Adult Mental Health Transformation
Briefing Paper for HOSC
October 2015
- Introduction:
Adult Mental Health services are currently provided by Worcestershire Health and Care Trust (WHCT) and commissioned by the Worcestershire County Council (WCC) and the 3 Worcestershire Clinical Commissioning Groups (CCG). There are a range of changes and developments taking place. This briefing note is designed to provide an overview of these for HOSC members.
In this current fiscal climate both commissioners and providers are faced with really difficult decisions around how we use our resources to best effect. Combined financial pressures across the system means that there will be a reduction in how much money is spent on mental health services across Worcestershire over the next few years. However, all stakeholders are committed to offering the very best services we can and modernising these within the constraints we have.
In the context of the above, GPs and commissioners have been reviewing Primary Mental Health Care Services to both extend the range of services available and provide a consistent service across the county but within current resource. Therefore, the new primary care developments are dependent on the redesign of secondary care services and reallocation of investment to support patients within primary care and helpGPs to manage patients and ensure a seamless step down into the new primary care provision.
Furthermore, changes to funding of the Reablement / Vocational Services and intentions to redesigninpatient bed provision need to be set in context and considered alongside the developments in Primary and Secondary care. The changes to adult mental services are significant but do offer a genuine opportunity to improve access to and availability of these services as well as managing reducing resources, growing demand and the changing needs of our population.
- Enhanced Primary Care Mental Health Service (EPCMHS) Model:
The review undertaken by commissioners resulted in the development of a new service specification which reflects what the public have identified is important to them and the direction of travel towards self-management of care and improving wellbeing for individuals. The full detail is included in the Summary Engagement Report attached.
The intention is to have a single service that provides a 'no wrong door' approach for both patients and GPs, which is delivered in collaboration with a variety of organisations, including the Trust, employment services and Local Authorities and the Voluntary and Community Sector (VCS) to ensure that:
- a consistent service is available across Worcestershire localities
- people can access support earlier without the need for referral
- those individuals with more complex mental health problems receive timely access to services and can step up and step down between primary and secondary care services in a way that promotes recovery
- resources are used to best effect. It is anticipated that savings will be identified from secondary care for investment back into the new wellbeing provision and expansion in primary care as well as the national efficiency programme.
The new EPCMHSmodel requiresthe development of a Wellbeing Hub and an increased focus on the role of the Single Point of Access (SPA) rolling this out county wide to Redditch, Bromsgrove and the Wyre Forest.
The SPA will manage referrals across the whole mental health pathway and provide appointment booking for first time mental health assessment both in primary care and for Community Mental Health Teams. The Wellbeing Hub provides a centralised access point for information, signposting and appointment booking for mental wellbeing services.
The intention is to reduce mental health stigma by emphasising ‘Wellbeing’ rather than the labelling of mental ‘illness’. Key to this is providing people with information so they are empowered to help themselves as early as possible or seek the help they need, including those with long-term medical conditions, and ensuring there is quick access to services such as psychological therapies.
Recognising that the VCS are better placed to deliver some aspects of the new service model, the Wellbeing Hub will be delivered in partnership with Community First as the “accountable body” for the VCS and provision of wellbeing programmes. The new primary care service will be part of the newly launched Healthy Minds Worcestershire service and include a range of support including on-line resources and the ability to self-refer for psychological support.
Those people who need more intensive help can quickly step-up to secondary care services and when people are recovering from a mental health crisis they can be cared for in primary care and access services to help them live well in the community. Care will be co-ordinated by mental health workers throughout the patient journey.
Worcestershire Health and Care Trust (WHCT) was commissioned to deliver the redesigned Primary Mental Health Service from 1st April 2016, which is now underway.In discussions with commissioners the Trust has now agreed to move £500K of existing funding from secondary care to support delivery of the new service and has identified a further £100k of new noncurrent monies to fund the initial developments to ensure that county-wide infrastructure is in place and accessible to primary care.
It is important to note that the proposed national cuts to the Public Health Ring-fence Grant could significantly impact on these developments. The Cabinet paper of 16th July 2015 references £960k of savings relating to Primary Care Mental Health services. While funding is secure until 2016/17, withdrawal of funding after then is a significant risk to this redesign and to the sustainability of mental health services for patients. The Trust is working with the Council and CCGs to identify alternative funding arrangements and understand any potential implications and delays to redesign timelines.
- Secondary Care Redesign:
Through the redesign of secondary care there is a further savings requirement of £500kfrom mental health budgets for the national efficiency programme. It expected that this would be released recurrently as the new primary care developments are established and the activity shift from secondary to primary care is underway and more patients are supported earlier in primary care and by the VCS.
The redesigned secondary care pathway will be co-produced with service users to ensure the delivery of evidence based services, to the appropriate client group, within the financial resources available. The engagement with stakeholders will be in accordance with Trust’s guidance ‘Working Together In Partnership With Patients’ – A Strategic Approach To Co-Production”. This will be supported by the Patient Engagement Lead, Communications Department, Finance and HR teams.
Workshops with patients, carers, public and staff will take place towards the end of 2015, and givens relating to the future model will be presented in order to identify service priorities and allow a deliverable and sustainable model to be agreed. It is anticipated a model will be developed during December and subsequently agreed in in early 2016. An update on these developments will be provided to HOSC in January.
- Other Adult Mental Health Developments:
Inpatients, Harvington Ward, Kidderminster
The recent Care Quality Commission (CQC) inspection highlighted a number of significant issues relating to the fabric of the building particularly in relation to ligature risks at Harvington ward based in the Robertson Centre at Kidderminster. There are a number of other weaknesses in relation to the ward including;
- Dormitory accommodation
- Isolation from other inpatient mental health services and senior management support
- Gender compliance requirements (Single sex accommodation)
Raising the standard of accommodation would be a considerable challenge. To undertake remedial works to Harvington Ward would cost £456k and the ward would have to be empty for a period of about 4 months to enable this work to happen. A further £72k would be required to make the accommodation on the Clifton/Abberley estate (Newtown site)suitable for patient care and accommodate patients moving from Harvington ward.
The Trust has a duty to ensure that it uses its finite resources to best possible effect, and while this could address some of the significant structural issues, it would not address the other shortcomings. Therefore, the justification for this level of investment which does not result in a longer tem sustainable solution is questionable. Harvington is also not part of the Trust’s long-term vision for inpatient care which is to move towards a centralised (Centre of Excellence) service based on the Newtown site in Worcester.
This offers the opportunity to invest in a more recovery-focused community based service. The intention is to reduce dependency on beds and make available a more effective and viable alternative to an inpatient admission. Camden and Islington Foundation Trust have developed a servicein partnership with the voluntary sector who provide the crisis care service elements. Their model promotes a ‘whole system approach’. It is task centered and goal specific which ensures the reason for admission is clear and meets the patient’s needs.
The Trust is proposing to develop a similar evidence-based model, including local crisis and respite provision, to deliver a better serviceby reducing length of stay in secondary care beds. Given the significant environmental challenge outlined above, this could mean the centralisation of the Harvington beds onto the Newtown site with crisis beds delivered locally. Clearly, there would need to be a period of consultation with external stakeholders and a plan to support this is being developed. The Trust will work collaboratively with commissioners to agree what would be appropriate in terms of capacity for inpatient beds and alternative provision to provide short-term crisis support and respite based on best evidence, and to understand any impact on out of area placements. An update on these developments via briefing to HOSC will be made later in the year.
Employment and Reablement Pathway:
Over the last 5 years there have been significant changes to the Employment and Reablement pathway, for example the closure of day centres as part of a move to provide more support in local communities designed around the individual needs and wishes of service users. Within the Employment and Reablement pathway, Vocational Centres provide activities within a supported setting for those not yet ready to access mainstream community based groups.
Changes already made across the pathway have been extremely successful, and working with commissioners we now want to provide a modern hub and spoke model across the county for vocational centres which will build on the successful changes in other parts of the pathway.
The Trust currently runs three vocational centres (Link Nurseries, Orchard Place Workshop and Shrub Hill Workshop). The budget to run these is around £700k. In this current financial climate service redesign initiatives are expected to be as efficient as possible and therefore commissioners have set a savings target of £250k which they expect to be released through this new delivery model of vocational support.
Given the scale of savings required there are some restrictions on what’s possible and the current model will have to change. The new Employment and Reablement Service will provide a range of activities which will support people to get into work, volunteering or education, but how and where these activities may take place will need to be different.
We recognise the need to provide the service with a ‘hub’ (more supported, safe environments) for people, but we also wish to continue to develop more outreach activities (‘spokes’) in the community which will help expand the range of options available. This will also ensure there is more equitable access to these activities across the county.
We recognise the need for a ‘hub’ in the North and a ‘hub’ in the South which are accessible and ensures equitable access for those who will use them. Therefore, a reasonable conclusion would be that the new model operates initially out of Worcester City (South hub) and Redditch (North hub), however through the co-production process we will listen to all views expressed and key elements of the model and valued interventions can be incorporated in the future design of these hubs including any longer term accommodation requirements.
While there are restrictions and parameters which we have to work within, this is a real opportunity to modernise the service and to increase the options available to help people trying to learn new skills and regain control and independence.
We will take an Appreciative Inquiry approach which is based around
- understanding what works well and why
- what we need to do more of or what new things we need to do make things even better
- working out how all our ideas are going to fit together
We will hold workshops and events to gain ideas, and we will develop a working group to help implement the new service and we want those representing service users, staff and other interested groups to be part of this.The new service will need to ‘go live’ in April 2016 and a plan will be put forward a plan to commissioners in Janaury. An update on these developments will be provided at December’s HOSC meeting.
- Conclusion:
This briefing note has provided an overview of the future developments in mental health services for Worcestershire. The Trust and Commissioners have been invited to attend future HOSC meetings to discuss the changes in more detail. December’s meeting will receive an update on the Employment and Reablement Pathway, and January’s meeting will receive an update on Primary/Secondary care redesign and the Inpatient bed proposal.
For further information please contact:
Susan Harris
Director of Strategy and Business Development
Worcestershire Health and Care Trust
Jenny Dalloway
Lead Commissioner – Mental Health and Dementia (Interim)
Integrated Commissioning Unit
Worcestershire County Council
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