Wolverhampton Mental Health Strategy Review March 2014

Structure of the report 1. 2. 3. 4. 5. 6. 7. 8.

Introduction The Referral and Assessment Service (RAS) Changes to inpatient services Medical staff resourcing across the system The secondary care/ primary care interface The Section 75 Agreement The Healthy Minds and Wellbeing Service Cross cutting themes

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Introduction Purpose of the review The purpose of this report is to review the implementation of the 2010 Wolverhampton City PCT and City Council Adult Mental Health Commissioning Strategy (the ‘mental health strategy’) which covers the period 2011 - 2015. The report was commissioned by Wolverhampton Clinical Commissioning Group (CCG) and The Black Country Partnership NHS Foundation Trust (BCPFT), the organisations now responsible for, respectively, commissioning and providing mental health services in the city. The terms of reference for the review were to: • Carry out a ‘high level’ review of the progress on the strategy; • Undertake a critical analysis of work undertaken to date – testing whether care pathways are working and identifying gaps / bottlenecks and inefficiencies and whether the most efficient models have been adopted – evaluating for clinical effectiveness, value for money and delivery within timescales; • Identify areas of improvement in service delivery and outcomes; • Identify areas of little / no progress; • Advise on potential solutions utilising national benchmarking comparisons or learning from nationally recognised good practice.

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Introduction This review does not constitute a new strategy as such, but does support future work on agreeing a strategy for the period 2015 onwards. The original brief for this review identified 14 areas of particular interest to the CCG and trust. We have grouped these 14 issues by theme in this report and added a on ‘cross cutting themes’ towards the end of this pack. The following areas are ‘in scope’: adult mental health services provided by BCPFT in Wolverhampton and the interface/ transition between these services and primary care, the trust’s age defined services i.e. child and adolescent and older people’s mental health, and services for people with learning disabilities. Services for people aged under 18, aged over 65 and/ or with learning disabilities, and services provided by the trust in Sandwell are, therefore ‘out of scope’ except in relation to transition. Methodology The review was carried out by triangulating information obtained through: • Interviews with a large number of stakeholders including service users and carers, GPs, commissioners, the voluntary sector and BCPFT staff. In total almost 50 interviews were carried out (see Appendix One for a full list) • Assessment and analysis of background papers, and commissioner and trust data sets including benchmarking with national data where possible (see Appendix Two for a list of documents used) • A review of best practice and examples from elsewhere. 4

Introduction The individual sections that follow are structured as follows: • The Referral and Assessment Service (RAS) • Changes to inpatient services • Medical staff resourcing across the system • The secondary care/ primary care interface • The Section 75 Agreement • The Healthy Minds and Wellbeing Service • Cross cutting themes Each section provides an oversight of the issue, our findings and conclusions, and our recommendations. The recommendations are categorised as: • ‘Do now’ • ‘Do soon’ • ‘Do later’

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The Referral and Assessment Service (RAS) The brief Review the role and function of the RAS as a single point of access including the impact upon service user pathways and interface with other assessment services within CAMHS and Older Adults Psychiatry Background to the Referral and Assessment Service The Referral and Assessment Service (RAS) was introduced as part of the mental health strategy. It was originally envisaged as a single point of access (SPA) to all BCPFT adult mental health services serving Wolverhampton. But it should be noted that: • Healthy Minds and the Wellbeing service can be accessed via the RAS or using Ticket to Recovery • Referrals to the early interventions service will also by-pass RAS as this service, somewhat unusually, sits within the children’s and not the adult mental health division. The primary function of RAS is to provide triage and where required an initial assessment for all patients deemed, by the referrer, to require primary or secondary mental health services (i.e. wellbeing, complex care, home treatment and/ or inpatient). It’s prime function can therefore be described as ‘ensuring that the right patients get to the right service’. The RAS combines the ‘old’ pre-mental health strategy roles of: • Adult liaison (formerly based at New Cross Hospital) • Triage and assessment of urgent and routine referrals which was carried out by CMHTs in the old model (equivalent to referrals for the complex care teams, inpatient and home treatment, and the Wellbeing service) • Crisis intervention (up to 14 day intervention and a maximum caseload of 20 patients) 6

The Referral and Assessment Service (RAS) The RAS takes referrals from professional across the city (GPs, the Police, A&E, acute hospital wards at New Cross Hospital, AMHPs and other BCPFT services). In theory referrals aren’t accepted from patients or their relations, but in practice RAS does receive a small number of calls from these groups: in these instances the patient is advised to contact their normal service during hours or, if out of hours and risks are identified, an assessment with RAS will be arranged. Referrals are responded to as per contractual targets (48 hours for urgent referrals and 28 days for routine referrals). The 48 hour urgent referral timescale didn’t fit well with the 4 and 12 hour targets associated with A&E. Therefore RAS have introduced an emergency pathway for A&E which is to respond within 6 hours. RAS is contracted to carry out 2,000 urgent assessments and 500 routine assessments per year, as well as to offer crisis resolution for up to 14 days to a caseload of up to 20 patients. These numbers are based on historic referral numbers for the old crisis service and CMHTs. The RAS is therefore responding to four times as many crisis calls as routine referrals. RAS is a nurse led service which operates 24/7 and, as at November 2013, was staffed by 11 x band 6 RMNs and 3 x band 3 outreach workers (total 14 staff). Resources are currently being increased to 14 x band 6 RMNs in order to replace the loss of Council employed social workers previously funded via the now defunct Section 75 agreement (see later section). There is no dedicated medical input into the service and no input from non-nursing disciplines such as occupational therapy and psychology. However, if a patient is accepted onto the RAS caseload for crisis resolution and requires a medical review, this is discussed and arranged with the acute medical team and the patient is seen accordingly. The RAS team also accesses fortnightly psychology training. 7

The Referral and Assessment Service (RAS) Findings The RAS was heralded as solving all initial assessment and navigation issues, but according to many interviews this failed to happen due to underfunding and communication issues which may have shaken confidence in the service. The service specification for RAS reflects some ambiguity in pathways into services; for example it states that: • ‘It is expected that typically patients who are clusters 1-7 will be referred directly to Health Minds/Wellbeing via their GP, however there may be occasions where the complex care service is an appropriate referral through RAS’; • The specification also states that ‘people are not assessed prior to referral and therefore the RAS should receive any referrals however, through education of referrals the majority should be from Clusters 4-8, 11-17’ • Finally lists ‘clusters 1-2 and 3’ patients as exclusions. This is confusing as it recognises the fact that GPs will not assess patients before referring, so the cluster will be uncertain if not unknown, but also implies that either clusters 1-7 or 1-3 (depending on which paragraph is referenced) would not usually be referred to RAS. We also discovered that the Directory of Services distributed to GP practices and which sets out referral routes into secondary care (and other) services, was incorrect in several respects e.g. listing services which no longer exist and stating that most services could be accessed via a GP referral instead of via RAS.

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The Referral and Assessment Service (RAS) We heard from GPs that they found the system ‘confusing’, particularly for non-urgent referrals – there was, however, considerable praise from GPs for the way the trust responds to urgent referrals (which make up the majority of referrals), e.g. stated as being “much better than before”. GP’s concerns are: • They find the system confusing and feel that the role and function of RAS has not been well communicated to them – “Who are these people”, was a comment made at one GP meeting. • The RAS is billed as a ‘single point of access’, but it is not as the Ticket to Recovery is an alternative route into services and the early interventions service, which they associate with adults as well as adolescents, is accessed via children’s services. The concept of a single contact point is strongly supported and there was a view that this should literally mean one point of contact for all BCPFT services i.e. including CAMHS, learning disabilities and older people’s mental health. • Whilst RAS is a good service for urgent needs, it is often perceived as an additional hurdle for routine referrals. Issues raised were: – A view that a consultant advice line (email or phone-based) was needed when GPs just wanted advice . For example , it was suggested that advice about changing medication should be provided via an advice line rather than an outpatient consultation. – A concern that RAS simply delayed routine referrals i.e. an up to 28 day wait to be assessed by RAS followed by a further wait to see a consultant as an outpatient. The suggestion made was that there needs to be a fast track option to tick a box on the referral form saying ‘outpatient consultation required’ which would negate the need for a RAS assessment. 9

The Referral and Assessment Service (RAS) – Too many patients were bounced back to GPs both by RAS and the receiving service (post-RAS assessment) and when this happened there was often a lack of communication as to why. The strongly held view is that : 1. The RAS assessment must be accepted by the receiving BCPFT service i.e. not overturned with the patient being sent back to the GP. 2. If referrals are inappropriate, either to RAS or to the receiving BCPFT service, the service must take responsibility for passing the patient on to the appropriate service rather than passing them back to the GP to ‘start again’. We call this the ‘Mind the Gap’ concept. We have received data from BCPFT relating to referrals into the RAS over the 19 months from 1/6/12 and 17/1/14. During this period 6,037 referrals were received equivalent to 3,697 p.a. Not all of these referrals will be assessed as some would be triaged to other services. A detailed report on September 2013’s referrals to RAS stated that 25% were triaged to other services leaving 75% to be assessed compared to a contracted 2,500 assessments. If we use the 25% as an estimate for the 19 month data it implies 2,772 referrals are assessed annually. This compares to the contracted volume of 2,500. Whilst an ‘over performance’ this variance is within the tolerance limits stated in the service specification. We also reviewed the data to ascertain how many patients were ‘revolving door’ patients i.e. had more than one referral into the RAS. During the 19 months assessed 1,140 patients (28% of the total) were referred more than once, and of these 90 people were referred to RAS 5 of more times and 9 people more than 10 times. Although the 90 patients is a small percentage of total patients (2%) the implication is that the whole system is not meeting the needs of this small, but ‘resource intensive’ cohort of people. The most common diagnosis amongst this group is personality disorders (see below). 10

The Referral and Assessment Service (RAS) Further analysis of the ‘revolving door’ patients shows that 53% of patients with six or more referrals were referred by A&E suggesting they regularly attended New Cross and that a liaison service could be used to meet their needs. 36% of the same group were on CPA. We heard some criticism from within BCPFT that there is a lack of consistency in the RAS teams’ assessment of which cluster patients should be allocated to (see section regarding clustering issues). This lack of consistency was suggested as the reason some patients were ‘knocked back’ by the receiving service and as a result were being passed straight back to their GP for re-referral. Although anecdotal this criticism is consistent with views expressed by GPs (i.e. patients being too frequently knocked back to primary care to ‘start again’) which further supports the need for a ‘Mind the Gap’ concept which would mean no patient being simply referred back to their GP. We also heard that the lack of medical or wider multi-disciplinary input to RAS resulted in the RAS nurses carrying a great deal of risk on their shoulders. This could risk serious incidents and is likely to lead to ‘out of hours’ admissions to hospital that were later deemed inappropriate – it is worth noting that our analysis of admissions shows that 139 (16%) of 888 in the 24 months of 2011/12 and 2012/13 were of 3 days or less duration. We can not definitively state that any of these short stay admissions were inappropriate, but the lack of medical input to RAS and the claim we heard that “RAS was risk adverse” does suggest that an enhancement of the skill mix available within RAS could result in fewer admissions. We also understand that a May 2012 AwayDay of the RAS identified issues relating to confusion in roles between RAS, home treatment and crisis. It was claimed that the teams were set up too quickly without a robust implementation plan and that this led to uncertainty regarding the management and escalation of referrals. Staff morale has apparently been an issue with high turnover rates . 11

The Referral and Assessment Service (RAS) It was also noted that the Make A Difference service users group had raised concerns about the functioning of the service, including the concern that RAS could only see patients in crisis at A&E and that for obvious reasons it is not always practicable for the patient to travel to A&E. Despite these issues, it is important to remember that GPs consistently told us that the crisis service was the best it has ever been. We also frequently heard the view that the crisis caseload held by RAS should be transferred to the home treatment team effectively recreating the National Service Framework’s crisis and home treatment model and refocusing the RAS team on triage and assessment. We heard mentioned of relatively high numbers of inappropriate referrals by GPs into RAS. We were provided with a summary of referrals dating from October to December 2013 which indicated that of 50 referrals reviewed 10 (20%) were ‘inappropriate’. If these 10, four were older adults who should have been referred to the older adults services and three were already being seen by BCPFT teams. The audit suggests that a significant proportion of inappropriate referrals are due to a lack of understanding by some GPs that RAS only deals with adults under the age of 65 and a lack of awareness that some patients are already on the secondary care caseload. Both of these reasons for inappropriate referrals can be said to stem from communications issues. RAS are contracted to respond to all urgent referrals following a six hour pathway. Support to A&E has become a major health economy priority to assist the acute trust in avoiding A&E breaches . Commissioners have recently funded a locum psychiatrist on a sessional basis to cover A&E and although welcome this requires further review to ensure that the post holder is being used to maximum impact. At present it has proved difficult to accurately map peak flow times. 12

The Referral and Assessment Service (RAS) The view was expressed by several interviewees that the liaison service should be reconstituted as a separate service from RAS with increased finding (possibly using the RAID model). It was noted that New Cross Hospital’s A&E department is being remodelled and space will be created for psychiatric liaison. We understand that the ability of the service to respond within the contractual time limits to liaison requests from A&E was a concern and that this had contributed to recent beaches of A&E targets. We reviewed a list of referrals to RAS from New Cross made during September 2013. There were 69 referrals from A&E in the month of which only one breached the six hour response time, but a further 12 waited for between four and six hours to be assessed, putting the patient in breach of the four hour A&E target. During the course of our review BCPFT and the CCG have drawn up a draft service specification for an enhanced acute liaison service. This initiative would take the liaison psychiatry responsibility away from RAS and setup a dedicated service based at the Royal Wolverhampton Hospital. The proposed liaison service would have response time targets which were aligned to A&E targets i.e. four hours not six hours. The service would also inreach onto the wards at New Cross. Establishing a separate liaison service would be in line with best practice as articulated in recent Royal College guidance (Liaison Psychiatry for Every Acute Hospital, 2013).

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The Referral and Assessment Service (RAS) Summary of findings The concept of a single point of entry and associated rapid assessment service has merit and is a development we have seen in many, if not most, mental health trusts (as well as in social care and community health organisations). The concept is supported in the February 2014 Mental Health Crisis Care Concordat, which states that “early interventions can include…the development of a single point of access to a multi-disciplinary mental health team”. There is no one ‘ideal model’ as local circumstances vary. The relatively recent development of these services also means there is little evidence as to what works well and what does not. Models vary with some delivering a service model that is multidisciplinary and integrated with social care enabling rapid assessment, intervention, de-escalation or escalation as deemed clinically appropriate. January 2014’s ‘Closing the Gap. Priorities for essential change in mental health ’ includes the clear priority that “no-one experiencing a mental health crisis should be turned away from services”. The need for a better co-ordinated urgent response to crisis (as envisaged by the RAS) is repeated in the Mental Health Crisis Care Concordat, published in February 2014. It is clear to us that the RAS is made up of skilled, conscientious individuals who fulfil a much needed role. The concept of a single point of access is well supported and the crisis element of the service is well regarded by GPs. We therefore wish to be clear that our recommendations and options for change set out below are designed to improve the service by responding to the issues raised with us.

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The Referral and Assessment Service (RAS) These issues are summarised below. 1. The role of the RAS is not well understood either within or outside of the trust, a factor compounded by the existence of an incorrect directory of services. This may be the root cause of many of the criticisms we have heard. 2. RAS lacks medical input and input from other professions, such as psychology and occupational therapy. This may be contributing to a risk averse culture. 3. Assessment decisions made by the RAS are not always accepted by the rest of the BCPFT services resulting in patients being ‘bounced back’ to GPs. This is almost certainly linked to a mistrust of RAS assessment conclusions by colleagues . 4. Patients inappropriately referred either to RAS by GPs or by RAS to other services are returned to their GP to restart the referral process. This is causing immense frustration to patients and GPs. 5. There are a cohort of patients who can be classified as ‘frequent flyers’ whose appear to be ‘bouncing around’ services and frequently dropping out only to be re-referred by their GP. Most of these patients have a personality disorders diagnosis. 6. The crisis service is described as ‘the best it’s ever been’, but there is also a view it can be better. 7. There is a likelihood that some patients are being admitted to Penn Hospital unnecessarily. 8. The withdrawal of social workers caused RAS some problems at the time, but the funding of new health staff has mitigated the negative impact on workload. 9. The withdrawal of social workers with the ending of the Section 75 agreement has resulted in two parallel but not integrated services existing (RAS and the Local Authority’s Intake Team). 15

The Referral and Assessment Service (RAS) 10. The proposal to establish a separate liaison service to replace this element of RAS’ role is in line with best practice as recommended by the Royal College. 11. A relatively high proportion of referrals to RAS (20% of those sampled) are ‘inappropriate’, but many errors appear to be due to a lack of understanding of the patient groups covered by RAS meaning the issue is largely one of communication and education of GPs.

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The Referral and Assessment Service (RAS) Recommendations 1. The RAS should continue to exist, but in a strengthened form (Do now). 2. The trust should strengthen the ‘senior decision making’ resource at the ‘front door ‘ by introducing medical input to RAS from within the existing medical resource (note: this recommendation does not mean all assessments must be attended by a medic) (Do now). 3. The trust should also consider additional professional input to RAS from professions such as psychology, occupational therapy and social work (Do soon). 4. A daily joint MDT report-out session is established and attended by RAS nurses and manager/clinical lead and a senior medic (on a rotational basis). The meeting would discuss referrals from the past 24 hours highlighting potentially complex or high risk cases for further discussion, formulation and management. On the basis of this meeting joint assessments would be arranged as required (Do now). 5. All trust services need to adopt a ‘Mind the Gap’ culture and philosophy whereby it becomes unacceptable to either: 1. Bounce a patient back to their GP when the patient is appropriate for another trust provided service (Do now) 2. Bounce the patient back to their GP without providing advice on alternative services and/ or a management plan, where the patient is not appropriate for any BCPFT service (Do now). 6. The RAS assessment must be accepted by other trust services , i.e. the patient must be accepted onto the caseload of the recipient service. Any subsequent referral on to other services must be made in a way which does not materially interrupt the patient’s care (Do now). 17

The Referral and Assessment Service (RAS) 7. The crisis caseload should be transferred with appropriate resource to the home treatment team (Do soon). 8. GP practices should be linked to the trust through a ‘Clinical Ambassador’ being nominated for each practice. The Clinical Ambassador would be responsible for meeting with the GPs in each practice on at least an annual basis to keep them informed of developments within the trust. In between annual visits the Clinical Ambassador would act as an ‘account manager’ by being the point of contact for their GP practices for non-patient specific issues of concern (Do soon). 9. A medical advice line is established to provide advice to GPs thus removing the need for some referrals (Do soon). 10. Consideration is given to reducing the ‘points of entry’ into BCPFT services available to patients and referrers (Do soon). We believe there are a number of options in addition to ‘no change’: a) One SPA for all BCPFT mental health services which would triage, assess and cluster all referrals i.e. for CAMHS and older people’s mental health services as well as adult mental health. b) RAS takes responsibility for referrals into the older people’s service as well as adult mental health. c) The RAS remains adult mental health only, but is a genuine ‘single point of access’ and takes responsibility for all Wellbeing and Healthy Needs referrals including triage of Ticket to Recovery. RAS would therefore triage, assess and cluster 100% of adult mental health referrals. 18

The Referral and Assessment Service (RAS) d) RAS takes all referrals except IAPT (Healthy Minds) which would use Ticket to Recovery. e) RAS takes all referrals except those from A&E and that a separate A&E liaison service is established (see below). f) The service undertakes triage and part one assessment leaving ‘part two’ assessment to each team (part one and part two assessments would need to be carefully described to avoid duplication e.g. clustering would probably be a part two activity). g) The service undertakes the triage function only and the assessment and clustering responsibility is passed back to each secondary care team. 10. The RAS is colocated with the local authority’s Intake Team and social work input is re-established (Do soon). 11. A bid is made to the Better Care Fund (BCF) to integrated mental health and social care access services (it should be noted that the implementation guidance for the BCT fund states that it is to be used to support vulnerable people rather than ‘just’ the frail elderly, so using the fund for mental health integration would be entirely appropriate) (Do later). 12. The trust considers the benefits of merging the Wolverhampton RAS with the equivalent service in Sandwell once the two services have ‘bedded in’ (Do later).

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The Referral and Assessment Service (RAS) 13. Routine referral waiting times should be reviewed to ensure that the ‘double wait’ to be assessed by RAS and then to be seen in secondary care does not lead to unreasonably long waits which risks patients dropping out of the system. The national strategy refresh (Closing the gap) prioritises establishing ‘clear waiting times’ for mental health services and hints that these will be the same as physical health waiting times (the principle of parity with physical health) (Do now). 14. Regular advice and training is provided to GPs with the aim of reducing the level of inappropriate referrals. It should be noted that if RAS were extended to cover older adult services (see option above) a substantial proportion of currently inappropriate referrals would be likely to become appropriate (Do soon). 15. There should be a clearly flow-charted pathway redesign for RAS referrals with defined avenues of entry and exit from RAS (Do now). 16. A separate liaison psychiatry service should be established (Do soon).

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Changes to inpatient services The brief This section covers the following issues raised: • The transfer of resources to community based services following reductions in bed numbers • The impact of the transfer of resources to community based services on service user experience and admission to hospital • Assessment of the impact of increasing demand on inpatient services and how this can be addressed or adequate contingencies put in place • The impact of the move of the male PIC beds to Macarthur Unit and access to Female PIC beds ‘out of area’. Background WCCG and BCPFT agreed a four year financial plan to support implementation of the strategy. Baseline funding was recycled to reorganise teams (e.g. assertive outreach and the integrated psychology and psychotherapy team were decommissioned) and growth of circa £1.4m (recurring) and £1.4m (nonrecurring) was invested. A savings plan to reduce expensive out of area treatments (OATs) was implemented linked to the criminal justice service (which forms part of the Complex Care Team). Assuming that the plan achieved its objectives of reducing OATs, the non-recurrent allocation would be made recurrent. The staffing establishments on the acute wards at Penn Hospital were reviewed following the reduction in the number of adult acute beds. This resulted in an overall reduction of two band 5 nursing posts.

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Changes to inpatient services There is a comparatively well resourced medical establishment operating across the two acute wards with four consultants ,four middle grades ,four SHOs and rotational posts. The post holders have responsibility for 36 beds and the Home Treatment service . The physical environment on the Penn wards was also altered following issues raised by the CQC. Nationally, as well as locally, admissions to inpatient care are increasing leading to recent concern that the trend of reducing acute beds has gone too far. The Wolverhampton PICU was closed and a service for men established at the Macarthur unit in Sandwell. Women requiring intensive care are treated out of area.

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Changes to inpatient services Findings Out of Area Treatments (OATs) Anecdotally we have been told (by several sources) that OATs have not reduced, but we have not been provided with hard data to support this claim. We do know that in early January there were: • 11 OAT patients who have stepped down from forensic units into locked rehabilitation units. • 7 OAT patients who were previously in Penn Hospital, but transferred to rehabilitation units on the basis that Penn Hospital was not a suitable environment for their treatment needs There is no national benchmarking data we are aware of to allow us to check these numbers against other CCGs, but in our experience: • It is not unusual to have a number of ex-forensic patients placed as OATs in rehabilitation units. Royal College of Psychiatrist guidance recommends one such ‘high dependency rehabilitation unit’ per 600k – 1m population, suggesting the Black Country as a whole, but not Wolverhampton alone could sustain such a service. • It is slightly unusual for a mental health trust not to provide its own non-forensic rehabilitation unit and we understand there used to be one run by NHS mental health services in the city. Royal College of Psychiatrist guidance recommends one rehabilitation unit per 250k population which, even if we assume the guidance is over generous, suggests BCPFT could provide one unit across Wolverhampton and Sandwell. However we understand that a service was previously run by BCPFT, but this was decommissioned 18 months ago and that the service is now provided by Cambian. 23

Changes to inpatient services We also note that it is also important to distinguish between Wolverhampton patients recorded as an ‘OAT’ when in a BCPFT bed at Hallam Street and patients placed in beds not managed by the trust: in our meetings we heard that “it’s helpful to be able to admit to Hallam Street now the trust is merged”. There is a small (three CPNs and one service lead) criminal justice team within the Complex Care Team which is responsible for the case management of forensic patients. The service case manages patients in prison (via in-reach); on probation; in court diversion schemes and placed in secure hospitals. The caseload is approximately 25-35 for each CPN of whom approximately half will be in prison and /or secure care, leaving an ‘active’ community-based caseload of approximately 50 for the whole team. These current (as at November 2013) caseloads are significantly different to the caseload numbers set out in version 8 of the relevant service specification. The specification states that “the Criminal Justice Mental Health Team shall provide a service for between 84 and 105 service users in the community and between 50 and 60 in secure care” and that “care co-ordinator caseloads shall be between 12 and 15 service users”. Taking these numbers together indicates that the team should have a minimum of nine members of staff compared to the current four. If correct this variation in required staff resource from the service specification may account for stated failure to reduce OATs.

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Changes to inpatient services Inpatient stays We heard that bed blocking on the acute wards at Penn is increasing and that this is leading to more patients being transferred to Hallam Street (we have not seen data to verify this point). Bed blocking could be the results of fewer beds at Penn Hospital, but also a reflection of reductions in social care budgets which delay discharge of patients who have completed their assessment and are waiting a move on to new accommodation and the lack of a BCPFT operated rehabilitation unit. Prolonged length of stay can potentially increase the risk of institutionalisation for these individuals rather than promoting their recovery. Six cases were cited as being currently (December 2013) delayed, although we note that declared delayed transfers of care (DTOC) were only 4.2% at the time of writing. In our experience there is often a difference between DTOCs and the number of patients not requiring the ‘level of care’ they are receiving. Given that a key principle in mental health is to ‘maintain the patient in the least restrictive environment’ we believe the focus should be on ensuring all patients are receiving the most appropriate level of care as opposed to focusing on what can be a misleading DTOC number. We therefore requested that BCPFT carry out an audit of Penn inpatients to understand how many could be treated elsewhere (at a ‘lower’ level of care) if alternative services/ capacity existed. The results were that 40% of patients (47% on Dale Ward – the female ward - and 33% on Brook Ward) were at an inappropriately high level of care (i.e. in a more restrictive environment than necessary). The alternative services required for these patients were: home treatment (50% of the total); a crisis house (19%); supported living (19%); and one patient each for a slow stream rehabilitation unit and a short stay stepdown unit. Commissioners buy ‘step down’ beds from Cambian, but possibly not in sufficient quantities to ensure a swift flow of patients through the acute wards. Although the study was a ‘one off’, the results are entirely consistent with results we have seen across similar wards elsewhere in England. 25

Changes to inpatient services We further tested our hypothesis that some patients were staying too long in hospital by reviewing all admissions to Penn for the period April 2011 – March 2013. 34% of inpatients had a LoS of more than 40 days and they used 72% of acute beds, despite average length of stay being less than 4 weeks and DTOCs being 5%.

Lots of beds used by patients staying ‘too long’ but not formerly recorded as DTOCs

The average length of stay (mean) is 33 days on the two Penn adult wards (the median is 15 days). We are aware of trusts that have reduced the average (mean) to 21 days by targeting a 14 day admission as the norm. This analysis and the inpatient audit suggest that greater capacity in inpatient alternatives would lead to more appropriate use of acute beds, more patients being treated in ‘the least restrictive (least intensive) environment’ and a reduction in length of stay. 26

Changes to inpatient services Despite the evidence presented above, we caution against a further reduction in adult acute bed capacity. We heard that the downward trend in bed capacity had resulted in a ‘concentrating effect’ with those patients still being admitted being more generally more acutely ill than historically. Whilst we have not been able to test this claim, the ‘concentrating effect’ has been evidenced in other mental health services so the claim is entirely credible. We are also mindful of national evidence of rising crisis contacts and admissions. We have reviewed Wolverhampton (and Sandwell’s) adult bed capacity against other English trusts. Although some care must be taken to ensure the comparison is ‘apples with apples’ we can see that BCPFT provide 27.6 beds per 100,000 weighted population in Wolverhampton (and 25 in Sandwell). These numbers are amongst the lowest number in England, although care must be taken as many trusts are reducing bed numbers. It is also worth noting that many other trusts will have rehabilitation units included in their figures and as stated earlier BCPFT does not provide this type of facility (see earlier discussion regarding OATs). Despite these two caveats these comparatively low bed numbers suggest that non-inpatient services in Wolverhampton would be under greater strain than equivalent services elsewhere. Beds per 100k MINI weighted popn aged 16 - 64

100.0

90.0 80.0

70.0 60.0 50.0 40.0 30.0 20.0 10.0

0.0

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Changes to inpatient services Psychiatric intensive care (PIC) Male patients who require treatment in a PIC unit (PICU) are transferred to the Macarthur unit (the PICU): for females the lack of a local unit requires an out of area placement. The Macarthur Unit was described to us as functioning well with strong clinical leadership. The issues raised with us were that: • Once patients are transferred to PICU the acute wards are unable to reserve the patient’s bed due to pressures to admit patients from the community. The result is that patients in PICU who have stabilised sometimes become stuck in PICU due to no acute beds being available. However, this statement is not supported by data on delayed transfers. • There are reports of low level risk patients being escalated to PICU resulting in inappropriate levels of management and restriction. Again we have not been able to confirm this statement. The lack of a formal agreement regarding access to female PICU beds requires urgent attention to ensure a consistent co-ordinated approach is available to support women in crisis. Once admitted to PICU the discharge (repatriation) plan for these patients should begin immediately to ensure that the patient returns to the right level of therapeutic environment as soon as deemed safe and appropriate. We understand that the Trust is preparing a business case for a female PICU.

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Changes to inpatient services Other issues A number of people reported issues with repeat admissions of patients who were previously cared for by the Assertive Outreach Team (AOT). It was suggested to us that this relatively small cohort of around 14 patients had not required admission to hospital for up to two years due to the intensive support offered by the AOT. However since the amalgamation of the AOT case load into the Complex Care Team it was suggested that these patients may have had repeat admissions due to the difficulty of caseload managers to balance their needs with the remainder of their generic caseload – there are 1,317 patients on the Complex Care teams caseload, (approximately 500 of who are on CPA and who receive care coordination and 700+ who are held as outpatients) suggesting there is real potential for a tiny percentage, such as the 14 ex-AOT patients, to be ‘lost’ in the system. This made the activities of closely monitoring and ensuring compliance with labour intensive care plans difficult to achieve. This claim requires further analysis of re admission statistics as we have not seen data to support the claims made. We also note that a caseload of 14 is remarkably small for AOT reinforcing the need to analyse the data referring to this group of patients. Learning disability (LD) services report a low level of emergency admissions to acute services. However low volume is often linked to high impact clients, some of which access the service through the Section 136 place of safety route. A lot of work has been done to manage length of stay in assessment and treatment services linked to a 16 week assessment cycle. Understandably, when LD patients with a presentation of aggression are admitted, there is a focus upon safeguarding them from harm given their vulnerability in this environment. 29

Changes to inpatient services Ward nursing establishments were described as being ‘too tight’ by one group e.g. no allowance for training. There was also a reported over reliance on bank/ agency staff with the belief that the trust could do more to bring regular bank/ agency staff ‘on board’ as part of the team, e.g. offer them training. We have, however, also been told that a full training package is in place for bank staff and that this mirrors that given to substantive staff. Furthermore a review of the skill mix, staffing levels and shift pattern has been undertaken to ensure compliance with Royal College of Nursing safe staffing levels. We note that commissioning intentions received by the Trust propose staffing cost reductions for adult wards of £230k and older adult wards of £160k linked to the new environment at Penn Hospital. We have not audited staffing rotas at Penn, but do suggest that commissioners and the trust discuss commissioning intentions in light of what we have heard about staffing and our finding that bed numbers for Wolverhampton adult services are low. We understand that there are no non-medical prescribers in the Wolverhampton service.

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Changes to inpatient services Recommendations 1. The audit of Penn inpatients is repeated on a regular (quarterly) basis to review progress towards reducing the number of patients treated at an unnecessarily high level of restriction (Do now). 2. Capacity within home treatment teams is reviewed to ensure there is sufficient capacity to enable the flow of patients through wards to be as quick as possible (Do now). 3. The trust reviews the potential to merge the Wolverhampton criminal justice team with its equivalent in Sandwell in order to create a ‘critical mass’ of experienced staff and to ensure ongoing viability of this small, but important service (Do later). 4. The trust produces a feasibility report for the creation of a Wolverhampton and Sandwell-wide rehabilitation unit to supplement independent sector (Cambian) beds in Wolverhampton (Do soon). 5. A clinical review of all OATs patients is undertaken to ascertain the potential to repatriate these patients to BCPFT services (Do soon). 6. The Trust and commissioners are already aware that the absence of timely access to female PICU beds is of concern and currently potentially disadvantages vulnerable women requiring a safe environment and a business case for a female PICU is being written. However, in the short term consideration should be given to commissioning a number of beds from a neighbouring provider in order to give assurance that appropriate quality standards were being met and would improve pathways (Do soon). 7. Data is reviewed to understand whether or not former AOT patients have experienced an increase in hospital admissions since the creation of the complex care service (Do now). 31

Changes to inpatient services Recommendations 8. The trust develops non-medical prescribers posts (Do soon). 9. The care co-ordinator role is ‘beefed up’ and inpatient/ community interface meetings are established to facilitate greater continuity of care (we understand that this type of meeting has been introduced since we commenced this review) (Do now).

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Medical staff resourcing across the system The brief Review the availability of consultant psychiatry sessions across the whole service model and if this requires re-adjustment . Background There are eight consultants employed in the adult mental health service in Wolverhampton. A ‘functionalised’ model is in operation with four consultants working in the inpatient/ home treatment teams and the remaining four working with the two complex care teams and with two sessions provided in support of the Wellbeing Service. The four inpatient consultants are aligned to the wards and complex care teams i.e. one consultant is for ‘north Wolverhampton males’ another for ‘south Wolverhampton females’ etc. The four community consultants are split into two ‘North Wolverhampton and two ‘South Wolverhampton’, but they do not operate a male/ female split.

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Medical staff resourcing across the system Findings We heard that there is a comparatively well resourced medical establishment operating across the two acute wards with 4 consultants, 4 middle grades and 4 SHOs. The post holders have responsibility for 36 beds and the home treatment service. This allocation was often referred to as “generous” during the course of our interviews (see graph below) and “inequitable” when compared to the community psychiatrist caseloads. Consultant job plans do not appear to be widely shared potentially leading to some of these statements - at present consultant job plans are held at clinical director level. It would assist the service if these were shared and jointly monitored by the divisional director. We heard varying opinions about functionalisation with strong arguments put forward for and against the demarcation of services. One telling comment was “the ship has sailed, so we need to make the functional model work”. A common concern is that the impact on services users is disruptive and not conducive to the maintenance of sustained therapeutic relationships . This can result in a stressful transition for service users or an escalation in behaviour with heightened risk particularly characteristic in cases of personality disorder (Wolverhampton was described as having a relatively high incidence of PD particularly in females). Discontinuity of care can escalate the level of behaviour exhibited by this group of patients and community teams struggle to manage risky behaviour leading to pressure to admit these patients. We did hear the claim that inpatient consultants were sometimes reluctant to discharge patients back to community colleagues, but this is disputed and the inpatient audit makes it clear that suitable services / capacity does not exist in the community to facilitate early discharge. Annual patient surveys always raise the issue of a lack of continuity in care e.g. different medics involved as patients are transferred around teams. 34

Medical staff resourcing across the system Problems have also been experienced in tribunals where there is a lack of continuity of responsible clinical care. We were shown an article written by Wolverhampton consultants in 2012 and published in ‘Mental Illness 2012, Volume 4’ which reported on staff satisfaction with the functionalisation of inpatient care. There was a clear overall dissatisfaction with the model amongst staff, although community staff were more likely to be dissatisfied than ward staff. A benefit of the functionalised model is that a patient being assessed by a dedicated acute consultant would receive a fresh and objective appraisal of their needs akin to a second opinion. It was also stated by staff and patients, but crucially not carers, that patients had a preference for community-based treatment where possible so the overall ‘direction of travel’ of fewer beds was supported. Our experience is that the national picture regarding functionalisation is variable with some trusts choosing this route whilst others maintain consistency of consultant cover throughout the pathway between community and acute services – this lack of a common model is reflected in BCPFT with a different model of functionalisation operating in Sandwell. The eight consultants together with an older adult consultant and service leads for home treatment, RAS, acute services, wellbeing and complex care, have produced a paper which considers the functionalised model and which states that “the functionalisation was a mistake”, “the Sandwell model of having a separate home treatment consultant from the inpatient/ community consultant is no better”, but that “reversing functionalisation now would be very disruptive” (we heard the statement “the functionalisation ship has sailed”. The paper suggested two possible solutions: 35

Medical staff resourcing across the system 1. The functionalised model continues, but with regular interface meetings to improve communication between inpatient and community services, or; 2. The service de-functionalises with a hybrid model put in place. This hybrid would have either eight patch-based consultants with their own teams or four twinned community teams with two consultants in each covering community, home treatment and inpatients. The preferred option stated in the paper was option 1 i.e. to effectively make functionalisation work better. Our view is that this is a pragmatic way forward given where the service has come from and a solution that can work if greater emphasis is placed on communication between teams facilitated by a more prominent care co-ordination role. We heard a consistent message that the current allocation of consultant time was wrong with too little resource being allocated to the Wellbeing service and RAS. The view of consultants and service managers can be summarised as “a solution to the current difficulties would be to refocus (medical) resource across all of the teams”. The need to provide more medical support to RAS was discussed earlier. There is a consistent view that the ambition to transfer clusters 4-7 and 11 patients into a service which did not have medical input (the Wellbeing service) was over ambitious. We heard time and again that these patients were too complex not to need some specialist medical input, even if the primary treatment is psychotherapeutic. We also note that the Wellbeing service is now supported with two sessions of consultant time. We also heard the suggestion that the management of personality disorder (PD) patients can be improved in terms of their care pathway, inpatient and crisis support, and psychotherapy by means of an enhanced extended hours community PD service. 36

Medical staff resourcing across the system It is clear to us that there is agreement amongst everyone we interviewed that the medical resource available is not being deployed optimally i.e. it is over focused on the wards and complex care service, and within this focus there are problems in continuity caused by functionalisation. We have compared the consultant resource available in Wolverhampton to that available in other mental health trusts (the comparison has only been possible where other trusts only provide mental health services meaning trusts providing mental health and community health services have been excluded from the chart below). Our analysis shows that Wolverhampton is well resourced when compared to other CCG areas on a population basis (population weighted for mental health need). This relatively ‘rich’ resourcing supports an argument for deploying some consultant time to supporting RAS and the Wellbeing service.

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Medical staff resourcing across the system Recommendations The current service model has potential deficits in terms of the deployment of medical sessions to support the robust assessment of patients by teams. This is particularly apparent within the RAS service which at present is nurse-led. The trust’s medical establishment is a valuable resource which should be appropriately deployed to meet service need and availability to other professional groups to escalate patients who are initially assessed as posing increased risk or vulnerability in a timely way. The trust should review the job plans and deployment of medical sessions in partnership with the consultant body and service managers. Specifically we recommend that: • Medical support is provided to RAS from existing resources (see earlier RAS section). • A medical advice line is established to support GPs from existing resources (see earlier RAS section). • The crisis caseload should be transferred with appropriate resource to the home treatment team (see earlier RAS section). • Medical support to the Wellbeing service is extended from the current two sessions from existing resources (Do soon). • A separate A&E liaison service is set-up with medical input (see earlier section). • The care co-ordinator role is ‘beefed up’ and inpatient/ community interface meetings are established to facilitate greater continuity of care (see earlier section on inpatients). • At present consultant job plans are held at clinical director level, it would assist the service if these were shared and jointly monitored by the service manager (Do now). 38

The secondary care/ primary care interface The brief This section covers: • The transition of clusters 0-7 as agreed within the original strategy implementation plan • The transfer of cluster 11 patients to primary care and also shared care arrangements • The interface between primary care and secondary care services Background The introduction of clusters and allocation of historic caseloads to clusters highlighted a large number of patients in clusters 0 – 7 (e.g. in July 2011 there were 1,110 adult mental health patients out of a total caseload of 2,396 clustered patients in these eight clusters). Many were receiving routine outpatient follow-up only. The existing IAPT service (Healthy Minds) was redesigned to become the Healthy Minds and Wellbeing Service which (initially) would not have medical input, with medical responsibility for these patients being passed back to GPs. More recently two sessions of consultant time have been allocated to the Wellbeing Service. Cluster 11 (ongoing recurrent psychosis: low symptoms) are described in the clustering guidance as patients with ‘a history of psychotic symptoms that are currently controlled and causing minor problems if any at all. They are currently experiencing a sustained period of recovery where they are capable of full or near functioning. However, there may be impairment in self-esteem and efficacy and vulnerability to life’. The mental health strategy aimed to transfer these patients out of secondary care back to primary care services. 39

The secondary care/ primary care interface Findings Cluster 0 -7 patients The majority of patients have been transferred from CMHTs to the Healthy Minds and Wellbeing Service, although a small number of cluster 7 patients remain on the caseload of the Complex Care teams. We heard consistent concerns regarding the accuracy of clustering. This issues results in some patients ‘bouncing between services’ and in some cases falling between services. Opinions shared with us included a view that too many people were able to cluster patients and that they had received insufficient training - it was claimed that the current training involves a two hour session. The potential outcome is that staff are not equipped with sophisticated skills in assessing and allocating the correct cluster to patients. It was suggested that staff require significant training to ensure that the assessments are insightful and rigorous rather than automaton form filling. A telling comment was that “Clusters not patient need, are King”. An example was cited around cluster 7 highlighting non-psychotic patients who have a higher actual clinical need e.g. OCD being sign posted to Wellbeing rather than the Complex Care Service . The general view was that there is a relentless focus upon the cluster allocation rather than diagnosis and individual needs assessment. This potentially leads to teams passing patients on the basis of where the number fits into the service rather than on the basis of the right treatment for the diagnosis and need – we also heard the suggestion that teams use inappropriate clustering as a reason to reject referrals resulting in delays to the patient receiving treatment: but it is also possible that because service specifications are cluster specific that a rigid system of adherence to clusters when accepting patients has become the norm (see earlier section on ‘Mind the Gap’. 40

The secondary care/ primary care interface This issue was further amplified by the consultants who stated that “ clusters should not be so rigid that they prescribe inappropriate management of the patient. There was an apparent lack of awareness that it is able to clinically override the cluster score if required. It was claimed that Wolverhampton is unique in splitting services between psychotic and non psychotic, but this is not the case. We heard comment that the resourcing of the teams was inequitable with Healthy Minds being well resourced whilst it was felt that the Wellbeing Service was under resourced. This is particularly important regarding medical support as patients requiring a medication review can bounce back to the Complex Care Team (see earlier recommendations about medical input). As a consequence of imprecise initial clustering the Complex Team apparently had high numbers of cluster 1-4 in contact - this has been reduced to 25 cases as a consequence of revised performance management arrangements. Arrangements are now in place to alert consultants to review patients in a timely manner.. A similar review is taking place across clusters 5 and 6 to resolve outliers. According to those interviewed the allocation of medical sessions to the Wellbeing Service has had a significant impact and that this temporary arrangement should be formalised. GPs are very clear that they are not mental health experts (we were reminded that the ‘G’ stands for ‘general’), so clusters mean little to most of them and, whilst they were willing to manage patients in the primary care, GPs felt that they needed quick and easy access to secondary care advice (see the earlier recommendations on an advice line and ‘named nurse’ links to each practice). We believe the system works well enough for clusters 1-3 (IAPT/ Healthy Minds), but is weaker for cluster 4-7 and 11 (the Wellbeing group of patients). 41

The secondary care/ primary care interface Cluster 11 Caution was raised by staff regarding the assumption that all patients on cluster 11 should automatically return to clinical management by their GP. There is a view that the strategy’s intent is unrealistic as many cluster 11 patients are stable due to the wider resource wrapped around them and because of sustained relationships with trusted staff who can intervene at an early stage if the softer signs of relapse are noted. Therefore it could be argued that for a core of cluster 11 patients ongoing support is more than routine attendance at a depot clinic. Furthermore, there has been difficulty in engaging GPs who have been reluctant to accept these patients – the comment was made that the strategy was in part worked up by GPs with an ‘interest in mental health’ who, by default, would be willing to manage cluster 11 patients, but most GPs are far less keen. GP support in the management of stable cluster 11 patients was described as poor with many GPs refusing to accept the transfer of cluster 11 patients back to primary care. This refusal resulted in the small percentage of GPs who had agreed reversing their decision. It is important however to balance the move to transfer all cluster 11 patients with the importance of have sound and robust arrangements and protocols in place to manage these patients. Many interviewees believe that the level of awareness of managing these patients within primary care is not yet sufficiently developed. The need for training and possibly a ‘advice line’ for GPs was suggested. A number of staff suggested that the CCG should fund the Trust to deliver a depot plus arrangement whereby patients would receive regular monitoring of their depot medication linked to physical health monitoring such as weight, diet, lifestyle and blood pressure etc. 42

The secondary care/ primary care interface It was difficult to ascertain if formal shared care protocols or arrangements were in place to support the management of these patients in a consistent way. GPs felt unsupported by BCPFT and stated the need to improve communications between secondary care and primary care. General interface issues Interviewees described relations with GPs as generally good and we have seen a survey of GP views on the Healthy Minds and Wellbeing service which illustrates a high level of satisfaction with the service (satisfaction rates ranged from 70% to 90% across different questions). The survey also illustrated the popularity of the ‘Ticket to Recovery’ (TTR)referral process. Nevertheless there are areas of concern which were raised with us including a general feeling that waiting times for Wellbeing were too long leading to many self-referring TTR dropping out before being seen. Waiting times for routine outpatient consultations were also criticised and the belief stated that routing routine referrals via RAS only adds a delay and further hurdle. The GP reticence to accept cluster 11 patients could have been compounded by poor communication at the time of the creation of the new teams and the lack of engagement of GPs when the strategy was developed. It has also been suggested that senior mental health clinicians felt isolated from the development of the strategy and we believe that, during times of service transformation, it is critical that regular clinician to clinician dialogue occurs. This helps manage the transition, responds to problems before they escalate and develops a joint understanding of the benefits to patients . At the time of the implementation of the strategy GPs were unhappy about the review and hand back of previous CMHT patients to the Wellbeing Service. Some issues have also been raised regarding GP concern about the resourcing of the RAS. 43

The secondary care/ primary care interface We also heard of instances when patients were discharged back to primary care without ongoing care plans and of discharge letters sometimes being inaccurate. Communications were said to be not as good as they could be. Stronger relationships were reported as being in place with the specialist LD consultants and their teams. LD is described as having a good pathway in place with strong primary care engagement. LD patients are seen as having a lifelong condition ,the service is perceived as being personally focussed on the individual with faster access (but with lower volume than mental health).

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The secondary care/ primary care interface Recommendations It was encouraging to hear from GPs that they would welcome the opportunity for training in the management of mental illness and for improved engagement with the trust, but note that GP uptake of training opportunities is often low possibly due to other demands on GP time. The Government’s refresh of the National Mental Health Strategy (Closing the Gap) priority 13 states that “Mental health and physical health care will be better integrated at every level“ and priority 19 “People with mental health problems will live healthier and longer lives“. We believe this is achievable in Wolverhampton: by joining forces, mental health and primary care can deliver an integrated response to these patients caring for both their physical and mental health needs. We, therefore, recommend that: 1. All trust services need to adopt a ‘Mind the Gap’ culture and philosophy whereby it becomes unacceptable to either: 1. Bounce a patient back to their GP when the patient is appropriate for another trust provided service 2. Bounce the patient back to their GP without providing advice on alternative services and/ or a management plan, where the patient is not appropriate for any BCPFT service. 2. GP practices should be linked to the trust through a ‘Clinical Ambassador’ being nominated for each practice. The Clinical Ambassador would be responsible for meeting with the GPs in each practice on at least an annual basis to keep them informed of developments within the trust. In between annual visits the Clinical Ambassador would act as an ‘account manager’ by being the point of contact for their GP practices for non-patient specific issues of concern. 45

The secondary care/ primary care interface Recommendations 3. A medical advice line is established to provide advice to GPs thus removing the need for some referrals. 4. Commissioners and the trust consider the funding of BCP run depot plus clinics at which Cluster 11 patients would receive their depot injections and physical health checks. If this is not possible then shared care protocols could be implemented (Do soon).

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The Section 75 Agreement The brief This section covers: • The impact of the end of the integrated Health / Social Care model and the withdrawal of the Section 75 agreement between WCC and BCPFT. Background The local authority withdrew from the Section 75 agreement in early 2012. The withdrawal of £1,395k in council funding resulted in the loss of 13.5 Social Workers and 6 Outreach Workers who would have been deployed to RAS and the Complex Care Service (source: BCPFT). The council’s new social care model does not recognise a role for social care within RAS and instead sets up a new social care Initial Intake Team to operate in parallel, rather than integrated with RAS. The Initial Intake team is not be the first point of contact for GP referrals, does not form part of the staffing for the 24/7 referral assessment service and does not contribute to the number of referrals triaged or assessed. The new social care model also means that social workers previously assigned to work in complex care (but managed by the local authority) do not act as care coordinators in the manner assumed by the mental health strategy, but are instead open to referrals to provide short-term support for complex clients, to manage specific social care needs. This support is time limited, based more on a model of provider of care rather than coordinator, and as such means that in practice health care coordinators hold higher caseloads than originally envisaged. This means there is less capacity to deliver more intensive interventions and as such achieve the complex care outcomes, including reducing reliance on inpatient beds. 47

The Section 75 Agreement BCPFT subsequently negotiated a contract variation with the CCG which provided additional health funds to run four projects designed to reduce pressure on the Complex Care Service – these projects were the transfer of former CMHT patients to primary care and the Healthy Minds/ Wellbeing service.

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The Section 75 Agreement Findings We initially reviewed the national picture - a September 2013 survey by Community Care magazine showed that 55% of local authorities currently integrate social workers into NHS mental health teams using Section 75 agreements, but that a further 16% of local authorities had withdrawn from such arrangements by ending their Section 75 agreements: Wolverhampton is, therefore, far from unique. The most common reason for ending the agreement was ‘loss of social work focus’ and the magazine article acknowledged that financial pressures on local councils were leading to more local authorities questioning the value of existing Section 75s. In this context the Wolverhampton decision to end the agreement and the reasons given, are not unusual. The key issue then becomes ‘what replaces the Section 75?’ given that integration is seen as the way forward for a wide variety of health and care services. From the interviews undertaken the general consensus was that the “service has gone backwards since the split” and that the split “is not conducive to effective and safe care co-ordination”: we also heard that the action “ has put the service back years in terms of how teams are constructed, the richness of the teams, the ability to jointly co-ordinate care and outcomes for patients”. Nevertheless the Trust’s services have put in place a number of ‘work arounds’ which have reduced the potentially negative impact. However, whilst BCPFT services still work closely with the local authority’s Initial Intake Team, BCPFT’s ability to influence what social workers do and how they operate, including resource allocation, has been lost. One acute inpatient consultant has responded by establishing weekly clinical interface meetings including attendance by social care representatives - this it is suggested has greatly improved relationships and co-ordination of care thus mitigating risk associated with the ending of the Section 75. 49

The Section 75 Agreement Our view is that the ending of the Section 75 in Wolverhampton has hampered the full development of services to patients and their carers as envisaged in the 2010 Mental Health Strategy. The development of strong and effective partnership arrangements between Health and Social Care has been a central theme of mental health policy for decades. The importance of this has been recently reiterated by the Government in their refresh of the National Mental Health Strategy “ Closing The Gap” which recognises the need for joint strategic plans to ensure that during tough financial times funding is channelled in the right direction to bring benefits to patients at all levels. The challenge to health and social care economies is to go further and faster to transform the support and care for people with mental health problems.

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The Section 75 Agreement Recommendations There is a real opportunity to make better decisions regarding funding where the CCG and the local authority have a consistent strategies in place for service development and consolidation. At present the system across Wolverhampton does not appear fully aligned around the patient - this situation has probably been compounded by the ending of the Section 75 agreement. The importance of developing strong partnership arrangements is not solely linked to financial resource allocation and assistance was given to BCPFT upon the cessation of the Section 75 to improve staffing levels. But the loss of dedicated social care input and expertise is importance and must have impacted upon the richness of multi disciplinary discussions and the ability of teams to deliver a recovery focussed model of care. The staffing and skill mix of teams is more important than simply concentrating on numbers of nursing staff. The Better Care Fund (BCF) was announced as part of the 2013 Spending Round. It provides an opportunity to transform local services so that people are provided with better integrated care. The Government believe that the fund will be an important enabler to take the integration agenda forward at scale and pace, acting as a significant catalyst for change. This initiative fits with the mental health agenda as it offers the chance to improve the lives of some of the most vulnerable people in our society, giving them control, placing them at the centre of their own care and support, and in doing so, providing them with a better service and quality of life. This recovery focussed approach will support the aim of providing people with the right care, in the right place, at the right time. This in turn will assist Wolverhampton’s commissioners to comply with priority area 1 of Closing the Gap which states that, ”high quality mental health services with an emphasis on recovery should be commissioned in all areas, reflecting local need”. 51

The Section 75 Agreement With the introduction of the BCF there is a new opportunity for health and social care commissioners to work with the trust to re-establish strong local communication and partnerships, and to align common strategic priorities. However, we are also aware that the bids for BCF monies are for different initiatives at the time of writing, so our suggested use of the BCF fund to replace Section 75 can only be a longerterm strategy. Given that BCF monies do not offer an immediate solution to the problems encountered, consideration should be urgently given to reviewing and reinforcing joint protocols which provide clarity and alignment between the trust, primary and social care and commissioners. This should reduce the burden on frontline staff of trying to make the current system work and improve the responsiveness and co-ordination to patients. The development of new partnership governance arrangements should be underpinned by senior over sight meetings across the trust, CCG and local authority.

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The Healthy Minds and Wellbeing Service The brief This section covers: The role and function of the Wellbeing Service and reasons for demand being significantly higher than that which was modelled as part of the strategy. Background Demand for the Wellbeing service is higher than forecast when the strategy was developed. The Healthy Minds and Wellbeing service was set up to manage patients in cluster 1 - 7 and 11. It replaced the old Health Minds (IAPT) service for patients in clusters 1 – 3 and the community recovery team. The service can be accessed via RAS of the Ticket to Recovery self-referral

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The Healthy Minds and Wellbeing Service Findings Referrers are confused about the purpose of the new service and referral methods. Whilst Healthy Minds (clusters 1-3) can be accessed using Ticket to Recovery’ (TTR), the Wellbeing element of the service (clusters 4-7 and 11) can be accessed using TTR or a RAS referral. There is a belief amongst Trust staff that the TTR has been almost too successful and has led to supply induced demand for Health Minds and Wellbeing. We heard statements such as “GPs hand the ticket out to any patient presenting with a mental health issue as it avoids the need for them to make a referral”. There is some evidence from the Trust’s GP questionnaire which supports this contention – 100% of GPs responding (30 out of 51 questionnaires sent out were returned) stated that the Ticket to Recovery was their preferred method of referral for mild to moderate depression. In effect the establishment of the Wellbeing service can be seen as an example of ‘supply induced demand’. The result of high demand is long waiting times. We also heard that the use of TTR for clusters 4 and above posed a risk as the service was receiving referrals which lacked detail. The resulting problems are compounded by the fact that patients in clusters 4-7 and 11 are not necessarily ‘simple’ cases that can be treated using an IAPT type approach of a fixed number of therapy sessions (see cluster 11 discussion above).

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The Healthy Minds and Wellbeing Service Recommendations 1. We have previously recommended increased medical input to the Wellbeing service (see above). 2. Treatment pathways are reviewed to ascertain whether a time/ session-limited psychological therapy approach (as per IAPT) is appropriate for the Wellbeing service (Do now). 3. If the IAPT style approach is not considered appropriate the Trust should seriously consider dividing the Wellbeing service from the Healthy Minds service to re-establish two separate services (Do now). 4. If division of these services is the result, that service specifications are redrafted to distinguish between the Wellbeing and Healthy Minds services (Do soon). 5. Access to the Wellbeing service is restricted to referrals via RAS i.e. TTR are no longer accepted for the Wellbeing service (Do now). 6. The trust pro-actively communicate to GPs the purpose and function of the service making clear the distinction between Wellbeing and Healthy Minds services (Do soon). 7. A waiting list initiative approach is considered to reduce the Wellbeing service waiting time (Do soon).

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Transition between services The brief This section covers: Arrangements for transition between children to adult and adult to older adult services Background Service users are always ‘at risk’ at points of transition between services, even if the two services are within the same provider organisation. The key risk is that the patient ‘falls between services’ resulting in breaks and /or delays in treatment.

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Transition between services Findings We heard no complaints or concerns about patients transferring between child and adolescent mental health services (CAMHS), and adult mental health services. But we also understand that only 6% of CAMHS patients transition into adult services: we understand that nationally the figure is closer to 20%. We find it remarkable that, assuming both estimates are ‘roughly right’ , the vast majority of service users do not transition. Whilst substantial numbers of patients seen by CAMHS may get better before they are due to graduate to adult services we believe the very small number actually transitioning in Wolverhampton requires further investigation. Our concern is that a number of patients may be falling between services. We heard mixed messages about the effectiveness and ease of transition into older people’s services. On one hand we were told that transition is not age based, but is based solely on patient need. But we also heard the opposite. For example, a concern was raised regarding patients with early onset dementia and their acceptance by the Older Age Psychiatry Team. At present there are a cohort of approximately 30 patients on the case load of the Complex Care Team. Once again we believe further investigation is needed.

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Transition between services Recommendations 1. The stated ‘6% transition’ from CAMHS to adult services figure is double checked (Do now). 2. The Trust audits a sample of cases to understand why so few CAMHS patients transition (Do now). 3. The Trust audits a sample of patients transitioning to older people’s services to check whether the move was ‘easy or not’ (Do now).

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Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team Workforce planning - we recommend the development of a workforce plan to support service transformation i.e. how to ensure the right people, with the right skills ,are in the right place at the right time(National Quality Board 2013). It would appear that Wolverhampton operates a traditional hierarchy model and has not developed higher level nursing and allied health professional posts. The service may find it helpful to review their workforce plan to check if the development of such posts could enhance the service and improve patient experience and outcomes. Linked to this a review of the organisations’ training needs may assist with developing higher levels of training for staff regarding cluster assessment and allocation. Training may also assist in the appropriate management of patients presenting with a personality disorder. Protocols - from the interviews undertaken as part of the phase 1 review it would appear that the service would benefit from the development of tighter service protocols to map pathways and expectations placed on each service. This should clarify thresholds for referral and escalation of urgent patient’s. The Trust has individual clinicians who would assist with the production of these protocols.

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Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

The management of personality disordered patients – Wolverhampton is reported as having a high incidence of personality disordered patients particularly females. The current community services supporting this group does not always have the required skills to manage risky behaviours leading to pressure to admit these patients. Once admitted these individuals can escalate their behaviours resulting in higher levels of resource to manage them ,which does not always improve the outcome for the patient. Training for staff in the management of personality disorder would be helpful - a number of mental health trusts have utilised the Knowledge and Understanding Framework developed by Nottingham University. Mind the Gap – a frequent criticism we heard was that patients not appropriate for the service they had been referred to were passed back to the original referral. We are aware of Trusts that have developed a ‘Mind the Gap’ philosophy which ensures that the service in receipt of an inappropriate referral take responsibility for transferring the patient to the appropriate service rather than passing the patient back to the original referrer.

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Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

Black and Minority Ethnic (BME) use of services – we reviewed an internal trust report which showed that: • In total 18% of service users were from a non-white BME group. This represents ‘under representation’ in services compared to the diversity within the city’s population – the 2011 census recorded almost one third of local people as being from a non-white BME community (17% South Asian, 7% Black, 5% mixed race and 3% other) Note 4% of people were ‘white other’ as opposed to ‘white British’. • When we looked at inpatient service users the number of people from non-white communities rose to 30% of the total, much closer to the local population total of 32%. The 30% BME inpatients was split 54% South Asian and 44% Black. By contrast 80% of service users in community teams were recorded as ‘white’. This fairly simple comparison suggests that Wolverhampton’s inpatients services do not exhibit the over representation of BME patients in total, but that the proportion of black inpatients (13% of the total) was more than twice the number of black people as a proportion of the local population. This finding is in keeping with ethnicity breakdowns for inpatient services across England. The ‘over representation’ of white people in community services (80% versus 64% of the population) was not further analysed between community teams. It would be interesting to see if the proportion 61

Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

was skewed by a high proportion of white people in the Healthy Minds service on the hypothosis that IAPT services appeal more to a white middle class demographic. The Healthy Minds service has recently recruited a BME link worker to work particularly with black communities in terms of access to the service. The trust has a ‘Play Fair’ strategy which seeks to tackle all forms of discrimination including racial discrimination. The strategy recognises that “there is evidence of ethnic differences in risk factors that operate before a patient comes into contact with health services, such as discrimination, social exclusion and urban living. There is also evidence of difference in treatment. For example, Black African and Caribbean people are more likely to enter psychiatric care through the criminal justice system than through contact with health services and people from BME communities are more likely to receive a diagnosis of mental illness than White British people and more likely to be detained under the Mental Health Act. These are national statistics which are reflected more locally in our Trust”. The strategy has led to a number of changes including the recruitment of the BME link worker referenced above. Our view is that the trust is to be commended in taking the initiative on issues relating to race and other possible forms of discrimination.

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Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

Financial issues – QIPP and CIP The continued pressure on NHS and local authority finances risks leading to a unmanaged decline in the quality and effectiveness of health services as funding decisions are made on an isolated organisational silo basis rather than considering what is best for the whole health and care community. Rubicon’s experience is that for several years there has been a real confusion between ‘QIPP and CIP’ not helped by unsophisticated block contracts being used to pay for most mental health services. A CCG’s QIPP target is caused by two factors: 1. Demand for healthcare rising at a higher rate than the commissioner’s funding allocation (primarily caused by a growing and ageing population, and rising expectations). 2. National diktat to transfer funds into the BCF and to retain a financial contingency. The result of 1 and 2 is that CCGs need to spend less on the services they currently buy. The options open to CCGs are: 1. Reduce tariffs – many of which are set nationally and incorporate an inbuilt tariff deflator (e.g. 1.8%). A variant on this would be tendering a service to achieve a lower price. 2. Reduce volumes of activity – for example through demand management initiatives such as raising referral thresholds or commissioning substitute services e.g. community-based alternatives to hospital admission. 63

Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

3. Decommissioning services or changing service specifications in such a way that some of the ‘old service’ is no longer provided. The experience of recent years is that most CCGs have managed to hit annual QIPP targets, but this is proving increasingly difficult as ‘all the low hanging fruit disappears’. Providers face an entirely different set of financial challenges incorporated in their cost improvement plans (CIPs): 1. The tariff and block contract payments made to the provider will reduce each year by the tariff deflator. 2. Costs increase with inflation. The combination of negative tariff deflator and inflation is the provider CIP i.e. a target which will occur each year automatically as long as there is inflation and tariffs are reduced. Services operated under contractual arrangements whereby income reflects activity done e.g. PbR, have historically offset their CIP targets by doing more activity i.e. the ‘profit’ made as a result of being paid tariff for activity delivered at marginal cost has helped to offset the impact of a lower unit tariff and inflation. The issue all mental health trusts face is that most of their income is earned through block contracts under which income often does not vary as activity varies, in other words mental health trusts unlike acute trusts can not ‘trade their way out of difficulty’. 64

Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

In our view the inability of mental health trusts to trade their way out of difficulty means that commissioners should aim to achieve mental health’s ‘share’ of the overall QIPP target by a mix of: 1. Applying the national tariff deflator to services commissioned under non-PbR contracts. 2. Market testing those elements of service which can be sensibly separated out. 3. Negotiating with providers changes to service specifications which would allow the provider to remove costs e.g. extending waiting times or reducing activity through changing referral thresholds. 4. Decommissioning whole services. There is a potential grey area in relation to making changes to continuing services i.e. ‘does the commissioner or provider’ benefit from reductions in the cost of providing a service? Our opinion is that contract specifications should be based on outputs and outcomes, and not inputs. In other words the specification should define the quantum of activity to be delivered (an output), but not the number of staff needed to deliver the activity (an input). Reductions in outputs should benefit commissioners financially whilst reductions in inputs should be to the benefit of the provider. Financial issues – funding the mental health strategy We have reviewed papers from the trust which set out how the strategy was meant to be funded in each of the four years from 2011/12 to 2014/15. 65

Cross cutting themes Background This section describes a series of ‘other issues’ raised with the Rubicon team

Our understanding is that by the end of March 2015 the position should be as follows:

Strategy related cost (health transition, criminal justice, peer review, young persons)

£1,180k

Inflation/ cost pressures

£968k

Tariff deflator

£960k

Total provider gap

£3,108k

Provider CIP

(£1,294K)

Contract changes (CQUIN and health transition)

(£351k)

Remaining gap

£1,463k

CCG funding from CCG surplus

(£1,463k)

After 14/15 the gap should be closed recurrently by the CCG through savings achieved from the out of area placement budget. 66

Appendix one The following individuals and groups were interviewed during the course of our review. • • • • • • • • • • • • • •

Dr Sami El-Hilu, (Mental Health Clinical Director) Kuli Kaur-Wilson, (Transformation Manager) Mike Harrison (Finance and Business Manager) Dr Sinha (CCG Lead GP for MH) Sarah Fellows and Joint Commissioning Team The Stakeholder Forum Positive Action for Mental Health Group Sue Timms, Complex Care Team Manager Anne Crawford-Docherty, AHP Lead Denise Lewnes, Wellbeing Service Team Manager Elin Hay, Service User Jeanette McLoughlin & Steve Scimshaw Eddie Azu, Criminal Justice Service Lead Denise Fawcett, RAS/HT Manager

• • •

• •

• • •

• • •

Carers Sub Group Wayne Jasmin, Service Manager Melvena Anderson, MH Divisional Manager & Donna Walters, Consultant Clinical Psychologist John Campbell and Debbie Mason Heidi Cater, Mental Health Division Lead Nurse Lesley Writtle, LD Divisional Director Scott Humphries, Acute Services Manager Vanessa Frost (lay member of aspergers syndrome and autism groups) and Christopher Conlan (make a difference group member) Wolverhampton Governors Action 4 Independence Group BCPFT Consultant Psychiatrists 67

Appendix one The following individuals and groups were interviewed during the course of our review. • • • • • • • •

•

•

Maureen, (lay member of CCG autism group) The Make a Difference Group Viv Griffin, Assistant Director, Health, Wellbeing and Disability, WCC Sarah Fellows, Commissioning Manager Dr Yusuf, Consultant Psychiatrist Richard Young, Wolverhampton CCG Dr Viswanathan, Consultant in Old Age Psychiatry June Pickersgill - Social Care Manager, Lesley Braizer – Interim Social Care Manager and Jason Viola Davis – Individual Placements Manager Juliet Grainger, Public Health Commissioning Manager and Margaret Liburd, Public Health Commissioning Officer Mental Health Commissioning Team

• • • • • • • • • • • •

Wolverhampton CPNs meeting Penn Hospital inpatient ward staff Susan Claire Marshall, Director of Nursing NE GP Locality meeting SW GP Locality meeting Thornley Road Surgery GPs NW GP Locality meeting Angela Lawrence, Psychology Tony Ivko, Wolverhampton Council BCPFT Trust Board Sue Wardle, Public Health Margaret Liburd, Alcohol Project Management & Commissioning Officer

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Appendix two The following documents were reviewed during the course of this project: 1. Wolverhampton Mental Health Commissioning Strategy 2010 2. Mental Health Strategy Progress Report – Dec 2012 3. Wolverhampton Mental Health Profile 4. Delayed Transfer Tracker 5. MH Supported Living Housing Provision 6. 2013/14 Service Specifications for: acute inpatients; home treatment; wellbeing & healthy minds; RAS, criminal justice and complex care teams 7. Delivery Plans for RAS, wellbeing and RAS 8. MH Strategy PID 9. Referral Pathway for Healthy Minds and Wellbeing 10. Health Transitions paper 11. Crisis Concordat 12. Closing the Gap 13. RAS modelling 14. TTR GP Experience questionnaire and report 15. Liaison business case 16. Draft Liaison service specification 17. Directory of Services 69