Venue: Remote - To be held remotely via Zoom - https://www.youtube.com/user/NottCityCouncil. View directions
Contact: Jane Garrard Senior Governance Officer
Apologies for absence
Councillor Kirsty Jones (unwell)
Councillor Dave Liversidge (personal)
Declarations of interest
To confirm the minutes of the meeting held on 17 September 2020
The minutes of the meeting held on 17 September 2020 were approved as an accurate record and signed by the Chair.
Caroline Nolan, Director of Urgent Care Nottingham and Nottinghamshire Clinical Commissioning Group (CCG), Lisa Kelly, Chief Operating Officer Nottingham University Hospitals NHS Trust (NUH), and Gemma Poulter, Head of Integration Adult Social Care Nottingham City Council attended the meeting to discuss planning for managing winter pressures, particularly in the context of the Covid-19 pandemic, across the health and adult social care system.
Caroline Nolan and Lisa Kelly highlighted the following points from a health perspective:
a) Winter is always a very challenging period for the health sector. The second wave of the Covid-19 pandemic will increase the complexity of issues and the EU transition period also presents challenges. While health partners are very experienced in managing winter pressures, the forthcoming winter is unprecedented. All pathways have to be segregated which increases complexity and presents physical challenges in terms of space and environment. Although a lot of modelling has been carried out there is a considerable degree of uncertainty about demand and an agile approach will be required.
b) Learning from previous years and the first wave of the Covid-19 outbreak is being used to develop a clinically-led approach.
c) At NUH demand for emergency care is returning to pre-Covid levels. It is positive that people are accessing services if they need to, but it is important to ensure that they are accessing the right services in the right location e.g. through 111 First. 111 First will be a significant change but it should enable people to better access the right part of the health system.
d) There has been an increase in the number of individuals presenting in mental crisis at the Emergency Department and emergency support liaison is being enhanced.
e) Health services have been working at restoration and recovery of services and want to be able to continue with this. NUH intends to continue with elective surgery as far as possible but it has to be safe. As part of the winter planning and to deal with the impact of Covid-19, partnerships are being developed with the independent sector to enable the clinically urgent elective programme to continue.
f) Partners are working together, for example NUH is working with CityCare Partnership and NEMS on access to urgent care to reduce demand for emergency services and ensure that the Emergency Department is only used by those who really need it.
g) NUH is focusing on same day emergency care, ensuring that patients get the right clinical input quickly that enables them to be discharged on the same day or able to be sent home and asked to return to see a specialist on the following day to reduce the need for overnight stays. In support of this a range of different pathways are being developed for specialities.
h) NUH is opening seasonal inpatient beds, but there are challenges due to the need to segregate patients with Covid-19 from those without the virus. This need for segregation has required some redesign of the Trust estate with some services moved from their usual location. There is a significant capital investment programme to support this.
i) Expansion of critical care was planned prior to the Covid-19 outbreak and there will be an additional eight beds in use on the Queens Medical Centre site by November.
j) There has been investment in diagnostics on the Queens Medical Centre site e.g. MRI scanner replacement to enable high quality diagnostics with a quicker turnaround time.
k) There are plans in place to deal with Covid-19 surges in demand.
l) In terms of discharges from hospital, there is excellent team work across the system, including local authorities and primary care providers to try and ensure that only those requiring an acute bed are in hospital. However, particularly for City residents, there is a need for more packages of care and this would help to improve the discharge process. One of the challenges going forward is the recruitment of care workers in the City. Plans for the creation of more community beds for rehabilitation are being accelerated and should hopefully be in place for winter.
m) More sections of the population have been added to the flu vaccination programme and the scale of the programme this year is uncharted. The addition of all individuals aged over 50 years is a significant increase in the number of people to vaccinate at a time when health services are already under pressure. There is also the possibility of a Covid-19 vaccination programme that would need to be delivered. The flu vaccination programme includes consideration of how to reach both the population and care services who support and care for vulnerable citizens e.g. support for homecare agencies. Through the Integrated Care Partnership there is a particular focus in the City on reaching those groups with lower uptake last year including school aged children, at risk women and vulnerable individuals aged under 65 years.
n) GP surgeries continue to be open with a telephone triage process in place to manage the flow of patients and ensure segregation of those with/ without Covid-19. Face to face appointments are available when needed. Digital access for GPs is being improved to enable remote access for those who need to work from home. The importance of the management of long term conditions is recognised e.g. carrying out physical health assessments for those with learning disabilities and although these were not carried out during the first wave of the Covid-19 outbreak, the need to maintain this work during the second wave is recognised.
o) NUH is supporting care homes, through the provision of training on how to spot deterioration in residents, carrying out vaccinations, support visits by multi-disciplinary teams and through a rapid assessment process at the hospital front door.
p) It has been a difficult year for staff and NUH recognises the need to do more to keep them mentally and physically well. It is particularly difficult for staff who are required to wear personal protective equipment all day.
q) Key challenges going forward include capacity to meet demand, which is unpredictable, and maintaining the flow of patients through the system both because it is the right thing for patients and to enable capacity for admissions through the front door of the hospital.
Gemma Poulter highlighted the following points from an adult social care perspective:
r) Having been dealing with the impact of the Covid-19 outbreak since March, services were moving into the recovery phase but now a crisis response is needed again.
s) There has been an increase in capacity in internal reablement services, but despite a sustained recruitment campaign during the Covid-19 outbreak it is hard to recruit and retain care workers. There is currently not enough capacity to meet demand for home care services. An Emergency Support Team has been put together through redeployment of existing staff and temporary contracts.
t) As set out in the Council’s Better Lives Better Outcomes Strategy, the aim is to support as many people as possible to live at home but there is significant pressure on the social care model due to a lack of capacity.
u) As the number of admissions and level of acuity increases it is becoming more challenging to maintain good flow of patients and service users due to insufficient home care in the external market. It is also challenging to find the right provision for those with complex needs.
v) The Council is working collaboratively with providers and supporting the local market.
w) The Discharge to Assess model is really important in facilitating smooth flow of patients from hospital, reducing demand for inpatient beds and increasing support for people at home. There is evidence that people recover, increase their independence and have reduced risks of infection at home. Having a minimum of 48 hours notice of the date when a person is expected to leave hospital really helps to better co-ordinate successful discharge. All citizens identified as potentially needing care in the community, receive reablement first and their needs are then assessed to ensure that they end up with the right care in the right place at the right time.
x) The Department for Health and Social Care requires that local authorities implement an Adult Social Care Winter Plan and reporting to the Department on this needs to take place by the end of October. Plans are currently being finalised and will then be shared with partners.
y) The Plan includes a focus on care homes, which are independent private businesses. Prior to discharge from hospital to a care home, patients are tested for Covid-19 and the results are communicated in order to minimise risks of transmission. Care homes then need to be able to safety isolate individuals and they can refuse admission. Alternative accommodation then needs to be identified that for that individual, so work is currently taking place to identify a specific location (a care home or wing of a care home) where this can happen in the City.
z) Local outbreaks of Covid-19 within care settings are being managed well, with comprehensive plans for testing, infection prevention and control measures in place, provision of personal protective equipment and minimising the number of visitors to care settings.
aa)Funding has been extended for infection control and provision of personal protective equipment (PPE), and the Council is continuing to support external providers with infection prevention and control services, access to PPE (both ordering future supplies and in an emergency) and by increasing capacity and sustainability. A pilot is currently taking place in St Anns to provide wraparound support in partnership with GPs, CityCare Partnership and a local homecare agency.
bb)Visits to care homes is now not supported in order to minimise infections. Work is taking place to ensure that all care homes have visiting policies in place that are in line with the guidance.
cc) The health and wellbeing of the workforce is really important, both internal and external. Flu vaccinations are being provided to all internal staff and the Council is working with external providers to support staff in accessing vaccinations, which previously hasn’t been at a high rate. Homecare providers have also agreed to support increasing the uptake of the flu vaccination amongst their service users.
During subsequent discussion and in response to questions from Committee members, the following points were raised:
dd)Planning for the flu vaccination programme started in May/ June and flu clinics are already up and running. It was confirmed that the first cases of flu have already been seen at NUH.
ee)In previous years some elective surgery has been cancelled to enable Trusts to focus on managing winter pressures. So far there has been no directive to stop all elective procedures so NUH is currently expecting to continue with its elective programme. However, a risk-based approach will need to be taken and while the Trust acknowledges that there is already a backlog of elective surgery and some people are waiting longer than they should, safety has to come first. The Trust is working with the independent sector and Sherwood Forest NHS Trust to create more locations in which elective surgery can take place safely so it may be that some patients have to travel to different locations for their surgery.
ff) The CCG representative reported that standard community beds don’t meet the needs of those with complex physical and mental health needs and more rehabilitation services and pathways are needed. There are plans for an additional 19 beds for this cohort this winter. Fewer community beds for those with lower levels of need are required as it is preferable for those individuals to be cared for at home, and, especially at this time, families are increasingly keen for individuals to be cared for at home due to concerns about Covid-19 infection and restrictions on visiting.
gg)Some individuals go into residential care from the community, rather than hospital. The Adult Social Care representative confirmed that a process is in place for testing those individuals for Covid-19 and support is then provided until the result of the test is available. It was also confirmed that the Infection Prevention and Control Team risk assesses the ability of care homes to effectively isolate residents, which can be particularly challenging if individuals have mental health needs. If necessary providers are supported to deliver 1:1 care.
hh)It was confirmed that there has been an increase in those coming to the Emergency Department in mental health crisis. If this happens then there needs to be a rapid response to quickly move the individual to the appropriate service. Work is taking place with child and adult mental health services and also other partners such as local authorities because many issues have a social element, such as housing. It was acknowledged that it can be challenging for individuals to navigate through the system and there is a long way to go to improve pathways.
ii) All representatives acknowledged the importance of appropriately supporting the workforce. The NUH representative stated that at the end of the first wave of the Covid-19 outbreak, staff were encouraged to take leave and have a rest; the successful employee support programmes that were put in place during the first wave, such as having wellbeing and rest rooms on both sites providing drinks, advice and a calming atmosphere will continue; working with the NUH Charity there has been investment in other staff rest rooms across the sites; and a range of mental health and psychological support is available to staff. The Trust has also tried to show visible leadership during this time by holding Question and Answer Sessions with senior leaders in the organisations. Feedback on these arrangements has been sought through the Trust’s People Committee and the Trust is also working with the trade unions to use their intelligence on issues affecting staff and their networks to communicate key messages. Across the Integrated Care System, a system wide staff survey is taking place to get comments and feedback on working through the Covid pandemic and to identify what support is appropriate going forward. It was reported that most adult social care colleagues are working at home, but those staff providing direct care have been provided with PPE, encouraged to take regular breaks and leave where appropriate, and ensure that team contact and peer support is maintained. While it is important for staff to rest, there is a tension between encouraging staff to take leave and ensuring capacity to deliver services.
Healthwatch Nottingham and Nottinghamshire reported that it had received some feedback about the accessibility of GPs at this time, with some patients reporting having to wait 20-30minutes on the telephone and some patients going straight to the Emergency Department or a specialist service because they have been unable to access GP services. The CCG representative acknowledged that they were aware of similar concerns and perceptions, and are working to get clarity in messaging about the availability of GPs and ensure that all GP practices are communicating effectively with their patients.
Subject to the need for additional scrutiny identified in the meantime, the Committee decided to review how the health and social care system coped with winter pressures combined with the impact of the Covid-19 outbreak in early-mid 2021.
Having been concerned about the relatively low levels of uptake by some population groups in the City in previous years, the Committee welcomed the work to expand, and focus on delivery of the flu vaccination programme this year. However, given its past concerns about uptake in the City and recognising that it is more important than ever this year, the Committee decided to review the implementation of the flu vaccination programme in more detail at a future meeting.
The Committee was concerned about the increase in individuals, particularly those not previously known to services, presenting at the Emergency Department in mental health crisis and decided to explore what support and pathways there are for those in crisis, capacity within these services and how pathways are managed and partners work together to support individuals when they present in crisis.
The Committee was reminded that the proposal to develop an NHS Rehabilitation Centre had been identified as a substantial variation or development of service.
Lewis Etoria, Head of Insights and Engagement, and Hazel Buchanan, Director of Special Projects, Nottingham and Nottinghamshire Clinical Commissioning Group presented the findings of the public consultation carried out in relation to development of an NHS Rehabilitation Centre. They highlighted the following points:
a) The public consultation period was two weeks longer than initially planned to recognise the differences arising from holding all the consultation remotely, and ended on 18 September 2020.
b) The consultation methodology included surveys, virtual events and focus groups and direct invitations to specific stakeholders to comment on the proposals.
c) 870 responses were received, two thirds of which came from individuals/ organisations from Nottingham and Nottinghamshire. 19% of responses were from current or former users of rehabilitation services or carers of current or former service users.
d) 86% of respondents supported the proposal. However, concerns were raised including the remoteness of the location and accessibility issues. Many of these concerns were raised in the responses from professional and clinical bodies. These were issues that had been previously identified in the pre-consultation business case and by scrutiny committees and mitigations had been proposed, but concerns were still raised.
e) Healthwatch was commissioned to carry out more targeted and detailed research with groups that traditionally don’t respond to such consultation. 91 telephone conversations were held, a third of which were with current or former service users or carers of service users. 86% of the respondents supported the proposal but the feedback raised different issues, such as the importance of privacy, concerns about childcare and the importance of assessing need on an individual basis.
f) The next stage is development of a decision making business case to be considered by the Governing Body in December 2020. The pre-consultation business case was subject to a robust assurance process with NHS England, and the decision making business case will be more focused on responding to the issues raised in consultation.
During subsequent discussion and in response to questions from Committee members, the following points were raised:
g) It was confirmed that mental health was a theme in the consultation responses, both in terms of support for patients with a pre-existing mental health condition and mental health issues arising from being an inpatient at the Centre.
h) Some consultation responses suggested that the option of retaining Linden Lodge and developing a new NHS Rehabilitation Centre should be explored. However, Clinical Commissioning Group representatives reiterated that this was not an option that had been consulted on and investment in both facilities had never been an option. The consultation asked respondents for their comments on the single proposal of developing an NHS Rehabilitation Centre as set out in the consultation document, and not on other alternatives. It has become apparent that communication about this single option opportunity consultation did not successfully reach all respondents.
i) It was confirmed that development of the survey questions had been sub-contracted to an independent agency to remove the potential for bias and leading questions.
j) A Findings Considerations Panel will meet twice to identify the key issues and concerns raised in the consultation that they would expect to see addressed, and make recommendations for inclusion in the decision making business case.
k) There were challenges in carrying out the consultation entirely remotely but the quality of insight is similar to that achieved previously. This demonstrates that it is possible to undertake successful consultation remotely with more flexibility, creativity and time. It was anticipated that it would be even harder to engage groups that primarily only respond to face to face engagement but the sample achieved by Healthwatch was similar to most previous Clinical Commissioning Group engagement work.
The Committee requested that representatives of Nottingham and Nottinghamshire Clinical Commissioning Group attend the Committee’s meeting in November to update the Committee on the development of proposals for an NHS Rehabilitation Centre and the decision making business case prior to consideration by the Governing Body, to enable the Committee to consider how the proposals are responding to issues raised in the public consultation and whether the proposal is in the interests of local health services.
The Committee noted its current work programme for 2020/21, including the following issues identified for inclusion earlier in the meeting:
a) how the health and social care system coped with winter pressures combined with the impact of the Covid-19 outbreak;
b) implementation of the flu vaccination programme;
c) support for those in mental health crisis;
d) proposals, and the decision making business case for the NHS Rehabilitation Centre.