Agenda item

5.1  The Chair explained that he would give senior SLaM managers, clinical staff and community representatives an opportunity to comment on the two consultations on service reorganisations under scrutiny tonight; Psychological Therapy Services and Mental Health for Older Adults and the possible impact on beds at Maudsely Hospital.

 

5.2  The chair invited senior mangers from SLaM to present on Psychological Therapy Services. Dr Jonathan Bindman from the Mood Anxiety and Personality CAG and Zoë Reed Executive; Director of Strategy and Business Development presented.

 

5.3  SLaM managers explained that they are proposing to develop a single integrated Psychological Therapy Service in Southwark to replace the existing three services; Maudsley Psychotherapy, Traumatic Stress Service and the Coordinated Psychological Therapy Service (CPTS). Officer said that this model creates confusion , but  this is mainly with professionals rather than service users and SLaM wishes to develop a more cohesive service.

 

5.4  Managers reported that they did some early consultation with service users and took their advice in developing the model. Managers reported that they did not initially take the view that it was substantial variation; however they stated it is clear that the proposals have raised concerns. The Lambeth, Lewisham and Southwark Stakeholder Reference Group raised concerns and recommended greater consultation. Following this a meeting was held with Southwark LINks. As a result of this SLaM managers explained that rather than relying on the service user group they are creating a wider service user reference group.  Managers stated that they are planning to have wider ongoing engagement on a three year cycle and have  agreed quarterly meetings with LINks.

 

5.5  A staff proposal was issued recently and SLaM managers reported that they have started to interview staff. They went on to explain they that this regretful situation has caused destabilisation and resulted in the suspension of new treatments on a  9 month cycle , however they are  hoping to restart these very soon.

 

5.6  The chair invited questions from members of the committee. A member commented that SLaM say that the service will be community based however it is not clear where it will be delivered from in trigger template, circulated with the papers. Managers responded that the service will be delivered form either Guys or Maudsley Hospital, however SLaM have not made a decision yet, but the location will need to accessible.

 

5.7  A member asked SLaM managers how confidant they are that the reorganisation would only result in a 10% cut to services.  The managers responded that in their view it is not an efficient service and that currently people are referred many times or referred to the wrong service. Managers went on to explain that it will take time for the service to bed down and time to monitor the affects of the changes. The 10 % is more of an aspiration or target and if waiting lists do rise then SLaM will need to take mitigating action to remedy the situation. A member commented that the written evidence is more definitive. SLaM managers responded that specialist psychological therapies will take time to make efficiency changes.

 

5.8  A member noted that the clinical staff predict that the service changes will result in a reduction of between 40 to 45 per cent of service. SLaM managers responded that this is wrong and came from initial suggestions and discussions with Lambeth.  Managers reported that this concern also came from band 8 cuts and they went on to explain that this has since been reviewed. Managers said that given the service reduction is going from 16 to 13 whole time staff they do not see how this could happen.

 

5.9  The chair raised the issue of the situation ofhonorariums .He said that his understanding was that full time staff need to managehonorariums so these cuts could have big impact. He also questioned the impact on the new generation of psychotherapists emerging through this process. SLaM managers acknowledged that the system is very dependant on the honorariums. Managers said that they have now modified the grade 8 cuts to take on board this risk. They went on to explain that they have chosen to select by grade rather than clinical specialism.  A member commented thathonorariums have raised concerns about continuity and managers said that while they can’t guarantee clinical continuity for individual placements they are keeping the system so still providing continuity of the model.

 

5.10  A member asked what are the risks and managers explained that bedding down may take time so waiting lists may rise .Managers also explained that community mental health practitioners will need to provide support in the community, people often have to wait if not acute.  However if they have to wait longer than a few months then this could be a worry.

 

5.11  A member asked if this is about cost reductions or improving efficiencies. Managers explained that there will be efficiencies savings, but we do have cost pressures in the current climate. Managers went on to explain that they are always looking to improve, for example by expanding peer support and seeking more equity from GP referrals. Managers explained that this proposal is our best prediction of an improved service, but they intend to closely monitor it to see if we need to adjust.

 

5.12  A member asked if the service was being cut to the bone and managers responded that no, this is a small cut in a range of services.

 

5.13  Attention was drawn to the letter circulated with the papers from UKIP. SLaM managers responded that UKIP are raising the concerns in the context of national fears about cuts to psychoanalytical in favour of cognitive therapy. They reported that SLaM have drafted a letter in response to the UKIP statement issued. The chair requested that this was circulated to the committee.

 

5.14  There was a question about the extent of consultation with service users using Psychological Therapy Services and managers responded that they thought it was an odd idea to consult with people in treatment  because of psychological treatment boundaries and because this  they did not contact them about future service delivery. However, SLaM managers went on to explain, that following feedback that people in treatment might be affected, and feedback from LINks SLaM have now widened consultation where psychologically appropriate.

 

5.15  A member noted that the reports states that the new team will be closely linked to the Community Mental Health Teams allowing people who may not require therapy to be diverted to a range of other community  services, including primary  care therapy (IAPT) . SLaM managers were asked if this means there will be increased access to IAPT.  Managers responded that IAPT is increasing its range generally, however the IAPT and psychological overlap is small.

 

5.16  Members drew SLaM manager’s attention to the Equalities Impact Assessment and asked about the evidence base. SLaM managers said the Equalities Impact Assessment is a work in progress and said that different census information can be added once this is received. Managers went on to say there is an ongoing question if Psychological Therapy Services are accessible to BME and explained that BME clients are under represented in the service. Managers said that they hope these proposed changes and referral processes will make positive changes, however they said it is a complex situation.

 

5.17  A member noted that the papers say that you don’t monitor for sexual orientation and managers responded that Lambeth colleagues had fed back this was a sensitive question. The member pointed out that services are required by law to monitor for sexual orientation and transgender and went on to say that he hoped this situation with Lambeth was resolved very soon and that SLaM worked with the council to improve data collection around transgender.

 

5.18  It was noted by a member that Equalities law around disability means that services have to ensure that they do not discriminate against people with different types of impairment, for example, he asked if this service discriminate against people with particular conditions such as depression or schizophrenia. Managers responded that this service is geared towards people with enduring problems and in particular people with personality disorders. Reduction to services could lead to people not getting service with post traumatic stress disorder (PTSD) or personality disorder. The question is what is the right treatment given the evidence. Sometimes people with PTSD could be better treated by community services.

 

5.19  The member elaborated that this is a question about consultation and that the duty required that this is not just a passive consultation but about engaging services users in developing services and furthermore fulfilling the duty to meet the requirements of equalities law. Managers responded that we have  consulted with service users and went on to say that while they did not initially  think this  was a substantial variation , now SlaM  think it is and as such  stakeholder involvement should have taken place from the outset .SLaM managers said that they accepted this point.

 

5.20  A member commented that managers from SLaM are obviously seeking to  reassure us that the reduction in  service will be nearer to  10% than 40% , however  what about the quality of service? Managers responded that a shorter length of therapy will not make it more efficient so they do not intend to change this. Waiting times are 6 months to a year and if this not maintainable then we will need to adjust as clients tend to get worse .There is shift in service design to peer support.

 

5.21  The chair invited senior clinical staff from SlaM to present their evidence on the Psychological Therapy Service reorganisation. Senior clinical staff members began by stating that they are committed to the service. Clinical staff said that they support increasing referral efficiencies and accessibility. They stated that there principal  concerns are that  cuts are front loaded and that because of that  service users will be seeing a bigger reduction in service and face cuts to a quarter of the service.  Clinical staff explained that they are putting forward an alternative vision of 7 per cent as this would enable staff to make cuts in hours worked and take voluntary redundancies. Clinical staff complained that services users have not been asked if they would like slower cuts and they would like service users to have a say and be able to make choices. They also said that staff would like to be collaborated with.

 

5.22  A member asked clinical staff to clarify that this is not a problem with the model and staff responded that they like the model and that services are integrated. Staff went on to raise concerns about services being concentrated in the Maudsley.  Clinical staff said that honorariums need to know rooms are available and they pointed out that this is a finely textured service and in danger of collapse.

 

5.23  Clinical staff were asked by a member if the frontloading is because of the way that government cuts are being made. Staff responded that some cuts may not be needed for two years. They also said that Lambeth residents are getting more of a service as Lambeth NHS are putting more in. Staff also pointed out that service users are not efficient as they often have chaotic lifestyles but clarified that the 9 month treatment cycles have not been postponed.

 

5.24  A member asked if there was any evidence that a particular group would be particularly disadvantaged and clinical staff responded that yes,  there is a group of people who are very socially disadvantaged with complex needs and they may not fit easily into this new structure.

 

5.25  A member clarified that the clinical staff proposal was for slower change and for service users to be consulted and clinical staff agreed.

 

5.26   Clinical staff were asked for their thoughts on the impact on honorariums and staff were asked to clarify if the location is the main issue or the hours and posts. The response was that it is both; the clinical staff interviews are for generic interviews so there is concern that honorariumswill be lost because of loss of specialism. Staff explained projections done twice by clinical staff both came up with a service loss of between 40 and 50 per cent. Clinicians explained that the projection would affect psychoanalytic and psychodynamic therapies in particular.  An honorarium present said that he is very concerned about the impact and was not sure he will be able to continue.

 

5.27  The chair summed up the discussion by saying there are concerns over the equality impact assessment work done on sexual orientation and transgender, as well as the potential for  this to adversely impact on people with different types of disability. The potential impact onhonorariums and with the scale and speed of cuts is worrying. Concerns were also raised with the extent of engagement with service users.

 

5.28  The chair noted that the committee could escalate this to the secretary of state; however he cautioned this is a nuclear option and instead requested an immediate pause and recommended a longer time for consultation. The chair asked senior managers if they had done a twelve weeks consultation and senior managers said that they had done 5 weeks with staff and done cycles of consultation with service users earlier in the year with an iterative process to develop this model.

 

5.29  The chair said that the committee would like you to take 12 weeks so you can consider the honorariums issues and the other concerns raised. He advised staff that SLaM could find itself open to a legal challenge.

 

5.30  Senior manager said that one of the impacts of taking longer to consult would be that it would be  hard to place people on the 9 month  therapy cycles as SlaM  will not know the future structure  and who the permanent staff will be. Senior managers said there is an intention is to go forward with LINk do ongoing work on implementing this structure and monitoring impacts. The chair responded that while he realised SlaM have a duty of care to people it was important that the proposed new structure would work and protect services.

 

ACTION

 

Recommend an immediate pause for 12 weeks consultation with staff and users.

 

Request an Equality Impact Assessment.

 

A letter will be written to SlaM

 

SLaM UKIP response will be circulated to the committee.

 

 

5.31  The chair invited Tom White from Southwark Pensioners Action Group (SPAG) to speak about the Mental Health of Older Adults service reorganisation. Tom began by explaining that the major concern is loss of beds at Maudsley Hospital and SPAG held a demonstration about this recently.  He went on to raise concerns about the consultation process and said that, in his view, SlaM do not do consultation. Tom said that this is a reoccurring problem, and mentioned   Felix Post and Marina House as examples. Tom said that he had a letter from his MP which stated that SlaM position was that they were not going to make cuts to wards, however this is part of the proposal. Tom said that SlaM made a press statement saying there would be pause but his understanding is that the beds are going now.

 

5.32   The chair asked Tom to clarify his statement about consultation and asked if there was a pattern of poor or no consultation. Tom said that was his view and the Trigger Template focused on staff rather than service user consultation.

 

5.33  The chair asked Tom what he saw as the risk and Tom responded that he saw this in the context of ongoing cuts to services to older adults with mental health needs. Tom mentioned that the former Felix Post unit was good at rehabilitation, but this was closed. Managers said that services users could go to Holmhust, however this was then closed. Tom went on to talk about Greenhithe Care Home Becket Unit and said this was recently closed and a service user made a choice to go on home leave, but sadly she lit some matches and died of smoke inhalation. Tom said he knows of someone else who went on home leave and also died. He ended by saying he is very concerned with the risks of community care.

 

5.34  The chair mentioned that the committee is due to visit SlaM and will visit the ward and indicated that the committee would want a public consultation before this ward is closed.

 

5.35  The chair invited SlaM senior managers to present and David Norman and Zoe Reed were invited to talk about the proposal and their consultation process. Managers explained that SlaM have been thinking for sometime about making better links between community and hospital acute care. Managers explained that feedback from users is that the service is not available over the weekend and there are more admissions at the end of the week.

 

5.36   Mangers referred to Tom’s comments and said that SlaM believes if we can provide support over the weekend we can make reductions to beds and this can help with providing the funds to expand the community team. Managers explained that there are no cuts to the wards at the moment and that the occupancy rates varies. Managers went on to explain that they are planning to set up a new team which will take referrals from people experiencing crisis.  The proposal is to take money from beds to pay staff so the service can offer support in homes. Mangers clarified that this new service will be 7 days a week not 24 hours a day.

 

 

5.37  Managers said that they have listened to the risks associated with people going home and acknowledge this , however managers said that in patient  provision is often not the best and that the service would like  to encourage support at home and independence .

 

5.38  The chair asked SlaM managers if they consider this a substantial variation of service. The managers responded that when we model it out we think a community model is better. The chair commented that SlaM seem to be less good at recognising what is a substantial variation than other Foundation Trusts.

 

5.39  The chair asked for clarity on the proposed bed reduction and managers explained that there is a total of 81 beds and the plan is to reduce this by 19; however managers said that this is what we are looking at but the service is not set on figures.

 

5.40  A member commented that the proposal dose not mention costs or the scale of the cuts and there is a need to understand this to carry out a meaningful consultation. . Mangers said they appreciated the points and that SlaM need to get better at this.

 

5.41  A member said he had concerns about risks. He went on to comment that while he could  see that community health care literature recommends community care, he had concerns  about bed capacity  if there are spikes in demand . He noted that the loss of the ward is a significant loss of capacity and admissions maybe hard to manage.  Managers said that SlaM can see if the service as a whole can flex better to make use of our overall capacity.

 

5.42  Members asked what can the service do to monitor the risks and in particular the one Tom has raised about people at risk at harm at home. Managers explained that this is not about eradication of acute and impatient care but trying to find a better balance between hospital and home and community care.

 

ACTION

 

The committee recommended that SlaM:

 

• Come back to the committee with more developed and budgeted proposals on the scale of the changes and how the service will manage the risks associated with the potential loss of ward capacity.

 

• Undertake a full 12 week public consultation.