This is a brief running order for this item:

·        Introductions (10 minutes)

·        History: scene setting (10 minutes)

·        Relationships and joint working (15 minutes)

·        Community concerns (20 minutes)

·        Primary mental health care (20 minutes)

·        Mental Health facilities in the borough (secondary care) (30 minutes)

·        Personalisation and recovery (secondary care) (20 minutes)

·        Findings, resolutions, recommendations and information requests (10 minutes)

 

Papers attached include:

 

Page No:	Title
9-14 15-20 21-30 31-46 47-48 49-60 61-64 65-116	Background briefing on mental health: who does what? Background Information – Mental Health Commissioning Service Provision Paper App 1 - Sutton Mental Health Action Plan App 2 - Sutton and Merton Interim Organisation Chart App 3 - Sutton Day Services Sutton Mental Health Foundation Background papers only

 

Expert witnesses:

Judy Wilson Chief Executive, SWLSTG MHT

Mark Clenaghan – Borough Director - SWLSTG MHT

Gill Moore, General Manager, Adult Community Services - SWLSTG MHT

Stuart Adams, Consultant Psychiatrist - SWLSTG MHT

Alison Beck, Associate Director for Psychology & Psychotherapies - SWLSTG MHT

Marion Ruttley – Previous Wallington Resource Centre Action Group

Bob Mayfield and Marilyn Burbage – Cheam Resource Centre Action Group

Ken Fish – Carers Action Group

Adrian Davey – Asst Director - S&MPCT

Stephen Evans – S&MPCT

David Jones – LINK (Sutton MH Foundation)

Adi Cooper – Strategic Director, ASSH

Shaun O’Leary – Executive Head Learning Disabilities

Inspector Warren Shadbolt – Head of Safer Sutton Partnership

Councillors Myfanwy Wallace and Ruth Dombey (as previous chairs of Health Scrutiny Committee)

 Richard Gorf – Joint Commissioning Manager

 

 

 

 

 

Witnesses invited to speak to this item included:-

Mark Clenaghan – Borough Director - SWLSTG MHT

Gill Moore - General Manager, Adult Community Services - SWLSTG MHT

Stuart Adams, Consultant Psychiatrist - SWLSTG MHT

Alison Beck, Assoc. Director for Psychology & Psychotherapies - SWLSTG MHT

Debbie Brough – Day Services Manager, SWLSTG MHT

Marion Ruttley – Previous Wallington Resource Centre Action Group

Bob Mayfield – Sutton Day Care

Marilynne Burbage and Ken Fish – Carers Action Group

Adrian Davey – Asst. Director - S&MPCT (Sutton and Merton Primary Care Trust)

Audrey McDonnell – Asst. Director Joint Commissioning S&MPCT

David Jones – Sutton LINK (Sutton Mental Health Foundation)

Adi Cooper – Strategic Director, Adult Social Services and Housing (ASSH)

Shaun O’Leary – Executive Head Learning Disabilities and Mental Health

Inspector Warren Shadbolt – Head of Safer Sutton Partnership

Councillors Myfanwy Wallace and Ruth Dombey (as previous chairs of Health Scrutiny Committee), and

Richard Gorf – Joint Commissioning Manager.

 

History – Scene Setting

 

Section 136 Provision

Superintendent Warren Shadbolt explained that in 2006 the police referred, to this committee, their concerns about the transportation of people detained under Section 136 of the Mental Health Act.  Section 136 deals with the situation when a person in a public place is in immediate need of care and considered to be of danger to themselves or others.  The police have the authority to remove that person to a place of safety to enable observation for up to 72 hours for assessment as to whether that person still needed to be detained under the Mental Health Act. 

 

The unit at Sutton Hospital had been refurbished and was purpose designed to take people detained under S136.  Superintendent Shadbolt tabled a photograph of the back of a police van, used to transport detainees, to illustrate how unsuitable they were except for very short distances.  The nearest unit was at Tolworth which accepted patients from five boroughs.  From September 2008 to April 2009, 191 detainees had been admitted to Tolworth from the five boroughs, including Sutton.  St Helier Hospital did not admit S136 detainees through Accident and Emergency (A&E).  Other A&E departments have refused S136 detainees because of staff shortages or if considered to be drunk.  On occasions, when Tolworth was full, it meant extremely long journeys, in transport considered to be unsafe for the detainee.  They could then end up being returned and detained back at a police station, which is considered to be a place of safety but not suitable for somebody showing the characteristic behaviour that triggered the use of the S136 power.   

 

In response to member questions Superintendent Shadbolt reported that:

·        At least 20 S136 detainees were recorded on custody records as having been detained at the police station from September 2008 to April 2009. 

·        He couldn’t confirm the date of the Sutton unit closure but it was over a year ago.  A new unit was planned but not given the go-ahead due to lack of resources. 

·        Detainees may have minor injuries or injuries requiring A&E attention.  A medical examiner is called to the police station to assess injuries.

·        That the refusal of admission via A&E is not unique to St Helier and that decisions to admit could even depend on which staff were on duty at any particular time.  However, talks were in place with St Helier Hospital to try to resolve this situation.

·        That he was unable to say if any of the figures included people with learning disabilities.

 

The Chair asked why when Sutton Hospital was suitable for S136 clients, that it was not used.  Mark Clenaghan responded that there was an average of three S136 clients per month and most of these presented at night.  National guidance stated that S136 should be attached to specialist intensive psychiatric units which were not available at Sutton.  There was more staff in a specialist area.  Therefore it was difficult to plan for three clients per month.  There were two S136 suites covering five south London boroughs and that this was repeated throughout London due to the unpredictability and specialist care needed for these clients.  They also had to take into account the safety of the client and staff.

 

Previous Health Scrutiny Feedback

Councillor Ruth Dombey expressed disappointment and frustration that what she considered to be the big issues when she was chair of health scrutiny, in 2003, still appeared to be the same big issues now.  She explained the time, patience and understanding that was required, when health scrutiny was first set up, due to the major differences in culture with the local authority and the NHS.  However, it was her opinion that huge strides had been taken and there was now a level of understanding to set an agenda, set a programme and work quite closely together on how to benefit the community.  Historically there was a problem with MHT staff, particularly with senior management, not providing information required and the high staff turnover.  It was felt by the previous committee that not only was mental health services a Cinderella service but that Sutton was not getting its fair share of the funding, even when comparing Sutton with Merton.  This difference between Sutton and Merton was never really understood and she would like to know if this disparity still exists today.  Councillor Dombey expressed her respect and faith in Mark Clenaghan and his role in changing things in this borough. 

 

Councillor Dombey listed several areas where she still had concerns and where there was some clarity lacking – these included:

·        the future of the Wallington Resource Centre, as well as services being delivered through Sutton Hospital,

·        the future of day services within this borough,

·        how the community mental health teams were being funded, what their role was and what the expectations were as more services were being delivered in the community,

·        whether there were enough resources for care in the community, and 

·        concern about GPs lack of training and resources.

 

 

Councillor Myfanwy Wallace, who was chair of health scrutiny in 2007, referred members to the background papers from a previous committee which showed the lack of information and detail received.  She praised the respect shown from general managers to their clients and between clients.  The lack of choice of services was described as well as the lack of clear data for old or new therapies. 

 

Joint Working

Adi Cooper reported that in mental health services there was a complexity of relationships that was probably specific to the area and what was seen in Sutton was typical of anywhere in England in terms of joint working.  As Director of ASSH she had a statutory duty for social care provision, assessment and provision for people with mental health problems.  As a commissioner, in partnership with the Primary Care Trust (PCT), the council works together to commission jointly mental health services.  As a provider, the local authority had responsibility for providing social care and social work mental health services as well as development of integrated services and teams.  The council have joint services with the MHT where staff who historically worked for the council, have been seconded to work in community mental health teams.  There was a Section 31 Agreement which formalised the arrangement and that was in the process of being updated.  There had been many challenges over the last three years which were contained within the written report.

 

The Chair explained that he was aware that there were three reviews taking place within mental health and that the PCT had a contract out for services and asked how the PCT reconcile this whilst reviews were taking place.

 

Audrey McDonnell explained that the PCT was currently tendering for psychological therapies.  They had taken part in a national pilot programme ‘Working for Wellness’ which was a national body for provision of this service and offered match-funding that totalled £2.4M.  As part of this process the PCT had opted to enter a procurement exercise in order to develop the market and identify service providers who offered innovative practice to this area. 

 

Shaun O’Leary explained that two of the reviews were around Sutton Hospital.  The HASCAS review (Health and Social Care Advisory Service), commissioned by the PCT and SWLSTG, was looking at the viability of services around the definition of health and safety and clinical governance.  The second review was a SW London review set up by four chief executives in SW London to look at world class commissioning in four boroughs.  Adrian Davey explained that, as part of one of these reviews, local modelling of inpatient services would take place and would include bed configuration.

 

Mark Clenaghan explained that the SWLSTG MHT covers five boroughs, Sutton, Merton, Wandsworth, Richmond and Kingston.  Inpatient sites where the MHT deliver services for the five boroughs were: Sutton Hospital for Sutton residents, Tolworth Hospital for Kingston and Richmond residents, Queen Mary’s Hospital for Wandsworth and Richmond residents, and Springfield Hospital (which was the MHT main site) for Wandsworth and Merton residents.  A range of specialist services were also provided, some for five boroughs and others, which were more nationally specialist, were based at Springfield

 

The Chair asked how a user would access care through a GP.  How the contracts with GPs were structured to ensure they have enough time to give to service users? How easy would it be for a GP to ensure that a user was referred on to secondary care if needed?

 

Audrey McDonnell explained that in the case of psychological therapies there was a formal referral process by a GP, in conjunction with the service user, to that particular service. GP’s can also refer into secondary care when required.   Mark Clenaghan reported that 90% of clients would be treatable in a primary health care setting, 10% would present with problems needing treatment by secondary care.  Also, only 3% of the 10% requiring secondary care would require inpatient services.

 

In response to concerns about GP training and lack of resources, Mark Clenaghan reported that there was a spectrum of abilities within GPs and that mental health, as part of a GP’s training, was more focussed than it was 10 years ago.  Psychological therapies and primary care service required close working with GPs and PCT.  Many counsellors and psychologists would be placed within GP surgeries and would serve both formal teaching and informal mental health awareness.  It was estimated that maybe one in three presentations to a GP would have a mental health element to them whether or not the mental health was a primary reason for visiting the GP. 

 

Richard Gorf explained that there were GPs with Special Interest (GPSI) in mental health both in Sutton and Merton who had taken a lead role in the development of the IAPT (Increased Access to Psychological Therapies) services.  He also explained that most of the issues around what happens at GP surgeries will be addressed by the psychological therapies initiative which is receiving further funding.  The specification had been written in such a way that whichever provider won the contract would have to work closely with GPs and they in turn would need to be satisfied with the service they were receiving.  The Chair requested further information on this service and details of the GPSIs in mental health. 

 

In response to member questions Audrey McDonnell explained that there was one GP in Sutton that had a special interest in mental health and she had been trying to promote the service with other GP’s.  However, all GPs could refer patients to the psychological therapies service.  From 1^st October 2009 patients would be able to self-refer if they did not want to go through their GP.  There would be a promotion campaign about this and information posted in GP surgeries.

 

Richard Gorf explained that his role was a difficult and complex one.  He said that there were so many structures in place now that it worked really well in getting different agencies together.  The Trust and the council were now working together much better to find solutions to problems.  He did not believe there were any difficulties in service delivery between the PCT and local authority but there were some issues, which had been raised tonight, that needed solutions and showed that they needed to work more with this committee.

 

It was reported that there was a national target of four hours in which a patient presenting to A&E should be seen, treated and admitted or discharged within that four hours.  Sometimes this target was breached in the case of mental health as there may be times when a diagnosis could not be made due to drugs or alcohol.  Audrey McDonnell reported the PCT was investing in a hospital liaison service for those that presented in A&E with a mental health problem, later this year, and which would be extended it to out of hours.  At present, four staff work from 9am -5pm for care of patients with a mental health problem that may be situated in A&E, medical or surgical wards.  The out of hours service will be for A&E and one doctor will cover the Sutton Hospital site as well as A&E.  Negotiations were taking place to get more cover for out of hours.  Several options for modelling were being investigated but they were looking to have more out of hours coverage for A&E.

 

Mark Clenaghan reported that the Sutton Mental Health Action Plan was written and agreed with the PCT and local authority and reflected recommendations from a number of previous reports as to how statutory mental health services should operate. That these reports did not therefore directly relate to the voluntary sector. 

 

The Chair asked why there was no joint commissioning strategy in place to which Audrey McDonnell explained that the PCT had invested in Adrian Davey’s post who would be doing a baseline review of mental health acute services.  From that work, the PCT intended to produce its own Mental Health Strategy for acute services.  The MHT Executive Group felt that any joint strategy, as a result of this work, would happen in 2010/11.  For this year a joint business plan was in the process of being agreed.  Adi Cooper explained that for the last three years there had been a joint business plan. 

 

The Chair asked how any joint plan would ensure choice over treatment and how would the quality of service provided be specified.   Mark Clenaghan explained that this was part of the personalisation agenda and described the cultural move from a choice of fixed services to one of more flexible services that work with patients.

 

Councillor Roger Thistle asked if the money was in the right place in terms of joint commissioning and if there was more flexibility between the NHS and local authority and would this make a difference to how services were commissioned?  Shaun O’Leary responded that more flexibility was needed in mental health commissioning and that there was general agreement that the current budget was not spent in the right way or as they would like.  The way it should be spent was under discussion.  An over emphasis on Acute Bed commissioning could impact on Joint Social care commissioning especially with monies not being channelled into preventative measures.  Much mental illness has a root cause in loneliness so we need to look at preventative measures beyond psychological therapies.  David Jones explained areas where the voluntary sector plays a part in mental health and asked the committee to bear these in mind and the need for maintaining them.  They provide services and depend on the statutory sector for funding for most services.  They also engage and support people that use services so that they can be represented in partnerships and they also act as critical friend to the statutory sector. 

 

Community Representatives

David Jones explained that Sutton Mental Health Foundation (SMHF) worked with clients that had a severe and long standing illness and one of the concerns that had been raised was that of the patient not being treated seriously enough when presenting with a physical problem.  The SMHF have contact with patients on Jasper Ward for which a development worker is involved with a patient’s council on that ward.  This provides the opportunity for patients to speak with someone outside of the management structure.  There were also peer support arrangements which the SMHF set up, with the help of the mental health trust, about 18 months ago.  This provides an opportunity for patients to speak about their experience on a one-to-one basis and on an equal footing as the person they are speaking to because this person would have been through Jasper Ward as a client.

 

Mavis Peart asked to know why learning disabilities were excluded from the scope of this investigation and wished to discuss the growing mental health need among the learning disability community and whether the five beds at Tolworth were enough.  Shaun O’Leary stated that nationally about one third of mental health patients in acute services had learning disabilities, many of whom had a categorisation of mild learning disabilities with a level of needs lower than that required to meet social services FACS (Fair Access to Care Services) criteria.  He explained that the beds at Tolworth were specialist NHS beds for people with learning disabilities whose behaviours challenged traditional services and these covered Sutton and Merton.  The number of beds was based on one bed per 100,000 population.

 

Mark Clenaghan stated that the focus of the statutory mental health services needed to be on active treatment for those who could not be treated in primary care, whereas the third sector may be better equipped to provide preventative and support services - thus, there should be a clear difference in the service specification for Mental Health Resource Centres than that of the SMHF run Sutton Drop-In Service. The focus of the resource centres was now more than something that clients just went to and was more for recovery focused.  It also provided more one-to-one intensive work with clients in resource centres as well as more work in the community and more outreach work with people that may be reluctant to attend the resource centres. 

 

Marion Ruttley explained that users had seen many changes within the day services with no consultation.  There had been a decrease in staffing levels in day services and as a user; she used to have a comprehensive care package of treatment which enabled her to move on with her life.  She felt that the concept of treatment within day services had been lost.  Whilst she recognised the good work provided by non-statutory and voluntary organisations, she did not see evidence of any alternatives being set in these sectors for the depleted day service.  There was a concern about the number of discharges against the number of new referrals and also suspected that there would be an impact on the number of clients able to use the service or not being referred because of the lack of resources.

 

Mark Clenaghan stated that they were not closing day hospitals by stealth.  He explained that all services needed to be looked at in terms of what they do and how recovery-focussed they were.  He stated that there was a minimal waiting list for patients being referred. 

 

Bob Mayfield claimed that some patients had been discharged without advocates and that some of those patients were not ready for discharge.  He had also requested information dated from July 2008, for the agenda, but had only been given information from October 2008 and that there were discrepancies, inaccuracies and lack of clarity in the report.  Mark Clenaghan apologised for the human error and stated that he would provide the information requested.

 

Marilyn Burbage stated that carers were concerned that when services get downgraded from NHS to Social Services that charges for services are made.  Clients are unable to pay for services and this leads to a decline in the need for services and increases loneliness, which in turn is a major factor in depression.  Carers were concerned that previous users had nowhere to go to be able to feel safe or to speak with someone in confidence.  She also stated that she was concerned about all the reviews taking place and there did not seem to be carer/user involvement at Stage 1.

 

Mark Clenaghan stated that there was a consultation mechanism which would include non statutory organisations as well as stakeholder days which included carers/users.  Marilyn Burbage requested that they be consulted at a much earlier stage in the process.

 

Ken Fish spoke about being involved with one review but was unaware of the other two reviews regarding Chiltern Wing.  Had he known about them his responses would have been more detailed at the review he took part in.  Adrian Davey explained that the HASCAS review was an immediate piece of work.  The full PCT review had given them a baseline of services and work would be undertaken, over a longer term, with the proper engagement and involvement of carers/users. 

 

David Jones requested confirmation that the risk assessment of the Sutton site, which would be an outcome from the HASCAS review, would indeed be made public as well as the information on which any decisions had been made.  Mark Clenaghan confirmed that it would be available this month and if there was to be a significant change in service, then formal consultation would take place, but even if the change did not fulfil that criteria they would still want to work with users on what has informed that decision.

 

In response to a member question regarding impact assessment of changes to services on carers Mark Clenaghan responded that they had a statutory responsibility to assess the needs of individual carers of service users.  We would then look to meet any need on an individual basis – that is what the Carers Grant is for.

 

In response to a member question regarding who would be undertaking the counselling service in GP practices Audrey McDonnell explained that this was part of the IAPT tendering process.  Currently the provision is provided by the Priory Group and SWLSTG. 

 

In response to comments made by Ken Fish, Mark Clenaghan explained that caseloads were too high at the moment and work was being undertaken to reduce case loads and provide a quality care that befits the needs of the clients and carers of those clients.  Sutton, on average uses two intensive psychiatric beds per year so this could not be cost effectively be provided in Sutton. 

 

Bob Mayfield asked why psychotherapy art had been closed in the Chiltern Wing and why they were not told of this change.  Shaun O’Leary explained that one of the objectives of the Joint Commissioning Strategy was to recycle the budget currently spent on institutional care, back into community care or the voluntary sector.  Mark Clenaghan explained that there was also a statutory duty to make year on year efficiency savings of 3%.  For Sutton this would mean approximately £600,000.  Therefore delivery of services needed to be challenged.  Part of a staff post had been deleted and they were now looking at providing a more vibrant service and efficiently.

 

Personalisation and Recovery

Mark Clenaghan described the changing ethos between clinician and users in mental health services in which both work in partnership and whereby the user has more choice and control with the service they receive.  This had brought challenges to services in that they needed to be more flexible.  The personalisation agenda had also increased financial flexibility through the direct payments scheme whereby users choose to pay for the service/provider that they want.

 

Debbie Brough spoke of integrating day services (resource centres) into the community so they were not building-based services.  Each user has a personalised care plan which was reviewed regularly.  The Links Project is a database of shared interests and users are linked with others of shared interest.  Initially, users may be supported but are led to independence.   Staff work with people leaving the service to help them support and lead their own groups.  There was also more linkage into community resources so that when users leave they are more integrated into the community.  Stuart Adams stated that he had worked at the Cheam Resource Centre for the last three years and that he had seen significant positive change, with recovery, over the last year.

 

Gill Moore explained that Direct Payments gave so many more options for clients in that it allowed clients to choose their package of care and services were moulded around them rather than moulding the client to the service.

 

In response to a member question regarding the perception of reduced staff levels, Mark Clenaghan responded that it was early days of personalisation and therefore too early to make judgements or correlation between personalisation and staffing levels.  Mark Clenaghan also highlighted that there were no building based day services operated by the Trust in other boroughs within the Trust, and that we therefore needed to consider carefully the balance between money spent on staff directly to support users and carers, and money tied up in buildings.  However, there had been a reduction of staff in Sutton over five years as part of efficiency savings needed to be made year on year.  Audrey McDonnell explained that whilst there may have been reductions in one area that there were significant investments in other areas by the PCT.

 

In response to a member question regarding the amount of PCT budget spent on mental health services and how that compared to previous years, Audrey McDonnell stated that in 2008/09 Sutton’s spend was around 10%.  Councillor Jayne McCoy requested comparative figures for other PCTs.

 

           

            Resolved: (i) To request further information on:

·        The psychological therapies service and detail of the GPSIs in mental health.

·        Details of modelling and staffing levels for the St. Helier Liaison Psychiatry Service. 

·        Comparative figures, of money spent on mental health, with other PCTs.

·        A copy of the standard list of consultees.

·        Paper from the Trust on cumulative effect of efficiency gains on the services provided by the Trust over the last 5 years.

·        A paper on the review of occupational therapy provision on Jasper Ward.

·        Shaun O’Leary to provide a paper on transfer of staff to St George’s.

·        Information about the position of other S136 suites in other parts of London, their usage and the issues that they faced.

 

 

(ii) To suggest further areas for the committee to consider would be:

·        Commissioning strategy and supporting plans.

·        S136 facilities – Best practice and how this worked elsewhere in London requested from Mark Clenaghan.

·        Personalisation and recovery.

·        To invite vulnerable tenancy officer from Housing Partnership to future meeting.

·        An open day with three Trusts, users/carers and local authority to look at the national strategy for dementia.

 

(iii) To thank all the witnesses for attending the meeting, this had been very useful for the committee.