BOROUGH OF POOLE

HEALTH SCRUTINY COMMITTEE

26 FEBRUARY 2008

The Meeting commenced at 7.05pm and concluded at 9.35pm.

Present:

CouncillorsBrooke (substitute for Cllr Curtis), Bulteel (substitute for Cllr Montrose), Mrs Deas, Mrs Evans, Gillard, Mrs Lavender, Maiden, Matthews (substitute for Cllr Meachin), Mrs Walton and Wilson.

Non-Voting and Patient Public Involvement (PPI Forum Members):

Roger Wilson(Poole Hospital PPI Forum)

Judy Birch(Bournemouth and Poole PCT PPI Forum)

In attendance

Cecily Cook:Regional Director of Nursing (NHS Direct South West)

Shaun McGrane:Regional Head of Operations (NHS Direct South West)

Norma Lane:Director of Urgent and Clinical Care (South Western Ambulance Service NHS Trust)

Dhanus Ramdharry:Non-Elective Commissioning Manager (Bournemouth and Poole Primary Care Trust)

Anne Swan:Director of Clinical Services (Bournemouth and Poole Primary Care Trust)

James Barton: Director, Poole Mental Health & Social Care (Dorset Healthcare NHS Foundation Trust)

Dr Adrian Dawson:Director of Public Health (Bournemouth and Poole Primary Care Trust)

Nicola Plumb:Head of Communications (Bournemouth and Poole Primary Care Trust)

Angela Schofield:Chairman (Bournemouth and Poole Primary Care Trust)

Jan Thurgood:Strategic Director (Adult Social Services), Borough of Poole

Liz Strothard:Democratic Support Officer, Legal & Democratic Services

Members of the public present: Approximately 5

HS43.08ELECTION OF CHAIRMAN

RESOLVED that Cllr Mrs Deas be elected Chairman of the Health Scrutiny Committee for the remainder of the Municipal Year.

HS44.08ELECTION OF VICE-CHAIRMAN

RESOLVED that Cllr Mrs Walton be elected Vice-Chairman of the Health Scrutiny Committee for the remainder of the Municipal Year.

HS45.08APOLOGIES FOR ABSENCE

Apologies for absence were received from Cllrs Curtis (substituted by Cllr Brooke), Meachin (substituted by Cllr Matthews) and Montrose (substituted by Cllr Bulteel).

HS46.08DECLARATIONS OF INTEREST

Cllr Bulteel declared a personal interest in Agenda Item 7 ‘Medicines Management’ as an employee of the Leonard Cheshire Foundation.

HS47.08MINUTES

RESOLVED that the Minutes of the Meeting held on 8 January 2008 be confirmed as a true record and signed by the Chairman.

HS48.08NHS DIRECT CONSULTATION ON APPLICATION TO BECOME AN NHS FOUNDATION TRUST

On behalf of the Committee, the Chairman welcomed Cecily Cook, Regional Director of Nursing (NHS Direct South West) and Shaun McGrane, Regional Head of Operations (NHS Direct South West) who gave a presentation on proposals by NHS Direct to apply for Foundation Trust status.

The presentation was preceded by a brief overview of the services provided by NHS Direct, which included:

  • The NHS Direct telephone service, handling approximately 8 million calls per annum;
  • A website receiving approximately 21 million visits per annum;
  • Interactive Digital TV services, available to around 17.2 million households able to receive either Sky Digital or Freeview (68% of all homes).

Via this media, NHS Direct was able to offer the public a variety of services including:

  • Advice on healthcare matters;
  • Information on local health services;
  • Advice on maintaining a healthy lifestyle;
  • Comprehensive information on specific conditions and illnesses;
  • Advice on medication;
  • Information on local out of hours and dental services;
  • Hospital appointment bookings (‘Choose and Book’);
  • Support for patients with long term conditions;
  • Care and support for patients before and after operations;
  • Co-ordinated advice and information around local and national health scares; and
  • Telephone-based hearing assessments (‘Hearing Direct’).

The triage system for assessing a patient’s needs, which made use of decision-support software, was explained to Members.

It was reported that NHS Direct employed 300 staff throughout the South West region based at six regional call centres in Bristol, Exeter, Ferndown, Plymouth, Taunton and Truro.

In response to Members’ questions the following issues were explored:

  • Health advisors who handled calls to the service were not qualified nurses; however each advisor undertook a comprehensive 4 week training programme before commencing duties and were expected to participate in regular ongoing training thereafter;
  • In response to concerns raised over how an accurate diagnosis could be effected simply by a caller relaying a series of symptoms over the telephone, it was explained that an individual’s answers were used to determine priorities for their care. Each diagnosis was based on an assessment of the symptoms with which the patient was presenting.
  • Cllr Mrs Lavender expressed grave concerns that health advisors were giving advice to patients based on only a few weeks training – roughly equivalent to the training a First Aider would receive. In response the Regional Director of Nursing explained that Health Advisors undertook a very comprehensive training programme and received a great deal of support from the Clinical Team Leader who was on duty at all times. Health Advisors were trained to use decision-support software and, where appropriate, a full assessment of a patient would be undertaken by a fully qualified Nurse Advisor. NHS Direct undertook frequent call reviews of staff and Advisors were constantly building on their experience and skills.
  • NHS Direct South West was working to ensure its services were tailored more closely to the region it served and would raise the issue for discussion at a national level;
  • Members explored the mechanisms by which NHS Direct monitored the quality of its advice line. This was currently assessed via a monthly voluntary patient satisfaction survey conducted over the telephone. Patient satisfaction currently stood at 95%.
  • the service had technical links with regional GP Out of Hours Services, which would contact the patient if this was the recommendation of NHS Direct Health Advisors;
  • The Bournemouth and Poole PCT PPI Forum Representative explained how, as a member of a specialist Panel, she had helped conduct trials into NHS Direct’s Interactive Digital TV Services and reported that at present the capacity of Freeview in the region was very limited. Work was underway to improve and expand this service.

Shaun McGrane, Regional Head of Operations (NHS Direct South West) gave a presentation on NHS Direct’s application for Foundation Trust status and its priorities for the next 5 years, which included improving core services, developing new services with and for other NHS organisations to meet current and future health challenges and being a better partner for other NHS organisations, which included working more closely with local services.

It was explained that in applying for foundation trust status, it was hoped that NHS Direct would be in a position to develop a more ‘localised’ focus through its accountability to members and governors as part of the overall Governance structure. Foundation Trust status would also give the service greater freedom to develop new services and more control over its finances.

Proposed membership arrangements were outlined as follows:

  • A membership body made up of public (over the age of 16 years) and staff;
  • A Council of Governors elected from the membership
  • A Board of Directors constituted of a Chair and seven non-executive directors appointed from outside the Trust, the Chief Executive and four executive directors.

Members considered a number of issues as follows:

  • Cllr Brooke explored how the greater autonomy proffered by foundation trust status would lead to the service becoming more accountable to local people, pointing out that there was a danger of the service becoming a ‘two-tier system’ if a significant number of the public did not wish to become members of the new trust. It was queried whether the proposed governance arrangements would be sufficiently representative of the South West region, given that the 29 Governors would be drawn nationally rather than regionally?

In response it was explained that the greater autonomy conferred by foundation trust status would allow the service to increase its investment in local services, as at present the service was driven nationally. It was felt that a move to foundation trust status would provide the public with a more structured means by which they could contribute to the way NHS Direct operated.

Whilst it was felt that proposals to draw Governors nationally were workable, the purpose of the consultation was to explore the views of stakeholders in order to determine whether this was the most appropriate approach. To this end, Cllr Brooke was invited to submit further questions to NHS Direct for a considered response. Cllr Brooke was invited to email questions to the Chairman and Democratic Support Officer (Scrutiny) who would forward them to the relevant Officers.

  • It was clarified that NHS Direct was not a private company but an NHS organisation, responsible to the Department of Health, whose vision was to be the first point of contact for people seeking advice on health care matters.
  • In response to a query from Cllr Mrs Walton, the Regional Head of Operations quantified the potential for financial risk posed by foundation trust status and explained that the service was currently undergoing a number of accreditation processes which would determine whether its financial processes were sufficiently robust.
  • In response to concerns expressed by Cllr Bulteel that the South West region may find itself with no representation on the Board, it was stated that NHS Direct were seeking representatives from each region of the UK.

The Chairman thanked the Regional Director of Nursing and Regional Director of Operations for their interesting and informative presentations and suggested that the eight consultation questions, as set out in the NHS Direct consultation document, be emailed to Members for further comment. It was suggested that Members email their responses, including their views on strengthening Governance arrangements at a local level, to the Democratic Support Officer (Scrutiny) who would compile responses on their behalf. Following the approval of the Committee a final response would be submitted to NHS Direct by the consultation deadline of 31 March 2008.

RECOMMENDED that

(i)the public consultation into proposals by NHS Direct to apply for Foundation Trust status be noted; and

(ii)that the Democratic Support Officer email the eight consultation questions to all members of the Health Scrutiny Committee for further comment. Responses to be compiled by the Democratic Support Officer (Scrutiny) for approval by the Committee, with a formal response submitted to NHS Direct South West by the consultation deadline of 31 March 2008.

HS49.08OUT OF HOURS SERVICES

The Chairman welcomed Dhanus Ramdharry, Non-Elective Commissioning Manager (Bournemouth and Poole Teaching Primary Care Trust) and Norma Lane, Director of Urgent and Clinical Care (South Western Ambulance Service NHS Trust) who gave an update on Out of Hours Services in Poole.

The Director of Urgent and Clinical Care (South Western Ambulance Service NHS Trust) outlined the future strategic direction of Ambulance services (both emergency and urgent care) and updated members on local service, local activity and local performance.

Services provided by South Western Ambulance Service NHS Trust in Poole included:

  • Emergency Ambulance 999 Services
  • Non-Emergency Ambulance Services
  • Specialist Falls Service
  • Urgent Care Services (including Urgent Care Centres; Pharmacy Services; provision of a Single Point of Access for residents and Out of Hours Primary Care Services for Dorset, Somerset, Prisons, Army, Navy and Dental services).

Key drivers for the service were outlined as follows:

  • The political context, as set out in the Department of Health publications: ‘Commissioning a Patient-led NHS’; ‘Taking Healthcare to the Patients’ and ‘Our Health, Our Care, Our Say’;
  • The need to simplify and improve the ambulance and Out of Hours service for all patients;
  • Ensuring that services were brought to the patient for immediate treatment;
  • Reducing unnecessary hospital admissions;
  • Treating people closer to their homes; and
  • Localising services.

Performance was measured against:

  • National quality standards
  • Abandonment rate
  • Triage (within either 20 or 60 minutes, as appropriate)
  • ‘Face to face’ treatment (either at local treatment centre or home visits)
  • Onward transmission of clinical record to patient’s own GP;
  • Clinical audit; and
  • Quality monitoring meetings.

Out of Hours Services in Poole were based at the Poole Local Treatment Centre in Poole Hospital (Red Clinic) and was Nurse Practitioner Led, with support from GPs. In January 2008, the centre treated 1,038 patients in the treatment centre, facilitated 182 GP visits to patients in their own homes and gave 369 patients advice over the phone. The Bournemouth Treatment Centre, a GP and Emergency Care Practitioner Led Service based at The Royal Bournemouth Hospital, was an advanced out of hours service which had recorded the highest levels of activity across Dorset and Somerset in January 2008.

Members received information on telephony performance for December 2007 across Dorset and Somerset as well as patient satisfaction data, which indicated that patients predominantly rated the service as either ‘Excellent’ or ‘Good’. An overview of performance for February 2008 was given, together with information on local Ambulance resources which were tailored based on clinical need at times of high and low demand. Ambulance response times to Category A calls (‘Immediately life threatening’) were well within national guidelines; response times for Category B calls (‘Serious’) were ‘very good’.

An invitation to visit the Urgent Care Service at St Leonards Divisional HQ was extended to Members. The Democratic Support Officer (Scrutiny) was requested to liaise with the Director of Urgent and Clinical Care in order to make the appropriate arrangements.

Dhanus Ramdharry, speaking for the Bournemouth and Poole Teaching Primary Care Trust, reported that Commissioners considered Poole’s Out of Hours Service to be a ‘good service’, which met the majority of its performance targets towards national standards. Some additional work needed to be done to ensure the service fully achieved its targets in the following areas:

(i)Clinical assessment targets (ie. Assessments for urgent calls started within 20 minutes; assessments for other calls started within 60 minutes);

(ii)time taken for initial call to be answered by a person (ie. within 60 seconds after the initial introductory message of 30 seconds). Target 100%; actual performance 91.3%;

(iii)face-to-face consultations started within one hour for ‘Emergencies’ (target 95% - actual performance 76% base calls / 75% visit calls) and 2 hours for ‘Urgent’ cases (target 95% - actual performance 91% base calls / 79% visit calls); and

(iv)ensuring details of all Out of Hours consultations were sent to the patient’s registered practice by 08.00hrs the following working day (target 100% - actual performance 94.2%).

Whilst negotiations for service development of Out of Hours Services were underway nationally, at a local level the PCT was negotiating extended opening hours via a Local Enhanced Service, 100% take up by GP practices, options for Saturday morning surgeries, practices working in localities, service provision for both registered and unregistered patients and additional services including repeat prescriptions and treatment for minor injuries and ailments.

In summary, the local Out of Hours service was felt to be ‘a good service’.

The Chairman thanked the Non-Elective Commissioning Manager (Bournemouth and Poole Teaching Primary Care Trust) and the Director of Urgent and Clinical Care (South Western Ambulance Service NHS Trust) for their interesting and informative presentation.

Members explored a number of issues as follows:

  • As an employee of a domiciliary care organisation, Cllr Bulteel explained that he had had cause to use Poole’s Out of Hours services on several occasions and had found the service to be ‘excellent’. However, he queried whether care organisations using the service to deal with falls by service users were a drain on resources? In response it was explained that the Ambulance Trust operated a specialist falls service to respond to such incidents. The PCT was working closely with the service in order to ensure this was part of a ‘one-call’ service;
  • Cllr Maiden explored how members of the public communicated with ambulance / out of hours services and whether there was a link via NHS Direct? In response, it was explained that in the first instance a member of the public was likely to contact their GP surgery where an answerphone message would relay contact details for the Out of Hours Service. There was also an immediate technical link to local Out of Hours Services via the NHS Direct triage system.
  • The PCT was responsible for publicising local out of hours services and data analysis indicated that, on average, a member of the public would have cause to contact the out of hours service only once in every seven year cycle;
  • Cllr Maiden complimented the Out of Hours Services on meeting the majority of its targets;
  • Cllr Gillard commended the efficient ‘joined up’ services provided by the PCT and Ambulance Trust.
  • Cllr Gillard explored whether there was a system that would reduce the need for patients to have to repeat the same information to different clinicians when receiving out of hours care? In response, it was explained that whilst this could be frustrating for patients, it was important to recognise that this was done with the safety of the patient at the forefront. Clinicians were accountable for their own clinical decisions and as such, would want to establish for themselves, the primacy of information.
  • the majority of GPs supporting the Out of Hours Services were local with very few drawn from outside the area. GP Registrars also supported the service as part of their training.
  • The PCT PPI Forum Representative suggested that in some cases emergency care could be avoided by GPs taking a more active involvement in their patients’ care and asked that this be fed back to the Trust;
  • Cllr Brooke congratulated Officers on the high standard of local Out of Hours Services which were clearly becoming effectively embedded within the system. Despite Members concerns about the service in 2006, it was clear that good progress had been made to date;
  • Cllr Brooke explored the role of NHS Direct in out of hours services, querying whether there was duplication of services? In response it was explained that there was a huge demand for health information and assessment from the general public and that NHS Direct was just one of many ‘portals in’ to services. Aspects of NHS Direct services could support local Ambulance services, for example utilising NHS Direct’s Gold Standard Nurse triage system to improve triage times. Local Out of Hours Services were based on a belief in an integrated model of work and admission avoidance and although there was an element of duplication between the services, NHS Direct was looking into ways of adapting its services to suit local need more closely. Officers were currently considering the structure of services in order to facilitate even better communication between the services;
  • Members explored how NHS Direct’s application for foundation trust status would benefit and advance the work of local trusts or whether in fact the application could lead to the service heading further towards national governance. Officers explained that the move to foundation trust status would lead to greater autonomy and allow NHS Direct the freedom to integrate locally. It was unlikely to make a difference to services as the Trusts were already working closely with each other;
  • The Poole Hospital PPI Forum Representative explored whether it was appropriate for out of hours services to offer repeat prescriptions? In response it was stated that Officers worked closely with GPs and pharmacies in order to explore ways of managing this demand, however any patient applying to the service for a repeat prescription would be assessed on an individual basis in order to determine their priority. A p/t Pharmacist was employed to assist with medicines management.
  • In response to a query from Cllr Maiden it was clarified that the out of hours service did not have access to a patient’s medical history. Clinicians were required to conduct a ‘cold’ clinical assessment of each patient.

RECOMMENDED that