CONSULTATION REPORT Redesigning: Adult and Older People’S Specialist Mental Health Services

CONSULTATION REPORT Redesigning: Adult and Older People’s Specialist Mental Health Services

Consultation from 6th March - 29th May 2018

University of Chester

10th September 2018

Table of Contents Tables ...... 5 Figures ...... 6 PART 1: Introduction and Background to the Consultation ...... 7 The Proposed Options ...... 9 Part 2: Methods ...... 12 Data Analysis ...... 12 Part 3: Results from the survey ...... 12 Section 1: Tell us about you ...... 13 a) Please indicate in what capacity you are answering this questionnaire ...... 13 b) Geographical distribution of questionnaire responses...... 13 c) Replying on behalf of an organisation ...... 16 Organisation ...... 16 Source ...... 16 d) Members, volunteers or involvement representative for any health or social care organisation (NHS, local government, private or voluntary) ...... 16 Participant demographics ...... 17 Gender of participants ...... 17 Age of participants ...... 18 Ethnicity ...... 20 Sexual orientation ...... 21 Religion or belief ...... 21 Caring responsibilities ...... 23 Disabilities reported ...... 24 Section 2: Importance of considerations when evaluating new proposals ...... 26 Service criteria ...... 26 Section 3: Comment on the proposals ...... 29 Responses to Option 1 ...... 30 Respondents were asked to what extent they agreed with Option 1 ...... 30 Overall opinion of all respondents ...... 30 Qualitative responses to Option 1 ...... 32 Reasons for agreeing with Option 1 ...... 32 Reasons for disagreeing with Option 1 ...... 35 Agreement with statements for Option 1 ...... 38 Groups considered disproportionately or unfairly impacted by Option 1 ...... 45 Suggested ways of overcoming the issues, concerns, challenges associated with Option 1 ...... 47

Responses to Option 2 ...... 50 Overall opinion ...... 50 Qualitative responses to Option 2 ...... 52 Reasons for agreeing with Option 2 ...... 52 Reasons for disagreeing with Option 2 ...... 55 Agreement with statements ...... 58 Groups considered disproportionately or unfairly impacted by Option 2 ...... 63 Suggested ways of overcoming the issues, concerns, challenges associated with Option 2 ...... 66 Responses to Option 3 ...... 69 Overall opinion ...... 69 Qualitative responses to Option 3 ...... 71 Reasons for agreeing with Option 3 ...... 71 Reasons for disagreeing with Option 3 ...... 74 Agreement with statements ...... 77 Groups considered disproportionately or unfairly impacted by Option 3 ...... 81 Suggested ways of overcoming the issues, concerns, challenges associated with Option 3 ...... 84 Comparison of options summary ...... 87 Rating of Options ...... 87 Ranking of Options ...... 88 Other comments ...... 93 Part 4: Conclusions ...... 95 Appendices ...... 97 Appendix 1: Data cut by CCG and Stakeholder group ...... 97 Appendix 2: Data cut by CCG and age grouping ...... 169 Appendix 3: Full coding for suggestions to overcome issues presented by each Option ...... 214

Tables Table 1: Responses received ...... 12 Table 2: Responses segmented by stakeholder group ...... 13 Table 3: Responses according to postcode district ...... 14 Table 4: Responses according to CCG ...... 15 Table 5: Organisational responses to survey ...... 16 Table 6: Other organisations to which participants belong ...... 17 Table 7: Reasons for agreeing with Option 1 ...... 32 Table 8: Reasons for disagreeing with Option 1 ...... 35 Table 9: Specific groups disproportionately affected by Option 1 ...... 45 Table 10: Suggested ways of overcoming the issues, concerns, challenges associated with Option 1 47 Table 11: Reasons for agreeing with Option 2 ...... 53 Table 12: Reasons for disagreeing with Option 2 ...... 55 Table 13: Specific groups disproportionately affected by Option 2 ...... 63 Table 14: Suggested ways of overcoming the issues, concerns, challenges associated with Option 2 66 Table 15: Reasons for agreeing with Option 3 ...... 71 Table 16: Reasons for disagreeing with Option 3 ...... 74 Table 17: Specific groups disproportionately affected by Option 3 ...... 81 Table 18: Suggested ways of overcoming the issues, concerns, challenges associated with Option 3 84 Table 19: Other comments split by CCG ...... 93

Figures Figure 1: Maps showing distribution of a) total responses, with the breakdown of b) online and c) paper based responses ...... 15 Figure 2: Gender of Participants ...... 17 Figure 3: Gender of participants by CCG ...... 18 Figure 4: Gender of participants by stakeholder group ...... 18 Figure 5: Age of participants ...... 19 Figure 6: Proportion of participants over 65 years by CCG ...... 19 Figure 7: Proportion of participants over 65 years by stakeholder group...... 20 Figure 8: Ethnicity of participants ...... 20 Figure 9: Sexual orientation of participants ...... 21 Figure 10: Religion or belief of participants ...... 21 Figure 11: Religion or belief by CCG ...... 22 Figure 12: Religion or belief by stakeholder group ...... 22 Figure 13: Respondents caring responsibilities ...... 23 Figure 14: Caring responsibilities by CCG ...... 23 Figure 15: Caring responsibilities by stakeholder group ...... 24 Figure 16: Respondent's reported disabilities ...... 24 Figure 17: Reported disabilities by CCG ...... 25 Figure 18: Reported disabilities by stakeholder group ...... 25 Figure 19: Importance of MH service aspects (number of people putting each in their top three) .... 26 Figure 20: Importance of MH service aspects by CCG ...... 27 Figure 21: Segmentation of important aspects by stakeholder ...... 28 Figure 22: Overall response to option 1 ...... 30 Figure 23: Response to option 1 by CCG ...... 31 Figure 24: Response to option by stakeholder group ...... 31 Figure 25: Agreement with statements re Option 1 ...... 39 Figure 26: Agreement with statements re Option 1 ...... 40 Figure 27: Agreement with Option 1 statements by CCG ...... 41 Figure 28: Agreement with Option 1 statements by stakeholder group ...... 44 Figure 29: Overall response to Option 2 ...... 50 Figure 30: Response to Option 2 by CCG ...... 50 Figure 31: Response to Option 2 by stakeholder group ...... 51 Figure 32: Response to Option 2 statements ...... 58 Figure 33: Response to Option 2 statements by CCG ...... 59 Figure 34: Response to Option 2 by stakeholder group ...... 62 Figure 35: Overall response to Option 3 ...... 69 Figure 36: Response to Option 3 split by CCG ...... 69 Figure 37: Response to Option 3 split by stakeholder group...... 70 Figure 38: Overall response to Option 3 statements ...... 77 Figure 39: Response to Option 3 statements by CCG ...... 78 Figure 40: Response to Option 2 statements by Stakeholder ...... 80 Figure 41: Overall rating of Options ...... 87 Figure 42: Overall ranking of Options ...... 88 Figure 43: Ranking of Options by CCG ...... 89 Figure 44: Ranking of Options by stakeholder group ...... 92

PART 1: Introduction and Background to the Consultation

The consultation led by NHS Eastern Cheshire Clinical Commissioning Group, NHS South Cheshire Clinical Commissioning Group and NHS Vale Royal Clinical Commissioning group working in partnership with Cheshire and Wirral Partnership NHS Foundation Trust (CWP) was run with patients and the public, between 6th March and 29th May 2018. This consultation aimed to gather and collate views on the redesign of Adult and Older People’s Specialist Mental Health Services in Eastern Cheshire, South Cheshire and Vale Royal.

User and carer feedback, along with recent audit recommendations and inspections, highlighted that although some parts of the service were working well, others required improvement.

The proposed service redesign aims to:

 Provide new services so that there is better access for people to help keep them well and active in the community  Provide much greater choice of services for those in, or at risk of, crisis  Support people with dementia and those who care for them to stay in their own surroundings.

Eight potential options were considered in detail, using a set of criteria including:

 How clinically safe the options were  Could they maintained over time  Did they provide the highest quality possible  Were they affordable  Were they acceptable to users of the service

The merits and capacity of other mental health service providers taking on both inpatient and community services was explored, but rejected due to the additional workload which some providers were unable to accommodate. Further the possibility of working with the private sector to achieve the goals of redesigning the service was explored, but also rejected as it was felt that there was neither the capacity nor the skills available to meet the often very complex needs of these service users.

After thorough analysis, three potential options were selected to be taken forward to be included in the public consultation.

The Proposed Options

The options selected for the consultation were as follows:

Option 1: Do not introduce the proposed new model of care

In this option there would be no prospect of improvement or development of the following services: community care, crisis care/choice of service, dementia outreach, or inpatient care unless funding was taken/diverted from other current local NHS services.

What this would mean for service users and carers:

• There would be no choice of crisis response, no new dementia outreach service. • To fully refurbish the Millbrook Unit to bring it up to the required standards for such units would cost in the region of £7 million. Borrowing the money and paying it back would mean a total cost to the local NHS of approximately • £14 million. These funds, that would be needed to repay the borrowed money, would have to be taken from the local NHS budget which would otherwise have been used to fund other local healthcare services. • As the current model of care costs more to provide than the funding that is available, in the region of £2.5 million annually, this money would have to be taken/diverted from other local healthcare services to fund the current level/model of service. • Inpatient care and outpatient services would remain on the Millbrook Unit and additional travel for some service users and carers would be avoided.

Option 2 Preferred option: Improve community and home treatment (crisis) teams, provide local crisis beds within the community, older people’s inpatient care at Lime Walk House, Macclesfield and adult inpatient care at Bowmere, Chester. This scored highest during option appraisal as it:

• Provides all of the improved community services • Has an onsite Psychiatric Intensive Care Unit (PICU) for adults • Doesn’t require additional travel for older people Enhance community and home treatment (crisis) teams to provide a wider range of services and improve access to care locally for the 7,000 adults and older people in our communities who currently access specialist mental health services. What this would mean for service users and carers:

For the 350 people per year who at the moment access inpatient care services currently provided at Millbrook, this would be replaced with NEW services as follows:

• A new older people’s inpatient service providing 22 beds and meeting CQC standards, based at Lime Walk House; with specialist rehabilitation patients currently at Lime Walk House transferred to the nearby specialist rehabilitation facility at Soss Moss in Nether Alderley. • A new dementia outreach service supporting people to remain in their own homes. • New 24-hour local crisis care services overseen by an enhanced community home treatment team which can visit a person a number of times a day to prevent the need for hospital admission, and including access to: . six new local crisis beds provided in centres, as an alternative to hospital admission and A&E attendance - with a dedicated hub open 24/7; . daytime crisis cafés and drop-in centres with links to other support services. • A new adult inpatient ward with 22 beds providing an improved inpatient experience, including access to a dedicated PICU and Electro Convulsive Therapy (ECT) if required, and meeting CQC standards at Bowmere Hospital, Chester. • An increase of three beds at Springview Hospital, Wirral to ensure adequate capacity across Cheshire and Wirral when required. In total, these inpatient services would provide 53 beds (a reduction of five beds from those currently available at the Millbrook Unit). The cost of adapting and expanding existing facilities is approximately £1.1 million and would be funded from CWP’s annual capital expenditure programme. There would be no requirement to divert funds from other services as this option would be less expensive to run and would enable the ongoing funding of the proposed new service model. In this option, approximately 260 adults from Eastern Cheshire, South Cheshire and Vale Royal would travel further to access acute inpatient care in Chester each year. There would be a support plan in place for their carers.

With this model, we would expect all 7,000 people on the community caseload to have improved access to support through the out-reach, crisis care and other newly provided services. Our needs10 analysis indicates this would mean the number of people requiring inpatient care per year could reduce by as much as 16 per cent (approximately 70 people).

Option 3

Improve community and home treatment (crisis) teams, provide local crisis beds within the community, provide adult inpatient care at Lime Walk House, Macclesfield and older people’s inpatient care at Bowmere, Chester.

Enhance community and home treatment (crisis) teams to provide a wider range of services and improved access to care locally for the 7,000 adults and older people in our communities who currently access specialist mental health services.

For the 350 people per year who at the moment access inpatient care services currently provided at Millbrook, this would be replaced with NEW services as follows:

The only differences to Option 2 are the following:

• The new inpatient service providing 22 beds and meeting CQC standards, based at Lime Walk House would be for adults, with specialist rehabilitation patients currently at Lime Walk House transferred to the nearby specialist rehabilitation facility at Soss Moss. • This would not provide on-site access to a Psychiatric Intensive Care Unit (PICU) so people requiring this service would need to continue to travel to the PICU in Chester. • The new inpatient ward with 22 beds providing an improved inpatient experience and meeting CQC standards at Bowmere Hospital, Chester would be for older people.

In this option, approximately 70 older people would travel further to access inpatient care in Chester each year. There would be a support plan in place for their carers.

The cost of adapting and expanding existing facilities is approximately £1.1 million and would be funded from CWP’s annual capital expenditure programme.

There would be no requirement to divert funds from other services as this option would be less expensive to run and would enable the ongoing funding of the proposed new service model.

Respondents to the consultation survey were asked a series of questions about each option, and given the opportunity to express any opinions they wished to share, regarding the process of change to the service, or the current service. This document reports the findings of the survey which formed part of the process.

Part 2: Methods

Data Analysis

Data from the online survey and the paper based survey were entered into separate databases on Elesurvey in order to maintain independence. The results were extracted as two discrete data files into SPSS statistical software, and these were combined for the purposes of analysis. Open ended questions were entered into Nvivo qualitative analysis software, and a thematic analysis of the data was conducted.

Part 3: Results from the survey A total of 324 responses to the consultation were received, see Table 1, with 148 submitted online through the Elesurvey portal. A further 176 paper copies were returned, including 27 easy read versions. The paper copies were manually entered into Elesurvey to facilitate consistency and enable analysis of the data.

Seven paper responses were received with letters or notes to indicate the recipient was unable or unwilling to complete the questionnaire, and these are not included in the data.

Responses Online 148 Paper 176 Total 324 Table 1: Responses received

Paper questionnaires received after the closing date of the consultation (29th May 2018) were excluded from the analysis. The cut off for these questionnaires was five days after the consultation closing date (4th June 2018), to allow sufficient time for transit through the postal system. To date six additional questionnaires have been received after the cut-off date, and these have been excluded from the analysis.

These procedures resulted in a database of 324 responses which were used in the analysis of the questionnaire.

Section 1: Tell us about you

a) Please indicate in what capacity you are answering this questionnaire The majority of participants who responded to the consultation survey were service users (n=124, 38.3%) followed by members of the public (n=76, 23.5%) and carers (n=65, 20.1%). Table 2 shows the segmentation of survey responses by stakeholder groups, including online and paper responses.

Online Paper Total

Service user 31 93 124

Carer - MH 27 38 65

Public 59 17 76

NHS (MH) employee 5 8 13

Other public sector 6 2 8 employee

Other organisation 7 2 9 employee

Other 11 10 21

Missing 2 6 8

Total 148 176 324 Table 2: Responses segmented by stakeholder group

b) Geographical distribution of questionnaire responses Respondents filled in the first part of their postcode to allow for segmentation of the data into one of the three Clinical Commissioning Groups (CCGs) taking part in this consultation. Responses were segmented by postcode district, see Table 3, and the largest number of responses were received from the SK10 and SK11 postcode districts in the Eastern Cheshire CCG.

Postcode Towns Local Authority Online Paper Total CCG

CW1 Crewe, Haslington, Cheshire East 7 11 18 SC Leighton

CW2 Crewe, Wistaston, Cheshire East 7 16 23 SC Woolstanwood

CW4 Holmes Chapel Cheshire East 2 5 7 EC

CW5 Nantwich, Willaston, Cheshire East 7 8 15 SC

CW6 Tarporley CWAC 1 0 1 WC

CW7 Winsford CWAC 1 7 8 VR

CW8 Northwich, Hartford, CWAC 6 6 12 VR Weaverham

CW9 Northwich, Wincham, CWAC 6 8 14 VR Lostock Gralam

CW10 Middlewich Cheshire East 3 2 5 SC

CW11 Sandbach Cheshire East 5 8 13 SC

CW12 Congleton Cheshire East 8 18 26 EC

SK9 Wilmslow, Alderley Edge Cheshire East 8 10 18 EC

SK10 Macclesfield Cheshire East 31 24 55 EC

SK11 Macclesfield Cheshire East 32 20 52 EC

SK12 Stockport Cheshire East 11 9 20 EC

CH1 Chester CWAC 0 1 1 WC

CH64 Ellesmere Port CWAC 1 0 1 WC

CH65 Ellesmere Port CWAC 1 0 1 WC

ST7 Kidsgrove, Alsager Cheshire East 0 7 7 SC

WA4 Warrington CWAC 0 1 1 n/a

WA16 Knutsford Cheshire East 2 6 8 EC

Postcodes 139 167 306 TOTAL

Unknown n/a n/a 9 9 18

TOTAL 148 176 324 Key: EC = Eastern SC = South Cheshire VR = Vale Royal WC = West Cheshire Cheshire Table 3: Responses according to postcode district

This distribution of responses is shown graphically in the maps below, which indicate the overall responses, online responses and paper based response distribution, see Figure 1.

Figure 1: Maps showing distribution of a) total responses, with the breakdown of b) online and c) paper based responses

Postcode data was combined to produce response rates for each of the CCGs in the consultation, and distributions of these are shown in Table 4 below. The largest number of respondents was from Eastern Cheshire CCG (n=186, 57.4%), followed by South Cheshire CCG (n=81, 25%) and Vale Royal (n=34, 10.5%). A small number of responses were received from West Cheshire CCG, and one from Warrington.

CCG Online Paper Total South Cheshire 29 52 81 Eastern Cheshire 94 92 186 Vale Royal 13 21 34 West Cheshire 3 1 4 Missing / out of area 9 10 19 TOTAL 148 176 324 Table 4: Responses according to CCG

c) Replying on behalf of an organisation Participants were asked if they were completing the questionnaire on behalf of any organisation. The following Table 5 shows organisations with representation in the survey data. These organisational responses have been incorporated into the overall findings reported in this document, however they have also been supplied to the CCG in a separate document to ensure they have been noted.

Organisation Source Labour Party Online Bosley Parish Council Online Irish Community Care Online Age UK Cheshire Online Age UK Cheshire East Online Henbury Parish Council Online ATMA Enterprises CIC; Members of Open Minds Online West Cheshire Mental Health Forum Online Adlington Parish Council Online Mottram St Andrew Parish Council Online NeuroMuscular Centre Online Belong Paper Table 5: Organisational responses to survey d) Members, volunteers or involvement representative for any health or social care organisation (NHS, local government, private or voluntary) Participants were also asked to record any organisations for which they were members, volunteers or representatives, but for which they were not completing the survey. Respondents recorded involvement in the following groups, but did not complete the survey as representatives of these organisations, see Table 6.

Other organisations CWP Member of the PPG Volunteer at the Disability Information Bureau, Macclesfield Cheshire east council NHS Self Care Nantwich Health Centre PPG CWP NHS Foundation Trust member. Talking Therapies Eastern Cheshire Alzheimers Society Irish Community Care Qualified nurse working fulltime for Manchester University Foundation Trust. Surgery patient participation group Greater Manchester Health and Social Care Partnership (I work for North Manchester CCG) ATMA Enterprises CIC Macclesfield District General Hospital Catholic Chaplain Parish priest/Pastor in South Macclesfield NeuroMuscular Centre Body positive, Crewe Ex member of PPG Belong care village

Cheshire East Borough Councillor 'In Together' A group for people with dementia and their carers at St Mary's Church Handforth RNMS Community Sister McIlvride Medical Practice GP, resident Methodist church CWP volunteer as a visiting pets as therapy volunteer Health Voice NHS Eastern Cheshire CCG NHS South Cheshire CCG Table 6: Other organisations to which participants belong

Participant demographics Gender of participants Overall the largest group of respondents were female n=175 (54%), 111 respondents were male (34.3%), 10 respondents (3.1%) ticked ‘prefer not to say’ and 25 respondents (7.7%) did not answer this question, see Figure 2.

200 175 180 n=324 160 140 120 111 100 80 60 40 25 20 10 1 2 0 Male Female Intersex Prefer not to say Other Missing

Figure 2: Gender of Participants

There were slight variations in the gender balance in each of the CCGs, however ‘female’ was the largest respondent group in all CCGS. The following Figure 3 shows the percentages of each gender within the responses from each CCG.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 32 41 5 3

East Cheshire 64 100 1 5 15

Vale Royal 7 23 1 3

West Cheshire 1 3 0

No CCG 7 8 4

Male Female Intersex Other Prefer not to say Missing n=323

Figure 3: Gender of participants by CCG

Further when analysing the data by stakeholder group, see Figure 4, the largest number of respondents in all groups were female. The following figure shows number and percentage of each gender as a proportion of each stakeholder group.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 48 64 3 9

Carer - MH 19 40 1 2 3

Public 28 40 1 3 4

NHS (MH) employee 2 11 0

Other public sector employee 1 5 2 0

Other organisation employee 3 5 1

Other 6 9 1 5

Male Female Intersex Other Prefer not to say Missing data n=316

Figure 4: Gender of participants by stakeholder group

Two hundred and seventy nine (86.1%) respondents stated that their currently identified gender is the same as that at birth, three reported their current gender was different at birth (0.9%), eight (2.5%) preferred not to say, and 34 people skipped this question (10.5%).

Age of participants The largest group of respondents were aged 50-59 years (20.4%), followed by 60-69 years (18.5%) and 70-79 years (16%). Twenty one participants (6.5%) did not answer this question, see Figure 5.

70 66 60 60 52 50 42 42 40

30 20 20 16

10 4 1 0 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+n=303

Figure 5: Age of participants

The data was analysed to compare the proportion of participants under and over 65 years; 200 respondents (61.7%) were aged under 65 years, and 103 (31.8%) were over 65 years (with 21 respondents missing this question). The following Figure 6 shows the proportion of participants over the age of 65 years from each of the CCGs. There was similarity in the proportions of respondents under 65 years and those over 65 years across the CCGs, with Vale Royal having a slightly higher proportion of those under 65 years (<65 years, SC=64.6%, EC=64.5%, VR=68.8%). However for those who did not provide postcode data and therefore were not included in the CCG grouping, the proportion of those under 65 years was higher at 81.3%.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 51 28

East Cheshire 111 61

Vale Royal 22 10

West Cheshire 3 1

No CCG data 13 3

Under 65 years Over 65 years n=303

Figure 6: Proportion of participants over 65 years by CCG

The age data was also segmented by stakeholder group, see Figure 7 below to illustrate the proportions respondents under 65 years and over 65 years. The proportion of respondents over 65 years in the ‘Service user’ group (31.3%) was lower than that in the ‘Carer’ (55.6%) or ‘Public’ groups (68.5%). As expected, respondents from the employee groups were predominantly under the age of 65 years.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 79 36

Carer - MH 28 35

Public 56 19

NHS (MH) employee 11 1

Other public sector employee 7 1

Other organisation employee 7 1

Other 9 8

Under 65 years Over 65 years n=298

Other Other Service NHS (MH) public Carer - MH Public organisation Other user employee sector employee employee Under 65 years 68.7 44.4 31.5 91.7 87.5 87.5 52.9 Over 65 years 31.3 55.6 68.5 8.3 12.5 12.5 47.1 Figure 7: Proportion of participants over 65 years by stakeholder group

Ethnicity The largest majority of participants (87.7%) were White British, with very small numbers reporting other ethnicity, and 27 participants (8.3%) choosing to skip this question, see Figure 8. This data has not been split by CCG or stakeholder group as the numbers with ethnicity other than white British were very low.

300 284 250 200 150 100 50 27 1 2 1 1 1 1 6 0 White White Irish White Mixed Mixed Chinese Black Other Missing British Polish multi-ethnicmulti-ethnic African White and White and Caribbean Black African n=324

Figure 8: Ethnicity of participants

Sexual orientation The majority of respondents were heterosexual (76.5%), with only six people reporting any other sexual orientation, see Figure 9. Twenty seven people indicated they ‘preferred not to say’ (2.5%) and 34 people missed this question (10.5%). This data was not segmented further due to the small numbers in groups other than ‘heterosexual’.

300 248 n=324 250

200

150

100

43 50 27 1 1 4 0 Heterosexual Lesbian Gay Bisexual Prefer not to say Missing

Figure 9: Sexual orientation of participants

Religion or belief The largest religion or belief of respondents was ‘Christianity’ (54%), followed by ‘No religion’ (25%). Thirty one people (9.6%) of people ‘Preferred not to say’ and 28 people (8.6%) skipped this question.

200 175 180 n=324 160 140 120 100 81 80 60 40 31 28 8 20 1 0 Christianity Buddhism No religion Prefer not to say Other Missing

Figure 10: Religion or belief of participants

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 42 21 9 4 5

East Cheshire 102 48 19 2 15

Vale Royal 21 1 7 2 3

Hinduism Christianity Judaism Buddhism Islam Sikhism No religion Prefer not to say Other Missing

Figure 11: Religion or belief by CCG

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 64 1 30 12 6 11

Carer - MH 45 11 5 2 2

Public 42 22 8 4

NHS (MH) employee 5 5 3

Other public sector employee 4 3 1

Other organisation employee 4 3 1 1

Other 10 5 6

Hinduism Christianity Judaism Buddhism Islam Sikhism No religion Prefer not to say Other Missing

Figure 12: Religion or belief by stakeholder group

Caring responsibilities Participants were asked to indicate if they had any caring responsibilities, and if so, who they cared for.

The largest group of respondents were those who were not a carer for anyone who had accessed mental health services (n=154), followed by those who were a carer of someone over 50 years of age (n=57).

160 154 140 120 100 80 57 60 40 23 20 12 0 I am not a carer for anyone I am a carer for someone I am a carer for someone I am a carer for someone who has accessed/ is under 24 years of age aged 25 to 49 years of age over 50 years of age accessing mental health services

Figure 13: Respondents caring responsibilities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 34 1 7 14

East Cheshire 98 7 14 28

Vale Royal 14 4 1 8

West Cheshire 1 0 3

I am not a carer for anyone who has accessed/ is accessing mental health services I am a carer for someone under 24 years of age I am a carer for someone aged 25 to 49 years of age I am a carer for someone over 50 years of age

Figure 14: Caring responsibilities by CCG

Results were similar when segmented by CCG, with a slightly higher proportion of respondents from Vale Royal with caring responsibilities (48.1%).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 69 1 3 6 Carer - MH 5 8 13 37 Public 49 3 3 8 NHS (MH) employee 7 0 1 2 Other public sector employee 6 0 2 0 Other organisation employee 5 0 Other 12 0 1 4

Figure 15: Caring responsibilities by stakeholder group

Splitting the data by stakeholder group shows, as would be expected, that most service users were not carers (87.3%).

Disabilities reported 120 102 100 80 56 60 46

40 30 27 25 20 0 Physical Sensory Mental health Learning Long term Other impairment impairment need disability or illness difficulty

Figure 16: Respondent's reported disabilities

The largest group of disabilities reported was mental health need (n=102), followed by long term illness (n=56), physical impairment (46%) and sensory impairment (n=30).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 16 10 32 10 22 7

East Cheshire 22 13 53 12 27 12

Vale Royal 3 6 12 2 4 4

West Cheshire 2 0 1 1 1 1

Physical impairment Sensory impairment Mental health need Learning disability or difficulty Long term illness Other

Figure 17: Reported disabilities by CCG

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 24 8 77 12 32 8

Carer - MH 5 2 8 2 4 8

Public 10 15 10 9 11 6

NHS (MH) employee 2 3 2 2 2 1

Other public sector employee 0 1 0 1 0

Other organisation employee 2 1 2 1 1 2

Other 2 0 3 1 4 0

Physical impairment Sensory impairment Mental health need Learning disability or difficulty Long term illness Other

Figure 18: Reported disabilities by stakeholder group

Section 2: Importance of considerations when evaluating new proposals Participants were presented with eight statements reflecting key aspects of Mental Health services, and asked which three they felt were most important. The following chart indicates how often each statement was selected as one of participants ‘top three’ aspects of MH services. Service criteria 300 248 n=324 250 200 181 150 118 91 85 84 100 80 49 50 0 Improving 24-hour Being able to A dementia Access to a More choice Better access Inpatient outcomes for access to visit hospital outreach better range about the to community services people with crisis services easily service of treatment services services meeting mental ill- supporting options available for privacy and health people in people in dignity their own crisis standards homes

Figure 19: Importance of MH service aspects (number of people putting each in their top three)

The most often chosen aspect overall was ‘Improving outcomes for people with mental ill-health’ (n=248, 76.5%), followed by ’24 hour access to crisis services’ (n=181, 77.3%), and ‘Being able to visit hospital easily’ (n=118, 50.4%), see Figure 19 for full details. Note as respondents could tick more than one disability, the figures add to more than the participants number of 234.

Responses were segmented by CCG to explore differences in geographical location, see Figure 20 below.

0% 20% 40% 60% 80% 100% Improving outcomes for people with mental ill-health

South Cheshire More choice about the services available for people in crisis

24-hour access to crisis services

East Cheshire A dementia outreach service supporting people in their own homes Better access to community services

Vale Royal Access to a better range of treatment options

Inpatient services meeting privacy and dignity standards West Cheshire

Being able to visit hospital easily

South Eastern Vale West Total Cheshire Cheshire Royal Cheshire Improving outcomes for people with mental ill-health 26% 27% 29% 25% 26% More choice about the services available for people in crisis 11% 9% 5% 8% 9% 24-hour access to crisis services 19% 20% 18% 17% 19% A dementia outreach service supporting people in their 11% 9% 12% 8% 10% own homes Better access to community services 9% 6% 13% 17% 9% Access to a better range of treatment options 12% 6% 13% 17% 9% Inpatient services meeting privacy and dignity standards 5% 6% 4% 0% 5% Being able to visit hospital easily 7% 17% 5% 8% 13% Figure 20: Importance of MH service aspects by CCG

The segmentation of the data by CCG, see Figure 20 shows that ‘Being able to visit hospital easily’ is more often one of the three most important aspects chosen by respondents in the Eastern Cheshire CCG (17%), whereas ‘More choice about the services available for people in crises’ appears more frequently in the South Cheshire CCG data (11%). Segmentation by stakeholder group is shown below, Figure 21, and shows there were similarities between service users, carers and public.

0% 20% 40% 60% 80% 100% Improving outcomes for people with mental ill-health Service user

More choice about the services available for people in crisis Carer - MH 24-hour access to crisis services

Public A dementia outreach service supporting people in their own homes NHS (MH) employee Better access to community services

Other public sector employee Access to a better range of treatment options

Inpatient services meeting privacy Other organisation employee and dignity standards

Being able to visit hospital easily Other

Other

Public

mployee

employee e

Carer Carer

Service user Service

Other organisation organisation Other

Other public sector public Other

NHS (MH) employee NHS

Improving outcomes for people with mental ill-health 28% 24% 26% 28% 33% 30% 23%

More choice about the services available for people in crisis 12% 5% 9% 8% 13% 15% 6%

24-hour access to crisis services 18% 22% 19% 26% 21% 7% 23%

A dementia outreach service supporting people in own homes 7% 15% 10% 5% 13% 19% 6%

Better access to community services 10% 8% 7% 10% 4% 7% 8%

Access to a better range of treatment options 8% 8% 11% 5% 4% 15% 11%

Inpatient services meeting privacy and dignity standards 6% 6% 5% 3% 0% 4% 3%

Being able to visit hospital easily 12% 12% 14% 15% 13% 4% 19% Figure 21: Segmentation of important aspects by stakeholder

Section 3: Comment on the proposals Respondents were presented consecutively with each of the three selected proposals, and asked to what extent they agreed with the option and why? They were also asked for each option, if they felt one or more groups of people would be unfairly burdened if the option was implemented, and if so any suggestions to overcome this. Finally the statement list in the ‘importance’ question was presented for each option, and respondents asked how well they thought the option fulfilled these aspirations and why (or not). The response data for the statements is presented in this section however, as the comments broadly reflected the comments from the overall responses to each option they were incorporated into the overall reasons for agreeing or disagreeing with each option

The data for each option is presented as follows:

 Level of agreement with the option - Overall opinion - Split by CCG - Split by stakeholder group  Qualitative comments - Table of frequency of themes given as reasons for agreeing and disagreeing - Top themes, each presented with selected quotes to illustrate the theme  Level of agreement with the statements - Overall opinion - Split by CCG - Split by stakeholder group  Qualitative comments regarding any group disadvantaged - Table of frequency of themes given as reasons for agreeing and disagreeing - Top themes, each presented with selected quotes to illustrate the theme  Qualitative comments regarding ideas to overcome issues with the option - Table of frequency of themes given as reasons for agreeing and disagreeing - Top themes, each presented with selected quotes to illustrate the theme

Responses to Option 1 Respondents were asked to what extent they agreed with Option 1

Overall opinion of all respondents The response to this option was somewhat polarised between those who agree / strongly agree and those who disagree / strongly disagree with the proposal, see Figure 22, however more participants disagreed or strongly disagreed (n=153) than agreed or strongly agreed (n=109).

Strongly agree 61

Agree 48

Neither agree or disagree 40

Disagree 83

Strongly disagree 70

0 10 20 30 40 50 60 70 80 90

Figure 22: Overall response to option 1

When segmented by CCG this shows the majority of participants from East Cheshire were evenly split between agree / strongly agree (n=79) and disagree / strongly disagree (n=78). However, in the other CCGs those disagreeing / strongly disagreeing were a much larger group (SC = 43:18, VR 21:6), see Figure 23.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South Cheshire 8 10 9 25 18 11

East Cheshire 49 30 25 42 36 4

Vale Royal 2 4 4 8 13 3

West Cheshire 1 0 1 2 0

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree Missing

Figure 23: Response to option 1 by CCG

Segmentation by stakeholder group, see Figure 24, showed a greater proportion of service users disagreed / strongly disagreed with this option (n=59: 38) , however carers and members of the public were more evenly split (carers n=25: 25, public n=38:33).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Service user 21 17 16 32 27

Carer - MH 13 12 11 16 9

Public 19 14 4 18 20

NHS (MH) employee 2 2 2 3 4

Other public sector employee 1 0 3 4

Other organisation employee 1 0 1 4 3

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree

Figure 24: Response to option by stakeholder group

Qualitative responses to Option 1 Participants were asked what they agreed with in Option 1, and what, if anything they did not agree with. The comments were analysed and coded into themes, see below Table 7.

Reasons for agreeing with Option 1 Reasons for agreeing with Option 1 1. South 2. 3. Vale 4. West No CCG Total Cheshire Eastern Royal Cheshire recorded Cheshire

Location of service 8 60 4 1 2 75

Stress and anxiety minimised 6 24 0 0 3 33

Travel minimised 1 18 4 2 2 27

Millbrook would be kept open / 4 19 3 0 0 26 improved

Finance / cost of options, either to trust 3 12 4 0 0 19 or individual

Agree with nothing 6 4 1 1 2 14

Level of service would improve / 2 8 2 0 0 12 maintain

Comparison of options e.g. better than 4 4 1 1 1 11 the other options

Need change 2 5 2 0 0 9

Bias in information presented 2 3 0 0 1 6

Community care and support 0 4 0 0 0 4

Continuity of care maintained 0 4 0 0 0 4

Staff levels and support maintained 0 2 2 0 0 4

Policy and legislation (need to meet) 2 1 0 0 0 3

Organisational response 0 0 0 1 1 2

Quality of life benefits 1 1 0 0 0 2

Insufficient information to judge 2 0 0 0 0 2

Coverage of service 0 0 0 0 1 1

Safe environment 0 1 0 0 0 1

Other 0 1 0 0 0 1

Total 43 171 23 6 13 256

Table 7: Reasons for agreeing with Option 1

The most frequently cited reasons for agreeing with Option 1 were:

 Location of service: the fact that this Option would mean services remained close to people in East Cheshire and Macclesfield. “..patients can access inpatient care in their own locality. This is paramount and it has been outlined by the government that individuals should not be travelling from their own vicinity to access inpatient beds. I do not understand why Cheshire East feel that this area is exempt from this pledge?”

 Stress and anxiety minimised: The close proximity of the service to those in East Cheshire / Macclesfield was felt to reduce the stress and anxiety associated with using the service / visiting those using the service.

“I strongly agree with this option. Patients that are in crisis and require a hospital admission need their family and friends to be able to visit. Transferring them to Chester would make it more difficult for families that can’t afford the travel expense. Travelling to and from Chester can be exhausting especially if you get stuck in traffic. As a carer of someone with mental health problems I know how sometimes visits can be upsetting to see your family member in crisis, imagine having to get in your car and travel back to [East Cheshire] following that. ………. If relatives also have to work full time hours putting a journey of 1-1.5hrs each way then however long the visit last can have an impact on their physical and mental health”

 Travel minimised: Again for those in East Cheshire / Macclesfield the amount of travelling was kept to a minimum.

“Inpatient care remaining in Macclesfield, easier for visits from carers and staff”

And

“No travel for family members who are key to supporting older people & whose partner may be too old/frail/ill to drive and/or travel.”

However

“Please also remember that LOCAL accessibility is important. Both Maccs and Chester are over a 50 mile round trip for residents of Vale Royal.”

 Millbrook would be kept open / improved: There was some support for keeping Millbrook open and / or refurbishing to a higher level.

“The Millbrook Unit must remain open. We cannot afford to lose the only mental health unit in Cheshire East a borough of around a quarter of a million people, for people to travel to the other side of the county for treatment/to visit their loved ones.”

“…keeping the Millbrook unit refurbing it to higher standards to conform with privacy and dignity”

 Finance / cost of options, either to trust or individual: Respondents questioned the costs provided in the consultation document, of this option and other options. They also highlighted that Option 1 would be less expensive for relatives / visitors in East Cheshire / Macclesfield.

“Why is it going to cost 7 million to improve the Millbrook and only 1 million to build new beds at Chester?”

“If a new ward can open at Bowmere Hospital why not spend that money on Millbrook instead?”

And referring to the cost to those using the service being lower if sited in East Cheshire

“They may be in financial hardship. A lot of services users are reliant on benefits as their only income and are therefore under financial hardship.”

Reasons for disagreeing with Option 1 Disagree with Option 1 1. South 2. Eastern 3. Vale 4. West No CCG Total Cheshire Cheshire Royal Cheshire recorded

Finance / cost of option 11 39 4 2 1 57

Service levels 11 33 8 1 3 56

Change is needed 13 23 9 1 3 49

Other 6 13 0 0 3 22

Bias in information presented 0 19 1 0 0 20

Disagree with nothing 3 10 1 0 2 16

Distance / travel 2 8 1 0 0 11

Inequality 3 5 0 0 0 8

Disagree with everything 0 5 1 0 1 7

Staff issues 0 1 1 0 0 2

Total 49 156 26 4 13 248 Table 8: Reasons for disagreeing with Option 1

The most frequently cited reasons for disagreeing with Option 1 included:

 Finance / cost of option: This theme covered all aspects of the cost associated with implementing option 1

“I disagree with taking / diverting funding from other current local NHS services.”

“In the light of the funding constraints a new model of care is necessary.”

“I don't want a lot of money spent on upgrading old and inadequate buildings when other suitable services are available, or better places, more suited to modern needs are around. In addition, borrowing money to fund any refurbishment reduces the services for others - maybe without mental health needs - e.g. pregnant ladies, or the elderly or those with Long term conditions. There is no crisis service, no choice, and no dementia outreach included in this model. The service is concentrated in one area - what about those in other areas who have needs - they will be disadvantaged. That inpatient stays are not suitable for all - often community services are a better fit for patients.”

However the group also included comments expressing scepticism at the information provided

“The financial implications, the Millbrook unit is obviously fit for purpose now, otherwise there would not be inpatients currently admitted there!”

“The costings look misleading. There is no formal proposal for the refurbishment and costings to review and I can only assume you are borrowing money from a payday loan company.”

 Service levels: this theme referred to the services which would not be implemented if this option was chosen, and also to the current service within Millbrook.

“There would be no change to services and the services would continue to deteriorate.”

“Having been in a situation to use/experience this option I found it difficult and there were long delays in being seen or accessing the services I need”

 Change is needed: Some respondents recognised that the current service could not remain as is, and there was a need for change to meet future requirements.

“I disagree with this option because it simply perpetuates a bad situation delivering sub- optimal inpatient Hospital care and increasingly stretched Community services. It also fails to address the priorities outlined in NHS England's 5 Year Forward Plan, i.e. enhanced crisis care options and improved dementia outreach services.”

“This is not a step forward, but a step back - what is the point if we improve one point of care but disregard others.”

“Doing 'nothing' is not an option. Community and acute services are not sustainable as they are.”

“This is not a solution to any issues… importantly it is also doesn't meet any of the requests/suggestions that the community of users of services have asked for.”

 Other: There were a number of comments which didn’t fit any theme in particular. Some of these were general comments on the questionnaire, the state of mental health services, the level of care received, other suggestions or comments on one of the other options (these were usually duplicated in the responses to the other options) e.g.

“Everyone needs someone to help them”

“If the highly paid professionals cannot plan the way forward without the help of amateurs we are in a pretty desperate state”

 Bias in information presented: there were a number of comments expressing scepticism regarding the information presented, and feeling directed to reject this option.

“The bias nature of the consultation document suggests that a decision has already been made. The emotive way of offering mental health care of dementia care is unfair to both service users. Both should be able to have care in their local hospital. There will be an increase in suicide rates if this proposal goes ahead and care is moved to Chester, research shows this.”

“The option is deliberately described in a negative light in the consultation document, designed to suggest this isn't really an option at all. (Even the photograph used in the document suggests despair and sadness!) “

“This is a slightly loaded question as clearly no-one can support this option as it would appear unaffordable.”

Agreement with statements for Option 1 Respondents were presented with the key statements regarding aspects of the service, and asked how much they agreed the option fulfilled these statements, see

Option 1 means people being able to visit hospital easily 80 61 42 34 36

Option 1 provides inpatient services meeting privacy 37 49 70 45 46 and dignity standards

Option 1 offers access to a better range of treatment 27 37 55 72 59 options

Option 1 will provide better access to community 25 30 55 80 59 services

Option 1 will offer a dementia outreach service 19 28 62 73 69 supporting people in their own homes

Option 1 will provide 24-hour access to crisis services 31 43 47 67 61

Option 1 will offer more choice about the services 30 31 49 80 65 available for people in crisis

Option 1 will improve outcomes for people with mental 40 42 45 73 54 ill-health

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree

Figure 26. Participants most often agreed or strongly agree that this option ‘means people being able to visit hospital easily’, but there was less agreement with the other statements.