<p> APPENDIX 1 – COMMISSIONING INTENTIONS, OUTCOMES & ACTIONS</p><p>Identified outcomes are consistent with, and complement, the anticipated outcomes in the No health without mental health: implementation framework and, as well as being informed by local performance data collection, outcomes will also be measured from data collected via the Adults Social Care Outcomes Framework, Public Heath Outcomes Framework and NHS Outcomes Framework. </p><p>While these indicators are likely to change over the lifetime of this plan, the indicators in the table below, which were applicable in 2013, give an example of the type of indicators which may be used to measure outcomes </p><p>Adults Social Care Outcomes Framework 1A: Social care-related quality of life 1B: The proportion of people who use services who have control over their daily life 1C: Proportion of people using social care who receive self-directed support, and those receiving direct payments 1D: Carer-reported quality of life 1F: Proportion of adults in contact with secondary mental health services in paid employment 1H: Proportion of adults in contact with secondary mental health services who live independently, with or without support 2A: Permanent admissions to residential and nursing care homes, per 100,000 population 2B: Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services 2C: Delayed transfers of care from hospital, and those which are attributable to adult social care 3A: Overall satisfaction of people who use services with their care and support 3B: Overall satisfaction of carers with social services 3C: The proportion of carers who report that they have been included or consulted in discussion about the person they care for 3D: The proportion of people who use services and carers who find it easy to find information about services 4A: The proportion of people who use services who feel safe 4B: The proportion of people who use services who say that those services have made them feel safe and secure Public Heath Outcomes Framework 1.6 People with mental illness and/or disability in settled accommodation 1.7 People in prison who have a mental illness or significant mental illness 1.8 Older person’s perception of community safety 2.9 Emotional wellbeing of looked after children 2.10 Hospital admissions as a result of self harm 2.23 Self reported wellbeing 4.9 Excess under 75 mortality in adults with serious mental illness 4.10 Suicide</p><p>1 4.11 Emergency readmissions within 30 days of discharge from hospital 4.13 Health related quality of life for older people 4.16 Dementia and its impacts NHS Outcomes Framework 1.5 Reducing premature death in people with serious mental illness 2.4 Enhanced quality of life for carers 2.5 Enhancing quality of life for people with mental illness 2.6 Enhancing quality of life for people with dementia 4a Patient experience of primary care 4b Patient experience of hospital care 4.7 Improving experience of health care for people with mental illness</p><p>2 PUBLIC HEALTH</p><p>In 2011 NHS Salford and Salford City Council published the Mental Wellbeing Strategy for Salford (2011 to 2015). The strategy identifies a number of key priorities to improve public mental health in Salford, detailed below are specific commissioning intentions and key actions for consideration to support both the Salford Mental Wellbeing Strategy and also the wider vision for services outlined in this commissioning plan.</p><p>Commissioning Anticipated Outcomes Rationale Intention To improve the  Positively influence  The Salford Mental Well-Being Strategy (2011 to 2015) highlights the emotional and mental individuals health and significant importance of mental ill health in Salford, stating: wellbeing of the wellbeing “the scale of the problem is so great, the potential benefits from population of Salford prevention are correspondingly large, improving our population’s mental ill over the life-time of  Integrated working resulting health will have a wider impact on physical health, improved educational this commissioning in a more coherent and attainment, quality of life and reduced sickness and unemployment” plan – with a specific consistent response  Mental health promotion, prevention and early intervention are intrinsic to this and key focus on commissioning plan and other key local strategies in Salford (e.g. Salford’s health promotion, Sustainable Community Strategy 2009-2024) prevention and early  Salford has been a ‘champion’ for the development of public health and the intervention development of non-medical approaches to emotional and well-being (e.g. social prescribing)  Moreover, there is a commitment in Salford to further develop these approaches as part of the public health agenda.</p><p>3 PRIMARY CARE</p><p>Commissioning Anticipated Outcomes Rationale Intention To improve  Improved and more timely  GPs were largely felt to have good access to specialist mental health partnership working referral pathways services in Salford. However, some key issues were identified, including: between primary care and secondary care  Improved communication  The need for access to specialist advice in CMHTs when GPs are services – ensuring across services resulting in considering making a referral to specialist mental health services expedient access to an increase in appropriate  The need to ensure that information on any changes made to mental services that are referrals health services and care pathways in Salford are clearly communicated responsive to the to GPs and primary care staff needs of service  Improved patient experience  A desire to develop approaches to providing mental health services users and GPs of community mental health directly into GP practices. services</p><p> Improved partnership working to support early intervention </p><p>4 FUNCTIONAL MENTAL ILLNESS</p><p>Commissioning Anticipated Outcomes Rationale Intention To continue to  More people have access to  Six degrees provides low intensity IAPT services in Salford, with: improve access to evidence based treatments  Low waiting times (3 weeks) psychological therapy services in Salford for  More choice regarding  Good recovery rates (>40%) all client groups treatment options  In the 2011 National Mental Health Strategy ‘No Health without Mental Health’ announced plans to invest £400 million to further develop and  More integrated approach improve psychological therapies - including provision for children and young resulting in a smoother people and older age adults. transition and patient  Nationally only 4% of people accessing IAPT services are aged >65. The experience national target is 12%.  Within the stakeholder engagement a need to review access to psychological therapy services for older age adults was identified – following the reconfiguration of services to implement ‘ageless’ functional CMHTs in Salford.  Demand for psychological therapy services is expected to increase over the life-time of this commissioning plan.  Meeting high and rising demand for psychological therapy services within resources will require new approaches and interventions.  There are key targets to achieve by 2014/15 including:  15% of population prevalence for anxiety/depression to enter treatment (for Salford that equates to circa 5500 people)  50% of all people who receive treatment to enter recovery To support more  More people living  A key focus of the national mental health QIPP programme is on the mental people with mental independently health acute care pathway – reducing admissions and lengths of stay. health problems to  Previous projects identified Salford as having above average length of stay – remain at home and  More people being although significant work has now been undertaken to address this</p><p>5 to return home more repatriated back to Salford  Delayed discharges are also identified as a key issue in Salford. This is quickly where thought to often be related to access to mental health supported inpatient admissions  Reduction in length of stay in accommodation do occur acute inpatient services  This commissioning intention supports wider national and local objectives to treat people closer to home and fits with other key programmes of work and  Reduction in readmissions to service re-design in Salford (see opposite). acute inpatient services</p><p>Personality Disorder Services and Services for Mentally Disordered Offenders</p><p>Commissioning Anticipated Outcomes Rationale Intention Agree and implement  More people with  The existing service models in Salford for personality disorders and services new service model Personality Disorders for MDOs are currently being reviewed for the treatment and supported appropriately  It is hoped and anticipated that re-modelling of both services will support wider management of commissioning intentions to reduce both acute mental health inpatient people with  Improved cross sector admissions and ‘revolving door’ A&E admissions at Salford Royal Hospital. personality disorders working and joined up responses </p><p> Reduction in bed occupancy Develop improved  Improved diversion and support for Mentally liaison of people with Disordered Offenders mental health problems (MDOs) from the Criminal Justice System</p><p> Improved cross sector working and joined up responses </p><p>6 Inter-face with Drug and Alcohol Services</p><p>Commissioning Anticipated Outcomes Rationale Intention Improve pathways  Improved pathways for  Patients with a dual diagnosis are currently either managed by one of the three around treatment and service users functional CMHTs or by the drug and alcohol team management for  Within the pilot 20-30 ‘complex cases’ with a dual diagnosis will be identified service users with  Integrated working and intensively case managed dual diagnosis and resulting in a more  It is hoped and anticipated that the service pilot will reduce A&E admissions at partnership working coherent and consistent Salford Royal and acute mental health inpatient admissions (at Meadowbrook) between mental response  This service model of intensive case management, if successful, could be used health and drug and with other client groups . alcohol services in  Improved management of  The co-morbidity of mental ill health with drug and alcohol problems are well Salford mental health and drug reported . and alcohol problems  This commissioning intention to improve partnership working between services links to our wider commissioning intentions to improve integration and  Reduction in A&E partnership working across all services. admissions</p><p>7 ORGANIC MENTAL ILLNESS</p><p>This section of the report details commissioning intentions that we have developed for organic mental disorders. In parallel to this NHS Salford and Salford City Council have developed an action plan for dementia services in Salford. The action plan maps and identifies progress against the 17 key objectives outlined in the National Dementia Strategy – with a key focus on information, awareness, and early diagnosis and support. The commissioning intentions detailed in this section of the plan are intended to support and compliment the Salford Dementia Action Plan.</p><p>Commissioning Anticipated Outcomes Rationale Intention Increase the capacity  More people receiving a  General Practitioners will be required to identify and assess patients with of the Salford formal memory memory/cognitive problems and refer as appropriate. Memory Assessment assessment.  High and rising demand for services locally – with over 100 new referrals per Service (MATs) in month to the MATs accordance with local  Improved identification and  The existing MATs is at capacity prevalence estimates diagnosis rates and national policy  Expansion of the MATs meets with local priorities and national priorities to guidance to improve  Integrated working provide early diagnosis and supports long-term commissioning intentions to pre and post- resulting in a more support more people to remain at home (reducing the use of inpatient and diagnostic support for coherent and consistent residential care). people with dementia response  Pre and post diagnostic support for dementia was identified a significant gap in in Salford current service provision in Salford (particularly for carers)  Earlier intervention  It was also identified as a key issue for those with vascular dementia (that are not on medication)  Improving pre and post diagnostic support for dementia links with the planned expansion of the MATs and provides good opportunities to work in partnership with the Dementia Support Service provided by Age UK Salford. Improve the quality  Improving the quality of dementia care in acute hospitals is a key priority in the and provision of National Dementia Strategy dementia services at  Evidence suggests that people with dementia stay longer in acute hospitals Salford Royal NHS</p><p>8 FT  Dementia is a CQUIN target at Salford Royal NHS FT and is part of their Quality Accounts  Significant progress has been made in improving dementia services at Salford Royal in the last 12 months – but with significant opportunities for further improvement  A National Dementia Audit has identified priorities for service improvement at Salford Royal that this commissioning plan should work towards achieving.  Identified need to improve dementia support services for patients post discharge from Salford Royal and ‘frequent flyers’ coming through A&E (including those that are not admitted).</p><p>9 TRANSITIONS TO ADULT MENTAL HEALTH SERVICES</p><p>Commissioning intentions for CAMHS in Salford are fully outlined in the (draft) ‘Emotional Health and Wellbeing Strategy for Children and Young People in Salford 2012-15’ (currently being developed by NHS Salford and Salford Council). The primary focus of this commissioning plan (as previously documented) is on adult mental health services. Detailed below, however, are specific commissioning intentions for children and young people with mental health problems that are in transition to adult mental health services (AMHS). </p><p>Commissioning Anticipated Outcomes Rationale Intention Ensure the provision  Improved patient  The national configuration of mental health services creates gaps through of high quality and experience of transition which young people can fall as they move from CAMHS to AMHS integrated mental  Commissioning effective transitions services should lead to reduced numbers health services for  Improved parent/carer of young people lost to services at this critical time and reduced periods of children and young experience untreated illness (eg. Self harm) people in transition to adult mental health  Integrated working  This should, in turn, lead to reduced morbidity, thus reducing downstream services) resulting in a more service demand on adult services coherent and consistent  Policy guidance has recently been published for children and young in response transition to adult mental health services.  Earlier intervention  Commissioning reflects implications of the Children and Families Bill (Health/Social Care/Education Plans will be upto the age of 25 yrs).</p><p>10 DEVELOPMENT OF REHABILITATION & RECOVERY SERVICES AND MANAGEMENT OF OUT OF AREA PLACEMENTS</p><p>Commissioning Anticipated Outcomes Rationale Intention To provide high  Fewer people supported  Out of area placements is a key part of the mental health Quality Innovation quality rehabilitation out of area Productivity and Prevention (QIPP) programme and recovery access  Key national policy drivers are focussed on treating patients close to home to services as close  Improved rehabilitation  This commissioning intention builds upon existing work that is currently being to home as possible pathway undertaken in Salford to develop local services to reduce out of area for mental health placements, including: service users in  Reduced length of stay  Improved case management – with the development of a multi-disciplinary Salford – with low rehab team reviewing existing out of area placements numbers of patients  Reduced readmissions  Development of new mental health rehab beds in Salford (at Meadowbrook) to placed in services repatriate patients back in area outside of Salford  Improved clarity and  Mental health supported accommodation is currently being reviewed to provide consistency regarding seamless and integrated care pathways in Salford placements  Work to date has focussed on reviewing NHS and joint funded placements.  Greater Manchester West NHS FT has responsibility for managing the funding for Council placements under the Section 75 Agreement </p><p>11 SOCIAL CARE</p><p>Commissioning Anticipated Outcomes Rationale Intention To continue to  Improved patient  Salford City Council is in the process of producing its Market Position develop approaches experience of community Statement which will set out its understanding of social care need, service to personalisation in mental health services patterns and other responses across the city. Over time it will become a vital Salford – ensuring reference point for all those who playa part in social care in Salford choice for mental  Integrated working health service users resulting in a more  In the stakeholder engagement it was identified that some staff working in the coherent and consistent response integrated health and social care teams have a lack of training and knowledge in mental health  Improved and more timely and personalised referral  Because of this it was felt that (in some instances) specialist mental health pathways services do not become involved in patient care until the point of crisis – which could be avoided through earlier intervention.  Improved communication across services resulting in  Although it was reported that some of the integrated teams have built up good an increase in appropriate relationships with mental health services – it was felt that this has been largely referrals driven through individuals and relationships not formalised processes. </p><p> Greater choice and control  Further key barriers to health and social care integration are information for service users systems and information sharing  Patient data is collected on separate information systems for health and social care (Health care data is collected on ‘ICIS’, social care data on ‘Care First’)  This creates significant challenges in respect of information sharing and reporting.  Improving access to personal budgets and direct payments is a key priority across health and social care services in Salford</p><p>12  Within the stakeholder consultation key challenges in implementing personalisation in mental health services were identified  Central to this was felt to be the need for a clearly defined re-ablement pathway for mental health service users in Salford  A review of how GMW NHS FT discharges their social care functions under the Section 75 Partnership Agreement is required.</p><p>13 INCLUSIVE COMMUNITIES: LIVING, WORKING & LEARNING </p><p>Commissioning Anticipated Outcomes Rationale Intention</p><p>14 Improve access to  Greater choice and control  Services will be re-specified to ensure that the outcomes required are housing and support for service users focused on recovery and personalisation. for people in Salford  The service will be developed in a way that clearly places it on a recovery with mental health  Improved pathway pathway from acute and specialist provision through to ordinary needs (specifically resulting in a more timely accommodation supported by outreach/floating support, commissioned by including people who and personalised service the local authority or through personal budgets and direct payments. are homeless)  The service will also be accessible to people who are experiencing crisis to  Reduced length of stay avoid admission into inpatient provision.  Expedient access to high quality housing for mental health service users is  Quicker discharge from a vital part of our wider commissioning intentions to provide integrated and hospital seamless mental health care pathways  Access to housing is a key issue for many people in Salford with mental  Integrated working health needs – particularly the homeless and those in criminal justice resulting in a more services coherent and consistent  Housing in Salford has recently been moved into the adult social care response directorate – providing opportunities to improve links between housing and health and social care services.  Work is currently being undertaken locally to specify a housing pathway for mental health  Housing providers identified a lack of information on whether tenants have a mental health disorder and the services that they are accessing / receiving  Consequently tenants were (in some instances) reported not to get access to the range of support that may help to avert a crisis and / or support them to remain in their tenancy.  It is reported that clients can sometimes find it extremely difficult to get a housing placement after eviction from a tenancy. Improve  Promotes recovery and  Employment is an integral part of recovery from mental ill health. employment,  There are very large (and growing) numbers of people with a mental illness volunteering and aids rehabilitation who are unemployed, yet most want to work learning  Leads to better health  Reforms to the welfare system are a key concern for vulnerable groups </p><p>15 opportunities for outcomes (including mental health service users) people with mental  Problems with finances / debt can be a key precipitating factor in causing health problems  Minimises the harmful mental ill health and / or a crisis effects of long-term sickness absence  Improves quality of life and wellbeing  Reduces social exclusion and poverty</p><p>MENTAL HEALTH AND PHYSICAL HEALTH SERVICES</p><p>Commissioning Anticipated Outcomes Rationale</p><p>16 Intention To develop and  Greater Manchester West NHS FT currently provide a psychiatric liaison improve the provision  Quicker discharge from service at Salford Royal NHS Foundation Trust of Mental Health hospital  A business case for an enhanced psychiatric liaison service at Salford Royal Liaison services at NHS FT has been developed by GMW NHS FT Salford Royal NHS  Reduction in readmissions  Mental health commissioners in Salford have identified a key priority to shape Foundation Trust the local development of psychiatric liaison services to ensure that the service over the lifetime of  Reduction in bed number model meets local needs. this commissioning days  Considerable work has been undertaken regarding physical health checks in plan Salford and this has been a CQuIN target for GMW for the past two years To ensure that the  Reduction in length of stay physical health needs of people with mental  Improved physical health health needs are outcomes being checked and addressed</p><p>THE VOLUNTARY SECTOR</p><p>17 Commissioning Anticipated Outcomes Rationale Intention To support the role of  Improved capacity in the  Both nationally and locally in Salford the voluntary sector plays a vital role in voluntary sector voluntary sector the provision of mental health services providers in mental  However, current financial stringencies in health and social care services have health services in  Increase in volunteering for severely impacted on voluntary sector providers throughout England Salford service users  In Salford we recognise the significant importance of services provided by the voluntary sector and we are committed to continuing to support the voluntary  Improved pathways in sector over the life-time of the commissioning plan work  This commissioning intention supports our wider strategic objectives to:  Improve access to services for hard to reach groups  Increase in the proportion  Promote emotional resilience and improve mental health and wellbeing in of adults in contact with Salford mental health services in  Manage the growing demand for secondary care mental health services paid employment  Provide service users with access to a range of services that meet their individual needs  Ensure an asset based approach to commissioning – building upon existing strengths of services</p><p>SERVICE USERS</p><p>18 Commissioning Anticipated Outcomes Rationale Intention Develop strategies to  Improved engagement  There are excellent existing processes for service user engagement in Salford improve engagement resulting in a clearer that can be built upon and developed with a wider range of ‘voice’ of service users in  However, current processes are felt to focus heavily on: mental health service the commissioning process  Users of secondary care services (with more limited feedback from primary users – including care) hard to reach and  More representative  A small cohort of service users – which does not ensure a ‘representative’ black and minority engagement view from mental health service users. ethnic groups, LGBT  This commissioning intention supports our wider commissioning objectives to Communities,  More service users empower and enable mental health service users in Salford – supporting them offenders, military involved in planning priority to access services in mainstream community settings. veterans, travellers setting and commissioning communities, young people leaving care  Increase in service user and young people on led groups and Education/Social organisations, giving Care/Health Plans. greater control to service users </p><p>CARERS</p><p>19 Commissioning Anticipated Outcomes Rationale Intention Ensure that the  Improved quality of life for  Nationally the emotional and mental health needs of carers are often not fully emotional and mental carers recognised and consequently they do not access the mental health services wellbeing needs of they require (particularly young carers) carers are met and  Improved understanding of  Failure to access services can result in a crisis for either carers themselves or that they themselves the needs of carers those that they care for can access mental  Carers needs to be recognised as an essential and cost-effective resource that health services when  More carers feeling involved support service users. required in the care and support  Some carers would like the opportunity to use personal budgets more flexibly planning for the person they to give them a break on a more routine basis (i.e. every week / month) care for  The use of carers personal budgets is currently being reviewed in Salford</p><p>COMMISSIONING SYSTEMS AND PROCESSES</p><p>20 Commissioning Anticipated Outcomes Rationale Intention Explore opportunities  More cost effective use of  High cost – low volume specialist mental health services can be difficult to for collaborative resources commission at a local level commissioning of  This presents opportunities for collaborative commissioning of services across mental health  More consistent clusters of PCTs / CCGs and local authorities. These services could include services with other approaches and responses  Aspergers neighbouring CCGs across a wider footprint  Eating disorders and local authorities  Services for MDOs – particularly services  Step down from secure services for those with  Rehab services specialist needs  Challenging behaviour and dementia  Early onset dementia  The new cluster wide commissioning structures in Greater Manchester provides opportunities for collaborative commissioning of services (particularly and high cost – low volume services). Review the impact of  Improved understanding of  The need for cost-improvement programmes are likely to be ongoing over the any service any impact of service life-time of this plan reconfigurations and redesign  The recent reconfiguration of services to implement ‘ageless’ functional cost-improvement CMHTs has highlighted a need to review the impact of this service programmes that are  Maintaining an oversight of reconfiguration on access to services for older age adults. implemented over the service change and life-time of this development commissioning plan</p><p>21</p>