Agenda item

Health Updates

Minutes:

Central and North West London NHS Foundation Trust (CNWL)

Ms Kim Cox, Hillingdon Mental Health Borough Director, advised that PC Victoria Hull had been unable to attend this meeting.  As such, she would attend a future meeting with representatives from CNWL to provide the Committee with an update on the Serenity Integrated Mentoring (SIM) project. 

 

Members were advised that work continued on the Integrated Care Connection Expansion Model with regard to physical and wellbeing/mental health needs.  The Care Connection Teams (CCTs) would work with providers (i.e., the voluntary sector, Council, pharmacists and other specialist and hospital services) to coordinate physical, wellbeing and mental health services.  A Mental Health Nurse would be the link worker with other mental health services. 

 

New models of care had been introduced with the Primary Care Networks.  The 45 GP practices in the Borough had been grouped into 9 neighbourhoods with each collectively serving a population of 30k-50k patients.  The work involved partners from across the health system including acute, community, mental health, primary care, social care and third sector services.  There was a clear focus on prevention which was supported by sharing data and information across all parts of the local system.  Multi-disciplinary teams had been working across organisational boundaries and there had been some robust data driving developments, including the use of whole population risk stratification.  Resources and workforce were being flexed and deployed to meet the needs of the population with care being delivered closer to home in the least restrictive environment. 

 

Ms Cox noted that a new children’s integrated therapy service was being mobilised which combined the current speech and language therapy, physiotherapy and occupational therapy pathways into a more streamlined service with one referral route. 

 

With regard to mental health services, it was noted that there continued to be an increase in the number of referrals to the service.  A major transformation plan had been put in place to improve the urgent and acute care and community care offer.  However, Ms Cox advised that this had been impeded as a result of the Council withdrawing from the Section 75 (s75) integrated services agreement.  Ms Robyn Doran, Chief Operating Officer at CNWL, advised that the Trust had been disappointed with way the s75 issue had been handled and the way that it had come out of the blue. She suggested that the action would not improve the service provision and that it would have implications for funding which would then impact on health colleagues.  Ms Doran also stated that this model had been implemented elsewhere and had not proved as effective as when the social workers were managed by CNWL. 

 

Ms Cox expressed concern that the caseload would now need to be split between those with a predominant social care need and those with a predominant mental health need.  Furthermore, CNWL would now need to look at securing alternative premises from which to operate the service within the next six months. 

 

Section 75 was an arrangement / ongoing contract for the sharing of staff whereby social care staff were embedded in that contract.  Although these social care staff were no longer embedded as part of the contract, there was no reason why they could not still work together.  It was noted that the decision to take action with regard to s75 had been taken at a high level and had been based on concerns that had been raised with regard to the appropriateness of the use of the expertise provided.  Although the Council would now manage the social care aspect of the service itself, it was hoped that the two organisations would work together with the same level of integration to the benefit of residents.  The effectiveness of this new way of working would need to be kept under review. 

 

Ms Caroline Morison, Managing Director at Hillingdon Clinical Commissioning Group (HCCG), advised that the Trust would likely need to consult on the changes that would result from the action being taken in relation to the s75.  The Committee would be included in any consultation that was undertaken. 

 

It was noted that additional funding had been secured with regard to instigating a bespoke community service for people with a personality disorder and separate funding had been received to enhance the mental primary care offer in conjunction with the neighbourhood teams.  The latter would see an increase in the number of primary care nurses from four to ten.  CNWL was commended for the positive advances it had made with regard to personality disorder services. 

 

Members were advised that a new five borough CAMHS team had been put in place which aimed to avoid admission, deliver care closer to home and focus on a home treatment model for the family and young person.  Advance Care Planning (ACP) had meant that additional clinical support had been provided within community health services to keep people in their usual place of residence.  ACP’s Coordinate My Care system was accessible to the London Ambulance Service with a Multi-Disciplinary Team supporting this to provide wrap around services.  This was currently being rolled out to 5/6 care homes that had been prioritised as high users of services in the Borough.  It was anticipated that the services would be Borough-wide by the end of the financial year. 

 

Ms Cox noted that Lavender Walk had recently celebrated its one year anniversary and had received excellent outcomes and feedback from patients.  During its first 12 months, the ward had been used by 12 patients from Hillingdon who would otherwise potentially have been placed a long way outside of London. 

 

CNWL had missed the 18 week CAMHS referral target for the last quarter.  However, a recovery plan had been put in place and the target had been brought back on track in December. 

 

Members were advised that workforce recruitment and retention remained a challenge.  There had been a national increase in the number of positions available so plans had been put in place to look at the skills mix and review the training offer. 

 

With regard to patient feedback, CNWL had received an average of 4.86 complaints per 1,000 patients in relation to Hillingdon mental health services, which equated to about 1-2 per month.  Complements for these services averaged at about 8.96 per 1,000 patients.  Insofar as Hillingdon community health services were concerned, there had been 0.33 complaints per 1,000 patients and 2.33 compliments.  Although, in both service areas, the compliments far outweighed the complaints, learning had been gleaned from this feedback.  The majority of complaints had been in relation to communication, processes and information issues rather than the service that had been received.  As a result, action was being taken to: increase communication between staff; clearly convey the complaints procedure; create more opportunities for staff to reflect on behaviours; communicate promptly and clearly; inform patients if staff were running late; and coordinate and act on care plans in a timely manner. 

 

Insofar as complaints were concerned, it was noted that those received during 2018/2019 had been mostly in relation to issues such as letters arriving late and clinics running late.  Furthermore, complaints were more likely from community mental health patients as the nature of the service meant that a large number were not happy about being patients.  Only about 15-20% of the complaints were in relation to the actual services provided.

 

The number of patients seen by community health services and mental health services in Hillingdon had increased over the last year.  In the last twelve months, Hillingdon mental health services had made 72,270 face-to-face contacts, undertaken 20,584 new appointments, admitted 523 patients to patient wards and completed 387 Section 136 assessments. 

 

Zero Suicide Alliance e-training had been uploaded onto CNWL’s intranet so that it could be accessed by all staff.  The majority of staff had now completed this training.  In addition, CNWL had secured funding for community health staff to have enhanced mental health training. 

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Sarah Tedford, Chief Executive Officer at THH, advised that the Hillingdon Improvement Plan had been put in place following the CQC inspection.  The Plan had focussed on actions to address the ‘should do’ and ‘must do’ actions highlighted within the CQC report and had grouped these into 13 work streams. 

 

Improvements had been seen in relation to baselines assessments and deep dives had been undertaken in relation to sepsis management and infection prevention and control.  A policy refresh was being undertaken and the Plan was being reviewed every two weeks to ensure that sufficient progress was being made.  External partners were being included in monthly review meetings to ensure that any action being undertaken was joined up and an evidence committee had been established. 

 

A peer review had been undertaken in non-clinical areas at Hillingdon Hospital on 4 December 2019.  This process had identified a number of areas of good practice and some areas where improvements needed to be made.  Ms Tedford advised that she would share the results of the peer review with the Committee.

 

Ms Tedford circulated a handout to Members that summarised the THH winter plan.  It set out the anticipated increased demand this winter based on historic trend analysis.  Additional capacity had been planned based on a range of schemes that had also been included in the handout (Admission Avoidance Schemes – how THH managed patients; Optimised AEC Schemes – ambulatory pathway expansion; and Effective Discharge Schemes – getting patients to the right place). 

 

It was noted that the hospital was under tremendous pressure.  There had been a 20% increase in A&E attendances in the last ten days.  Bed meetings were being undertaken 3-4 times each day to ensure that bed usage was being optimised.  Walk throughs were being undertaken during the day and a nurse had now been stationed in the A&E waiting area to ensure that the patients were safe and comfortable.  Staffing levels in A&E were being monitored and reviewed throughout the day to ensure that they were optimised. 

 

Up to mid-November 2019, the Trust has been achieving around 88% against its 4 hour A&E waiting time target.  However, following the increase in the number of patients being seen, this percentage had dropped to the mid-70s but without increasing the number of admissions.  It had become apparent that the additional pressure/demand was coming from outside of Hillingdon. 

 

Ms Tedford advised Members that THH was not currently contracted to provide tuberculosis vaccinations. 

 

With regard to complaints, two leaflets were circulated to Members: PALS: Patient Advice and Liaison Service…we are here to help; and Raising a concern or making a complaint.  These documents provided information on how to make a complaint.

 

The Chairman noted that the Committee had been concerned for some time about THH’s performance and the Trust’s response to criticism.  Whilst it was acknowledged that the estate played a contributory factor, the additional pressure felt by the Trust could not be solely attributed to the estate.  With regard to the issue raised by the CQC in relation to discharges from hospital, residents were still complaining about poor discharge processes.  Ms Tina Benson, Chief Operating Officer at THH, advised that patient discharge was now being planned the day before.  This meant that medication was already available for the patient to take home and all that needed to be completed on the morning of discharge was a quick medical assessment.  Although this procedure was already being practiced, staff still needed to get into the habit of doing it.

 

It was suggested that THH concentrate on improving in a small number of impactful areas rather than trying to tackle everything at once.  Ms Tedford recognised that the estate could not be blamed for all of the issues being faced by the Trust.  THH now had a new management team and clear objectives had been set for each year with refinements for each ward so that all staff were clear about what these objectives meant for them. 

 

Previously, there had been no senior individual overseeing the effectiveness of patient administration processes.  This had now been rectified and standard operating procedures were being put in place. 

 

It was noted that, irrespective of what action was taken, emergency and elective patients still came to the hospital and needed to be balanced in a more effective and measured way.  Ms Tedford advised that she would be happy to return to a future meeting to talk to Members about this in more detail. 

 

Members were keen to set up an additional meeting to solely talk to THH about measures that had been put in place and progress that had been made.  Ms Tedford would welcome the opportunity to talk to the Committee. 

 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Caroline Morison, Managing Director at Hillingdon Clinical Commissioning Group (HCCG), advised that, from 1 July 2019, GPs had been working to establish primary care networks (PCNs).  In Hillingdon. HCCG had endorsed seven PCNs covering the majority of the GP-registered population: HH Collaborative PCN; North Connect PCN; Colne Union PCN; MetroCare PCN; Synergy PCN; Celandine Health PCN; and Long Lane including First Care Group PCN.  Of the 45 GP practices in Hillingdon, 43 had signed up to PCNs (Church Road Surgery and West London Medical Centre had not signed up).  Although GP practices were not required to sign up to a PCN, there was a requirement that all patients must be covered by a PCN to ensure that they received equal access to the available health services.  Each PCN had appointed a local Clinical Director who would be responsible for the development of the network and would need to ensure that it worked closely with the other local services serving its population.  These Clinical Directors would also cover the ‘neighbourhoods’.

 

The following would be included as part of the PCNs:

·         Increased access to clinical pharmacists to advise on medication (many practices already had clinical pharmacists);

·         Access to additional appointments (by phone, online and face-to-face) with a GP or nurse;

·         Benefits of a combined multi-disciplinary team across general practice, community services and local authority support;

·         Additional support through a referral to non-medical or voluntary sector support (e.g., weight loss groups, exercise classes, walking groups, etc) via ten Social Prescribing Link Workers (which was a new role to facilitate links with the voluntary sector); and

·         Access to specialist skills from GPs, nurses and other professionals within the whole of the PCN, rather than from a single practice. 

 

The Hillingdon PCNs had already been asked to work on projects to enable their development.  Where these projects had worked well, they could be scaled up and included:

  • Long Lane PCN: identifying and improving support for adults who repeatedly turned up at A&E or those who were at risk of deterioration; and
  • North Connect PCN: establishing remote telephone advice clinics across multiple practices.

 

‘Neighbourhoods’ (each comprising 30k-50k patients) had been created to bring together primary care community physical and mental health, social care services and the voluntary and community sector partners.  They existed to avert and avoid unnecessary hospital care, particularly for people with multiple health, care and wellbeing needs.  PCNs sat alongside core neighbourhood teams and wider provider services.  It was anticipated that the neighbourhood teams would work holistically with GPs to meet the needs of the entire practice population, but to specifically identify and manage the 15% of patients that were at greatest risk of future admission to hospital. 

 

PCNs would continue to identify local priorities and ways of working with local partners to improve service quality.  Extended hours arrangements were also being set up so that patients had consistent access to appointments throughout the week.  It would become increasingly important to ensure that residents were aware of this service and it was suggested that practice out-of-hours answerphone messages could highlight the availability of the service.  The service was currently commissioned by HCCG but would be transferring to PCNs and online access was being investigated further.  Online consultation had been effectively introduced in other boroughs such as Brent and, whilst it was recognised that these types of consultations would not suit everyone, could reduce the demand for face-to-face appointments and free them up for those patients with more complex conditions. 

 

Members queried whether the introduction of PCNs had reduced the waiting times for patient GP appointments.  Ms Morison advised that it was still early days but that telephone triage had also been introduced in the North of the Borough to address the issue.  The introduction of PCNs was key to address the varied effectiveness by standardising the access to / availability of services provided across the 45 practices in Hillingdon.

 

Ms Morison noted that HCCG were preparing the following 2-4 year service specifications from April 2020 and that further information on them would be available later in the year:

  1. Structured Medicines Review
  2. Enhanced Health in Care Homes
  3. Anticipatory Care
  4. Personalised Care
  5. Support with Early Cancer Diagnosis

 

A further two service specifications were planned for 2021/2022:

  1. Prevention and Diagnosis of Cardio-Vascular Disease
  2. Tackling Neighbourhood Inequalities

 

It was noted that, in September 2019, the governing bodies of the eight North West London (NWL) CCGs had agreed that they would work towards a single CCG from April 2021 in line with the direction set by the NHS Long Term Plan.  In addition, each of the CCGs had made a commitment to cut administrative costs which would require a change in working practices rather than continue with smaller teams.  Any changes made would form the start of the transition to integrated care partnerships (ICPs) in NWL.  Ms Morison noted that consideration would need to be given to where growth was coming from and that, insofar as integrated care was concerned, it would be important to look beyond Hillingdon to ensure the Borough did not become an island as there were interdependencies across borough boundaries.

 

Local teams would continue to retain responsibility for working with GP members, primary care and community-based services and maintaining local relationships, for example, with local authorities, Healthwatch and the voluntary sector.  These local teams would support the development of PCNs and ICPs with provider partners and local authorities.  The structures for the local and ‘Once for North West London’ teams were being developed and were likely to be published for staff consultation at the middle/end of January 2020.  It was possible that there would be four teams: Brent and Harrow; Ealing and Hounslow; Westminster, Kensington & Chelsea and Hammersmith & Fulham; and Hillingdon.  It was anticipated that the new management model would be implemented in March/April 2020. 

 

Concern had been expressed by residents that they were unable to get an appointment at their local GP practice, yet the practice was still taking on new patients.  Furthermore, it appeared that the proposed new practice at the top of Church Road was now not happening.  Ms Morison advised that workforce pressures in Hillingdon were greater than elsewhere in London.  If residents were struggling to get a GP appointment, there were people that they could speak to / report this.  It was noted that the Committee had set up a Select Panel which had undertaken a lengthy review into GP pressures and which had made a number of recommendations.  GPs appeared confident that, once the pressures had been addressed, more doctors would come to work in the Borough.  The final report would be presented to Cabinet on 23 January 2020. 

 

Ms Morison advised that plans were in place to reopen the Michael Sobell House (MSH) inpatient unit on 5 January 2020 and that it would now be run by Harlington Hospice working with Michael Sobell Hospice Charity.  Staffing had been arranged and the equipment for use in the unit was available as expected so there were no outstanding concerns.  It was noted that events to mark the reopening had been held on 14 and 16 December 2019. 

 

Members were aware that the reopening of the MSH inpatient unit was a medium term measure and that consideration was being given to a more long term end of life care strategy that reflected the needs of patients.  HCCG would be speaking to residents to establish what the future provision should look like. 

 

Healthwatch Hillingdon (HH)

Mr Dan West advised that he had recently been appointed as the new Managing Director at HH and that Mr Turkay Mahmoud had reverted back to the HH Vice Chairman.  He noted that HH’s sexual health services review had been published on its website – the review had highlighted issues with regard to confidentiality. 

 

Young Healthwatch continued to work well.  Ms Kim Markham-Jones had been working with the young people to roll out the mental health and wellbeing programme in schools across the Borough. 

 

Healthwatch Hillingdon had again been commended in relation to its hospital discharge report at the Healthwatch Annual Conference. 

 

In November 2019, a roadshow concept had been piloted.  The HH Board had been provided with feedback and the presentation had been refined so that it could go out again in the new year and continue to be used on an ongoing basis. 

 

Mr West noted that further information about the extended access hubs needed to be provided to residents. 

 

RESOLVED:  That:

1.       Ms Tedford share the results of the peer review of non-clinical areas undertaken on 4 December 2019 at Hillingdon Hospital;

2.       Ms Tedford attend a future meeting to talk about action to taken to better balance elective and emergency care in a more effective and measured way; and

3.       the presentations be noted.

Supporting documents: