Health Scrutiny Panel Minutes

Health Scrutiny Panel Minutes

Date:
Tuesday 28 November 2017
Time:
10:00 a.m.
Place:
Mandela Room, Town Hall, Middlesbrough
 

Attendance Details

Present:
Councillor E Dryden (Chair), Councillor A Hellaoui, Councillor L McGloin, Councillor M Walters
Apologies for absence:
Councillor S Biswas, Councillor C Hobson, Councillor J McGee, Councillor R Brady, Patrick Rice - Director of Adult Care and Health (R&CC), Craig Blair - Director of Policy and Operations (South Tees CCG)
Declarations of interest:

There were no declarations of interest.

Item Number Item/Resolution
PUBLIC
17/21 MINUTES - HEALTH SCRUTINY PANEL - 31 OCTOBER 2017

The minutes of the Health Scrutiny Panel meeting held on 31 October were approved as a correct record.

17/22 SOUTH TEES HOSPITALS NHS FOUNDATION TRUST - UPDATE

The Director of Nursing and Deputy Director of Finance at South Tees Hospitals NHS Foundation Trust were in attendance to provide an update on the current financial position, overall performance / areas of concern, healthcare associated infections (HCAI) and car parking.

 

Health Care Associated Infections (HCAI)

 

The Director of Nursing opened the presentation with information on HCAI. The panel was informed that Clostridium difficile, also known as C. difficile or C.diff, was a bacterium that could infect the bowel and cause diarrhoea. The infection most often affected people who had recently been treated with antibiotics and could easily spread to others within a hospital or care home environment. In terms of current performance it was explained that the Trust was over trajectory by 6 in terms of total number of trust apportioned cases. Enhanced actions had, as a result, been implemented and were monitored on a weekly basis to ensure compliance with infection prevention and control policy and process. Monthly reports were submitted to the Board of Directors and cleaning standards were also monitored via Director led monthly meetings.

 

A meeting had taken place on 15 September with NHS Improvement, the CCG and N. Tees FT to review collective action associated with C.Difficile reduction plans. At that meeting it was acknowledged that locally rates of C.Difficile both in and out of hospital were high and a HCAI Collaborative had been established. The national team was providing comments on all action plans, as well as advice on any gaps. It was accepted that this was an issue of concern for the Trust but every action that could be taken on this issue was being taken. There was no single factor that could be identified as to why the numbers were higher than in 2016/17.

 

In respect of HCAI nationally it was explained that there were a number of challenges. 10 to 15 years ago there was a huge amount of work undertaken in respect of MRSA and as a result the figures have reduced substantially, the Trust has had 1 case in the last 7 months. MSSA was a growing problem nationally, however the Trust was on track to deliver a 15 per cent reduction objective in 2017/18. It was advised that E-Coli was the single biggest infection challenge that the Trust faced and it was a significant challenge. The Trust’s apportioned rate was higher than the national average, with 29.77 per 100,000 bed days compared to 22.5 per 100,000 bed days nationally. Around 80 per cent of those infections had a community onset, with the most common source being a urinary tract infection.

 

One of the Trust’s objectives was to reduce gram negative bacteraemia by 50 per cent by 2020 and although this was a bold statement, it was the ‘right thing to do’. In 2016/17 400 people came into hospital with E-Coli, which highlighted the need to collaborate with colleagues in Public Health and GPs to address this issue as a health system. Health economy action plans had been developed with both CCGs.

 

Finance

 

The Deputy Director of Finance was in attendance to provide a financial overview of the South Tees NHS Trust’s Financial position for the year to date. The panel was informed that the key summary points for month 6 were as follows:- 

  • EBITDA (£1.50m) behind plan
  • Control Total £0.05m ahead plan
  • Income
  • Clinical (£2.63m) behind plan
  • Non Clinical £0.13m ahead plan

 Expenditure

  • Pay £2.2m ahead plan
  • Non Pay (£1.1m) behind plan
  • Exc. Drugs Devices (£0.1m) behind plan
  • Expenditure £1.0m ahead plan

 The main challenges facing the Trust over the next 6 months were as follows:-

  • £30.2m productivity and efficiency savings schemes with majority scheduled for delivery Month 7-12.
  • Operational pressures through winter period.
  • Enhanced financial controls and strategic oversight of key expenditure headings in place.
  • External support received as part of Finance Improvement Programme Wave 2 (FIP2).
  • FIP2 programme of activity developed with support from PwC with further work required to ensure operational delivery of schemes.
  • Cash position challenging whilst managing the productivity and efficiency programme.
  • Car Parking

The Director of Estates, Procurement and ICT and Hotel Services Manager at JCUH were in attendance to update the panel on the car parking improvements. The panel was advised that contractors were currently installing new barriers and pay on foot, as well as pay and display machines at JCUH. In addition there had been provision made for additional blue badge accessible spaces, more drop off spaces closer to A&E, a front and back of house model for car parks and new parent and child spaces created. Investment had also been made in the Prissick car park, with 1100 spaces opened for staff at a cost of £1m. That investment had enabled the reconfiguration of car parking spaces at JCUH to allow for another 130 visitor spaces in the V2 car park.

 

In light of the investment made in the car parking provision new charging arrangements had been introduced as follows:- 

  • 0-20 minutes free
  • 20minutes - 2 hours £3.00
  • 2 hours - 3 hours £4.00
  • 3 hours - 4 hours £6.00
  • 4 hours - 24 hours £7.00

Neighbouring Trusts charges ranged from £2.50 - £6.00 for up to 24 hours parking.

 

It was advised that in 2014 the Trust had announced that it would start charging for blue badge holder parking, in line with other Trusts but had held off introducing the charge to enable special pay machines to be installed. The blue badge parking pay and display ticket was to be charged at the reduced fee of £3 for 24hours and was due to be implemented on 1 December 2017. However, it would now be January 2018 before the charges were introduced.

 

Changes to regular visitor charges had also been proposed and these were highlighted as follows:

 

Current: 

  • 1 month £9.70
  • 3 months £20.20
  • With a £10.00 refundable deposit on return of the barrier card

 Proposed 

  • Weekly £10.00
  • Monthly £25.00
  • No deposit will be needed

Details on car parking charge notices and the appeals process were provided. In respect of the appeals process it was advised that appeals against parking charge notices should be submitted within 30 days from the date of issue. All correspondence needed to include name, address, reference number and vehicle registration, evidence as to why the driver was parked in violation of the parking terms and conditions as displayed on the contractual warning signs.

 

A panel met monthly and any decision to accept or reject an appeal was based on the evidence supplied. All parking charge notices were placed upon hold upon receipt of a written appeal. Any driver appealing against a parking charge notice within 30 days from the date of issue would be given the opportunity to provide payment at the reduced rate in the event that their appeal was unsuccessful. A written response was provided once the appeal panel had met and reviewed the appeal.

 

In terms of the income generated from fees in 2016/17 and future car park investment plans it was explained the total income for 2016/17 was £2.7m. The income was used to fund security and traffic management services, CCTV, lighting, environment upkeep, general maintenance and winter maintenance. Any additional money raised was reinvested in frontline services.

17/23 DDTHRW STP - EVIDENCE GATHERING

The South Tees Integration Manager was in attendance at the meeting to provide an overview of the integration work that was currently taking place across South Tees. It was explained that the vision for South Tees Integration involved "South Tees working together to promote health and wellbeing, reducing dependency and minimising the need for ongoing care. Ensuring our citizens are well informed and can access the right services at the right time, in the right place." This would be achieved through maximising integration opportunities, great partnership working and a real focus on prevention and sustainable outcomes.” The aim by 2020 was to create a health and social care support system where: 

  • Services and pathways were designed around people’s needs;
  • Traditional barriers between primary, acute, community and social care were broken down and better coordinated care was provided;
  • Barriers around accountability, information, incentives and time were removed;
  • Care was brought closer to home;
  • Information technology was best used to its best effect to integrate systems, records and information;
  • Capacity was increased by extending access, eliminating waste by reducing hand offs duplication and making the best use of all health and social care resources i.e. the best use of the South Tees Pound (£);
  • There was a cohesive, whole system planning and commissioning through aligned teams and pooled budgets arrangements.
  • There was a more holistic, lifelong and seamless people centric approach to health and well-being, rather than illness.

It was emphasised that South Tees integration was not about cost shunting or removing individual responsibilities but ensuring the best use of the South Tees pound. In terms of integration in action it was explained that 4 projects had been identified, which were being worked on to help alleviate the financial and demand pressures this winter and help organisations move closer together. It was emphasised that these were not new projects, it was more a case of looking at these specific issues through a more focussed lens i.e. why are we doing what we are doing and how effective is it? The 4 projects were highlighted as follows:-

  • Keeping People Healthy
  • Admission Avoidance
  • Discharge Home
  • Out of Hospital Care

Each project had a senior lead officer assigned and these included the Council’s Director of Adult Social Care and Health Integration, the South Tees Director of Public Health, the Director of Policy and Operations at South Tees CCG and the Director of Adult Care and Health at Redcar and Cleveland Borough Council.

 

Keeping People Healthy - Reduction in people developing long term conditions

 

The South Tees Director of Public Health was responsible for the 'Keeping People Healthy' project. The Director of Public Health was in attendance at the meeting and explained that there were different levels in respect of prevention. The first included building resilient communities by, for example, working with the over 50’s in a health promoting setting or making best use of high footfall areas to promote the importance of keeping healthy. Public Health had worked very closely with the hospital and it was not all about illness.

 

South Tees NHS Hospitals Foundation Trust employed 9000 staff and one quarter of the population went through JCUH each year. It was about capturing that audience and engaging them in choosing to live a healthy lifestyle. Work had also been undertaken with the college and university to develop an ExtraLife package for staff, students and residents, which was again focussed on health promotion and positive wellbeing. The question now was how Public Health could work with other local agencies to promote that same message, especially with services / organisations that people had a relationship with and had the ability to influence them to make positive changes and healthy lifestyle choices. Fire Safety was one of the ways in which, for example, the Fire Brigade were able to assist in delivering the stop smoking message, rather than it coming from a Public Health professional, which could at times be a deterrent.

 

Reference was made to the Live Well Centre and it was advised that Public Health campaigns would operate from the Centre with the aim of maximising awareness raising for residents. It was intended that the Live Well Centre became a single, trusted source of information and that information provided by the Centre was standardised and recognisable.

 

The second related to the ability for services to take preventative measures where there was evidence of risk. For example, the wave 3 national diabetes programme was now in operation and this allowed for people to have earlier tests, which meant they could be provided with information as to whether they were at risk of diabetes earlier. A new programme was also being launched for 2018 in respect of prehabilitation work. Prehabilitation involved physical and/or lifestyle preparation that was designed to improve recovery time following surgery. A pilot programme would operate from the Live Well Centre in partnership with Primary Care colleagues to ensure people were well supported. It maybe that in advance of their operation they have a social need, which needs to be met, for example they maybe socially isolated or affected by fuel poverty. Instead of a medical prescription they may need a social prescription. Safe and well visits have taken place in 10,000 homes across Teesside.

 

Admission Avoidance - Reduction in non-elective admissions

 

The Council’s Director of Social Care and Health Integration was responsible for 'Admission avoidance', which was focused on how do we prevent people from stepping up, as well as how do we support them when stepping down. Characteristically this area of work fell within the Director of Public Health’s domain, however, prevention was an important area for Adult Social Care and this was because it was the right thing to do. There were also financial benefits to be gained in preventing people from needing higher level care.

 

In terms of step up care it was often the case that an individual needed some form of reablement but not necessarily intermediate care and consideration needed to be given, as to whether it was possible to provide that targeted reablement in a different way. There were only 22 intermediate care beds in Middlesbrough and a lot of individuals required reablement support. The purpose of expanding this type of support was to help people with their physical recovery, with the aim of achieving the maximum benefits from our resources. Led by Occupational Therapists targeted reablement in the home environment meant that immediate care could be used as both a step up and step down approach.

 

Reference was made to Care Homes and the fact that Middlesbrough had a high reliance on Care Homes, which was something Adult Social Care was trying to reduce. This was an area where a substantial level of focus had been invested and a pilot had been in operation for the last 12 -16 months to highlight some assistance people could receive at home to improve their quality of life. Nurses were undertaking additional visits around care planning, up to 15 visits per day, and their involvement was resulting in a reduction in Care Home admissions. The majority of this work had been funded from pooled budgets and all of the projects needed to be evaluated to assess whish projects had the biggest impact. It was emphasised that this work was undertaken collectively and would form part of the evaluation to assess if financial benefits can be achieved how do we reinvest?

 

Other work in respect of this project focussed on improved nutrition, falls prevention, additional staff training, the patient passport folder and additional work on infection control. 24/7 access to Consultants in A&E was also having a significant impact, as confident / assured decisions were being taken about whether a patient needed to be admitted.

 

Risk stratification and the use of Community Matrons were a further way of improving how people at risk of hospital admission were identified. The Community Matrons worked with particularly complex cases in the community and at present both the Local Authority and South Tees NHS Foundation Trust provided a Rapid Response service. Work was underway to ensure that a single offer was in place.

 

The single point of access had been rolled out and health and social care staff were co-located as one team. Work was still ongoing to better promote integrated working, which was very much a work in progress.

 

GP feedback and incentives made up the final component of the project and consisted of a payment scheme to support GP’s. The aim of the scheme was for GP’s to offer services above their core service provision, which would assist in reducing hospital admissions. In response to concerns raised by Members it was emphasised that the purpose of the initiative was to strengthen the Primary Care Team rather than offer any perverse incentives.

 

Discharge Home - Reduction in delayed transfers of care

 

The South Tees Integration Manager advised that the Director of Adult Care and Health at Redcar and Cleveland Borough Council was the lead officer for the Discharge Home project. Unfortunately he had had to submit his apologies for today’s meeting. It was explained that some of the interventions involved in this project focussed on moving people through the hospital and looking at how services could work together, as part of a Multi-Disciplinary Team (MDT) to ensure the right packages of care were in place at the point of discharge. Discharge to assess and the provision of seven day services were also included as part of the project.

 

The use of 'Trusted Assessors' was highlighted as a further measure by which to reduce delayed transfers of care. It was explained that a new piece of work had started in South Tees to develop a regional choice policy. As one of the issues that frequently arose in Care Homes was that at the point of discharge individuals were assessed by NHS staff as being able to do a number of tasks. However, when the individual arrived at the Care Home that assessment was viewed as inaccurate and the Care Home would advise that they could no longer accept the individual. In their view the individual’s requirements exceeded the Care Home’s CQC registered provision. It was explained that there were enormous benefits to be gained in reaching that point of trust between an accurate hospital discharge assessment and Care Home acceptance.

 

The panel queried how all of the above collaboration work happened in practice. The South Tees Integration Manager explained that the work was progressed through the Better Care Fund, via Task and Finish groups and the Integration Executive groups. The Director of Adult Social Care and Health Integration advised that he spent the majority of his senior managers spent a great deal of time working with health colleagues. A lot of time was being devoted to the integration work and it was advised that the benefits to be gained were enormous. It was accepted that the integration work needed to take place at an operational level.


Reference was made to the Discharge to Assess project and it was advised that if an individual was medically well enough to be discharged the aim was to move them into another setting to receive a care assessment.

 

In respect of the use of Belle Vue Care Home as a step down facility by JCUH and whether this had played a role in the home’s failing it was acknowledged that all Residential Care Home providers were now dealing with more complex cases. What the Belle Vue Care Home issue had emphasised was the importance of good commissioning. It was explained that the Council had advised the acute sector to go through the Local Authority’s contracts and commissioning unit. Given that the LA has extensive experience in setting up contracts with residential and nursing care providers. However, this offer had not been taken on board and Belle Vue had simply been overwhelmed by the demand placed on them. There was nothing inherently wrong with the proposal it was more about ensuring that the plan was properly assessed.

 

Out of Hospital Care - Reduction in dependency on hospital based services

 

The panel was informed that the Director of Policy and Operations at South Tees CCG was the lead officer for the Out of Hospital Care Project. The following sub-projects had been identified as those most likely to support increased out of hospital care; Integrated Rapid Response services, Develop and implement discharge to assess model, Community Matrons and District Nursing, Increased Access to Primary Care (7 day access over extended day) and the Outpatient Programme (IMPROVE). Improved links had also been established with the VCS and quite a lot of work was taking place in North Ormesby.

 

The development of an integrated falls service was another area of focus and staff were currently exploring the potential as to how that resource could be pooled. Often preventative falls initiatives were funded through non recurrent funding streams and consideration needed to be given to how such schemes could become sustainable.

 

The Chair queried how the South Tees Integration work presented fitted with the high level DDTHRW STP. During discussion the following points were raised:- 

  • At a recent meeting of the DDTHRW STP Joint Scrutiny Committee the lead officer for the STP, who as of 1 October 2017 had also been appointed as the lead officer for the new combined Cumbria and North East Sustainability and Transformation Plan, acknowledged the NHS was underfunded.
  • The Director of Adult Social Care and Health Integration advised that a lot of the work referenced, including for example the discharge to assess project and development of community networks had already been in place even before the introduction of the Better Care Fund (BCF). The BCF had effectively acted as a financial lever to stimulate closer collaboration.
  • In terms of how the South Tees Integration Programme fitted with the high level DDTHRW STP the truth was that even from the Director’s perspective this was simply not known. It was emphasised that as far as the Council was aware there had been no final proposal and the really important element of the STP, relating to community investment had received very little attention. There was also a need for local planning if proposals in the STP were to come to fruition and yet at present the STP seemed to have receded from the local authority and the current position was simply not clear.
  • In respect of areas that the panel may need to be concerned about it was advised that one of the concerns around the STP was around whether particular elements would be prescriptive. If so, clarity was needed around what these areas were and what that would mean locally.
  • It was acknowledged that there were many specialist areas in hospitals where changes would need to be made and delivery would be expanded over a wider footprint. However, the importance of retaining local staff for local people was emphasised.
  • The Director of Estates, Procurement and ICT at South Tees NHS Hospitals Foundation Trust advised that from an estates perspective one of the ‘big ticket’ items had been the proposal for a single maternity unit to accommodate in the region of 10,000 births per annum. This, however, had not been signed off, however, such proposals would require JCUH to grow in terms of its physical footprint. At this stage everyone was still awaiting developments.
  • The question was posed as to whether if JCUH grows in terms of its footprint would access to hospital services that Middlesbrough resident’s currently access be displaced? The Chair expressed the view that it was important for Health Scrutiny to flag up what concerns around where those changes may impact to ensure that Middlesbrough residents retained the services traditionally associated with a local district hospital.
  • In terms of financial implications the Deputy Director of Finance advised that the financial modelling work for the STP had yet to be undertaken.
  • In respect of the workforce challenge Professor Chris Grey (Medical Director NHS England - Cumbria and the North East (CNE)) had stated that the workforce challenge was as great as any. Achieving a sustainable workforce was as important as balancing the books.
  • The Director of Public Health advised that the longer it took to have a clearer plan / model the higher the likelihood that reconfiguration of acute service provision would occur in a reactive rather than planned way, as the workforce challenge was significant.
  • A number of clinical senates had been held to address future sustainability issues and the views expressed fed into the STP process.
  • The point was made that there were two overriding risks in respect of the STP, the first was that the toxic branding associated with STP’s impacted on its delivery. The second related to the lack of local authority engagement in the process.
  • The Director of Adult Social Care and Health Integration advised that in September 2017 in the ranking of 150 LA’s Middlesbrough was rated as 22 out of 151, evidencing that Middlesbrough was hitting the targets in terms of its Adult Social Care performance.
  • It was emphasised that the DDTHRW STP needed to be a whole systems plan rather than an NHS plan and incorporate Adult Social Care and Children and Young People.

AGREED that the information provided at today’s meeting be incorporated in the panel’s final report on the topic of DDTHRW STP and the implications for Middlesbrough residents.

17/24 RESPITE OPPORTUNITIES AND SHORT BREAKS JOINT HEALTH SCRUTINY COMMITTEE - UPDATE

The Chair made reference to the work undertaken by the Respite Opportunities and Short Breaks Joint Health Scrutiny Committee in respect of South Tees and HaST CCGs’ current consultation on the future of respite provision for people with learning disabilities, complex needs and autism. It was advised that the next meeting of the Joint OSC was scheduled to take place on 14th December at 4.30pm in the Jim Cooke Conference Suite in Stockton. At that meeting the CCG’s would provide an update on the independent consultation feedback report, the number of clients per local authority / CCG receiving respite and short breaks at Aysgarth and Bankfields and case studies for people with complex needs who were in receipt of bed based respite provision in the community. Following that meeting the CCG’s were scheduled to make a decision on proposals and the Joint OSC would need to provide a formal response to the consultation in advance of the 11th January 2018.

17/25 OSB UPDATE

The Chair provided a verbal update in relation to matters considered by the Overview and Scrutiny Board on 7 November 2017.

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