Agenda and minutes

Apologies had been received from Councillor Chrissy Stamp with Councillor Mahil substituting. 

To approve the record of the meeting held on 18 June 2019.

The record of the Committee meeting held on 18 June 2019 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 (OSIs)

There were none.

Other interests

Cllr Mahil declared an other interest in agenda item number 8, the Medway NHS Foundation Trust (MFT) Update as a relative was a senior member of staff at the Trust. Cllr Mahil remained in the room during discussion of the item.

At its meeting in March 2019, the Committee received a briefing on the proposed development of an integrated care system across Kent and Medway. In particular, the meeting was informed about the proposed establishment of:

• An Integrated Care System (ICS) fully operating across Kent and Medway from April 2021
• A single CCG operating at a Kent and Medway level from April 2020 (formed through the merger of the existing eight CCGs)
• Integrated Care Partnerships, operating across local geographies of circa 250,000 to 500,000 resident population
• GP-led Primary Care Networks (PCNs), serving a registered population of circa 30,000 to 50,000, acting as the provider and delivery vehicle for local care.

This briefing provides a high level summary of the work to date in establishing these arrangements, and in particular the development of a single CCG.

Discussion

A presentation was given to the Committee on the proposals, the key points of which were as follows:

·      A strategic commissioning function was needed to enable more effective planning and commissioning of services, based upon local needs. This would be realised through the establishment of a single Kent and Medway Clinical Commissioning Group (CCG).

·      It was anticipated that, nationally, single CCGs would be created to match Sustainability and Transformation Plan (STP) footprints. A single CCG would be able to achieve scale efficiencies that could not be achieved by the existing 8 Kent and Medway CCGs. There was a need to reduce CCG running costs by 20%.

·      Services were not currently as joined-up as they could be, with there being too many individual agencies and it was acknowledged that there was currently too much inequality and not as much prevention work as there could be. Differences in life expectancy between areas needed to be addressed.

·      Government policy had acknowledged the internal health market was not working to improve quality or reduce costs. The internal NHS market was being replaced by a culture of collaboration and mutual responsibility.

·      The health system also faced a number of workforce related challenges.

·      It was anticipated that the establishment of a single CCG would help facilitate the commissioning of the services required to meet need rather than blanket commissioning by area.

·      Integrated Care Partnerships (ICPs) would include acute hospitals, primary care, community services the voluntary sector, council services, the ambulance service and mental health providers. Four Integrated Care Partnerships would cover Kent and Medway, including one for the Medway and Swale area. The Integrated Care Partnerships would work collaboratively to provide services commissioned by the single CCG. The Sustainability and Transformation Plan and Medway CCG was working closely with Medway Council to develop this collaborative working.

·      Primary Care Networks would help facilitate groups of GPs to work collaboratively to deliver services to populations of 30 to 50 thousand. This would enable pooling of resources and a greater focus on the holistic needs of the local population, including preventative work. The Networks would be able to draw on local intelligence to identify and address local need, with analysis having already been undertaken by the Council’s Public Health function. Seven Primary Care Networks had been established in Medway and three in Swale.

·      The single CCG would use findings of population needs assessments to identify and prioritise service provision in conjunction with partners. The Kent and Medway Joint Health and Wellbeing Board would have an important role.

·      Development of this work was being overseen by the Sustainability and Transformation Plan Programme Board, which was attended by the Leader of the Council.

Members asked a number of questions as follows:

Business case, funding, staffing and the role of Medway – A Member raised concern that they had not seen a business case, that there may not be sufficient staff and funding available and that the Medway and Swale Integrated Care Partnership area was too small. The Committee was advised  ...  view the full minutes text for item 219.

The report updates the Committee on the following:

i)     The Proposed consolidation of the stroke service at Maidstone and Tunbridge Wells (MTW) NHS Trust onto a single site at Maidstone Hospital.

ii)    Medway's referral to the Secretary for Health and Social Care of the NHS decision to establish Hyper Acute Stroke Units (HASUs) at Darent Valley Hospital in Dartford, Maidstone Hospital and the William Harvey Hospital in Ashford and the result that there would be no acute stroke provision at Medway Maritime Hospital.

iii)   The possible submission of a Judicial Review by Medway Council and an update on Judicial Reviews already submitted.

Discussion

The report provided an update on Medway’s referral, to the Secretary of State for Health, of the decision in relation to the Kent and Medway Stroke Review as well as in relation to two Judicial Reviews on the same matter. It also provided the rationale for the consolidation of stroke services, currently provided at Maidstone and Tunbridge Wells Hospitals, onto a single site at Maidstone Hospital. In March 2019, the Committee had referred the decision made by the Joint Committee of Clinical Commissioning to establish hyper acute stroke units in Dartford, Maidstone and Ashford and not in Medway, to the Secretary of State for Health and Social Care. On 19 June, the Minister of State for Health referred Medway’s request to the Independent Reconfiguration Panel (IRP), requesting an initial response by the end of June. The IRP advised that it would not be able to meet this deadline due to other referrals it was already considering. It is not currently known when the IRP will consider Medway’s referral. Two parties had also made a submission for Judicial Review. The courts had decided to join these into a single action, with Medway Council having been named as an interested party. A decision on whether the Judicial Review could proceed was due to be taken on 3 and 5 December.

Maidstone and Tunbridge Wells NHS Trust had made the decision to consolidate its stroke services onto a single at Maidstone Hospital. This was on safety grounds, with the service provided at Tunbridge Wells having become unsustainable. The Trust said it respected Medway’s referral and the Judicial Reviews, advising that the change was reversible.

A Committee Member said that no issues in relation to the sustainability of the Tunbridge Wells service had been raised during discussion of the stroke review and that the frailty of the Tunbridge Wells population had been one reason for the option of locating a HASU there. The Member questioned whether the safety of patients at Maidstone Hospital could be assured.

The Chief Operating Officer of the Trust said there was confidence that Maidstone would be able to absorb the additional patients safely. The additional patients averaged just 1.2 per day or a maximum of 3. The stroke service at Maidstone was a highly performing service with good clinical leadership. Despite attempts to recruit, it had not been possible to retain enough staff at Tunbridge Wells Hospital in order to safely provide a stroke service. This was in view of the fact that Tunbridge Wells would not be providing stroke services in the longer term with staff being aware that the service would close. The standard of service provided at Tunbridge Wells was therefore not as good as the one that could be provided at Maidstone. Engagement had been undertaken with the Kent Health Scrutiny Committee, the local MP and other stakeholders.

The Chief Executive of the Trust added that there had been a material change in the ability to staff the stroke unit at Tunbridge Wells since  ...  view the full minutes text for item 220.

The report informs the Committee of progress in the Kent and Medway Pathology Programme since the update in October 2018.

Discussion

There were three types of hospital pathology laboratory services - microbiology, blood sciences and cellular pathology services. There were currently hub laboratories in Maidstone, Dartford and Ashford and essential services laboratories in Tunbridge Wells, Medway, Canterbury and Margate. Work had been underway for a year to consider how to better collaborate and increase productivity and quality through the establishment of a single Kent and Medway Pathology Service. An outline case had been agreed by the four hospital trusts with a number of business cases being developed. These were due to be completed by the end of 2019.

In relation to transfer delays and other issues in relation to the North Kent Pathology Service (NKPS) that the Committee had previously been advised about, a Committee Member asked whether there was confidence that similar problems would be avoided by the new Kent and Medway service. They also asked whether it was still planned that emergency testing would be retained at all acute hospital sites and what the current standard was for waiting times. This was following the Member having encountered a patient at Medway Hospital who had waited six hours for blood test results.

The Chair of the Pathology Programme Board said that business cases being developed for the single service would include lessons learned. Every hospital had an essential service laboratory and this would not change under the proposal. Some testing was also undertaken at the patient’s bedside. The turnaround time for off-site testing was typically a few days.

The Chief Executive of Medway Foundation Trust said he was keen to ensure that lessons were learned from the problems encountered by NKPS and that the service had now been stabilised but still faced problems. Medway was, therefore, in principle, supporting the establishment of a single service. Patients should not be waiting at the hospital for six hours in order to get results. In the event of the wait being long, patients should be asked to go home and then provided the results separately. The Chief Executive offered to investigate further if details were provided.

Decision

The Committee noted and commented on the progress of the Kent and Medway Pathology Programme.

The report at Appendix 1 provides an update on progress since the Trust last attended the Committee in March 2019.

Discussion

The key points of the report were summarised as follows:

·      Strategic objectives - MFT was making clear to staff the direction the organisation would be taking in the next 3 to 5 years. This had included refreshing the Clinical Strategy and the People Strategy. A fifth strategic objective, ‘high quality care’ had been added to the existing four objectives. In addition to the strategic objectives there were also core quality objectives that set out what the hospital was planning to achieve in the next 12 months.

·      Local care - work was taking place with NHS Medway CCG to provide local care closer to where people live.

·      Finances - The Trust had met its budget control total last year and achieved the cost improvement target of just over £21 million. This was the first time for ten years that both had been achieved, with it being expected that both would also be achieved for the current year. However, a large budget deficit remained. Spending on agency staff had further reduced with an expected spend of £11million in the current year, down from £16 million the previous year and £50 million previously.

·      Staff survey results – the aim was to be in the top quartile of trusts for survey results. The latest results showed an increase in the percentage of staff who would recommend Medway as a place to work or to be treated.

·      Discharges – work continued to ensure that patients were discharged effectively and efficiently. This included work to ensure that patients were streamed to the most appropriate department and to prevent patients staying in acute beds longer than necessary.

·      Executive changes – The former Chief Executive, Lesley Dwyer, had left towards the end of 2018, with the current Chief Executive, James Devine, having initially taken over on an interim basis and substantively from April 2019. The number of chief operating officers had been reduced from 2 to 1 and a Deputy Chief Executive appointed. The Medical Director had left their post while the Director of System Transformation had been seconded to the Medway and Swale Integrated Care Partnership.

·      Patient numbers – July had been busy with a similar number of patients to during the winter. Performance in relation to the four-hour Emergency Department wait target was 80% compared to a national average of 79% and a target of 95%.

·      Same Day Emergency Centre – MFT was the first hospital in Kent and Medway to have one. The Long Term Plan specified that all acute trusts should have such a facility. It was treating 60 to 80 patients each day with patients either discharged the same day or referred for further treatment.

·      Diagnostics - 92 per cent of patients referred for diagnostics in June had tests undertaken within the target time compared to a trajectory of 99%. MRI testing was challenging with the hospital needing to use a mobile scanner for the next 4 to 6 months.

Members asked a number of questions which were responded to as follows:  ...  view the full minutes text for item 222.

The changes to the phlebotomy service provision in the community is part of the wider changes to adult community health services; to transform the way services are delivered across Medway to make them easier for patients to access and to use.

Discussion

The report provided an update on changes being made to phlebotomy services from September 2019. This was part of the wider adult community health services programme. Engagement on this programme had taken place in September and October 2018 with the majority of respondents having supported the proposed changes. In line with the Medway Model, services would be provided closer to the patient. The changes would increase the provision of phlebotomy services in Medway and make service provision more even. Phlebotomy services at MCH House would be reduced and then removed with provision extended at three Healthy Living Centres, including evening and weekend provision. Some GP practices in Medway, mainly in the Rochester area, also provided phlebotomy services. These services would continue and would not be affected by the changes.

Members asked a number of questions which were responded to as follows:

Recommissioning of community services – The reprocurement of community health services had been delayed by two years in view of the changes resulting from the NHS Long Term Plan, the development of Integrated Care Partnerships and anticipated changes to legislation. This had no effect on current service provision and the timescales for making improvements to phlebotomy services. 

Provision in central Chatham and opening hours – Provision in Chatham was planned but a location for this had not yet been identified. It was anticipated that this would be provided by the end of March 2020. A Member request for evening and Saturday opening of the Chatham service would be taken into account. Service usage would be monitored across locations to ensure there was enough capacity.

Accounting for Population Changes and staff terms and conditions – provision was based on current populations. Information was provided by Public Health and capacity would be kept under review to reflect growth in localities. Medway Community Healthcare staff who currently provided services at MCH House would work at other centres in the future. Therefore, there would be no change to their terms and conditions. There would be sufficient staff capacity to be able to meet demand.

Communications and service quality – in response to a Member who emphasised the importance of communicating the changes, along with his hope that service quality would be maintained, the Medway Community Healthcare representative said that they would not expect the changes to lead to any reduction in service quality. Work was being undertaken to ensure that the changes were advertised and that patients were made aware of their options.

Staffing capacity – Medway Community Healthcare had a flexible, mobile workforce. This would help ensure that all the locations that phlebotomy services were being provided in were sufficiently staffed.

Provision of Isle of Grain – In response to a Member’s concern about lack of provision on the Isle of Grain, the Committee was advised that there was insufficient demand to provide a dedicated phlebotomy service. Patients from this area travelled to the Keystone Centre in Strood.

Decision

The Committee noted the planned changes to the phlebotomy service provision.  ...  view the full minutes text for item 223.

This paper has been written by the East Kent CCGs, (on behalf of Kent and Medway commissioners) on proposed changes to the way acute adult mental services are delivered across Kent and Medway.

The proposed changes are based on latest best practice and are in line with Kent and Medway Partnership Trust’s (KMPT) programme of transformation, corresponding service redesign, and ongoing programme of refurbishment across its estate. The refurbishment will be funded by the sale of the St Martin’s (west) site in Canterbury to Homes England, releasing a capital receipt which will be used to reinvest in, modernise and upgrade existing KMPT estate.

Discussion

Work undertaken so far had shown reduced reliance on inpatient beds. The sale had been agreed of part of the St Martin’s Hospital site, which would release capital to fund the estates improvement programme. The Cramer Ward, which was no longer fit for purpose, would close as a result. The report listed the future options for provision of this capacity. The proposals had been considered by the Kent Health Scrutiny Committee, which had considered them to amount to a substantial variation to the health service in Kent. Therefore, should Kent consider the proposals to be a substantial variation for Medway they would need to be considered by the Kent and Medway Joint Health Overview and Scrutiny Committee. An assurance process had been started with NHS England with it considering that public consultation would be required.

A Committee Member said that they considered the proposals to be a substantial variation as they involved a possible reduction in beds. Another Member agreed and said that they did not consider that work to reduce demand for inpatient facilities was sufficiently advanced in order for a reduction in beds to be considered. She requested that the consultation include engagement with service users to understand whether they considered that the need for inpatient beds was reducing.

In relation to the total out of area bed days of 3085, referenced in the Committee agenda, a Member was concerned that further loss of beds would lead to more out of area placements.

The Chief Operating officer of Kent and Medway NHS and Social Care Partnership Trust said that the patients placed out of area had specific needs and that any closure of St Martin’s would not impact this group. KMPT was committed to identifying capital to build a unit for this cohort. There was agreement that public consultation would be a positive step.

Decision

The Committee:

i)             Considered the proposed service change and determined that it constitutes a substantial development of or variation in the provision of health services in the local authority’s area.

ii)            Agreed that the proposals do warrant formal public consultation.

iii)           Noted that as the Kent Health Overview and Scrutiny Committee had also deemed the proposals to constitute a substantial development or variation, the proposals would need to be considered by the Kent and Medway NHS Joint Overview and Scrutiny Committee.

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

Discussion

KMPT had appointed a new Chairman with the Trust welcoming the opportunities available to it as an organisation. This was against the backdrop of mental health having increasing importance at national level. The Care Quality Commission (CQC) rating of the Community Mental Health teams had improved from requires improvement to good. The Ruby Ward, an inpatient ward for older people with acute mental health difficulties at Medway Hospital, would be upgraded. This necessitated a temporary move to Dartford as there was no suitable alternative location in Medway. Members of the Committee were shortly due to visit the Community Mental Health Hub in Ashford. The hub enabled services to undertake more collaborative working and was similar to the Hub that was planned for Britton Farm, Gillingham. It was acknowledged that some GPs were critical of the provision at Canada House in Gillingham and that work was required with GPs to help them  navigate the services available. The CCG had been able to provide some additional funding for primary care mental health provision. The way in which therapeutic services were delivered would change in order to ensure a more consistent service.

Work was taking place locally with the Mental Health and Learning Disability Steering Group to identify opportunities for joint working. The Kent and Medway STP had secured additional funding for developing and improving the crisis care treatment team. There had also been success in improving the resource available for Safe Havens. Partnership working, including working with the voluntary sector had increasing importance, particularly in the context of the development of Primary Care Networks. The opportunity to work as part of the Network and shape its development from the outset was welcome. There was a need to improve diagnostic rates for dementia and ensure that people with serious mental illnesses also received physical health checks.

Members asked a number of questions which were responded to as follows:

Liaison Mental Health Service – In response to a question about patient feedback on the liaison mental health service, engagement was taking place with the Enabling Kent programme in order to obtain more robust feedback. Work was undertaken with Healthwatch Medway in relation to particular issues, with Healthwatch also taking part in Mystery Shopping activities. Few, if any complaints had been received regarding the service over the last few months.

Needs of people with complex mental health issues - Medication prescribed to this group, particularly patients with psychosis could have a significant impact on physical health. For example, some anti-psychotic medicines could result in significant weight gain. There was a need to develop primary care mental health services and to utilise social prescribing for those affected by complex mental health issues, although this group was likely to need additional support to engage in available opportunities. 40% of people referred to KMPT had serious mental illness, with this group being far more likely to have reduced life expectancy.

Support for people while recovering – It was questioned what support was available for people who were  ...  view the full minutes text for item 225.

Medway’s Council Plan 2016/21 sets out the Council’s three priorities. This report summarises how the Council performed in quarter 4 and at end of year 2018/19 on the delivery of the delivery of the priority relevant for this committee: Supporting Medway’s people to realise their potential.

Discussion

A Member was pleased to see that performance against a number of the success measures had met or exceeded target and commended staff for their work. However, performance of some other success measures had been below target for a significant time. The measure, ‘Proportion of adults in contact with secondary mental health services who live independently’ was considered to be one example of where performance could improve if work was more joined-up. The Member asked, in view of the decreasing number of care home places available locally, whether the local market was able to meet demand. The Member also asked that the Committee commend the ‘Men in Sheds’ initiative and its role in addressing social isolation.

The Assistant Director – Adult Social Care said that performance for the proportion of adults with learning disabilities who lived in their home had been persistently below the national average but that there had been significant improvement. 2018/19 year end performance was 69%, a 2% improvement on the previous year and a 10% improvement compared to a few years previously. The gap between Medway and the national average had significantly reduced. Initiatives to support improvement in this area included growing the Shared Lives Service, with the ambition being to double its size in the next two years. The Service was an alternative to residential care for people with learning disabilities. A small transitions team had been created to ensure the effective management and support of people transitioning from children’s to adult services.

A Mental Health and Disability Steering group had been established within Medway. This would look at how to support people with learning disabilities or mental health issues to live independent lives. It would also deliver the priorities set out in the Medway Mental Health Strategy and the Learning Disability Strategy, the latter of which was due to be considered by the Committee at its October 2019 meeting. Homelessness and housing options for people with mental health issues was an area that would be further investigated. It was acknowledged that improving performance against some measures would take time.

Adult Services undertook a range of work to help ensure that the care home provider market was sustainable. This included a small quality assurance function. There was sufficient supply of residential care available. Extra care provision had been developed, including two new schemes, as an alternative to residential care. It was acknowledged that there was pressure around nursing and nursing dementia provision locally. Work was taking place with NHS Medway Clinical Commissioning Group to develop this and ensure sufficient provision to meet future needs.

A Member considered the transition work to be excellent and also mentioned the increasing propensity of care homes to take day patients.

Decision

The Committee considered the quarter 4 and end of year 2018/19 performance of the measures of success used to monitor progress against the Council’s priorities.

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.

ii)    Agreed to request that information on the Community Pharmacy Contractual Framework how it aligns with the Kent and Medway transformation programme is requested as part of a proposed Member Briefing on the NHS local Five Year Plan.