Report of NHS Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) and Midlands Partnership NHS Foundation Trust (MPFT)

The Deputy Chief Executive MPFT introduced the report and explained that the presentation would be led by the Integrated Care Board ICB as the commissioning body. The Chief Medical Director ICB confirmed that no decision had been made at this stage of the process and introduced the presentation.

The presentation – ‘Finding a long-term solution for the inpatient mental health services previously provided at the George Bryan Centre’ provided background, context and highlighted matters in the business case and process to be followed for further discussion:

·       Updated on the clinical case for change in mental health services

·       Explained the recommendations from clinicians/staff for inpatient mental health services for people living in south east Staffordshire

·       Shared the robust process followed

·       Shared the next steps

The Chief Medical Director highlighted that proposals must be viable and invited members questions and points for clarification.

The Chairman thanked partners for the presentation. The slides and the link to the video would be circulated to members and uploaded to the webpage.

The following matters were discussed, comments and responses to questions during the debate were noted:

Role of Members: Members paid tribute to the dedication and hard work of staff and to the value of mental health services in Staffordshire.  Members highlighted their role was to represent people in the community to ensure their voice was heard in developing mental health services in their communities.

Service User Satisfaction - A member questioned satisfaction ratings for inpatient services in 2021 and whether the business case proposal was moving away from what the people thought worked well. It was explained that population of the unit had reduced between 2019 -2021 and it was difficult to compare unit for unit.  The 2022 figures were not available but would be provided.

Workforce safety on site – Members questioned if there had been an issue with the level of workforce at the George Bryan Centre (GBC) prior to the fire. Committee acknowledged that workforce in isolated buildings was difficult to manage and that there had been issues with the number of staff to patient ratio.  Recruitment and retention at the GBC had been a challenge, it was a small centre. As part of involvement process MPFT had talked to the staff that were previously employed at GBC – they ascertained that none of the staff who responded would want to move back, they had moved on to other roles and felt reassured in a hospital setting, which had more people on site. It was acknowledged that recruitment and retention was a big problem for the NHS in all settings.

Workforce safety in the community – Community Mental Health Services have larger teams; staff also work alongside police officers when required. Members were advised that staff safety in community services had not presented a risk.  It was clarified that if someone was identified as a high risk to safety, they would be referred to an inpatient service. Members queried whether incidents where police were called to GBC were now happening in the community. It was explained that GBC was a small crisis unit with a small number of staff, safety was a concern, and prior to the fire GBC had become a pre-release setting where patients condition was stabilised before going on to community services. The inpatient crisis centre at St Georges worked better for crisis because there were more specialist staff and support services in one place.

Wider community safety – unintended consequences. It was explained that out of the people supported for their mental health issues in the community very few would need a hospital bed. From a community perspective there were wider integrated teams and specialist teams that provided support in the community and in their own home. There was a whole raft of provision in the community that manage the bulk of provision, starting with primary care, Improving Access to Psychological Services (IAPP) before moving into specialist services.  The majority of people live at home and were supported by family and community services. The hospital was a small part of their lives. This model had been managed since the fire – unintended consequences had been part of the learning process and would continue to listen and learn from feedback.

Cancelled appointments – In response to a question about appointments being cancelled at short notice, it was explained that a person in crisis had to be the priority, the urgency of the call and safety of staff was paramount. It was clarified that on occasions community appointments had been cancelled - when a patient was in crisis more than one staff member may be called to attend – they had to prioritise and assess the risks.

Community Mental Health Services - Members questioned how the perception and understanding of community services would be improved.  Members were advised that community mental health service was an evolving model in year two of the transformation. Work was ongoing to look at the entire model of mental health care, services were being built into a cohesive community model - including embedding in community services and inpatient support in hospital 24/7.  MPFT was evaluating and learning from the ongoing programme of work, looked at what meaningful care was and what was working best for residents.

Model based on a step care model, a staged approach to mental health service.  The least intensive self care self help right through to the most intensive stage - inpatients.  Community model focus was on more lower step care to prevent inpatient need.

Involvement – Members considered the reach of the involvement activity. It was clarified that provider engagement activities in October 2021 and March 2022 focused on services at GBC, it was acknowledged that there would be a need for wider involvement (and include patient satisfaction surveys) to get a broader perspective relating to St Georges.

It was clarified that there had been two key listening events:

o   October 2021 online - a wider public listening event and survey- which informed the technical group. The event was online to ensure safety of participants during the pandemic, no in person events were held at this time. Support was provided for people to gain access online.

o   March 2022 - This was a reference group not a wider public listening exercise, to consider the detail and receive clinical presentations, the group looked in detail at impact and any mitigations that needed to be taken into account.

The need for further involvement listening events was under consideration.

Transport / Accessibilityto services. Committee raised concerns about transport for relatives to visit loved ones at St Georges.  Anecdotal evidence was provided relating to a relative catching a bus from Tamworth to St Georges at 5.30 pm but being unable to secure public transport back.Data was requested to confirm that relatives had been receiving support with transport needs. It was confirmed this could be produced, however there may be difficultly evidencing the period over the pandemic. 

It was confirmed that the business case included an offer to ensure people could access services through a variety of ways:

o   Access via telephone and digital means.

o   Transport (which may be re-imbursed).

The Chairman indicated that it would be impractical to handle travel claims on a case-by-case basis and indicated that there should be a transparent policy.  MPFT confirmed that there would be a clear, user-friendly policy and there would be a more accessible transport guide for public on the website.

The Committee emphasised the need to look at how people travel to Stafford from all over Staffordshire and to consider the level of support required. The transport data in the business case was not very informative and the Chairman suggested that a map would be useful to look at the mode of transport and how people get to and from visits.

Volunteering – A member referred to the proposed reliance on community volunteer groups in the business case and indicated that the enthusiasm for community volunteering had reduced considerably post pandemic, it was questioned whether thenumber of volunteers leaving volunteering may be a risk in the business case. It was confirmed that when referring to voluntary community sector partners in the business case the commissioners were resourcing and commissioning voluntary sector groups.  It was agreed that the shift in the pandemic has caused a shift in volunteering and there was a need to think about how to make mental health services an attractive place to be part of the workforce, both through formal qualified posts and through volunteering.

Centre of excellence at St Georges.
St Georges offered a range of services and delivered specialist mental health services – the hospital inpatient service was a small part of the mental health service;  patients may only be in hospital for a short time and would continue their care in the community mental health services.  Inpatient services required specialist skilled roles, the challenge was to train people in the community services, where the majority of mental health provision was. NHS England had released more training posts due to increase in mental health, most of the posts were based in the community, and trainee consultants were getting training in the local areas.  Training roles included working with GPs, pharmacists and other health professionals to meet the need of the population.
Members welcomed that specialist providers would be on site at St Georges. There was a need to enter a collaborative level of commissioning understanding the value of commissioning in the community and do the specialist work in centres of excellence.

MPFT had developed services in Staffordshire and particularly in the South, a specialist team to support personality disorder, and particularly those with high risk behaviours.  Built on evidence-based practice, based on structured clinical management process and this was part of key offer going forward. 

Workforce / Staffing  Members recognised that workforce was an issue and there was a need to recruit, there was no mention of vacancy numbers in the business case.  It was clarified that workforce shortage was an issue Nationwide but that the posts referred to in the business case were recruited to when the decision was taken to close the George Bryant Centre temporarily.  The biggest part of recruitment to posts in MPFT moving forward was to recruit to the community model which had come from the NHS plan to support the development of the workforce. Although a challenge to recruit, MPFT was looking at development of a workforce strategy to develop staff from apprentice right the way through.  Data would be provided re vacancies for the South Staffs mental health services.

Resource – Committee raised concern that there did not seem to be  enough money allocated for the new community approach.  It was explained that the community transformation work and mental health investment fund coming from Government would start to reinvest and bolster support in mental health services. There was a clear understanding that nobody should be disadvantaged across the County and that there would be a safe and good quality mental health offer.

MPFT welcomed any support to encourage the commissioners for increased funding. ICB advised that the £6.2 million across services in Staffordshire and Stoke on Trent by 2023-24 was specific to the community mental health transformation, it did cover the whole of the County but was only part of funding available (this was one programme amongst a number of programmes). The expectation was that the ICB increases investment year on year and would bring investment together across all areas to build resilience against poor mental health.

The ICB Mental Health Programme Board had a community mental health transformation steering group where partners and relevant bodies work at a whole ICB level.

Is the Mental Health Service in Crisis? – Members voiced concern that there was a big mental health service crisis and that it was how it felt and looked to the public.  They sought assurance that monitoring, and outcomes were measured.  Members were advised that during the pandemic mental health services were not stood down but were asked to deliver services differently.  Service transformation was progressed quickly, and digital services were introduced at pace virtually. 

This was the first-time there has been ringfenced funding for community mental health services, also there was the Mental Health Investment Funding. Assurance was given that even though mental health services were incredibly busy, there was dedicated investment to strengthen services and think about how to work differently.Partners re-assured and re-affirmed the assertion that the mental health service was not in crisis.

Contracts expire in 2023 – in the business case it was noted that many contract dates ended in 2023, the Chairman highlighted that in the move towards community services greater commitment in terms of timelines was needed so that when one service expired the next service was established. Members were advised that the contract date was not the end of that commissioned service but an opportunity to look at how to transform the commissioning model into a collaborative style of commissioning services.

Relationship with Social Care –MPFT has had a partnership agreement with Staffordshire County Council (SCC) for 10 years covering the South Staffordshire area, predominately for social care around mental health services. When MPFT integrated with Staffordshire and Stoke on Trent Partnership Trust, MPFT took on a partnership arrangement with SCC for social care around older peoples and physical disabilities and provided integrated health and social care teams. The teams work together, deploy resource,  share care loads, and case management, all work together well. It was noted that social care influence goes wider than the workforce and work together with Local Authority colleagues.

Statistics – There should be more performance statistics in the paper submitted to help evidence the business case.

Impact measurement – The Evaluation outcomes and performance quality group had been set up by ICB and regularly seeks service user/carer feedback.  ICB was looking at how this model would improve access, improve outcomes, improve experience of service users and ensure that families were getting the support and care they need.  Data would be used to build services as part of the programme.

The Chairman highlighted that the measures of success should capture a range of metrics broader than how patients feel, such as timelines for referral, when patient was seen etc and none of these were in the business case. The Chairman indicated that members should be able to see what was the commitment that ICB was proposing for our residents in relation to the specialist services. It was acknowledged that the measurements should see direct demonstrative benefits to patient care and capture tangible and non-tangible benefits which should strengthen the business case. These would be brought back to Committee to consider.

Use of the George Bryan Centre – The discussion focus was on the business case, clinical model associated with inpatient services not at this stage about the building use. However, the temporary community location for mental health services in Tamworth was at the sexual health clinic, the Trust had committed to review and strengthen the community service offer, the temporary location would be looked into. The Chairman accepted that provider did not include future use of the building in the business case, however indicated that the commissioner should be clear what future proposals were for the people of Tamworth and to see clear views as to what these building would be used for in the future.

Insurance money  - Following the fire insurance money of £1 million revenue had been re-invested into the community service offer which was currently being reviewed.The Chairman was surprised that the rebuild costs were £8 million when insurance was only £1 million.

One viable option – closed East wing:  the Chairman was disappointed that no modelling had been done to consider expanding services from the west wing.  The transformation paper was silent on this. He understood that clinically there was only one viable option put forward, but the business case needed to demonstrate options had been considered.

Clinical quality and clinical safety – in-patients specialist workers – GBC does not have specialist services on site and would not have skills to support an acute in-patient ward.

Community Mental Health Strategy  - There was a requirement on the ICB to develop a Community Mental Health Strategy over the next few months and the ICB would meet to start to see an overall strategic commissioning process across mental health which would span the life cycle. There would be a lot within the strategy that had a very specific focus, including developing community mental health options first and inpatient services as a last resort. There was more work needed to consider the strategic direction, how to provide in the community, what were the barriers to access, the need for in-patient beds and how to provide them in the safest way possible. This would be progressed by the Staffordshire Integrated Care Partnership ICP. Discussion would be joined up, a system wide conversation based on the needs of local residents.

Are resources sufficient and how do we measure that.  This is the first-time investment in community mental health services, the money made available gives opportunity to invest in community mental health services and it will be important to work alongside our partners in local authority and in partnerships. We have to use public funding in the right way - Invest and re-engineer what we have got.

With regard to response time, the crisis resolution service was a good model of service delivery.  They had really clear timelines about dealing with people within timelines especially with people in urgent need. They were in a good position with regards to finance and could provide data on this through key performance indicators.  The services also work closely with the police, there was a whole range of services across the community that could respond when someone was in crisis.

ICB had a series of metrics that measure MPFT and other providers, building and refining metrics as part of the transformation programme.  There was a whole dashboard that underpinned mental health services in terms of assurance that could be shared.

Clarity on Police involvement in the Community mental health services was considered and members asked to see some evidence on how this activity was being recorded.  The data could be requested from the community triage team but also the PCC office could be asked, they collect data. It was agreed to ask through Police and Crime Panel next time they meet.

Mental Health Practitioners Committee asked how many mental health practitioners were imbedded in primary care networks in Staffordshire and if everyone had taken up the offer. This was a nationally mandated programme and an expanding programme, in year two. The figures were not available at the meeting, but committee were advised that Staffordshire had done well, with the exception of East Staffordshire, which had made the decision to delay to wait for the funding this year.

Needs analysis - Acute Admissions The Chairman referred to the business case  - given that 36% of acute admissions were not known how did we know if we have built in the capacity required. MPFT advised that a Health Quality Assessment toolkit was used to assess needs analysis.

Mental Health Strategy partners were working with Staffordshire County Council on a draft Mental Health Strategy but it had been delayed. ICB advised that the strategic ambition in the NHS was outlined in the NHS long term plan, and the ICB was working towards the ambition in the plan. The Chairman stressed the need to align the strategies in the absence of the Staffordshire Mental Health Strategy. Assurance was given that all partners were working together across Staffordshire, it was noted  there was also a Northern Staffordshire mental health provider that worked out of Harplands Hospital, North Staffordshire Combined Hospital Trust NSCHT.

Summing up

The Chairman thanked presenters for providing a detailed and useful presentation to better understand the professional advisors views and detailed analysis of the questions raised.

The Chairman established that Committee was broadly in support of the principle to move towards Community Services but stressed that further information and more clarity would be needed to strengthen and evidence the proposal. Committee was in support of the principle to move people with dementia into community services if it benefitted those individuals.

The Medical Director ICB welcomed the discussion and found the useful and interesting questions asked beneficial.  He confirmed a composite response would be provided and indicated a desire to maintain scrutiny involvement to keep talking through the information to ensure we provide safe services for the people in Staffordshire.

Resolved:

1. That the Health and Care Overview and Scrutiny Committee note the report relating to  Inpatient services in south east Staffordshire for adults and older adults experiencing severe mental illness or dementia.
   
   
2. That the comments and requests for further information of the Health and Care Overview and Scrutiny Committee be considered to strengthen and clarify matters in the business case for Inpatient services when next considered:

a.   The importance of communication and raising awareness of the community mental health offer, the patient pathway and the measures of success.

b.   Key performance indicators (KPIs) were lacking in the business case.

c.   Mental Health Inpatient Service user satisfaction rating data for 2022 requested. 

d.   Evidence of transport and support provided for relatives visiting St Georges Data would be provided re vacancies for the South Staffs mental health services requested.

e.   The longer-term commitment in terms of the Community Mental Health Services.

f.    Clear transport policy was needed to look at impact on visitors due to a centralised site.

g.   Clarity whether the Community Services were ringfenced requested.

h.   Greater detail in terms of the transport mapping was needed.

i.     Technology complimenting human contact – more clarity on this needed.

j.    Safety aspects – there is a need to be satisfied.

k.   Discussion with wider partners about future commissioning at George Bryan Centre if it were not a mental health inpatient facility along with local need and timescales in ICP.

l.     Aligning proposals in line with the MH Strategy.