MINUTES OF THE MEETING OF THE North Central London Sector Joint Health Overview and Scrutiny Committee HELD ON FRIDAY 16 JANUARY 2015
MEMBERS: Councillors Alev Cazimoglu and Anne-Marie Pearce (LB Enfield), Alison Cornelius and Graham Old (LB Barnet), Alison Kelly (LB Camden), Gideon Bull and Pippa Connor (LB Haringey), Jean-Roger Kaseki and Martin Klute (LB Islington)
Officers: Andy Ellis, Jane Juby (LB Enfield), Rob Mack (LB Haringey)
Also Attending: Dr Josephine Sauvage (Islington CCG), Clare Henderson (Islington CCG/LB Islington), Deborah Sanders and Andrew Panniker (Royal Free), Graham McDougall (Enfield CCG), Dr Samit Shah (Clinical Lead – NHS 111 Governance, North Central London CCGs), Alison McMilan (NHS England), Emma Whitby (Healthwatch Islington), Four Members of a Deputation – Defend Haringey Health Services Coalition and 38 Degrees.
Approximately 12 members of the public.
Apologies for absence were received from Cllr Klute.
Condolences were expressed to the family of Cllr Brayshaw.
2. DECLARATIONS OF INTEREST
3. URGENT BUSINESS
Cllr Cazimoglu requested an update on the current position regarding A&Es in all hospitals in the five Boroughs and what plans were in place to address the significant demand and pressure on these services.
It was proposed that a letter be written to the relevant Trusts to request an urgent update and details of any Action Plans. Cllr Bull confirmed that he would co-ordinate this with colleagues ACTION: Cllr Bull.
The Minutes of the meeting held on 21 November 2014 were APPROVED subject to any amendments put forward by Cllr Cornelius.
5. INTEGRATED CARE
Dr Josephine Sauvage, Clinical Lead for Integrated Care, Islington CCG and Clare Henderson, Programme Director Integrated Care, gave a presentation, the key points of which were as follows:
The following questions were then taken:
Q: With the high level of health inequalities in Islington there are a lot of people that potentially need support. How are you engaging with hard to reach communities to ensure they get this support?
A: We have very active representation within the CCG who work with Healthwatch and smaller interest groups to inform what we do. This work is of course, always ongoing. We are trying to look at new ways of doing things all the time, for example at the New River Green Estate which is an example of a very targeted engagement programme.
Q: Can you comment on the Expert Patient Programme?
A: Whittington Health formed part of the original pilot in this respect. There are generic and specialist elements to the Programme. The Programme is not just aimed at patients but is complemented by a programme of educational change for clinicians. We also look at the commissioning that supports all of this; for example, increasing GP appointment slots so that they have extra time to talk to patients about ongoing conditions such as diabetes. We also, for example, arrange for diabetic patients to receive test results before their appointments so that they can discuss these with the GP at the time.
An attendee requested that the links to recent research on personalised care and the NIT pilot be circulated ACTION: Dr Sauvage.
Q: What is possible for those local authorities who are not quite as far down the road as Islington to implement Integrated Care and face ongoing cuts?
A: It is partly about identifying those areas where you can really work together with other partners; looking at areas of high spend and working across the system to reduce these. Health and Wellbeing Boards have an important role to play in this. You need, essentially, the ‘right people in the room’.
Q: It feels that the implementation of Integrated Care is very patchy across the 5 Boroughs. How far away are we from delivering such aspirations across the board?
A: The issue is to make sure that leaders are working together. System leadership is about working together and getting the message across. This does take time. It also means having honest conversations and prioritising what you can achieve.
Q: Is implementing Integrated Care more difficult if services are being externalised?
A: There are national requirements around competitive tendering but in the interests of integration local solutions are equally valid. You need to make sure that services are developed in a particular way. Local authorities are accustomed to a more contract management approach than perhaps the NHS has been; the challenge is to bring these two approaches together.
Q: We are talking more of evolution, then revolution. What is different about Islington’s Integrated Care Programme? The critical success factors seem to be spreading the vision, mentoring leaders and a bottom-up approach. What else has contributed to its success?
A: I’m not sure that there is much difference in our aspirations than any other’s. However, we have put GPs and hospitals much more at the centre of what we are doing. Working closely with hospitals is key, as well as developing good primary care.
Q: Where on Islington’s Integrated Care Journey is social services? Social services are responsible for a wide range of provision including meals-on-wheels and drop-in services critical to the success of Integrated Care?
A: Social services are embedded in our N19 pilot and a very much a part of the MDT process. Adult social care is embedded all along the system.
6. ROYAL FREE ACQUISITION OF BARNET AND CHASE FARM HOSPITALS - UPDATE
Andrew Panniker (Director of Capital and Estates, Royal Free NHS Foundation Trust) and Deborah Sanders (Director of Nursing, Royal Free) updated the Committee as follows:
· It was now 7 months since the Trust has acquired Barnet and Chase Farm Hospitals.
· Focus issues post acquisition were RTT (18 week pathway), A&E, infection control and cultural change.
· A&E – the pressures on A&E services were the same as those being experienced nationally. Weekly systems resilience meetings were being held to respond to this. These meetings involved the London Ambulance Service, Barndoc, social services and a number of other partners. All partners were experiencing high levels of demand. Community nursing had experienced a 36% rise, and there had been an increase of 13% for attendances at Barnet Hospital. The target of 95% of patients being discharged or admitted within 4 hours was not being met this month; this had also been the case for December. Chase Farm’s Urgent Care Centre had, however, met its target. The issues behind this were multifactorial; one of which was delayed discharge.
· Delayed discharge comprised two groups – delayed transfers of care (currently 38 patients) and pending patients (waiting on social or community care services). The current level of pending patients was 90. There were therefore 128 patients medically ready to leave hospital but which could not be discharged. Weekly meetings were being held at each site to address the issue.
· Cllr Bull requested that a breakdown of this number over the different sites be circulated ACTION: Deborah Sanders.
· Figures were presented for A&E attendances for the week ending 4 January. Performance in the current week had fallen from these levels.
The following questions were taken:
Q: Why wasn’t this situation anticipated? Why were A&E services downgraded without the agreed primary care in place? What is planned now in light of the situation?
A: I cannot answer for any plans that were in place up until the implementation of the BEH Clinical Strategy. It is a national issue and there are many other reasons for the rise in demand.
Q: What proportion of the increased levels of attendance at A&Es is due to lack of primary care/primary care being inaccessible?
A: We know that particular groups of people are choosing to come to A&E rather than access primary care, for example the younger age bracket (18-34). We do not have, however, proportions available as this is not something that we ask patients whilst they are at an A&E.
Q: You refer to the 18-34 year age group as attending A&Es rather than accessing primary care. Are there any particular days of the week or times of the day when they do this? If this age group, the majority of whom should be in employment, find it difficult to access a GP outside of working hours, then this might explain why they present to an A&E.
A: We do not have this information; we do not routinely provide this kind of breakdown.
Cllr Cazimoglu commented that the situation was particularly acute in Enfield and that the reason many young people may choose to attend an A&E is that they were unwilling to wait a number of days for a GP appointment. The situation regarding A&Es was also just part of the picture; GPs were experiencing high demand and long queues at practices.
Q: What is the Royal Free Hospital doing in terms of implementing Integrated Care?
A: We do have some integrated care programmes. We are interested in what, for example, the Whittington Hospital is doing especially with regard to its A&E services. We agree we can learn from this and we will be speaking to CCGs and other partners in this respect.
A member of the public felt that, since the A&E had closed at Chase Farm Hospital, those who had taken this decision had not been held accountable.
Q: Why aren’t patients awaiting care services being moved into alternative temporary accommodation, rather than staying in hospital?
A: There is always the question of who will meet the cost of this accommodation. It is also not just a question of finding patients somewhere to stay, the right services to support them also need to be available before they can move out of hospital.
Q: A&E services are not working as they should in Enfield, particularly with an increasing population. Why can we not re-open Chase Farm Hospital A&E?
A: It is not within our gift to re-open the BEH Clinical Strategy. The Royal Free’s acquisition of Chase Farm Hospital is based on that Strategy and therefore we are not planning to re-open an A&E at Chase Farm.
Cllr Bull commented that, as owners of the site, he believed there was no reason why the Trust could not re-open an A&E at Chase Farm Hospital, should they wish to.
It was requested that a breakdown of the 128 patients currently awaiting discharge be provided; were any of these patients from care homes, since they could be returned to the care home. ACTION: Deborah Sanders.
Deborah Sanders confirmed that the Trust was looking at the proportion of A&E attendees coming from nursing homes. The Trust was in the process of setting up a call system for London Ambulance staff through which they could contact the patient’s GP to establish if they did, in fact, need to be taken to hospital.
It was reported that in LB Barnet, GPs has ceased to undertake evening visits and this was becoming an issue. CCGs had assured members of the Committee that this was being addressed; it was requested that this be taken back to the CCGs to ensure this was the case ACTION: Deborah Sanders.
Deborah Sanders added that there was now in place a specific member of staff who acted as a liaison between the Royal Free Hospital and nursing homes. Acute admissions were checked each morning to establish which patients could be discharged back to their nursing home.
Q: I have heard of someone waiting 5 hours for an ambulance and 14 hours to receive treatment for a fractured hip at the Whittington Hospital. What is being done to prevent this happening again?
A: The Royal Free keeps a bed specifically for fractured hip patients open at all times, to enable someone to be referred directly from A&E if necessary. I cannot answer specifically for the instance at the Whittington Hospital.
Q: Is there a maximum wait time between admission to A&E and admission to/treatment on a ward?
A: The maximum wait time is 4 hours.
An attendee commented that, although ambulatory care had relieved pressure on A&E services at the Whittington Hospital, it was not the best financial model. Until CCGs paid differently for admissions, this would continue to be a problem.
Q: What is the BEH Clinical Strategy and how can it be changed?
A: The Strategy resulted in the reconfiguration of all of the main hospitals and pathways in Barnet, Haringey and Enfield. The result for Chase Farm Hospital was very prescriptive for the services to be delivered on the site. The Strategy was 10 years in the making. It has been implemented and the changes it prescribed undertaken. The document is available on the Royal Free NHS Foundation Trust’s website.
Chase Farm Hospital Development
Andrew Panniker gave the following update:
· The planning application was submitted to Enfield Council on 21 November and was due to be heard at the Council’s Planning Committee on 24 February.
· An initial Planning Committee briefing session was held last week and some learning taken from this meeting relating to the transport infrastructure for the site.
· A confidential draft Business Case would be sent to the Trust Board on 29 January and to the Department of Health thereafter. It was anticipated that the Department of Health would take 8 weeks to issue their report.
· A contractor had been appointed for 2 months to work on the designs to date and to look at costings to ensure these were still within the Trust’s affordability limits.
· The media had recently taken an interest in the issue of the tenants on site, on the proposals for the roadways and the main entrance and on the viability assessment. These were being responded to.
The following questions were taken:
Q: There are still concerns around transport to and from the site, particularly in regard to the school. What is being done about this?
A: We are aware of the access issues and Enfield Council’s Highways team are looking at this, with the possibility of acquiring land from the Mental Health Trust in order to facilitate better access at certain points.
Q: What is your future vision now for the Highlands wing, which has effectively been ‘mothballed’.
A: The Highlands building was originally to house the outpatient facility but we realised that it did not lend itself to the space requirements of a modern ward. We then considered what could be accommodated instead in the building. It became apparent that the services currently in the building were over 20 years old and would need to be completely stripped out in order to do this. The cost of the degree of alterations needed was approaching that of a new build; so it was decided not to proceed. The Trust intends to retain and protect the building for health use but at present, we have not decided on its use. The Trust is prepared to enter into a covenant to ensure future health use.
Q: A large proportion of the medical staff currently living on the site are from abroad and are therefore potentially at high risk of homelessness if alternative accommodation is not found. What is being done about this and about ensuring there is affordable housing for keyworkers on the site?
A: All tenants on the site were notified of our intention to seek vacant possession by the end of March 2015 at the time of acquisition (July 2014). Tenants have therefore had longer than the usual notice period (2 months) to seek alternative accommodation. We have continued to liaise with tenants, with housing associations, with Enfield Council and with local agents to assist tenants in finding accommodation. It should be noted that although we might provide subsidised accommodation, it is not tied to any employment contract. Leases are renewed on a 6 monthly basis. The sale of the land is critical to part fund the redevelopment. The Trust therefore feels that it has done the best that it can in this respect. As to provision of affordable housing for keyworkers; 90 units will be built for this purpose.
Q: Has the Trust provided more disabled parking bays?
A: The Trust will be providing more disabled parking bays; but this is dependent upon relocating people currently in portakabins on the intended site. We are looking to complete this by early summer.
Q: What are the parking restrictions now for disabled visitors and how is this being communicated to people?
A: New signs have been put up conveying this information and staff are walking around car parks to provide assistance. We have also undertaken leaflet drops.
7. NHS 11/OUT OF HOURS SERVICE COMMISSIONING
The Committee received a deputation from members of Defend Haringey Health Services Coalition and 38 degrees, as outlined in the paper provided.
Members of the deputation emphasised the lack of public consultation undertaken, which was a legal obligation, the recommendations from Camden’s Scrutiny Panel of Enquiry into its OOH services, potentially increased travel times for patients and the need to have local services with local GPs.
Members of the deputation mentioned that they had recently attended a meeting of the Haringey CCG but were not given the opportunity to put a question to them as the issue they wished to raise was not on the agenda.
In addition, they commented that what the public wanted should be taken into account when planning OOH and 111 services; residents did not want a large, ‘faceless’ organisation running these services.
They added that the proposed model was becoming a discredited one but that GPs did not yet have the capacity to take over.
Members of the deputation expressed the view that they could not see evidence of proper integration of OOH and 111 services in the proposals and had no confidence that the proposed model would work. A clearer plan needed to be consulted upon.
They also expressed concern at the procurement process and that it seemed to be moving forward too rapidly. They asked what the implications of the upcoming purdah period might be on the process.
The Committee then received a presentation from Dr Samit Shah, Clinical Lead for NHS 111 Governance, North Central London CCGs and Graham McDougall, Enfield CCG, the main points of which were as follows:
Dr Shah concluded by responding directly to the concerns raised by the Deputation and made the following comments:
The following questions were then taken:
Q: Do GPs receive any training so that they can effectively negotiate the areas they operate in?
A: GPs have drivers with them who are familiar with the local area; however, there is no suggestion as yet that the current hubs will change.
Q: If more people are using the 111 service, why is there still a pressure on A&Es?
A: In my personal opinion, I think this is because the case complexity has changed.
Q: You refer to integrating IT platforms; will patient data be shared with external providers?
A: There are different types of arrangement with regard to data sharing but there is an overarching governance structure nationally within the NHS. Barndoc, for example, currently does not have access to GP patient notes. This may be something we would like to implement, but it will depend upon GPs consenting to this.
Q: Staffing of the 111 service is currently on a ‘customer call centre’ basis and staff are not clinically trained to go ‘off framework’. Would this in itself be a factor for more people attending A&E?
A: Any health advisor on the 111 service can pass the call to a clinician if they feel it needs to be managed off framework. A clinician can also reverse any previous decision to refer a caller to A&E.
Q: Is there a public consultation running at the moment on the proposals and how does one get involved with the CCG?
A: As this is the start of the process, CCGs would welcome your views on how to do this.
Cllr Bull invited attending members of the public to submit any questions they wished to raise in writing after the meeting, and to lobby any individual scrutiny panels if they were concerned about the procurement process.
Q: What is the timeline for the procurement process? Has this been impacted by the urgent care review which doesn’t conclude until July?
A: The impact of the review has been taken into account, although the urgent care review has a slightly different remit.
Cllr Cazimoglu commented that many people were concerned about companies running the service ‘just for the money’ and asked if consideration had been given to using not for profit organisations?
Dr Shah responded that all options were open and a mixed economy of providers would be needed. The process did not preclude anyone, including local GPs and not for profit organisations, from bidding. It would be essential, however, to ensure that any providers did not derogate away from quality.
8. COMPLAINTS REGARDING PRIMARY CARE SERVICES
Alison McMilan, Head of Complaints, NHS England, gave a presentation which detailed the process for submitting complaints, which was as follows:
The following questions were then taken:
Q: Are customers encouraged to contact the Practice Manager in the first instance in respect of GP related complaints?
A: Yes. We also work with GPs to encourage them to raise awareness with patients that they should do this. Many GPs have set up Patient Participation Groups to raise awareness and discuss issues of concern.
Q: Is the formation of a PPG required in legislation or is it at the discretion of individual GP practices?
A: I believe it is required in legislation.
Q: Will the improved data you mentioned be useful to organisations like Healthwatch?
A: Yes, we do already provide data to Healthwatch but this is very high level information; the new system will enable us to provide more detailed statistics.
Q: How accessible is NHS England’s complaints process for people, for example, with disabilities, deaf people or blind people?
A: We do have translation services available but, as customers contact us primarily by telephone, sometimes it is difficult to ascertain what their needs are immediately. We do, however, have processes and systems to help us do this.
Deborah Fowler, Healthwatch Enfield, commented that there could be improved accessibility for BSL users and those from BME communities.
Q: Where and how is organisational learning taken?
A: I review any organisational learning with the NHS England London Team. We share any organisational learning in respect of independent contractors with the Medical Director. Meetings are held monthly to discuss complaints and learning from them. With individual GP practices, Action Plans can be put in place and we track these.
Q: Is the learning publicly available?
A: NHS England currently produces a national annual report; however at the moment there is no local equivalent that is publicly available. Sometimes it is not appropriate to share information, for example, when it relates directly to independent contractors. We do identify themes and trends however and raise them with practices accordingly. Our new IT system will track any organisational learning and produce this information in a more appropriate format for sharing.
Cllr Cazimoglu and Pearce commented that they had recently met with members of the deaf community who had raised as an issue the accessability of NHS services. They suggested a meeting with NHS England representatives would be useful. ACTION: Andy Ellis
Q: If a complainant withdraws their complaint, does NHS England still take this forward if necessary as an anonymous complaint?
A: Yes, particularly if the issues raised are of high risk; we still need to capture that learning anonymously.
Q: Can the contact details for the Ombudsman be provided?
A: Yes, I can obtain these ACTION: Alison McMilan.
Q: Do you produce leaflets with information on how to raise a complaint or display such information in GP practices?
A: Healthwatch Islington reviewed the information displayed at GP practices and this has since improved. Mystery shopping was also conducted to ensure practice staff were able to deal appropriately with anyone raising a complaint.
Q: Will you be able to capture diversity data on the new IT system?
9. WORK PLAN AND DATES FOR FUTURE MEETINGS
The date of the next meeting was NOTED as 20 March 2015, to be held at a venue in LB Camden.
The Work Programme was NOTED.
It was proposed that a meeting with the Barnet, Enfield and Haringey Mental Health Trust be arranged prior to the Purdah period ACTION: Rob Mack.
It was also suggested that dates/times of the meetings going forward be reviewed ACTION: Rob Mack.
Cllr Bull requested any proposed agenda items be sent to him.