Agenda and minutes

Councillor Dave Trimble – leave.

None.

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

The minutes of the meeting held on 14 July 2022 were confirmed as an accurate record and signed by the Chair. It was noted that Councillor Campbell-Clark had only been appointed the day before the meeting and hence had another commitment and was unable to attend.

The Chair outlined that the focus of the meeting was on system oversight and assurance of Nottingham University Hospitals NHS Trust (NUH) maternity services to seek assurance that there are adequate oversight and assurance processes in place and that they are working effectively.  Nigel Sturrock, Medical Director NHS England Midlands Region, and Rosa Waddingham, Nottingham and Nottinghamshire Integrated Care Board, attended the meeting to discuss the oversight and assurance arrangements in place locally and regionally.  They highlighted the following points:

a)  In autumn 2020 enhanced oversight and surveillance arrangements were put in place.  The Trust is currently on Oversight Level 4, which is the most intense oversight category.

b)  To seek assurance on quality and safety, the ICB works with partners such as the Care Quality Commission and NHS England to track progress and hold the Trust to account.

c)  An Improvement and Assurance Oversight Group that involves all key stakeholders meets every month and considers evidence of the work that has been done and triangulates that with other information sources to get a full picture. Meetings are chaired by either the ICB Chief Nurse or NHSE Regional Medical Director and the aim is to understand improvement at the Trust in reality.  Regular insight visits are used to provide a check and balance against information provided by the Trust.

d)  There is a large support programme provided to the Trust that covers a wide range of issues such as leadership, governance and culture.

e)  An Improvement Director has been appointed by the national team to work with the Trust and is based in the Trust full-time.  They offer critical friend feedback and challenge.

f)  The Trust has been ‘buddied’ with Birmingham Women and Children’s Hospital to provide opportunity for clinical staff to see the delivery of maternity services outside NUH, learn about alternative environments and approaches and feed back to NUH if there are elements that could be used to improve services at NUH.

g)  There has been evidence of significant change and improvement in some areas, such as in maternity triage which has significantly improved and in the training of staff on foetal monitoring, in which the Trust regularly reports compliance.  The way that the Trust investigates and learns from incidents has changed and the Trust now needs to embed the way in which it assures its self on this.  However, the Trust has not improved at the pace and scale required and after almost 2 years there will be a full stocktake of the Maternity Improvement Plan. 

h)  The experience of working with the new leadership at the Trust has been positive and now that key appointments of Trust Board Chair and Chief Executive have been made a stable, effective Board needs to be put in place.  This is essential to driving improvement.

i)  The system welcomes, and is committed to working with the review being led by Donna Ockenden to ensure families have a voice and that there is further learning to support improvement.

Anthony May, the Chief Executive NUH, and Michelle Rhodes, Chief Nurse NUH, attended the meeting to provide an update on the Trust’s ongoing work to improve maternity services and to give the Trust’s perspective on system oversight.  Anthony May reiterated his unreserved apology to families affected by the failures of the Trust’s maternity services and assured the Committee that he is fully supportive of the drive to address the issues identified and acknowledged the impact on families and public confidence.  They highlighted the following information:

j)  There has been a step change in the way that the Maternity Improvement Programme is organised and, as Chief Executive, Anthony May will be taking personal oversight of the Programme.

k)  A lot of learning has taken place from Shrewsbury and Telford Hospital Trust including the way that action is evidenced and success measured.  A new software system has been purchased and this will make it easier to see whether improvement actions are on track or not.  The system requires robust evidence to be provided before an action can be categorised as ‘embedded’.  Currently 64% of indicators are categorised as being ‘achieved’ but 26% require further evidence before they can be considered as ‘embedded’.

l)  Another area of learning from Shrewsbury and Telford Hospital Trust has been in relation to the involvement of staff.  The Trust has been criticised for having a ‘top down’ approach and arrangements are now being put in place to give staff a sense of ownership over the Division with more opportunities to suggest and discuss improvements.  Meetings are chaired by a midwife or obstetrician and decisions are made in the forum before being subject to a confirm and challenge process.

m)  The Trust’s Maternity Oversight Committee is witnessing a lot more energy, dynamism and pace in delivering the improvement programme.

n)  Capacity is being put in place to manage improve systems and processes alongside managing delivery of frontline services.

o)  The Maternity Improvement Programme currently has 75 actions categorised as ‘Red’ and the most significant of these is the number of midwives and obstetricians.  The Trust has a significant number of vacancies in these roles, particularly midwives.  This reflects a national shortage.  Lots of work is taking place to address recruitment and retention issues, including offering pay enhancements to new starters and offering flexible working.  This has been quite successful but it is recognised that there is more that the Trust can do, for example lots of staff are choosing to work as ‘bank staff’ because of the high degree of flexibility but this can mean it is difficult to ensure staff coverage during unpopular times.

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

p)  Committee members welcomed the improvements made in involving and listening to frontline staff, which had previously been an area of concern for the Committee.  Rosa Waddingham commented that she considers there to be a shift in culture with increasing engagement of families and staff and a focus on Board to Ward. She cited a recent insight visit at which staff were readily able to share the lived reality of work taking place.

q)  Anthony May acknowledged that there has been a lack of visible leadership but that this was improving.  He has been carrying out announced and unannounced visits to services across the Trust to gather honest feedback and help him understand the pressures and tensions facing staff.

r)  The Improvement Assurance and Oversight Group has looked at the Trust’s work on culture and has had input from Health Education England on its perspective. 

s)  Staff stress is an issue.  The Trust has learnt from past experiences and, for example, has put counsellors in place to support staff in relation to inquests

t)  NUH’s Chief Nurse acknowledged that the Trust hadn’t always got listening to women and families right.  She had recently met with the new Chair of the Maternity Voices Partnership to discuss improving engagement.  The Trust is also recruiting a Matron for Engagement and Inclusion.

u)  A committee member commented on the need for robust project management of the Trust’s Maternity Improvement Programme so that the Trust can evidence when it is achieving key milestones.  Rosa Waddingham commented that the Trust does have a clear project plan in place but acknowledged that it has had issues with articulating it.  NUH confirmed that there is a project plan in place setting out 272 actions, action owners and dates for completion.  A project management office has been established to manage the programme.

v)  The key areas of focus for the next three months are training, staffing, culture and leadership.  There are clear criteria for what the Trust needs to do in order to move from Oversight Level 4 to Level 3.

w)  In response to a question about how the system identifies and acts upon early warning signs, Rosa Waddingham explained that data is inputted into a Maternity and Neonatal system which is part of the ICB’s quality arrangements.  There are triggers within the system for example full assurance work is taking place on neonatal deaths in recent years.

Resolved to:

(1)welcome the change in Nottingham University Hospital NHS Trust’s approach to listening to its staff;

(2)visit Nottingham University Hospital NHS Trust to view how the Maternity Improvement Programme is project managed; and

(3)gather evidence from trade unions representing staff working for Nottingham University Hospitals NHS Trust to understand their perspective on improvement at the Trust.

Further to the Committee considering issues around access to psychological therapy services in September 2021, Alison Smith, Consultant Clinical Psychologist, Kazia Foster, Deputy Director of Local Mental Health Services, and Louise Randle, Head of Transformation Mental Health Services, all from Nottinghamshire Healthcare NHS Foundation Trust attended the meeting to update the Committee on progress in reducing waiting times for assessment and treatment for Step 4 psychological therapy services.

The following points were highlighted and responses provided to the Committee’s questions:

a)  Between July 2021 to July 2022 there was a reduction in waiting times, and in June and July 2022 there were no people waiting over 26 weeks.

b)  Since September 2021, the number of clients waiting for assessments has fluctuated from 36 in September to a low of 19 in March 2022 and 43 in July 2022.

c)  The average wait for treatment has reduced from 35 weeks in September 2021 to 10 weeks as of 29 July 2022.

d)  Representatives of the Trust outlined that following recommendations from the Committee in September 2021, all patients waiting over 26 weeks were reviewed -  small number were able to be appropriately discharged from the waiting list and all those who had elected to delay therapy have now commenced therapy; and communication with Local Mental Health Teams has taken place to clarify referral processes including highlighting the need for patients being referred to be ‘therapy ready’.  The Trust feels that communication with Local Mental Health Teams has significantly improved.

e)  As part of the transformation of services, in the County multi-disciplinary conversations take place before referral to ensure that it is appropriate and this includes a telephone triage appointment with the patient to ensure there is a rounded picture of their situation.  The initial priority is stabilisation and then identifying the most appropriate pathway to meet patient need. If they are therapy ready, some clients are escalated to longer term therapy, such as Step 4, some are directed to an appropriate alternative treatment pathway, whilst others are able to be appropriately discharged.  The intention is to use a trusted assessor model within Local Mental Health Teams.

f)  In the County, Local Mental Health Teams have access to a stabilisation service for those who have been in crisis.  In response to a question from a Committee member about access to stabilisation services not under a Local Mental Health Team, it was explained that access via primary care will be rolled out.

g)  An Associate Psychologist has developed a programme of 8 sessions to get people ready to access psychological therapy as compensation for the lack of a stabilisation service in the City.

h)  Representatives of Nottinghamshire Healthcare Trust clarified that there isn’t a limit on the number of referrals accepted but, based on analysis of anticipated demand, triage capacity is currently resourced to manage approximately 20 referrals a month.

i)  New roles within the team have been created including Associates in Psychology and seven additional Mental Health and Well-Being Practitioners who will start in November. These posts only cover mid-Nottinghamshire and Bassetlaw areas currently but the same approach will be rolled out in the City from next year.  One of the challenges in achieving this is recruitment, which is a national issue.

j)  The transformation of severe mental health services, including Step 4 Psychological Therapies, is taking place over a three year period and will be rolled out in the City next year (year 3).  Representatives of Nottinghamshire Healthcare Trust acknowledged that there are gaps in pathways for City residents now.  It is intended that services that are being piloted elsewhere in the County will fill those gaps, and benefits are being seen from those services, but transformation won’t be fully rolled out in the City under year 3 of the programme. Transformation is being successfully embedded within the county.

k)  City residents are also able to access a range of treatment and therapy pathways including services offered by Mind which works closely with the Trust and offers three options of treatment, including one-to-one, peer group or a hybrid model, usually over a period of 6 to 8 weeks to support a variety of conditions including stress and relationship issues. The Mind service can be accessed through Local Mental Health Teams.  Mind provision has been running for two years and has been evaluated as ‘good’. A personality disorder project is running within city and geographical rollout is ongoing.

l)  Recruitment is the biggest challenge to successful roll out of the transformation programme.

m)  The city and county populations are very different, as are the populations in the north and south of the county, and these populations will have different needs to take into account when commissioning and providing services.  For example, it is anticipated that city services will need to link more strongly with partner organisations supporting rough sleepers and substance misuse. Therefore, resourcing will differ with the variance of need, added to which historically commissioning arrangements have differed.

While recognising the benefits of transformation of services in the County, Committee members expressed disappointment that these services are not available for City residents to access and that gaps in service continue to exist for City residents.  The Committee asked Nottinghamshire Healthcare Trust to report on progress in implementing transformation in the City in 12 months time so that the Committee can assess what has changed in the City and what impact that has had.  The Committee encouraged future service changes to be made on an Integrated Care System basis in order to achieve access to services for all.

Resolved to:

1)  review implementation of transformation to severe mental health services, including Step 4 Psychological Therapies, in the City in 12 months time; and

2)  recommend that, where possible, future changes to services should be made on an Integrated Care System basis rather than for specific geographical areas to order to provide equity in access.

Jane Garrard, Senior Governance Officer, presented the Committee’s current work programme for the 2022/23 municipal year.

The Committee noted the work programme.