Agenda and minutes

Apologies for absence were received from Councillor Freshwater and from Councillor Howard. 

To approve the record of the Committee meeting held on 15 March 2018 and the record of the Joint Meeting of Committees held on 16 May 2018.

The record of the meeting held on 15 March 2018 was agreed and signed by the Chairman as a correct record.

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 (OSI)

Cllr Price declared an OSI in relation to agenda item number 8 (Kent and Medway NHS Social Care Partnership Trust (KMPT) Update) as he was acting as an independent case worker in support of a client working for the community health team. He stated that he would leave the room during discussion of the item.

Cllr McDonald declared an OSI in relation to agenda item number 10 (Three Conversations Model Briefing) due to his involvement in the procurement process. He stated that he would leave the meeting should there be any specific discussion on this matter.

Other interests

Cllr Murray declared an other interest in relation to agenda item number 10 (Three Conversation’s Model Briefing) as her mother’s care was partly funded by the Council.

This report updates Members on the development of a single strategic commissioner across the eight NHS clinical commissioning groups (CCGs) in Kent and Medway and the appointment of a single accountable officer across the eight CCGs. It is for information only.

Discussion

The Committee was advised of the new shared senior management structure  of the nine Clinical Commissioning Groups in Kent and Medway. Glen Douglas was now the Accountable Officer for all these CCGs. Medway had been grouped with West Kent, Dartford, Gravesham and Swanley in this structure. Ian Ayres had been appointed Managing Director for this group with Simon Perks as his deputy. Caroline Selkirk, previously the Accountable Officer for Medway CCG, was now the Managing Director for the separate group of CCGs in east Kent, while Patricia Davies had been appointed Director for Acute Strategy.

The Clinical Chairs of each CCG were leading the work to develop a Strategic Commissioner and it was confirmed that local authorities and their health scrutiny committees would be kept fully informed and engaged in relation to development of the Strategic Commissioner and of the wider Sustainability and Transformation Plan. Significant work would be undertaken during Autumn 2018 to develop the structure of the Strategic Commissioner. However, it was important to note that individual CCGs retained their sovereignty and their legal entity as commissioners of health services. The Strategic Commissioner was currently being developed on the basis that there would be no changes to legislation with this regard.

A Committee Member was very concerned that Medway CCG could be at risk of losing its status and felt that Medway CCG should remain as a separate entity in order for local people to be provided with the best possible health services. The Member was concerned that a larger organisation would struggle to meet local needs effectively. She also stressed the need for the Committee to be provided with regular updates on the development of the Strategic Commissioner.

Another Member said she had not previously been aware of the development of the Strategic Commissioner, which was concerning, and questioned what the implications would be for the development of local care of the Medway Model. The Member was also disappointed that the report did not emphasise the scale of the changes to commissioning arrangements that might take place.

In response, the Deputy Managing Director of Medway North and West Kent informed the Committee that the Strategic Commissioner would look to address urgent needs across Kent and Medway. He apologised that the Committee had not been informed of developments sooner but noted that the Council was represented on the Programme Board of the STP , which had previously discussed the developments. He also advised that information in relation to the proposed developments had been in the public domain since Autumn 2017. However, the concerns of the Committee were noted with the Deputy Managing Director undertaking to provide further updates to the Committee as and when required. He would also ensure that health scrutiny was fully engaged in the developments.

The Deputy Managing Director recognised that there was a need to maintain and strengthen existing arrangements. He emphasised that no changes to the Medway model were being proposed and that there was not currently a clear view on  ...  view the full minutes text for item 89.

Medway’s Council Plan 2017/18 sets out the Council’s three priorities. This report sets out the end of year and quarter 4 2017/18 performance summary against the Council priority relevant for this Committee: Supporting Medway’s people to realise their potential.

Discussion

The Committee was given an overview of performance against the indicators relevant to the Committee’s terms of reference under the Council priority ‘Supporting Medway’s People to realise their potential.’

The percentage of long term packages that were placements had improved from 33% to 31.4% during 2017/18. This indicator was a measure of how well people were supported to remain in their own home. It was noted that development of the Three Conversations model was the principle way in which the delivery and support of Adult Social Care provision in Medway would be strengthened.

In relation to the percentage of clients receiving a direct payment for Adult Social Care services, performance had improved slightly but remained below the target of 32%. Performance had remained at around this level in recent years and it was acknowledged that service transformation was required to improve the figure significantly. There were plans to create a deeper pool of personal assistants, strengthen employer support training and to launch pre-paid cards. As part of the re-procurement of Homecare provision, there was a move towards a model which would utilise individual support funds. This would enable clients to access personal budgets through other providers.

Performance against the indicator for the percentage of adults with learning difficulties in settled accommodation had improved significantly from the 41.5% shown in the report to 67.5%. While this remained below the Medway target of 75% and national average of 76%, it represented significant improvement compared to the figure of 58% for the previous year. It was noted that individuals would only be included in the figures if they had received a review in the previous 12 months, with some clients having not had one during the year. This was something that the service would be looking to address.

In relation to the proportion of adults in contact with secondary mental health services, who were in settled accommodation, performance had improved between Q2 and Q3 from 60% to 64%. This was below the target of 70% but was above the national average of 61%.

One area of particularly good performance was for hospital Delayed Discharges of Care. Significant and sustained improvement had been achieved through joint working between the Council, Medway Foundation Trust and Medway Clinical Commissioning Group.

A Committee Member emphasised the need to keep the system for applying for direct payments simple and to engage service users to clearly explain the advantages. The Assistant Director, Adult Social Care agreed that there was a need to simplify processes and to ensure that there was a staff culture of promoting direct payments and explaining them in a simple and straightforward way.

Another Member said that there would be some people who would not want the responsibility of direct payments, particularly in the case of older people who may not have someone to support them. The Member considered, therefore, that a target of 32% was quite high. She also felt that, given the total population of Medway, it should be possible to provide a  ...  view the full minutes text for item 90.

The report provides an update on progress Since the Trust last attended the Committee in December 2017. Key areas covered in the report include progress made in relation to the Trust’s Improvement Programme, Better, Best, Brilliant as well as updates on the latest Care Quality Commission (CQC) inspection; work being undertaken to address the Trust’s deficit and information in relation to the workforce and vacancies.

Discussion

The hospital had faced difficulties due to winter pressures, including a snow event. The most significant challenge faced related to the Trust’s finances, with there being an urgent ongoing need to address the budget deficit while maintaining access to services. This would require transformation and new ways of working. A draft report had been received from the Care Quality Commission following the recent inspection but this had not yet been published. The report highlighted the challenges faced by the trust but also acknowledged the work taking place to respond to the challenges.

The Trust had a £62m deficit at the end of 2017/18 and had agreed a control total deficit of £46.7 million for 2018/19 with the regulator, NHS Improvement. This deficit represented the worst performance of any acute trust in terms of deficit as a percentage of turnover. Work was taking place to build more expertise in Medway rather than relying on external people. It was acknowledged that efficiency needed to improve with Medway paying more for medical staff than many other areas due to lower productivity, procurement costs and management of the administration function.

The Better, Best, Brilliant programme is the Trust’s improvement programme. The Better stage had helped to enable the Trust to exit special measures. The Best stage was currently being implemented to enable care to be consistently provided at the required standard. It was noted that the number of emergency department attendances across the NHS in May had been at its highest level ever. Medway had one of the best performances in the country for Delayed Transfers of Care with Medway being used as an exemplar for other areas to improve. Performance for cancer waits had been sustained. However, referral for treatment had deteriorated due to a national pause over the winter period. The figure of 82% was below the 92% target.

The ratio of substantive staff employed by the trust compared to agency staff  had increased, while a significant number of the agency workers only worked at Medway Hospital. The recent change to tier two work visas was welcome as it enabled the Trust to employ overseas graduates more easily.

It was anticipated that the nationally mandated  requirement to see patients in accident and emergency within four hours would be delivered by the end of the year.

The Deputy Medical Director of MFT chaired the Mortality Committee, which met monthly. HSNR, which was the ratio for the number of deaths for various diagnoses against an estimate of the number of deaths expected, had a tendency to increase on occasion, particularly recently. The crude mortality rate, which was the level of deaths compared to the number of patients treated had remained unchanged for two years. It had previously fallen from 8% to 6.5%. Between 20 and 40% of all deaths at the hospital were reviewed by a GP not directly involved in care of patient in order to identify trends and any concerns. It was noted that a number of patients at the end  ...  view the full minutes text for item 91.

The report provides an update on the work of Kent and Medway NHS and Social Care Partnership Trust (KMPT).

Discussion

The Street Triage pilot had contributed to a 19% reduction in use of Section 136 detentions in Medway under the Mental Health Act. The service had been running for nine months and there would now be a detailed evaluation with a view to making it permanent.

The Care Quality Commission (CQC) had previously raised concerns about the quality of service provided by the community mental health team at Canada House in Gillingham. The CQC had found caseloads to be too high, with these having been halved since the comprehensive inspection undertaken in January 2017. KMPT was also focusing on employing substantive staff and ensuring that clear care pathways were created. However, a further CQC visit in January 2018 had found that there had not been enough progress made and the CQC had therefore issued a warning notice to KMPT. A further engagement meeting between KMPT and the CQC had taken place to discuss progress and it was considered that good progress was now being made.

Medway had been chosen as an area to pilot a Personality Disorder Pathway due to the relatively high number of people with a personality disorder in Medway. This work was important to help people with a personality disorder to stay in the community. The Rosewood Unit, a mother and baby mental health facility, was about to open in Dartford. This would be the first time for many years there had been such a facility in Kent and Medway.

A Committee Member expressed her disappointment with the CQC findings. She was also concerned that people were struggling to access services and that even GPs were sometimes not clear what provision was available or how to access it. The Member was also concerned that patients were not being monitored effectively following discharge and considered it to be unacceptable that provision for patients with a personality disorder had previously opened and then shut again, with patients not having had an inadequate service for two years. The Member also asked for clarification of whether patients of no fixed abode were able to access Canada House.

The Chief Executive of KMPT agreed that the concerns highlighted were unacceptable. KMPT was building consistent leadership and standard setting. Caseloads had been reduced from 80 to 40, which was considered to be a manageable level. The number of patients being referred by GPs was challenging with only 40% of referrals requiring KMPT services but it being necessary to see all referrals in order to evaluate them. It was acknowledged that the single point of access created had not worked as intended. Staff were now clear about patient referral pathways. It was confirmed that people with no fixed address would be able to access the Canada House service and that KMPT had a responsibility to help this group.

A Member considered the Street Triage programme to be very good. He asked whether it was sustainable and if funding was dependent upon KMPT, Medway NHS Medway Clinical Commissioning Group and Kent Police. The Member  ...  view the full minutes text for item 92.

This report aims to provide the Committee with an overview of Improving Access to General Practice and the mandated requirements from NHS England. It provides an update on the progress on its implementation.

Discussion

Improving Access to General Practice was a nationally mandated scheme. It included clear requirements from NHS England for Medway NHS Clinical Commissioning Group to ensure that additional capacity was provided for general practice. The programme was a key element of the Medway Model and would put general practice at the centre of local care ambitions.

Requirements of the scheme included providing access to GP appointments seven days a week, including during evenings and increasing capacity by 100% by October 2018. This had been brought forward from April 2019.  Consultation capacity would have to increase by 30 minutes per 1,000 of population per week (this was expected to increase to 45 minutes in the future). This equated to 150 additional hours in Medway. The CCG was working on an interim scheme with the local GP Federation and Medway Practices Alliance ahead of a full procurement process taking place by April 2020.

Other requirements included providing a mixture of pre-bookable and same day appointments, ensuring that patients would be able to make bookings through existing channels and ensuring that digital options, such as e-consultations were fully considered. The scheme also required the needs of the local population to be taken into account and did not allow there to be a focus on particular groups of patients. Effective access and links to urgent care and NHS 111 would also need to be ensured.

There was a significant amount of local flexibility in terms of service design and not all GP practices would be required to open late or at the weekend. Consideration was currently being given as to how to deliver the increased provision. Options under consideration included delivering the extra six appointments through three or six hubs or via something between three and six hubs. Staffing, such as utilising nurses and pharmacists to staff the extra provision was also being considered as was which buildings and rooms to use.

A Communications and Engagement Strategy was currently being developed to set out how patients would be informed about the changes. An engagement event would be held on 18 July to test the planned delivery model with Patient Participation Groups. Following this, communications with patients would take place between August and October with the CCG targeting hard to reach groups.

A Committee Member was concerned about the capacity to deliver additional GP appointments in view of there currently being a shortage of GPs locally and the increasing population.

The Committee was advised that there were challenges in relation to the workforce and general practice capacity in Medway and that this was a more significant problem in Medway than in many other areas. It was hoped that part time GPs and older GPs may be attracted by the new provision but it was acknowledged that the programme was ambitious in nature.

A Member was concerned that the amount of funding available appeared to be significantly less than what would be required to fund the increased availability of appointments. She was also concerned that the  ...  view the full minutes text for item 93.

This report provides an update to the 3 Conversations Approach which is being implemented across Adult Social Care.

Discussion

The Three Conversations Approach was being implemented across Adult Social Care. Three Conversations was an approach to support frontline staff to have three specific conversation with individuals in order to establish their needs and find ways to support people to live independently. The approach had been tried and tested within other local authorities. Conversation 1 was about listening to and connecting with people to establish their aims and the resources available to support these. Conversation 2 involved more intensive working to reflect changes to the situation of the client and also to support reablement. Conversation 3 considered long term support needs.

A Test for Change had taken place during the previous year in the ME4 and ME5 postcodes. This showed that the majority of conversations undertaken  were Conversation 1 and also suggested that there were distinct advantages to the Three Conversations approach, although there were significant complexities associated in rolling out Three Conversations across Medway. Views had been sought from service users and staff. 

There had been a restructure of Adult Social Care in September 2017. This had included moving towards working as part of a three locality model. This connected with Medway’s Local Care model and involved social care staff working closely alongside health colleagues. Two new Community Link Worker posts had been created. The role of the link workers was to co-ordinate community resources and strengthen links with the voluntary and community sector. This included close work with the Walderslade Together (WALT)and wHoo Cares (Hoo Peninsula Cares CIC) community interest companies.

The next steps would include work with the Programme Management office to ensure that the rollout of the Three Conversations model was developed. There would be a focus on the co-design of services with staff involved at every stage of the process. Developments would also include the re-design of forms, streamlining of processes and upskilling staff to ensure that they can work in multi-disciplinary strength based way. Further Tests for Change were planned with one having just started. This involved Assistant Practitioners working alongside colleagues answering calls in the Customer Contact Centre. Tablet computers were currently being rolled out to staff. This would ensure they were able to access information when out in the community.

In response to a Committee Member who asked whether engagement was taking place with carers and who also expressed concern that Council carer visits were sometimes cut short due to them being caught in traffic, it was confirmed that engagement was taking place with carers through the Provider Forum as well as directly with service users and their carers. Work was due to take place in relation to the commissioning of homecare to look at how services could be provided in a different way.

A Member questioned why the Test for Change covered postcodes ME4 and ME5 but the statistics presented in the report only appeared to cover ME4. Officers clarified that the Test for Change work had been referred to as the ME4 team but that the results covered  ...  view the full minutes text for item 94.

Discussion

Proposed changes to the work programme were highlighted to the Committee.

Decision

The Committee

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

ii)    Agreed that a date be determined for the Holding the Health and Wellbeing Board to Account report to be presented to the Committee and that this should be earlier than the January 2019 meeting.

iii)  Agreed that the following items be added to the Work Programme:

a.    A further update on the development of a Kent and Medway NHS Strategic Commissioner be added to the August 2018 meeting.

b.    A further update from Medway NHS Foundation Trust be added to the October 2018 meeting

c.    An item on GP services and provision in Medway be added to be brought to the Committee following the roll out of the Improving Access to General Practice arrangements and for this to include statistics in relation to GP provision in Medway.