Agenda and minutes

Apologies for absence were received from Councillor Dan McDonald with Councillor Mark Prenter substituting and from Councillor Chrissy Stamp with Councillor Simon Curry substituting.

To approve the record of the meeting held on 15 October 2019.

The record of the Committee meeting held on 15 October 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)

Cllr Price declared an interest in agenda item number 5 as he was the Chair of the Board of Trustees of the Sunlight Development Trust, which leased the building that the Sunlight Centre GP surgery was located in. Cllr Price left the room during brief discussion of GP surgery reconfiguration. He otherwise remained in the room.  

Other interests

Cllr Ahmed declared an interest in agenda item 7 as she worked in the office of one of the Medway MPs who had submitted a letter in relation to proposals, as referenced in appendix 2 of the report. Cllr Ahmed confirmed that she was approaching this discussion with an open mind and did not consider herself to be pre-determined. Cllr Ahmed remained in the room during discussion of the item.

The report provides an update on proposals, previously considered by the Committee, to reconfigure GP services provided at some Gillingham and Chatham GP surgeries. NHS Medway CCG has advised that this proposal is no longer under consideration.

This report also advises the Committee of action taken by the CCG, in collaboration with DMC Healthcare, in response to patient concerns raised in relation to GP access, telephone access and prescriptions.

Discussion

The report included a summary of patient concerns that had been sent to the Chairman of the Committee by Ms Zi Fincham. These related to GP Services provided by DMC Healthcare at Medway GP surgeries the Sunlight Centre, Balmoral Gardens, the Pentagon, St Mary’s Island, Twydall and Kings Family Practice. It was explained that the Committee could not consider individual patient complaints and that these should be submitted to the provider or NHS Medway Clinical Commissioning Group (CCG). The Committee was, however, able to ask the CCG for a response if patient experience suggested that acceptable standards of patient care may not be being met.

The Director of Primary Care Transformation at the CCG reminded the Committee that it had previously been advised that the CCG was considering the rationalisation of five GP surgery sites to three as part of a contract review. It had since been agreed that the five sites would be maintained. The Committee had considered that the proposals amounted to a substantial variation to the health service in Medway, therefore any further review of the configuration would be presented to the Committee. There were currently no plans for any such reconfiguration.

Since Ms Fincham had submitted complaints in August 2019, the CCG had received a further eight complaints about services at these surgeries. The complaints related to GP access, telephone access, repeat prescriptions and prescription reviews. The response to these was managed in line with CCG and NHS England complaints policies. All patient complaints had been considered as part of an action plan agreed with the provider, DMC Healthcare and progress was monitored via KPIs. DMC had been asked to undertake audits in relation to referrals, access to GPs, length of time to answer phones and prescriptions. DMC had been asked to undertake further public engagement and work with Patient Participation Groups (PPGs).

Ms Fincham addressed the Committee. She asked for an apology from the Chairman of the Committee and from the Clinical Chair of the CCG for the way in which her complaints had been dealt with. Miss Fincham said she had been advised that the CCG was not responsible and told to complain to NHS England who had advised her to complain to the CCG. She said that patients were still waiting two weeks for appointments and that it was very difficult to get an appointment. There were still difficulties relating to prescription processing and repeat prescriptions. Ms Fincham was concerned that her patient records were being centralised without her permission and that unauthorised persons would be able to access them. She also considered that public engagement had not been transparent. Ms Fincham then left the meeting and did not return.

Maggie Cane from Healthwatch Medway addressed the Committee. Healthwatch had received some complaints that related to the issues outlined by the CCG. GP access was still a concern and some apps were not currently allowing patients to make GP appointment bookings. There had been an improvement in comments made on NHS choices  ...  view the full minutes text for item 567.

This paper provides the Committee with an update on the North Kent Dermatology service following the contract award to DMC Healthcare in April 2019. This includes an overview of current performance and the next steps.

Discussion

DMC Healthcare had taken on the contract for the North Kent Dermatology service during a period when the service had been struggling. In relation to the cancer pathway, performance against the two week wait target had been particularly poor during the final two months that Medway Foundation Trust had been the provider. DMC had inherited a significant backlog of patients waiting for appointments. The vast majority of this backlog had now been seen and the patients who had not yet been seen had been contacted. Work had been undertaken to make the dermatology service less fragile with review meetings between NHS Medway CCG and DMC Healthcare taking place monthly. Overall waiting times for non-urgent patients had been reduced and the number of complaints had reduced to minimal levels.

The volume of phone calls from patients had reduced and the two week wait target for urgent referrals was now being met. Full data reporting was now in place and tele-dermatology clinics were being provided. This enabled patients to receive a diagnosis from images and therefore to be diagnosed within 3 days, quicker than would otherwise be possible. 600 patients had gone through tele-diagnosis with 65% of these having been diagnosed from photos and discharged back to their GP.

Members of the Committee made comments and asked questions as follows:

Tele-diagnosis - A personal experience of the service, where it had not been possible for a tele diagnosis to be made, was highlighted and concern raised about the length of time it had then taken to see a consultant. DMC representatives said that there had been initial difficulties with quality of photos and that these had been addressed. There was a national shortage of dermatologists. Work continued to reduce the number of patients waiting. Reducing waits was challenging in the context of the high number of referrals received since DMC had taken on the Dermatology Service. Over the next few months it was anticipated that patient waiting times for appointments would be reduced.

Appointment Waiting Times – In response to a question about how waiting figures were calculated, it was reiterated that the two week wait performance had improved. Data for November 2019 showed that 95.8% of these referrals were seen within two weeks. 14 patients were not seen within 14 days. All of these patients had been offered an appointment within the 14 day timeframe but had been unable to attend. These patients were rebooked for the next available slot.

Patient Engagement – Feedback was requested on the DMC Healthcare facilitated patient engagement event held on 3 December. The event had taken place in Gillingham with eight attendees. This was disappointing given that the event had taken place in the evening and had been promoted. A presentation had been given on the issues facing the Dermatology Service and how these had been overcome. More engaging methods of obtaining patient feedback were being established.

Referral Statistics – The report stated that the service had received over  10,500 new referrals since April  ...  view the full minutes text for item 568.

HASC has previously received reports on the proposed establishment of:

• 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 750,000 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 report provides an update summary of the work to date in establishing these arrangements, and in particular the development of the single CCG.

Discussion

Ahead of the report being introduced a comment was made highlighting dissatisfaction with it. It was highlighted that there were references to engagement with voluntary and community organisations and to letters from MPs, who had not supported the proposals, but that details had not been provided. It was also suggested that the consultation that had been undertaken in relation to the Kent and Medway Stroke Review could not be considered to have been successful in the context of ongoing Judicial Reviews and Medway’s referral of the decision to the Secretary of State for Health.

The Director of System Transformation at the Kent and Medway STP introduced the report. It was explained that stakeholder engagement, including with the voluntary and community sector, had been undertaken and would continue during the process of establishing the single Clinical Commissioning Group (CCG). The lack of information on this in the report was an omission. NHS England had approved, subject to a number of conditions, establishment of a single CCG. These included a requirement to appoint an Accountable Officer and a Chief Financial Officer. The process of appointing clinical members of the governing body was underway with a Clinical Chair having been appointed. The key purpose of establishing a single CCG was to support development of Integrated Care Providers and the development of Primary Care Networks to enable care to be delivered as close to home as possible. The Council was a key stakeholder of the Integrated Care Partnership in Medway with the Chief Executive being Chair of one of its committees. The single CCG was due to go live on 1 April.

Members of the Committee made comments and asked questions as follows:

Engagement, collaboration and savings – It was suggested that levels of engagement were low because the proposals were not meaningful for patients and that the need for financial savings required more joint working. It was considered that the papers presented did not adequately set out the impact of the changes and that improvement plans were being motivated by a need to make savings rather than by a need to improve services. The savings  figure of £190million quoted was significant. It was questioned whether the savings already made in the last few years were considered to have had an impact. The Director said that the purpose of the report was to highlight the proposals and that that it was not intended as a public facing engagement document. In 2016, there had been a deficit of £450 million. The fact that it had now reduced to £190million was significant. There was no evidence available to suggest that savings made so far had led to reduced service quality although it was not clear whether the changes proposed would completely eliminate the deficit. It was anticipated that a single CCG would be able to more effectively support primary care providers and the Primary Care Networks that would be fundamental to improving local care and reducing the pressure on hospitals. It was acknowledged that engagement  ...  view the full minutes text for item 569.

This report provides an update on progress to deliver improvements in service performance and quality for Kent and Medway’s wheelchair service users.

Discussion

There had been ongoing steady improvement in performance of the Wheelchair service, with waiting lists for equipment provision and repairs continuing to reduce. It was anticipated that the 18 week standard for children’s wheelchair waits would be achieved in the current month. A good quality service was being delivered but it was acknowledged that further work was required in some areas. The provision of personal wheelchair budgets was being rolled out.

It was questioned why the target for achieving the 18 week wait for children and adults was 92% rather than higher. The Committee was advised that 92% was a national target for children’s wheelchairs. There was no national target for adults so it had been decided to use the same 92% figure locally as for children’s. Notwithstanding the targets, the aim was for all service users to receive the highest quality service.

In relation to a question about repair times and provision of spare parts, the source of parts varied. Some were provided in-house while more specialist bespoke parts came from external manufacturers. It was asked how waiting times were measured. The waiting times recorded an episode of care from first referral until case closure through provision of new equipment or adjustments to the current equipment having been completed.

In response to a question about whether those being provided personal budgets had to arrange their own maintenance, it was agreed that information about this would be provided to the Committee following the meeting.  

It was requested that further details be provided about a service user engagement event that had taken place in spring as well as the work of the Service Improvement Board. The provider had held three events which had being more about providing information and collecting user feedback. A detailed user engagement programme was being developed with there being an aim of developing small focus groups. Monthly meetings also took place with a regional wheelchair users group. A mapping exercise for stakeholder engagement was being undertaken and a communications plan would be subsequently developed.

Decision

The Committee noted and commented on the report and requested that a written progress update be provided to the Committee.

In accordance with the Care Act 2014, the Kent and Medway Safeguarding Adults Board is required to publish an Annual Report each financial year.This report introduces the Kent and Medway Safeguarding Adults Board’s (KMSAB) Annual Report for April 2018–March 2019.

Discussion

The Director of People – Children and Adults said that Members had sometimes expressed concern that being part of a Kent and Medway Board could lessen the focus on Medway. Assurance was given that the Independent Chair had strong awareness of Medway specific issues and that she worked closely with the Assistant Director, Adult Social, who was Deputy Chair of the Board. Both Chair and Deputy Chair engaged actively with the local adult safeguarding executive to ensure close working.

The Independent Chair of the Board introduced the Safeguarding Board Annual report. The Board was a strategic body responsible for setting the direction of adult safeguarding in Medway and Kent. It had an annual budget of £261,000. An easy read summary of the report had also been produced. Responsibilities of the Board included challenging partners in relation to effectiveness and quality; undertaking safeguarding adult reviews and; delivering learning following completion. Board priorities had included raising awareness of exploitation, isolation, loneliness, abuse and neglect. Key achievements had included development of a new quality assurance and assessment framework; review and update of key safeguarding policies; training of 661 multi-agency operational staff across Medway and Kent and; design of a training and evaluation framework.

The Board had produced more accessible information for families and monitored a range of complex action plans. It had co-produced, with Medway’s self-advocacy group, some easy read versions of a user guide and had led an adults safeguarding awareness campaign, the theme of which was loneliness and exploitation. This had culminated in the delivery of a number of public information days. A Communications and Engagement group had been established with a Business and Development officer employed to progress this work. This would include more intensive working with the voluntary sector and inter-faith groups.

There had been 1387 safeguarding concerns raised in Medway in 2018/19, which was higher than the previous year. 700 of these were investigated under a Section 42 safeguarding enquiry or other enquiry, an increase of 43% from the previous year. These increases were attributed to improved systems and resource management and the development of the Three Conversations approach. Abuse in Medway health trusts and care homes was below the national average. The most common type of abuse nationally was neglect with the Kent and Medway figure for self-neglect being 26%, below the national average. The national figure for the percentage of safeguarding interventions that saw risk of abuse reduced or removed by a safeguarding intervention was 89%. Medway’s figure was 82%, an increase of 8% from the previous year.

Members of the Committee made comments and asked questions as follows:

Safeguarding Training – It was questioned whether the provision of safeguarding training by care homes was compulsory as only one home out of three that a Councillor volunteered in had offered it to them. The Independent Chair said that safeguarding training had to be provided and this should be being checked as part of Care Quality Commission (CQC) inspections. The Assistant Director – Adult Social Care  ...  view the full minutes text for item 571.

The NHS Long Term Plan, published in January, sets out the future of healthcare over the next 10 years. To respond to this, the local area is required by NHS England to prepare and implement a local plan to cover the next five years. The draft five year plan set out within the Exempt Appendix for discussion by the Committee.

Discussion

The Committee agreed that the press and public be excluded from the meeting during the consideration of the exempt material relating to agenda items 10 and 11 because consideration of these matters in public would disclose information falling within one or more categories of exempt information contained in Schedule 12A of the Local Government Act 1972 as specified in agenda items 10 and 11 and, in all the circumstances of the case, the Committee considered that the public interest in maintaining the exemption outweighed the public interest in disclosing the information. 

The NHS Long Term plan had been published in January 2019 with all local health systems being required to produce a local Five Year Plan in response. The Five Year Plan had not yet been published and discussion with health and wellbeing boards had been delayed due to the General Election. The Plan was a technical document but a shorter summary version would be produced. Four public engagement events had been held within the four Integrated Care Partnerships (ICPs), including the Medway and Swale ICP. ICPs would be responsible for translating the Plan into local delivery through the annual operational planning process. In the future there would be more focus on the overall health of the population and less focus on individual services and health conditions.

A number of topics were discussed including the stroke and vascular reconfiguration, the primary care workforce, health inequalities in areas of deprivation and acute mental health provision.

Concerns were raised about the potential impact on Medway of the Five Year Plan covering Kent and Medway, rather than it being Medway specific. Concern was also raised that the Plan was a long term strategic document rather than focusing on the more immediate future.   

Decision

The Committee considered and commented on the Draft Five Year Plan.

Kent and Medway CCGs have agreed to the procurement of a Kent and Medway Neurodevelopmental (ND) Health Service for Adults (18+) which will improve quality and value for money and is fully supported and identified as a priority need by the Sustainability and Transformation Partnership (STP) and NHS Long Term Plan (2019). The primary purpose of the proposed Kent and Medway ND pathway is to reduce the health inequalities and improve the quality of life for Medway residents with Autistic Spectrum Conditions (ASC) and/or Attention Deficit Hyperactivity Disorder ADHD.

Discussion

The proposals aimed to improve and enhance specialist services for those with autism and Attention Deficit Hyperactivity Disorder (ADHD). Services would be enhanced and improved with there being no service reduction. Existing services for autism were not compliant with legislation and NICE guidelines and were therefore not meeting the needs of the local population. Patient experience was poor with there being increased clinical risk and risk of deterioration in health where conditions were not managed effectively.

In relation to autism, there was currently no pre-diagnosis or post-diagnosis provision in Medway and no pre-diagnostic support for ADHD. Patients being assessed and treated currently had to travel to London. Kent had undertaken engagement work with health professionals and the public to consider how provision might be developed and similar engagement was planned for Medway. A Kent and Medway Complex Autism Service had been piloted. This was helping to avoid the needs of patients escalating, through the provision of locally based community services. The proposals had been supported by NHS Medway Clinical Commissioning Group’s Commissioning Committee and were deemed to be the most appropriate way forward.

Members of the Committee made comments and asked questions as follows:

Diagnosis of Patients – It was suggested that patients currently had to travel too far for services and that waiting times were too long. The Committee was advised that a number of innovations were being considered in relation to diagnosis. A pilot was currently taking place in Kent. Services could be provided quicker at lower cost and without reduction in quality. It was agreed that local provision was needed.

Finances – It was confirmed that the service cost of £2.87 million contained in the report was the annual cost for one year in Kent and Medway. In response to a question about service redesign, Members were told that although there would be pathway redesign, the substantive parts of it would not be changed. Assessment and diagnosis would be made available locally with services being co-designed and produced.

Availability of Providers – In response to a question about availability of providers and staff, there had been some market testing in Kent, including a  pre-procurement market engagement event. Multiple providers had attended and there had been significant interest. Providers were starting to upskill their workforce with there being a number of locally accessible providers. An existing provider currently commissioned to provide autism services in Kent was also able to provide ADHD related services.

Substantial Variation, timescales and transition – It was suggested that such a change to a health service would normally be a substantial variation, whether a reduction or as in this case, an increase in provision. However, in this case it would be appropriate for the Committee to consider not determining the proposals to be substantial in order to ensure that service improvement could take place at pace in the context of patients facing lengthy waits to receive a diagnosis. It was asked how quickly the changes could be made and whether there would  ...  view the full minutes text for item 573.

This report provides an update on progress towards setting the Council’s draft capital and revenue budgets for 2020/21. In accordance with the Constitution, Cabinet is required to develop ‘initial budget proposals’ approximately three months before finalising the budget and setting council tax levels at the end of February 2020. The draft budget is based on the principles contained in the Medium Term Financial Strategy (MTFS) 2019-2024 approved by Cabinet in September and reflects the latest formula grant assumptions. 

Discussion

The Chief Finance Officer advised that the process of developing the 2020/21 Council budget had begun in September 2019, with consideration of the Medium Term Financial Strategy (MTFS) by Cabinet. The MTFS had identified a gap of £5.956 million. Portfolio Holders and officers had been working together on proposals to address this deficit and savings identified would be included in the final budget to be presented to Cabinet in February. It was not anticipated that there would be any additional grant that would significantly change the Council’s budgetary position.

It was questioned how achievable the savings required in the Children and Adults directorate were in view of the pressures faced and the continuing national strain on social care. The Director People – Children and Adults acknowledged that there was significant pressure in the directorate regarding children’s services. Following recent publication of the Commissioner’s report on ways forward for Medway Children’s Services, substantial investment in Children’s Services had been agreed with Members. It was anticipated that this would lead to improved service quality.

Medway had been one of 32 local authorities required to develop a deficit plan in relation to the Dedicated Schools Grant, due to overspend. In relation to Special Educational Needs and Disability (SEND) provision, Ofsted and the Care Quality Commission had indicated there being a need to continue working with the education sector to improve inclusion. Growth in demand for Adult Social Care impacted on performance. Whilst there was currently a good supply, work was taking place with residential, nursing and domiciliary care providers to ensure this continued. The Assistant Director – Adult Social Care said that the MTFS had accounted for growing demand for adult social care services. £1.5 million of savings had already been identified with there being a £4million pressure for 2020/21.

It was asked whether there was concern about the provider market locally. The Assistant Director said there had not been significant handing back of contracts by providers and that levels in Medway were lower than elsewhere. The local homecare market was strong with a reprocurement exercise having been undertaken ahead of a new framework going live from April 2020. While there was good supply of nursing and residential care there were challenges in relation to nursing dementia provision. Work was being undertaken with the provider to bring forward additional provision.

Concern was expressed about rising demand for services and fragility associated with the continual need to make savings, including the required savings in public health in the context of new health plans having a specific focus on prevention. The Director of Public Health said that the NHS would be putting resources into prevention. It was not yet known how much Public Health funding would be available for 2020/21 but nationally there was an expectation of an average increase of 5.1%. The NHS had already provided nearly £0.5 million for preventative programmes across Kent and Medway and NHS Medway Clinical Commissioning Group had also provided additional resource. There were currently sufficient resources available  ...  view the full minutes text for item 574.

Medway’s Council Plan 2016/21 sets out the Council’s three priorities. This report and appendices summarise how we performed in Q2 2019/20 on the delivery relevant for this Committee: Supporting Medway’s people to realise their potential.

Discussion

Members of the Committee made comments and asked questions as follows:

Information for the Committee - In relation to indicators ASCOF 1G and ASCOF 1H (Proportion of adults with a primary support reason of learning disability support who live in their own home or with their family and Proportion of adults in contact with secondary mental health services who live independently, with or without support) it was suggested that the performance of these indicators could have been discussed at Business Support O&S. The Assistant Director, Adult Social Care said that further detail could be provided and that deep dives had been undertaken in relation to some indicators. There had also been work to understand performance relating to the indicators, Percentage of long term packages that are placements and Percentage of clients receiving direct payment for social care. The Director of People – Children and Adults added that inter-directorate work was being undertaken to consider the relationship between health, housing and care. It was suggested that a report on these areas could be added to the Committee’s Work Programme.

Percentage of Adults with Learning Disability Living in own Home – It was referenced that there was a significant difference in performance for this indicator between national level and the south east. While south east performance was better than nationally, Medway’s performance was below that of the south east. The Assistant Director – Adult Social Care said that sustained long term action was required to address performance for this indicator. It was difficult for people already in nursing and residential care to be supported to become more independent and to live in their own homes. Ensuring that those transitioning from children’s to adult services received effective support was one way to help address this. The Shared Lives initiative was also helping but the number of people participating in it was relatively small. Resources were being put into the service and it was being marketed.

Direct Payments – Disappointment was expressed that the uptake of direct payments had not been higher. The Committee was informed that targeted work was being undertaken to try to increase uptake. The experience of people who had opted for direct payments was very good. Discussion of this was proposed at the Committee’s next agenda planning meeting with a view to a report being added to the Committee Work Programme.

Decision

The Committee:

i)  Considered Q2 2019/20 performance against the measures used to monitor progress against the Council’s priorities.

ii) Noted the amended Strategic Risk Register as set out in Appendix 2.

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)    Noted a further report on the Frank Lloyd Centre, Sittingbourne, may need to be considered by the Committee at the March 2020 meeting.

iii)   Noted that, subject to publication dates, the outcome of a Care Quality Commission inspection of Medway Foundation Trust may need to be be considered by the Committee at the March 2020 meeting.