Agenda and minutes

Councillor Anne Peach

None

To confirm the minutes of the meeting held on 16 September 2021

The minutes of the meeting held on the 16 September 2021 were confirmed as a true record and signed by the Chair.

John Brewin, Chief Executive, and Alison Newsham-Kent, Eating Disorders Service Manager, Nottinghamshire Healthcare NHS Foundation Trust attended the meeting and gave a presentation about the Nottinghamshire Adult Eating Disorder Service.  The following information was highlighted:

a)  Nottinghamshire Adult Eating Disorder Service is a multi-disciplinary Team currently consisting of 9.7 whole time equivalents comprising nurses, occupational therapists, a dietician, consultant psychiatrist, psychology and administration staff.

b)  The Service offers assessment, diagnosis and NICE compliant psychological interventions for adults with a diagnosed eating disorder, bulimia nervosa, and anorexia nervosa.

c)  The number of individuals being referred to the Service has increased in comparison to previous years.  In Nottinghamshire there were 307 referrals in 2019, in 2020 there were 313 and it is anticipated that by the end of 2021 445 referrals will have been made to the Service.  The increase in referrals reflects the national picture.

d)  The current average wait for an assessment is 37 days and the average wait for the first treatment is 43 days. There has been an increase in waiting times for the Service which had been most evident during the first Covid 19 ‘lockdown’.

e)  The predominant ethnicity of those referred to the Service is ‘White British’ at 83%; the highest age group is 20-29 year olds; and only 10% referrals are for males.  This is in line with national statistics.

f)  The impact of Covid 19 had led to an increase in the number of referrals, an increase in waiting times, a reduction in face to face meetings and a shift from active therapy to supportive contacts. Staff sickness had been higher than average and this has significantly impacted the service due to size of the Team.

Kazia Foster, Head of Transformation Mental Health Services, Nottinghamshire Healthcare NHS Foundation Trust updated the Committee on the Severe Mental Illness Transformation. The following information was highlighted:

g)  There is a large programme of works being undertaken in relation to Severe Mental Illness Transformation. £975million will be invested in services by 2023-24 to treat those suffering from severe mental illness. This will benefit over 370,000 people through the following improvements:

·  expanded access to support, care and treatment

·  increased access to psychological therapies

·  removal of thresholds

·  a ‘no wrong door’ approach

·  enabling choice and flexibility

·  facilitating a multi-sector approach

·  integration between services and providers

·  a person centred and strengths based approach.

h)  The Adult Eating Disorder Transformation plan includes the expansion of the Team with a growth of 6.2 whole time equivalents over the next 6 months with improved medical monitoring.  The Children’s Eating Disorder Transformation Plan includes a growth of 8.4 whole time equivalents, from the current establishment of 10 clinical and 1.5 administrative staff.  An Eating Disorder Transition worker will be recruited to support movement from children to adult services.

In response to questions from the Committee, and in the subsequent discussion the following points were made:

i)  Internet research carried out by the Chair specifically relating to the service found images of underweight young white women in Trust documentation.  The Chair commented that she did not consider this appropriate as it could be triggering for those suffering from an eating disorder and expressed disappointment that it was unrepresentative of those suffering from disordered eating.

j)  Information had been submitted to the Chair in advance of the meeting by a member of the public who had received a letter from their GP stating that they could not be referred to the Service because they did not meet the BMI (Body Mass Index) criterion. The Trust stated that BMI is not used as a factor for acceptance to the Adult Eating Disorder Service, and a much broader range of measures are used.  A patient who has been referred to the Service may be signposted to an alternative service if that is more clinically appropriate and some services do have BMI criteria that affects who can be referred to them.  The Chair raised concern that, despite that assurance, this letter had been received by an individual and there could be other people receiving similar communication.  In response, the Trust said that it would be willing to look at the particular case referred to for further investigation.

k)  In response to a question about why not all referrals are accepted, even though they are made by health professionals who should knowledgeable about the Service, the Trust stated that assessment is carried out on the cognition and behaviours described in the referral prior to acceptance.  In some cases, individuals may be referred because of significant fluctuations in weight but this could be attributable to another factor, such as trauma, and therefore the Eating Disorder Service may not be appropriate as weight/body image is not the primary issue.  Instead, the Trust will signpost to a more appropriate alternative service.  Any referrals that are not considered appropriate are recorded.

l)  Referrals are screened on a daily basis to identify any individuals requiring urgent assessment.  Other less urgent referrals are discussed at a weekly meeting to identify the most appropriate pathway.

m)  Concern was raised that current difficulties in getting GP appointments could impact on referrals to the Service and the Trust was asked about the ability of individuals to self-refer.  The Trust confirmed that there is currently no mechanism for self-referrals into the Service due to a lack of sufficient capacity in the Team. There is an ambition for people to have better access to the Eating Disorder Service, including self-referral as already happens for child and adolescent services, and this will be explored once increased resource is in place.  In the meantime, progress is underway to engage with other stakeholders and the community and voluntary sector to streamline accessibility to allow for earlier contact.

n)  Committee members commented on the benefits of having a single point of access to prevent people getting rejected from multiple services and instead identify the most appropriate service and pathway at the outset.  The Trust Chief Executive acknowledged that access to specialist services can sometimes be difficult and people often start by seeing GPs who may not having the skills or experience to refer appropriately.  The NHS Long Term Plan and the Severe Mental Illness Transformation Plan, which both include ambitions for easier access, should help to address this. 

o)  The Trust considers that the Service is culturally competent but acknowledges that there is a need to explore further why there are relatively low numbers of patients from ethnic groups other than White British.  There is also an aim to improve the representativeness of the Team to the population it serves.

p)  Home visits are not provided by the Team but occupation health and community support workers are able to provide this to a very small number of people. 

q)  There are no specialist inpatient services in Nottinghamshire, and Nottingham patients usually receive inpatient care in Leicestershire through provider collaboration across the East Midlands.

r)  As part of the Transformation Programme a number of improvements are underway which include looking at individuals who had not been diagnosed with a specific eating disorder but suffer from disordered eating, improving medical monitoring and increasing staffing levels.  An investment of £394,000 to expand the current Adult Eating Disorder Team had been secured, with further investment planned as the model develops.  One of the most significant challenges to improving the Service will be the recruitment of staff, especially at a time of increased demand.

s)  The Trust is currently working with commissioners to develop a vision for what the Service will be like after transformation.  A steering group, led by Nottingham and Nottinghamshire Clinical Commissioning Group, is developing a new service model and it is anticipated that the new model will be implemented within the next year.  Service standards for severe mental illness are currently being tested nationally, but it is anticipated that there will be a target of a maximum four week wait across severe mental illness services.

The Committee welcomed the Trust’s plans to improve access to the Adult Eating Disorder Service.

Resolved to

(1)  request that Nottinghamshire Healthcare NHS Foundation Trust provide anonymised information on the reasons why referrals to the Adult Eating Disorder Service are not accepted; and further information, including patient feedback, on the transition from child to adult eating disorder services;

(2)  hold an informal briefing for Committee members on the Severe Mental Illness Transformation Plan; and

(3)  review Nottinghamshire Healthcare NHS Foundation Trust’s progress in improving access to the Adult Eating Disorder Service in autumn 2022.

Lucy Dadge, Chief Commissioning Officer, and Lisa Durant, System Delivery Director for Planned Care, Cancer and Diagnostics, Nottingham and Nottinghamshire Clinical Commissioning Group updated the Committee on the local position in relation to the impact that the Covid pandemic has had on delays in elective care and elective care recovery activity.  The following information was highlighted:

a)  The Covid-19 Pandemic had significant and far reaching implications across the NHS as hospitals responded to high numbers of patients with complex urgent needs. In direct response to the Covid-19 pandemic the NHS received an instruction to cease all non-urgent elective activity, and as a result waiting times increased.

b)  Waiting times against the 18 week Referral to Treatment standard in Nottingham were proportionate to other local health systems and slightly better than the national position.  Nottingham has always worked well in order to meet the 18 week treatment target and there is a real commitment to return to the pre-Covid position.  In July 2021, performance against the 18 week standard was 71.6% compared to a target of 92%.  This type of data is used to actively oversee elective patient waits.

c)  Some individuals chose to wait longer for treatment due to Covid concerns.

d)  There are still challenges associated with Covid-19 affecting elective recovery activity, including:

i)  capacity continues to be limited due to Infection Prevention and Control measures (IPC)

ii)  there is a need for clinical staff who worked tirelessly during the height of the pandemic to take leave to recover

iii)  pressures from urgent admissions continued during the summer

iv)  staff continue to test positive for Covid-19, creating gaps in resource across the health and social care system

v)  referrals reduced initially but are now increasing

e)  Various methods of communication are used to engage with patients waiting for elective care and patients with a health concern were, and continue to be encouraged to seek advice without delay.

f)  The risks of winter pressures on the NHS and elective recovery from the impact of Covid-19 are recognised, and therefore the system-wide ‘winter plan’ supports elective recovery.

g)  Work is underway to build upon the existing cancer programme and it has been apparent that, at the onset of Covid-19, patients were reluctant to seek health advice.  Cancer surgeries/treatments have been cancelled or delayed due to the pandemic and there is now a lot of pressure to address this.  Emphasis is placed on the protection of elective beds for cancer patients and this is a matter of highest focus and priority.  Focus therefore continued on earlier cancer diagnosis including:

  i.  Targeted Lung Health Checks.  This has been successfully rolled out in Mansfield and Ashfield since April 2021. Patient uptake has been high, with 2,000 patients scanned to date. The programme will be extended to Nottingham City in early 2022/23.

  ii.  Rapid Diagnostic Centre pathways based around clinical pathways that offer a more holistic assessment. Investigations are coordinated to reduce hospital visits and the time to reach a diagnosis. Patients will have a single point of contact who will keep them informed of test results and next steps.

Councillor Adele Williams, Nottingham City Council Portfolio Holder for Adults and Health addressed the Committee and explained that there had been an incredible amount of hard work across all of the health systems in order to achieve the best outcomes for people during the Covid-19 pandemic. She acknowledged the importance of home care in supporting timely discharge from hospital that, in turn, creates capacity to support elective recovery activity.  She welcomed the system funding that has been available.  The Portfolio Holder noted that there had been some issues with recruiting social care staff in part, due to the initial lack of Personal Protective Equipment (PPE) at the beginning of the pandemic combined with low pay and a perceived low status of care sector workers.  Issues with low pay and status remain and this affects the ability to recruit and retain staff.

In response to questions from the Committee and in the subsequent discussion, the following points were made:

h)  The Independent Sector was used to provide elective care during the pandemic.

i)  Treating patients in order of clinical priority is crucial with the primary aim being to offer fair, equitable access to elective care for all patients across the system based on clinical priority. There has been some very good joint working between the sectors and shared decision making for the benefit of patients, for example once waits have been reviewed, an individual’s GP will be contacted to agree an approach which might include advice on keeping as well as possible, ways to prepare for surgery and other options available to the individual.

j)  Emphasis is placed on patient empowerment and it is considered that good communication is key to this. Health inequality still remains.  The disparity has not significantly changed and health inequality gaps in the City have not grown as a result of the pandemic, however there continues to be disproportionate health issues amongst those classed as living in deprivation. This is recognised and focus has been placed on addressing the unacceptable variations in treatment and access to care.

The Committee agreed to consider carrying out a deep dive into a particular pathway to examine the specific actions being taken in relation to elective recovery and what difference those actions are making.

The Chair reported that, as agreed the previous meeting, the findings of the Care Quality Commission Well-led inspection of Nottingham University Hospitals NHS Trust, which was published in September 2021, and the action being taken to respond to those findings, will be considered by the Committee at its next meeting in November.  Representatives of Nottingham University Hospitals NHS Trust, Nottingham and Nottinghamshire Clinical Commissioning Group and NHS England/ NHS Improvement have been invited to attend.  There will also be an item on provision and access to GP services in the City.

The Committee noted its work programme for the remainder of 2021/22.