Minutes of the meeting held on 8 December 2016 were agreed and signed as an accurate record of the meeting.

The following amendment was agreed for the Minutes of the meeting held on 17 January 2017:

• Page 11 - Cllr Andy Stranack pointed out that, in relation to the top paragraph, this will be first year of running the contract which was to have begun in April 2017 but it has not started yet.

The minutes were then agreed and signed as an accurate record of the meeting.

There were no disclosures of pecuniary interest at this meeting.

Cllr Andy Stranack declared a personal interest in that he is involved in the Specialist User Group reviewing Outcome Based Commissioning for Over 65s and one of the work streams.

There was none.

There were none.
 

(Agenda Item 6)

The following attended from South London & Maudsley (SLaM) NHS Trust, to present this report:

• Neil Robertson (Service Director - Psychological Medicine Services)
• Amanda Pithouse (Director of Patient Experience & Quality and Trust Deputy Director of Nursing)
• Dr Rau (Consultant Psychiatrist)

Headlines from the report:

• Patient stories provided an emphasis on the important process for service user involvement.
• CQC inspection gave positive feedback about improvements, particularly effective reporting on Safeguarding Adult issues.
• SLaM has been successful in reducing out of area bed usage.
• Social care - last year there were challenges with delayed transfers of care. Robust mechanisms have been put in place with social care colleagues.
• KPIs have been agreed in relation to social care outcomes.
• Integrated mental health and social care arrangements are being finalised in relation to Section 75 agreement.
• Recruitment of social workers - useful recruitment pathways and more robust opportunities for professional development have been set up.
• SLaM is ensuring that the Care Act is being implemented and joint working around strategy, to ensure carers' needs are assessed.
• Central Place of Safety is now operational.
• Engagement with partners to develop partnership working
• Need to engage the workforce better has been recognised
• Quality improvement strategy - using health based methodology to improve frontline services.
• Research - engaging service users and carers.
• Staff training - debriefing at the end of each shift is improving patient experience

Questions were raised about the steep increase in Aug 2016 on delayed transfer of care and the level of restrictive interventions.  Neil Robertson and Amanda Pithouse assured Members that both have been significantly reduced and the aim is to reduce the figures lower, eventually to zero, if possible.  Previously the data was not robust, so they are looking at how incidents are reported, timing and position. 

Cllr Sean Fitzsimons asked what are the financial constraints, challenges and successes.  Neil Robertson explained that it is a challenging health economy. The trust has worked hard to ensure it maintains Foundation Trust status and keeps within financial balance. SLaM needs to ensure the corporate and infrastructure functions are as efficient as possible. There have been challenges for the CCG over last couple of years and SLaM is working with them in partnership to address financial challenges.  Bed usage on acute wards is higher than other boroughs and they are working to identify why it is higher. They need to ensure that front facing services are not impacted.

Croydon has been funded lower than other boroughs on an amount per head of population basis and it has had a knock on effect on staffing.  Cllr Sean Fitzsimons asked how Croydon is now placed in making mental health services comparable with other boroughs. There is a government commitment to increasing funding but what is the gap? Where are the challenges in terms of resources and staffing?
Neil Robertson responded that IAPT will benefit from some other streams of funding. Last year there were bed occupancy issues but SLaM is working with CCG to balance tis. Community services are better funded now. Front door and primary care are particularly pressured and the introduction of the Care Act has had an impact on capacity. Some of the pathway barriers are strengthening offers within primary care. GP practice is still not meeting the national IAPT target - 15.1% but will meet 11% this year.  Councillor Sean Fitzsimons commented that GP services were variable and that issue needs to be addressed.

Councillor Margaret Mead enquired about workforce development, as the results of the 2015 survey were lower than 2014.  As not all staff are informed about changes to services, what is being implemented to address that?  Councillor Andy Stranack asked what were the negatives from the survey.

Neil Robertson explained the difficulties around getting people to complete the survey.  SLaM is not far behind other London mental health trusts. They are encouraging senior staff to complete it. Staff have experienced some harassment and SLaM is trying to support staff to speak out. Support staff can be accessed to talk about experiences in an informal way - kept away from HR.  There are 'Speak Out' champions nominated within each department. It is about whistleblowing and has been running for a few months. Directors speak with champions on a monthly basis.

In relation to change, there has been a lot within the organisation, with the reconfiguration of community services. However there are very clear procedures around change management but there is a need to do things differently in some areas.

Councillor Andrew Pelling asked what conversations are being had with CCG about funding, in view of their £2m overspend.
A Programme Board has been set up, including the CCG and SLaM's Chief Operating Officer and Chief Executive.  It meets monthly to address challenges.  There is a reduced number of people that can be treated, so they are ensuring those who do access services are treated quickly.

Councillor Andy Stranack asked about involvement with the GP hub.
John Goulston (Croydon Health Services) explained that the personal independent co-ordinator is from Healthcare Croydon, providing services for older people.  The hub is to join up services so people have access to the right service.

Councillor Kathy Bee wanted to know if SLaM was where they wanted to be with regard to improvement in risk assessments.  Amanda Pithouse confirmed that in 2015, the situation clearly needed improvement. Risk was not being linked to care plans. They have evaluated electronic journey records. Now there is one risk assessment, which is easier for clinical staff to use, and it is linked through to care plans. Staff are being trained on the new process.  CQC mentioned significant improvements in the acute re-inspection pathway but there is still a long way to go.  This is a new project - a pilot in one borough, looking at quality and making sure risks recorded are formulated so there is understanding how to manage them

Councillor Carole Bonner pointed out that JHOSC had asked that the report be sent to them when everything was in place but, although things have happened, they have not fed back to JHOSC.

Neil Robertson apologised and will investigate further.

(N.B. The report has sections 7 and then 9, which was a mistype - it should have been section 8.)

The Committee NOTED the contents of the report.

(Agenda Item 8)

The following attended from Croydon Health Services (CHS) NHS Trust, to present this report:

• Mike Bell (Croydon Health Services NHS Trust, Chairman)
• John Goulston (Croydon Health Services NHS Trust, Chief Executive)

Mike Bell gave an update.  This was the third meeting since they were placed in financial special measures.

• Plans were not only approved but have remained on track for 11 months of this financial year.
• As of February, CHS has exited the financial measures programme.
• Staff in the trust have worked really hard and throughout the 3 principles have not been compromised.
• Every decision has been scrutinised.
• Focused on achieving performance goals - there has been no dip in performance.
• Hitting targets - just short on A&E targets.
• Now in top half of performance nationally.
• Croydon CCG is also in financial special measures and CHS is working with them to achieve savings and ensure their plans are robust.
• Plans for next year are ambitious.
• By end of 2018-19 hope to be down to almost break even. 
• From 1 April, they will regain control of urgent care.
• Health and social care gains are being delivered.
• In tough times but have not cut services nor staff and have not reduced quality.

Councillor Margaret Mead queried whether the significant reductions in staff costs is achievable.  She was also concerned about moving to electronic/paperlight records as recently thousands of patient records disappeared.

Mike Bell explained that the staff reduction was in agency and bank staff. Croydon is now a good place to work so recruitment is getting easier. There is a range of threats on the horizon, such as Brexit, and a number of European staff are feeling unsettled.
John Goulston expanded on NHS Improvement.  Admin & clerical costs are above average - currently 8-9% of overall costs.  The aim is to get down to 6% in 2017-18.   The electronic patient system is used broadly and deeply but the system on top was not as user friendly as it could be. However it is data rich and the software system above it now makes it easier for clinicians. The medical director now has no paper records in her haematology clinic. Podiatrists are also paperlight. Reducing paper records can cut clerical costs by 10% and reduce external costs.  CHS has the same electronic patient system as St George's. They have looked at the problems St George's had and they are not a problem in Croydon. Cyber attacks are an area of constant vigilance.

Councillor Margaret Mead asked if part of the improvement was due to encouraging agency to convert to permanent staff.
Mike Bell explained that bank staff are permanent staff who do overtime. Agency staff have been encouraged to become bank staff. However, a significant area is around medical locums and this is looking even more significant as nursing staff spending is reduced.
John Goulston provided details of agency staff rates - a year ago they were £36ph but now £26ph and bank staff rates now compare favourably as they were £24 but are now £25ph and additionally include annual holidays and other benefits.

Agency admin and clerical staff have seen changes around IR35 and there has been a deep trawl into the use of those. There are plans to move quickly on eradicating them.  The hardest area is medical, where there is a number of agency staff. NHS Improvement has given national guidelines to help.

Councillor Andy Stranack asked for clarification around sustainability and transformation funding.  He also asked what the savings are which have been identified already.

Mike Bell explained that there was an allocation for the next 3 years, which CHS will receive providing they hit the given control - 70% for hitting the control total. This amounts to £9m for both 2017-18 and 2018-19.  Other targets provide further funding, on a sliding scale, if they are reached.  Costs need to be reduced by about £18m. CHS is looking for £4m approximately this year. Then £14m savings need new plans for 2017-18 and £10m has been identified.

Councillor Carole Bonner was concerned that Brexit might derail some of the plans with regard to staff from Europe.  It is a real risk to the NHS in general.
The Chairs and CEs of trusts are getting together on 22 March.  The effect has been greater than anticipated and there is a fear around retention. Staff are concerned about the removal of rights such as bringing over their family. It depends how quickly a resolution is confirmed on the right to stay.  Another impact is devaluation of the pound against the Euro.  CHS is the biggest employer in Croydon, with 3,700 staff. A lot of support staff are affected, such as contractors (porters, cleaners).

Councillor Andrew Pelling asked about the impact on recruitment.
Recruitment within Croydon has been about 10 a week but not all is from the EU.  CHS has not been running a recruitment drive recently.  40 nurses from Italy were recruited and 25 are still here.

Councillor Carole Bonner asked about the reduction of beds.
The STP plans are currently being worked through. One side is about the reduction of acute beds. The other is about community support for patients at home.  NHS England has advised that any provider which can reduce beds, has to meet certain criteria.  The anticipated increase in demand and what can be done out of hospital have to be balanced.  CHS is looking at future models of care in the community.  There is potential to reduce beds at hospital, working with other hospitals across London.

Paula Swann added that the work joins up with the South London STP but the whole strategy is around out of hospital care. If it can be supported, the best place for patients is at home. Across South West London last year, a bed audit across all hospitals demonstrated that 22% of non-elective admissions could have been avoided if there was a better setting of care in the community.  Croydon is following this approach regardless of the STP, working with CHS and the Council to develop a business case. We need to ensure we have the services in the community to reduce beds needed in hospital but we have to pass the NHS England test.

Councillor Carol Bonner asked if the bed audit could be circulated after the meeting.  South West London JHOSC has been chasing the report.

The Committee NOTED the contents of the report.
 

(Agenda Item 7)

The following attended the Council, to present this report:

• Councillor Maggie Mansell (Chair of Health & Wellbeing Board)
• Barbara Peacock (Executive Director of People)
• Steve Morton (Head of Health & Wellbeing)

Councillor Andy Stranack asked about the role of the Health & Wellbeing Board as Outcome Based Commissioning (OBC) develops and how the Board sees the alliance working.
Councillor Maggie Mansell responded.  The contract starts from 1 April and having promoted this way forward, we next expect to see a report in a year's time as to how things are going.

Barbara Peacock added that this is at an exciting point in OBC work. Health & Wellbeing Boards have an important strategic role in driving the whole system and looking at how to reduce health inequalities. OBC and the alliance are about how to change the system. The role of Scrutiny has a stronger role in seeing how they are doing together.
Paula Swann also stressed the importance of the Health & Wellbeing Board in terms of driving integration, which will be a key outcome from OBC. It will be integrating not only commissioning but provider services and, over time, it will reduce duplication and ensure user pathways are more seamless.

OBC is not looking at just the service but also at the patient pathway. That is reflected in the systems we have. Prevention is an important part of that. OBC takes into account the experience of the patient, to provide a new way of looking at provision. Sometimes it costs more initially but is better for the patient and savings come later.

Councillor Sean Fitzsimons queried that the Executive Summary mentions key achievements - integration, promoting health & wellbeing etc - but does not tackle health inequalities. He expressed surprise that this was not such a key aim. What about the health outcomes of people on lower incomes, where their lives are significantly shorter and old age not as enjoyable as others?

Rachel Flowers explained that health inequalities are integral to everything the Director of Public Health does. Maybe it was not made as explicit as it should have been.
Cllr Mansell confirmed that inequalities are inherent in everything the Health & Wellbeing Board does. A report to the next Board meeting will be on the Gateway service, which has done a great amount to address inequalities of income, which is a key determinant of ill health. This feeds through the work the Health & Wellbeing Board is doing - also through housing, debt etc.  The Board is keen to have more reports on determinants of ill health and how the Council is addressing them.  Previous topics covered include exercise, to counter obesity and diabetes; the Food Flagship; work being done in parks, providing exercise equipment; the Just Be website - information on how to improve life choices to keep healthy. Work has been done by a number of staff.  There is a 9% gap between deprived and other wards.  Closing the gap is difficult unless one can change people's affluence in the different areas.

Councillor Sean Fitzsimons raised the issue of air pollution as a major cause for concern.
Councillor Maggie Mansell felt that it is important to focus on giving children a good start in life.  Air quality is a complicated issue and people affected by obesity are just a big a concern.  The Council is looking at the relationship of schools to particular hot spots. In Croydon bad pollution is mainly on bus routes and a lot of air quality issues are dealt with on a London wide basis.

Councillor Kathy Bee asked why she no long receives the annual JSNA report.

Barbara Peacock explained that it is no longer produced as a document.
Rachel Flowers emphasised that it is a much more dynamic document but the link can be circulated.

Councillor Kathy Bee wanted to know how Croydon compares with other areas on the 6 areas for improvement.  She also asked about the Risk Register.

Councillor Maggie Mansell felt that in all areas where there are inequalities inherent in them, we could do better.  The areas are based on the JSNA.

Steve Morton explained that with the 6 areas of improvement, it is useful to have sight of the JSNA.  The Board looks at comparative performance regularly and, under each heading, it shows where the Board focuses. However, the problems remain depressingly similar. The Executive Group review the Risk Register and, not surprisingly, the highest risk is around financial sustainability. One area of challenge the Executive Group would like to address is around patient public involvement. Healthwatch Croydon is on Board and has provided some recommendations.  Public do attend Board meetings and are invited to ask public questions.  They are also involved in strategic discussions and the Board holds seminars, inviting a broader range of people.  Not a large number of people attend the Board meetings but the individuals do vary.  Better publicity is needed to promote what is being discussed.

Councillor Andrew Pelling asked if Councillor Maggie Mansell felt the nature of questions was portraying misapprehension about the executive role the Health & Wellbeing Board has.  Councillor Maggie Mansell did not think so.  She agreed that sometimes it was looking at minutiae when the big picture is important.  The Health Service is heading for £1bn overspend/underfund.  It is right to do as much as possible within the community.  The big factor is the lack of qualified people being trained.

Councillor Andrew Pelling was struggling to understand if the key role of the Health & Wellbeing Board is executive or about participation.
Barbara Peacock pointed him to clear guidance on the LGA website, where there are examples of where Boards have made significant local contribution. (See: health-and-wellbeing-boards-engaging-effectively-providers-0)

The Committee NOTED the contents of the report.

(Agenda Item 12)

The following attended from the Council, to present the report:

• Sarah Baker (Independent Chair of Adult and Children Safeguarding Boards)
• Guy van Dichele (Interim Director of Adult Social Care and 0-65 Disability)
• Nick Sherlock (Head of Adult Safeguarding and Quality Assurance)

The following points were highlighted:

• Safeguarding Adult Board is now statutory
• There is good support from a wide range of partners
• The report identifies 6 priorities for 2015-16 and evaluation.

Councillor Margaret Mead expressed concern about the increased number of safeguarding activities.  Is 1638 a significant number compared with other boroughs of this size and are referrals of a particular nature or only partly a safeguarding concern?
Nick Sherlock responded that Croydon is not hugely out of line with other boroughs. The triage system enables the focus to be on what is safeguarding. Looking at the figures, there will be more referrals this year - 2000+.  A smaller percentage is likely to go on to triage. It is important for people to get the right service.  The focus is more on personal needs and outcomes.
Sarah Baker assured the Committee that the increase in reports showed more awareness of safeguarding. The higher number reflects practitioner and community awareness.

Councillor Margaret Mead asked about capacity to deal with extra referrals.
Guy van Dichele answered that capacity is always looked at within the team. One concern may not lead to further action but may indicate areas to look at. Abuse/safeguarding might be about a family member, so it would be about working with individuals.
 

In previous years, the sub committees have not been well attended and it was asked whether that had improved.

Sarah Baker commented that the process of reviewing committees for priorities for next year is current. Committees are continually reviewed to ensure they are focusing on the right issues and have the right membership.

Councillor Carole Bonner felt it would be useful to see priorities as they are developed in future, to keep the Committee in the loop, in addition to the formal annual report.  If something of concern is spotted, it can be added to the work programme. When the CCG went into financial special measures, there were two extra Health Scrutiny meetings.

The Committee NOTED the contents of the report.

(Agenda Item 13)

Paula Swann (NHS Croydon Clinical Commissioning Group (CCG), Chief Officer) attended to present this report and respond to questions.

Paula Swann explained the background:

• On 14 March the governing body considered the proposal to stop routine provision of IVF and ICSI.
• Reviewed rationale for decision, various reports, impact assessment and alternative provision.
• Took difficult decision to fund IVF and ICSI only for those with exceptional clinical circumstances.
• It was agreed to review the decision on an annual basis.
• It is recognised that the decision will have a significant impact on a small cohort of patients.

Councillor Sean Fitzsimons described the decision as a failure of imagination on the part of the CCG.   People used to have to pay themselves so it was exclusive, only for those who could afford it. People affected are those in their 20s and 30s and economic circumstances have changed, making it even more difficult financially.  When cuts are made it is either because there is fundamental under resourcing or it is a failure of the organisation to eke out proper efficiencies. This is an easy cut. Croydon is first borough in London to do this. Fertility declines after the early 20s and making people on low income save for years is not the solution. This is about inequality - it is a fundamental right.  He asked the Committee to refer the decision to the Secretary of State.

Paula Swann agreed it had not been an easy decision for the CCG to make. Over 4 years the CCG has delivered £50m+ in savings, without making cuts in services. It is in financial special measures and has a statutory duty to live within the resources available. We are looking at other areas of efficiency and working with partners across Croydon to transform transcare.
Dr Agnelo Fernandes confirmed that the CCG was placed in a difficult position. He had been to all the public consultations. For the last 5yrs over £70m savings have been made, without making a cut. He emphasised that the CCG had not gone for the easy option. They are working across South West London. There is an element of inappropriate activity within the NHS, in terms of procedures. The CCG has to do something whilst preventing making cuts which affect the life and death of patients. £32m in savings is not easy to achieve. The money is not there to provide all the services currently offered. The CCG has gone through the process to identify different areas but this is only the beginning.

Councillor Sean Fitzsimons stressed that some people will lose their window of opportunity if they have to wait another 3-4-5yrs.  He questioned the evidence on why this particular service should be chosen. Croydon is in the national press about these cuts.
Dr Agnelo Fernandes reiterated that it is about the wider health service, which has not got the funds to sustain itself.

It was confirmed that if the Committee was not happy with the evidence they have heard, they can refer the decision to the Secretary of State. The Secretary can then recommend to the NHS that they do certain things differently, if the CCG's decision is overturned.  The CCG's decision would not be able to be implemented until the matter is resolved.  However, it would need a strong argument and a detailed report to submit to the Secretary of State.

Councillor Andrew Pelling wanted more evidence that the CCG had acted unreasonably. He asked what other options are being considered for cuts.

Paula Swann elaborated that, in September 2016, the CCG published a document identifying their approach to recovery and it included a number of areas for review:

• Reviewing the back office and re-enforcing existing policies for thresholds,
• Reducing provision and changing thresholds to care.
• Reducing child & adolescent mental health services
• Reducing the number of urgent care GP hubs
• Increasing waiting times for out patient diagnostics and elective surgery
• Reducing investment into the Better Care Fund.

Decisions have already been taken for reductions to planned expenditure which impact on services for IAPT and at Foxley Lane. Some of the cuts include withdrawal of gluten free products, Vitamin D, over the counter self-care medications and baby milk.  This is a flavour of the process followed.

Councillor Kathy Bee was concerned about taking responsibility for overriding the choices of the CCG.  Everything they do affects people's health. It is difficult to be faced with these decisions on what not to do.

(N.B. At 9:35pm the Chair, Councillor Carole Bonner suggested suspension of standing orders, as the business was unlikely to be completed before the guillotine at 10pm.  The Committee agreed.)

The Committee RESOLVED to defer the decision, pending legal advice on the process.

(Agenda Item 9)

Royal Borough of Richmond serve this committee. The next meeting is likely to be April but the date has not been set yet.

(Agenda Item 10)

Councillor Carole Bonner attended the meeting, where there was a presentation from NHS England and The King's Fund.  The latter report was into STP across London. It was discussed at the GLA Health Committee last week. A date in May has been set for a further meeting which the GLA will host. The King's Fund has been invited to come and present here, to contribute to our discussions.

(Agenda Item 11)

The work programme was considered by the committee and noted that there was one meeting remaining for this year, which would be considering the Quality Accounts. It was acknowledged that the urgent issues affecting Health Services in Croydon, in particular Financial Special Measures, had increased the work of the committee and had meant that two extra meetings had been needed. The Chairs will look at whether this can be avoided in the coming year.