To receive apologies for absence.

Apologies were received from Councillors MJ Fishley, GA Powell and PJ Watts.

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

Councillor PGH Cutter substituted for Councillor MJ Fishley and Councillor DW Greenow for Councillor PJ Watts.

To receive any declarations of interest by Members in respect of items on this agenda.

Councillor SPA Daniels declared a personal interest as an employee of Hereford Hospitals NHS Trust.

To approve and sign the Minutes of the meeting held on 20th September, 2007

It was noted that the apologies of Councillor KS Guthrie and the attendance of Mr Wilkinson and Mr Hardy had not been recorded in the Minutes circulated with the agenda papers.  An amended set had been prepared for signature by the Chairman.

RESOLVED:   That the Minutes of the meeting held on 20th September, 2007 as amended be confirmed as a correct record and signed by the Chairman.

Preparation of Agenda Papers

The Chairman commented on the difficulties experienced in obtaining reports from partner organisations in time for despatch with the agenda papers.   This was hindering the ability of the Committee to prepare and perform its role efficiently and effectively and was unacceptable.  Also, information was not being published in the public domain at the time at which it should.

The Committee agreed that the Chief Executives of Health partners should be reminded of the importance of submitting information to the Committee and the public in a timely fashion.

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.

To provide an update on the preparation of a memorandum of understanding between the Council and the Health Protection Agency.

The Committee considered an update on the preparation of a memorandum of understanding (MOU) between the Council and the Health Protection Agency (HPA) dealing with the protocols for tackling infectious diseases.

The Committee had received an update on emergency planning arrangements in March 2007, following on from the Committee’s Review of the response to the 2003 outbreak of Legionnaires Disease in Hereford.  The Committee had noted that at that time an MOU had not been finalised and had requested an update in six months time.

The Emergency Planning Manager presented the update, reporting on developments since the Committee’s meeting in March.  He confirmed that the HPA had now produced the MOU and although formal ratification was awaited this was imminent. He commented on the content of the MOU itself, copies of which had been circulated separately to Members of the Committee. 

The report also noted, on a further point raised by the Committee in March about offering Members the opportunity to observe future emergency planning exercises, that a seminar was being programmed for the New Year following which invitations to Members to observe future emergency planning exercises would be made.

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

·         In response to a question about emergency planning exercises the Emergency Planning Manager confirmed that exercises had been undertaken at various levels both strategic and local and gave examples.  He referred to plans to involve Members as set out in the report and noted a request for Local Members to be kept informed of exercises in their area.

·         Asked if he was satisfied that effective measures were now in place to deal with an infectious disease outbreak the Emergency Planning Manager said that the Civil Contingencies Act 2004 had led to changed arrangements.  Looking back at the Legionnaires Disease outbreak there had been some evidence of parallel chains of command and some disjointedness in communication.  He considered that the protocols in the MOU addressed these issues.  He was also particularly pleased with the appointment of an Emergency Planning Officer for Health who would produce coherent plans on behalf of the Council, the Primary Care Trust and the Hospitals Trust.

The Emergency Planning Manager thanked the Committee for their contribution to taking the production of the MOU forward, bringing the issue to a conclusion.

RESOLVED: That the development of the Memorandum of Understanding between the Council and the Health Protection Agency be welcomed.

To receive a presentation on the Annual report of the Director of Public Health and consider issues arising from it.

The Committee received a presentation on the Annual Report of the Director of Public Health 2007 and issues arising from it.

Dr Frances Howie, Associate Director of Public Health gave a presentation on the report.  She said that she would be happy to report to the Committee in greater depth on any of the key issues.

The presentation focused on general health, health inequalities, risk-taking (smoking, drinking, obesity); and other challenges (ageing, climate change).  The main points made in the presentation are summarised below. 

General health

Generally health is good in Herefordshire and people have a higher life expectancy compared with national averages.

Childhood mortality rates are low, infant mortality is also low. Standard Mortality Ratios (SMR) are generally below average.  However, they are above average in three key areas: stroke, all accidents and land transport accidents.

Although, small in number the statistics for years of life lost showed 7% of all years of life lost up to 75 come from land transport accidents, and 11% from all accidents.  There was scope for the Health Service and its partners to influence  these areas.

Cancer deaths account for 36% of all years of life lost. 

Circulatory diseases account for 24%.

The female SMR for stroke was 133 against the SMR for England of 100 and had proved resistant to change: there had been SMR of 131 in 1993.

Dental health of children is poor.  The mean number of decayed, missing or filled teeth in 5-year olds in 2005/2006 was 1.78, compared with 1.02 in the West Midlands.  There were significant differences between different social classes.

Health inequalities

These exist in Herefordshire as elsewhere with a 4 year life expectancy gap between the well-off and less well-off quartiles. SMRs are higher in the socio-economically deprived areas.  SMR = 133 for men in South Wye (compared with the Herefordshire figure of 100). SMR = 129 for men in 18 most deprived Super Output Areas (SOAs). Gender differences: for women in South Wye SMR =110, and 102 in SOAs.

Perinatal mortality: 4 years data, rate of 4.71 in least deprived quartile; 9.43 in most deprived quartile; and 13.8 in South Wye.  Inequalities are reflected at a low age.

Hospital admission rates per 1,000 – men 177.2 for whole county, 234.7 for D18, 248.4 for South Wye.  Especially high admission rates for coronary heart disease, respiratory, psychiatric and paediatric from D18 and South Wye.

Key risk taking behaviours (Smoking Drinking, and Obesity) are more likely in the deprived areas.  Action directed at these behaviours would have the most significant impact on health.

Risk-taking:  smoking

2005 Adult Regional Lifestyle Survey - 21% of adult population in Herefordshire smokes - 25% of men and 19% of women. Highest rate here is among 35-44 year olds (29%) (regional average of 22%).

2006 Teenage Lifestyle Survey (Years 7, 8, 9 and 10) - 10% of 15 year old boys, 25% of 15 year  ...  view the full minutes text for item 33.

To receive an update from the Trust on various issues.

The Committee received an update from the Primary Care Trust on various issues.

A report from the PCT was circulated at the meeting.  This covered the following issues:  the delivery of the target of treating 90% of patients within 18 weeks of referral to the Hospitals Trust; the Reforming Unscheduled Care Project designed to improve the way urgent and emergency (unscheduled) care was planned, delivered and used looking at reducing or avoiding attendance at A&E, reducing emergency admissions and reducing emergency length of stay; the membership of the Professional Advisory Commissioning Executive and the development of the Local Area Agreement and the Local Delivery Plan.

Mr Paul Edwards, Director of Commissioning and Strategy, presented the report.

The summary of progress on delivery of the 18 week target was that there was one major risk (orthopaedics) to the delivery of the admitted patient target but it was still expected that the target would be achieved by the end of December 2007.  The target for non-admitted patients was also expected to be achieved.  It was noted that issues around the transfer of records to the new computer system installed by the Hospitals Trust were being resolved and data should be available to demonstrate achievement of the targets.

Performance monitoring of indicators relevant to the Reforming Unscheduled Care Project showed that there had been some reduction in emergency occupied bed days, length of stay and admissions.  However, there was scope to deliver further change particularly around the avoidance of A&E and the development of alternative pathways.

The Local Delivery Plan for 2008/09 had to be submitted by the end of March 2008 and a report could be made to the Committee then if required.

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

·         In response to questions about the 18 week target Mr Edwards reported that about 1,300 patients were involved and 800 had been treated to date within the target.  Asked about the cost of meeting the target he said that whilst difficult to quantify precisely it was about £2.7 million.  It was a Department of Health target.

One of the key actions listed in the report to meet the target was to facilitate early discharges including the use of community hospital beds.  It was asked how this would be implemented when community hospital beds were themselves full.  Mr Edwards said that work was being carried out to look at the patient care system as a whole in order to move patients through the system.  More transfers were being achieved year on year. Two extra social workers had been appointed.

·         Asked about the rate of readmissions to hospital Mr Edwards said that this was regularly monitored and that it was not a problem. Readmissions were not in the hospital’s interest.  He was confident the data was accurate.

·         It was asked what communication arrangements were in place to direct patients to the correct source of care.  Mr Edwards said that anyone attending A&E inappropriately was given  ...  view the full minutes text for item 34.

To receive an update from the Trust on various issues.

The Committee received an update from the Hospitals Trust on various issues.

A report from the Hospitals Trust had been circulated separately.  This commented on infection prevention and control in particular Clostridium Difficile (C Diff) and MRSA; bed occupancy and access targets; communication with patients; and the link to the Patient and Public Involvement Forum.

Mr M Coupe, Director of Business Development, presented the report.  He added that there had been one additional case of MRSA since August 2007 but the patient had brought the infection into the hospital.

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

·         Reassurance was sought on the position on infection prevention following a report by the Health Protection Agency in the summer that had shown high levels of infection compared with other Trusts.  Mr Coupe replied that the Agency’s report had not taken into account that the statistics on Hereford Hospital had been flawed because the hospital provided a testing service for all the GPs in the County and those cases had been included in the Hospital’s figures.  He also referred to a press release issued by the Trust’s Chief Executive.  Incidences of infection were lower than in the previous year and the Trust was reassured by the current position.  He added that where infection did arise the whole health community needed to work together to control the infection.  For example, the Trust needed to consider how best it could support nursing homes and other like facilities.

·         He reported that one of two wards closed because of the Norovirus had been opened that day.

·         In response to a question about suggestions that staff were not changing uniforms after dealing with cases of infection Mr Coupe said that whilst he could not comment on specific cases the hospital did have a very rigorous infection control policy and systems in place and encouraged all issues to be raised with the management team. 

·         Asked about bed occupancy Mr Coupe acknowledged that there were times when insufficient beds were available.  He referred to a range of steps that could be considered, including shortening lengths of stay, increasing day case numbers and removing blockages in the system.  The Trust was reviewing the number of beds needed.  Amongst other things this would take account of national guidance on spaces between beds, designed to reduce the risk of spreading infection.

·         It was asked whether consideration had been given to screening patients for MRSA prior to discharging them, say, to Community Hospitals.  Mr Coupe said that with an average length of stay of 4 1/2 days the vast majority of patients who would manifest MRSA would have already had it when entering the hospital and the benefit of pre-discharge screening for MRSA was therefore questionable. 

·         It was asked how cleaning arrangements today compared with those in the past.  Mr Coupe that there was now a much greater science in monitoring cleanliness than there had been 25 years ago, with a national monitoring regime in place.  The Trust’s contract with its  ...  view the full minutes text for item 35.

To receive an update from the Trust on various issues.

It was reported that a representative from the Trust was not able to attend the meeting as had been expected.  No update could therefore be provided.

The Chairman asked to be notified of any particular issues that the Committee wished to bring to the Trust’s attention.

To receive a progress report on the development of a Local Involvement Network.

The Committee considered progress towards procuring a host for Herefordshire’s Local Involvement Network (LINk).

The Senior Community Involvement Officer presented the report.  He commented on some of the issues that had been raised at the stakeholder event on 3 December.  These had included establishing a clear link to the Council whilst maintaining the independence of the LINk and clarification of the role of the Council as host organisation and the role of the LINk itself.  The importance of avoiding duplication in the arrangements would be reflected in the invitation to tender.

RESOLVED:  That a progress report be made to the next meeting.

To discuss information relevant to the review.

The Committee received a presentation on falls prevention for older people and the care of people who have fallen.

A scoping statement for a review of elderly falls had been approved by the Committee in September 2007.

Lillian Somervaille, Public Health Consultant at the Primary Care Trust gave a presentation.  The principal points are summarised below.

Why focus on falls?

Every year around 35% of people over the age of 65 and 45% of people aged over 80 will have a fall.  Of those that fall 20-30% will suffer moderate to severe injury. Falls result in loss of confidence, increased dependency, isolation, and depression.  A history of falls is a good predictor of hip fracture in older people.  Someone with osteoporosis and a recent fall is 25x more likely to have a fragility fracture.

Cost

Locally in Herefordshire there is an older population than the national average and this older age group is increasing.  A large number of hospital in-patient admissions are due to injury caused by falls.  The rate of hip fracture in older people is higher than the national average – and remains high when age and rurality are taken into account.  The 2007 Director of Public Health’s report calls for a county wide audit to establish the action triggered when an older person attends with a falls related injury.  There is a need to work with partners to reduce hospital admissions for hip fractures.

Preventing falls –  national picture

Fewer than 1 in 50 older people recorded as having a high risk of falling has a recorded referral to a falls service or exercise programme.  Older patients are unlikely to have a computer recorded history of falls.  Most patients returning home from A&E after a fragility fracture were not offered a falls assessment; only 22% were referred for exercise programmes to prevent future falls.

Caring for those who have fallen – national picture

Nearly three quarters of older women with diagnosed osteoporosis and a previous fracture receive the appropriate drugs.  After recovery from hip fracture surgery less than 50% were on appropriate treatment for osteoporosis.  For the minority of patients attending a falls clinic, the falls and fracture assessments and treatments were improved.

Case Study

Mr W – an 85 year old widower in rural area with frequent falls attendance at Minor Injuries Unit.  He eventually agreed to home assessment.  The problem was related to  chopping firewood  to raise income.  Following a referral to benefit check it was no longer necessary for him to chop wood.  The study highlights desire for independence and that people are entitled to refuse help.  Solutions are often not found within the NHS.

What should we do?

Are national findings reflected in local practice? Local benchmarking is needed. 

Referral to the falls clinic is very important.  Equity profiling is needed to see if  referrals to the falls clinic are consistent around the county and if not, why not.

Identification of those at risk of falling - are the right  ...  view the full minutes text for item 38.

To note an update on developments within the mental health service.

Further to the report to the Committee in September the Committee received an update on developments within the mental health services.

One report had been included in the agenda papers and an additional report had been circulated setting out key changes being implemented following the Future of Mental Health Services Consultation Paper.

The Committee noted both reports.

To consider the Committee’s work programme.

The Committee considered its work programme.

The following additions were proposed:

·         Arising from the Director of Public Health’s report:  reports on stroke services and sexual health.

·         Local Delivery Plan 2008/09

The Chairman informed the Committee that she was requesting that the number of scheduled meetings should be increased to six to facilitate the conduct of business.

RESOLVED:   That the work programme as amended be approved and reported to the Strategic Monitoring Committee.