To receive apologies for absence.

Apologies were received from Councillors W.U. Attfield, G Powell, A Seldon and P. Watts.

To receive details of any Member nominated to attend the meeting in place of a Member of the Committee.

Councillor PA  Andrews substituted for WU Attfield, W.L.S. Bowen for G. Powell and B.Hunt for A. Seldon.

To receive any declarations of interest by Members in respect of items on the Agenda.

GUIDANCE ON DECLARING PERSONAL AND PREJUDICIAL INTERESTS AT MEETINGS

The Council’s Members’ Code of Conduct requires Councillors to declare against an Agenda item(s) the nature of an interest and whether the interest is personal or prejudicial.  Councillors have to decide first whether or not they have a personal interest in the matter under discussion.  They will then have to decide whether that personal interest is also prejudicial.

A personal interest is an interest that affects the Councillor more than most other people in the area.  People in the area include those who live, work or have property in the area of the Council.  Councillors will also have a personal interest if their partner, relative or a close friend, or an organisation that they or the member works for, is affected more than other people in the area.  If they do have a personal interest, they must declare it but can stay and take part and vote in the meeting. 

Whether an interest is prejudicial is a matter of judgement for each Councillor.  What Councillors have to do is ask themselves whether a member of the public – if he or she knew all the facts – would think that the Councillor’s interest was so important that their decision would be affected by it.  If a Councillor has a prejudicial interest then they must declare what that interest is and leave the meeting room.

There were no declarations of interest.

To approve and sign the Minutes of the meeting held on 3 April 2008.

RESOLVED:  That the Minutes of the meeting held on 3 April 2008 be confirmed as a correct record and signed by the Chairman.

To consider suggestions from members of the public on issues the Committee could scrutinise in the future.

There were no suggestions from Members of the Public.

The Committee considered an overview of the burden of disease and mortality from stroke, the range of services in Herefordshire for the prevention of stroke and the treatment and care of people who have had a stroke. 

The Committee had requested a report in greater depth on Stroke Services following its consideration in December 2007 of the Director of Public Health’s Annual Report 2007.

Dr Akeem Ali, Director of Public Health, referred to his report on stroke services included with the agenda papers and gave a presentation highlighting key issues.

Whilst deaths from heart disease and stroke were lower than the national average stroke remained the leading cause of death in Herefordshire.  Factors included old age and lifestyle issues.  It was clear that more could be done within the County to reduce deaths.

He highlighted the need in particular for preventative action through measures such as lifestyle advice.  It was estimated that 80% of strokes could be prevented.  The PCT was one of the few PCTs spending a reasonable amount on such measures and he suggested this provided scope for practitioners to do more.

He also remarked on the need for improved clinical support, noting that many stroke patients required long term care outside the hospital environment.  This required an integrated approach from a range of organisations.

There was a tension in that the pressure to meet targets created an incentive to invest in acute services rather than preventative measures.  The development of a prevention plan was needed to address this and ensure that services worked together.

In the ensuing discussion the following principal points were made:

·         Treatment of stroke within three hours of the onset of stroke symptoms was required to improve outcomes.  It was asked whether this was achievable in the County.  In reply it was said that work was being done to seek to improve the position but the three hour standard was not being achieved at the moment.  It was noted that the Ambulance Trust was also working on the problem, for example considering the use of an air ambulance in the more rural areas.

·         Asked about the scope for improvement Dr Ali reiterated that although there was currently a better outcome than the West Midlands average more needed to be done.  Long term plans needed to be put in place.  He had asked GPs to look into risk areas and he intended to develop a quality risk framework.  Joint working was taking place with social care on a single assessment process.

·         Questions were asked about limits on capacity, including resources.  Dr Ali replied that rurality was an issue but the development of practice based commissioning could contribute to meeting that challenge.  There was also a clinical governance issue to be addressed.  A critical mass of patients was needed to ensure that specialisms could be maintained to the required standard.  The Stroke Network was considering this issue to seek to avoid inequality of care.

·         It was acknowledged that there was scope to increase involvement with  ...  view the full minutes text for item 6.

To consider an update on sexual health.

The Committee considered an overview of Sexual Health Service provision in Herefordshire, an illustration of the successes of the department, and the challenges and medium term work plan for Herefordshire within the remit of Sexual Health.

The Committee had requested a report in greater depth on Sexual Health Services following its consideration in December 2007 of the Director of Public Health’s Annual Report 2007.

Dr Akeem Ali, Director of Public Health, referred to the report included with the agenda papers and gave a presentation highlighting key issues.

He said that, as with Stroke Services, there was clear scope for improvement.  For example the Herefordshire was not meeting the Department of Health requirement for screening for Chlamydia, a major sexual health issue in the County.  There was a clear need to increase provision beyond Hereford City, to destigmatise sexual health services and to think more broadly of reproductive health.

It was noted that the support of the National Support Team had been invited to review and advise on service delivery to achieve improvement.

In the ensuing discussion the following principal points were made:

·         In discussing the issue of destigmatising sexual health services, the work on providing choice to people as to where they were treated and the integration of sexual health services with mainstream provision was noted.   The majority of local people now sought treatment within the County.  The role social care services, independent providers and school nursing services had to play was acknowledged.

·         The effectiveness of providing screening services at pubs and nightclubs was discussed.  The reply was that in the previous year the Service had failed to meet the screening target for 15-24 year olds.  This had been addressed and in the current year performance against this target was above average.  The screening service at pubs and clubs alongside the delivery of broader sexual health messages was proving successful, although more males used the service than females. 

·         It was added that services aimed at young people were also provided at local festivals.  It was acknowledged that the PCT was financing services to many people who would be from out of the County but residents of Herefordshire travelling to other festivals would benefit equally from services provided by other PCTs.  It was requested that the focus on local youth provison should not be overlooked.  Dr Ali assured the Committee that he paid keen attention to the effectiveness of investment in services.

·         The importance of the role of schools and support afforded by facilities such as the South Wye Learning Centre in engaging communities was acknowledged.

·         In response to a question Dr Ali confirmed that the PCT was engaging with migrant workers in the County and their employers.

RESOLVED:  That the involvement of the National Support Team in reviewing service delivery be welcomed and a report be made to the Committee on the outcome of the review and the proposed action in response to it.

To consider performance in meeting targets for response times.

The Committee considered the Trust’s performance in meeting targets for response times. 

At the Committee’s request additional information had been provided showing response times by postal code area.  Mr Nick Harris, Divisional Commander – Worcestershire, and Mr Lee Hutchinson (Group Station Manager – Hereford), attended to present the report and answer questions.

Mr Harris reported that since 1 April 2008 a new standardised performance reporting system (Call Connect) had been introduced across the ambulance service.  Response times were now calculated from the time the call was received rather than from the time the message was passed to the control room.  Previously time had been allowed to collect details from the caller.  The effect of this was that in the context of an 8 Minute response, on average some 90 seconds had now been lost requiring a quite significant improvement in performance if the target was to be met.

He added that the Trust had to be selective in deploying its resources.  These were concentrated where assistance could be provided to the larger centres of population.  The Community First Responders Scheme was used to provide an initial response in the more outlying areas with additional support being provided as soon as practicable.

In response to the Call Connects initiative extra funding had been provided by the Primary Care Trusts to increase provision in control rooms, buy additional vehicles and recruit additional operational staff.

In the ensuing discussion the following principal points were made:

·         NH confirmed that if a Community First Responder attended an incident with a defibrilator and Oxygen this would qualify as a response against the target.

·         Attention was drawn to response times in HR8 and HR9 which respectively included the Towns of Ledbury and Ross-on-Wye and their surrounds.  NH confirmed that it would be possible to provide a further breakdown of the data to examine response times to incidents in the Towns themselves where the Ambulance Stations were, compared with the surrounding areas.  However, the key point was that, for example with one ambulance only in Ross, if that vehicle was on call transporting a patient to Hereford hospital and another call was received this clearly presented a challenge.  The Trust did seek to deploy its vehicles strategically to provide cover in Ross as elsewhere.

·         It was observed that performance in the Market Towns as a whole against the 8 Minute target was not good and it was asked at what point the Trust decided that additional resources were needed.

NH replied that demand analysis was ongoing and there were quarterly reviews to allow trends in demand to be identified.  Resources were finite and with six staff required to man a car for 24 days a week, 7 days a year and 11 staff for an ambulance the Service had to provide evidence to justify further investment.

A performance review plan was required to be produced to demonstrate that local need was being met.  There were also areas targeted for the number of Community First Responders to  ...  view the full minutes text for item 8.

To consider the development of a GP-led walk-in health centre for Herefordshire.

The Committee considered the development of a GP-led walk in Health Centre for Herefordshire. 

Mr Euan McPherson (EM) and Charmaine Hawker (CH), Programme Managers, gave a presentation on the proposed development.

EM said that the national model would not suit Herefordshire’s needs.  The Government had provided £800,000 for the developments in the base budgets of all Trusts although this sum was not ring-fenced.  Finance for the proposed Herefordshire model was therefore not easily identifiable, but it was considered that the proposal would be cost effective, sustainable and meet local needs.

He noted the need to retender for the provision of the out of hours service (6.30 pm to 8.00 am Monday to Friday and weekends) and the potential cost effectiveness and benefits for patients that a single procurement exercise for this service and the Health Centre could deliver.

A national timescale had been prescribed for the development of the Centres across the Country.  However, the PCT had considered that the Darzi model was more suited to urban areas and, notwithstanding the time pressure, had undertaken a local needs analysis.

The key findings were:Herefordshire is currently well provided with GPs and GP services; 87% of local people are happy with existing GP opening times; access to GPs is very good in Herefordshire.  The 2007 patient survey about GP access showed that 92% of patients could make an appointment with a GP within 48 hours (86% nationally) and 80% of patients could book an appointment with a GP two or more days in advance (75% nationally); population growth forecasts showed that the existing GP base should be able to accommodate this increase; there are a substantial number of people who commute into Hereford City each day, any new development should be based in Hereford City as a result of the demographics of the county, commuter travel flows and existing service delivery models; and a Hereford City based service would have the potential to alleviate inappropriate attendances at A&E and provide more appropriate services to some patients.

The County’s demographics suggested the Walk-in Centre should be located in Hereford City, but consideration could be given to the development of satellite facilities and outreach work.

The potential service model envisaged a single point of contact from which patients would be directed to the appropriate service whether it be A&E, GP, Dental Care, Social Care (out of hours), or District Nurse (out of hours).

He explained that the views of 270 individuals, organisations and groups  had been sought and reported the key findings of the feedback from this engagement:

the Herefordshire PCT Model was seen as innovative and rational; the response was generally supportive across all stakeholders; there were concerns about destabilising existing services; respondents were keen to see links and/or referral routes into other Primary Care and Social Care services; and there was a need to address potential risks that could arise from lack of continuity of care and poor communication.  He sought the Committee’s views on whether this  ...  view the full minutes text for item 9.

To receive an update on the proposed expansion of radiotherapy services.

The Committee considered an update on the proposed expansion of local radiotherapy services by the 3 Counties Cancer Network (3CCN). 

In March 2008 the Committee had affirmed its support for the Hereford County Hospital option for extra radiotherapy services provided on a satellite basis and asked the Three Counties Cancer Network to consult on this preferred option, taking account of the National Cancer Strategy recommendation that no patient should have to travel more than 45 minutes for cancer treatment and supporting the development of a treatment facility at Worcester as the next subsequent phase of development after that recommended at Hereford.

A letter from the 3CCN dated 4 June 2008 had been circulated to Members.  This enclosed a pre-consultation paper inviting comment on the proposed decision making and consultation processes.

Mr Antony Walsh, Service Improvement Lead at the 3CCN, gave a presentation.  This described radiotherapy, reminded the Committee of the current provision in the 3CCN and the options for expansion.  Decisions to date were that a linked service would be managed by the Oncology Centre at Cheltenham and would utilise the same clinicians (and some other specialists); it would comprise 2 linacs to provide cover (although a single linac might be an interim solution); the 3CCN Board could not make a decision which impacted on other Networks and patients would not be made to travel to improve the cost effectiveness of an option.

Factors to be considered included cost effectiveness, although it was noted that each PCT had agreed to underwrite its preferred option; clinical and radiation safety; and access – noting national guidance that a maximum journey time of 45 minutes should be seen as best practice. Some patients (c. 20-30%) would still need to travel to the Centre for more specialised treatment (including some of the sickest patients). Recruitment to radiotherapy posts had been difficult.

Nine criteria had been weighted by the Network Board, PCTs and patients and carers.  The top three were: patient access, patient safety and cost effectiveness.

He outlined the next steps which envisaged the 3CCN identifying a preferred option in July for consultation in July, with a final decision in December 2008

In the course of discussion the following principal points were made:

·         The Committee reaffirmed its support for the proposed extra provision to be located at Hereford County Hospital as set out in its decision of  5 March 2008.

·         Herefordshire PCT’s view that there was a need for a radiotherapy service to be provided locally was also reaffirmed.  It was added that the PCT had made financial provision for the Service to be provided.  It was noted that the Gloucestershire PCT was neutral on the proposal given that it would benefit from increased local capacity whichever option was chosen.  The Chief Executives of the Trusts therefore had to decide whether provision was to be at Hereford or at Worcester.

·         In response to a further question on funding it was reiterated that the PCT had made provision for revenue funding.  Further consideration would  ...  view the full minutes text for item 10.

To receive an update on intermediate care services.

The Committee considered an update on the development of intermediate care services, as requested following consideration of the Local Delivery Plan in March 2008.

Mr Paul Edwards, the Primary Care Trust’s (PCT’s) Director of Commissioning and Strategy, gave a presentation describing the service, a typical case study, the national policy context and models of intermediate care. 

He gave an overview of Herefordshire Services and current developments, concluding by saying that many people benefited from the current service arrangements to reduce their hospital stays and remain independent in their own homes.  The range of services was in transition towards a single countywide service being developed by the PCT, the Council and the Hospitals Trust. Intermediate care was part of a wider pattern of services to promote independence and deliver care closer to home.

The Head of Adult Social Care said that the potential for integrating services was good but more work remained to be done. This was one of her key priorities for the year.  Asked about the cost implications of the proposal to provide six weeks free intermediate care she said that the proposal was based on the benefit to the individual and the reduced level of service they would then need following that care. 

Members extolled the benefits of integration and concluded that there was evidence of the service improving but that the degree of improvement should continue to be monitored.

To receive an update on changes in the management of mental health services.

The Committee received an update on the development of mental health services in the last 18 months.

Mr Mark Hemming, Directorate Manager of Herefordshire Mental Health Services, described a number of developments that had taken place.

The Committee welcomed the changes in response to local needs.

To consider a presentation on audiology services in Herefordshire.

The Committee considered presentations from Herefordshire Primary Care Trust (PCT) and Hereford Hospitals NHS Trust (HHT) on audiology services in Herefordshire.

In considering its work programme in April the Committee had noted concerns had been expressed about HHT’s  audiology service.  Reassurance had been provided to the Committee at the meeting by the Chief Executive of HHT and the PCT’s Director of Commissioning and Strategy.  The Committee had requested a written update confirming the position.

Marcia Perry, PCT Directorate Manager Children’s Services gave a presentation on Paediatric Audiology Services in Herefordshire.  She described the current establishment, the numbers of children seen by the service and the services provided. 

She said strengths of the current service included that the service was a child focussed local service, combining education and PCT provision in a seamless service.  The Children’s Hearing Services Implementation Group  had been commended in a new born hearing screening programme (NHSP) review.  The Service was well regarded by many families.  There was easy access for parents when there were problems with hearing aids etc.  There were many positives from the external review of NHSP.  There were skills in testing complex cases and close links with HHT.

Challenges included workforce and recruitment, Premises, NHSP inspection Autumn 2007 and action plan to address issues, a low critical mass issues for maintaining  competence  and skills, the target for an 18 week wait, meeting targets for assessment, the possibility the  NHSP would move to regional commissioning and organisational change and reorganisation.

Future Developments included choose and book, an external review of the service by the National hearing Services Modernisation Team to commence July 08 to inform future development, the need to develop networks, skill mix, and the countywide review of provider services.

Representatives of the Hospitals Trust gave a presentation on the audiology services at the County Hospital.  This described the demand for the service, the hospital audiology team and the range of services.  He detailed a number of improvements in the service highlighting the reduction in waiting time for digital hearing aid assessment and fitting from over 3 years to 10 weeks.

Future developments included the implementation of the choose and book direct booking system, decentralisation of services to community settings, increasing the skill base, and development of a hearing therapy service.

Members welcomed the improvements made and expressed support for the extension of the planned decentralisation of services. It was suggested an update should be provided following the outcome of the external review of the paediatric audiology service.

RESOLVED:

That    (a)        progress made in improving the audiology service for adults including the reduction in waiting times and the transition to digital technology be welcomed;

(b)               an update on paediatric audiology service should be provided following the outcome of the external review of the service: and

(c)               the update should include a report on progress in decenralising adult audiology services and plans for extending the programme.

To consider the Committee’s work programme.

The Committee considered its work programme.

The Chairman commented on the range of health issues the Committee would need to consider in the coming months.  She said that it was highly likely that additional formal meetings would be required.  In addition she thought some informal meetings would also be necessary.

The Committee agreed that provision should be made for their next two scheduled meetings to be extended into the afternoon to ensure that they could give proper consideration to issues before them and to make more efficient use of the time of visiting presenters.

It was proposed to add consideration of access to appropriate Healthcare in the South Wye area to the work programme given the lower health outcomes for this area and the expanding population.

RESOLVED: 

That    (a)        it be formally requested that an additional two meetings for the Health Scrutiny Committee be scheduled when the 2009/10 Council diary is prepared and that the Strategic Monitoring Committee give consideration to requesting that the same provision be made for the other Scrutiny Committees; and

            (b)       the work programme, as amended, be approved and reported to the Strategic Monitoring Committee