Agenda and minutes

Councillor Nayab Patel

Councillor Cate Woodward

Resolved to appoint Councillor Maria Joannou as Vice-Chair of this Committee for this municipal year (May 2022 to April 2023)

None.

To confirm the minutes of the meeting held on 14 April 2022

The Committee confirmed the minutes of the meeting held on 14 April 2022 as a correct record and they were signed by the Chair.

Nick Carver, Chair of Nottingham University Hospitals NHS Trust (NUH) Board, introduced himself and outlined the role of the Board in driving improvement, including in relation to maternity services, which includes development and delivery of the long-term vision for NUH, holding the Chief Executive to account, and making sure that Nolan Principles are followed, particularly in terms of openness. He stated that while the Trust is improving its maternity services, he acknowledges that more needs to be done and at greater pace.

Sharon Wallis, Director of Midwifery at NUH, then delivered a presentation to the Committee about the action that has been taken to improve maternity services since the last update to the Committee and how the Trust is responding to verbal feedback from the most recent Care Quality Commission (CQC) inspection of maternity services.  She highlighted the following information:

(a)  The majority of women are happy with the maternity service that they receive at NUH but it is acknowledged that some have not received appropriate care. Recent improvements include estates work at the City Hospital and a new 24 hour maternity advice line which has received 100% positive feedback.

(b)  There is a national shortage of midwives that also affects NUH, which has significant numbers of vacancies. Notwithstanding this national shortage, the Trust is working to address issues with staffing shortages.  Ten new midwives have been appointed since January, and sixteen maternity support workers have been supported to begin foundation degrees.  An interim deputy director has been appointed as well as full time midwifery advocates.  Staffing will also be improved with 15 overseas midwives joining in July through an external recruitment agency. Including these there are currently 43 additional midwives in the recruitment pipeline. A recruitment event is organised for 21 May. A full Birthrate plus assessment will be carried out in the summer.  It is important that staffing levels also provide sufficient ‘headroom’ to allow time for staff to undertake training.

(c)  Feedback meetings are held with women who feel that they received a poor service, and some of these will be appointed as Safety Champions. The Director Midwifery holds a monthly question and answer session on Facebook.

(d)  The Service is working with the Maternity Voices Partnership on collaboration and co-design of improvements.

(e)  Following the CQC inspection of maternity services in February, a Section 29A Warning Notice was issued relating to issues with staffing of the triage section, which was being used for both emergencies and women with appointments. This has now been separated, staffing improved, and oversight made stronger with quicker escalation as appropriate. No issues have been reported of women not being seen quickly enough.

(f)  The Warning Notice also related to appropriate monitoring and safety procedures for the triage service. Alerts for escalation have been strengthened so that both the midwife and flow co-ordinator receive alerts to any issues.

(g)  The final report of the inspection has not yet been published by the CQC, but the Trust published the initial feedback letter as part of the papers for its Trust Board meeting in March and has been open about the initial verbal feedback received and how the Trust is responding.

(h)  It is acknowledged that the pace of improvement needs to increase. Additional capacity has been brought in to assist with this.

(i)  The NUH Board is committed to openness, and has offered to hold pre-Board briefings with the Committee Chair and visits to the Service.  It will share the CQC report when available.

During the discussion which followed, and in response to questions from the Committee, the following points were made:

(j)  Representatives of NUH agreed with the importance of having a systematic approach to delivering improvements and confirmed that a project plan for service improvement is in place but it is complex and constantly evolving, and therefore difficult to share. It could potentially be discussed as part of a visit by Committee members.

(k)  A new end-to-end clinical IT system will soon be introduced which will reduce the use of paper records, include alerts to prompt action and allow for translation of all information. This will improve accessibility for all who are seeking information and advice.

(l)  Committee members questioned the report of 100% positive feedback in relation to the new advice line as universal approval for a service is unusual, and asked about feedback from those who have not accessed the advice line.  Representatives of NUH agreed that the level of positive feedback was surprising.

(m)Challenges in increasing staffing levels are complex. There is a lot of interest but limited university places, which NUH is hoping to work with local universities to increase. It is important to offer opportunities for development and flexible working arrangements, and to sell Nottingham as a great place to work.  Flexible working is available for all front-line staff.  This can impact on service delivery but is essential for staff morale and retention. ‘Golden hellos’ are also offered as an incentive.

(n)  The Chair commented that the Section 29A Warning Notice issued related to the period when the Trust last attended a meeting of the Committee to discuss maternity services, but the Trust did not raise any of the issues referred to in the Warning Notice at that Committee meeting.  Representatives of NUH responded that, at that time, the Trust believed that it was meeting targets but was unable to provide sufficient assurance to the CQC of the robustness of oversight.  The Trust advised that there are no national standards for maternity triage and therefore the Trust is assessed against its own locally set high targets.  Since that time administration systems have been strengthened to better record the data.  There has been no evidence of harm caused to women.

(o)  Representatives of the Trust stated that the Trust has done its best to address the issues raised in the Warning Notice in the time available and has provided evidence to the CQC by the deadline about this.  It is awaiting the assessment of that evidence by the CQC.

(p)  Representatives of the Trust confirmed that, having had sight of the draft CQC report, there are no significant issues contained within the report that it has not made the Committee aware of.  It is anticipated that the rating will remain the same as currently.

(q)  The Chair commented that the response rate to the Families and Friends Test is relatively low. NUH commented that in addition, it has commissioned a local survey of women that wish to provide feedback.

(r)  The Director of Midwifery receives Safety Every Day reports every day.  The rating can vary throughout the day.  If it is not rated as ‘green’, then flow-coordinators will take action to mitigate risks for example by moving staff to areas of greater need, pausing elective activity, or looking for support from neighbouring trusts.  The Chair expressed surprised that, when asked, the Director of Midwifery could not recall the safety level for previous days in the current week.

The Chair welcomed the offer of briefings prior to each Trust Board meeting.

Resolved to:

(1)  request that Nottingham University Hospitals NHS Trust:

i)  provide information about when safety levels in maternity services were rated ‘red’ and ‘green’ over the previous month;

ii)  provide an update on key indicators to the Committee every month.  Indicators to be agreed with the Nottingham and Nottinghamshire Clinical Commissioning Group Quality Assurance Group;

iii)  provide an update on progress against the issues raised in the Section 29A Warning Notice;

iv)  provide a more detailed breakdown of feedback about the maternity advice line; and

v)  provide a briefing on how the Trust is responding to the Care Quality Commission report, when it is published.

(2)  arrange a visit to see Nottingham University Hospitals Maternity Services, if the Trust agrees to allow a Trade Union representative to be present for any discussions with frontline staff;

Debbie Graham updated the Committee on the work of the Independent Thematic Review into Nottingham University Hospitals Maternity Services, highlighting the following information:

(s)  A Thematic Review is different from a Public Inquiry, being considerably shorter and therefore able to make recommendations for improvement in a more timely way.

(t)  The review team has spoken with service users and staff in order to gather their experiences and feedback, to identify themes and issues. The Review covers the period April 2006 – October 2021.

(u)  Benchmarking has been undertaken against five other Trusts with similar profiles of deprivation, ethnicity, age complexity and size.

(v)  A detailed report on the delivery phase of the maternity pathway was drafted at the end of April and this will be followed by the neonatal phase by the end of May 2022.

(w)  To ensure that feedback to the Review is as representative as possible of the local community, the Review Team is going out to more under-represented groups, voluntary groups, radio stations, the Romanian community, the Traveller community, and those with mental health problems.

(x)  Listening sessions have been held to share experiences, including with service users from under-represented groups including refugee/asylum seeking women; Urdu and Arabic speaking women in community settings.  Further sessions are planned.

(y)  The Review has a public facing website in multiple languages, a family hotline and a dedicated email address.

(z)  Dedicated and bespoke psychological support is also offered to families engaged with the Review.

(aa)  To date 590 families have engaged with the Thematic Review. 81 families have completed listening sessions and 81 families have written about their experiences. 30 women and families from under-represented groups have been actively sought and spoken to.

(bb)  59 listening sessions with staff have been held, and 3 written submissions received.

(cc)  The Thematic Review is awaiting an update from the national team in relation to a new Chair, following the resignation of Julie Dent CBE.

(dd)  Once the assurance process associated with the Interim Report has been finalised, it will first be shared with families and then with wider stakeholders.

The Committee welcomed the work of the Review Team to try and reach out to families from the range of diverse communities in Nottingham to ensure that evidence to the Review is as representative of local communities as possible; and encouraged this to continue.  The Committee commented that there are a number of issues affecting the progress of the review which are outside of the direct control of the Review Team, for example a lack of national leadership in appointing a new Review Chair.  Given the importance of the Review for families now and in the future, the Committee agreed to write to the Secretary of State for Health and Social Care and NHS England about the impact that the lack of a Chair is having on the progress of the review and the need for the Secretary of State to work with families to appoint a new Chair as soon as possible. 

Resolved to:

1)  request that the Independent Review’s Interim Report is shared with the Committee when it is available;

2)  ask the Review Team to clarify how implementation of recommendations contained within the Interim Report will be monitored and reported on;

3)  write letters to the Secretary of State for Health and Social Care and NHS England to express the Committee’s concerns about the impact of a lack of a Chair on the progress of the review and the need to urgently address this issue.

Mark Wightman, Director of Strategy and Reconfiguration, and Alex Ball, Director of Communications, Nottingham and Nottinghamshire Clinical Commissioning Group, introduced the report on findings of the pre-consultation engagement that had been carried out in relation to the development of proposals under the Tomorrow’s NUH programme, highlighting the following:

(a)  Phase 2 of pre-consultation engagement has taken place on the proposals through briefings, telephone and online surveys, and public engagements events. Overall, there was 78% support for the broad proposals.

(b)  When looking at each of the proposals in turn, the level of support varied.  There were lower levels of support for the proposals for Family Care and Outpatients.

(c)  Feedback on each of the proposals included concerns and common themes relate to a potentially negative impact on patient choice and the co-location of specific services, car parking, public transport and travel times.

(d)  The findings of this phase of engagement will be shared with all key stakeholders for the Programme and directly to those groups and communities that took part in the engagement.  It will also be used to further shape development of the proposals.  As a result, there may be further pre-consultation engagement before the full public consultation in spring 2023.

During the discussion which followed, and in response to questions from the Committee, the following points were made:

(e)  The CCG acknowledged that the Stakeholder Reference Group, which helps provide quality assurance, has not met for some time, and the Group has been unable to look at this activity.  The CCG stated that it hopes to restart the Group soon, and the input of Healthwatch Nottingham and Nottinghamshire will be very welcome.  This will enable Healthwatch to provide assurance to the Committee in the future.

(f)  The CCG acknowledged that men are under-represented in the engagement response, which is typical for most health consultations, and more needs to be done to address this.

(g)  Recruitment and retention of staff is just as important for service provision, quality and safety as the capital infrastructure.

(h)  In response to recommendations from the Committee in March the survey was made available in the 10 most commonly used languages in the local area and circulated to groups with particular connections to communities leading to engagement sessions being held with groups such as the St Anns and Meadows Advice Centre and the Arabic Women’s Group.  The intention is to consider enhancing this further for the full public consultation.  Proposals are also being developed for mental health provision within Emergency Care.

As the areas with the lowest levels of public support, the Committee decided to look at proposals for Family Care and Outpatients in more detail to help it determine whether the proposals reflect the patient and public interest and are in the best interests of local health services.

Resolved to recommend that the Nottingham and Nottinghamshire Clinical Commissioning Group:

1)  continue to work on implementing the recommendations made by the Committee at its meeting on 17 March 2022;

2)  proactively engage with Nottingham University Hospitals NHS Trust staff and trade unions about the proposed changes to seek views and input on the development of proposals and the impact of change;

3)  continue to provide regular briefings to the Committee on development of the Programme; and

4)  share specific detailed proposals for Family Care and Outpatients with the Committee.

Resolved to:

(1)  note the Terms of Reference for the Committee;

(2)  note the work that is currently planned for municipal year 2022/23;

(3)  note that meetings are being arranged with providers to discuss their Quality Accounts 2021/22 and that Committee members are encouraged to attend if possible; and

(4)  postpone the next Committee meeting until 23 June 2022 to enable attendance by all relevant contributors to the item on support for people with co-existing substance misuse and mental health issues.