Agenda and minutes

Apologies for absence were received from Councillors Jonathan Bianco, Keith Burrows, Richard Lewis and Ray Puddifoot and Mr Bob Bell, Ms Robyn Doran (Ms Maria O'Brien was present as her substitute), Mr Nick Hunt, Mr Rob Larkman (Ms Caroline Morison was present as his substitute) and Ms Allison Seidlar.

RESOLVED:  That the minutes of the meeting held on 27 June 2017 be agreed as a correct record.

It was confirmed that Agenda Items 1 to 14 would be considered in public.  Agenda items 15 and 16 would be considered in private.  It was agreed that Agenda Item 10 would be taken after Agenda Item 6.

The Chairman welcomed the significant amount of work had been undertaken in relation to the development of the Joint Health and Wellbeing Strategy over the summer.  At its last meeting, the Health and Wellbeing Board members had been critical of the Strategy with regard to it not fully reflecting a Hillingdon dimension, including reflecting issues faced such as air quality, obesity, etc.  Discussions had been undertaken at the Transformation Board and, although great progress had been made to include local factors, further work would be needed on the presentation of the information to make it more user friendly via the consultation.   

It was noted that there would be an opportunity for further work on the Strategy up to the next Health and Wellbeing Board meeting on 7 December 2017.

RESOLVED:  That the Health and Wellbeing Board agreed to the draft Hillingdon Joint Health and Wellbeing Strategy 2018-21 being issued for consultation with findings brought back to the Board for consideration at its meeting on 7 December 2017.

The report consolidated the information that had previously been included in the report considered by the Health and Wellbeing Board at its meeting in June 2017 and provided detail of the 2017-2019 Better Care Fund (BCF) Plan.  It was noted that the guidance for the Plan had not been received until very late, and even then clarification was required.

Although the new improved BCF money had been intended to relieve the pressure on social care, the BCF guidance now had a new focus on delayed transfer of care (DTOC).  The imposed DTOC targets appeared to be challenging and not without risk but, overall, were felt to be achievable and it would be important to ensure that all agencies worked together as a partnership to achieve them.  The Chairman noted that if any funding were to be taken away as a result of underperformance, the Council would strongly object.

Key developments under the proposed plan included the closer alignment between Adult Social Care and the Care Connection Teams and maximising the benefits from the purpose-built Dementia Resource Centre at Grassy Meadow Court extra care scheme.  Work was also underway to establish the business case for the Accountable Care Partnership to enable the Council to decide whether to join.

It was noted that there had been a disconnect nationally between the NHS and local government requirements with regard to DTOC.  The local government view recognised that any hospital closing its doors over the winter would be a greater immediate priority than social care but argued that adequate separate funding should, therefore, be in place for DTOC rather than being taken out of other essential budgets. 

To reduce the number of avoidable admissions and avoid a possible crisis this winter, it was suggested that flu vaccinations be promoted as soon as possible amongst hospital staff and vulnerable residents.  In 2016, 80% of Hillingdon Hospital staff were vaccinated and a campaign would be undertaken again this year to promote the initiative.

RESOLVED:  That the Health and Wellbeing Board:

1)        approved the 2017/19 Better Care Fund plan for submission to the London Regional Assurance Team by 29 September 2017 as described in the report or with any amendments that it required;

2)        delegated authority to make any further amendments to the plan following the assurance process to the Corporate Director of Adult and Children and Young People's Services, LBH, and the Chief Operating Officer, HCCG, in discussion with the Chairman of the Health and Wellbeing Board, the Chairman of HCCG's Governing Body and the Chairman of Healthwatch Hillingdon's Board;

3)        noted the delayed transfers of care (DTOC) target for 2017/18, noted the provisional target for 2018/19 but made approval of any nationally imposed target for 2018/19 subject to consideration by the Board about its deliverability; and

4)        noted the content of the updated Health and Equality Impact Assessments (Appendices 4 and 5 of the report).

It was noted that a number of initiatives were underway at The Hillingdon Hospitals NHS Foundation Trust (THH) to improve performance against the 4 hour emergency care target.  Accident and Emergency departments had been ranked in one of four categories: 1 = 95%+; 2 = 90%+; 3 = <90% but with scope to improve to 90%+; 4 = <90% but little chance of improving to 90%+.  As THH had been rated as 3, the Emergency Care Improvement Team had been working with the Trust to help improve patient flow and patient experience and performance was being monitored through the A&E System Change Board. 

Red2Green was a method of ensuring that the care that was planned to take place for a patient on any given day actually took place.  This was linked to SAFER (a patient flow bundle) in that the care required through the day was identified at the senior review and then tracked to ensure that it happened through Red2Green.  Embedding these initiatives systematically had proven to be a challenge but work was underway to identify planned dates of discharge and ensure that early discharge started sooner in the day. 

A review had been undertaken of those patients that had been in hospital for more than seven days regardless of the reason for their admission.  This had identified that 50% of patients at Hillingdon Hospital were “stranded” against a target of 35-40% (based on best practice in London). 

With regard to evaluation, THH was beholden to the 4 hour emergency care target, a performance measure which was regularly monitored.  However, it was recognised that this target was not currently tracked back to the original investment.  This type of tracking would ensure that investments were paying off and would provide sustainable improvements.  Ultimately, the question of whether the sum of the parts delivered the headline performance metric needed to be answered.

The Chairman asked that partners continue to discuss further, via the Transformation Board, issues around benefits realisation of the new discharge schemes to ensure that improvements were genuinely better for residents and that they were sustainable.

RESOLVED:  That the Health and Wellbeing Board noted the content of the paper.

It was noted that a significant amount of work had gone into developing the Pharmaceutical Needs Assessment (PNA) since the Health and Wellbeing Board’s last meeting and that the PNA would be reported back to the Board before publication.  It would be important to ensure that adequate opportunities were available to ensure sustainability.

Concern was expressed regarding the provision of services in Heathrow Villages and it was agreed that this situation needed to be monitored.

It was noted that the statistical analysis included in the report was indicative of the size of the Borough.  The predicted growth over the next five years showed a net migration of approximately 7k new residents.  However, the housing development trajectory indicated a need for 13k-14k new homes to be built.  As such, it was suggested that population figures should only be used for guidance and it should be recognised that there were other figures in the public sector which indicated very different projected population figures in Hillingdon.

It was noted that the Mayor of London’s Housing Plan was expected to be published in November 2017.

RESOLVED:  That the Health and Wellbeing Board:

1.     agreed the draft recommendations set out in Hillingdon's Pharmaceutical Needs Assessment (PNA).

2.     agreed the plan to review and publish Hillingdon’s PNA by the required deadline, including the statutory requirement to undertake a minimum 60 day consultation.

3.     agreed to delegate the final approval of Hillingdon's PNA consultation document prior to consultation to Deputy Director Housing, Environment, Education, Health and Wellbeing in consultation with the Chairman of the Health and Wellbeing Board.

It was noted that the report outlined the progress that had been made over the summer following the Anna Freud National Centre for Children and Families (AFNCCF) workshop.  A more detailed CAMHS report would be considered by the Council’s Children, Young People and Learning Policy Overview Committee on 27 September 2017.  Ms Caroline Morison would circulate a copy of the report to Board members.

The key priority areas identified by AFNCCF for developing a coherent pathway for children’s mental health were:

• Thriving: Prevention and mental health promotion
• Advice and Support
• Getting help in mainstream settings
• Getting help in targeted and specialist settings

It was anticipated that these developments would see the service move from a tiered model to one that was more flexible and responsive to patient needs.  There had been a focus on co-production and work was underway with children and young people in schools.  The new pathway was due to go live from March/April 2018 and was expected to drive down the waiting list.  Furthermore, the Thrive Model of Care was expected to be in place by July 2018 and would provide supportive and effective early intervention services.  Consideration was also being given to refreshing mental health transformation which would be led by Jane Hainstock at Hillingdon CCG. 

Whilst the AFNCCF workshop had been a valuable exercise in terms of engaging with schools, it was thought that many of the priority areas had been previously recognised.  It would be important to ensure the process not only looked at ‘what’ but also how financial headroom could be created to help implement changes.  This would need to be injected at pace, else it would just be an unimplemented wish list.

Board members noted that it had taken too long to get to this position but felt that the Borough was now in a good position to make improvements to the service.  CAMHS update reports would be included as a standing item on the Health and Wellbeing Board agenda to enable members to monitor progress. 

Concern was expressed regarding investment by schools and identifying the relationship between investment and outcomes as there were no models currently available.  Consideration would need to be given to identify links with the hospital and to quantify the system benefits/outcomes of funding.  The system benefits needed to be traceable back to the original investment and patient outcomes to justify the investment.

RESOLVED:  That the Health and Wellbeing Board:

a)    approved recommendations outlining a new approach to commissioning CAMHS services which were to be developed and were subject to approval by HCCG GB and LBH.

b)   noted the current performance against CAMHS waiting times (Appendix 1 of the report).

The report set out the approach to meeting future demand with progress updates but was felt to lack timescales for development, e.g., of new hubs.  It was suggested that a more specific timescale be included in the report to provide more clarity and enable the Board to review progress.

S106 funding totalling almost £45k had been mentioned in the report with spend deadlines in the next 18 months (else the money could be returned to the developers).  Although this money had been earmarked towards a new health hub in the north of the Borough, it was suggested that consideration be given to an alternative project if this one did not look like it would materialise. 

The Chairman advised that a working group of the Council’s External Services Scrutiny Committee had undertaken a review of GP pressures and had looked at alternative delivery of primary care.  This review was currently undergoing a redevelopment and it was anticipated the final report would be ready before the end of the municipal year. 

With regard to the Yiewsley Health Centre, it was noted that the two practices based there had been consulted and the redevelopment would result in additional primary care support.  This would manifest itself in the form of additional clinics and could be used as a training practice.

RESOLVED:  That the Health and Wellbeing Board noted the progress being made towards the delivery of the CCGs strategic estates plans.

The report set out that the Clinical Commissioning Group (CCG) was half way through a two year commissioning cycle.  It gave services an indication of the CCG’s direction of travel and areas where the CCG would like to see changes made.  There had been a refocus consistent with the draft Joint Health and Wellbeing Strategy and the Sustainability and Transformation Plan (STP) and local chapter priorities so that the document now fitted in well against that suite of strategic documents.

Board members suggested that the report read better than it had previously.  It was recognised that it better reflected the BCF and the detail could now be drilled down.

It was noted that the population figures on page 390 of the agenda were at odds with the population figures included in Agenda Item 7 as the sources were different.  This further highlighted the volatility of data.

RESOLVED:  That the Health and Wellbeing Board considered and noted Hillingdon CCG's commissioning intentions for 2017-18.

Although Hillingdon CCG had received official confirmation of its assurance rating for 2016-17 and had been rated as ‘Good’, it aspired to be ‘Outstanding’.  To achieve an 'Outstanding' rating, improvements would be needed around delivery against the 4 hour A&E standard, use of personal health budgets and ongoing post-diagnosis dementia support.  These areas had all been included in the 2017/18 plans. 

It was noted that the procurement for urgent and emergency care would take place next year to better integrate the emergency services (e.g., being able to book GP appointments and live access to clinicians through the 111 service).  It was hoped that this would alleviate some of the challenges currently faced within the existing system.

Hillingdon’s Accountable Care Partnership (ACP) had moved to the testing phase following an assurance process which was approved by the CCG in May 2017.  There was currently a shared budget and investigations were underway on capitation.  It was thought that the calculation for capitation would: be more sensitive to patient types; reduce unnecessary admissions; and provide patients with more independence.

Four Care Connection Teams had been fully recruited and were linked to multi-disciplinary teams.  They aimed to encourage self help and self awareness to ultimately reduce admissions.  The CCG had been working with the voluntary sector and Hillingdon4All to extend the service to those with long term conditions such as diabetes and had also been developing an outcomes framework. 

The CCG’s financial position continued to be challenging, particularly in relation to planned and emergency care at Hillingdon Hospital and continuing care budgets.  Within North West London (NWL), every CCG and provider had a financial target.  CCGs used QIPP to achieve these targets.  Although the 2016/2017 target had been tough, it was thought that the 2017/2018 target of £14.4m would be an even bigger challenge. 

Over the last 2-3 months, the 8 NWL CCGs had been working together to identify improvements.  Although the CCGs were not merging and would remain separate entities, they were looking to merge certain functions to gain economies of scale and reduce time spent in meetings.  As the CCG governance seemed to be confusing to some, this simplification was welcomed but concern was expressed at the possibility that local decision making would be lost. 

The Board was advised that Sarah Crowther had been appointed as the CCG Governing Body’s new lay member for public and patient involvement and engagement. 

With regard to Choosing Wisely, the Board was advised that there had been two separate processes underway at the same time:

1. theNWL review had been taking place over the last three months and looked to encourage patients to buy over the counter remedies for a range of minor conditions.  This had overlapped with the national NHS campaign; and
2. stopping pharmacies from automatically reordering repeat prescriptions without ascertaining whether all of the medication on the prescription was needed.  This poor practice had resulted in a 7% wastage of drugs.  Patients were being encouraged to register  ...  view the full minutes text for item 25.

The Chairman thanked Healthwatch Hillingdon on behalf of the Health and Wellbeing Board for an excellent report that reflected the breadth and depth of work it had undertaken.  The independent organisation had provided valuable insights and added a great deal to the understanding of a range of issues. 

It was noted that the report had included a breakdown of 112 experiences, concerns and complaints recorded by Healthwatch Hillingdon in the last quarter.  It was suggested that this information needed to be collated alongside the comments received by the Council and the local Trusts to give a fuller picture of public concerns.  This information would be made available. 

RESOLVED:  That the Health and Wellbeing Board noted the report received.

It was noted that the Local Safeguarding Children's Board (LSCB) Annual Report would be considered by the Health and Wellbeing Board at its meeting on 7 December 2017.  The LSCB had been asked to consider changes that had been brought in which meant that it was now open to the police, NHS and councils to make their own arrangements regarding safeguarding.  This was something that Healthwatch Hillingdon might also like to consider. 

As the Hillingdon Clinical Commissioning Group had difficulties in attending meetings on Thursdays, it was agreed that the meeting scheduled for 8 March 2018 would be changed. 

RESOLVED:  That, subject to the suggested amendments, the Health and Wellbeing Board's Board Planner be noted.

RESOLVED:  That the confidential minutes of the meeting held on 27 June 2017 be agreed as a correct record.

The Board discussed a number of issues in relation to how the Health and Wellbeing Board was functioning, the MOPAC consultation and a health hub in Uxbridge. 

RESOLVED:  That the discussion be noted.