Agenda item

3.1  The Chair thanked the management team from SLaM for attending the meeting and noted the additional consultation which had been carried out since the two committees started looking at this matter and the changes which had been made as a result.

 

3.2  The Service Director, SLaM, the Director of Strategy, SLaM, the Joint Mental Health Commissioner NHS Southwark , and the Assistant Director Mental  Health Commissioning, NHS Lambeth, introduced the item, highlighting the following:

 

• Extensive consultation on the proposals had been carried out since March 2012, as set out in further detail within the paper, and many helpful comments and feedback had been received as part of the consultation exercise.

 

•  A further engagement exercise had been carried out that afternoon, with approximately 120 people, mainly service users and various groups. The session had been helpful in enabling people to contribute constructively to the proposed model, with for example proposals for more self guided help in the future for service users. Overall, service users were keen to be involved in the process going forward and both management and service users and other interest groups were keen to develop a collaborative process. The afternoon session had highlighted how well things could be done when everyone was working together. A commitment had been made to confirm key elements and areas of focus in writing to all who had participated in the session that afternoon.

 

• A lot had been learnt in relation to engaging more effectively with service users currently in treatment, and although initially there had been some concerns in terms of the effectiveness of this process, engagement with service users had proved very fruitful.

 

• Previous consultation had highlighted the need to focus more on services tailored to people with more severe mental health problems and a flexible approach would be taken to this in the future.

 

• Work was now underway to develop the proposed model further, also involving the LINks and staff groups to ensure that those areas highlighted by staff were being focused on in the future.

 

3.3  Nicola Kingston, joint chair of Lambeth LINks, spoke on behalf of Southwark and Lambeth LINks saying that there was unanimous agreement that the meeting that afternoon had been very good..  There had been some good suggestions from the floor and a commitment from SLaM Management to write back to the participants as well as to involve LINks in ongoing evaluation of the new service.  She felt that all had learnt from the experience and that there was a real commitment to ongoing dialogue and engagement.

 

3.4  Committee Members raised a series of questions which were responded to by the Service Director SLaM. Following this  a service user and three members of staff were given the opportunity to state their case.  Set out below is a summary of the key points made :

 

• Further details and clarification was required on how changes would be evaluated. The Lambeth and Southwark LINks were keen to be involved in the evaluation process and to work with both the Committee and SLaM in carrying this forward.

 

• It was noted that progress had been made since the previous report to the Committee in March 2012 and that was set out in the written report to the Committees, however concern was expressed that  the verbal presentation to the committees was mainly relating to comments made at that afternoon’s session.

 

• Further clarification was sought on the way in which the changes proposed would ensure the service met the needs of those with serious and complex mental health issues, particularly how a flexible approach would be developed to take into account of the specific needs of such service users.

 

• It was noted that the EIAs for each Borough were considerably improved and that SLaM management intended keeping them as live documents particularly to ensure that the Committees’ concerns that no disproportionate impact occurred  on vulnerable service users within the new model.

 

 

• Concerns were expressed at future service changes for people with Post Traumatic Stress Disorder (PTSD) and those who were suffering mental health problems following experiences from conflict zones. It was unclear what the service would bring to such patients and what skills would be required in the new model to treat those patients.

 

• That working together on the prevention agenda was key and to this end further collaboration between SLaM, social services and housing services, and any other service which might be relevant when addressing mental health issues, would be required for the future to ensure a more holistic approach to mental health service provision.

 

• Queries were made as regards to the possibility of the reconfiguration of the service providing better longer term support for people with mental health issues. Service users had expressed anxiety that they were currently not given adequate time to recover in the longer term.

 

• Concern was expressed at support provided outside of normal opening hours, particularly for those most vulnerable and further clarity was sought on what measures had been put in place to address this. 

 

3.5  In response to the comments made, representatives from SLaM highlighted the following:

 

• A lot of written information relating to the proposed changes made had been produced and circulated widely. This had been followed up with individuals and  groups,  demonstrating that lots of preparatory work had been undertaken to engage with groups and this had aided the engagement exercise carried out that afternoon. Information had been circulated to both existing service users and those currently on waiting lists and a process had been prepared for meeting with staff groups to identify and address key areas of concern. As such, engagement had been carried out over a number of months.
• In relation to patients with more severe mental health problems, it is being proposed that the new psychological therapy teams will work closely with the current community mental health team in order to facilitate a speedy process for assessing such patients and ensuring that adequate support is given at an early stage. 

 

• The starting point for developing the future model for mental health service had been the borough based model which was based on already identified problems and issues specifically related to the two boroughs. Further work was also being carried out to ensure that future services were aligned with provisions by other groups and agencies. To develop the best possible future model, attempts had been made at populating the model with various facts, e.g. how people access services currently, whether a single point of contact would be beneficial etc. It was firmly believed that the borough based model was the most sensible way to provide the best service also for the future.  This model is supported by commissioners and staff. 

 

• A key concern for future service provision was the need to identify ways in which people with severe mental health issues could access services more quickly to avoid them deteriorating further. This would be done by developing more flexible and more accessible services. Management had also sought to address issues relating to users from BME backgrounds, ensuring that future services were not impacting negatively on those groups and this had been done mainly by working closely with BME groups to identify specific needs. There was significant evidence that BME groups were not accessing services as quickly as other groups within the community and this had an adverse effect on their longer term mental health and recovery time.

 

• A restructure of the service to align with the new model would not result in a reduction of honoraries. There was currently a high demand to work in the service by honoraries and the restructure was not thought to impact on this demand. The location of honoraries, and staff more generally, was yet to be decided and would depend on the appointment of staff within the new structure. 

 

• The PTSD services are currently delivered from the  Traumatic Stress Service. Under the proposed re configuration such interventions will be delivered within each local borough team.People with PTSD often required assistance from the community mental health team who would attempt to address both social and mental health issues. Practical support would be better coordinated in the future.  PTSD. National services were also being provided and would continue

 

• Concerns relating to current waiting times for patients with mental health issues had been identified as part of the consultation exercise and increased attempts would be made to ensure that waiting times were reduced in the future. Waiting times varied across a range of specific services, however, it was acknowledged that ideally patients with mental health issues should not have to wait to be assessed or indeed receive services. The average waiting time was currently 9-12 weeks, with some functions offering services much faster. A future single point of assessment would assist in providing  faster services and less waiting time, as well as offering more flexibility of services and enabling practitioners to gain a better understanding of people’s specific and individual needs. It was also being proposed that support would be provided whilst people were waiting, e.g. peer support, coping strategies etc. Such schemes were currently being piloted successfully other boroughs, including Croydon, and Lambeth and Southwark would benefit from introducing such schemes.

 

• Linking the proposed new service with other services provided, including housing and benefit services, was key to improving services, particularly given the new provisions contained in the Health and Social Care Act 2012, which gave local authorities more responsibility for health functions. A joint health strategy should be developed to address this and provide a holistic and joint approach to mental health services for the future.

 

• In relation to longer term support for people suffering mental health issues, it was confirmed that this was an area of concern and attempts would be made to ensure that future service provision addressed this. The service model would be significantly different to the one used currently and it was anticipated that less individual longer term psychotherapy  would be provided. However, a range of shorter term evidenced based therapies and groups would be made available in addition to peer and social support services  All users would continue to receive adequate assessment when entering the system and be provided with a detailed care plan.

 

• Workshops held with staff groups from within the three boroughs (Lambeth, Southwark and Lewisham) had identified four main areas of focus: single point of entry system, activity levels, issues of access for BME groups and finally necessary training. Subsequently, three steering groups containing representatives from all current services had been held to work on these issues.

 

• In defining mental health problems, including more severe types of mental health issues, different service models would be developed to ensure that all patients were covered. Making sure that some of the most vulnerable users were not excluded were a top priority going forward and the use of more senior assessors would assist in addressing this problem.

 

• Equality Impact Assessments (EIAs) would be carried out when developing new services to ensure that no user group was disproportionately affected by the changes and that services were tailored to specific needs of different groups. The EIAs would be live documents, with ongoing amendments as appropriate. 

 

• Care plans provided for individual service users within all local services identified actions the service user may trake if they experience a crisis out of hours. Within the proposed service, consideration is being given to delivering a peer support group facilitated by staff for people with long termn psychological / relationship issues. A similar service is successfully run in Croydon, assists service users in developing their own crisis / coping plans.

 

• A full review of staffing structures has been carried out to assess competencies and skills required within the new model, including ensuring an adequate number of honoraries and senior staff as well as adequately trained assessors. There were clear national and local standards stipulating skills required for staff in supervisory roles as well as those assessing patients when entering the system.

 

• More work was to be carried out to identify the specific needs of people from BME groups to enable tailored services for those patients. Evidence gathered so far suggested that patients from BME groups seek help much later than other groups and this had an adverse impact on their longer term recovery.

 

 

3.6  Mental health practitioners and honoraries provided the following comments in response to the discussion:

 

• Overall, appreciation was given for the work already carried out in designing a future service delivery model for mental health, however, it was highlighted that the proposed model fell short of addressing adequately a number of issues which were of significant importance to patients with mental health issues. Some treatment options proposed did not take account of the underlying causes of mental health in many patients and would therefore not adequately address symptoms in the longer term.

 

• Many patients had been in the system for a long time and had experimented with a range of treatments, without success, and this called for an increased attempt by providers to address the needs of the service users and engage fully to understand what treatment options would benefit patients in the longer term.

 

•  Psychodynamic psychotherapy was one of the most beneficial treatment options for patients with longer term mental health issues and concern was expressed at the proposals to cease this service in the future.

 

•  The single point of entry system was also highlighted as problematic as this did not adequately take into account background information on a patient which was often very helpful in deciding treatments. The single point of entry system did not take account of people’s complex needs.

 

• Recent intervention had created time and opportunities to address the challenges faced by the existing mental health services and the service was in a better position overall as a result. However, there was a need for further integrated therapy to be developed and a range of issues, as identified as part of the new model, would require more scrutiny, including the issue of honoraries, unequal provision of services across boroughs and future funding cuts to local authority funding. 

 

• Focussed further work was also to be carried out with BME groups and other more vulnerable service users, including women from poorer backgrounds.

 

• Concerns were raised at the future of psychotherapy services for the future and more work was to be carried out to shape this to ensure a service which is fit for purpose.

 

• Reducing honoraries was also a key concern, given the very valuable work being carried out by honoraries in a range of areas, particularly given that honoraries were often paid very little or nothing at all for their hard work. Honoraries also required proper supervision to carry out their work and develop in the career and it was concerning if supervisors were to be reduced in the future as this could result in honoraries leaving the service.

 

 

 

3.7  Vanessa Hann, current service user, addressed the Committee and highlighted the following:

 

• She thanked the Committee for reading the report of the service user meeting on 8 May 2012 at St. Thomas’ Psychotherapy Department, where she had given a talk. This had been a very valuable session which she felt privileged to have been part of and the session had been attended by as many as 15 service users. She confirmed that she was speaking on the behalf of all service users at this meeting.

 

• She noted the significant difference between the shorter, simpler treatments (such as those mostly offered by CMHTs (Community Mental Health Teams or IAPT) and the deeper, longer treatments offered by St. Thomas' Psychotherapy Dept in particular, stating that the shorter treatment options would often require continued and regular attempts and did not address the underlying causes for mental health issues. The longer treatments, on the other hand, was a slower methods but one which offered real results in the longer term, by addressing the underlying issue for individual patients.  She also noted that one difficulty with the longer term treatments has been that their effectiveness is more difficult to measure within the NICE guide-lines than, for instance, CBT (Cognitive Behavioural Therapy), thus making it harder to resist funding cuts.  However, there were several ways to measure the effectiveness, e.g. the reduction in interactions with medical and other agencies (crisis interventions such as A&E visits regarding suicide attempts, relevant visits to GPs, court appearances resulting from rent difficulties, children taken into temporary or permanent care, and so on) and the reduction in medication over time.

 

• Concerns were raised that deeper and longer treatments were being reduced, just as a result of mental health issues not being curable, and she argued that mental health issues should be viewed in the same way as chronic physical health conditions, where on-going treatment costs are expected and accepted.  She also noted that the ‘deeper’ treatments do enable a lot of healing for many. 

 

 

• IAPT CBT therapy was thought to be more effective for less complex cases, e.g. those without deep rooted issues and very dysfunctional family backgrounds. 

 

• It was further noted that St. Thomas’ Psychotherapy Department was one of the very few which has their most experienced staff assessing incoming referrals.  This has the obvious advantage of picking up on things possibly missed otherwise and making it much more likely that an appropriate treatment is provided.

 

• She concluded by listing three measures which would aid future success of mental health services: ensuring senior experienced assessors (psychiatrists and psychotherapists as well as psychologists; not solely from the community mental health teams), a safety procedure providing a simple recourse (sideways or higher up)  if a patient, or professional involved in their care, believes there’s a mistake being made and finally the option for the IPTT Panel, or referring professional, to request a IPTT face-to-face patient assessment where appropriate. 

 

 

 

3.8  The Chair thanked all for attending and addressing the meeting, noting the difficulty and complexity of the issue.  The focus of the committees was on the need to ensure that proper consultation had been carried out because involving people who use services in their future design both leads to a better service and gives those involved a sense of empowerment.

 

RESOLVED:

 

1  To agree that SLaM management and staff meet once more to resolve differences over the delivery of different modalities and invite representatives from these professional bodies to attend: British Psychoanalytic Council and UK Council for Psychotherapy.

 

2  To agree that SLaM be given time to adequatenly digest the concerns raised during the consultation event held earlier that day, via the written submissions and at the scrutiny meeting and that these concerns be reflected in the final consultation proposals.

 

3  To agree that SLaM set out and agree an action strategy for ongoing consultation and evaluation of the Psychological Therapy Service with LINks, Southwark and Lambeth Clinical Commissioning Committee, and any other relevant other service user bodies and stakeholders. The evaluation framework should ensure that SLaM has a clear idea of what constitutes success and how staff and services users will feed into the evaluation; particularly service users with complex needs. The evaluation should ensure that data is captured on:

 

·  Clinical outcomes

·  Waiting times

·  Activity levels

·  Patient-Reported Outcome Measure (PROMs)

 

4  To agree that Psychological Therapy Service and Lambeth and Southwark council services, such as housing and social care, build effective links.

 

5  To recommend that service users awaiting treatment should be given clear information at entry stage on waiting times, support services and what type of service they will be receiving. Issues of access by BME individuals, and particularly late access, should also be followed up potentially as part of the monitoring framework. 

 

6   The committees welcomed SLaM’s proposed round table discussions to consider proposed changes to services over the coming three years and indentify those areas which are most likely to be contentions or benefit from in-depth engagement with Scrutiny and other stakeholders. In addition to this it is recommended that SLaM regularly attend the Stakeholder Reference Group for Lambeth Southwark & Lewisham (SRG LSL) to highlight and help identify issues of concern.

 

7  To agree to write to the SCCC / LCCCB asking for their views on the service reorganization and whether they are satisfied with proposed structure and outcomes for the service. In particular the potential drop in psychodynamic psychotherapy in Southwark will be highlighted and commissioners will be asked if they have a view on if they would like to invest more of their budget on this and less in other areas.

 

8  To agree to write to Monitor, the regulatory body for Hospital Foundation Trusts, highlighting the issues and concerns raised over the proposed reorganisation of Psychological Therapy Services.

 

9  To note that concerns remain about Honorariums and agree to request the following information:

 

·  The number of individual honorariums, their clinical specialism’s, the amount of patients seen and the level of therapeutic hours delivered over the last two years.

 

·  The anticipated reduction as a result of this reorganization on the modalities delivered, numbers of Honorariums, patients seen and therapeutic hours delivered.

 

·  The level of qualifications of Honorarium supervisors in the new proposed structure and clarify with the UK Council of Psychotherapy on the level of accreditation required.

 

10  Concern was raised about unequal provision between Southwark and Lambeth; details were requested on the availability of different modalities in the different boroughs and how this could be made more equal.