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Health Overview and Scrutiny Panel - Thursday 10 July 2025 7:30 pm
July 10, 2025 View on council website Watch video of meetingSummary
The Health Overview and Scrutiny Panel met to review Kingston's Adult Community Health Services, receiving an update on public health matters and discussing future work plans. The panel reviewed the plans for standardisation and developments in line with the 'left shift' to community based care. Councillors requested more information on the Connected Kingston website, and discussed how to involve the neighbourhood system and residents in health service changes.
Adult Community Health Services Review
The panel reviewed Kingston's Adult Community Health Services, receiving a report from Anna Jebb, Acting Director of Strategy at Kingston and Richmond Foundation Trust (KRFT), Grant Henderson, Board Lead Frontline Services at Your Healthcare (YHC), Julia McDonald, Corporate Head of Service, Adult Social Care, Strategy Transformation Partnerships at Royal Borough of Kingston upon Thames (RBK), and Katy Scammell, Director of Public Health at RBK.
The report provided a review of local health partners' plans for standardisation and developments in line with the 'left shift' to community based care, directly addressing the Panel's Key Lines of Enquiry.
Standardising Community Health Services
The panel heard that South West London Integrated Care Board (SWL ICB) have been working with place leads and community providers across SWL to review the provision of community services. Service specifications have been reviewed and revised to ensure a consistent set of core service specifications to be used across SWL, including Kingston. The ICB will also develop a suite of consistent quality and productivity metrics to be included in all provider contracts.
The next step will be to understand the baseline position for Your Healthcare in relation to the specifications and metrics, and to develop an action plan to demonstrate how Your Healthcare will deliver services to the revised service specifications.
Your Healthcare and Community Nursing
The panel heard that Kingston has a highly skilled community-based adult nursing service which provides a range of skilled nursing care to adult residents within the borough, or those registered with a Kingston GP. The community nursing service is a central component of Your Healthcare's community provision and is focussed principally on the delivery of expert clinical care and the contribution nursing makes to the promotion of healthier lifestyles.
Community nurses visit housebound patients in their own homes, as well as residential care settings, to provide a comprehensive range of clinical nursing support across a broad range of interventions including wound management, medicines management, palliative, end of life care and symptom control, equipment provision to facilitate discharge, long term condition management, admission avoidance, continence and catheter management, immunisation, health education and promotion.
Impact of Kingston and Richmond NHS Foundation Trust Merger
The panel heard that the merger of Hounslow and Richmond Community Healthcare NHS Trust (HRCH) and Kingston Hospital NHS Foundation Trust (KHFT) took place in November 2024, and in the 18 months leading up to the merger, there were a number of clinical projects started, looking to implement changes and improvements to pathways for patients across hospital and community services. A number of these projects included Your Healthcare as well as Richmond Community Services - and so were an excellent opportunity to learn and share good practice across Kingston and Richmond.
Examples of how the merger will positively impact delivery of quality of Community services in Kingston include:
- Urogynae Pathway a project which will put in place (from August 2025), a urogynae pathway, which is based in the community and aims to see patients much more quickly (with specialist nursing and physio) and much earlier in their symptom pathway - treating their condition and avoiding referrals into the hospital and more invasive treatment.
- Fracture liaison service which is a pathway that identifies patients at risk of fragility fractures when they attend the hospital with a first fracture, and refers them to appropriate services in primary care/community or acute; and ensures that they get appropriate treatment quickly to avoid a secondary fracture and further admissions.
- Deconditioning Pathway which was a programme of work to engage therapies staff across hospital, and Kingston and Richmond community teams, to increase communication between community and hospital teams, standardise pathways of care, and raise the awareness of deconditioning and its impact on patients.
Prevention and Early Intervention in the Community & Future Need
The panel heard that within Kingston the Proactive Anticipatory Care model (PAC) delivers a multi-disciplinary approach for all residents who are identified with needs associated with rising complexity, possibly due to frailty. This multidisciplinary approach is delivered by primary care, community health teams, adult social care and the voluntary sector. Central to the success of the model are the coordination of care functions.
As of June 2025, there are 419 clients on PAC programme in Kingston - where people have been on the programme for 12 months, unplanned care reduced by 49% (SWL Health Insights, June 2025).
Strengthening Community Based Provision Through Commissioning & Partnership
The panel heard that RBK commissions some key services from YHC in order to deliver social care type services, including Reablement, Shared Lives, as well as Handyman services. In addition, RBK as lead organisation for equipment services works very closely with YHC to ensure smooth equipment provision via community based services, where both YHC and social care intersect.
Reducing Levels of Need & De-escalation
The panel heard that YHC and RBK are closely working together on key prevention services, including the Proactive Anticipatory Care (PAC) model. The model was launched in 2021 across Richmond and Kingston. Under PAC, each patient is the focus of a weekly multi-disciplinary team meeting which includes GPs, community, social care and hospital-based services working together to provide more proactive and coordinated care.
Addressing Inequalities
The panel heard that YHC is committed to promoting equality and diversity within their workforce and ensuring that they are compliant with the requirements of the Equality Act 20101 and national frameworks and strategies.
Staff Flux
Councillor Andrew Bolton raised concerns about staff flux, as highlighted in the report. He asked what sort of challenges, problems, or opportunities did the organisation face because of the staff flux.
Ed Montgomery, Managing Director of Your Health Care, said that it's a known issue for London boroughs around the movement of staff and the pressures on actually keeping staff, especially as Kingston is an outer London borough. Bernice Constable, Acting Chief Nurse at Kingston Richmond Foundation Trust, added that the hospital has had significant challenges with recruitment in various elements of the professions.
Proactive Anticipatory Care
Councillor Susan Skipwith asked what exactly is meant by the proactive anticipatory care, and how does that interact with social prescribing?
Grant Henderson explained that it is people who have a rising trajectory of need, so the service is trying to get a little bit more upstream in terms of their presentation with the idea of approaching things in a very much more kind of multidisciplinary way, looking at all aspects of their care and planning a kind of prescription in consequence of that.
Shane Brennan, Chief Executive of Stay Well, added that the model has been rolled out across Richmond and Kingston, and the way it's been working, is now the kind of template for what's going to be happening nationally, which is really good.
Connected Kingston
Councillor Skipwith said she's always been very intrigued about the Connected Kingston website, which she knows is theoretically part of social prescribing, but it does seem to her that it's something that ought to be enabling the community to help themselves. She said she feels like it's really really poorly understood outside of healthcare professionals, and even the name doesn't really give you a clue as to what it is.
Katy Scammell said that what she's hearing from officers not only in public health, but also more widely is how fantastic that resource is, and how well used it is. She added that there's been a lot of discussion lately around how the council can utilise that more.
Councillor Skipwith suggested a briefing to all councillors to give feedback.
Councillor Involvement
Councillor Mike Massimi asked why local councillors are not part of the care and prevention network. He said that if anyone knows what's happening in a ward, who is actually at risk, who might need additional support, it tends to be either the Police Community Support Officer (PCSO) or the local councillor.
Shane Brennan said that all councillors are welcome to come to Stay Well to rally house and to Bradbury, and that Stay Well will be celebrating 80 years next year, so they're going to have a number of events open events to do that.
Carers
David Still from Kingston Carers Network, said that one of the things that they sometimes see is where there are people who are caring and the care package that is being delivered to people isn't really meeting fully the needs of the individual. He added that there are some people who are seeking more care and more support and they're not being given the support that they feel they need and that puts more pressure on the carers and they feel more isolated, they feel as though there is a greater burden being put onto them.
He also raised concerns about the impact on carers when people are being discharged quickly from hospital, and said that he would particularly like it when people are considering presentations, that they always consider what the impact is going to be on the carers in that situation as well.
Neighbourhood Health
Councillor Roger Hayes said he'd listened to Wes Streeting2 at the start of the week telling everyone how fabulous neighbourhood health hubs were going to be, and yet there was still no mention of the integration with social care. He asked where on earth is that element.
Ed Montgomery said that the neighbourhoods versus the primary care network areas is a known issue from the point of view of the overlaps, but it's one the council just needs to tackle and get over. He added that a lot of those Primary Care Networks (PCNs) have a very good view and a really good feel for what's going on in their areas what the requirements are and actually how does that build into this.
Shane Brennan said that Kingston's got a lot going for it, it's not a massively huge borough, it's a great place to live, and the needs and issues that it faces are very real, but he thinks they're very dealable with as well if you take up all the resource that the council has, whether it's the local authority or the health resource.
Katy Scammell reassured the panel that the council is part of that discussion, and that they are meeting to discuss it. She added that what's really helpful in the NHS 10-year plan is they specify that local neighborhood plans need to be developed in partnership under the health and well-being board.
Navigating the System
Councillor Tom Reeve said he was concerned about how people navigate the health and social care system, as it's very fragmented. He asked what the council is going to do to make sure that people can really navigate this system as it changes, and whether the council needs to be thinking in terms of designing a system that's simple to navigate from the start.
Ed Montgomery said that this is about design, and about making sure that the information flows are as simple to the individual that is using the service as anything. He added that it doesn't matter whether you're in the same organisation, you can be within the same organisation and still having the same discussion, so it's about actually how do we design the system so those records flow so so our teams are able to make the most use of their time and we're not we're not using that time as well so it has to be better for both sides to be able to do that and that is part of the design architecture.
Bernice Constable added that there is a culture piece in this as well, and that the council has to start thinking slightly differently and put the infrastructure in place to support people to do the right thing and use the systems appropriately.
Capacity
Councillor Yvonne Tracey said that Rally House is in her ward and she knows it does a wonderful job, but she's just worried that if the council is trying to pick people up earlier, if there was suddenly an influx of people wanting to attend Rally House, whether it has the capacity.
Shane Brennan said that the service is pretty full, and that they work with an awful lot of dementia. He added that post-Covid it's a different service to what they used to run, with a lot more personal care, so it's quite high level needs. He said that they could probably fill another Rally House quite easily to be honest in terms of needs and supporting people.
Coordination
Councillor Andrew Sillett said he was involved in a case that troubled him, where a guy in his 80s had an incident and he'd smashed up his flat. He said that he was trying to get information, but apparently he had four carers four times a day helping him with meals and things like that, and they had tests that found there was nothing wrong with him the brain scans and that so they took away his carers. He couldn't be sent home because his flat had been a bit smashed up the door was smashed or the window was smashed, but it the carers weren't responsible for doing that. He was still in the hospital for two weeks, then he got covered and then he got released and then he heard he'd had another instance and he was back in hospital.
Councillor Sillett said that it seemed to him that there should have been better coordination between the nurses and doctors and the social services, as they seem totally separate.
Shane Brennan said that when you create multi-disciplinary teams ways of working you could you've got to hold people a place where people take ownership of that that case and they work out who's going to do what and they feedback about what they're doing what progress they're making was it one step forward one step back and it's about bringing things together which is a challenge because the way things historically divide and it is a cultural thing as well about way people work you and there's big there's the beginning of changing that because people recognize they need to have more voices in the room more eyes on things more advice about what goes on so but they make better decisions about how better to support people.
Data
Councillor Helen Grocott said that the panel needs to focus on facts and figures, and reminded everyone that when the panel looked at social prescribers, one of the issues they identified was that not all the GPs were putting their data into the same system and not all GPs were signed up to putting their data into the system.
She asked each of the groups, RBK Public Health, Stay Well, Your Health Care and the hospital, what their biggest challenge is, based on what they've written in the paper, what their strategies are, and what the councillors can do to support them and help them with that challenge.
Katy Scammell said that from a public health perspective, the biggest challenge is all the uncertainty at the moment, as the ICB is going through big change, halving their budget and losing a lot of staff.
Julia McDonald said that in terms of what she's written in the paper, around commissioning reablement equipment and how the council works with Your Health Care and the Better Care Fund3 more widely, the biggest challenge is that while it's an opportunity to build together a sort of neighborhood model and to go through the changes, it does also create risks in terms of just capacity to continue with all the transformation work and all the good work that the council is already putting in place.
Denise Madden, Deputy Exec Lead for Kingston Place as part of South West London ICB, said that the biggest challenge is the balance of addressing the need and the demand while maintaining the focus on prevention.
Bernice Constable said that the challenges from the hospitals and community services perspective are around the pace of change, and the need to scale up and look at how to shift a lot more from acute services into community services, on the backdrop of doing more with less money. She added that where the council needs help is how to describe what the hospital is doing to the local population, and to make sure that the council is not over complicating things and that they use the right language to describe the change to people, and keep the patient at the center of anything that they're doing.
Ed Montgomery said that the need to develop, improve and change is happening at a time when the operational pressures remain high, and the finances get tighter and tighter.
Shane Brennan said that the challenges that face Stay Well is that they're dealing with an increasingly elderly frailer crowd, that just absorbs more resource and takes more time, and there's more people like that that they're finding. He added that working in partnership or certainly effective partnership isn't easy, it takes building up relationships it takes up building trust etc etc that takes time and that time is a resource in itself.
Seldom Heard Voices
Councillor Andrew Bolton asked who exactly is meant when the report talks about difficult to reach people, and how the council is actually doing that, and what sort of problems do these difficult or seldom heard voices have.
Grant Henderson said that some of those who aren't well represented include the gypsy roma traveler community, and specific populations of different ethnicities within the borough. He added that the council tailors some of its resources, like cardiac rehab for example, to make sure they particularly reach out to some of those individuals who might feature disproportionately in requiring that service given their propensity to develop issues with their heart.
Julia McDonald added that the council is quite proactive in sharing intelligence and awareness and data and insight, because the council is actually quite in quite a good position to know its communities and have that engagement and co-production approach.
Voluntary Sector
Councillor Farshid Sadr-Hashemi said that he was surprised that everybody didn't say that their biggest problem was money, and that when there is no money, the council needs to use more community activists and volunteers. He said that he has tried for three and a half years to get a voluntary force that works between the hospital and the council, but he hasn't had any help.
Councillor Liz Green said that this is a discussion for the work plan to look at how the voluntary sector can be encouraged more used more enhanced more whatever words you want to use.
Public Health Verbal Update
Katy Scammell gave a verbal update on public health matters in the Borough. She noted that:
- The Director of Public Health's annual report has just been launched, and it's on healthy hearts.
- There's a yellow heat health alert on until the 15th of July.
- It's alcohol awareness week, and the theme this week is the relationship between work and health.
- Measles are on the rise in London.
Work Plan
The panel discussed possible items for the work plan.
David Still said that one of the things that would be very useful would be to discuss the mental health bill, and what the impact might be on carers.
Councillor Tom Reeve said he'd like to look at Child and Adolescent Mental Health Services (CAMHS), and the progress that's being made in that area.
Councillor Helen Grocott said she was really keen that the panel have something where they describe the strategies to address and proactively manage the additional impact on resources for health, looking at GP surgeries and dentistry education primary and secondary schools for the new residents in the new build catchment areas around the Curzon Estate Signal Park and potentially in future Hook Park development if it comes to pass.
Councillor Lorraine Dunstone said she was sure that it may well come under the remit of the work plan to have a conversation on doctor surgeries that are really not fit for purpose.
Ed Montgomery said that there's the neighborhood health component, and a wrap around into some of the sites and facilities at the same kind of time, especially from a community asset perspective.
Bernice Constable suggested an update on how the carers clinical liaison service at the hospital operates, and how the hospital supports carers who don't even know they're carers when they first arrive at the hospital.
Councillor Grocott suggested something about the assisted living bill and how is it going to affect Kingston residents and are we ready and how are we going to do it how are we going to offer it.
Councillor Reeve said that it would be nice to have the prevention and PAC work brought back to the panel, and to look at how the voluntary sector is used effectively within the health service. He also suggested looking at how carers are going to be impacted by the changes that are taking place, and the issue of care across boundaries.
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The Equality Act 2010 is a UK law that protects people from discrimination. ↩
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Wes Streeting is the Shadow Secretary of State for Health and Social Care. ↩
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The Better Care Fund (BCF) is a programme spanning health and social care, intended to join up services so people receive better, more co-ordinated care. ↩
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