Agenda and minutes

Apologies for absence were received from Councillors Reg Adams and Ellie Harmer.  Apologies were also received from Dr. Angela Bhan and

Dr. Nada Lemic and Meredith Collins and Agnes Marossy attended as their respective alternates.

The minutes of the meeting held on the 26^th September 2013 were considered and he following amendments were agreed:

Page 2, 2^nd paragraph, first line, change definitely to possibly.

Page 3, 2^nd paragraph, delete the last line.

Page 4, the last four paragraphs refer to the previous minute on integrated care.

RESOLVED that the minutes of the meeting held on 26^th September 2013 be agreed subject to the amendments above. 

The Chairman outlined some of the activities that had taken place since the last meeting;

He thanked Dr. Parson for arranging for him to attend a CCG meeting which he found very interesting, he also attended a meeting on progress with the ProMISE programme and a VSSN event arranged by Community Links Bromley.

He noted developments with Kings.

He also extended his thanks to Peter Gluckman who had arranged and facilitated groups involving Officers and Members of the board. 

The Chairman then explained that he was aware that there some administration issues which needed to be resolved to ensure that reports are not late or were tabled as this did not give the Board sufficient time to consider reports before the meeting.  He will be working with Officers to ensure this did not happen again.

A total of 8 written questions were received.  The questions and responses are appended to these minutes at Appendix A.

At its meeting in July the Director had presented a report on Winterbourne View and the Board requested that an update report should be presented to every second meeting.

Members were reminded that Winterbourne View was an Acute Treatment Unit (ATU) for Adults with Learning Difficulties in South Gloucestershire that had been the subject of a serious case review.

The Director reported that Bromley had seven residents accommodated within hospital settings, admitted under Section 3 of the Mental Health Act.  Admissions under this section of the Mental Health Act provided a statutory framework for review with a minimum frequency of 12 months and gave each patient a named manager, local clinician and ensured patients received an Annual Care Management Review in addition to the Care Programme Approach Review.

Bromley had commissioned a joint group of CCG and LBB commissioners with the Community Learning Disability Team (CLDT) Joint Team Manager looking at the requirements of the Winterbourne View programme and to ensuring targets were delivered. It also works to ensure adequate planning for ATU users who wish to return home following discharge or who wish to settle in the locality of where they have been admitted. In addition advocacy services local to the person in the STU are engaged to ensure that patient views are heard.

The opening of a private ATU at the London Autistic Centre by Glencare provided in safeguarding alerts resulting in close scrutiny by LBB, the CCG, NHS London and NHS England.  Neither LBB nor Bromley CCG had any patients placed within the service, nor had any placements ever been made there.  The primary provision for local patients was Atlas House run by Oxleas Foundation Trust.

The Chairman commented on the numbers of acronyms used in the report and suggested that a glossary of terms be produced.  Members of the Board asked that the first acronym in reports is written in full but that the acronym can be used thereafter.  The Director agreed to take responsibility for producing the glossary.

Councillor Jefferys sought clarification in reference to 4.10, the opening of a private ATU at the London Autistic Centre by Glencare stating Bromley had closer scrutiny of the safeguarding alerts.  The Director explained this was scrutiny in a wider sense and not a specific role of Bromley. However as the local authority in which the facility is located, Bromley had a responsibility for ensuring safeguarding was effective. The management of the unit was accountable to the chair of the local adult safeguarding board for the safe operation of the facility.

In defining the client group the Director explained that it referred to both adults and children.  However clients with severe challenging behaviour amounted to less than 1% of those on the autistic spectrum. He added that, had there been a proactive approach, all the patients at Winterbourne could have been identified and treated before they reached adulthood;

RESOLVED that the report is noted and a further updated will be presented to the Board at its meeting  ...  view the full minutes text for item 33.

Angela Bhan had been due to produce a report on A&E performance at the Princess Royal University Hospital (PRUH).

Her alternate Meredith Collins provided a verbal update. He explained that Dr Bhan was currently at the PRUH with partners from Kings and NHS England to start to progress a planning process to monitor A&E performance. 

The Director added that he and Dr Bhan had agreed the performance data for the PRUH identified it as not having made significant improvement.

The progress on this work would be reported to the next meeting of the HWB and he would request that hospital representatives attend to speak to the Board about Urgent Care. 

As the next meeting was on the same day as the Health Scrutiny Sub-committee officers would look at combining the two meetings to enable both groups to meet the representatives from the PRUH.

At its meeting on the 26^th September 2013 the Health and Wellbeing Board (HWB) agreed it would receive regular updates on the progress in completing the annual Joint Strategic Needs Assessment (JSNA) to increase its knowledge which would assist in informing the HWB priorities.

The report outlined the process for undertaking the 2013/14 JSNA, the suggested areas that would be covered and the key milestone dates and actions.

Dr Marossy explained that a Steering Groups had considered the JSNA and identified 3 additional areas for the new JSNA; Ward Health Profiles, Frequent Attenders to Unscheduled Care Services and Asset Based Community Development. Following this a working Group had indentified leads for the specific sections and the information was published on the “My Life” website.

The timetable for the production of the plan was that Key Milestone data would be collected, collated and drafted by April 2014.  A draft could be circulated between May and July 2014 and the plan would be finalised in September; allowing the Board to prioritise the needs for the following year.

The chairman highlighted the importance of the information being available to the public and Dr Marossy explained the JSNA was already on the “My Life” website however the tables and data were not published as they were constantly changing and would be difficult to keep updated on the web.

Officers then explained that the strategy covered the period from 2012 – 2015.  However a “desktop” strategy would be undertaken to look at any minor changes.  Planning for the new strategy would begin once the JSNA had been agreed.

The Chairman re-iterated that Member involvement was crucial and encouraged Members of the Board to become involved in the working Groups.

When referring to the detail in the Ward Health Profiles the Board was informed that for some indicators, for example life expectancy, the data would be very detailed but for others, such as air quality may be less so. 

Members highlighted the areas could vary considerably between wards and that the dichotomy between polling districts and the ward boundaries meant that some of the detail could be lost. Dr Marossy agreed this was an area that needed further consideration as there were a number of discrepancies.

The Board representative for the voluntary sector reported on a “robust” discussion that had taken place and, in summary, requested an easy to read copy of the executive summary.  Dr Marossy would progress the request. 

Councillor Evans sought clarification on the reference to Asset Based Community Development, a framework for using assets.  In response Dr Marossy explained this was a complex area of the JSNA.  In the past certain areas had been designated as deprived and in need and therefore received funding.  This was no longer the case and officers would be looking at projects and schemes that were currently running in the community and offering support with smaller amounts of funding.

RESOLVED that the report is noted.

Richard Hills, Education, Care and Health Services, London Borough of Bromley, made a presentation to the Board. The slides for this presentation can be viewed under the following link: 

http://cds.bromley.gov.uk/ieListDocuments.aspx?CId=617&MId=4636&Ver=4

He explained The Spending Round 2013 announced a pooled budget of £3.8 billion for local health and care systems in 2015/16.  Referred to as the “Integration Transformation Fund” (ITF).

The fund was designed to support an increase in the scale and pace of integration and also be a mechanism for promoting joint planning for the sustainability of local health and care economies against a background of significant savings targets right across the system.

Although announced as if this would be new money into the health and care system the fund was mainly created through top slicing existing budgets. Top slicing Clinical Commissioning Group (CCG) budgets made up over 65% of the fund, the rest was from top slicing the Local Authority budget and adding the existing Department of Health (DoH) Social Care Grant which was now subsumed into ITF.

The fund could not be accessed individually it had to a joint application from the LA and CCG through their relevant Executives, it would then go to the HWB and finally to NHS England.  Additionally access to the fund would be dependant on agreement of a 2 year plan for 2014/15 and 2015/16.The plan needed to be submitted to NHS England by February 2014. There were measures that still needed to be determined; Delayed transfers of care, Emergency admissions, Effectiveness of reablement, Admissions to residential & nursing care and Patient & service user experience and £4m of the fund would be performance related, but this should not be problematic as Bromley’s integration was already ahead when compared to other authorities. 

The new fund would be simpler to budget and account for and any under spend could be easily identified.  In addition the Board would have a clear oversight of the fund.

Members of the board raised concerns about sharing data using National Insurance Numbers.  It was explained that the Government had not been prescriptive about how data was collected.  Paul White, ProMISE Programme Director would be looking at how best to streamline this process,

In terms of accessing the system it was likely that when users logged on to look at a resident’s record through the “Carefirst” Portal they would be advised that there was also a record on that resident under the RIO Portal and users would need to access both systems.

In response to a question about the involvement o the London Ambulance Service (LAS), pharmacies the Director explained that the Pharmaceutical needs assessment formed part of the integrated services.  However it was not intended, at this point, to include the LAS.

In relation to targets the Director explained that one of these was Accident and Emergency admissions and this would need the involvement of the PRUH as there was a collective responsibility to improve the targets.  There was a strong incentive for the Board to ensure the  ...  view the full minutes text for item 36.

A report on a Board Member Development and Engagement Programme was due to be included on this agenda.  However, it would now be considered at the January meeting of the Board in order for officers to develop a work programme with partners in the CCG.

Members were provided with an update on the Proactive Management of Integrated Services for the Elderly (ProMISE) Programme by Paul White, Associate Director of Development & ProMISE Programme Director from the CCG.

He explained the rationale behind the ProMISE programme was to create a pro-active system, a transition from a reactive approach. This would mean Case Management would be at the heart of the programme and patients who appeared to be struggling would be offered a detailed home based assessment allowing early intervention to reduce the need for secondary care.  The programme would be running a pilot scheme in December 2014. Such intervention may help to reduce the numbers of falls and fractures which contributed to a number of unplanned hospital admissions.

For diabetes, an upskilling of primary care staff, nurses and GPs, was required, with the intention that each diabetes patient would have a care plan.

End of life services would enable patients to die in a preferred place with support offered to those patients who wished to die at home.  In addition “Falls” clinics would be established.

The Board was informed that a new programme, FLO, was being introduced, at present 30 GP practices had enrolled.  The aim was allow cost and very simple Healthcare system provided via the patients own mobile phone or landline.  Primarily an automated SMS (text) messaging based system used by clinicians to send reminders, health tips and advice to patients; and collect, monitor and track patient’s health readings taken by the patients using self monitoring equipment such as blood pressure machines.  Patients can text back their readings to FLO and messages are free even if the patient has no credit on their phone.

Another development, Patient Liaison Officers, provided an enhanced service for signposting, identifying carers and non-clinical co-ordinating.

For UTI (Urinary Tract Infections) simple training would be offered to spot the signs of UTI.  Already 5 patients had been identified early avoiding hospital admission. The training costs were minimal, only requiring 3 hours of a matron’s time and a web based programme may also be considered.

The Chairman was impressed with the on going work and pleased to see a move towards a more pro-active approach and community based initiatives. Although this did make savings that could be used elsewhere it provided cost avoidance in reducing the dependence on secondary care. Councillor Evans sought greater clarification and Mr White explained that the aim was to reduce demand so that capacity could be reduced which would lead to a reduction in expenditure.

The Board recognised the importance of communicating the programme to residents.  It was noted that a communication working group was working on raising the profile of the programme.  A report from Bromley’s communication team would be submitted to a future meeting.

Members questioned whether any legacy work was being considered for 2016 onwards.  In response Mr White explained that the programme was about enabling and establishing a pro-active approach to reduce the dependence on secondary care and freeing up money to invest  ...  view the full minutes text for item 38.

The Public Health Report “Top Body, Top Mind” aimed at Men’s Health was due to launched on 9^th December.  Members had received invitations to the launch.

The report would then be circulated to Members of the Board via an information briefing.

A work programme showing forthcoming items generated from matters arising at this meeting would be produced by Officers and included in future agendas.

The dates for the next meetings are:

?  30^th January 2014

?  20^th March 2014

?  22^nd May 2014*

Officers would circulate a timetable showing the dates for report submission and agenda publication.

* As this meeting clashed with the Local and European Elections it has now been removed from the programme.  An alternative date will be considered at the next meeting.  

Appendix A

Written questions for the Heath and Wellbeing Board meeting on 28^th November 2014

Three questions from Mrs Tricia Choppin for Written Responses:

During the Public Questions section of the Clinical Commissioners meeting last week I asked a question and I also submitted a series of further questions all regarding the same subject matter and all have yet to be answered, however, I will receive a written response in due course.  The subject matter was the decision by Bromley CCG and Kings to open a Clinical Decisions Unit in A&E at the PRUH and, after a maximum stay of 48 hours, discharge some (although the Dir of Soc Services did write ‘many’ in his comments to the Care Services ODS) elderly patients from A&E to care/residential homes. I have attached a copy of my questions to the CCG for information.  The attachment marked extra question is the question I asked at the meeting itself.

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1. A&E/CDU admission is a maximum of 48 hours.  What framework is in place ensuring that elderly patients discharged from A&E to care/residential homes have the time before discharge for their relatives/friends etc to locate the best home, arrange a suitability visit and then arrange for the patient to visit?

2. What are the criteria regarding patients for whom an appropriate nursing/residential home bed has not been found within the 48 hour period?

3. Specifically regarding elderly patients discharged from A&E after 48 hours: will the local authority assume financial responsibility for all placements pending completion of financial assessments or securing of alternative placements if requested by the patient and/or relatives?

Response from Bromley CCG:

The answer to Qs 1 and 2 is amalgamated.

The intention of a Clinical Decision Unit is to allow for short term assessment of patients, which allows for the most appropriate onward referral to an acute ward, intermediate care, or discharge to a care setting, or to home. It will manage adult patients of all ages. It is not intended to change the appropriateness of referral to a care/residential home, or the assessment and selection process for accessing this option. We expect that all patients, whatever their age and condition, are treated with dignity and due care, whether their inpatient stay is on a ward or the CDU or both.

Q3 relates to the financial responsibilities of LBB, and should be properly answered by them.

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Two questions from Mr Stuart Choppin:

1. How will the number of elderly patients discharged from A&E to a care/residential home be recorded and where will these numbers be published?

2. On 22^nd November, BBC News reported that Croydon Trust has been told by the CQC (following an inspection) to reduce the number of night-time discharges of elderly patients.  What steps are Bromley taking to  ...  view the full minutes text for item 43.