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Contact: Jane Garrard Senior Governance Officer
Apologies for absence
Declarations of interest
To confirm the minutes of the meeting held on 16 July 2020
The minutes of the meeting held on 16 July 2020 were approved as an accurate record and signed by the Chair.
Lucy Dadge, Chief Commissioning Officer, gave a presentation updating the Committee on the current status of services that were changed in response to the Covid-19 pandemic. She highlighted the following information:
a) A number of services have been fully or partially restored to pre-Covid delivery models, some services have changed slightly and there are still some services that have yet to be restored. Details of this are set out in the report circulated with the agenda.
b) Moving into the recovery phase, work is taking place to identify how the health and social care system needs to look different going forward. In some cases there will be a desire to accelerate already planned change and other changes will be in response to emerging issues such as particular health inequality aspects.
c) There are two main areas – acute stroke services and the urgent care pathway – that changed in response to the Covid-19 pandemic based on transformation work that was already being considered prior to the pandemic. Work is taking place to review the benefits of these changes and therefore whether the changes should be retained. Proposals for permanent change will be subject to the usual requirements for engagement and consultation.
During subsequent discussion the following points were raised and responded to:
d) Throughout the Covid-19 outbreak, patients have still been able to have interventions with their GPs and GPs continued to refer patients for secondary care, including operations. However, due to safety considerations, the Trust has been unable to carry out some operations and waiting lists have increased. Waiting lists are reviewed by clinicians, but for a range of operations patients will experience delays.
e) Some health inequalities have been exacerbated by Covid-19 and, in particular the disproportionate impacts on Black, Asian and Minority Ethnic patients and staff is recognised. A lot of work is taking place to explore these issues.
f) Nottinghamshire Healthcare Trust responded quickly to the need to provide mental health services differently and put in place 24hour wrap around crisis care. It is recognised that there may be some demand for specialist mental health services to deal with Covid-related issues and the Trust is looking at how to respond to this. Overall there has been an increase in capacity for mental health service delivery within the Trust.
g) The recently revised national guidance on access by partners to maternity services will be implemented locally.
h) In the early stages of the pandemic there were pharmaceutical shortages but currently there are no significant issues in relation to this.
i) Detailed national guidance is being developed on the rehabilitation needs for patients post-Covid and this guidance will be responded to locally.
Mark Simmonds, Consultant in Acute Critical Care Medicine, updated the Committee on the reconfiguration of acute stroke services provided by Nottingham University Hospitals NHS Trust (NUH), noting that transformation work had been underway prior to the pandemic and was implemented in an accelerated way in response, and the outcomes are being reviewed to assess whether changes should be retained permanently. He highlighted the following information:
j) In response to the Covid-19 pandemic, there was an urgent need to make changes to ensure that patients with Covid-19 could be treated separately from patients without Covid-19 by creating additional admission assessment capacity on the City Hospital campus. The only suitable area was the Stroke Unit, which was located on the respiratory corridor.
k) Hyper acute stroke services were brought together on the Queens Medical Centre (QMC) site, with the Hyper Acute Stroke Unit and Acute Stroke Ward moved from the City Hospital campus.
l) Stoke rehabilitation services have remained on the City Hospital campus.
m) This reconfiguration of stroke services was already being considered prior to the Covid pandemic as there is analysis that it would be clinically beneficial for the treatment of stroke, it aligns to regional and national plans for stroke services and supports the longer term strategic direction for NUH as articulated through the Tomorrow’s NUH programme. The move was accelerated to support the response to the Covid pandemic.
n) Treatment of strokes has changed considerably over recent years and since the previous configuration of services was established. It has been demonstrated that acute, rapid intervention improves outcomes and there have been a range of new interventions introduced many of which overlap with services provided on the QMC site. Another benefit of centralising acute stroke services on the QMC site is 24 hour a day, seven days a week access to the CT scanner in the Emergency Department.
o) Analysis so far shows that it has been a positive move. A full review will be carried out in November and if, following that review, it is proposed to make the changes permanent then those proposals will be brought to this Committee for consideration and there will be appropriate public and patient engagement and consultation.
Caroline Nolan, System Delivery Director – Urgent Care updated the Committee on plans in relation to the urgent care pathway which has also changed to support response to the Covid-19 pandemic and consideration is being given to retaining those changes permanently. She highlighted the following information:
p) There have been a number of key changes that were already being planned before the Covid-19 outbreak and brought forward as they were identified as being beneficial for managing services during the outbreak.
q) The Urgent Treatment Unit has been relocated from the QMC campus to Platform 1, Upper Parliament Street to support the response to the Covid-19 outbreak and enable more space to be available in the Emergency Department area to meet Covid requirements for social distancing.
r) The service continues to operate 24 hours a day, seven days a week and accepts patients from the Emergency Department. The number of patients seen has significantly reduced but this reflects a reduction in patients using face to face urgent care services. This reduction and the location has enabled NEMS to provide more telephone-triaging as well as providing face to face services if needed.
s) The new location fits with the improved navigation that should flow from the ‘111 First’ pathway, with less need for primary care to be co-located with the Emergency Department.
t) Given the continued need for social distancing within the Emergency Department and its support for the wider direction of travel in urgent care services, it is intended to keep the service in its new location and monitor attendances across the pathway and amend the service offer as appropriate.
u) The new ‘111 First’ initiative is a national change being introduced on 30 November, stating that NHS 111 or a GP practice is the first place that an individual should go when experiencing a health issue that is not immediately life threatening (rather than immediately going to a physical location). 111 will then book patients direct appointments with time slots at the appropriate service enabling demand for urgent care to be better managed.
v) It is envisaged that this will take advantage of the remote working technology that has been widely used during the Covid-19 outbreak and should help prevent hospital acquired infections because patients do not need to congregate together in the Emergency Department waiting to be seen.
w) Systems are being put in place to support a transfer of 20% of unheralded Emergency Department attendances (the national objective) to the 111 services, such as improving the Directory of Services and increasing the number of dispositions available on the Directory.
x) New access routes to emergency care assessment and hot clinics are being opened to reduce the need for people to unnecessarily walk through the Emergency Department.
y) Lots of communication work is taking place to support this change and it is hoped that having a timed appointment will be an incentive for individuals to engage with the new pathway.
z) This approach aligns with the Navigation and Access Model strand of the Urgent and Emergency Care Clinical Strategy which was developed pre-Covid. NHS 111 has a key role to play is supporting good navigation through the system and therefore this national initiative is welcomed locally.
aa)The benefits include that individuals should be seen by the appropriate service in a timely way with reduced waiting times; it should enable safer and more timely care for those individuals who do need to attend the Emergency Department; the Emergency Department should be able to operate in a more effective way reducing risks to patients and staff; and the transfer of patient information will allow greater oversight of patient flows and an improved ability to match capacity with demand.
bb)A range of stakeholders have been spoken to about this new approach and this is informing implementation. There will be a specific focus on trying to reach those who are over-represented in Emergency Department attendances.
During subsequent discussion, it was confirmed that there will be clear pathways for mental health accessible by NHS 111.
The Committee requested that if commissioners decide to propose that changes in relation to the reconfiguration of acute stroke services are made permanent, those proposals along with plans for consultation and engagement are presented to the Committee for consideration.
Lucy Dadge, Chief Commissioning Officer, gave an early briefing about ‘Tomorrow’s NUH’ (Nottingham University Hospitals), highlighting the following information:
a) NUH is currently based on three main sites and although the Care Quality Commission has assessed the quality of care as good, the estate is not fit for the future and requires significant ongoing investment and reconfiguration. This is an exciting opportunity to address these issues for the benefit for the whole healthcare system.
b) Through the Hospital Infrastructure Programme, national funding has been identified for 40 new hospitals to be delivered in two waves. NUH has been identified as a potential Trust for this capital investment.
c) NUH will be developing a case for capital investment, but prior to that there is a need to demonstrate the case for change in terms of service improvement and outcomes. The Clinical Commissioning Group will be leading on this, informed by engagement with the Trust. This will include carrying out population health needs analysis, engaging with clinicians to explore innovate new ways to provide services and ensuring good links with the primary and community care sectors. The ambition is for the highest quality facilities to be available for hospital care, when it is needed.
d) Work is currently at an early stage. Engagement and consultation will be carried out at appropriate points in development of proposals. This will include engagement with the Nottingham and Nottinghamshire Health Scrutiny Committees. It is anticipated that the pre-consultation business case will be presented to the scrutiny committees in spring 2021, with wider consultation carried out in summer 2021. There will be engagement with the general population on the overall changes and consultation with patients, and other stakeholders, on specific clinical changes.
e) This represents not just an opportunity for health services but also has wider benefits for the economy, academic research etc.
During the subsequent discussion the following points were raised and responded to:
f) During the development, services will continue to be provided in a safe way that maximises patient experience.
g) The impact on the environment and environmental consideration should be taken into account in the development of proposals. Transport and access to care will be a factor and there will need to be a balance between access and carbon-reduction strategies.
h) The business case will determine the level of investment in new building. It isn’t possible to pre-judge the outcome of that, but at this stage it seems unlikely that it will be an entirely new hospital site. A range of options will be looked at to try and achieve the best possible estate for the population.
i) The Naylor Review is about efficiency and a desire for a more efficient and effective system is driving this work.
j) Restrictions as a result of the Covid-19 pandemic could impact on the ability to carry out consultation in a way that everyone is able to engage with and is representative of the populations. It is hoped that it will be possible to carry out face to face consultation by summer 2021 but that it is currently unknown and these issues will need to be taken in account.
The Committee noted its current work programme for 2020/21, acknowledging the need to retain flexibility to deal with issues as they arise given the current circumstances.
Future meeting dates
To agree to meet on the following Thursdays at 10am:
· 15 October 2020
· 12 November 2020
· 17 December 2020
· 14 January 2021
· 11 February 2021
· 11 March 2021
· 15 April 2021
The Committee agreed to meet on the following Thursdays at 10am:
· 15 October 2020
· 12 November 2020
· 17 December 2020
· 14 January 2021
· 11 February 2021
· 11 March 2021
· 15 April 2021