Agenda item

Betsi Cadwaladr University Health Board

Presentation from Betsi Cadwaladr University Health Board.

Decision:

(a) That the presentation be noted;

(b) That further information on any risks associated with crematoria be circulated to the Committee;

(d) That the suggestion for engagement with GPs in England be taken into consideration in the development of the Enhanced Care at Home Service in North East Flintshire and an update provided to the Committee;

(e) That a progress update on the implementation of the Home Enhanced Care Service be included on the Forward Work Programme;

(f) That the briefing note on Dementia from Betsi Cadwaladr University Health Board be reported to the Committee; and

(g) That the request to increase the number of x-ray sessions at Mold Hospital be taken into consideration.

Minutes:

The Chair welcomed the representatives from Betsi Cadwaladr University Health Board (BCUHB) and invited them to deliver the presentation, copies of which were circulated.

Mr. Andrew Jones, Executive Director of Public Health expressed his gratitude for the Council’s support on challenges such as the Measles, Mumps, Rubella (MMR) vaccination. He then gave a brief presentation on the North Wales Health Protection Team based in Mold which, although small, was part of a larger group on which additional resources could be drawn if required. He outlined work undertaken by the team and statistics on disease notifications across both Flintshire and the whole of North Wales. He outlined the North Wales response to the current outbreak of measles in Swansea, which had invoked an additional catch-up programme. He said that although there was a reduction in the number of new cases in Swansea, the objective was for all children in North Wales to be vaccinated with two doses of MMR and work was being done with the Council to increase uptake levels. He said that almost 9,000 children in North Wales had not received the MMR vaccinations which remained a challenge.

Dr. Judy Hart explained her appointment as a proper officer for communicable diseases, to work with Local Authorities on matters relating to Environmental Health, Emergency Planning and Public Protection.

The Chair noted that there was no mention of Clostridium difficile (C.diff) in the presentation. Dr. Hart explained that C.diff was an organism which was not notifiable, unlike those which had been listed. She said it was recognised that there had been an increase in cases within communities and hospitals but that it had a special remit in healthcare settings.

Councillor S. Jones referred to individuals who had been put off by the ‘3 in 1’ MMR vaccination due to previous bad publicity and asked if BCUHB was aware of the total number of people this related to and whether separate vaccinations could be offered as an alternative. Dr. Hart gave explanation on single vaccinations that had been previously available but were no longer licensed. The introduction of MMR vaccinations in the UK in 1988 had been successful in controlling the diseases and the health scare relating to this had been scientifically disproved, with health visitors and school nurses assisting by offering explanation on the evidence and safety profile to encourage a greater uptake. Dr. Hart said that the organisation’s immunisation co-ordinator compiled information on the number of people who had not consented to the MMR vaccination and that further opportunities were offered when children were entering and leaving school. There was an opportunity to pay for single vaccinations in private clinics, however there would be no audit.

Mr. Jones said that BCUHB was working with Councils to reinforce a consistent message that MMR vaccinations were safe and effective, and that efforts were focussing on those who had not consented to ascertain whether this was due to lack of access or reluctance.

Councillor M. Bateman asked if any public health risks were associated with crematoria. Dr. Hart said that locally, the Health Board received advice from a Public Health Wales consultant based in Cardiff, however it was her understanding that omissions from any site were controlled and monitored by environmental air quality standards. She did not have any concerns but offered to obtain more detailed information to share with the Committee.

On Cryptosporidium, Councillor H.J. McGuill asked what measures were in place to liaise with the Environment Agency to monitor water supplies. Dr. Hart replied that water supplies were very safe and were monitored, with water companies obliged to report any breaches. Problems mainly occurred in water treatment works although there had been no incidents for many years. Other causes were more environmental such as outbreaks arising from individuals coming into contact with farmyard animals.

In response to a question from Councillor I. Smith on Scarlet Fever, Dr. Hart said that this mainly related to children and could be easily treated. Any reported incidents would be notified to the relevant school and GPs.

Mr. Jones said that, following the outbreak of C.diff at Glan Clwyd Hospital, the Acting Chief Executive of BCUHB had requested that an update be provided to reassure Members that the matter was being taken seriously and that more could be done and would be done. He advised that a leading expert was being engaged to carry out a review and that further details could be shared with the Committee at a future meeting. The Chair welcomed this and said that there were a range of issues relating to this, including the prescribing of antibiotics. Councillor McGuill asked if the remit of the expert would include a review on the use of antibiotics. Mr. Jones said that the terms of reference were extensive and would include this.

Councillor Jones expressed her disappointment that negative incidents at some hospitals were allowed to overshadow the achievements and stricter controls that were in place at other hospitals, such as Wrexham Maelor. Mr. Jones responded that the Board focussed on improving health care associated infections at all of its hospitals and community premises and the external review would inform this.

The Chair raised the six questions which had previously been put forward by Members of the Committee.

Q: Enhanced Care at Home - details of the rollout and progress made across Flintshire

On the Enhanced Care at Home Service (ECH), Ms. Clare Jones said that following the consultation exercise last year, the service would be rolled out to North West Flintshire, as the first of three localities in the county. A multi-agency Task & Finish Group was in place to support this, and most of the nursing posts had been filled subject to training and induction. All GPs in Flint and Holywell had been contacted to seek support for the service and work was ongoing with Social Services for the provision of community equipment. It was confirmed that partners had signed up to the level of investment required. It had been agreed that BCUHB would fund a full-time Social Worker with the potential for additional part-time provision for the county at a later stage. Although the implementation date for ECH had previously been set at the end of May 2013, this was now anticipated to be the end of July 2013. Ms. Jones said it was important that the service was not launched until ready and that every effort was being made to get the service in place as soon as possible.

Councillor McGuill raised queries on the implications for patients if GPs refused to sign up to the service, provision for those living alone and location of the team.

Ms. Jones explained that, under the GMS contractual arrangements, GPs were not obliged to sign up to the service. Where a patient’s GP practice did not provide the medical support for ECH, they would be admitted to hospital to manage their care safely. It was noted that although there had been initial resistance from some GPs on the introduction of ECH in North Denbighshire, all were now supporting that service, with positive feedback from patients and carers. As part of individual assessments, those living at home alone would be identified and an appropriate care package allocated.

The Service Manager (Older People) said it was hoped that the new appointment of a Nurse Practitioner for Flintshire would further engage GPs with the service. On the latter query raised by Councillor McGuill, she said that ECH would work alongside the Crisis Intervention and Reablement services to enhance provision and it was planned that the teams would be located within County Hall before the end of July 2013.

Councillor McGuill commented on the confidentiality of information held by GP practices and asked how many had signed up in the first rollout in North West Flintshire Ms. Jones said it had been indicated that all GPs in Flint would sign up but that there was less interest from those in Holywell, however a number of responses were still outstanding.

Councillor Jones questioned whether ECH had also been rolled out to South Flintshire as she was aware of one case where this was working well with the support of a relative. She was concerned about staffing levels once the service had bedded in and asked if people with Dementia would receive 24-hour care at home or be admitted to hospital. Ms. Jones explained that other services were available for people in their own homes in other areas of the county. The Chair said that the question on Dementia would be addressed during discussion later in the item.

When asked by Councillor Smith about the number of those accessing the service, Ms. Jones said that 4-5 referrals were anticipated per week.

The Chair asked when ECH would be rolled out to the remaining localities in Flintshire and the level of investment being made. Ms. Jones said that it would cost £4.2m to provide the service across North Wales equating to around £327K per locality, however population sizes would differ. Investment in North West Flintshire had been significantly higher at just over £400K, in view of the two full-time appointments mentioned (which would subsequently support the other localities). Learning from the introduction of ECH in that area would support the remaining two localities which were intended to be in place by the end of September 2013. The total cost for Flintshire would have to be contained within the original level approved by BCUHB.

Councillor V. Gay asked how the service would support patients living in Wales who were registered with GPs across the border in England and said that there may be issues with IT systems not matching up. Ms. Jones said that there were currently no contracts with English GP practices but that she would take this back for consideration when developing services for North East Flintshire and provide follow-up information to the Committee.

Mr. John Darlington said that efforts were being made to collaborate with English counterparts but that there were difficulties with two different NHS systems. He acknowledged that this was an issue although added that responsibility was with regional GP practices and that it was individual patients’ choice where to register for their GP services. Councillor Gay pointed out that residents in some areas had no choice but to access GP practices across the border.

Councillor D.I. Mackie felt that more could be done to access GP provision and train carers, for example lifting and moving a wheelchair user. Mr. Bradshaw offered to discuss specific issues outside the meeting and referring to the forthcoming Carers Measure where an enhanced duty would be placed on the Health Service to provide greater support, including training.

Councillor McGuill agreed with the need for training for carers and asked about the length of time that ECH would be available for individuals. Ms. Jones explained that the key indicator for ECH was to support people to maintain their independence. The Service Manager (Older People) said it was her understanding that ECH would be provided for around two weeks before the individual could move on to Reablement or other community services. The multi-agency team would assess need for ongoing cases and put in place relevant provision.

Councillor Jones felt it was important to have a full financial assessment of the cost of the service, including any additional cost to the Council and contributions from BCUHB, in view of the current economic climate. Ms. Jones said that there had been no cost to the Local Authority in setting up the team and that the Health Board would pick up the cost for individuals who did not already have a care package. However, if the Council was already funding a care package, there would be a continuation of that funding. The Head of Social Services for Adults said that some ECH patients on care packages may previously have been admitted to hospital which meant that some outcomes and costs were difficult to estimate. This would continue to be monitored as part of the ongoing evaluation of the service.

The Chair shared the concern raised by Councillor Jones and referred to the reported costs which equated to approximately £2,000 per client. She was concerned that any overspend would impact on the service rollout to other areas and said that the Committee would need to revisit the issue.

Mr. Bradshaw said that the additional costs arising from those already with a care package are likely to be less than those incurred by the Council in setting up a whole new care package. Although this was a potential additional cost to the Council, the outcomes were better as the package would be less intense, as per the experience in Denbighshire.

Q: Hospital Waiting Lists - impact of unscheduled care pressures on delivery of elective care resulting in cancellation of operations and hospital waiting lists. Details of trends in waiting times for Flintshire residents/Welsh waiting times standards for patients etc/lack of beds available in district hospitals

Q: Members have given examples of people waiting outside hospitals in ambulances for several hours - how is this being addressed?

Mr. Bradshaw spoke of the challenging winter period and ageing population both of which had greatly affected unscheduled care provision and hospital waiting times across the UK. Within Wales, the target was that 95% of patients should commence their first treatment within 26 weeks of referral from their GP and that no patient should wait longer than 36 weeks. These targets had not been met, a situation which was not unique to North Wales. Trends in Flintshire could not be reported as data was collated on an all Health Board basis. It was noted that there were 130,000 inpatient and daycase admissions across North Wales, of which 46,000 had an elective Care Plan and 84,000 were in emergency care.

Although there had been no reduction in the number of hospital beds, there had been some unplanned restricted access due to short-term staff sickness and some restrictions due to hospital infections.

In response to a question from Councillor McGuill on waiting times within two specific specialities, Mr. Bradshaw said that this related to the past year and was mainly due to staff sickness absences and increased demand in two particular departments, however this was not about the recruitment of staff.

The Chair asked whether the C.diff outbreak at Glan Clwyd Hospital and short-term infections had occurred as a result of the loss of hospital beds in Flint, Llangollen and Ruthin areas. Mr. Bradshaw replied that there had always been issues with short-term infections and there was no direct correlation with the number of community hospital beds. Issues on ambulance waiting times were not unique to Flintshire and were being addressed by putting in a range of actions at the three main hospital sites. In addition, specialist nurses supporting A&E departments had helped to improve A&E waiting times.

On ambulance waiting times, Councillor Bateman cited an example where a person had endured long waiting periods and unnecessary delays in seeking hospital treatment. The Chair commented that this could have been as a result of the ambulance being unable to discharge the patient due to insufficient capacity in the hospital. Mr. Bradshaw agreed that this delay was not acceptable but pointed out that the Welsh Ambulance Services Trust was responsible for providing ambulance services. He referred to the challenging winter period which had affected A&E departments and ambulance services, and whilst he could not comment on specific cases, he offered to pick up any issues outside the meeting.

The Chair remarked that Welsh Ambulance Service representatives would be attending the next meeting of the Committee.

Councillor McGuill asked what measures were being used to improve the flow of ambulances waiting outside hospitals and asked if improvements in a Sheffield hospital had been noted. Mr. Bradshaw gave assurance that the focus of the action plan was to improve the flow of patients and gave a reminder that patients waiting in ambulances were under the care of trained paramedics. Where A&E departments were busy, areas could be created to discharge and monitor patients, freeing up ambulances, however this was not always possible. Mr. Darlington referred to meetings with leading clinicians and gave assurances that this was being actively pursued, taking account of improvements made in other areas such as Sheffield.

Councillor D.E. Wisinger also commented on the lengthy waiting time of ambulances and felt that the problem should be observed within hospitals. Mr. Bradshaw assured Members that this was a priority for the Health Board to address, as indeed it was for NHS Wales and the Minister.

Councillor Jones was in agreement with the concerns raised by Members but said that from a different viewpoint, the unnecessary time taken up by hospital staff in having to deal with preventable issues should also be recognised and that proper security should be allocated. She expressed her gratitude for the hospital services which she had received. The Chair agreed and remarked that there were other positive stories from those who had experienced a high level of care and aftercare.

Q: Dementia Care - concern expressed by the Committee about the care available for those with Dementia, including the whole spectrum of services provided - diagnosis (waiting times etc), day care provision, memory clinics, training, care of patients with Dementia when admitted into hospital, Dementia trained staff (are nurses/health care workers being trained sufficiently?) and update on the role of the specialist Dementia nurse

Mr. Darlington said this issue was of major concern across the UK and that a briefing note could be brought back to the Committee. The Health Board had set a benchmark of 24 weeks for assessment and across North Wales, the average time had decreased from 28 to 20 weeks. This was an improvement but there were variations, with better access in western areas than east. The role of the Consultant Nurse on Dementia, Sean Page, had helped to identify a need for staff training and better use of resources to minimise stress to all. Information was provided on the ‘Butterfly Scheme’ which had been launched to raise awareness of Dementia training at Glan Clwyd hospital, one of only eight hospitals selected in the UK. Other initiatives on Dementia included work commissioned by Bangor University on improving the environment of wards, the development of a specific liaison service and the establishment of a governance group to progress the action plan. Mr. Darlington said that although a significant amount of work was being undertaken on Dementia, more was required on tackling variations across North Wales in the face of a growing population and the improvement of training remained a key priority for the Health Board.

The Chair spoke of ongoing work with the additional provision at Llys Jasmine and a pilot scheme on the Deeside strip.

Councillor McGuill asked if the Butterfly Scheme would be rolled out to GPs and Social Services and whether the strategy was clear. Mr. Darlington replied that the ‘Red’ scheme was the equivalent communication scheme for GPs. He was unclear on the timescale for rollout but would include this in the briefing note to be reported back to the Committee. Ms. Jones added that locality teams were meeting with Social Services to look at areas of priority across Flintshire. The need for training and early identification of those with Dementia had been raised at a recent meeting, along with arrangements for partnership working.

Q: Minor Conditions Referrals - waiting times/how many GPs in Flintshire perform minor surgery, impact on closure of community hospital

Ms. Jones said that although GPs were not obliged to perform minor surgery, 21 out of 23 practices in Flintshire did so, with 22 providing joint injections. There were no waiting times as patients pre-booked these appointments with their practice.

Councillor Jones asked when the six full x-ray sessions at Mold hospital would increase back to ten. Ms. Jones explained that as part of the Health Board’s approval of changes to x-ray services, it had been agreed that six sessions would meet the demand. It was therefore not anticipated that this number would increase, although demand would be monitored. Councillor Jones felt that this needed to be reviewed and referred to funding from the community to upgrade equipment. She also remarked that GPs should be directing patients to Mold hospital for x-ray services, as some appeared to be unaware of the facility. Ms. Jones agreed to take this back but said it was important to assess need and make best use of staff time.

Councillor Bateman commented that some GPs were still referring patients for x-rays to Wrexham Maelor Hospital and asked if the eight sessions available in Deeside would be monitored. Ms. Jones explained that monitoring was carried out and that the consultation had taken into account patients recognised by postcode. She pointed out that there could be a range of reasons why patients would choose to go elsewhere rather than their local unit.

Councillor C. Hinds referred to a patient diagnosed with three different disorders who had been told to write to three different consultants for them to communicate on his issues. Mr. Darlington said that the matter should be referred to the patient’s GP. Mr. Bradshaw was unaware of any reason as to why the patient had been told this and said that more detail may provide clarity.

Q: Primary Healthcare Centres - update

Mr. Bradshaw gave an update on the three principal schemes in Flintshire. On Buckley, he was pleased to report that the delay due to the third party developer objecting to a clause in the standard national lease had just been resolved and was awaiting confirmation of the revised programme. The bid to the Welsh Government (WG) for the scheme at Hope had been approved and a timetable for commencement was awaited. The scheme at Flint required the Health Board to submit a bid to WG against the All Wales Capital Programme. WG had included the scheme within their forward programme, but funding would be subject to approval of the business case. A project team comprising Council Members and officers had been established and discussions were ongoing on integration with the Flint Masterplan. A commitment had been given for the facility to be in place by 2016.

The Chair thanked the representatives for their attendance and responses provided to the Committee.

RESOLVED:

(a) That the presentation be noted;

(b) That further information on any risks associated with crematoria be circulated to the Committee;

(e) That a progress update on the implementation of the Home Enhanced Care Service be included on the Forward Work Programme;

(f) That the briefing note on Dementia from Betsi Cadwaladr University Health Board be reported to the Committee; and

(g) That the request to increase the number of x-ray sessions at Mold Hospital be taken into consideration.