Agenda item

The Chairman thanked those present for attending the meeting. 

 

Central and North West London NHS Foundation Trust (CNWL)

Ms Kim Cox, Borough Director – Mental Health at CNWL, advised that the waiting times for the CAMHS service were now more stable that they had been.  Although there had been huge improvements over the last two years, there was still some way to go. 

 

An eating disorders community service was available in Hillingdon.  The performance of this service was consistently good even though demand was high and the referral to treatment targets were being met.  Only the occasional patient was referred to the inpatient unit in central London. 

 

Concern was expressed that a reduction in the capacity of Cognitive Behavioural Therapy (CBT) practitioners could impact negatively on the patient journey.  Ms Cox advised that the additional funding had been made available for CAMHS to clear its backlog and return to an even keel.  Funding was now being diverted to core pathways and the service was being more creative in relation to its activities. 

 

Hillingdon Health Care Partners (HHCP) CNWL in conjunction with Hillingdon CCG had bid for additional funding for mental and physical health nurses who would carry out Advanced Care Planning in care homes and extra care facilities.  Ms Cox would provide Members with an update on this at a future meeting.  It was noted that the Primary Care Mental Health Teams would be realigned to the eight neighbourhoods being developed as part of the Case for Change.  The GP confederation was identifying Clinical Directors for each of the neighbourhoods with a view to having a matrix style integrated management structure.  CCTs would expand their remit to include all adults and there would be an increase from 15 to 18 CCTs. 

 

Ms Cox advised that Life Line 24/7 had been successfully keeping people at home.  In the last six months, palliative care services had been used to help 60 people to stay at home. 

 

Members were advised that the number of Section 136 (s136) assessments undertaken had hit an all-time high (59) in April 2019.  CNWL had recently started the SIM project (Serenity Integrated Mentoring).  This project was being delivered jointly with the police to provide intensive interventions from both a health and criminal justice perspective for a caseload of service users.  The project enabled a full time police officer working in mental health to look at alternative (and more appropriate) interventions to a s136 when needed - about one third of people brought in by the police did not need a s136 as they were in distress rather than suffering with mental health issues.

 

In partnership with health commissioners, CNWL had bid for additional parity of esteem funding to increase the support in primary care for people with a mental health problem (the outcome of this bid was expected on 12 July 2019).  CNWL had also bid for funding for a service specifically for service users with a personality disorder. 

 

Ms Cox noted that Arch had been awarded a public health grant to implement fibrous (liver) scanning.  The service provided a comprehensive ‘welfare, physical and wellbeing’ offer for alcohol misuse clients in the Borough, providing them with a ‘health passport’.  It was noted that there had been an increase in the number of street homeless accessing Arch.

 

A number of actions had resulted from the CQC inspection of the Immigration Removal Centre (IRC) Colnbrook.  These actions had included work in relation to supervision and translation services.  Ms Cox advised that, if Members required any further information, she could ask the IRC to attend a future meeting of the Committee. 

 

Hillingdon’s Offender Care Liaison and Diversion Service was operating an all age and all vulnerability model across three sites: Uxbridge Magistrate’s Court, Heathrow Police Custody and Hillingdon Youth Offending Service.  This enabled the diversion of people with a mental health issue to the most appropriate service between 8am and 8pm. 

 

Members were advised that CNWL had been taking part in the filming of a Channel 5 documentary which would be screened in September 2019.  The camera crew had followed a number of men who had had suicidal thoughts and Ms Cox had also been interviewed.  She noted that the Zero Suicide Alliance training was being rolled out extensively. 

 

With regard to the complaints information that Members had previously requested, Ms Cox would forward this to the Democratic Services Manager for circulation.

 

The Chairman asked that Ms Cox pass on the Members’ thanks to Ms Maria O’Brien who had recently been promoted and would therefore not be attending future Committee meetings.  Her engagement with the Committee had always been brilliant and Members were grateful for her contributions to their meetings. 

 

London Ambulance Service NHS Trust (LAS)

Ms Desiree Papadopoulos, LAS’ Business Support Manager North West, advised that the LAS had a CQC inspection coming up.  At its last inspection in November 2018, the Trust had been rated as Good in the ‘Safe’, ‘Effective’, ‘Responsive’ and ‘Well-led’ domains and Outstanding in the ‘Caring’ domain, giving an overall rating of Good (its previous inspection in February 2017 had resulted in an overall rating of Requires Improvement).

 

Members were advised that the LAS had expanded its pool of midwives from one to three.  A paramedic and mental health response car had been piloted in South East London.  It was hoped that this service would be expanded across London in the near future.  Ms Papadopoulos advised that the evaluation of the mental health response unit trial was being undertaken but that she would enquire as to the expected timescales for roll-out. 

 

Other work undertaken by the LAS included the deployment of a falls vehicle in Hillingdon.  This resource reduced the number of emergency department conveyances. 

 

Ms Papadopoulos advised that North West London (NWL) comprised five groups which each had an end of life volunteer.  This person attended CPD events to help train colleagues.  End of life care (EOLC) was high on the LAS agenda and the “Coordinate my care” facility meant that LAS staff could be notified about the patient’s EOLC choices (if they had developed their own plan) when they were en route to the patient.  Ms Papadopoulos noted that it could be quite scary for families and that they often needed support.  The Life Line 24/7 service and the Palliative Overnight service also looked to support EOLC choices. 

 

Concern was expressed that, in the past, the LAS draft quality account report had been circulated to the Committee for comment prior to publication.  However, this had not happened in 2017/2018 or 2018/2019 and the final version of the report had only been received on 8 July 2019, prohibiting Members from being able to properly digest the information contained therein before the meeting.  Ms Papadopoulos would raise this issue with Ms Natasha Wills. 

 

Members were advised that NWL was top in relation to ‘Handover to green’: the time from when the patient handover had taken place to the time the ambulance was available for further deployment.  Blue calls (the time taken to transport a patient to hospital under blue lights) were taking an average of 16½ minutes.  This time still needed to be reduced and action would need to be taken to educate LAS and hospital staff on how improvements could be made. 

 

Ms Papadopoulos advised that Category 1 (high priority/critical) patient waiting times were good (an average of 6m 4s in Hillingdon against a 7m target).  Category 2 (sick but not critical) patient waiting times had been challenging across the whole of London (an average of 24m 8s in Hillingdon against an 18m target).  It was thought that the latter performance had been impacted by the geography of the Borough. 

 

Staff communication was undertaken regularly and on-scene times were routinely measured.  Ms Papadopoulos would need to seek further information in relation to the technology used to monitor this. 

 

It was recognised that NWL had experienced some challenges with regard to the recruitment and retention of staff.  A large number of Australians had been recruited in the past and, having completed their contracts and gained the experience of working in the UK, they were now going home.  It was hoped that the opening of an operational placement in Hanwell with 30 crews might lead to more newly qualified paramedics staying in NWL.  It was anticipated that approximately 300 staff would pass through this facility in the next 12-18 months.

 

Members were advised that there continued to be a significant number of inappropriate calls to the 999 service.  The call handlers were not clinically trained which meant that ambulances were sometimes responding to calls when they were not really needed.  Ideally, calls needed to be assessed and by someone that was clinically trained so that they could then be referred to the most appropriate pathway.  Members were advised that, as well as 111 calls being diverted to 999, 999 calls could now also be diverted to 111.

 

It was more cost effective to have clinicians in the control room who could triage calls and refer patients to other services rather than sending ambulances out for all calls.  However, it was recognised that clinicians wanted to work on the front line and did not want to be based in an office.  As such, recruitment into these call centre triage roles was not easy.

 

Royal Brompton and Harefield NHS Foundation Trust (RBH)

Mr Piers McCleery, Director of Strategy and Planning at RBH, advised that, if agreed, the project proposed in conjunction with Kings Health Partners (comprising King's College London, Guy's and St Thomas' NHS Foundation Trust, King's College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust) would not be fully effective for 8-10 years.  NHS England (NHSE) had been taking an active interest in the changes to the provision of paediatric congenital heart services but had not yet provided any direction or decision on the way forward.  In the meantime, multi-disciplinary teams (MDTs) were being developed and ‘passports’ were being provided for all staff to be able to move to different teams on different sites within the scope of the partnership Trusts.  Members were advised that Harefield Hospital was likely to benefit from the RBH proposal as there would need to be a redistribution of some services. 

 

Although timescales for a decision on this issue had not been specified, Mr McCleery believed that the determination of all clinicians involved to deliver something transformational would be a decisive factor.  He also noted that the prospect of a judicial review would not appeal to anyone. 

 

It was noted that the Darwin Programme, an ongoing productivity project, had been implemented to identify efficiencies.  For example, of the four theatres at Harefield Hospital, three were used for cardiac surgery, with effort made to do 2 operations per day.  Action had been taken to streamline process so that this had now increased to 3.7 cases per day with further work expected to help achieve 4.2-4.3 cases per day, giving a 33% increase in productivity.  Although the overheads would not reduce, this increase in activity would improve value for money. 

 

Members were advised that, in the past, only around 15% of patients attended Harefield Hospital on the day of surgery (as opposed to being admitted the day before).  Over a six month period, and with the dedication and determination of a single member of staff to drive it, there had been an increase to around 70%.  This had been achieved through the use of taxis and better planning, and effectively meant that patients were able to spend more time in familiar surroundings with their loved ones prior to surgery. 

 

Mr McCleery advised that, with regard to the Referral to Treatment (RTT) pathway, more than 92% of elective referrals were being seen within 18 weeks.  However, this figure was approximately 50% in relation to cardiac surgery.  As this performance was partly resultant from inefficiencies and poor wait list management, it was anticipated that the Darwin Programme would be used to drive improvements in this area. 

 

With regard to recruitment, Harefield Hospital had introduced an innovative Band 5 nurse recruitment where new recruits were rotated through four different areas of the hospital.  This had helped to increase recruitment levels with PICU vacancy levels currently at around 15%.  However, it was noted that the Cleveland Clinic would be opening premises in central London in approximately two years and would be recruiting aggressively for nurses and technicians.  Consideration would specifically need to be given by RBH to how it would retain its intensive care staff list as these were the staff that were most likely to be targeted by the Cleveland Clinic. 

 

A new model of care had been developed for cystic fibrosis patients who could use a digital prototype platform (developed in conjunction with MeadowPad) to monitor their condition.  The facility was accessible through mobile phones and tablets and was used in conjunction with other medical equipment to upload data about the patient’s condition.  The patient would then be able to decide whether or not they wanted to share this information with medical professionals and could have a Skype conversation if they had any concerns.  It was anticipated that the app would prevent patient admission and deterioration.  Whilst the app could possibly be replicated for other conditions, it would take time as the model of care would need to be designed slowly with lots of input from patients.

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Tahir Ahmed, Executive Director of Estates and Facilities at THH, advised that the longest standing member of the THH management team was the Chief Executive (who had been in post for approximately 7 months) and that there were still two interim posts that would need to be filled with permanent staff.  This meant that the team was currently getting up to speed.

 

Mr Ahmed had been in post for approximately one month and, over the last three weeks, had been trying to understand the condition of the THH estate.  He noted that some of the buildings had been on site since 1907 and that they were not fit for modern service provision.  As the building had aged, the lack of investment meant that the system started to fail (for example, problems with the infrastructure: water supply, drainage, heating, ventilation, etc).  Both Mount Vernon Hospital and Hillingdon Hospital had suffered from a lack of investment.  Mr Ahmed paid credit to the staff who had managed to keep the estate operational despite these huge challenges. 

 

Members were advised that THH had engaged with NHSE and NHS Improvement (NHSI) in relation to the estate.  An emergency capital request had been submitted for consideration by the Department of Health and it was clear that a new hospital was needed.  The Good Governance Institute had been engaged to try to progress this but there was little evidence to show that there had been a request for a new hospital in the past.  Work was also underway with Brunel University and other partners to develop a new hospital but this would have to go through a gateway review with NHSI to set clear objectives for going forward.  In summary, Members were advised that there were a number of options available to take this issue forward. 

 

It was thought difficult to grasp the extent of the work required with regard to the estate and the minimum standards expected by NHSI and NHSE.  Mr Ahmed advised that there were minimum standards which THH fell below but that these were just guidelines (not statutory).  There was such a huge backlog list of works needed at Hillingdon Hospital with no part of the hospital meeting the minimum requirements; only a redevelopment would suffice.  The outstanding work needed would cost in excess of £200m and would not address the building’s limitations. 

 

It was noted that the Committee had previously asked for further information about the HR strategy that was in place to ensure that there was adequate staffing for the expanded A&E department.  Mr Ahmed advised that the new management team had been developing a range of new strategies: people and organisational development strategy, information strategy, digital strategy and estates strategy.  The estates strategy would underpin the clinical services strategy.  Mr Ahmed advised that the expanded A&E department was on plan to deliver later this year and he would seek clarification of the action being taken with regard to the associated staffing requirements. 

 

Members had previously been assured that THH would meet the A&E 4 hour target by March 2019.  Mr Ahmed would liaise with colleagues to get an update on the Trust’s performance with regard to this target. 

 

Members queried what preparations were being made for winter pressures this year.  As Mr Ahmed was unable to provide a response, he would speak to colleagues and provide the Democratic Services Manager with further information for circulation to the Committee.  From his perspective, he was looking at ensuring the provision of suitable accommodation in the event of a need to flex capacity to meet demand. 

 

It was suggested that an additional meeting be scheduled so that Members could talk to the THH management team about issues of concern.  In the meantime, Mr Ahmed would establish whether or not he was able to share the Trust’s Strategic Outline Case which would provide the necessary information in a format that would enable the Trust (and any public sector partners) to assess the scope of the project and any investments in service improvement. 

 

Local Medical Committee (LMC)

Dr Veno Suri, Vice Chairman of Hillingdon LMC, advised that GPs had been given new contracts and that there had been a move towards more collaborative working.  In the last month, arrangements had been made for practices within the same area to be put into groups covering 30k-50k patients.  He noted that some services would be delivered by GPs in one of the eight ‘neighbourhoods’ in Hillingdon and the delivery of other services would be shared. 

 

Each GP practice would be working under a PMS, GPS or AMPS contract.  Some would provide some services such as insulin initiation, whilst others would provide other services.  The services provided would be a network decision based on what the GPs thought was best to meet their patients’ needs.  It was noted that two practices (where a single GP was a partner at both practices) had concerns in relation to patient lists and GDPR which needed to be resolved.  Although these two practices had not joined the networks, there were still already six networks up and running. 

 

Members were advised that the GP pressures review being undertaken by the Council would be publishing its final report and findings in the near future. 

 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Caroline Morison, Managing Director at HCCG, advised that the Case for Change had been included as part of the published agenda.  The document included clear messages in relation to the highly valued local clinical leadership, local accountability and relationships.  Positives in the document included the Integrated Care Partnerships (ICP) and the Primary Care Networks which would have eight directors that could prove useful.  It was hoped that further information would be available for the meeting that had been scheduled with the Council and Mr Mark Easton, Chief Officer at NWL Collaboration of CCGs. 

 

Ms Morison suggested that currently a significant amount of HCCG’s daily business was transactional so could therefore be undertaken centrally to free up time and enable officers to focus on outcomes.  However, the future had not yet been clearly articulated. 

 

Concern was expressed in relation to the geographical spread in NWL as well as the fact that Hillingdon was currently in a good place.  It was not thought that the changes being introduced would have a beneficial impact on Hillingdon and that they would instead level performance down. 

 

Members acknowledged that there was a need to identify huge savings across the NHS but that this should not come to the detriment of responsiveness to local needs, local relationships or local knowledge.  HCCG had managed to exceed its management cost reduction target so was therefore hoping to maintain its local team.

 

It was noted that Hillingdon’s 2019/2020 control total position was a £1.7m deficit.  This placed the Borough in the middle of the eight NWL boroughs with only the Royal Borough of Kensington and Chelsea expected to end the year with a surplus.  It was thought that this position had been brought about in large part by the weighting of the allocation formula where funding per patient was higher in central London.  Although this fee structure was getting flatter, the merger of NWL CCGs was unlikely to help the situation as commitment had been given that (in the short term) CCG allocations would remain on a borough basis. 

 

The CCGs had been advised of their provisional allocations for the next five years.  As the current trend of end of year deficits was not sustainable, consideration would need to be given to looking at combined funding at some point. 

 

Hillingdon had made greater progress with regard to its ICP partly because Hillingdon Hospital was in the middle of the Borough and had 85% congruence with the local population.  Consideration had been given to this over the last five years and some models of care were already in place (for example, Care Connection Teams (CCTs) and the frailty unit at the front end of Hillingdon Hospital).  Partners had also built strong relations and, as such, NWL was looking to Hillingdon to show the other boroughs the way. 

 

Ultimately, any changes would need to be voted on by the GP members at the CCG.

 

Healthwatch Hillingdon (HH)

Mr Turkay Mahmoud, Interim Chief Executive Officer at HH, advised that the External Services Select Committee meetings were always helpful in piecing together information that had been sourced elsewhere to get a better picture of what was going on. 

 

With regard to the proposed merger of the eight NWL CCGs, HH had concerns about ensuring that the needs of the local population continued to be met.  There were also concerns regarding the impact that the changes might have on the good local avenues of communication and partnership that were in place in Hillingdon. 

 

Members were advised that the HH Annual Report had recently been published.  The report showed that HH had received almost 3k enquiries in 2018/2019.  Mr Mahmoud also noted that HH had published a report on lower back pain and that 3k-3½k young people had been reached through Young Healthwatch Hillingdon (YHwH).  Three YHwH events would be undertaken during 2019/2020 as well as some work around care homes and a relook at hospital discharge. 

 

RESOLVED:  That:

1.    Ms Cox provide Member with an update at a future meeting on the HHCP bid for additional funding for mental and physical health nurses to carry out Advanced Care Planning in care homes and extra care facilities;

2.    if required, Ms Cox would ask officers to attend a future meeting to talk about the inspection of the Immigration Removal Centre (IRC) Colnbrook;

3.    Ms Cox forward information in relation to complaints to the Democratic Services Manager for circulation to members;

4.    Ms Papadopoulos provide the expected roll-out timescales for the mental health response units;

5.    Ms Papadopoulos provide further information in relation to the technology used to monitor on-scene times;

6.    Mr Ahmed provide clarification with regard to the action being taken to provide adequate staffing for the extended A&E at Hillingdon Hospital;

7.    Mr Ahmed provide the Committee with THH’s latest performance in relation to the 4 hour A&E target;

8.    Mr Ahmed provide the Democratic Services Manager with further information on the preparations that had been made for winter pressures for circulation to the Committee; and

9.    the presentations be noted.