The minutes of the meeting of the Health Scrutiny Panel held on 23 October 2012 were submitted and approved as a correct record.

The Scrutiny Support Officer submitted a report the purpose of which was to introduce senior representatives from the South Tees Hospitals NHS Foundation Trust (STHFT) to address the Panel concerning pressures facing the Maternity and Paediatric Services based in North Yorkshire and possible implications for Middlesbrough. The Chair welcomed representatives from the STHFT who highlighted the key points raised in a briefing note previously circulated to the Panel.

As part of the background information it was reported that the Hambleton, Richmondshire and Whitby Clinical Commissioning Group had been leading a process of engagement on the need for changes to children's and obstetric services at the Friarage Hospital, Northallerton (FHN) as a result of medical staff of the Trust raising concerns about their ability to continue to offer these services in a safe and sustainable way into the future.

In terms of Paediatric Services it was explained that children generally spent less time in hospital and that with modern ways of diagnosing and treating illnesses they were more likely to be cared for at home or by a brief visit to hospital. Given current arrangements for medical staff the Panel was advised that they would need to deliver the service in a different way to ensure that children and the new born could be assured of being seen quickly by a senior doctor with experience in the treatment of children and the new born.

With reference to Obstetric Services it was noted that complex obstetric care had become more specialised and dependent on the availability of paediatric medical staff to deliver an appropriate service.

In response to increasing problems the creation of a Paediatric Short Stay Assessment Unit was proposed at the FHN which would minimise time spent in hospital for children with minor or moderate acute illness by providing safe and rapid access to assessment, observation and suitable intervention by clinicians with appropriate expertise. Children who required the facilities of a department with inpatient paediatric beds would be directed to James Cook University Hospital or to other hospitals which provided such a facility.

The alternative option for children's services was to provide an outpatient service at the FHN. Consultants, junior medical staff and nurses would continue to work at the hospital during the day. As part of the clinic provision an urgent clinic would be developed for assessment of children who were unwell but did not require admission.

Both of the options would result in the FHN no longer having a paediatric inpatient beds (currently 14 staffed beds) and no Special Care Baby Unit for which there were currently 10 cots.

In terms of JCUH the Panel was advised that the changes, as outlined, the subject of wide ranging lengthy engagement placed the Trust in a stronger position to recruit, retain and deploy staff appropriately across both sites. Staffing numbers at JCUH would increase to cope with the transfer of activity to ensure that extra activity would be safely managed and that patient experience was not compromised.

The Panel was advised that North Yorkshire County Council had agreed to refer the matter to the Secretary of State for Health on the basis that the proposals would not meet the health needs of the local community. It was anticipated that the matter would be reviewed by the Independent Reconfiguration Panel an independent and advisory body.

Members were keen to seek assurances about potential implications for capacity at JCUH.  In response the STHFT representatives indicated that no real pressures were anticipated in the foreseeable future.  It was pointed out that there was some flexibility with regard to the current 40 bed capacity. As previously indicated children generally spent less time in hospital and with advances in diagnosis and treatment they were more likely to be cared for at home or by a brief visit to hospital. It was noted, however, that the birth rate had increased in recent years and there were currently 4,300 deliveries per annum which had been taken into account in examining current facilities.

The Panel was advised of the need for additional parental accommodation although it was noted that from experience many parents from the immediate area to JCUH went home after any initial period of intense care for babies and children.

Following Members' questions the STHFT representatives also confirmed that the higher incidences of such illnesses as bronchiolitus at this time of the year had been taken into consideration when examining the capacity of current arrangements.

In terms of paediatrics it was confirmed that there was sufficient ward accommodation at JCUH to cope with the additional workload and sufficient space within the Special Care Baby Unit (SCBU) to accommodate the transfer of SCBU cots from FHN.

Taken into account the upward trend in the birth rate and possible change in service model at FHN an initial scoping exercise had been undertaken and plans were being drawn up to provide additional space and alterations to the delivery suite, Neo-natal parent accommodation, Ante-natal/post natal beds, Gynaecology surgical day unit and Maternity Day unit.

 AGREED that the representatives of South Tees Hospitals NHS Foundation Trust be thanked for the information provided which was noted.

The Scrutiny Support Officer submitted a report the purpose of which was to introduce representatives from NHS Tees with a view to providing an update on progress around developing NHS Emergency Planning and Preparedness in advance of NHS structural reforms due for implementation in April 2013.

The Chair welcomed representatives from NHS Tees who gave a PowerPoint presentation which provided background information and details of the current position leading to implementation in April 2013.

It was noted that with effect from1 April 2013 Public Health England would deliver the Emergency Preparedness Resilience Response (EPRR) amongst other functions currently delivered by the Health Protection Agency locally and nationally. The NHS Commissioning Board (NHS CB) would lead the NHS response to emergencies which required co-ordination across health organisations through its local structures as appropriate. Local Authorities would take on new roles in relation to health protection.

Post April 2013 the NHS CB in EPRR terms would take on roles of former Strategic Health Authority and PCT’s having four regions with 27 local area teams, nine in respect of the North of England. Graphical information was displayed which demonstrated how Local Health Resilience Partnerships (LHRP) with lead Directors of Public Health and NHS CB Local Area Teams (LAT) Co Chairs linked to the above and also to Local Resilience Forums to local authorities and Ambulance Service, CCG’s, NHS Provider and other relevant organisations in terms of accountability and partnership arrangements. It was noted that Cameron Ward had been appointed as the Local Area Director for the Durham, Darlington and Tees NHS CB.

Earlier in 2012 the NE EPRR steering group had amongst other activities been charged with the oversight of the revision of the system wide frameworks (critical care escalation plans, radiation framework, infectious diseases plan, mass vaccination plan, Scientific Technical Advise Cell plan) to reflect the new command and control arrangements for the NHS to be in place for 31March 2013.

The Panel’s attention was drawn to the current position in that there was a need to continue to develop the LHRP’s for the North East in line with changing national guidance to ensure that they were fit for purpose on 1 April 2013. Each shadow LHRP was co-chaired by the NHS CB LAT Director and a lead DPH. The North East Ambulance Service attended the LRF as a first response organisation and LHRPP as a NHS body. LHRP had been established across all the North East but responsibilities would not be handed over to successor bodies until there was an assurance that they were robust.

Specific reference was made to a major incidence exercise which had taken place in early November 2012 in order to test the emerging EPRR arrangements. It was acknowledged that good communication channels were of overriding importance. The Panel was advised that there had been good feedback from the exercise but that a detailed debrief on lessons learnt would shortly take place.

Members expressed differing views as to how the changing role of local authorities was seen ranging from a position of a consultee being able to influence a situation to an opportunity for strengthening its current position.

Middlesbrough Council’s Director of Public Health indicated that there was a strengthening role in the Health Protection Plan and of crucial importance was the support of the Health and Wellbeing Board in mobilising resources and clarifying areas of responsibility. The need to work together whilst under significant pressure was acknowledged but at the same having clarity about the lines of responsibility.

In discussing previous and future scenarios the Panel reiterated the importance of carrying out Health Impact Assessments for all major initiatives and projects. Given the membership of the Health Wellbeing Board it was considered appropriate to seek assurances from the Board that local health protection plans were robust.

Members referred to previous scenarios such as that of mutual aid as in the case of supplies of flu vaccination in recent years. STHFT representatives gave examples of other mutual aid such as that of pressures on beds but gave an assurance of procedures in place in order to respond to major incidences. Essentially there would be no difference but there was a need to ensure clarity about the role of new organisations in such circumstances.

An indication was given of current reporting arrangements with regard to Directors of Public Health which included weekly meetings of the Public Health Board and regional monthly meetings and links to Tees Valley Chief Executives.

AGREED as follows:-

1.That the representatives be thanked for the information provided which was noted.

2. That the Chair, Vice-Chair in consultation with the Scrutiny Support Officer and the Director of Public Health compile a report for submission to the Overview and Scrutiny Board prior to the Executive in order to raise the issues of importance of having robust arrangements for EPRR and appropriate reporting arrangements including the importance of the role of the Health and Wellbeing Board.

The Scrutiny Support Officer submitted a report the purpose of which was to introduce the Director of Public Health and Heidi Douglas, Speciality Registrar Public Health on the topic of children with complex needs with particular regard to issues around low birth weight.

The introductory report also included the following draft terms of reference for the scrutiny investigation:-

1. To investigate the key indicators of child health in Middlesbrough and specifically, what they say about child health in Middlesbrough.

2.To investigate the prevalence of complex needs amongst children in Middlesbrough.

3.To investigate the current range of services available for children with complex needs in Middlesbrough.

4.To investigate whether there are any gaps in service provision for children with complex needs.

5.To explore the future challenges for services for children with complex needs.

6.To investigate the extent to which the local health and social care economy co-ordinates its efforts, in the provision of services to children with complex needs and their families.

The Chair welcomed Heidi Douglas to the meeting who gave a PowerPoint presentation in addition to a detailed report previously circulated which provided an overview of current data relating to low birth weight babies (LBW) and preventable environmental factors that contributed to poor maternal health and LBW babies.

LBW was a major factor in infant mortality and had serious consequences for child health both in early years and later life. It was defined as births as being under 2,500g.

The Panel was advised that LBW babies were more common in the following circumstances:-

• Babies born to mothers under the age of 20 and over the age of 40;
• Babies born to mothers living in deprived areas or mothers with low socio-economic status;
• Babies born to lone mothers;
• Babies born to mothers outside of the UK especially to some black and minority ethnic groups.

International comparisons suggested that factors beyond genetic constraints were responsible for differences in birth weight within populations and that birth weight distributions could potentially be altered by public health interventions.

Smoking during pregnancy was reported as the major modifiable risk factor contributing to LBW and preterm delivery. Statistical information was provided which illustrated the association between increased social and economic disadvantage and higher levels of smoking amongst women with young children.

The risk factors which contributed to LBW included substance misuse; depression and lows levels of social support; micronutrients low dietary intake; and a lower uptake of prenatal care.

Middlesbrough’s proportion of LBW children (9.5%) was reported as approximately 1% above the Tees Valley average and 2% above the national average in 2010. Current performance indicators for 2012 for Middlesbrough showed that the numbers of LBW babies continued to rise (10.1%).

In Middlesbrough between 1991 and 2004 the average rates for LBW children ranged from a low 2.4% in Nunthorpe to19.9% in relation to Pallister Park.

A recent analysis of the pregnant smoking population in Middlesbrough using Mosaic confirmed that such a profile was replicated in Middlesbrough maternal smoking population. The prevalence of smoking in pregnancy in Middlesbrough was reported as 27.2% which was double the national average in England of 13.5% and significantly higher that the regional average of 21.1%. The distribution of smoking prevalence in Middlesbrough mirrored the pattern of deprivation with the deprived wards having higher percentage of smokers compared to more affluent wards.

Births to women under 20 years was a known risk factor of increased likelihood of LBW children. Middlesbrough had the second highest rates of teenage conception in England. In Middlesbrough there was a strong correlation between teenage pregnancy and levels of deprivation.

Alcohol consumption of more than one unit per day during pregnancy was a risk factor for LBW disorders. Substance misuse during pregnancy was associated with a range of health problems for both the mother and baby due to a complex combination of the direct impact of drugs and other health issues and wider social and economic factors.

It was pointed out that further work was required to understand the patterns and levels of drugs and alcohol consumption during pregnancy and the current services that were in place to address such issues for pregnant women.

The report outlined current workstreams to address LBW in Middlesbrough and confirmed that the Middlesbrough Children and Young People’s Trust Executive Board had formed a task and finish group that would oversee a number of workstreams including a maternal health needs assessment, co-ordination of maternal working groups, local and regional surveillance and social marketing.

The Health Needs Assessment would as part of its work seek to engage service providers and stakeholders to gain an understanding of services and programmes that were currently being delivered, interagency working and gaps in the current model. Given the NHS reforms the need to ensure co-ordinated efforts and collaborative working to avoid duplication was acknowledged. There was a need for robust monitoring and local surveillance systems to capture demands placed upon special care services and the nature of the complexity of the presenting cases.

AGREED as follows:-

1. That Heidi Douglas be thanked for the detailed information provided which would be incorporated into the overall review.

2. That the draft terms of reference for the scrutiny investigation as outlined be approved.
 

In a report received from NHS Tees the Panel was advised of the rollout of the Doctor First telephone appointment service (Doctor First) by some GP Practices across the NHS Tees area with effect from late November 2012 to early 2013.

The Doctor First system meant that every patient who telephoned the surgery spoke directly to a doctor on the day that they called who would agree with the patient whether an appointment /visit to the surgery was necessary or not.

The aim of the system was considered to be more equitable for patients in that they were prioritised on clinical need and enabled doctors to work more efficiently by freeing up appointment time previously spent seeing patients who did not need to attend the surgery.

NOTED

In a report of the Chair of the Health Scrutiny Panel, Members were advised of the key matters considered and action taken arising from the meeting of the Overview and Scrutiny Board held on 13 November 2012.

NOTED