South West Strategic Clinical Network
Conference report: Call to action for mental health in the peninsula Wednesday 26 February 2014
#mentalhealthpeninsula About this report
This report summarises the contributions and outcomes from a conference, Call to Action on Mental Health in the Peninsula, which was held by the South West Strategic Clinical Network for Mental Health on Wednesday 26 February 2014.
It includes summaries of the keynote speeches and details of the commitments made by delegates on the day to take action to improve the management of mental health crises.
“There’s a really big drive, nationally, politically around mental health. We are the first area – the first Strategic Clinical Network, that is – to host such an important event.”
Amanda Fisk, Director of Operations and Delivery for NHS England (Devon, Cornwall and Isles of Scilly), welcoming delegates to the event
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What the event was all about
The Call to Action conference had three main objectives:
1. To identify potential improvements that could support people in mental health crisis.
2. In response to the national Concordat1, published on 18 February 2014, to build consensus for a local crisis care Concordat for mental health.
3. To identify what each person attending the event could commit to this agenda and to pledge to take action.
1 See Appendix 1 – Concordat principles and outcomes https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281242/3 6353_Mental_Health_Crisis_accessible.pdf
3 Who attended
The Call to Action conference was attended by 125 delegates, including: people with lived experience of mental health, carers, MPs, clinicians, hospital leaders, GPs, and representatives from CCGs, voluntary sector bodies, local authorities, health and wellbeing boards and the police. See Appendix 3 for the full list of attendees.
4 Setting the scene
Statistics in brief One in four people in the UK will suffer a mental health problem in the course of a year. The cost of mental health problems to the economy in England has recently been estimated at £105 billion, and treatment costs are expected to double in the next 20 years.
Cornwall has a significantly higher rate of hospital admissions for mental health than the England average but Devon has a significantly lower rate.
Depression Depression is common and disabling. Mixed anxiety and depression contributes 12 per cent of the total burden of non-fatal global disease and by 2020, looks set to be second after cardiovascular disease in terms of the world's disabling diseases.
Dementia Dementia is a syndrome characterised by progressive global deterioration in intellectual function and is a main cause of late life disability. The prevalence of dementia increases with age and is estimated to be approximately 20 per cent at 80 years of age. In a third of cases, dementia is associated with other psychiatric symptoms such as depressive disorder, adjustment disorder, generalised anxiety disorder and alcohol related problems.
The peninsula has higher proportions of people registered with their GP as having dementia compared to the national average (2011-12). This may reflect the older structure of our population.
Schizophrenia Schizophrenia is one of the most common serious mental health conditions. The illness has a range of symptoms including hallucinations, delusions and difficulty in thinking. Doctors describe schizophrenia as a psychotic illness. Devon and Plymouth have significantly lower rates than the national average.
Spend on mental health 2011/12 The average national spend on mental health services (both NHS and Local Authority) is £182 per head. Spend in the peninsula is in line with this national figure.
See Appendix 2 for more detailed statistics about mental health in Devon, Cornwall and the Scilly Isles.
5 Opening comments
Opening comments: Adrian James, Chair of the Strategic Clinical Network for Mental Health (SW)
“We need to be sure that everybody who uses services, everybody who works in services, has great aspirations for people and that we don’t accept second best and we don’t accept that there is nothing that can be done.”
Today is all about action. Each of us here needs to think what we are going to do as a result of today to improve outcomes and the experience of care for people with mental health issues. Part of today is about holding people to account.
There are many examples of great care in our region but more needs to be done. We need a true recovery approach so everyone can reach the aims that they want to achieve.
Parity of esteem Today is about parity of esteem for mental health. Parity of esteem starts with everybody accepting that they could have a mental health problem; they could have a mental health crisis.
It’s also about raising aspirations. We need to be sure that everybody who uses services, everybody who works in services, has great aspirations for people and that we don’t accept second best and we don’t accept that there is nothing that can be done.
There are lots of people in the community who know what a physical health crisis is, they know what to do.
If you experience a physical health crisis, you know exactly what will happen. For example, you know that an ambulance will come in about eight minutes and that you will be admitted to particular unit in a particular hospital.
6 If you have a mental health crisis, you don’t know what is going to happen. You don’t know the response of people around you – they are sometimes scared, they don’t want to know. You don’t know where you will be taken – you might be taken to a police cell rather than a healthcare facility. We have a particular problem here in Devon and Cornwall with this. And you don’t know what will happen at the end of that period of care.
I would like when Norman and Geraldine come back to visit us in three years that they could talk to service users and members of the public and they would say “this is what happens when someone has a mental health crisis in Devon and Cornwall.” If we can achieve that we will have achieved parity of esteem.
7 The government perspective
Keynote speech: Norman Lamb, Minister of State for Care and Support
“When I became Care Minister, I made it my mission to put mental health and physical health on an equal footing.”
Mental ill health can affect any one of us and, when it does, it is the responsibility of a wide cross-section of society: from hospital staff, GPs, carers, the police. So it’s good to see representatives from all those services, and others, here today. It’s great to see service users and carers present, too – you are vital in the shaping of personalised and appropriate care.
What the government is doing to support people with mental health problems We have enshrined in law the equal importance of mental health.
We want to give people more control over how, where and when they get their mental health treatment, by extending personal health budgets.
And more local areas are improving their mental health services, with support from our Mental Health Implementation Plan and Suicide Prevention Strategy.
Closing the Gap, launched just over a month ago, outlines how patients will have a choice about where they get their mental health care – exactly the same as people can choose their hospital they want to carry out an operation. It also states that, from next year, waiting time standards will start to be introduced for mental health.
Talking therapies, which are already helping 600,000 people, will be expanded so that 300,000 more people will get help.
As the Deputy Prime Minister said, we know we have a mountain to climb to gain equality in mental health, but we are making sure the rights of those with mental health issues are championed.
8 Work in the South West You, too, in the South West have been challenging the status quo, and the projects that you are running are not only remarkable but having a great effect.
Projects like the Corner Retreat Crisis House in Devon – which opened last November – where people who are experiencing mental distress have access to intensive 24 hour support, to prevent hospital admissions.
Almost all the people who have been referred to the service have successfully avoided going to hospital.
This type of innovative approach is exactly what is needed so we can respond to situations in a way that will benefit people with mental health problems.
“That’s what impresses me about the South West – an appetite for positive change, a desire for innovation, a recognition that the status quo can be challenged and that care can become better.”
The Crisis Care Concordat The Crisis Care Concordat, launched last week, is an agreement between NHS England and several organisations representing the police, mental health services, ambulance service and social workers about how to handle someone who is suffering a mental health crisis.
On average 15,000 people every year are detained and taken to hospital by the police. Last year, however, the Police took another 7,700 people to police stations instead of hospital. This is simply unacceptable, particularly if the person is a child. But it isn’t the fault of the police.
All too often, a police cell seems the only destination for someone having a mental health crisis, because health services aren’t able to respond quickly enough. For me, this makes no sense. It is intolerable. A police cell is surely the worst place for someone experiencing a mental health crisis to be – and is likely to exacerbate their condition.
The Concordat makes several significant changes to combat this happening:
• First, it requires local areas to have plans in place to stop people being unnecessarily detained in police cells.
• It will provide agreed response times for ambulances to respond to mental health crises in 30 minutes, and 8 minutes if their condition is life threatening, in line with a protocol agreement by ambulance CEOs.
• And more work is being done to improve services for people with mental health and substance misuse problems, which also requires proper liaison psychiatry services to be available in A&E.
9 Integration What makes our Concordat an innovative approach is that we have brought organisations – who have historically not always found it easy to work side-by-side – mindful of our shared goals. And I’m not just talking about the Department of Health and the Home Office.
In my time as Care Minister, and as an MP, I have had countless conversations with people about their health and care, and how it could have been so much better if people simply worked together. Likewise, when I have visited GP surgeries, care homes, mental health facilities – their desire to work in a connected way with other health and care professionals is palpable.
I am delighted to be here alongside two of our fourteen Integration Pioneers. The Cornwall pioneer is working over a large area, including the Isles of Scilly, to provide more care and support to those with long term conditions. And South Devon and Torbay are working to provide mental health support in schools, screening more young people for mental health issues, and putting mental health workers in more GP surgeries.
Conclusion In conclusion, I believe that events like today’s are so crucial – so much of our future success will depend on the links and partnerships we make, not only across the health and care system, but other community services like the police, schools and local authorities. Today will help you build upon the great work that you are doing to support your local areas that depend on you daily. And you are in the position to make a difference that will benefit their lives.
Questions and answers Rob Gough, service user: - How do you intend to overcome the disconnect between the people at the top who aspire to these changes and the people at the coalface?
Norman Lamb: - We have to find levers to make things happen, specific actions that hold the system to account and make things happen. If a mental health trust chooses to ignore the Concordat, they will receive a poor rating. We also need to get the financial incentives right to encourage local areas to redesign their systems.
Wayne Kirkham, National Lead for Veterans Mental Health Unit for NHS England: - I am disappointed that you made no mention of veterans’ mental health in the speech
Norman Lamb: - My apologies. The fact that I did not specifically mention it does not mean that I don’t recognise its importance. I have recently talked to Simon Wesley about these issues and I recognise there needs to be more support. I would be happy to meet you to discuss this.
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On Twitter RT @HarriottRebecca : #mentalhealthpeninsula call to action Norman Lamb-let's spread personal health budgets to mental health.@NEWDevonCCG
@normanlamb Just spoken at conference on mental health at Saltash, Cornwall. Brilliant work here - signing up to MH crisis care concordat!
@HarriottRebecca #mentalhealthpeninsula Norman Lamb lets sort CAMHS transition so 18 year olds get the right services- Integration & determination @NEWDevonCCG
@HarriottRebecca #mentalhealthpeninsula call to action Norman Lamb determined to shift focus to MH so funding follows. Fits @NEWDevonCCG ethos.
@LouiseHardyOD #mentalhealthpeninsula for three big questions to support wellbeing for all. @normanlamb we must achieve parity of esteem
11 How do we make parity a reality?
Making parity and making action a reality: key priorities for 2014/15: Geraldine Strathdee, National Clinical Director for Mental Health, NHS England
“In the South West, you are seen as the part of the country that we are looking to, to absolutely lead the charge on crisis.”
What you are going to get from me are some hard core facts and hard core thinking.
I am utterly delighted to be here with people like you, who are the leaders, who are the “orchestra” who are going to try and make this work because we’ve got to do this together because money is tight, time is tight, people are under pressure.
The priorities People are trying to focus on two clear priorities across the country:
1. Reducing premature mortality and improving physical health. We have allowed premature mortality levels for people with mental ill health to stay at the same level as it has been for the rest of the population for the whole of the 1950s. 2. To lead the charge on the treatment of mental health crises.
“I want to pay enormous tribute to the leaders you have in the South West. You are so lucky to have Adrian and so lucky to have many of the other people in the room that I see.”
Profile of mental health Mental ill health is a young and middle age persons’ condition - 50% of problems happen before the age of 14, and the bulk of between 20 to mid 50s. When people are older, there are problems of isolation and, in the South West, the suicide rate is rising. Yet, we are more and more prioritising the money in a different place.
12 Mental ill health is a consequence of things not happening in society. Mental health problems are everywhere. A lot of mental health issues are right across the whole of the system.
Thinking differently There is something about our British health and social care, and perhaps our attitudinal system, that says we can think about bodies and we can think about minds and they aren’t integrated and they don’t impact on each other. We have a monocular vision. So, one of the first things we have to do is to get people thinking differently, to get people understanding about mental health.
Learning from international evidence We need to learn from international evidence. Across the world we are now seen as taking the British stiff upper lip far too far. You would not go to see a cancer specialist, in most first world countries these days, and just see the chemotherapist and the radiologist. You would be seeing a psychological therapist to help you think about how you are going to manage that condition. With cancer and Type 1 Diabetes, depression occurs in about 40% of cases. One of the fundamental things we have to do is to raise England to the best standards of the first world and incorporate mental health into all conditions.
One of my questions to the South West is have you got mental health in all your other strategic clinical networks? If you have, you will be the first SCN in the country to do that.
The facts • Less than one third of people get access to treatment, with the exception of psychosis. • 80% of people with psychosis get treatment but often it isn’t evidence-based NICE guideline-concordant treatment. • How are we going to do for psychosis what has been done for stroke? How are we going to make sure it’s not a postcode lottery?
How will we make parity of esteem a reality? There is no national service framework. We’re in an era where, rightly, we look to local leaders. We look to give you the information you need about what services will work. And, we listen more to people.
People prefer to be treated at home. They want to be treated as individuals. They want their care to be in one place. And they want every experience in the health service to inform, to enable.
What we’re also trying to do in NHS England is provide people with some of the commissioning tools they need. One of the things I’m most passionate about is information. We have got information we can give your local CCGs, leaders and partners to show how common particular mental health problems are. We can tell you about the levels of access, standards and spend that you can design your services on.
What does “good” look like? I go around the country sitting in on clinical assessments and CPAs. There is not one single mental health problem that an organisation somewhere isn’t tackling brilliantly.
13 Communication will change what people believe about mental health. We need a social communication media strategy.
I’ve worked in a lot of organisations that aren’t mental health organisations. The job for people like me is persuading people who know nothing about mental health what it means. The challenges I’m getting are these: • “You say it’s 1 in 4 people. Isn’t that just life?” • “You say you’ve got scientific evidence, so where is it? Explain it to us in a language we can understand.” • “Explain what your treatments are. Does it work on the mind, does it work on the body, where does it work?”
Alastair Campbell has been a very brave celebrity to speak out. The Deputy Prime Minister urged people with all sorts of mental health conditions to speak out as part of Bridging the Gap.
When I was on Radio 4’s You and Yours, after Bridging the Gap was launched, more than 100 people rang in and they bust more myths than I have ever seen. What these stories did was to say; mental health is not a blob – nobody talks about “medicine” or “surgery”. I believe it disadvantages us because people look at mental health and say “it’s got 14% of the budget, it’s far too much.” They don’t understand that mental health is just a generic term.
Encouraging people to speak out and talk about their condition and how they got better and how they want to be a contributing citizen is the key. Explaining how we work in mental health in these terms will work better, it will raise the profile more.
What are we going to do? We need to act now. If we want parity, we have an absolutely wonderful minister and so many people coming on board to do this. We need to think what we can do for children and young people, in liaison, for primary care, in employment circles? These are my top things that we want to do.
We need to tackle the causes. We, in primary care, cannot solve the nation’s mental health. We can bring in resilience but not solve it. We need other people to tackle the causes.
So, what are the societal causes of mental ill health? • Employment stress. • Children at school – dyslexia, dyspraxia, bullying, gangs. • People at life transitions – there is a big move in universities now to support freshers. • Isolated women with children.
How to tackle the causes • Get employment practice right – good employment practice saves employers money. • School nurses and form tutors who understand how to support children with mental health problems.
14 • Transport for older people – isolation is a major cause of depression.
The five-year ambition This is a document that provides details of what people are commissioning around the country. There are some great examples, including: • Integrated physical and mental health groups in the GP practice – they are called things like Living Well After Stroke Programme not “integrating physical and mental health”. Language is important. The words “programme” or “course” suggest the programme will equip people with the skills they need to tackle their issues. It also attracts funding from training and other parts of society. • In East London, where there are some of the highest levels of young people with schizophrenia and bi polar, they are setting up enhanced schemes for people with these conditions – i.e. extra practice nurses, nurses and GPs trained, a collaborative commissioning model with providers who do shared CPAs. • Learning from international examples – for example, mental health case managers in Seattle for older people in primary care. It is a model that is being adopted in this country. • Virtual case conferences for frequent attenders – mental health organisations and acute organisations are coming together to look at who are the most frequent attenders to A&E every week and what they can do together to support these people. • Practice nurse master classes – we have an entire workforce who have had very little mental health training. What fast track ways of training have we got to upskill people? A train the trainer module for practice nurses looked at what are the physical health checks, the side effect checks and the risk assessments around suicide and depression. Specialist mental health nurses received training and then trained practice nurses. This increased understanding of mental health conditions and also formed bonds between practice nurses and mental health nurses. • The model of crisis care. Are 14 different routes into crisis services sensible? We’ve always got money piecemeal; it is difficult to take stock. In Northumberland Tyne and Wear and Gateshead CCGs, they now have a single crisis number to ring for the whole patch, they have a good directory of services, they have trained tele triage and tele health workers who respond to the calls. Internationally, if you have trained tele triage and tele health workers you reduce the need for face-to-face contact by 42%. By doing this type of transformation, this area can provide a 24/7 crisis and treatment service. They are using the best of digital dictation to dictate the plan with the service user in front of them. They also have fantastic liaison mental health services.
A cultural change I’m not going to go into complex needs. We’ve had the national service framework. We have 150 NICE guidelines. If it was anyone in my family receiving treatment, I’d want to know this service was safe, empowering, used evidence-based interventions and could demonstrate it, recorded outcomes, but above all, that people leave feeling they have learned something really good and new and it had been a really good experience.
Do you want more national service frameworks? In my view it’s all there. What’s not there is “so how do we make this happen in every single team and service?” I think there’s a cultural challenge outside mental health and in mental health. But, if I have
15 confidence in one Strategic Clinical Network getting to grips with it, I think it’s the South West.
On Twitter @ normanlamb So impressed by Geraldine Strathdee, National Clinical Director for Mental Health, speaking at Saltash Mental Health conference!
@LouiseHardyOD Geraldine Strathdee @DrG_NHS good message re wellbeing, making mental health at the heart of #integrationpioneers
16 The integration pioneers… the story so far
The vision for Pioneer South Devon and Torbay: Louise Hardy, Director of Organisation Development for Pioneer, South Devon and Torbay CCG
“Our aim is to make mental health mainstream, not separate.”
Thirty sites nationally were shortlisted to become Pioneer sites. In total, 14 sites were chosen, including two in the South West.
Since 2005, in South Devon and Torbay we have used the fictional character of Mrs Smith to provide a philosophical grounding for our services.
One of our five overarching aims is to make mental health mainstream, not separate. Our vision is the de-segregation of silo services, to be replaced by people with mental health problems having the services they need all around them.
By the end of 2014, we will have community hubs in Newton Abbott and Torquay. We plan to open at least one further hub.
Other deliverables include: • A joined-up IT strategy. • 7-day service. • A single point of contact for service users.
What we’d still like to achieve with our mental health partners: • A single pot of money (aligned budgets). • Honest conversations about shared outcomes. • Wellbeing regarded as the health of mind and body, with no difference between the two.
17 The key questions we still need to answer are: • How do we make mental health sustainable? • Where do professional services and community resilience stop and start? • How can we grow a flexible workforce?
What we have done so far at Pioneer South Devon and Torbay: Vanessa Ford, Interim Director of Nursing at Devon Partnership NHS Trust
“We need to stop believing that mental health professionals are the experts.”
We need to stop believing that mental health professionals are “the experts”. To help people experiencing loneliness, for example, our main aim is to get communities to support one another.
Our work so far includes: • A perinatal mental health service to support midwives in asking difficult questions about how women feel about pregnancy.
• Introducing mental health workers into GP surgeries, which has broken down barriers between practice nurses and mental health nurses, and created dialogue between them.
• Step-down beds to help people who have been hospitalised for several weeks to reintegrate into their community.
• A crisis house, where people can choose to come and receive treatment without the use of the Mental Health Act.
• A 24-hour telephone line, staffed by mental health staff and people with lived experience.
• A veterans’ programme, with priority access to psychological therapies, run by people with real experience.
• Street triage, with nurses working alongside the police
18 • Recovery Learning Communities – these are co-produced courses on topics that people with mental health problems feel are important – for example, cooking a nutritious meal or counselling.
• A Mindful Employer Programme, which supports people to engage back into employment.
• Neighbourhood Health Watch, which encourages people to look out for each other locally and to support each other at difficult times.
We still need to consider: How we might effectively tag people with mental health problems when they go to A&E. Maybe, instead, we need a universal set of questions that we could ask everyone. We are working with A&E departments to identify what questions they could ask.
Living well – Pioneer for Cornwall and the Isles of Scilly: Tracey Roose, Chief Executive, Age UK Cornwall and Isles of Scilly and Integration Director for Kernow CCG
“We realised, it’s not about hitting targets, it’s about people.” Our defining principle is to deliver long-term affordable costs and improve quality of care and outcomes for individuals.
We build our system around the individual so every new model begins with a conversation. We ask; how can we connect them back to their communities?
How do we hit our target? We realised, it’s not about hitting targets, it’s about people. We need attractors to “pull” and motivate individuals.
Can we create community coalitions to connect the unconnected and improve their outcomes? We are creating community-owned initiatives, developed by people. To make them sustainable, we have to win hearts and minds. Where are we in the matrix of competition versus co-operation between providers? We are moving towards a way of binding us together to work towards shared objectives – co-opetition!
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Case study: Beatrice Beatrice is one of 130 of the most complex high users on the Newquay Pathfinder. She has diabetes, has had a stroke and suffers from anxiety. By listening to her story, we discovered she used to run a B&B and wanted to be a host again. She has been supported, via tele health and counselling, to host coffee mornings in her own home. She now only receives two visits per week and has far less reliance on health and social services. This demonstrates what we are aiming to do – to change the mindset of people from illness to recovery.
On Twitter @normanlamb Really great presentations from Vanessa Ford and Louise Hardy from S Devon and Torbay Integrated Care Pioneer! V exciting work here!
20 The service user perspective… working together to improve services
My experience: Iola Davies, Co-chair South West Mental Health Alliance
“Professionals are facilitators not fixers. I need to be empowered so I can help myself. Be honest, be human.”
I am a former primary school teacher with a personality disorder. People with mental health problems have a lower life expectancy. My own life expectancy is 62.9 years. Why are we dying earlier? And, why does society tolerate this?
There is a real sense of “them” and “us” – and this comes both from staff and service users. So, parity of esteem is also about seeing yourselves having an equal relationship and working together. We are all experts – the service user is an expert in their own mental health.
Why is it important to work together? • Because people with a variety of different skills come together – we pool our resources. • Because it leads to personal development for both service users and staff. • Because, by finding out is most helpful for people with mental health problems, the service saves money. • Because, often, staff and service users want the same things. • Because when we don’t work together, we’re missing a trick.
What we have achieved in Bristol by working together NHS Bristol has opened a crisis house for women and one for men. A third house is planned.
21 Service users campaigned for a retender of mental health service delivery and has been actively involved in the tender process. I run a national personality disorder training KUF in London and the South West
About the Mental Health Alliance South West • We aim to be the voice of anyone with an interest in mental health in the South West. • We are creating communicational channels to share up-to-date information and good practice. • We work closely with the Strategic Clinical Network. • 50% of our steering group is made up of service users.
My experience: Mary Ryan, person with lived experience of mental health problems
“The more we are just people working together, the better the services will be.”
I have recent experience of inpatient care, supported by crisis services.
The South West of England Safety Initiative is helping to reduce violence and improve urgent and crisis care. Sometimes these are tiny changes that really make a difference. For example, wards become safer places when people are asked how they feel rather than being ticked off a list.
The Suicide Prevention Group aims to reduce suicide in the South West to zero by 2018. Being part of the group makes us feel very valued and able to have our say. We recognise that young people are missing from the group. People who have killed themselves also need to have their voices heard; their stories need to be shared.
I have also been working with the CQUIN programme. When I started a few years ago, there was no-one with a service user perspective involved. We got ordinary people together to talk about the targets for 2014/15. Next year we will be involved earlier on, in the target setting process.
An awful lot of what happens is still too little, too late and there is still a long way to go until the system no longer does things to me or for me.
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My experience: Rob Gough, service user consultant
“I want to see more collaborative working, with service users and carers helping to train mental health professionals and give them a personal insight.”
When I first came to Cornwall, I worked with a great CPN. He recognised that the most helpful thing he could do for me was to give me as much power and control over my care as he could. He gave me the care co-ordinators’ handbook and asked me to identify what might help me. We wrote my care plan together.
It has been an emotional journey for me. With another CPN I have worked with, the relationship has been very confrontational. I have felt trampled on by the system and powerless to do anything about it.
I think mental health professionals of all backgrounds have a really difficult job to do. They don’t get the support and training they need. I want to see more collaborative working, with service users and carers helping to train mental health professionals and give them a personal insight.
As a service user, I would like to no longer feel shame talking about mental illness; I want to be open and honest about where I am and how I feel.
It takes no small measure of courage to talk to you like this, but if people like me don’t then nothing will change. A huge number of service users don’t feel safe enough to make a noise, but this is what we need if we are looking to change. People like Adrian [James, Chair of the Strategic Clinical Network for Mental Health South West] are willing to take the risks and make a real difference.
On Twitter NHS England South @NHSEnglandSouth Feb 26 Local MH service rep says "We have to tell our stories in order to make a difference although it may be painful" # mentalhealthpeninsula
Francesca @Francesca_AH#mentalhealthpeninsula wonderful to hear service user speak so highly of his CPÑ @Francesca_AH #mentalhealthpeninsula Iola Davies "everyone has value and strength" patients and clinicians
23 The MP’s perspective
No esteem without parity: Sarah Wollaston, Health Select Committee member and MP for Totnes
“We all know what the problems are, why there isn’t parity of esteem. Now what we need to do is to be very clear about what we are going to hold national politicians to account for.”
The issues that Rob touched on go to the heart of what it says in “the Francis Report” that so often we do the system’s business and forget to focus on the people who use the services and actually hear what they want.
One of the things that everyone is being asked to do is to say what they will do differently as a result of today; what action will you take? My brief presentation is about holding the system to account. I would like to think that everyone will add to their list to go and see their MP.
The role of politicians in holding the system to account What role do politicians have in holding themselves and the system to account?
I was a GP and frontline clinician for 24 years before I decided to apply to be an MP. What you see as an MP is a completely different picture of the health service. People don’t go to their MP to tell them how marvellous things are, they go to their MP to tell them how difficult things are. This week, I’ve met with the parents of a very young person who took her own life. I’ve met with the parents of a young man who died in crisis as a result of complications with his medication.
But, also this week, I’ve met with an independent mental health advocate who explained that if you’re a voluntary inpatient on Haytor Unit, if you’re a resident of Torbay you won’t be able to access mental health advocacy but if you’re a patient from a few hundred yards away down the road in Devon, you will. I was able to talk to him about the review that the Health Select Committee has done of the mental health act and what
24 we discussed about advocacy. That was a very useful two-way conversation and we need to have more of these two-way discussions.
While I have experience of working in the health service, I can’t tell you how many of my colleagues don’t, so while it is important for them to hear the very powerful stories of service users it is just as powerful for them to hear the experience of people in this room, about how the system works and what the problems are.
So please add this to your list of what you’re going to do.
Asking challenging questions Also, you can make suggestions to your MP about how they are going to hold the system to account locally but also nationally.
What MPs can do as well is to ask written parliamentary questions which are then on the parliamentary record. For example, questions about how the money is spent. My point is that we aren’t going to see parity of esteem unless we see the funding to accompany that. Politicians can ask these challenging questions, as well as questions about how the funds are spent locally as well as nationally.
Leading campaigns MPs also have a role locally and nationally in raising issues in the media and leading campaigns. I know you’ll be familiar with section 136. When I wrote about this in The Guardian in November, there had been 25 young people under the age of 18 who had been detained in police cells. On three occasions, we are talking about children of 12 or 13 years old.
Whilst I hear that the West Country is going to lead the way on crisis, unfortunately the reality is that we’re only second to Sussex in having the worst use of cells around the country. That’s not a record we can be proud of unless we can see real change.
There are many parts of the country where they don’t use the cells at all so it is possible to achieve that.
I hope when we meet in a few years’ time that there will be no children and only adults in exceptional circumstances being detained in police cells.
Working with limited resources I do appreciate that a lot of this, politically, comes down to resources but this is a reality that isn’t going to go away, whatever happens at the next election, so we need to work to get the best value out of the resource we have. We have to focus on what people actually want, rather than what the system wants to deliver. I am keen to involve more of the voluntary sector because it delivers such good value for money. If you have ideas about how funding resources can be changed, how existing systems can be challenged, it is very powerful to go and see your MP because these are the people who can advocate on your behalf about why that change needs to happen. It is something I am very privileged to do in the Select Committee.
25 We’ve been hearing for a very long time now about how the system needs to change. Now we need to be asking when is it going to change? Who is going to take responsibility if it doesn’t change?
We all know what the problems are, why there isn’t parity of esteem. Now what we need to do is to be very clear about what we are going to hold national politicians to account for. What are the measures by which we will know that we have achieved parity of esteem?
I can’t tell you how important it is to speak to your MP and get this firmly on the agenda. The change in the way mental health is prioritised has been extraordinary and the challenge we have seen from organisations like Time to Change in getting people to talk about their own mental health experience and to get that national conversation at every level of our society is fantastic. You are a very powerful part of this so if you do nothing else I hope that some time in the next month, you’ll go and see your MP or you’ll write to me.
Questions and answers - Q: It often feels that it has to reach crisis point before it gets onto the national radar, like with Tier 3 and Tier 4 services. We need to make more beds available locally. Transformational change is very difficult to achieve.
Sarah Wollaston: - A: I agree that we need to have better early intervention services but we still need more inpatient beds. It is about presenting the evidence – why haven’t we got this service without a pooled budget?
- Q: How do we address the issue of hard to engage groups?
Geraldine Strathdee: - A: There is no easy answer. People are getting away from looking at QOF numbers. There is lots of evidence of what works – tele health, outreach, texts, third sector support to help people with simple things like cooking a meal or going over their medication. If we just set up primary care services and don’t look at how to get out to the people, we are not serving the population well.
Sarah Wollaston: - A: Sometimes professionals may need to step outside their own role and recognise that, while they might not be my job, I need to step outside this and do what is in the best interests of the individual.
On Twitter @drwollastonmp #MentalHealth peninsula conf today thanks to all service users, mental health teams, primary care & police working to transform crisis care @LouiseHardyOD Sarah Wollaston@drwollastonmp asks what we'll do differently after today #mentalhealthpeninsula
26 What we will do to begin making things better
“I am really pleased that we’ve had a major sign-up across all organisations to a mental health crisis concordat, but one thing is very clear; that this is not the end, this is just the beginning.”
Adrian James, Chair of the Strategic Clinical Network for Mental Health (South West)
The afternoon session comprised a series of break-out workshops during which mixed groups of delegates identified actions that they could take to improve crisis prevention, crisis response and recovery. These included improvements to commissioning, treatment and care.
The key points that emerged from the afternoon sessions are summarised below.
Our objectives for improving crisis prevention 1. Commissioning strategy/service development plan to support the aims of the Concordat. 2. Planning with communities. 3. Personal plans. 4. Mainstreaming successful prevention pilots.
Our proposed actions for achieving better crisis prevention 1. Education and training (multi-agency pooling resources). 2. Leadership summit.
Our objectives for improving response to crisis 1. Crisis to be defined by the individual. 2. Alternatives to admissions. 3. Stop using police cells for children. 4. Swift care planning by multi-disciplinary teams and patients together.
Our proposed actions for achieving better response to crisis 1. Crisis house model. 2. Joint working format.
Our objectives for improving recovery from crisis 1. Increased choice of talking therapies to include those offered in the voluntary sector. 2. Better review post-completion of service episode. 3. Flexible approach to complex cases.
Our proposed actions for achieving better recovery from crisis 1. Multi-agency implementation group. 2. Better information for individuals.
27
On Twitter @CllrJeremyRowe @normanlamb A useful event all round. Great for a room full of 'decision makers' to hear the experiences of real people. Thanks for coming.
@normanlamb Just spoken at conference on mental health at Saltash, Cornwall. Brilliant work here - signing up to MH crisis care concordat!
28 In conclusion
Closing comments: Adrian James, Chair of the Strategic Clinical Network for Mental Health (SW)
We need to get the leaders of the main organisations to sign up to a strategic plan within six weeks. Amanda Fisk, Director of Operations and Delivery NHS England will lead this alongside Sam Barrell, Clinical Accountable Officer, South Devon and Torbay CCG.
We need to engage users and carers from the start, at every level.
Leading on from today, we will produce our own local Concordat and sign up to it. We will set up a learning set and implementation group around some of the key people who are going to deliver the Concordat. This will be led by Amanda Fisk and Justine Faulkner, Manager Strategic Clinical Network, Mental Health and Dementia, NHS England South West.
We will map what is happening with services in the South West, identifying good practice and where there are any gaps. Ian Harrison, Interim Chief Operating Officer, South West Academic Health Science Network has agreed to lead this work with Justine Faulkner.
We also need to ensure that CCGs recognise the Concordat within their two-year and five-year plans.
In terms of specifics, in the South West we want to ensure:
• A swift end to children assessed in police stations under section 136 and a target for reducing136 assessments for adults in police cells except in exceptional circumstances. • CQUINs to deliver financial incentives to providers for people with major mental health problems. • A single point of access for people in crisis.
29 Creating a Peninsula Mental Health Concordat The event also set out to create a South West response to the national mental health Concordat and to identify the key statements and principles that our local response should contain.
Key statements and principles • Relationship between the mind and the body – whole person. • The person and their family at the heart of their care plan. • Commitment to multi-agency education and training. • No distinction between mental and physical health in everything we do. • A 24-hour seven-day Peninsula-wide helpline for people in distress.
The commitment from delegates Everyone attending the Call to Action conference committed their organisations to signing up to these aims, with no contrary opinions expressed.
“This is a great start but there is still much to do. We should be ambitious and use this impetus to drive forward change for the whole Peninsula.”
30 Glossary
CCG Clinical Commissioning Group: groups of GP Practices that are responsible for commissioning most health and care services for patients. CPA This stands for Care Programme Approach. Anyone with mental health problems is entitled to an assessment of their needs by a mental health professional, and to have their needs regularly reviewed. CPN Community Psychiatric Nurse CQUIN This stands for Commissioning for Quality and Innovation. It is a payment framework that enables commissioners to reward excellence by linking a proportion of the healthcare providers’ income to the achievement of local quality improvement goals. Integration Pioneer This is a Department of Health initiative. The 14 integration pioneers, selected from across England, are transforming the way that health and care is being delivered to patients by bringing services closer together. The government and national partners would like to see similar approaches adopted across England. NICE The National Institute for Health and Care Excellence provides independent, evidence-based guidance to healthcare professionals on the most effective ways of preventing, diagnosing and treating disease and ill-health, as well as reducing inequalities and variation. QOF The Quality Outcomes Framework is a voluntary incentive scheme, introduced in 2004, for GP practices in the UK, rewarding them on how well they care for patients. Section 136 Section 136 of the Mental Health Act 1983 relates to people with mental health disorders found in a public place. It sets out what the police are entitled to do to safeguard the individual and members of the public. CAMHS Tier 3/4 Child and adolescent mental health services (CAMHS) are split into four ‘tiers’, with non-specialist care provided at Tier 1; specialist primary care mental health workers supporting other professionals at Tier 2; specialist multi-disciplinary teams in local clinics at Tier 3 for complex conditions; and specialist day- and in-patient care at Tier 4 for more-severe conditions. Tier 3 services are provided by a multidisciplinary team who aim to see young people with designated complex mental health problems such as ADHD, autism spectrum disorder, eating disorders or mental disorders associated with intellectual disability. If the young person’s needs require movement between Tier 2 and 3, this should be fluid and seamless, often with the same professionals working at both tiers.
31 Tier 4 services are very specialised services in residential, day-patient or out-patient settings for children and adolescents with severe and/or complex problems requiring a combination or intensity of interventions that cannot be provided by Tier 3 CAMHS.
32 Appendix 1 - Concordat: principles and outcomes
MENTAL HEALTH CRISIS CARE CONCORDAT: CORE PRINCIPLES AND OUTCOMES
1. Effective commissioning ensures that services reflect:
1.1 The needs of people of all ages and ethnic backgrounds reflecting the diversity of local communities;
1.2 An equal relationship between physical and mental health;
1.3 The contribution of primary, community, and hospital care, as well as other partners;
1.4 The inclusion of seldom-heard groups or those that need improved early intervention and prevention.
2. People should expect, and receive, a whole system approach:
2.1 People should have their mental health issues understood within the context of their family, cultural or community setting and other urgent needs / risks;
2.2 There should be an effective emergency mental health response system with detailed co-ordination arrangements in place between all agencies;
2.3 People needing help should be treated with respect, compassion, and dignity.
3. Access to support before crisis point:
3.1 A variety of early interventions should be made available to people whose circumstances make them vulnerable to crisis.
33 4. Urgent and emergency access to crisis care:
4.1 People in crisis are vulnerable and must be kept safe, have their needs met appropriately, and be helped to achieve recovery; 4.2 People should have equal, appropriate access to services;
4.3 There should be access to new models of working for children and young people;
4.4 All staff should have the right skills and training to respond to mental health crises appropriately;
4.5 People in crisis should expect an appropriate response and support when they need it;
4.6 Where police officers are the first point of contact, people in crisis in the community should expect them to provide appropriate help. The police must be supported by health services, including mental health services, ambulance services and emergency departments;
4.7 When people appear to need urgent assessment, the process should be prompt, efficiently organised and carried out with respect;
4.8 People in crisis should expect that statutory services share essential “need to know” information about their needs;
4.9 People in crisis who present in emergency departments should expect a safe place for their immediate care and effective liaison with mental health services to ensure they get the right on-going support;
4.10 People in crisis who access the NHS via the 999 system can expect their needs to be met appropriately;
4.11 People in crisis who need routine transport between NHS facilities, or from the community to an NHS facility, will be conveyed in a safe, appropriate and timely way;
4.12 People in crisis should not be excluded from a health-based place of safety;
4.13 People in crisis who are detained under section 136 powers can expect that they will be conveyed by emergency transport from the community to a health-based place of safety in a safe, timely, and appropriate way.
5. Quality of treatment when in crisis:
5.1 People in crisis should expect local mental health services to meet their needs appropriately at all times;
5.2 People in crisis should expect that the quality of care and services they receive are subject to systematic review, regulation, and reporting;
34
5.3 When restraint has to be used in health and social care services, it is appropriate;
5.4 Quality of treatment and care for children and young people in crisis should be age appropriate.
6. Recovery and staying well / preventing future crises:
6.1 People using mental health services who may be at risk should be offered a crisis plan;
6.2 Advance statements can be facilitated for mental health service users;
6.3 Appropriate transitions and comprehensive pathways need to be organised around the patient;
6.4 Joint commissioning of services, integration of drug and alcohol service response and joined up support are required.
35
MENTAL HEALTH CRISIS CARE CONCORDAT: WHAT PEOPLE WHO USE SERVICES SHOULD EXPECT
1. Access to support before crisis point:
1.1 When I need urgent help to avert a crisis, I know who to contact at any time;
1.2 People take me seriously and trust my judgment, and I get fast access to people who help me get better.
2. Urgent and emergency access to crisis care:
2.1 If I need emergency help for my mental health, this is treated with as much urgency as a physical health emergency. If the problems cannot be resolved where I am, I am supported to travel safely in suitable transport to where the right help is available;
2.2 I am seen by a mental health professional quickly. If I have to wait, it is in a place where I feel safe;
2.3 Every effort is made to understand and communicate with me, staff check any relevant information that services have about me and, as far as possible, they follow my wishes and any plan that I have voluntarily agreed to;
2.4 I feel safe and am treated kindly, with respect, and in accordance with my Rights;
2.5 If I have to be physically restrained, this is done safely, supportively, and lawfully by people who understand I am ill and know what they are doing; 2.6 Those closest to me are informed about my whereabouts. I am able to see or talk to friends, family or other people who are important to me if I wish. I am confident that timely arrangements are made for people or animals that depend on me.
3. Quality of treatment and care when in crisis:
3.1 I am treated with respect and care at all times;
36 3.2 I get support and treatment from people who have the right skills and focus on my recovery in a setting which suits me and my needs. If I need another service, this is arranged without unnecessary assessments;
3.3 If I need longer term support, this is arranged;
3.4 I have support to speak for myself and make decisions about my treatment and care. My rights are clearly explained to me and I am able to have an advocate or support from family and friends, if I so wish. If I do not have capacity to make decisions about my treatment and care, any advance statements or decisions that I have made are checked and respected. If my expressed wishes or previously agreed plan are not followed, the reasons for this are explained clearly to me.
4. Recovery and staying well / preventing future crises:
4.1 I am given information about, and referrals to, services that will support my process of recovery and help me to stay well;
4.2 I, and people close to me, have an opportunity to reflect on the crisis, and to find better ways to manage my mental health in future, that takes account of other support I may need, around substance misuse or housing, for example;
4.3 I am supported to develop a plan now for how I wish to be treated if I experience a crisis in the future, and there is an agreed strategy for how this will be carried out;
4.4 I am offered an opportunity to feed back to services my views on my crisis experience, to help improve services for myself and others.
37 Appendix 2 – statistics
Mental Health in Devon, Cornwall and Isles of Scilly Briefing – February 2014
Community Mental Health Profiles 2013
The network of Public Health Observatories have produced local profiles for mental health which are available at http://www.nepho.org.uk/cmhp/
One in four people in the UK will suffer a mental health problem in the course of a year. The cost of mental health problems to the economy in England have recently been estimated at £105 billion, and treatment costs are expected to double in the next 20 years.
Directly standardised rate for hospital admissions for mental health Admissions to hospital for a mental health condition should be avoided wherever possible through the use of assertive community based services and crisis teams. This indicator shows the rates of hospital admissions for mental health 2009/10 to 2011/12. The actual number of admissions has been converted into a standardised rate per 100,000 to allow comparison between areas
Hospital Admissions for Mental Health
Torbay
Plymouth
Isles of Scilly Devon Cornwall
South West England
0 50 100 150 200 250 300
Cornwall has a significantly higher rate of admissions than the England average but Devon has a significantly lower rate.
38 Percentage of adults (18+) with depression Depression is common and disabling. Mixed anxiety and depression contributes 12 per cent of the total burden of non-fatal global disease and by 2020, looks set to be second after cardiovascular disease in terms of the world's disabling diseases. Major depressive disorder is increasingly seen as chronic and relapsing, resulting in high levels of personal disability, lost quality of life for patients, their family and carers, multiple morbidity, suicide, higher levels of service use and many associated economic costs.
Percentage of Adults with Depression Torbay Plymouth Isles of Scilly Devon Cornwall South West England
0 5 10 15 20
All of the areas in the peninsula have a higher percentage of adults with depression (2011-12) than the national average.
Percentage of the adults (18+) with dementia Dementia is a syndrome characterised by progressive global deterioration in intellectual function and is a main cause of late life disability. The prevalence of dementia increases with age and is estimated to be approximately 20 per cent at 80 years of age. In a third of cases, dementia is associated with other psychiatric symptoms such as depressive disorder, adjustment disorder, generalised anxiety disorder and alcohol related problems.
The peninsula has higher proportions of people registered with their GP as having dementia compared to the national average (2011-12). This may reflect the older structure of our population.
Percentage of Adults with Dementia
Torbay Plymouth Isles of Scilly Devon Cornwall South West England 0 0.2 0.4 0.6 0.8 1
Considering expected prevalence however, Devon and Torbay appear to have less people registered with dementia compared to other areas. This could suggest that that
39 there may be a higher proportion of people not yet identified as needing care for this condition in Devon and Torbay.
Admissions for schizophrenia and delusional disorders Schizophrenia is one of the most common serious mental health conditions. The illness has a range of symptoms including hallucinations, delusions and difficulty in thinking. Doctors describe schizophrenia as a psychotic illness. The actual number of admissions has been converted into a standardised rate per 100,000 to allow comparison between areas (2009/12-2011/12).
Hospital Admissions for Schizophrenia and Delusional Disorders
Torbay
Plymouth
Isles of Scilly
Devon
Cornwall
South West
England
0 10 20 30 40 50 60 70
Devon and Plymouth have significantly lower rates than the national average.
Numbers of people using adult & elderly NHS secondary mental health services Commissioners of services need to be aware of the number of people using mental health services in order to plan for future provision. The numbers of individuals using adult and elderly NHS secondary mental health services in the peninsula (except Plymouth) are significantly lower than the national average which may suggest people are not being identified or referred for treatment.
Number of contacts with Community Psychiatric Nurse The rates of contacts across the peninsula (except Torbay) are significantly lower than the national average, again possibly suggesting people are not being referred for treatment.
Spend on mental health 2011/12 The average national spend on mental health services (both NHS and Local Authority is £182 per head. Spend in the peninsula is in line with this national figure.
40 Appendix 3 – Attendees
Name Organisation Age UK Cornwall and Isles of Scilly and Kernow CCG Tracey Roose GP Sarah Dobson Anne Marie Morris MP Eilis Rainsford Community Care Trust Kirsty Luxton Cornwall Carers Service Naomi Laws Cornwall Carers Service Andrew Wallis Cornwall Council Charlotte Hill Cornwall Council Jeremy Rowe Cornwall Council Jon Dunicliff Cornwall Council Philip Brigham Cornwall Council Andy Fox Cornwall Partnership NHS FT Angie Turner Cornwall Partnership NHS FT Bernadette Rheeder Cornwall Partnership NHS FT Paul Bell Cornwall Partnership NHS FT Philip Confue Cornwall Partnership NHS FT Marita Ward Cornwall Rural Community Council Kathy Gilmore Devon and Cornwall Housing Guy Blackford Devon and Cornwall Police Hannah Hart Devon and Cornwall Police Julia Moore Devon and Cornwall Police Lynne Callaghan Devon and Cornwall Police Phil Kennedy Devon and Cornwall Police Sharon Taylor Devon and Cornwall Police Meg Compton Devon Carers Andy Moore Devon Partnership NHS Trust Chris Burford Devon Partnership NHS Trust Sarah Joy Boldison Devon Partnership NHS Trust Terence Grace Devon Partnership NHS Trust Vanessa Ford Devon Partnership NHS Trust Mark Bolt East Cornwall Police Iola Davies Emergence CIC and Self Employed Gemma Hodgson ERS Medical LTD Rachel Hixson ERS Medical LTD Jim Gale Exeter, East and Mid Devon Local Policing Area Lesley Seward Health Education South West Peter Edwards Healthwatch Plymouth
41 Norman Lamb House of Commons Sarah Wollaston House of Commons Isobel Down ID Consultancy Jonathon Williams Independent Julie Harvey Independent Steph Jibson Independent Wayne Kirkham Independent Crispin Holmes Independent Kate Philbin Independent Richard Croome Independent Julie Stone Independent Consultant in Healthcare Law and Ethics Andrew Abbott Kernow CCG Andy Gordon Kernow CCG Chris Blong Kernow CCG Jude Bowler Kernow CCG Paul Cook Kernow CCG Sandra Miles Kernow CCG Tracey Marsh Kernow CCG Sarah Trickett KUF and the Bridge Collective Laura Ashton Mevagissey Surgery, Cornwall Linda Walton New Devon CCG Lorna Collingwood-Burke New Devon CCG Paul O'Sullivan New Devon CCG Rebecca Harriot New Devon CCG Tim Francis New Devon CCG Gavin Thistlewaite New Devon CCG and Devon County Council Allysia Wood NHS England Carol Williams NHS England Geraldine Strathdee NHS England Glen Everton NHS England Karen Tucker NHS England Salena Taylor NHS England Shelagh McCormick NHS England Will Doran NHS England Amanda Fisk NHS England Jo Gage NHS England Northern Devon Healthcare Trust, working with Devon Chukumeka Maxwell and Torbay Public Heath Robin Miller NSL Care Services Gary Wallace Office of Director of Public Health Plymouth City Tony Hogg Office of Police and Crime Commissioner
42 Office of the Police and Crime Commissioner for Devon, Ian Ansell Cornwall and the Isles of Scilly Francesca Haydon Outlook South West Louise Knox Pentreath Paul Reeve Pentreath Chris Everatt PIPS Plymouth Involvement and Participation Anna Coles Plymouth City Council Claire Anderson Plymouth City Council Ian Lightley Plymouth City Council Sarah Lees Plymouth City Council David McAuley Plymouth Community Healthcare Dr Liz Adams Plymouth Community Healthcare Debbie Stark Public Health England Kevin Elliston Public Health England Nicki Glassbrook Public Health, Devon County Council Geoff Lynn Recovery Devon Linden Lynn Recovery Devon Ian Bowden Rethink Mental Illness Andrew Virr Royal Cornwall Hospital Trust Lerryn Hogg Royal Cornwall Hospital Trust Christine Thomas Samaritans Sylvia Powlesland Samaritans (Cornwall at Truro) Penny Newman SEAP Wayne Lewis Somerset CCG Ann Redmayne South Devon and Torbay CCG Charlie Daniels South Devon and Torbay CCG Derek O'Toole South Devon and Torbay CCG Jacqui Hawkins South Devon and Torbay CCG Jennifer Baker South Devon and Torbay CCG Louise Hardy South Devon and Torbay CCG Sallie Ecroyd South Devon and Torbay CCG Sam Barrell South Devon and Torbay CCG Wendy Bull South Devon and Torbay CCG South Devon and Torbay CCG & Torbay and SD Health Jacqueline Bamford Care Trust Ian Harrison South West Academic Health Science Network Adrian James South West Strategic Clinical Network Frances Tippet South West Strategic Clinical Network Mary Ryan South West Strategic Clinical Network Rob Gough South West Strategic Clinical Network Sunita Berry South West Strategic Clinical Network & Senate
43 Frank Davey Stennack Surgery, St Ives Chris Lewis Torbay Council Gerry Cadogan Torbay Council Neil Bent Torbay Council Katy Rendle West Cornwall Mind
44