Agenda and minutes

Apologies were received from Councillor Aldous with Councillor Thorne substituting.

To approve the record of the Committee meetings held on 12 March and 14 March 2019 and the record of the Joint Meeting of Committees held on 22 May 2019.

The records of the Committee meetings held on 12 and 14 March 2019 and the record of the Joint Meeting of Committees held on 22 May 2019 were agreed and signed by the Chairman as correct records.

There were none. 

Members are invited to disclose any Disclosable Pecuniary Interests or Other Significant Interests in accordance with the Member Code of Conduct.  Guidance on this is set out in agenda item 4.

Disclosable pecuniary interests

There were none.

Other significant interests (OSIs)

There were none.

Other interests

There were none.

The Committee has asked for a further update and presentation on the Eating Disorder Service. This follows consideration of a report at the December 2018 meeting. Eating disorders are serious, often persistent, mental health disorders associated with high levels of impairment to everyday functioning and development, and a high burden on families and carers. They can be associated with life-long physical, psychological, educational and social impairment and in some cases can be fatal.

Discussion

The Committee had previously considered a report on the All Age Eating Disorder Service at the December 2018 meeting with a further update having been requested at this meeting. In 2014, NHS West Kent Clinical Commissioning Group (CCG) had sponsored a project across Kent and Medway to improve eating disorder services. At this time, waiting times had been longer than national standards, patients were experiencing excessive travel times and there were concerns about the effectiveness of the service in treating eating disorders. A procurement process had been undertaken with NELFT having become the provider of the £2.7 million contract in 2017. A key feature of the new service was that it now covered both children and adults, helping to overcome the previously problematic transition from child to adult services. The service was now considered to be good although it was acknowledged that there were associated issues that needed to be addressed. This included a lack of inpatient beds and GPs often not referring patients to the Eating Disorder Service soon enough. There was also a need to increase outreach work with schools to raise awareness of eating disorders and the services available.

NELFT was involved in national level work to bid for funding with the aim of being able to deliver more services closer to the patient home. In the year April 2018 to March 2019 there had been 98 referrals to the Eating Disorder Service, with an increase in referrals having been seen in the autumn. 61 of the referrals had been made by GPs. There had been 12 re-referrals. The current caseload was 66 with 5 male patients and 61 female. Patients covered the age range 8 to 65 with the majority being children and young adults. It was noted that a small Medway specific service would not be able to have the range of specialists that a service, covering both children and adults, across Kent and Medway could.

There were currently no children waiting for non-urgent treatment. Assessment for non-urgent child cases was completed within four weeks and for urgent cases, within seven days. Where there was an urgent physical health need liaison was undertaken with acute health trusts to enable more urgent treatment to take place. The target for assessing non-urgent adult cases was 8 weeks with there currently being 10 adults waiting. Urgent cases were due to be assessed within 7 days but could be admitted to hospital immediately where there was an urgent physical need. An out of hours team was available to provide support 24/7. Following treatment, patients were discharged to the care of their GP. Each patient was provided a relapse plan. A range of support was available following discharge.

The firstline treatment for under 18’s was family therapy with this also being available for over 18’s where required. There were also under 18’s and over 18’s carer groups available to provide support to the families of patients. Child inpatients could be admitted to a unit in Staplehurst but there were  ...  view the full minutes text for item 75.

This report updates the Committee on the progress being made by the South East Coast Ambulance Service (SECAmb) to improve its CQC rating, Executive leadership development, the Demand and Capacity review and resulting Service Transformation and Delivery Programme, alongside other strategic performance updates and local performance for Medway.

Discussion

South East Coast Ambulance Service (SECAmb) had recently had its core services inspected by the Care Quality Commission (CQC). The inspection had been brought forward as the CQC had recognised that SECAmb was on a significant improvement trajectory. A separate well led inspection was due to be undertaken in the second week of July, with an inspection of the NHS 111 service in Ashford due to take place in the first week of July. There was confidence that the inspections would show significant improvement with it being anticipated that the caring inspection domain would receive an excellent rating. The latest staff survey had been undertaken in September 2018. The number of responses received had increased compared to previous surveys with survey results showing that staff considered performance in the majority of areas to have improved. The Chief Executive of SECAmb had left the Trust in April to take up a post at the North West Ambulance Service. A new Chief Executive had been appointed and was due to start in September. The Director of Human Resources had also left the Trust. An interim was currently in post pending the recruitment of a permanent replacement.

A Demand and Capacity Review had been undertaken throughout 2017, having been finalised in 2018. In order to deliver Ambulance Response Programme standards, an additional 2,413 staff would be needed compared to 2018 staffing levels. 256 entry level staff had been recruited in the last year and 160 staff trained from entry level to become Associate Ambulance Practitioners. There was now a nationally recognised apprenticeship scheme. This enabled staff who had completed the apprenticeship with one ambulance service to transfer without having to repeat similar training. 82 internal staff had been educated to paramedic level. Assessment centres were taking place to recruit newly qualified paramedics who had completed university courses. There were 146 places available to be filled in the current recruitment campaign. A single assessment centre had resulted in 32 of the 33 attendees being offered jobs. The recruitment completed so far meant that a further 2,034 staff were still needed.

93 new vehicles had been added to the ambulance fleet in the current year with a further 50 vehicles due to be added over the next two years, taking the total ambulance fleet to 386 vehicles. A non-emergency transport tier had been introduced. This operated in a similar way to the separate patient transport service not operated by SECAmb, but with the difference that the SECAmb staff operating these vehicles were trained in emergency driving and could provide a greater clinical input in relation to patient treatment. The non-emergency transport tier was used for patients assessed by a clinician as not requiring emergency transport. This had been piloted in East Kent and was due to be rolled out to Medway.

Questions asked by Committee Members were responded to as follows:

Bullying and harassment and categorisation of patients – Members asked how work to address bullying and harassment was progressing, what  ...  view the full minutes text for item 76.

This report updates the Committee on improving the outpatient services across Medway and Swale. This is in line with the Medway Model and community service redesign which will enable care to be delivered closer to people’s homes. The improvement programme will be bringing services together, this will enable health and care staff to work more closely together and develop services that focus on the needs of the patients.

This report from NHS Medway Clinical Commissioning Group (CCG) updates the Committee on the progress of the programme since the previous paper on the Community Service Redesign and the Medway model that was sent to the Committee in January 2019 and the paper related to Improving Outpatient Services sent to the Committee in March 2019. At this meeting, the Committee deemed that the proposal to reconfigure the delivery of outpatient services does represent a substantial development of, or variation to, the health service in Medway. The Committee requested that a further update report be provided.

Discussion

The plans were part of a long term plan across the NHS to improve outpatient facilities and provide appointments closer to the patient home. Consideration was being given to what services could be delivered through healthy living centres and various community networks. Engagement sessions had started across the health sector. Services under initial consideration included neurology, cardiology, respiratory, clinical haematology and rheumatology. Cardiology, neurology and respiratory patient engagement workshops had been held with a variety of feedback provided to suggest how services could be improved and moved away from an acute hospital.

In relation to neurology, there had previously been some unnecessary referrals as patients had not always been referred in accordance with National

Institute for Health and Care Excellence (NICE) guidance. Consideration would be given to the referral pathway and the education of GPs in relation to referrals. In some cases, patients were initially referred by their GP but were then referred back to their GP by a consultant without an appropriate care plan being put in place. This could result in the GP needing to refer the patient back to the consultant. Ensuring that appropriate care plans were developed would help to ensure that patients could be treated in the community.  Previously, GPs had been able to obtain advice from consultants without making a referral. This tended to no longer be the case. Consideration was being given as to how this consultant access could be reintroduced, with a view to reducing referrals. The possibility of making increasing use of phone consultations and tele health was also being looked at, with it suggested that the provision of blood test results and minor changes to treatment could be undertaken via telephone rather than the patient having to visit hospital.

Questions asked by Committee Members were responded to as follows:

Risk management – In response to a Member question about the risks in relation to stakeholder engagement set out in the report, it was confirmed that while the report stated that there was a risk of poor stakeholder management and engagement, it was currently considered that these had been good. There had been strong, positive engagement across the health sector with task and finish groups having been established in four areas, in line with the engagement plan.

Appropriateness of telephone consultations – A Member expressed concern that some patients would be provided a telephone consultation when they were not in a fit condition to undertake a meaningful discussion. The CCG representative said that telephone consultations would only be used for specific groups of patients and would not be used to assess pain. Patients with more complex needs would not meet the criteria for telephone assessment. Services would be provided by a multi-disciplinary team comprising consultants, physiotherapists, pharmacists and nurses. The changes under consideration did not involve service reduction, rather they were about providing services that were better able to meet the needs of the patient. There would be a move away from disease pathway management to creating treatment pathways based  ...  view the full minutes text for item 77.

In September 2018, Medway NHS Foundation Trust (MFT) served notice on their Dermatology service (including the cancer pathways), following which the North Kent CCGs jointly commenced procurement to identify a new provider to deliver Dermatology services. Following a successful procurement process the contract for the North Kent Dermatology Service was awarded to DMC Healthcare. The new service commenced on 1 April 2019.

In view of concerns raised, it was agreed at the agenda planning meeting held on 29 May that a report should be included on the agenda for the June 2019 meeting.

Discussion

Medway NHS Foundation Trust (MFT), the previous provider of Dermatology Services, had served notice on the contract in September 2018. This followed challenges relating to the service, including increasing waiting lists and it not meeting national targets. Following a procurement process, DMC Healthccare had won the contract to provide Dermatology services, with the new service having commenced in April 2019. At commencement of the new contract there had been a significant number of patients on waiting lists and NHS Medway Clinical Commissioning Group (CCG) had not been aware of the extent of the waiting list. The MFT provided service had been breaching 52 hour wait targets and in March, it was reported that only 4% of cancer patients were seen within the two week target.

The task of moving the Dermatology Service from a hospital to community based service had been challenging, particularly in view of the unexpectedly high number of patients. Nurses responsible for delivering the service had successfully transferred from MFT to DMC Healthcare. However, none of the consultant dermatologists had transferred. This had been particularly challenging as DMC had understood that these consultants would transfer. DMC had established a system of electronic notes with notes from the previous MFT provided service having been uploaded to the system. In April 2019, DMC had received 46,000 phone calls as MFT had advised patients to contact DMC Healthcare. This high call volume had presented a significant challenge. DMC had run additional clinics in order to reduce the backlog of patients waiting to be seen. An advantage of the new service was that, for many patients, services were now being provided closer to their home. DMC Healthcare was in the process of acquiring a phototherapy machine. This was due to be installed at Rainham Healthy Living Centre the week after the Committee meeting and patch testing was due to commence within the next four weeks. Staff were positive about how the new service was running. The aim was to build on this, to provide further training and to recruit a full time dermatologist. It was acknowledged that establishing the new service had been difficult.

In response to Member questions about the size of the waiting list and when it would be cleared, recruitment plans and the difficulty patients faced in getting GP appointments, it was confirmed that the waiting list inherited from MFT had been 8,800. This had been reduced to the current figure of around 8,000. Engagement had taken place via practice learning events at each of the Kent and Medway CCGs to tell clinicians about the new service and to promote the adoption of a dermatology app. There was a national shortage of dermatologists with it being considered that word of mouth was more likely to be successful for recruiting dermatologists than the formal advertising of vacancies. Patient feedback was important, this would be shared at monthly commissioning meetings. 

A clinical triage process had been undertaken to review patients who had been on the waiting list for an  ...  view the full minutes text for item 78.

In Medway, the Public Health team provide strategic leadership for suicide prevention, including the suicide prevention strategy and steering group.

In 2018, new funding of £667,978 was secured from NHS England for suicide prevention work across the Kent and Medway Sustainable Transformation Partnership (STP) area in 2018/19. Sustainable Transformation Partnerships (STPs) bring together a range of stakeholders including the NHS and local government. Kent and Medway was one of eight areas nationally to receive funding.

This paper provides an overview of suicide prevention work that has taken place during 2018/19 and plans for 2019/20. The programme was agreed by the multi-agency suicide prevention steering group that supports this work in Kent and Medway. The proposed interventions are based on the best evidence available to inform suicide prevention.

Board Members are asked to note the progress to date and future plans for the suicide prevention programme.

Discussion

It was recognised that suicide was a tragic event that could have a devastating impact for family and friends of the person and on the community as a whole. In Medway, as nationally, men, particularly middle aged men, were at greater risk of suicide than women. In the year before a suicide, a third of people had contact with secondary mental health services, a third had contact with their GP and a third had no contact with health services. This suggested that there was a need to look at community interventions as well as interventions relating directly to health services. Work had taken place with partners through the sustainability and transformation partnership to secure funding from the NHS for work on a suicide prevention programme. Kent and Medway was one of eight areas nationally to have been awarded additional funding for an intensive programme.

The Kent and Medway Suicide Prevention Partnership and its steering group included a wide range of partners, including transport and education providers and voluntary sector representation. The focus of work was on the groups most at risk of suicide. The programme delivered over the last year had consisted of nine strands. Some examples of this included the ‘Release the Pressure’ social media campaign. The campaign targeted middle aged men currently not in contact with any services, signposting them to a 24 hour helpline. This had been promoted widely across a number of places in Medway. 4,500 calls from Medway residents had been made to the helpline during the previous year. Other examples included the launch of the Saving Lives Innovation Fund. This provided grants to community organisations to undertake suicide prevention projects. 29 such projects had been undertaken in the year, with over 1,000 people benefitting from these. A range of suicide prevention awareness training was available to both adults and young people.

Each suicide prevention workstream was assessed and externally evaluated to determine its impact and qualitative feedback collected. Feedback from the national team responsible for funding the programme suggested that work in Medway was more advanced than in the other seven areas to have been awarded funding. 

Funding had been secured for the next year to enable the local programme to continue. The aim would be to build upon lessons learnt from the previous year, to introduce additional work around systems leadership and to look at pathways in relation to depression. Medway’s Suicide Prevention Strategy was also due to be refreshed with the Suicide Prevention Partnership being responsible for monitoring the Strategy’s action plan.

A Committee Member said there was a need to undertake awareness raising of suicide prevention with universities. There were legal challenges as universities were usually unable to make families aware of concerns without the consent of the individual. It was suggested that the development of a protocol with universities be investigated to enable the disclosure of certain information about students to the families where there was a history of depression or other mental health disorder. The Member, while pleased  ...  view the full minutes text for item 79.

As a Medway, North and West Kent footprint system, we have developed a single operating plan for 2019/20. This has helped deliver the consistency in planning aspired to in the Medway, North and West Kent (MNWK) Planning Approach (submitted to February 2019 Governing Body at Medway CCG).

The attached document has been adjusted to reflect local feedback from across Kent and Medway and national feedback from regulatory partners. Formal feedback is still to be received following 4 April 2019 submission and thus in-year amendment may be required. The plan documents the key developments for 19/20: Local Care, Outpatient Transformation and the development of Primary Care Networks, Integrated Care Partnerships and Integrated Care Systems.

Discussion

The NHS Medway Clinical Commissioning Group (CCG) representatives acknowledged that there were a significant number of acronyms that had been used without explanation in the Operating Plan and undertook that consideration would be given to this when producing future plans. In response to a Member question, they also undertook to establish why the Operating Plan had not been presented to the Committee in draft form.

The Operating Plan covered all services provided by the CCG. The Plan covered four CCG areas, including Medway. It was anticipated that this would help to ensure consistency of approach across CCGs as they moved towards an integrated care system and a single strategic commissioner. The Plan had been submitted to NHS England on 4 April 2019 with no formal feedback having yet been received. The contents of the Plan were now being communicated to ensure that CCG staff and health providers were aware of its contents. Monitoring was being undertaken against the commitments included in the Plan and delivery plans developed where these were not already in place. There was a focus on developing a local five year response to the NHS Long Term Plan. This was due to be submitted to NHS England in the Autumn. The outcomes of the Operating Plan would be factored into these longer term plans.

A Member asked whether the pseudonymization [a process by which personally identifiable information is replaced by one or more artificial identifiers] described within the Operating Plan would lead to data no longer being useful. The Member was also concerned that there appeared to be fewer actions in the Plan specific to Medway than to West Kent, in view of the level of health inequality in Medway. The Member also voiced concern about existing priorities being consumed by the development of a five year plan and asked about the development of Care Navigators in Medway.

The CCG representatives advised that 2019/20 was the first year of a five year plan and that all priorities contained in the Operating Plan were still valid. It was considered that the pseudonymization being used had not made the data meaningless. It had not been the intention for the Plan to any way suggest that there was less need for services in Medway than in other areas. They agreed further work was needed in relation to tackling health inequalities, given that some inequalities were increasing locally. It was envisaged that the development of the local Five Year Plan and work with Public Health, would be catalysts to addressing this. It was considered that Care Navigators would have significant impact on the local health system and patient access to services. The Assistant Director – Adult Social Care, said that the Council was working jointly with the CCG to procure community care navigation services. Care Navigators were currently based at Medway Maritime hospital and also worked in the local community. The Navigators would support people to be connected to other services in the local community. EU funding  ...  view the full minutes text for item 80.

Discussion

Proposed changes to the Work Programme were highlighted to the Committee.

A Committee Member said that a representative of Kent Healthwatch had made comments at the Kent Health Overview and Scrutiny Committee that suggested that Healthwatch across Kent and Medway was in favour of the option selected for the Kent and Medway Stroke Review. It was requested that Healthwatch Kent be asked to explain these comments.

Decision

The Committee:

i)     Considered and agreed the Work Programme, including the changes set out in the report.

ii)    Asked that the Healthwatch Medway representative request that Healthwatch Kent provide a written response to the Committee to explain comments made at the Kent Health Overview and Scrutiny Committee in relation to the Kent and Medway Stroke Review.

iii)   Asked that the Healthwatch Medway representative ask Healthwatch Kent to provide a written response to the Committee to explain comments made at the Kent Health Overview and Scrutiny Committee in relation to the Kent and Medway Stroke Review.

iv)  Agreed the following additional changes to the Work Programme:

a)     That an update on eating disorders be added to the Work Programme for a future meeting of the Committee.

b)     That an update from South East Coast SECAMb be added to the Work Programme for a future meeting of the Committee.

c)     That an update on the redesign of outpatient services be added to the Work Programme for the October 2019 meeting.

d)     That a report on the Dermatology Service be added to the Work Programme for the August 2019 meeting and that a representative of Medway Foundation Trust be asked to attend.