan and the upcoming Spring 2019 Prevention Green Paper – though further reductions to the Public Health grant will still be implemented.
Some further information was provided, following questions and comments from the Committee:
(f) the current flu season has not yet concluded, but that there have been more vaccinations and fewer flu cases than in previous years. Practices are advertising the vaccinations and take-up rates are growing, but there is still capacity for improvement;
(g) Public Health is committed to achieving a 95% coverage rate for vaccinations to achieve herd immunity, with a major focus on improving the uptake of the MMR vaccine, which is currently at around 90-91%. It is hoped that the distribution of evidence-based information on the benefits and safety of vaccines will help to address citizens’ concerns, but this can be an emotionally contentious topic – particularly on social media. Some cases of measles have started to appear, so it is important for GPs to promote vaccines and keep take-up records;
(h) there is no legal requirement for care home staff to receive an annual flu vaccine, but policy is that they should be vaccinated as part of their duty of care to residents;
(i) there are a number of specialist staff available, but a more universal approach is being developed. In the context of stopping smoking, many people now approach their GP or try to quit by themselves rather than seeking specialist services, so new online, group and one-to-one support structures are being established. As smoking has such a large impact on a person’s health throughout their life, it needs to be addressed by medical staff as routinely as possible;
(j) every effort is made to assess a patient as a full person and arrive at the right diagnosis, and alcohol-related issues will not prevent a patient from also having full access to mental health support services;
(k) early investment in the health of children has a huge benefit and there are substantial expectations on Health Visitors, who provide a strong, early intervention service. Nottingham City has a relatively high number of Health Visitors, who receive assistance from support officers and practitioners with other skills on the team. A reduction in Health Visitors is not proposed, but recruitment has proved to be difficult. A minimum required number of visits from a Health Visitor is in place, with additional visits at the professional judgement of the Health Visitor;
(l) statistics on the number of women drinking during pregnancy can be compiled from the data gathered by Midwives and Health Visitors. The guidance is that women should not drink alcohol while pregnant, but there is always some difficulty in clearly diagnosing foetal alcohol syndrome;
(m)ideally, free full health checks should be delivered to all adults over 40 in a rolling 5-year period, with a particular focus on people with a family history of certain diseases. Health checks are often carried out by nurses at a GP practice.
1) thank the Director of Public Health for the progress report on Targeted Intervention services and to note the contents;
2) acknowledge the progress made in the context of the need for efficiencies following challenging cuts to the Public Health grant; and
3) request a further update on the progress of Targeted Intervention services in 6 months’ time, in the context of the developing NHS Long Term Plan and upcoming Green Papers on Social Care and prevention.
Report of the Head of Legal and Governance
Zena West, Senior Governance Officer, presented the proposed work programme for the remainder of the municipal year and the Chair confirmed that the upcoming March meeting will take place. The CityCare Quality Accounts will not be in their final form by the March meeting due to the upcoming local elections. A written update on progress concerning the refresh of the Suicide Prevention Plan will come to the March 2019 meeting for information, while the full report on the refreshed Suicide Prevention Plan will be deferred to July 2019.
1) note the work programme for the remainder of the 2018/19 municipal year.