Minutes:
The Chairman welcomed the witnesses to the meeting and invited them to present their report to the Committee. It was agreed at the External Services Scrutiny Committee meeting on 16th June 2010 that representatives from Hillingdon PCT and Central & North West London Foundation Trust (CNWL) be invited to this Committee meeting to provide a further update. At the last meeting it was anticipated that the transfer to vertically integrate Hillingdon Community Health with CNWL would be completed by April 2011.
Vertical Integration
Ms Maria O’Brien, Managing Director of Hillingdon Community Health (HCH), presented the Committee with an update on vertical integration. Two providers stood out as the best options and the panel of stakeholders chose CNWL as the preferred option. There was a detailed due diligence exercise carried out. This report received approval by the Cooperation and Competition Panel (CCP), also reviewed the proposal and did not find any issue to prevent it from proceeding. The business case was approved and was awaiting sign off by the CNWL Board in November and was awaiting sign off by the NHSH Board at their meeting on 30th November 2010.
There were benefits of trying to bring together physical and mental services which made CNWL an attractive option. CNWL would also bring economies of scale. There was a need at Board level for an individual to concentrate on community services and Mr John Vaughan would take on Board level responsibility for community services from January 2011.
All staff affected by the transfer had been contacted and consulted with, and a TUPE transfer was being completed to CNWL. There were a number of benefits for staff with this integration, including more opportunities for staff as they would be part of a larger organisation, and would retain all of their NHS benefits. Ms O’Brien and other senior officer had met with staff at different sites and it was clear there were no major concerns to note.
A group had been set up to look at improvements for Clinical Service Provision. Mr Keith Bullen confirmed for the PCT that there was no intention of de-commissioning or reducing the funding available to community services.
CNWL had entered into an arrangement with Boots the Chemist for a Wellbeing Centre. This was already open. It was hoped that a number of the HCH services would be moved into the Wellbeing Centre to offer more to the public. The centre would also reduce duplication of work; heart failure service would be brought together, a community based cardiology centre be set up, more focus on children’s mental needs and also on dementia.
Although IT and estates would remain intact, the whole team and day-today management would transfer to CNWL. Nationally a decision had not been made on ownership of estates.
Ms O’Brien spoke about the tough economic climate and the efficiency savings that had to be made. It was anticipated that some savings would be made from management overheads and some from estates. The reduction in the duplication of work would also produce some savings. Whilst consideration would be given to the commercial mind-ness of contracts, it was stressed that there would be no noticeable change to the service provided to the public.
A variety of cards, letters and posters were being produced and staff were speaking to patients on a one-to-one basis regarding the changes that were taking place. Patients were nervous about what they were hearing on the news, so the one-to-one attention they were getting was be reassuring for them. GP’s had been involved throughout the process and were onboard. CNWL and HCH officers had been meetings with to LINks, various community groups and a number of different forums to discuss the changes. There was no intention to reduce the service. A full page advert would appear in the Hillingdon People in the new year about the changes.
A report was going to the PCT Board for final approval on 30th November 2010 and the Strategic Health Authority (SHA) would be reviewing the business case at their meeting on 14th December 2010. It was hoped that the transfer would take place on 1st January 2011 once approved by the SHA.
Mr John Vaughan, Director of Strategic Planning and Partnerships at CNWL, stated that this was a large and complex process but that it was being done thoroughly and had been a smooth process.
The Members stressed the importance of reassuring patients about the service they would be receiving and how the changes should not have a negative impact.
Members commented that a significant amount of NHS estates across London was not being utilised. That we should not wait for changes to happen but make them ourselves.
Ms Linda Sanders, Director ASCH&H, stated that vertical integration was an opportunity to embrace enablement, re-focus on in-house home care staff and enhance other services such as Tele-care, physiotherapy and IT.
It was agreed that the ESSC would be updated on the vertical integration in 2011. Members thanked Ms O’Brien for her presentation.
Physiotherapy
Ms Jill Dady, Hillingdon PCT, updated the Committee on the physiotherapy services in the Borough. They offered patients the usual range of services as well as O.A. knee school, acupuncture for pain relief, physiotherapy for acute soft tissue, core stability/clinical pilates exercise classes and women’s health and Continence Specialist Physiotherapists. A GP referral to the Hillingdon Community Health Physiotherapy Services provided access for patients to these services and at the end of the treatment, a discharge report was sent to the patient’s GP.
Clinics were spread across the Borough and they had expanded in the South where historically they had the longest waits. There was one extra clinic compared to last year, and a new one had replaced an old clinic.
In April 2009, only 41% of patients were seen within 3 weeks of referral; in October 2010, this figure had increased to 92%. This success was partly due to the revolutionised centralised booking system. This allowed patients to be seen quicker at the clinic that was most convenient for their home or work situation. The increase in treatment plints had increased staff levels from 14 full-time to 23 full-time. This had also improved the waiting time figures. A huge amount of effort had been put in from staff to reduce the waiting times even though the number of referrals had increased.
Members questioned how the referral times had been successfully reduced even though the number of referrals had increased. Officers commented that the centralised systems had assisted, as had an increase in staff numbers. The increase in the number of referrals may also have been as a result of GP’s feeling more confident about referring patients as the waiting time was reducing.
Members congratulated staff on the success of reducing waiting times on referrals. Members thanked Ms Dady for her presentation.
Councillor O’Connor left the meeting and Councillor Kemp was elected to chair the reminder of the meeting.
Children’s Speech and Language Therapies
Ms Freda O’Driscoll, Hillingdon PCT, presented the Committee with a report on Children’s Speech and Language Therapies. This service covered 0-16 year olds and those up to the age of 18 years if in full time education. The aim of the service was to provide assessment and service for speech therapy. The service covered Pre-School Early Years Team, Complex Special/Additional Needs (0-5 years old), Mainstream Schools Service and Hearing impairment. It also covered those without a statement, which previously was not the case. A ‘Statement’ was a statutory entitlement to receive support of a certain amount. Therefore the Local Authority (LA) had a statutory obligation to provide for the child. There was a great need for the service from those that did not have a statement, so this change was beneficial to all.
The service was delivered in partnership with schools so was joint-working. Children were seen within a school environment and there were also specialist hearing impairment centres. The PCT was working closely with LA colleagues to ensure integrated pathways and a working group had been set up. A number of recommendations had been made through partnership working.
A resource pack had been produced for pre-school early years. This gave tips and advice for parents. Timely and accessible information was key for parents. Posters had been put up in GP surgeries and a resource book was produced for professional use. This had a CD ROM attached. This publicity was running in parallel for school age children and the information packs were being distributed to all parents of children in a mainstream Hillingdon school.
2011 was the national year of communication and 7000 booklets had been for distribution during the period.
The service wished to promote communication development as a life skill to children from 0–16 years old and make Children’s Centres more user friendly. A Small Talk drop-in session across Hillingdon was being organised for parents to seek advice and get a brief screening for their children. Parents would receive an on the spot hand written report. This would be done for 12 months.
The service’s focus was on early identification and intervention. All children of reception age would be screened for receptive understanding of language on school entry. The intention was also to limit long term damage and this project would send the school a report on those children that failed on a moderate or severe level after the screening.
There were joint projects to target those areas that had historically low oracy levels. This project encouraged parents and children to communicate as much as possible. A digital camera would be given to them and they would take pictures and talk about the photographs of interest. The end result would include a t-shirt being made with a photograph on it. This project was to be rolled out in January/February 2011.
The service also targeted areas where they historically received high levels of referrals. These areas would receive more time for support and it was anticipated that this would improve the ongoing relationship which would develop over time to improve the longer term referrals.
Members commented that residents had spoken to them about their concerns regarding waiting lists for children that needed speech therapy. Ms O’Driscoll stated that this had been the situation 12-18 months ago but now waiting times had been cut to 6 weeks and under.
Members commented on schemes that Children’s Centre’s or Schools had which they could get involved with. For example, ‘Look who’s talking’ competition.
Members thanked Ms O’Driscoll for her presentation.
End of Life Care
Ms Maura St George, Hillingdon PCT, updated Members on end of life care. The team was made up of 8 whole time equivalent specialists. Their work was predominately with cancer patients. Over the last year, the good life model from cancer patients was used for all patients.
Approximately 2,000 people a year died in the Borough. 20% of these were unexpected deaths. A large proportion were an older age group, with a heath condition. It was noted that as a society we often did not start up an end of life conversation.
The approach undertaken by the service was not to alarm people when speaking about this, but to ask what they would do when they were less well and less able to do things for themselves.
40% of people that died in hospital had no condition that showed that they needed to be in hospital. Within Hillingdon the service was working with nurses to enable them to be a key worker for care. Their knowledge, skills and confidence were very important.
A patient’s preferred place to die could often be different to what their families/partners wanted. It was important to identify and assess all needs and it was also important to be open and flexible as people change their minds. Carers’ needs were also of huge importance. If the patient’s and carer’s needs differed, discussion was very important so that both parties could do what they felt was right.
The fundamental point was that everyone would die eventually and the need was there to consider the emotional consequences. Around 45% of those that registered to die in a care home were dying in hospital. A recent publication, ‘Dying for a change’ discussed how people wanted to die and looked at having these conversations before the crisis.
There were many tools to guide professionals in this field. It was very much about empowering colleagues.
Ms Sanders commented that, in Social Services, how they enabled people to die was important. That having these conversations with people with learning difficulties was not always achieved as well as it could be. It was suggested that sharing ideas and more joined up working would improve this.
Members commented on the flexibility required of the service and questioned whether there were times when a persons place of death was most suitable to a hospital even though their preferred place was somewhere different. Ms St George advised that pain management had become a lot better in the last 10 years so that it was not necessarily the case that people suffered more pain at the end. In the majority of cases pain management at home should be sufficient. People were more likely to die in hospitals when it was a crisis or there was no planned approach.
Members thanked Ms St George for her presentation.
Tuberculosis
Ms Hannah Kaur, Hillingdon PCT, updated the Committee on the Tuberculosis service (TB). She worked in a small team with one other colleague. They worked closely with a multi-agency team comprising other hospitals, Health Protection Agency, Public Health, Children Services, School nurse and Social Services.
The service provided included: a Find & Treat Team for those patients that went missing; a Homeless Team, work with Local Authorities and Drug; and Alcohol Support Networks.
They served the local population of Hillingdon and sometimes people outside the Borough. They also worked with the general public, Heathrow airport and Immigration removal centres.
Ms Kaur spoke about the follow-up of patients from hospital, screening, home visits and community TB clinic. Earlier this year a community centre/clinic opened in Hayes, giving patients more choice. Initially patients were seen at hospital for the necessary tests and risk assessments. There was stigma attached to home visits and disclosure of information.
The TB Pathway was discussed. Information on TB was recorded on the London TB Register. There was some issues with recording all information on treatment, this was due to treating those people in immigration. They were working on improving recording data.
They service worked towards NICE guidelines and Department of Health guidelines. It was noted that the TB rate had gone up 20% in London. Hillingdon had a high rate in comparison to the rest of London and nationally had the 11th highest rate for 2004-6. The NHS waslooking into developing a pan London service. Members asked for the figures to be sent to them on the recent rates in Hillingdon.
Members questioned what the situation was regarding BCG immunisation in Hillingdon. Ms Kaur commented that this was now done within the 1st year of birth in a clinic and not at school. It was more beneficial if done within a child’s first year rather than later on in life.
Members thanked Ms Kaur for her presentation.
Community Dental Service
Ms Claire Foster, Hillingdon PCT, updated the Committee on community dentistry services in the Borough. The service was predominantly for referrals, mainly from GP’s. This referral service provided an advice and treatment service, oral health promotion and liaison with other dental providers to develop care pathways. The advice and treatment service was based on 2 clinic sites, Uxbridge and Ickenham and they employed 22 people in total.
There were 3 main categories of service provision, which covered: paediatric dentistry; adults with special needs; and adults advanced restorative care specialties such as periodontics, prosthodontics and endodontics.
It was typically children of 3-7years old that needed treatment of teeth removed due to the extent of decay. They gave parents advice in order to treat preventatively. In order to help detect dental disease early and at a stage where it could be more easily treated the service carried out dental screening in special schools. Work was also undertaken with 12 Children Centres to promote healthy eating and good oral health.
Within Hillingdon there was nowhere for general anaesthetic removal so children were sent to Chelsea and Westminster Hospital for children and adults went to Central Middlesex Hospital.
It was noted that although adults with special needs could have dental needs that were quite straight forward their other needs that had to be considered were often more complex.
Members questioned why 50% of children that started school needed fillings. Ms Foster commented that it was mainly as a result of the diet the parents gave their children as well as not brushing their teeth at night. A poster and care pack would be sent to every school in Hillingdon which gave tips and advice on tooth care.
Members also questioned where people should go when they broke a tooth outside of the opening hours of dentists. Ms Foster stated that this was a big issue as there was a lack of provision for children who required emergency treatment.
Members spoke about tooth clubs and it was noted that there were informal drop-in sessions in Children’s Centres.
Ms Sanders asked what key messages should be taken away by Council officers. The importance of providing services in care homes and to those with special needs was noted. Ms Foster spoke about the lack of continuity of dental care for people with care homes. They could suffer remarkable decay, in particular those with dementia. It was an area of personal care that carers were a bit reluctant to address. This linked in with end of life care.
Members thanked Ms Foster for her presentation.
RESOLVED: That
1) the presentations be noted;
2) the External Services Scrutiny Committee be provided with a further update on vertical integration in 2011.
Supporting documents:
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