Agenda item

Context:

 

Representatives of the Aneurin Bevan University Health Board (ABUHB) were welcomed to the meeting and introductions were made. 

 

Key Issues:

 

ABUHB representatives presented a briefing report as part of its ongoing engagement with Monmouthshire County Council.  The report included:

 

·         Key developments since December 2015 (when ABUHB last met with the Authority).

·         An outline of current performance across a range of services, Welsh

            Government targets and current improvements plans.

·         Updates on other areas of the Health Board’s activities including

            Its ongoing engagement with local communities and a series of service

            developments (many of which are being taken forward in partnership)

 

Members Scrutiny:

 

A Member welcomed the clearly presented report.

 

·         Mortality Rate: The definition of “crude mortality rate” was queried.  It was explained that the term refers to the actual number of deaths occurring among the population of a given geographical area during a given year.  It was further explained that health services from across the UK prepare risk adjusted mortality rates to consider various conditions and make adjustments for relative risks.  This figure is well below the rest of Wales and is comparable with the best health authorities in England. It was added that it is a priority to learn from every death that occurs in the system.

 

·         GP Revalidation: It was recalled that there had been a suggestion to review GPs periodically, and queried if this had occurred.  In response, it was advised that this has been an outstanding change.  A 5 year cycle of revalidation was set up by the General Medical Council linked to annual appraisal.  This has been a very successful exercise and reassurance was provided that every doctor has successfully completed revalidation, and the appraisal process.  The process had provided useful information for ongoing learning and development, and also provided the opportunity to hold doctors to account professionally as necessary.

 

·         Diabetes/Obesity: A Member questioned why there was no mention of obesity or diabetes in the report, and if there was a need to do undertake more education about diet in schools to encourage young people to be healthier and reduce the cost of medication in future. It was explained that, whilst not specifically in the report, there is a separate plan for diabetes included in the Chronic Conditions Management Plan (which also includes separate plans for e.g. Heart Disease, Respiratory Disease and Cancer (further information available on the website http://www.wales.nhs.uk/sitesplus/866/home ).  It was added that the ABUHB Weight Management Team is at the forefront of weight management in the UK noting that the next stage is to develop a childhood obesity strategy to improve outcomes for future generations.  It was acknowledged that diabetes and other chronic conditions also come under the scrutiny of Children and Young People Select Committee and also the Public Service Board Select Committee.

 

A Member, referring to a recent Joint Adults Select Committee and Children and Young People Select Committee meeting, recalled that statistics were presented that nearly 50% of young children are overweight or obese in Monmouthshire and encouraged early education strategies in this respect. 

 

·         Specialist and Critical Care Centre: It was queried if any problems were envisaged in staffing the new centre without withdrawing resources from other facilities in the locality.  Details of the transitional arrangements were also requested as parts of the new facility become open before being open completely.

 

It was explained that the new hospital at Llanfrechfa is essential as it is impossible to sustain services at Nevill Hall Hospital and Royal Gwent Hospital indefinitely.  It was confirmed that staff will be moving from both hospitals to the new hospital with their services e.g. critical care and consultant led obstetrics and this will help with future workforce issues.  It was further explained that part of the transition plans is to consider how to maintain services between now and the new hospital opening. 

 

A commitment was provided to return to report transitional plans, and any other necessary changes for the interim period to address the services currently under significant pressure.

 

The Committee was advised that recruitment and retention of nursing staff is being addressed e.g. increasing numbers going through nurse training (3 years duration).  Training places will also be made available for medical specialities e.g. more radiologists

 

·         Sepsis: A member noted a recent report that more people in Wales die of sepsis than any other factor and queried if there was any link with lack of diagnostic resources. It was advised that the trend is improving in terms of outcomes.  It was added that it is important to design teams that work across systems to combat issues such as sepsis.  Whilst it is important to pick up symptoms early, diagnostic tests have minimal impact. It was explained that   work focussing on sepsis has been undertaken for 18 months which has included a visit to a pioneering hospital in the USA that concentrates on a team approach to overcome sepsis.  Consequently, collaborate work across the NHS in Wales is in progress which has established a trigger tool for teams to pick up physiological markers and the use of one, easily accessible laboratory test.  This has been successful with the trigger tool being used for 100% of patients visiting Accident and Emergency (A & E) Departments in Nevill Hall Hospital and 80% visiting A & E in the Royal Gwent Hospital.  So far there has been significant, positive impact on mortality rates and it was commented that ABUHB is at the forefront of the campaign. Members expressed reassurance and the ABUHB Team responsible were congratulated upon this achievement, and also the inroads into Stroke services. 

 

·         Dental Caries: A Member raised the prominence of dental caries as a concern and in response it was confirmed that there is an oral health plan which covers all aspects of oral health including public health advice, mobile dental health services and access to NHS dentistry.

 

·         Primary Care Resource Centres: It was queried if there were any plans for improved access to primary care citing the example of resource centres that co-locate services on one site.  It was confirmed that there are two resource centres in the region in Rhymney and Blaenavon.  It was explained that other similar centres are planned and that primary care strategy is under review.  It was explained that whilst there are no current plans for a centre in the Monmouth area, the “Care Closer to Home” strategy will highlight other areas for development of such services.

 

·         Engagement with the Community: A Committee Member expressed appreciation for a presentation received by the Abergavenny Action 50 Plus Group regarding services for stroke patients.  The Group had many questions which were answered well by the presenter and provided reassurance.  It was added that a further presentation on end of life care was also excellent.   It was queried if enough is being done to promote the availability of such presentations to groups and communities.

 

In response, it was confirmed that teams are keen to engage with groups, but will also engage at public venues (e.g. outside Shire Hall) to reach people who are not part of a group. Members were informed that there are events planned in many locations.

 

A Member stated that in rural communities, there is often no collective area to meet to receive presentations from ABUHB representatives, and explained that farmers are notorious for not seeking help.  It was suggested that the new cattle market would be an appropriate venue to locate literature.  It was responded that this suggestion would be followed up and that no community is too small. 

 

·         Complaints: It was commented that a good indicator of satisfaction is how an organisation deals with complaints, and queried if a summary of information on complaints could have been included in the report.  It was agreed that information on complaints would be included in the next report.

 

·         A & E Department at Nevill Hall Hospital: A Member sought reassurance regarding the future of the A & E Department at Nevill Hall Hospital.  In response, it was reported that it is accepted that there is a need for improved space for A & E facilities at Nevill Hall Hospital and the case for capital development is under consideration.  Some work has been carried out to reorganise major and minor streams of patients and to redesign space.  This has led to some efficiencies including that patients are seen a lot earlier and return home quicker.

 

It was confirmed that it is intended to maintain a consultant led A & E Department in Nevill Hall until the new hospital is operational.  Afterwards, the hospital will have a nurse led minor injury department.

 

·         Stroke: A question was asked about recent news of a successful new system of treating a stroke involving physical removal of the clot. It was queried if the approach is in use in the Royal Gwent Hospital.

 

Regarding the treatment of stroke patients, it was confirmed that clot retrieval is not available in the Gwent area.  It was explained that, in Wales, the service is offered in Cardiff.  It was clarified that clot removal is not a new intervention, and also that stroke is sometimes caused by haemorrhage, and not always clots.  It was added that there is also a training need in this area.  This type of procedure will become more prevalent in years to come but reassurance was provided that service available for stroke patients are comparable with the best on offer in the rest of Wales.

 

Additionally, it was confirmed that the hyper acute stroke service will be located in the SCCC and rehabilitation will be in local hospitals.  Currently, the hyper acute stroke service is located in the Royal Gwent Hospital as part of the transition process.

 

·         Local Hospitals: The Chair queried if there was a broader vision for Nevill Hall Hospital and it was confirmed that the Clinical Futures Strategy proposes its development as a local general hospital.  There is a clear view of the proposed range of services and numbers of beds to be available.  It was confirmed that, as yet, there is no approval from the Welsh Government for the plans for Royal Gwent Hospital and Nevill Hall Hospital once the Specialist and Critical Care Centre (SCCC) is open. 

 

It is proposed to complete the plans and submit them next year. Consultation has already taken place.

 

·         Car Parking: The Chair explained that there is a perception that Nevill Hall has a park and ride service for shoppers in the town which exacerbates parking difficulties for patients and bona fide visitors. In response, it was commented that an application has been made for increased parking but without support due to flood plain rules.  A further attempt at resolution involves the purchase of additional land in a plan that it is acceptable to all parties.

 

·         Transport: A Member asked a question about the new SCCC and queried how patients from, for example, Monmouth would travel to the new facility.  It was confirmed that transport links will be a key project area, and the ABUHB will be working closely with local authorities. 

 

County Councillor V. Smith congratulated the initiative in partnership with Specsavers in Newport.   The SCCC success was also applauded and Councillor Smith questioned if the infrastructure was adequate to serve the needs of the new facility providing the example of the A4042 at Llanellen which is prone to closure due to flooding. 

 

The Chair agreed that transport links are an important consideration.

 

Additionally, the problem of poor mobile signal in rural areas was raised in relation to appointment text reminders. 

 

·         PET Scanner: A Committee Member asked if there were any plans to locate a PET scanner in the Royal Gwent Hospital or in the SCCC.  It was confirmed that there are no plans for a PET scanner in either location. The ABUHB will continue to utilise the facility in Cardiff but will also monitor developments in new technology.

 

 

·         GP Out of Hours Service: Councillor Easson also queried if there is any information available on the success of the recent trialled change to GP Out of Hours Service at Nevill Hall Hospital at night.  In response it was explained that there has been a six week pilot to reduce overnight cover to ensure that the busiest of times at weekends could be accommodated.  The results are currently being recorded and the results will be available in due course.  It was confirmed that only small numbers of patients had to be redirected (only 3 from the Monmouth area, and all patients that contacted the service during the six week period are being followed up to provide feedback on their experience).  It was added that operationally the outcome has been that it has been possible to cover the whole of Gwent more consistently and more robustly.  Feedback from the Ambulance Service has been that there is a lot more confidence in the model instead of closing services because of a lack of staff. The use of advance paramedics has enhanced the service.  It was commented that evaluation of the pilot will be critical.

 

·         Stroke and Dementia Support: Councillor Easson asked about aftercare for stroke patients acknowledging that whilst there are valued stroke support services in some areas and also for dementia patients, they can be difficult for people in rural areas of the county to access.  It was queried if there was any opportunity to improve the availability of such support services and resources.

 

It was responded that aftercare and support for dementia and stroke patients could be better.  It was clarified that there have been some areas of substantial review e.g. mental health third sector services.  Collective work between the five local authorities and health board has produced an updated needs assessment to understand what services are required at a grass roots level, and priorities therefrom.  It was commented that the contribution of neighbourhood care networks and from the third sector was an important element of service provision.

 

·         Budget: Councillor Easson commented that the Gwent area has the highest prescription drug costs in Wales noting that there is a possible £12.8m deficit currently, predicted to rise to £16m.  It was queried if drug costs are a major component of the deficit position.

 

In response it was commented that the deficit was not necessarily due to high prescribing costs, but because of a range of reasons mainly workforce issues e.g. costs of covering posts due to absence and resignation noting that often it has been necessary to pay a premium.  It was explained that significant work to review when medicines are prescribed across services, consistency of approach to prescribing drugs and checking cost effectiveness is in progress.

 

Councillor Easson asked a further question regarding demand for drugs and services and if there was an element of waste that could be reduced.   It was acknowledged that drug prescribing is a huge financial issue and that across the country, 10% of turnover is spent on drug.  Members were reminded of the “Prudent Health Care” initiative which encouraged the prescription of the minimum amounts needed and also to reduce the risk of side effects.  It was confirmed that the Gwent area has one of the most cautious approaches to antibiotic prescription and also the prescription of opioids has been altered to a cheaper option with comparable effects.

 

It was explained that a value based approach has been established which involves removing high cost medications from pathways in some areas and reinvesting the money in the community to provide more sustainable services providing the example of pulmonary rehabilitation services. 

 

A Member, in the context of the cost of the NHS and free prescriptions, queried if paracetamol and similar should be prescribed as they are cheaply available to purchase by individuals. 

 

It was responded that when prescribing paracetamol etc. clinicians should be sensible and judicious but there was agreement that this point could be the subject of a national conversation.

 

·         Integrated Services: The Chief Officer, Social Care and Health, welcomed the Clinical Futures plans and the joined up primary and community care approaches under the Social Services and Wellbeing Act which will build on the strengths of the existing integrated teams.  The Care Closer to Home Strategy will be introduced in due course to further develop integrated teams and develop hubs for services according to population needs assessment.  It was agreed that this is a time of great opportunity and plans for the future in partnership are ambitious.

 

It was confirmed that ABUHB will be working with the Council on the Young Carers strategy

 

Councillor Easson thanked the ABUHB for its support of Flying start.

 

·         Chepstow Hospital: County Councillor A. Easson explained that there is concern in the Chepstow and Caldicot area regarding why Chepstow Hospital can’t be used more.  It was noted that 10% of outpatients don’t keep appointments and queried if there was any data on reasons for non-attendance.

 

It was explained that Chepstow Hospital forms part of Out-Patient Strategy; a transformation board is currently being set up to review efficiencies that will include analysis of patients that didn’t or couldn’t attend.  ABUHB is one of the first hospitals in Wales to provide a text reminder service, and also uses some other strategies, which have led to improvement.  Additionally, more out-patient services are being provided at Chepstow Hospital to relieve pressure in other hospitals. 

 

It was explained that feedback has indicated that reasons for not attending appointments are not mainly due to non-availability of the clinic, or transport but due to timing.  To combat this, increased repeat information packages are being sent to patients to explain what the appointment is for and other details. 

 

The Chair was encouraged to hear the suggestion that there is more potential for Chepstow Hospital and raised the issue of the closure of the Minor Injuries Unit (MIU).  At that time, it was stated that there was a need for clear public information.  It was noted that initiatives are mainly in the north of the county (e.g. Choose Well and proposed neighbourhood care networks) and queried if there was a way to reinstate a MIU in Chepstow Hospital as residents now travel predominantly to Lydney for services.

 

It was confirmed that the MIU in Chepstow will not be reopened and added that the decision to make a capital investment in the Royal Gwent was based on services being delivered from a Portacabin and unrelated to the diminishing numbers attending.  It was explained that significant work has been carried out in the Monmouth area for the Choose Well scheme.  The scheme offers information and the choices available for minor injury services.  It was added that it will be possible to do the same for other areas of Monmouthshire.  The example of the Fall Service was provided where patients can be supported at home instead of being transported to hospital.  The Chair was grateful for the answer provided and advised that Chepstow Town Council will also welcome the response.  It was suggested that the Town Council could be an instrumental link in the provision of information.

 

A Member was unaware where the Monmouth information was available.  It was explained that that the information was widely circulated to households.  It was agreed that the information would be sent to the Member by E mail.

     The Member expressed his dissatisfaction that GP receptionists can become        involved in clinical discussions in an attempt to filter calls.  It was confirmed          that this practice is discouraged, and the comments would be followed up.