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Briefing paper for Health, Community and Care Overview and Scrutiny Committee June 2012 1.
Introduction
1.1
The Chair of the Health, Community and Care Overview and Scrutiny Committee requested in May 2012, that the Committee receive a full briefing on the work of 2gether, an overview of current service, our performance with an outline of the challenges ahead.
2.
2
2.1
2
2.2
The organisation is regulated by Monitor as a Foundation Trust and by the Care Quality Commission.
2.3
Services provided in Gloucestershire In Gloucestershire, our three locality service areas are aligned to our local general practice surgeries and deliver local services to our communities through multidisciplinary and specialist teams. They are: • One Stop Teams • Primary Mental Health Care • Specialist services including Prison Healthcare, Managing Memory, Hospital Liaison • Let’s Talk – Improving Access to Psychological Therapies
gether NHS Foundation Trust
gether NHS Foundation Trust (2gether) is a specialist trust providing social and mental healthcare services in Gloucestershire, Herefordshire and South Gloucestershire, serving a population of over 761,000.
a) Gloucestershire One Stop Teams The One Stop Teams are community based teams that offer a strong focus on the promotion of recovery, social care and personalised care planning. The teams deliver specialist secondary mental health care for adults with acute episodes of serious mental ill health and/or learning disability needs. The team’s focus is to deliver personalised care, based on the person’s individual needs by making reasonable adjustments where required to a range of evidence based mental health and learning disability care packages. Services are delivered by professionals including psychological therapists with a specialism within Community Learning Disability; Recovery; and Older People Mental Community Mental Health care and integrated social care is offered to adults aged 18-65 with mental health difficulties.
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b) Gloucestershire Primary Mental Health Care Service Our Primary Mental Health Care Teams work to support people in close partnership with primary care colleagues. The teams provide assessment, advice and signposting to primary care to support the understanding and management of mental health issues, including the promotion of positive emotional wellbeing. The team can also facilitate access to our Improving Access to Psychological Therapies service for evidence based treatments for depression and anxiety and our Managing Memory 2gether service for memory assessment and management. Where required, the team also offer short term interventions to support primary care in the management of common mental health disorders; and supportive mental health intervention for physical health issues. The teams work closely with the local One Stop Team to facilitate mental health recovery and support people with longer term conditions, such as stable psychosis within the primary care setting. Services are provided in general practice surgeries, service user homes and other community settings. c) Gloucestershire Countywide Services The countywide services provide acute inpatient care for adults over 18 years old and rehabilitation and habilitation support for people with a learning disability, across seven separate sites. There are two main mental health inpatient units - Wotton Lawn and Charlton Lane Hospital. At Wotton Lawn there is Psychiatric Intensive Care within our Greyfriars Unit, a Low Secure facility and the Maxwell Centre, our Section 136 Assessment Suite. The service also includes teams that provide crisis and home treatment, assertive outreach and specialist substance misuse treatment. d) Gloucestershire Children & Young People Services The Children and Young People services (CYPS) provide a specialist emotional wellbeing and mental health service for all children and young people who are registered with a GP in Gloucestershire through a specific contract with NHS Gloucestershire. The service sees children and young people up to 18 years of age. Usually children and young people referred to the service are experiencing emotional wellbeing problems that significantly affect their ability to cope with normal stresses and demands of life. In addition, the service also accepts referrals for developmental disorders, eating disorders, bipolar disorders, psychosis, attachment difficulties, infant mental health problems, conduct disorders or when a young person is at risk of harming themselves. 3.
National framework and priorities
3.1
One in four adults experience mental illness at some point during their lifetime and one in six experience symptoms at any one time – making mental illness the largest single cause of disability in our society.
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Policies in this area need to focus on outcomes, emphasising identification of what actually happens to the health of the patient as a result of the treatment and care they receive, as well as giving emphasis to the voice of patients and service users. 3.2
National Service Framework for Mental Health (1999) This was a fundamental Department of Health document which set out the national standards and service models for mental health promotion; primary mental health care and access to mental health services; caring about carers; and preventing suicide. Over the next 10 years, mental health services developed in line with these specific requirements and performance has measured against the implementation of the required service changes.
3.3
No Health without Mental Health This was published in 2011, and is a cross-Government mental health outcomes strategy for people of all ages outlining the mainstreaming of support for people with their mental health, with the aim of achieving parity of esteem between physical and mental health. The key areas are: • Early identification and intervention as soon as mental health problems emerge • The promotion of positive mental health and prevention of mental disorder in childhood and adolescence • The promotion of positive mental health and prevention of mental disorder in adults • Addressing the social determinants and consequences of mental health problems • Improving the quality and efficiency of current services The planned outcomes from the strategy are: a) More people will have good mental health More people of all ages and backgrounds will have better wellbeing and good mental health. Fewer people will develop mental health problems – by starting well, developing well, working well, living well and ageing well. b) More people with mental health problems will recover More people who develop mental health problems will have a good quality of life – greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates, and a suitable and stable place to live. c) More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health d) More people will have a positive experience of care and support
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Care and support, wherever it takes place, should offer access to timely, evidence-based interventions and approaches that give people the greatest choice and control over their own lives, in the least restrictive environment, and should ensure that people’s human rights are protected. e) Fewer people will suffer avoidable harm People receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service. f) Fewer people will experience stigma and discrimination Public understanding of mental health will improve and, as a result, negative attitudes and behaviours to people with mental health problems will decrease.
4.
Local priorities
4.1
The local priorities for mental health and learning disability services mirror what is expected nationally of mental health services, but take account of the local population requirements.
4.2
In Gloucestershire, over the past three months there has been focused work to develop a Gloucestershire Care Strategy with a key theme of mental health and wellbeing running through the strategic themes: • • • • •
. 4.3
Preventing people having to be admitted to hospital unnecessarily. Helping older people to return home after a stay in hospital. Supporting more people with long term conditions to live at home independently. Sustaining campaigns to promote good health and prevent illness. Further improving the efficiency and effectiveness of hospital based care.
The key local priorities for mental health and learning disability services provided in 2gether are reflected in strategic response to Gloucestershire’s growing needs. These are to: • meet the needs of our ageing population • safeguard the most vulnerable people in our communities • help everyone achieve their full potential regardless of their state of health • use our limited resources by focusing on those in the greatest need and support people to manage their own health and care needs where this is possible This will include: • Placing more emphasis on prevention - supporting people to take more responsibility for their own health and wellbeing. • Helping people to find sources of information and support within their local communities (‘Living Well, Listening Well’) and help people to cope with their caring responsibilities.
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•
Integrating service provision for the benefit of the person using the services.
5.
Working in partnership
5.1
2
5.2
Some key examples of this are: • The Mental Health Liaison Team which provides services in both Cheltenham General Hospital and Gloucestershire Royal Hospital. It provides a 7 day assessment service of service users who may need mental health assessments as part of their care. Also there is liaison support service provided to the Community Hospitals in the county.
gether is committed to working in partnership with other statutory, independent and voluntary sector partners within Gloucestershire, acknowledging that the people who use our services want an integrated approach to the delivery of care and support.
•
Work has continued with Gloucestershire Care Services to have access in mental health services to specialist nursing advice from specialist nurses in physical health, which is enabling an integrated approach to care.
•
The Dementia Training Team continues to provide training to all providers across the county including care homes and domiciliary care providers.
•
Integrated pathways for both drug and alcohol service users exist between the Independence Trust and 2gether and joint working is encouraged.
•
The Children and Young People’s Service works with Action for Children through a formal contract to provide care to children and young people (Tier 3.5 service) to provide care and support them at home preventing admission to hospital or enabling early discharge when they have been admitted.
6.
Performance
6.1
Key national performance indicators There are specific performance indicators that we are required to comply with as part of our Monitor authorisation. Last year, we were fully compliant with all the indicators and it is anticipated that we will be compliant this year. There are also a significant range of performance indicators that our contract with NHS Gloucestershire requires, which are reported monthly to them. Key Monitor Performance indicators Clostridium Difficile objective MRSA bacteraemia objective
Target for 2011/12 0 0
Performan Changes in ce for indicators for 2011/12 2012/13 0 0
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Key Monitor Performance indicators 7 day CPA follow-up after discharge CPA formal review within 12 months Delayed transfer of care Access to Crisis resolution/home treatment services before admission Provision of service for new psychosis cases by early intervention teams MHMDS data completeness: identifiers MHMDS data completeness: CPA outcomes Learning Disability – six criteria
6.2
Target for 2011/12
Performan Changes in ce for indicators for 2011/12 2012/13
95%
100%
95%
96.6%
≤7.5%
4.2%
90%
This now includes social care delays relating to bed days delayed
Target now 95% 99%
95%
127%
99%
99.5%
50%
86.9%
6/6
6/6
Target now 97%
Experience of people who use our services We actively encourage and seek feedback from people who use our services in a variety of forms e.g. Surveys of people when they leave hospital, kiosk with feedback questions in our service sites, feedback post cards. The feedback is actively reviewed within the organisation by the Governance Committee and the Board, and is shared with NHS Gloucestershire and NHS Herefordshire.
6.2.1 Key questions we asked people on discharge last year from Gloucestershire in-patients are outlined below and 97 people responded. Question
Response that was positive – Yes
When you arrived, did staff tell you about the daily routine of the ward, such as meal times and when people can visit you? Were you involved in deciding what was in your care plan?
72%
Were you told about possible side effects of the medication you take? During your most recent stay, did you feel safe?
66%
70%
91%
6.2.2 The Patient Experience quarterly report provides information on complaints, concerns, comments and commendations, and most importantly what we have done as a result of the feedback.
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During January to March 2012, there were 39 complaints received, against 490 compliments. Examples of recent comments received and action taken You said – Waiting Areas Carers told us that the waiting area in Albion Chambers had posters that were inappropriate and made them feel uncomfortable.
We did Reviewed and revised the poster information in the waiting area at Albion Chambers. Team Managers have been asked to review information that is available in waiting areas for service users and carers.
You said – Children and Young People
We did
We’d like to see improvements to waiting rooms, suitable magazines, access to a vending machine, posters and pictures, more games, accessible toiletsGloucester and better signage, You said – HMP better chairs
Concerns are raised regularly by prisoners with regard to the lack of medication that is available.
Magazines have been ordered for all 3 sites Better signage has been arranged for toilets Better chairs have been agreed Reception staff will ensure pens/pencils and paper We did are provided at all sites to complete suggestion forms for Suggestion Boxes
Staff ensure patients see the doctor if they feel unhappy with the change in medication. Clear explanation is given as to policy regarding change in medication.
Compliments were received verbally, by letter, card or through gifts such as fruit or biscuits/chocolates. Compliment –Managing Memory 2gether: ‘An interesting and informative session was delivered about ‘The Brain and Behaviour’. Good discussion was also facilitated of individual experience within the group.’ Thank you.’ ‘Brilliant! To use activities to make us think/feel/experience exactly how things are for the person with dementia’
Staff received thanks for a variety of reasons. In some instances the carer, family or service user thanked staff for the treatment/care/support they received or for the supportive environment encountered and the recovery achieved. Compliment – Recovery Unit, Honeybourne I feel very well indeed. Thank you for what has been a very successful stay at Honeybourne. I feel set up for a happy and rewarding life in the future. A big thank you to all the staff.
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6.2.3 Other initiatives to ensure that there is involvement and feedback on our services Managing Memory 2gether and Village agents Representatives of the service have had a series of meetings with Village Agents who are working across the county to answer questions about memory services and support. These sessions have been helpful in understanding the specific work of Village Agents and some of the issues they face, meeting people with memory problems and dementia in the community. Drop in sessions at Wotton Lawn Priory Ward, Wotton Lawn Hospital are piloting ‘drop-in’ sessions from other support services. The aim is to raise awareness of the additional supports that are available to service users, their family members and carers. Participating support services include: Gloucestershire Guide and PALs; 2gether’s Better2Work service; 2gether’s Community Development Team and carers Gloucestershire. Working 2gether with carers in Gloucestershire Carers Gloucestershire are facilitating Carer Voice meetings and have provided helpful feedback information about waiting areas, carer assessments, interface with the police, and developments in Fair Horizons. Information has been provided to locality areas so that the comments made are considered as developments are made in practice.
7.
Service changes
7.1
Impact of previous service changes In 2006, there were a number of service changes which focussed upon the centralisation of specialist in-patient services and the increase of community services to provide more care in people’s homes. A review of the impact of these changes was completed last year with a particular focus upon admissions for older people which are centred in Charlton Lane in Cheltenham. The 2010/11 data shows that on average there were 2.2 admissions per 1,000 population over 65 years of age, with the Cotwolds having the lowest admission rate and Cheltenham and Tewkesbury having the highest admission rate. In 2011/12, there were 248 actual admissions which is broadly comparable to 2010/11 when there were 224 admissions. The reduction of in-patient beds was supported by an increase in more care provided in people’s own homes. This support has been developed and continues to increase in the older people community teams which are now part of the One Stop Teams. The Managing Memory Service is currently supporting over 1,100 people within the county with a memory problem. The specialist Community Dementia Nursing service commenced formally in November 2011 and their
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caseload is growing steadily and currently stands at 120 people supported through short term frequent interventions to reduce risk of care breaking down. 7.2
Recent Service developments Fair Horizons development Over the past year there has been a development in community mental health services in the county referred to as ‘Fair Horizons’ which the Committee has been briefed on. The focus of this development has been to provide services on the basis of need and not age and intelligence. In the past we have provided services according to whether someone was over a certain age or had a learning disability. Fair Horizons has led to the creation of One Stop Teams in localities that provide care on the basis of need to people in that area. There are still practitioners with specialist skills e.g. Learning disability community nurses, but they have been brought together into one overarching team. The newly formatted teams were implemented in May 2012. There has also been significant work to develop and introduce care pathways for clinicians to follow for the key areas of need nationally prescribed by the Department of Health in care clusters. A third Fair Horizon’s Reference Group event for service users, carers and community stakeholder groups was held on 27th June 2012, as part of the process to continue to seek input into this change in how services are provided. Reasonable Adjustments and Care Outcomes for People with a Learning Disability New ways of working with people who have a Learning Disability have been introduced, to ensure that they are enabled to access all services, and their care plans reflect what outcomes they want to achieve. This development work is contributing to national work on measuring outcomes for people with a Learning Disability. Children and Young Peoples Service The contract with NHS Gloucestershire for a new Children and Young Peoples Wellbeing Service commenced on 1 April 2011. The service has just completed an Annual Report demonstrating the improvements made in the service, which include that 95% of referrals are seen within 8 weeks and that if a child or young person needs crisis support then this is provided within 24 hours of referral. The Home Treatment Services have been successfully minimising the need for hospital admission, and enabling early discharge to a service users family and familiar surroundings. AIMs Accreditation Programme AIMS is a standards-based accreditation programme run by the Royal College of Psychiatrists which is designed to improve the quality of care in inpatient
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mental health wards. It accredits acute and assessment wards for workingage adults, wards for older people, psychiatric intensive care units, inpatient learning disability services, inpatient rehabilitation units and care for young people on adult wards. All our in-patient units have this accreditation. 7.3
Future developments planned for 2012/13 within Gloucestershire Building on the work of the new Fair Horizons One Stop Teams, a Contact Centre for all referrals will be fully operational by the Autumn 2012. This will be enable primary care colleagues to refer directly to the services for assessment, support and treatment without having to consider exactly which service is required and how to contact them. Further developments are taking place in the following areas: • Patient Safety Programme • Quality initiatives in the Quality Report • Ensuring that the quality and delivery of service meets the needs of people who use our services as well as complying with the developing national and local requirements e.g. Payment by Results • Capital programme of work in Wotton Lawn and hubs for the One Stop Teams in the Localities • Responding to the tendering the services e.g. Gloucestershire Substance Misuse Service
8.
Impact of the Health and Social Care Act on 2gether
8.1
The changes outlined in the Health and Social Care Act (2011) have far reaching implications across the NHS. Specifically in 2gether the following aspects will have an impact.
8.2
Clinical Commissioning Groups The structure of the NHS will significantly change over the coming year, with Clinical Commissioning Groups taking over the local commissioning from Primary Care Groups. This will build upon the current positive partnership working with clinical colleagues from primary care and work is already planned on specific pathways of care for people with mental health problems.
8.3
Regulation changes New Monitor licensing arrangement that will come into force will change the current approach to authorisation of Foundation Trusts, it is not anticipated that this will cause any issues. We welcome the opportunity for Monitor and the Care Quality Commission to work more closely together on the regulation of providers.
8.4
Competition The Act further progresses the competition agenda in the provision of health care services, with the ability for ‘any qualified provider’ be able to tender for services in the future if they meet specific requirements.
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The new approach to completion does have an impact this year, with NHS Gloucestershire currently tendering for Substance Misuse Services within the county. This will mean that the services we currently provide in this area may be provided by another provider if 2gether is not successful in winning the tender. 8.5
Payment by Results Monitor’s role changes in relation to Payment by Results, with it having the responsibility for pricing of services in the future. Payment by Results has been implemented in mental health services this year, with a local agreement with NHS Gloucestershire. Further work is planned nationally on a tariff, which may impact on the amount that the organisation will get paid for pathways of care in the future.
8.6
Patient Experience The Health Act places increasing emphasis on the patient experience of services, reflecting that there should be ‘nothing about me, without me’. We already have a positive focus upon this area of work, but will be developing this further with increasing feedback mechanisms from people who use our services and particularly asking them whether they would recommend the service to friends and family.
Shaun Clee Chief Executive
June 2012
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