A better future in mind Mental health services in the North West October 2008 Snapshot of the North West

Cumbria 487,000 people Includes: Carlisle Penrith Kendal

Lancashire 1.4 million people Includes: Blackburn with Darwen Blackpool Burnley Chorley Lancaster 1.5 million people Morecambe Preston Includes: Halton and St Helens Knowsley Liverpool Sefton Wirral

2.5 million people Includes: Ashton, Leigh and Wigan Cheshire Bolton 864,000 people Bury Includes: Heywood, Middleton and Rochdale Chester Manchester Crewe Oldham Macclesfield Salford Warrington Stockport Tameside and Glossop Trafford

2 Contents

Background

Why have a Commission on mental health services? 5 What did we find? 7 Some long-standing problems 8

How have we been trying to address these long-standing problems?

The engagement of service users, carers 11 and the public How can we make the voice of service users, carers 13 and the public more powerful?

Commissioning and investment 16 How can we strengthen commissioning to 18 achieve more change? How can we change patterns of investment? 23

Developing staff 24 How can we enable staff to deliver better services? 24

Conclusion 26

Summary of recommendations 27

An electronic version of this report with active internet links is available at: www.northwest.nhs.uk/projects/mental_health_commission/

This webpage will also direct you to additional information, reports and references cited in this report.

3 A better future in mind mental health services in the North West Introduction

A better future in mind NHS North West Commission on mental health services

This report is the culmination of a that our recommendations will by a cross-section of bodies in year-long piece of work sponsored have a positive impact for them ; Sir Jonathan Michael’s by NHS North West, the region’s all. During our work we found independent inquiry into health strategic health authority (SHA), no shortage of passion and services for people with learning and shows its commitment to commitment for improvement disabilities and the Bradley advancing mental health services. but despite this, some significant Review and Dementia Strategy problems still persist. These Consultation currently under way It recognises the challenges problems predominantly relate will all need to be taken forward which people with mental health to the wider system within together to find ways to improve problems across the North which services are delivered, mental health services. West face and the difficulties of including the engagement of tackling these in the NHS and We commend this report to the those we should be seeking to other sectors. It also recognises SHA, the NHS and social care serve, choices and priorities for that much progress has been community, the independent investment and the focus of our made through the dedication sector and, most importantly, responses on treating illness rather and enthusiasm of staff and the people across the North West who than trying to avoid it. contribution of service users, their either are, or could be, affected carers and the wider community. We have looked at the way these by mental health problems. Much of this progress has been problems have been tackled Pursuit of our recommendations made as a result of the 10-year and reviewed the effectiveness can and will make a significant National Service Framework for of these approaches. We have contribution to ensuring that the mental health published in 1999. made recommendations which people of the North West access As the framework now nears will strengthen the system overall better services and have better its end it is time to evaluate its and be more effective in finding mental health for many years to impact and consider how best to lasting solutions to these come. take the agenda forward over the long-standing problems. John Boyington coming years. We have also tried to identify Chair Most of the money spent on some of the places and projects mental health goes through the where very different, innovative NHS and as such we have focused and imaginative things are our attention there. However, happening to demonstrate We have also tried we are very aware of the part what can be achieved. We have “ to identify some of played by a wide range of other included examples of these in an the places and organisations and have sought to electronic annexe to this report. projects where reflect this in our report. This report does not sit in isolation very different, We have tried to consider the nor can it be taken forward alone. innovative and needs of all client groups in the Locally and nationally, the past six imaginative things North West. Whilst the report months has seen the publication are happening to does not identify issues and of other relevant reports. Healthier demonstrate recommendations for each one Horizons published by NHS North what can be of these groups, we believe West; Vision 2015 produced achieved. 4 ” Background

Why have a Commission on mental health services?

Significant changes have been and healthy eating, the North mental illness. seen in mental health services West does consistently badly. Such a high level of population since the introduction of the It is not surprising, given this need requires investment, National Service Framework for relative deprivation, that the efficiency, innovation and quality Mental Health (DH, 1999). The psychological well-being of the from those who commission and SHA took a decision to review people of the North West is also provide mental health care and the impact of these changes substantially below the national services to prevent illness and in the North West and use the average. Relative to the other promote mental well-being. But findings to set a new agenda for regions of England the North is this the case in the North West mental health. West has: and what could be done not only Mental health problems are • the second-highest rate of to meet these challenges but to common. Nationally, one in people on incapacity benefit for make the North West’s mental six people has a mental health mental or behavioural disorders health and mental health services problem that requires treatment something to be proud of? • the second-highest suicide and one in four GP consultations rates for men and women under involves a mental health the age of 75 component of some kind. The Figure 1 cost of poor mental health to • the third-highest rate of drug the national economy has been misuse. • The North West has the estimated to be as high as £110 The high use of health services highest level of hospital billion a year in the UK is also a reflection on the poor admissions for depression and Friedli & Parsonage (2007) psychological well-being of the anxiety at 55 per cent and www.niamh.co.uk population www.nepho.org.uk 29 per cent above the national Personal costs can also be high (Figure 1). average respectively with people who experience Factors that can increase the risk • The region’s rate of hospital a prolonged mental health of mental health problems in the admission for schizophrenia problem or have a severe North West include a higher-than is also the highest nationally and enduring mental illness, -average unemployment rate and – 39 per cent higher than the often living in poverty and one of the lowest employment national average experiencing a lower quality of rates amongst people once they • It has a hospital admission life. have a mental health problem. rate for self-harm 26 per cent According to national statistics The recent review of the higher than the average for the North West of England health of Britain’s working age England is the second most socially population (Black, 2008) • It has the highest rate of deprived area of the country. www.workingforhealth.gov. hospital stays for alcohol- Data available on the North uk reported that initiatives to related problems West Public Health Observatory help people back to work, while website www.apho.org.uk successful overall, have had a show that on indices such as life limited effect for those whose expectancy, children in poverty main health condition is 5 A better future in mind mental health services in the North West Background

What the Commission did

The Commission was set service users, carers, family behalf with 35 groups of up in September 2007 to members and the general public. stakeholders from across the review mental health services We also received evidence region whose voices often go in the region and make from commissioners, service unheard. recommendations that would providers, voluntary and private We studied information ensure that world-class sector organisations, social collected on services including services are being consistently care and other local authority reports of bodies such as the provided for the people of service providers, criminal justice Healthcare Commission, the the North West. Further professionals, professional bodies Mental Health Act Commission, information on Commission and trade unions. the Commission for Social Care members is available at www. We held meetings across the Inspection and HM Inspectors of northwest.nhs.uk/projects/ North West to hear stakeholders’ Prisons and Probation. mental_health_commission/ views on current services, their Biographies.html We used information and data strengths and short-comings. from existing reports written The Commission was supported Particular attention was paid about mental health services in by a reference group made to reaching people whose the North West over the past five up of 43 regional and national views are often not gathered, years including the enquiries into stakeholders, at least a quarter including children, older people, homicides committed by patients of whom were service users or people with a learning disability, in the care of mental health carers. This group also aimed minority ethnic groups and services. to be representative of the people who have been on geography of the region and to We thought about our probation or in prison. reflect an ethnic and gender mix. terminology and agreed to use The University of Central the terms in Figure 2 for the We took evidence from a wide conducted a specific remainder of the report. range of stakeholders, especially engagement exercise on our The Commission team (left to right): John Boyington, CBE (Chair) Joanne Nightingale (Project support officer) Professor Mark Gabbay (Commission member) Professor Max Marshall (Commission member) Colin McKinless (Commission member) Professor Jennie Popay (Commission member) Julie Cullen (Programme director) Terry Lewis (Deputy chair) 6 Some of the consultation events held by the Commission

Figure 2 We also looked at high-quality access to services because of The terms we have used services in the North West and their social, economic or cultural The stigma attached to mental elsewhere, to get a sense of the circumstances; and that these illness has encouraged the use best practice to which the region inequalities may cause higher risk of the term mental health to should aspire. We were fortunate of mental illness or make them less describe treatment and support to visit a number of services which likely to have positive mental health were operating innovatively and we services for people with mental • acknowledge the benefit to have produced an electronic annex illness. This contributes to all of positive mental health, the to this report which gives further confusion about the concept opportunity for some of preventing details of all these initiatives. of mental health as well as mental illness and the focus Our website also contains a list of mental illness (WHO, 2004). In on recovery for those who are people who we met, those who this report we have used the experiencing mental illness following definitions: provided evidence and also a list of additional information we • see the experience of service • Well-being – to describe reviewed at www.northwest. users and carers as at least the a positive state of mental and nhs.uk/projects/mental_health_ equal of all other measures of physical health commission success, and recognise that the best • Mental health problem – to results for service users and carers describe a range of experiences What did we find? come from positive relationships which cause significant and that fully engage them in all levels sometimes prolonged distress We found evidence of progress and of decision-making for people. The majority of innovation across the North West • acknowledge that non-statutory these problems are not and saw examples of excellent services, including those led by diagnosed as mental illness. care and support being provided service users, are equal to those of They may develop into mental by passionate and enthusiastic the statutory sector and encourage illness, or similar to personality professionals in the health and collaboration between the two. disorder, present life-long social care sector, independent As well as this consensus, we also difficulties for the people sector, not-for-profit organisations found evidence of some significant involved and lay people. We found a consensus about what people and long-standing problems which • Mental illness – to describe thought were the characteristics have been resistant to change and conditions with clear symptoms of an effective system and are a key focus of this report. that lead to a formal diagnosis identified many people, and some These problems are not unique to • Severe and enduring organisations, within the North the North West, nor do they persist mental illness – to describe an West, committed to achieving this. through lack of efforts to address illness which is likely to be serious Such a system should: them. They are complex problems, which need key mechanisms to long-lasting and relapsing • be comprehensive and inclusive, be working well and working • Mental health services – promoting the principles of together to resolve them. Too often to describe primary, secondary fairness, respect, equity, dignity and approaches in the past have been and tertiary health care services autonomy for service users, carers partial or short-term and solutions focusing on prevention, and staff have failed to stick. diagnosis, treatment and care • recognise and address the fact in relation to mental health that some people have unequal problems or illness 7 A better future in mind mental health services in the North West Significant Figure 3 long-standing Crisis Resolution Home Treatment Teams (CRHTs) problems All crisis teams said that the telephone was their main point of access. Our regional survey conducted on two occasions during office hours In our survey of crisis Patchy availability showed that only 71 per cent intervention services we of services and 67 per cent of calls were found that almost a third of calls answered on the first attempt. Many of the service users and were not answered personally carers whom we talked to but diverted to an answering www.northwest.nhs.uk/ described difficulties obtaining machine. (Figure 3). projects/mental_health_ services such as long-term commission community support, crisis care Quality and psychological support and Despite some perceived Figure 4 treatment. improvements in recent years Acute inpatient mental GPs also told us of the difficulties many service users and carers we health wards they experienced in getting spoke to were unhappy with The 2006/2007 National Audit help for some of their patients, the quality of the care they of Violence pointed to an especially those with mild to had received. These concerns increase in the frequency and moderate mental illness. Some were confirmed by a review severity of incidents. On acute services are not available in some of Healthcare Commission wards for adults of working parts of the region because of reports carried out for us that age: local decisions about resources. highlighted variations in service • 61 per cent of nurses and The availability of appropriate quality (www.northwest.nhs. 43 per cent of patients had felt services to people in a variety uk/projects/mental_health_ upset or distressed of minority groups was raised commission). Across the North frequently and the problems with West, relationships between • 73 per cent of nurses and service availability for those in professionals and service 31 per cent of patients had the criminal justice system are users and carers were often been threatened or made to well documented. Often even described as poor with the feel unsafe when services were available, physical environment and ‘hotel’ • 45 per cent of nurses and they were not the ones that aspects of care often falling short 15 per cent of patients had people felt they needed. of expectations. been physically assaulted (www.healthcarecommission. We received a lot of feedback Access to services org.uk) from service users, carers and People described many staff about poor facilities difficulties in accessing services. and services for people who Figure 5 This was a particular problem were most acutely ill. Many Young people admitted for groups with different needs of these described acute wards to acute wards such as those with a learning as frightening places (Figure The North West of England has disability or black and 4) where they often felt they by far the highest number of minority ethnic groups. Access had little access to support occupied bed days of children problems were often caused by or therapeutic activity and aged under 16 and young a lack of information about where disturbed behaviour was people aged 16 and 17, and available services, the siting of common. This is known to be a accounts for almost a quarter services and a lack of cultural particular issue in the North West of national total occupied bed appropriateness. Services to for young people (Figure 5). days for this age group. people arguably most in need are often not easy to access. Survey of adult psychiatric bed utilisation in the North West. 8 McDougal & Bodley-Scott (2008) Figure 7

Positive mental health Professor Corey Keyes from the USA presented evidence to the commission about his work on mental health and ‘flourishing’. Keyes has developed tools to measure mental health as Lack of investment in prevention opposed to the absence of Most of the money in the North Helping those who become mental illness and asserts West is spent on secondary ill to achieve a full recovery that the two are separate mental health services to help and stay well remains under things. He describes people people who have become ill to resourced (2.6 per cent) with good mental health get better (Figure 6). (Figure 8). as ‘flourishing’ and those whose mental health is Relatively little (10 per cent) NHS resources need to be more poor as ‘languishing’. He is spent on primary care effectively applied to supporting has produced statistics that services, which treat most of and complementing those demonstrate that young those with a mild to moderate deployed by local government people whose mental mental illness and manages and other bodies in relation health is poor (languishing) undiagnosed mental health to this agenda, where there are more likely to develop problems (Figure 7). are significant personal and economic benefits to be mental illness. He has also Even less (0.2 per cent) is spent achieved (Figure 9). produced evidence that on helping people to stay those with poor mental mentally well or to prevent health are much more likely people becoming mentally ill. to suffer from poor physical health and are likely to take longer to recover. Friedli & Parsonage (2007) Figure 6 www.niamh.co.uk Percentage spending on mental health in the North West (2006/07)

Source: Commission on mental health Figure 8 services survey of PCTs Levels of prevention • Primary prevention – aims to improve the mental health of communities so that people do not become ill • Secondary prevention – aims to identify people who are developing early signs of mental illness so that more serious illness can be Secondary care Secondary Specialised commissioning prevented Primary care • Tertiary prevention – Prevention/health promotion Prevention/health User engagement

aims to prevent people who support Recovery have become ill from 73.3% 13.7% 10% 2.6% 0.2% 0.2% relapsing, or helps them to recover 9 A better future in mind mental health services in the North West Significant Figure 9 Investing in prevention for long-standing families problems Children of mothers with perinatal depression are more vulnerable to developing mental health problems and have a higher rate of referral to children’s mental health services. Staff attitudes and working practices Murray (2001), Hay et al (2001). Children of depressed parents As we have pointed out, In their work for us, are two to three times more most of the NHS budget is the University of likely to present with childhood spent on clinical services. A Central Lancashire anxiety, disruption and depressive medical approach is at the (www.northwest.nhs.uk/ conditions. heart of the NHS and in the projects/mental_health_ Weissman et al (2006). North West, as elsewhere, commission identified a “Although associated with medical and other health problem they defined as very severe disturbance, early professional education has a ‘professional stigma’. onset puerperal psychosis and significant clinical focus. severe depressive illness are very Health professionals were responsive to treatment…” Whilst good clinical services felt to be as likely as other Royal College of Psychiatrists (2000). are essential to effective people to stigmatise people treatment, they alone because of their mental Figure 10 cannot enable people to health status, their group achieve a full recovery from membership, culture or Principles of the strengths-based mental illness, reduce the difference. approach to recovery likelihood of a recurrence or Professionals therefore • The focus of the helping process prevent the onset of illness. often reflect the is upon the service user’s strengths, The way in which most prejudices of wider interests, abilities and capabilities, professionals are trained society but this can have not on deficits, weaknesses or and their values and a greater consequence problems attitudes framed too often because of their role in • All service users have the contributes to a mismatch supporting people. capacity to learn, grow and change between what people tell • The service user-practitioner us they need, or prefer, relationship becomes a primary and and the services they are essential partnership offered. • The service user is viewed as the A strengths-based approach director of the helping process to recovery (Figure 10) is • Continuity and acceptance are widely acknowledged as essential foundations for promoting beneficial to those who recovery have been, or are, ill but it is • The helping process takes on an not the predominant model outreach perspective of service offered. • The local neighbourhood is viewed as a resource rather than as an obstacle. Natural neighbourhood resources should be considered before segregated mental health services www.practicebasedevidence. com/files/OpenMind- StrengthsBasedPractise.pdf 10 Addressing long-standing problems

How have we been trying to address these long-standing problems?

These problems are already well recognised by service users, carers, professionals and organisations, and a number of mechanisms are in place to “We believe that the true potential for the long- try to improve mental health services term transformation of health in the North West and make them more responsive to lies in creating an NHS that is driven by citizens people’s needs. who know that their views and decisions count The mechanisms which we believe are and who are enabled to play their part in critical to tackling the long-standing managing their own health and well-being.” problems identified earlier are: Healthier Horizons for the North West (2008)

ENGAGEMENT OF SERVICE Engagement of service users, carers USERS, CARERS & and the public THE PUBLIC There is a well-established and formal commitment that service users, carers and the general public should play a central role in the design and delivery of mental health COMMISSIONING services. The recent report on the NHS in the North West & INVESTMENT Healthier Horizons for the North West highlighted this as key to the improvement of services. Some PCTs have developed service user and carer reference groups (Figure 11) and we have also seen some very positive examples of the engagement of service users and carers in treatment and care DEVELOPING planning (Figure 12). STAFF Figure 11

The Patients’ Council: Take it to the top The Patients’ Council for mental health is a service-user-led We have reviewed how well these organisation funded by Bolton PCT, which facilitates the mechanisms have been working in involvement of service users in every aspect of mental health. the North West, and considered how It promotes a positive image of mental health and runs a they might be made to work more range of activities to enable Bolton people to lead long and effectively. healthy lives. The Patients’ Council initiated ‘Take it to the top’ so that anyone wishing to raise issues on mental health could do so in a monthly public forum.

11 A better future in mind mental health services in the North West “I didn’t feel welcome when I “People listen went to hospital. very politely, Engagement It seemed as if I but nothing was a nuisance” ever changes” Service user who Service user accesses acute representative hospital services talking about formal consultation

The new Local Involvement However, we have consistently Figure 12 Networks (LINks) are intended been told by many people to give citizens a stronger voice that, despite commitments in The Salford early in the health and social care national and local policy and intervention team services in their area. There these formal mechanisms for The early intervention team works are also new opportunities engagement, service users and in partnership with service users, for service users/carers and carers too often feel ‘done-to’ their families and friends and public engagement through rather than ‘engaged with’. This seeks to ensure that the service membership of Foundation applies equally to the planning user is at the centre of care and Trusts (FTs). and delivery of services at service delivery. The focus is individual and population level. NHS provider organisations on helping the service user to which achieve FT status have A recent review of research make sense of their experiences more freedom from central evidence undertaken for the and to identify strengths, needs control and as a consequence National Institute for Health and and areas of difficulty, as well as can lead the way in greater Clinical Excellence (NICE) was working towards future hopes and local engagement. These trusts subsequently used to inform the aspirations. The team works with have the potential to establish production of NICE guidance a recovery-orientated philosophy, stronger connections between on engagement. It identified which means that as well as local services and people recurring organisational, focusing on improving symptoms living in the communities they professional and managerial and social functioning they serve, who are able to become barriers to effective engagement support the person to develop members of the FT and take of lay people in health decision- a life that feels meaningful and a role in its governance. More making. These barriers stem satisfying. than half of the mental health from: trusts in the North West region Figure 13 • unequal power relationships are now FTs. North West region mental health • communication and In these five FTs (Figure 13) Foundation Trusts knowledge about 42,800 members of • Cheshire and Wirral Partnership • the practices of engagement NHS Foundation Trust the public (including service users, carers and employees) • Cumbria Partnership NHS • the costs of engagement for Foundation Trust are now members. These lay people members could be a powerful • Greater Manchester West • professional and force promoting the public Mental Health NHS organisational culture and accountability of FTs and Foundation Trust attitudes increasing the likelihood • Lancashire Care NHS that services will more • community resistance to Foundation Trust accurately reflect the needs engagement • Pennine Care NHS and expectations of local Foundation Trust • political imperatives including people, and be more effective national demands for policy in engaging service users ‘quick wins’. and carers in the design and delivery of their care pathways. www.nice.org.uk/PH009

12 How can we make the voice of service users, carers and the public more powerful?

Commissioners and providers of contribution wherever it is The goals for this would be services in the North West need needed. The NHS and wider to improve organisational to recommit themselves to giving systems need to build on such performance and its service user, carer and public examples to significantly improve measurement, focused on engagement the high status and the engagement of service users, service user, carer and public influence that it requires if we are carers and the public. engagement. to improve service experience and The programme in Recommend- outcomes. This will mean major ation 1 will require financial changes in organisational and RECOMMENDATION 1 resources and would need to be professional cultures and ways supported by a range of agencies of working. It also needs greater We recommend as well as NHS North West. It financial and other support. The the strategic health should be shaped and developed evidence about common barriers authority uses its through close involvement with to engagement is known. What leadership and influence those with experience of using, is needed is action to overcome to create a cross- or caring for those who use, them. agency programme to mental health services. This will require commissioners support and scrutinise The focus should be on the and providers to work in different significant performance means of promoting better ways with service users, carers improvements in service engagement in decision making and the public – recognising that user, carer and public about the design, commissioning, they are informed stakeholders engagement in mental delivery, evaluation and who expect to be seen as health. This should development of services. an equal and authoritative directly address the presence. Particular attention known organisational, should be given to the effective managerial, professional engagement of minority groups. and cultural barriers to C Organisations and professionals h effective engagement. an need to be held to account g in for showing the impact that g t engagement has had. There also Figure 14 h e needs to be a greater recognition f of the need to implement more Liverpool Mental Health Consortium (LMHC)a c paid roles for service users and e

LMHC is a service-user-led membership organisation for stakeholders carers. o

that includes statutory authorities, providers, voluntaryf sector

The Liverpool Mental Health organisations, individuals and groups who experiencem mental

e

Consortium (Figure 14) is a distress. It promotes partnership working basedn on the experiences

t

positive example of service of people who use services and operates througha managed l

user, carer and community h

networks embracing the principles of communitye development

a

engagement and of a structure l

and participation. It provides a structuret for stakeholders’ views, that seeks to support service experiences and aspirations to be influentialh in formal, joint-planning users and carers to make an systems and to feed back developments to its community members. informed and authoritative

13 A better future in mind mental health services in the North West Figure 16 User Controlled Evaluation Engagement (UCE) This has been developed in the North West by service users and professionals to gather feedback from service users on the service they have received. Service We see a number of ways by • supporting the development users are involved from which this programme could of incentives which value the start to finish – having enhance the role and status of experience of service users designed the questionnaire, engagement in the design and and carers including extending been trained to interview evaluation of services: the incentive-based quality other service users and to improvement scheme ‘Advancing interpret and produce the Quality’ to mental health, to findings. While UCE has include measures of recovery and Figure 15 been well received, in many an extension of these principles areas funding has not been Mental Health Centre of into social care (see page 17 and available to introduce it Denver recovery measures Figure 26 on page 18) as a part of the routine The Mental Health Centre of • supporting and developing evaluation of services. Denver (MHCD) is a mainstream, better user-centred quality www.northwest.nhs.uk/ not-for-profit, community measures such as those developed projects/mental_health_ mental health care organisation. and introduced into the Mental commission It provides a strengths-based, Health Centre of Denver in the recovery-focused service to 6,500 USA to support their approach people living in the Denver to a strengths-based model for Figure 17 metropolitan area. Researchers recovery (Figure 15) Patient Opinion at MHCD have collaborated Patient Opinion is a not- with service users to develop • supporting and developing for-profit social enterprise, a number of well-validated outcome measures that directly which uses its national recovery measures. For example, measure the service user and carer website to hear about the Recovery Markers Inventory experience, perhaps using patients’, service users’ is completed every two months ‘User Controlled Evaluation’ and carers’ experiences. by clinicians and charts progress (Figure 16) and mechanisms being Patients, service users and across eight dimensions from developed by ‘Patient Opinion’ carers generate content symptom interference to (Figure 17) by sharing their stories on housing, employment and • developing a service user the site and by rating the education. kitemark with which to accredit service they have received. services and organisations that A similar measure is completed Anyone can then view this are truly user-focused, perhaps by service users and includes feedback to find out what modelled on lines similar to symptom interference, active/ people thought about a Investors in People or the Charter growth orientation, hope, safety particular department, Mark schemes and social networks. ward, service or procedure. The success rates of clinicians • supporting the development Mental health trusts and and clinical teams are assessed and implementation of Refocusing other organisations are by these measures and are used of the Care Programme encouraged to respond to to inform initiatives to improve Approach (DH, 2008) which pays this feedback – be it positive clinical quality. attention to a person’s strengths, or negative – on the website achievements and aspirations and creating a radical new way to www.mhcd.org incorporates the use of advanced have a dialogue and improve decisions and statements services and care. www.patientopinion.org.uk

14 Figure 18 The youth consumer participation model This is a user-developed enterprise from New Zealand which promotes informed representation and influence at all levels of engagement from service users. The organisation • supporting effective Like Recommendation 1, identifies, trains and develops implementation and evaluation this initiative will require service users for the roles they of the personalisation agenda financial resources and needs undertake, and makes sure that • supporting the develop- to be supported by a range of they are kept abreast of service ment and implementation of agencies as well as NHS North and policy developments, thus integrated community-centred West. ensuring that the advisor’s commissioning models such It must be shaped and contribution is equal to that of as ‘Connected Care’ run by developed in close any other stakeholder. Turning Point and described collaboration with those who www.werrycentre.org.nz later in the report (see page 20 have experience of using, or and Figure 28 on page 21). caring for those who use, Figure 19 Ensuring effective performance mental health services. It should build on the experience Cumbria mental health group across the system is only part of the solution. Although and successes of existing Set up as a user and carer-owned there are examples of effective service user organisations and organisation. The objectives are: engagement across the region, groups. We believe that it • provide effective communic- the means, mechanisms should as a minimum: ation to enable people to and resources for enabling • secure opportunities to participate in decisions about service user, carer and public develop knowledge, skills and design and implementation of engagement also need to be competencies the whole range of services to developed. help communities’ mental well- • support the development being of means by which service user and carers can effectively • provide access to non RECOMMENDATION 2 engage with and represent threatening, safe and relaxed their constituents local forums to enable them to debate and understand issues We recommend • support shared learning • provide those who wish to that the strategic and collaborative working be more actively involved with health authority uses across the North West support and training to do so. its leadership and amongst service users, carers To give information about influence to support and the public, to increase national and local policies and the North West NHS their involvement at all levels, successful services elsewhere and other partners to including as providers of user-run services and working • actively encourage people establish a user and with mental health users to take part in wider public carer engagement groups, LINks, FT members forums to promote the inclusion development initiative. and governors. See the youth of people with mental health This should enable consumer participation model problems service users, carers (Figure 18) and the Cumbria and communities to • promote service user and mental health group (Figure participate effectively carer strategies while providing 19). a forum in which commissioners as equal partners in the and providers can test ideas, design, delivery and issues and solutions. evaluation of services. www.scmhforum.org.uk

15 A better future in mind mental health services in the North West World-class Commissioning “ commissioners are central to a self- improving NHS. Commissioning ” In 1990, the landscape of the NHS developed by the DH publications Figure 20 was changed when commissioning World Class Commissioning World Class (deciding what services should (Figure 20) and the Framework Commissioning (WCC) be provided and by whom) was for Procuring External Support for separated from the organisations Commissioners (FESC) (Figure 21). WCC sets out a vision that deliver services (providers). for a long-term Over the past decade, legislation, Since then there have been strategic approach policy and guidance has considerable attempts to organise to developing encouraged more integrated commissioning so as to maximise commissioning; an commissioning models between the its contribution to securing high- assurance system to NHS and social care. Despite some quality health and social care performance manage innovative examples, this process services. commissioning by the has been patchy and inconsistent. PCTs; a description In 2001, the Department of During this time, integrated or of the functions and Health (DH) document Shifting partnership arrangements have also competencies required the Balance of Power set out developed on the broader health of commissioners and a how most of the responsibility for improvement and well-being front, programme for support commissioning health services in through the mechanisms of Local and development. England would move from the then Strategic Partnerships (LSPs) (Figure 100-plus health authorities to 300 22) and Local Area Agreements WCC competencies newly-created PCTs. This increase (LAAs) (Figure 23). • Locally lead the NHS in commissioners placed an This review found that there are enormous strain on commissioning • Work with still major weaknesses in the expertise in mental health at a community partners commissioning system on which critical time when the National • Engage with public earlier changes have struggled to Service Framework for Mental and patients have sufficient impact. This has Health was in the early stages of resulted in many mental health • Collaborate with implementation. service users and carers not seeing clinicians In 2005, Commissioning a the full intended benefits of the • Manage knowledge Patient Led NHS was published reforms. The absence of an agreed and assess needs by the DH to further strengthen payment system for NHS services, • Prioritise investment commissioning. Many of the for example, has delayed the • Stimulate the market smaller PCTs would merge to form implementation of choice between • Promote larger organisations with clearer providers for service users. improvement and commissioning responsibilities. The Many of the stakeholders we innovation North West currently has 24 PCTs. spoke to, including those working • Secure procurement Alongside this, a system of as mental health commissioners, skills practice-based commissioning lacked confidence in the mental • Manage the local was introduced, which involved health commissioning process and health system GPs more directly in planning in many PCTs it was described as and purchasing local healthcare. marginalised, fragmented and • Make sound In 2007, the processes for lacking senior leadership. financial investments commissioning were further

16 Figure 21 1.5 Framework for Procuring Figure 24 £1.49

External Support of PCTs mental health commissioning £1.36 Commissioning (FESC) spend per head (£) £1.24 FESC provides the £1.23 1.2 Source: Commission on mental health opportunity for PCTs to services survey partner independent providers, who can £1.05 undertake aspects of the £0.97 commissioning function, 0.9 whilst remaining accountable to the PCT £0.70 board throughout. £0.67 £0.66 £0.63 Contractual arrangements 0.6 £0.61 £0.58 £0.58 VALUE IN POUNDS VALUE are robust and payment £0.56 £0.49 models are designed to £0.48

incentivise providers to £0.39 £0.38 £0.38 £0.36

deliver to the required value. £0.33 0.3 £0.28 £0.27

Figure 22 £0.21 Local Strategic Partnerships (LSPs) 0 Western Cheshire Western 0 Stockport Blackburn with Darwen Cumbria Warrington and Eastern Central Cheshire Sefton Lancashire Central Trafford and Glossop Tameside Lancashire East Oldham Knowsley Leigh and Wigan Ashton, Wirral average North West Salford Bolton Bury and St Helens Halton Blackpool North Lancashire Liverpool Manchester The community leadership PCT role of local government (working with a range of We found great variation in In future, the effectiveness of local partners) provides, the amount being spent on the treatment and the quality of the amongst other key local process of commissioning mental patient experience will become key priorities, the opportunity health services with some PCTs incentives to payments under PbR. spending up to eight times as to focus on the health and To further develop quality much as others (Figure 24). We well-being of the local incentives the North West is have already described a major community, helping people introducing a mechanism focus of resources into specialist to stay mentally well and called ‘Advancing Quality’ services, with only 10 per cent preventing people from (Figure 26). To date there has on primary care and even less on becoming mentally ill. been no development of this prevention or well-being. mechanism in mental health Figure 23 Most mental health services but we believe this should be Local Area Agreements continue to be commissioned addressed as soon as possible. (LAAs) through simple contracts with

limited detail, with the focus One of the LAAs’ main generally on what goes into roles is to provide a formal services (inputs) rather than what mechanism for partners Figure 25 is achieved (outcomes). This to agree local health approach generally fails to provide Payment by Results (PbR) and well-being priorities, incentives for people to improve pooled budgets and is a mechanism to promote services or to achieve outcomes joint measures or targets choice by patients about where which service users value. where appropriate. The their care and treatment is effectiveness of LSPs and Payment by Results (PbR) is a more received. Providers are paid a LAAs is monitored through sophisticated mechanism used standard rate for each episode the Comprehensive in the commissioning of some of treatment – so the more Area Agreement (CAA), health services for physical illness patients they attract the more which also appraises the (Figure 25). The development of they are paid. performance of partners PbR in mental health has lagged www.dh.gov.uk in delivering according to far behind that in other areas. local community priorities. 17 A better future in mind mental health services in the North West Commissioning

Recently there has been more benefits which will result from How can we strengthen of a focus on prevention and wider implementation of practice- commissioning to promotion of positive mental based commissioning. This may be health as a part of the measures especially true in services for those deliver more change? or targets included in LAAs. These with mild to moderate mental There is a widely-held view that include, for example, measuring illness and in helping to drive commissioning for mental health the number of people with mental innovation and flexibility centred needs to improve significantly if health problems returning to paid on the user or carer experience. we are to maximise the benefits of work, and could be extended to The data presented earlier in this pivotal lever for change. include those pursuing education, Figure 6, on page 9, shows that leisure and volunteering, as ways Changes to improve commission- all PCTs need to review the pattern of building purpose into their ing need to impact in a number of of their investment across well- lives. However, as there is no ways: being, prevention and treatment. requirement to include mental The variance in investment • build capacity to deliver the health measures or targets in LAAs, demonstrated in Figure 24 clearly WCC competencies the benefit they deliver is not indicates that further investment consistent across the North West. • develop more integrated in the commissioning process is commissioning We know that setting targets warranted in a number of PCTs. has contributed to improvements However, we believe that the • develop more sophisticated especially in non-mental health impact of such an increase would means of contracting to promote services, as, for instance, with not be maximised if it simply greater effectiveness and positive waiting times for hospital spread more thinly the current user experience. operations and other procedures. limited expertise in mental health commissioning. Most targets in mental health relate to measurements of the Even if PCTs increase their inputs not the outcomes. This is investment in the commissioning clear in crisis resolution and home process to improve their capacity, treatment teams, where targets competence and capability, we relate to the number of teams in believe that it will be difficult Figure 26 place and the number of patients to find sufficient senior and seen but not to the effectiveness experienced people to achieve this Advancing Quality of the intervention or user across 24 organisations. satisfaction. This initiative is intended to improve quality by We believe that the implement- providing rewards for ation of policy on WCC will positive patient experience bring about improvements but and patient-reported we do not see how this alone outcomes as well as clinical will address the issues of service outcomes. marginalisation and lack of senior www.advancingqualitynw. leadership, which have been nhs.uk frequently highlighted to us. We also acknowledge some of the

18 PCT/LA Figure 27 locality Proposed commissioning model

Mental health commissioning team Possible key functions • Leadership/profile and influence PCT/LA • Engagement/influence with service PCT/LA locality locality user/carer development initiative cautious, partner. The proposed • Clinical, social care expertise model is based on a contracting • Analytical input mechanism with individual PCTs • Health economics PCT/LA PCT/LA and their LA partners. Each locality • Development capacity locality local partnership holds its own • Interface with well-being LA role contract with the commissioning • Good practice dissemination team and retains authority to • Regional strategic influence decide on investments and • Market management priorities. and development The commissioning team benefits from the ‘pooling’ of resources and would in our view be able PCT/LA to more effectively discharge the locality competencies outlined in WCC to achieve improved outcomes from the commissioning process. Building capacity This model (Figure 27) is The effect of ‘pooling’ consistent with the FESC. Across commissioning resources the North West, we may see three would be to allow more senior RECOMMENDATION 3 to five such teams being created, leadership in mental health with precise footprints to be commissioning, a clearer focus agreed between PCTs and local of commissioning resources and authorities (LAs). a greater degree of leverage, We recommend the influence and impact across a The aim of this model is to creation of mental more strategic area. However, capitalise on ‘pooling’ resources health commissioning the individual nature of contracts for the commissioning process, teams operating would ensure that local priorities without compromising the across a city region or and goals have to be delivered. statutory accountability of PCTs other wider footprint and LAs or their local aspirations We anticipate that individual and contracted by and priorities. Others in the PCT and LA partners will need individual PCT/LA North West and elsewhere have to retain resources for some partnerships to deliver used models of collaborative elements of the commissioning significant elements commissioning to achieve the process. We feel that flexible of mental health ‘pooling’ of resources. We have working with the commissioning commissioning on heard from many of them that the team would enable them also to their behalf main limitation of this approach is be involved in these elements of (Figure 27). the tendency to promote progress the process to keep the spread of at the pace of the slowest, or most costs to a minimum.

19 A better future in mind mental health services in the North West Commissioning

Developing more integrated commissioning

We also recognise that there We believe that the new model the public should be involved in are locally-sensitive issues such for commissioning would enhance service design, development and as the delivery of the well-being integrated commissioning between monitoring. Whilst the benefits agenda, service user and public local partner organisations as they to integration outlined above involvement and practice-based develop clarity on their objectives stem from our revised model for commissioning. Capacity would and resources as part of the commissioning, we recognise have to exist either at local contracting process. that there also needs to be or commissioning team level further development of the role We recognise the need to further with flexibility to use either of communities and the public develop the capability of the NHS mechanism in different areas in securing improvements to to work with other bodies across according to local discretion. people’s mental well-being. PCTs, government departments on LAs and proposed mental health This smaller number of mutually-important areas such as commissioning teams will all need commissioning teams would recovery, access to employment to work closely with practice- also find it easier to coordinate and training opportunities, benefits based commissioning teams to commissioning activity across and criminal justice support and ensure local issues and feedback the North West for some rehabilitation. are prioritised and innovation specialist services and assist We believe that more focused encouraged. in reducing out-of-area commissioning processes would placements. We have been impressed by be better placed to facilitate some the potential of models such as More effective market areas of work between PCTs, LAs Turning Point’s ‘Connected Care’ development and management and other agencies to develop currently being implemented in could be facilitated by fewer more concerted approaches Bolton and delivering a bottom-up, commissioning teams, and this to these challenging issues. In community-designed approach to new configuration could also many cases, the support required more integrated commissioning provide better opportunities should be led by other agencies, (Figure 28). to promote innovation and using the vehicle of LSPs and disseminate good practice. It LAAs as described earlier in the could also serve to facilitate a report. Whilst some of this is best clearer development structure developed locally, some would RECOMMENDATION 4 and career progression for benefit from a wider approach. people involved in mental Strengthened commissioning health commissioning. needs to work more closely with We recommend service users, carers and the further investigation public, in order to be more explicit and implementation about the wider outcomes valued of models like by people. This smaller number ‘Connected Care’ as a of teams could operate more means of developing effectively with the proposed more community- engagement initiatives highlighted centred and integrated in Recommendations 1 and commissioning for 2, to develop new means by health and well-being. which service users, carers and

20 Developing more sophisticated mechanisms for driving service improvement

We have highlighted that We have also recognised mechanisms for contracting the positive work being RECOMMENDATION 7 mental health services taken forward in some local have not developed in as partnerships to develop sophisticated a way as in measures and targets in We recommend some other health areas and LAAs in support of the that commissioners, that this in turn has hampered well-being and prevention working with other change. agenda. agency partners, One of the deficits is in the We recognise the develop and implement development and application importance of purposeful more measures of measurements of service activity to everyone, whether and targets that user and carer experience. as a means of helping them promote paid work, Another is the ability to define to stay healthy, preventing education, leisure and measure outcomes which them from becoming ill or and volunteering in are important to service users helping them to recover, support of well-being, and carers. and we would encourage illness prevention and agencies to work together recovery for those to promote this aspect in experiencing mental RECOMMENDATION 5 people’s lives. illness.

We recommend RECOMMENDATION 6 a programme of work Figure 28 in conjunction with service users and Connected Care We recommend carers to develop and Turning Point’s ‘Connected Care’ model the wider use by implement more service is currently being implemented in commissioners across user and carer-defined Bolton and Hartlepool and delivering the North West of the measures of outcome a bottom-up, community-designed measures of recovery and experience as approach to improvement of health, developed and in use part of the Advancing housing and social care services. This in the Mental Health Quality initiative. model takes the expressed needs of Centre of Denver, USA. people living in the local community www.reachingrecovery. as its starting point, and invests org considerable time and resources in Development of these measures communicating and engaging with should be greatly aided by them. When those needs have been the existence of the service identified, the local community is user and carer engagement supported to design and deliver development initiative and solutions using multi-agency resources. their implementation should www.turning-point.co.uk be supported by the new commissioning model.

21 A better future in mind mental health services in the North West Investment

Investment

The budget for the NHS in the weighted head of working age even after allowing for local North West is now around £12 population – £14 per person variations of need. We accept billion a year, of which just over below the national average. that levels of spending do not £1.5 billion (12.1 per cent) is The other source showed all give any indication of whether spent on mental health services. NHS spending on mental health the money spent is being used Nationally, since 2001, there (excluding substance misuse) per efficiently or effectively. As we has been a 38 per cent increase weighted head of population in have already highlighted there is in spending on mental health the North West to be £6 below little or no data about outcomes services for adults of working the national average. Not all and therefore the relative value age and in the North West PCTs were spending less than derived from different levels of an increase of 46 per cent. average. However, both sets investment can not be gauged. However, the North West still of figures indicated that the However, there can be little lags behind. amount required to bring the doubt that in the many PCTs (16) North West’s lower-spending that are spending less than the There are at least two national PCTs up to the national average national average, an increase sources of information on mental would be approximately £100 to the weighted average would health spending (Mental Health million a year. represent a significant additional Strategies and Programme investment in mental health. In Budgeting), although these Figure 29 demonstrates the one PCT the additional amount are not entirely consistent. variability of investment in would be as much as £15 million According to Mental Health mental health across the PCTs whilst in another nine PCTs it Strategies, the North West in the North West with a 75 per would be £5 million or more. region in 2006/07 spent the cent difference between the second-lowest amount per lowest and highest spenders,

Figure 29 PCT spending on mental health in 2006/07 per weighted head of population £200 Source: Programme budgeting, excluding substance abuse £193 £182 £175 £181 £173 £173 £161

NATIONAL AVERAGE £153 £153

£150 £150 £147 £147 Manchester Cumbria £145 Knowsley £142 £142 £137 £134 £132 £127 £125 £126 Salford Liverpool £123 £122 £121 £121 Sefton £118 £116 £112 Wirral Blackpool Trafford North Lancashire Oldham

£100 Bury Central Lancashire Central 0 Bolton Bolton West Cheshire West Warrington 0 0 0 0 Stockport Stockport

£75 0 0 0 0 0 North West average North West 0 0 Tameside & Glossop Tameside 0 0 0 0 0 0 0 0 0 0 0 £50 0 Halton and St Helens Halton East Lancashire Lancashire East Blackburn with Darwen Ashton, Leigh and Wigan Ashton, Central and Eastern Cheshire and Eastern Central Heywood, Middleton and Rochdale Middleton Heywood,

22 How can we change patterns of investment?

We are in no doubt that some We have already highlighted We believe that there are further PCTs need to increase their that most NHS resources are efficiencies to be achieved in investment in mental health if committed to treating those mental illness services and that the required improvements are with severe and enduring mental a more-focused approach to to be made. Better information illness and that relatively little commissioning would help to on investment levels should is invested in mild to moderate achieve this. However, there also be available more widely to problems, prevention or are also significant deficits in allow greater accountability by promoting better mental health. some mental illness services PCTs to their populations. and simply withdrawing money The national survey of from efficiencies made in More-empowered service users, investment in mental health these services could act as a carers and the general public services commissioned by the disincentive to the improvements would be able to play a much DH showed investment in needed in service quality. more active role in holding the illness prevention or well-being PCTs to account for their levels indicates 0.1 per cent being As a general principle we think of investment. The proposed committed to these areas whilst that efficiencies here should new commissioning model our North West survey showed be reinvested to support the should also enable a more- this to be 0.2 per cent (Figure 6, improving quality agenda. We focused approach to deliver on page 9). Across PCTs in the recognise that in those PCTs greater value for money. North West, we found a range that are already investing at, or from 8p to £1.40 per head on above, the national average, this However, to facilitate this well-being and prevention, with may not be possible. process and to enhance the spending overall from £88 to ability to hold PCTs to account In some areas, a proportion £200 per head. for levels of investment, it will be of any additional investment necessary to ensure that simple, Greater investment is required will be required to support the clear, financially transparent and at this end of the spectrum to quality of services to those who consistent data on spending is improve mental health and to are ill, but a significant focus made widely available. lower the personal and societal for new resources should be to costs of mental illness and poor support the prevention and well- mental health. being agendas. Strengthened RECOMMENDATION 8 integrated commissioning should help to achieve this. RECOMMENDATION We recommend 9 that financially transparent comparative We recommend information on levels that commissioners of investment by PCTs critically review on well-being, mental their expenditure on health prevention, and well-being, illness mental illness treatment, prevention and including recovery, be recovery, to ensure that made publicly available they are maximising to ensure greater the opportunity to accountability for lower the personal and investment choices. societal costs of mental illness and poor mental health.

23 A better future in mind mental health services in the North West Developing staff

Developing staff How can we enable staff to deliver better services?

In our presentation of long- We believe that most of the people with personal experience standing problems we highlighted policy and guidance relating to of mental illness and would offer the challenge of staff attitudes and workforce development is very greater opportunities to support working practices for the range, positive and there is much to service users in a return to paid nature and quality of services which agree with. However, the desired employment built upon their are offered in both primary and outcomes of much of this policy experiences. We also believe secondary care. and guidance are not built into that service users and carers commissioning plans or service have more of a role to play in The problems in this area have outcome measures. The tendency the appointment of staff and been recognised in many policy and therefore is for these policies the ongoing assessment of their guidance documents from national to be readily adopted by those capability and competence. to local level. who need them least and easily In 2005 and 2007, the DH avoided by those who need them published documents entitled New most. Ways of Working to highlight ways We therefore believe that the in which staff needed to work RECOMMENDATION 10 success of workforce policy as differently to support new service a means of improving quality models. Delivering Race Equality in is directly linked to our earlier Mental Health published by the DH We recommend recommendations about the in 2005 highlighted issues such as that paid roles which effectiveness of commissioning. stigma and discrimination. value the service In short, if commissioners user experience The need to offer a wider range required services to deliver more are developed and of support beyond clinical services outcomes valued by service users implemented more has also been well recognised and carers, providers would then widely and that service in national policy, including need to adjust the make up and Our Health, Our Care, Our Say practices of their workforce to users and carers are particularly in relation to social care, deliver these. more involved in the prevention, well-being and positive appointment of staff Strengthened commissioning physical and mental health. The and the on-going needs to be explicit about strengths-based recovery model assessment of their the outcomes required of a for mental health services also competence and strengths-based recovery model, recognises this need. capability. including employment and The impact of policy in all these education. The role of providers areas has been limited by the lack is to work with service users and of an effective means of driving carers to determine what type of it forward and then measuring workforce is required to produce its success. Again the focus has these agreed outcomes. been largely on inputs, such as This focus would also serve to workforce numbers, rather than the promote the development of new effect these new roles have had on paid roles such a peer mentors, service users’ experience. that value the contribution of

24 Institutional and professional“ attitudes and practices that stigmatise people During our review we have Earlier in this report we quoted with mental health met and heard of many staff the words of a service user problems, still across all organisations who are who told us: “I didn’t feel pose a significant working hard to try to deliver a welcome when I went to personalised and individual service hospital. It seemed as if I was challenge across to service users and carers. a nuisance.” the mental health However, we have also received Whilst we have only selected community. frequent feedback from staff, this one quote, it represents the service users and carers, that sentiment of many comments ” institutional and professional made during our review. We attitudes and practices that have already highlighted that stigmatise people with mental many staff feel pressured by health problems still pose a their working environment and significant challenge across the the challenges they face. mental health community. The attitudes described to us In a recent study carried out by can in our view often result from Rethink called ‘Stigma Shout’, working with distressed people health professionals were who often have complex needs identified by service users and in difficult settings. carers as one of the main groups whose attitudes, if inappropriate, had serious implications for them. RECOMMENDATION 12

RECOMMENDATION 11 We recommend investing more in the development, We recommend training, supervision that the recently- and coaching of staff, launched ‘Time to to better enable them Change’ campaign is to deliver strengths- used by mental health based approaches to service providers as an recovery. opportunity to work with staff to challenge attitudes and practices and further promote new ways of thinking and working. www.time-to-change. co.uk

25 A better future in mind mental health services in the North West Conclusion

Conclusion

This report has been developed address these problems and doing things with innovations following a year-long have sought to identify why from within the North West programme of engagement, they have not been able to and around the world. The discussion, debate and analysis bring about the expected challenge is to ensure that with stakeholders across the improvements more quickly. the best is available more mental health community in the consistently across the North We found that the engagement North West. West. of service users, carers and the Our extensive engagement public in decisions about the We believe that our recommend- programme identified design, delivery and evaluation ations, if implemented, will that, whilst there has been of services is not as well better harness and focus the commendable progress, in developed as it needs to be. enthusiasm and commitment some areas and on some evident across the North West to Commissioning – one of the key issues a number of long- ensure that this challenge is met. mechanisms for improvement standing problems remain. in the NHS – is not functioning These problems are causing effectively in many places. We great difficulties for the many found that levels of investment thousands of people who use, in mental health services are or care for someone who uses, varied and that some PCTs in mental health services. the North West lag behind the We found that some important national average by considerable services are not always available amounts. or accessible and that there is a We also found that staff often significant variance in the quality struggled to provide care and of services across the North support in partnership with West. service users and carers based Investment has been focused on on a strengths-based recovery treating people with a serious model. People often described The challenge and long-standing mental feeling ‘done to’ rather than “ illness, with relatively little ‘worked with’. is to ensure being invested on those with We have made a set of that the best is mild to moderate difficulties, recommendations which we available more on preventing illness or helping believe will strengthen the people to stay mentally well. consistently mechanisms for engaging Problems with staff attitudes service users, carers and across the and working practices were also communities, strengthen raised. North West. commissioning and develop the We looked at the mechanisms workforce. which the NHS and other We have seen some different ” agencies have been using to and more successful ways of

26 Summary of recommendations

RECOMMENDATION 1 RECOMMENDATION 5 RECOMMENDATION 9 We recommend the We recommend a We recommend that strategic health authority uses programme of work in commissioners critically review its leadership and influence conjunction with service users their expenditure on well-being, to create a cross-agency and carers to develop and illness prevention and recovery, programme to support and implement more service user to ensure that they are scrutinise significant performance and carer-defined measures maximising the opportunity to improvements in service user, of outcome and experience as lower the personal and societal carer and public engagement part of the Advancing Quality costs of mental illness and in mental health. This should initiative. poor mental health. directly address the known organisational, managerial, RECOMMENDATION 6 RECOMMENDATION 10 professional and cultural barriers to effective engagement. We recommend the We recommend that wider use by commissioners paid roles which value the service RECOMMENDATION 2 across the North West of the user experience are developed measures of recovery developed and implemented more widely We recommend the and in use in the Mental Health and that service users and strategic health authority uses Centre of Denver, USA. carers are more involved in the its leadership and influence appointment of staff and the to support the North West RECOMMENDATION 7 on-going assessment of their NHS and other partners to competence and capability. establish a service user and We recommend that carer engagement development commissioners, working with RECOMMENDATION 11 initiative. This should enable other agency partners, develop service users, carers and and implement more measures We recommend that communities to participate and targets that promote paid the recently launched ‘Time to effectively as equal partners work, education, leisure and Change’ campaign is used by in the design, delivery and volunteering in support of well- mental health service providers evaluation of services. being, illness prevention and as an opportunity to work with recovery for those experiencing staff to challenge attitudes and RECOMMENDATION 3 mental illness. practices and further promote We recommend the new ways of thinking and working. creation of mental health RECOMMENDATION 8 commissioning teams operating across a city region or other We recommend that RECOMMENDATION 12 wider footprint and contracted financially-transparent, We recommend by individual PCT and LA comparative information on investing more in the partnerships to deliver significant levels of investment by PCTs development, training elements of mental health on well-being, mental health supervision and coaching of commissioning on their behalf. prevention, and mental illness treatment (including recovery) staff, to better enable them to deliver strengths-based RECOMMENDATION 4 be made publicly available to ensure greater accountability for approaches to recovery. We recommend further investment choices. investigation and implementation of models like ‘Connected Care’ as a means of developing more community-centred and integrated commissioning for health and well-being. 27 A better future in mind mental health services in the North West Published by NHS North West October 2008

NHS North West Gateway House Piccadilly South Manchester M60 7LP 0845 050 0194 www.northwest.nhs.uk

An electronic version of this report with active internet links is available at: www.northwest.nhs.uk/projects/mental_health_commission/

This webpage will also direct you to additional information, reports and references cited in this report.

Design: GM Design 0161-748-3072 [email protected] Print: The Studio 0161-793 7377 www.thestudio.co.uk Printed on Nine Lives 80 recycled paper