Councillor Cate Woodward - Medical appointment.

None.

To confirm the minutes of the meeting held on 17 December 2020

Ajanta Biswas, Healthwatch, Nottingham and Nottinghamshire was present, but not listed as such in the minutes of the meeting held on 17 December 2020.

With this addition, the minutes of the meeting held on 17 December 2020 were approved as an accurate record and signed by the Chair.

Keith Girling, Medical Director, Nottingham University Hospitals (NUH), Lisa Kelly, Chief Operating Officer, NUH and Sarah Moppett, Acting Chief Nurse, NUH spoke to the Committee about actions taken to address the outcome of the inspection of maternity services at NUH (on both the City Hospital and QMC sites) carried out by the Care Quality Commission.  They highlighted the following information:

a)  The unannounced CQC visit took place in October 2020 and the CQC report was published in December 2020.

b)  NUH colleagues acknowledged that care was below the standard which NUH aspires to and expressed their extreme sorrow at the distressing experiences of and anxiety caused to patients and their carers.

c)  NUH was aware of the need for improvements prior to the CQC visit and had already started taking action to put remedial measures in place to ensure safe care.

d)  NUH has established an Improvement Board and an improvement plan and action plan are in place to address key areas of concern.  These have been put together by listening to families and staff at all levels.

e)  To address leadership concerns an interim Director of Midwifery has been appointed.  In addition, recruitment has started to increase the number of midwives across both sites at NUH and additional capacity has been created for medical staff.

f)  NUH has taken up the offer of local support from Sherwood Forest Hospitals Trust, where the CQC rating for its maternity services was positive. In addition, as part of a national maternity programme, NUH has been allocated a colleague in Yorkshire as a critical friend and is taking account of the national recommendations arising from the Ockenden Report review of maternity services at Shrewsbury and Telford NHS Trust.

g)  Discussions are ongoing within NUH and with partners on how to embed people’s experience into training.

h)  NUH has established a Maternity Oversight Committee, chaired by non-executive members, which is responsible for maternity safety. The Committee includes colleagues from outside the NHS.

i)  NUH uses a national ‘safe today’ template twice a day to determine that all processes and staffing arrangements are safe for women undergoing care in NUH services. ‘Safe today’ findings are collated weekly and reported via assurance committees to the Maternity Oversight Committee and to the Quality Committee of the NUH Board.

j)  The Maternity Improvement Board has a number of workstreams, including governance, people, safe practice and quality improvement and has also established a clinical reference group which advises these different workstreams.

k)  NUH expects the improvement work to take a number of months to fully address and embed the issues identified by the CQC. Their ambition is to see the Maternity Unit move from an ‘inadequate’ to ‘good’ rating within 12 months.

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

l)  NUH acknowledged committee members’ concerns about longstanding issues with the leadership of the Maternity Unit, the top-down approach and staffing pressures which had existed for a significant period.

m)  NUH has been making a number of interventions to support teams and to review and increase staffing; work which started prior to the CQC report. Two years ago NUH had a significant number of vacancies. The target numbers required were calculated using the national tool based on birth rate.  A recruitment campaign resulted in recruitment to this target.  However, while the birth rate is dropping, the level of acuity in care needs has increased. The national tool has now been changed to ‘birth rate plus’ and takes into account acuity, eg diabetes, obesity and high blood pressure, all of which add to potential risk and complications and need more staff support. A ‘birth rate plus’ assessment (carried out through an external assessment process) in early 2020 and reported in June/July identified a further deficiency of 73 full time equivalent (FTE) midwives.  NUH is now recruiting to this target and now has appointed 18 more FTE midwives above the previous establishment target.  In response to a question from a Committee Member, NUH assured the Committee that working to the lower target using the original birth rate tool was not a way of saving money. Some beds are currently closed to relieve some of the pressure on staff while recruitment is ongoing. While NUH turnover of midwives benchmarks well, there is a national shortage of midwives which adds challenge to recruitment.

n)  The new Director of Midwifery, who started a week ago, is a welcome addition to the team.  There has been a staffing gap with no Head of Midwifery in post (a role difficult to fill nationally). NUH now has two Deputy Heads of Service supporting the service.  The new leadership is bringing a fresh, new perspective.

o)  NUH needs to get better at making the voices of patients and staff heard.  Staff have been raising issues which need to be addressed for a while.  NUH is building on its experience of involving staff in shaping other services to make care as good as it possibly can be; for example, by having conversations with staff in different ways and seeking their opinions on changes they would like to see to shift the existing top-down approach. Change needs to be designed and led by those working in the service.  NUH acknowledged that it will take some time to build credibility and trust.

p)  In the light of the CQC findings, NUH took immediate actions to put safe care in place. These were necessarily top-down.  However, the long term implementation plan takes a bottom-up approach.

q)  Communications have been targeted to reassure pregnant women and mothers about NUH maternity services. The initial communications strategy has included a number of strands, including Facebook and other social media; working with senior colleagues, hospital and community midwives on how to assure provision of a safe services. Over time NUH will refine what they can share with partner organisations and user engagement forums on the work they are progressing.

r)  NUH will ensure that feedback from staff is included in delivering improvements and in the process to change culture and behaviours.  The Improvement Board is creating an expert advisory panel, to be in place by April, for collecting feedback and reflecting it to the Board. The Clinical Advisory Group and the workstreams include staff at all levels, eg non-clinical junior staff, reception staff, new midwives. 

s)  NUH maternity staff have been working very hard within a culture where they felt they could not raise concerns.  NUH is listening to staff and working on applying best practice in other areas to maternity services. Within the first week of the CQC report NUH held tens of staff sessions to listen to feed into plans.  These were held at all times of day to make sure they were accessible to all staff.  They have highlighted their Freedom to Speak Up Guardian and the Trust Executive has held virtual open listening events where midwives have been able to express views and ask questions. There is now an emphasis on senior staff visibility, ie making sure the new Director and other senior staff (clinicians and managers) are seen by midwives and other staff at the front line.

t)  NUH is working on increasing training and development for midwives, a programme already started before the CQC report. NUH has a virtual nursing and midwifery institute, which leads on the staff education programme, eg a scheme which offers an opportunity to focus on an area of expertise is being progressed in the maternity unit.  There is significant senior expertise in the institute and they are working with maternity teams look at developing their offering from induction to looking after midwives at the end of their career (eg legacy mentors to coach more junior midwives).  In addition, NUH has introduced a foetal monitoring midwife specialist whose role started last week, to ensure effective training and support for foetal monitoring.

u)  NUH is developing a single improvement plan to include other recommendations as well as the recommendations of the CQC report, eg the Ockenden Report.  Reports from investigations into stillbirth and neonatal death cases by the Healthcare Safety Investigation Branch have resulted in recommendations which are consistent with themes in the Ockenden Report and the CQC Report.  The current action plan comprises over 150 actions pulling together all of the responses to all of the recommendations.

v)  Covid has made some things more complex, but improvements to maternity services need to be carried out whatever else is going on, so delivery of improvements has not slowed down and actions are being delivered in Covid-secure ways, eg remotely and 1-1 training instead of group training.

w)  In response to concerns that services had been allowed to deteriorate so far, NUH acknowledged that they have not addressed the issues to the extent that was needed, but that there is now complete commitment across the organisation to remedy the situation and improve services to a good standing.

The Committee welcomed the commitment of NUH to improving maternity services, but also expressed concerns about the long standing problems with maternity services, which existed prior to the CQC report and which had not been fully addressed. To ensure that progress continues to be monitored and scrutinised, the Committee asked that NUH return in six months’ time with an update.

The Chair of the Committee asked that the NUH representatives pass the Committee’s thanks to colleagues working on the front line, to recognise their work and support for Nottingham citizens.

Lucy Dadge, Chief Commissioning Officer, Nottingham and Nottinghamshire Clinical Commissioning Group (CCG), Sarah Fleming, Head of Programme Delivery, Nottingham and Nottinghamshire CCG, Philip Britt, Programme Director – Tomorrow’s NUH, NUH and Lewis Etoria, Head of Insights and Engagement, Nottingham and Nottinghamshire CCG and Integrated Care System spoke to the Committee to seek its views about the pre-engagement activity that has taken place so far and plans for public consultation during 2021 in relation to the Tomorrow’s NUH Programme.  They highlighted the following key information:

a)  While the outcome of the programme will be new hospital buildings as the funding is available for capital investment, form has to follow function and work on a clinical model over autumn 2020 has provided a basis for talking to the public about the programme.

b)  Nottingham clinicians have had input to the early model proposals. However, to ensure that any clinical services model proposed reflects best practice nationally and internationally, the Clinical Senate (made up of experts from all areas, largely from outside Nottingham) has been engaged to provide an objective view. They have fed back that they do support the proposals, but recognise that there is a lot of detail to develop.  The detail of the model is now being worked on with partners, including NUH, GPs, community providers and Sherwood Forest Hospitals Trust.

c)  Other things in train include:

  i.  Impact assessments of the new proposals, especially in relation to environment and sustainability, travel, equality and the overall impact on the health of the population, with a focus on vulnerable groups.

  ii.  Workforce modelling for staff to provide support to the local population.

  iii.  Modelling what the population will need in future years and associated costs.

  iv.  Developing a digital strategy, eg for the use of remote consultations, telephone appointments, in both primary and secondary care.

  v.  Learning from the Covid 19 pandemic, identifying what needs to change and what needs to be retained. The pandemic has revealed the opportunities for digital communication but also highlighted its risks in exacerbating inequalities.

d)  The engagement work carried out to date is very early stage and pre-consultation. Full engagement will take place over the coming summer. The programme has worked with the North of England Commissioning Support Unit (NECSU) and Healthwatch to lead on some of the pre-engagement activity. In addition, initial engagement has taken place with a range of patient groups/ forums, health providers, health interest groups and staff in health organisations. Feedback from the latter groups is in line with both reports from the NECSU and Healthwatch.

e)  The NECSU-led engagement took the form of a survey (available online and in hard copy), public events and focus groups, which were focused on areas where there is expectation of some contention, ie maternity, urgent care and cancer services. 527 people participated, including just over 400 responses to the survey.

f)  Healthwatch was asked to target and reach populations not reached by traditional engagement methods. To add value by reaching a broader demographic, the survey was carried out largely by phone interview.  Three separate focus groups were held with a mixed population, young people and substance users. While numbers were not as high as the NECSU survey, the responses were more detailed so the insight is much greater.

g)  The key findings from all methods of engagement were as follows:

  i.  People broadly supported initial proposals.

  ii.  Plans were not detailed enough to take a clear informed view.

  iii.  There was some scepticism of the credibility of proposals.

  iv.  Concern about resources, including staffing, to deliver in community settings.

  v.  Remote consultations/ appointments have benefits but are not accessible to all.

  vi.  Concern about transport, parking and access, especially for specific communities.

  vii.  People want to hear about the whole model and how it all fits together

h)  Following reflection on this feedback, colleagues will produce recommendations for how to take forward the public consultation. Key areas of work now are:

  i.  Further engagement to provide more detail of proposals in real terms so everyone can understand their impact.

  ii.  Clarity on how the model of hospital and community delivery will work.

  iii.  Clarity on access.

  iv.  Broadening the conversation in terms of who to speak to and the level of detail of conversations.

i)  Colleagues are continuing to work on a detailed model, which will include the principle of bringing all forms of emergency care together. Pre engagement work is an ongoing dialogue, ie not a one off activity.

j)  Once affordable and deliverable options are fully worked through they will form the basis of a consultation plan, to be presented to the Health Scrutiny Committee in the late spring for approval to go to public consultation.

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

k)  The full consultation must be bottom up.  The pre engagement work is not public consultation, but rather an opening a dialogue based on national and international advice on best practice for the future.  Proposals need to be informed by clinical opinion and health policy and the public will be asked what is the best way to deliver these services so that decisions can be made about hospital and community services. 

l)  The level of openness in the approach has been welcomed by Healthwatch.

m)  Because the funding available is for capital investment (ie buildings) it can be confusing that the consultation is about service delivery.

n)  Consultation must include the voice of Black and Minority Ethnic (BAME) people, those who are vulnerable and those who experience multiple disadvantage. It must also go beyond GPs to include the range of community services, eg, physiotherapy, midwifery, homelessness providers and mental health providers and must focus on longer term outcomes, eg through rehabilitation.

o)  Covid 19 has highlighted the importance of the impact of services in vulnerable communities and more deprived areas.

The Committee welcomed the breadth of the pre-engagement process and will remain involved in the consultation process and development of proposals.

It was agreed that it would helpful for the Committee to undertake a number of thematic reviews in relation to the development of proposals, eg the impact on patients with a particular condition. This will be taken forward as part of the Committee’s work programme planning.

Ross Leather, Nottingham City Safeguarding Adults Board Manager, presented the Annual Report of the Safeguarding Adults Board to the Committee.  He highlighted the following key information:

a)  The Board has strategic oversight of safeguarding and the Annual Report is a statutory requirement. This report predates lockdown, so represents a pre-pandemic world. The delay in publication is as a result of Covid 19 pressures.

b)  The report focuses on four strategic goals: prevention, assurance, making safeguarding personal and making sure the Board is functioning.

c)  The report aims to provide assurance that the Board is fulfilling its role to scrutinise the system for local arrangements in health, social care and the criminal justice systems and ensure that all 14 partners represented on the Board have safeguarding procedures in place to protect vulnerable adults in line with adult safeguarding criteria.

d)  2019/20 saw just under 4,000 cases; a 20% increase on the previous year. Enquiries only increased by 7%.  The Safeguarding Team which triages referrals as they come in welcomes an enquiry as it opens up a conversation about a safeguarding issue.

e)  In line with national data, most abuse occurs in people’s homes and the most common types of abuse are financial and physical abuse.  Risk is reduced or removed in 75% of cases referred, which is comparable with national rates. These issues have been amplified beyond the timescale of this report.

f)  2019/20 was characterised by greater demand, increased complexity, the impact of austerity, an increase in cases involving modern slavery, an increase in financial abuse, physical abuse and the financial constraints on partners.

g)  The Board focused on improving the safeguarding offer to the voluntary sector in terms of training and on seeking assurance of service provision for homeless people.  Latest data shows that there has been no increase in the trend of deaths of homeless people, which is good news.  In addition, the Board has looked at assurance in the Integrated Care Partnership (ICP) and the Integrated Care System (ICS) to make sure that adult safeguarding is on their agendas.  Work is ongoing with care homes and home care.

h)  Covid 19 has dominated beyond the report period.  The Board took a step back to allow an operational focus in response to the pandemic and has supported where it can. It has done some work on financial abuse with Trading Standards, has worked with the CCG on the appropriate use of DNRs (Do Not Resuscitate) by GPs and has worked with partners on safeguarding under pressure.

i)  There has been some return to business as usual, eg

  i.  A great deal of work has been undertaken on the Independent Inquiry into Child Sexual Abuse (IICSA) report (as many of those children are now adults and some part of Adult Services).

  ii.  The Board has looked at the Shared Lives scheme to check that staff of all partners working with adult survivors of non-recent abuse are trained. 

  iii.  The Board continues to identify and disseminate learning from safeguarding adult reviews.

j)  The Board is now drafting its plan for 2021/22.  This will be impacted by Covid and some action plan items will be rolled over from the previous year. There will be a focus on joint agenda setting with the Crime & Drugs Partnership and the Children’s Partnership to tackle issues in jointly and on financial abuse and making safeguarding personal.

k)  A new independent Chair has been recruited to start on 1 February 2021.

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

l)  During the first lockdown referrals went down. As of today they are 28% down, as professionals are unable to go into people’s home. It is expected that they will rise again when lockdown ends. Colleagues in Adult Social Care are working hard to stay in touch with everyone they are aware of and follow up on information they receive. The impact of Covid on safeguarding for vulnerable adults, particularly those who live alone and may not be in contact with services is something the Committee may want to look at in more detail in the future.

m)  Specific cases where adults have not been provided with the care they should have received (pre-Covid) are being followed up.

n)  It is a long term ambition to ensure that homeless people are not sleeping on the streets.  The Board has a representative from the Strategic Housing Team, so is in a better position to monitor this. The Board had sight of the Winter Plan and the impressive local response to accommodating homeless people and following them up. It is extremely rare that the offer of support is refused. The Nottingham Plan aim is that no one has a night out or a second night out.  Not everyone who is homeless is Care Act eligible, so services have to be mindful of what they can or cannot do. If a homeless person dies the Board looks at the case to see if Care Act criteria were met. 

The Committee notedthe Safeguarding Adults Board Annual Report and the significant changes which had taken place due to the Covid 19 pandemic during 2020/21.  It welcomed the work of the Safeguarding Adults Board during this period.

Councillor Eunice Campbell-Clark, Portfolio Holder for Health, HR and Equalities, supported by Alison Challenger, Director of Public Health, Nottingham City Council, attended the meeting to report on delivery of her responsibilities in the Council Plan in the light of Covid and the implementation of budget savings.  She highlighted the following key points:

a)  Covid 19 has significantly impacted on the work of local Public Health teams resulting in the need to pause ‘business as usual’.

b)  Savings agreed in March 2020 and October 2020 have been achieved and staffing capacity within the Public Health team has been temporarily expanded using specific Covid 19 grant funding.

c)  The slides circulated with these minutes detail the key achievements in relation to the management of Covid 19.

d)  The Portfolio Holder is the Vice Chair of Nottingham City Council’s Outbreak Control Engagement Board.

e)  Six of the 11 Council Plan expected outcomes are rated Green, three Amber and two are Red.  Performance against these outcomes is detailed in the slides in the appendix to these minutes.

f)  There is significant pressure on the Public Health team.  Challenges in 2021/22 are outlined in the appendix and include

  i.  The continuing pressure on staff resources of Covid 19 and the likelihood that the Public Health Grant allocation for 2021/22, while not yet confirmed, is likely to remain the same as the current budget (excluding the Covid 19 additional grant).

  ii.  The need to review priorities in the light of Covid 19.

  iii.  Building on the momentum to address health inequalities which have been highlighted by Covid 19.

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

a)  To tackle health inequalities, all key agencies need to link together through a single framework, for example all agencies working on housing and homelessness need to work together. The Integrated Care Partnership offers an opportunity to do this.

b)  The change to the national structure of public health from Public Health England to the National Institute for Health Protection is ongoing. There are still decisions to be made about where all elements of public health improvement will sit.  The Council’s Public Health team is aware of the process and will feed into the consultation about future public health structures.

c)  Fluoridation is progressing through a nationally recognised programme.  A technical feasibility study of local water has been carried out and there will be further feasibility studies to do. There will be local consultation, but the process has not yet reached that point having been slowed down by Covid.  The Public Health team is looking at carrying out a survey on local dental health.

d)  Test and Trace is still operating. If Test and Trace has not been able to make contact without someone after 48 hours, the local authority is notified. The local authority then picks up details from a national database and tries to contact the relevant individual to ask them to self-isolate.  The Public Health team monitors national guidance to follow any proposed changes to the Test and Trace system.

e)  Covid 19 vaccinations are led by the NHS.  Vaccinating is still a very fledgling service in terms of getting centres open and data and reporting in place. More detailed information about local level vaccinating should be available soon. Alison Challenger agreed to share a stakeholder briefing note and the vaccination health inequalities plan with the Committee.

f)  In most cases Covid 19 has exposed health inequalities that already existed. Public Health colleagues would be happy to attend a Committee meeting to further explore health inequalities. There is a lot of existing activity which needs to be co-ordinated, ie the Integrated Care System (ICS) Health Inequality Strategy, the Council’s own Health Inequalities framework, and an Integrated Care Partnership (ICP) Health Inequalities Programme.

g)  There have been some mixed messages regarding vaccinations and a committee member raised concerns about confusion surrounding the invitations for vaccination. Alison Challenger clarified that individuals should wait for their NHS letter before arranging a vaccination appointment. 

h)  Specific funding is allocated to carry out Test and Trace at the local level and for community Covid 19 lateral flow testing (due to start next week).  The standard Public Health grant is likely to have no uplift in 2021/22 but this has not yet been confirmed. It would be helpful to receive additional funding via the standard grant as pressures on some key Public Health services continue.

The Committee welcomed the update provided by the Portfolio holder for Health, HR and Equalities and the Director of Public Health.

The Committee requested that Alison Challenger provide it with copies of the vaccination stakeholder briefing note and the health inequalities vaccination plan.

The Committee noted its current work programme and plans for the work programme 2021/22, including the following issues identified for inclusion earlier in the meeting:

a)  Health inequalities - with a view to looking at particular areas to focus on.  Following discussion of potential focus, members of the Committee were asked to forward their suggestions to Councillor Georgia Power or Governance Services (Kim Pocock).

b)  Tomorrow’s NUH - to consider plans for public consultation and to review specific themes to inform proposals.

The Committee discussed items to take forward to its work programme for 2021/22 as follows:

c)  Access to mental health services - several aspects have been identified to consider, including crisis services, capacity in secondary care, preventative services, the gap between primary and secondary care and suicide.

d)  Items previously suggested for next year’s work programme have been logged at the end of the 2020/21 work programme.

e)  It was agreed that the Committee (plus the Healthwatch representative) would hold an informal meeting to discuss the work programme 2021/22 to prioritise items for scheduling within resources and capacity.  A tight focus will help the Committee to make realistic recommendations which have a more meaningful impact.

Items currently scheduled for the Committee’s February meeting are:

f)  Platform One – to scrutinise the mobilisation plan and discussions with new provider.

Tomorrow’s NUH – Governance Services will check with the Clinical Commissioning Group to establish the most appropriate timing for the next update in the light of discussions at this meeting.