Agenda item

The Committee will receive an update from Coventry and Warwickshire Partnership NHS Trust (CWPT) about the transformation of community mental health services.

The Committee received a report and presentation from Eleanor Cappell, Alastair Penman and Richard Onyon of Coventry and Warwickshire NHS Partnership Trust (CWPT). The report confirmed the commitment to expanding services for people experiencing mental health illness. A revised approach would enable people to take an active role in their care planning and delivery, promoting greater choice and control over their own health and wellbeing. CWPT was committed to people not having to repeat their story or have multiple assessments. The report set out the approach to fostering a sense of safety and support, building trusting relationships with individuals, to promote recovery and a strengths-based approach.

The impact and benefits of this approach were reported, along with the aims to reduce health inequalities.  Key aspects were a multi-disciplinary approach, providing better access with greater geographical reach. There would be closer links with the community and localities, including partnership working with the voluntary and community sector (VCS). The aim was to be more responsive preventing people reaching a mental health crisis requiring their admission to hospital. The transformation had and would continue to deliver these positive impacts to reduce health inequalities, through specialist social work services, having a stronger presence in community teams, and moving to a strengths-based specialist assessment. As the transformation progressed with teams coming together, the focus would be on improving referral pathways, moving away from diagnosis-led services towards more ‘open door’ personalised support.

The report was for the Committee’s information but also sought support to the permanent closure of the pre-existing day services. The supporting presentation drew out the key messages including the rationale to close the day hospitals. Slides covered the following areas:

• Community mental health transformation - impact
• The National ‘ask’
• CWPT’s impact
• Adult social care offer
• The commitment
• What are the benefits?
• Key areas of focus for 2024/25
• Learning and what will change moving forward
• Day hospitals – The former Clinical Commissioning Group commissioned the Oakwood and Fennel Day Hospitals. The services were largely suspended in response to the Covid pandemic. The pandemic had accelerated the development of modernised mental health services.
• Recommendations for the permanent closure of the day hospitals, as they duplicated services now delivered via multi-disciplinary assessment, care planning and delivery of new therapeutic options within a place-based model.
• The benefits of the modernised service, which was more responsive, integrated, and individualised, with care closer to home and with the ambition to achieve better outcomes for patients.

In closing the presentation, Alastair Penman confirmed that currently people requiring inpatient care were being cared for locally. Richard Onyon emphasised the benefits of the community teams in providing constant and more responsive cover for the whole of Warwickshire, rather than requiring people to travel to specific centres like that located at Nuneaton. The new service was holistic and enabled better management of inpatient beds. It had removed the previous requirement for patients to be located at centres a considerable distance from their home. Eleanor Cappell reminded of the earlier presentation to the committee at the start of the transformation process. Historically, mental health services had been underfunded. There was a plan and aims to embed the current approaches. Eleanor emphasised the valuable input from experts by experience, people with lived experience of local services, who had been involved in the design of the new model.

Questions and comments were invited, with responses provided as indicated:

• The Chair opened the questions, and it seemed that the revised arrangements were working well. She asked how well the cover for 24 hours each day, seven days per week (24/7) was working, whether there were sufficient staff and they were attracted to this role. She asked about the impact for the police, who often had to respond when people were in crisis. Alastair Penman spoke about the new NHS service, known as NHS111*2. It provided access to local trained call handlers who could connect the person with the correct service. In cases involving urgent mental health needs, it may be the person was referred to the police or was signposted to the local A&E department, which was recognised as not being ideal. More often, it would be a ‘warm transfer’ to the crisis resolution home treatment teams which provided 24/7 cover and a qualified mental health practitioner would provide initial support. There were dedicated mental health liaison teams located at the three acute hospitals serving Coventry and Warwickshire. Reference was also made to the police initiative, ‘right care, right person’ which aimed to reduce the amount of police time spent supporting people in mental health crisis. This area could be the subject of a future presentation and the Chair suggested that this should be received. Richard Onyon spoke of the initiatives in place in Warwickshire linking mental health services with the police. In some cases, there was both criminality and the person had a mental health condition. This could be when the person was in custody and there was a street triage team where mental health nurses accompanied police response teams.
• Councillor Rolfe asked about the pathways available to the Samaritans, who people were more likely to call than using the 111 service. Richard Onyon praised this well-known charity and the service it provided. They were not the main partners of CWPT, which worked with Rethink and Mind operationally. Samaritans were aware of the access routes into mental health services including the crisis teams. Councillor Rolfe suggested that CWPT should have more contact with Samaritans. A lot of the calls to Samaritans in Stratford were from people in mental health crisis and she considered that closer working with this charity might help. The Chair agreed as councillors had many connections in their local areas and this suggestion could be helpful.
• Councillor Drew referred to psychological therapy, asking how many new psychologists and specialists would need to be recruited. Alastair Penman spoke of the significant investment in talking therapies, more than in other areas of mental health services. He gave an outline of the way this service was delivered the range of conditions treatment was provided for and the qualification and career pathways. The roles attracted many applications with the example of a psychology assistant used. It was estimated that 25-26 additional staff would be recruited subject to having sufficient funding. 
• Eleanor Cappell added that secondary care mental health teams also had an uplift in roles and pathways. As an example, CWPT had been a regional lead for taking on mental health and wellbeing practitioners. It was emphasised that development of services was continual. A pilot scheme in neighbouring Birmingham and Solihull was used to show the move to more locality-based community mental health services, with hubs which could provide a range of mental health services for that locality.
• Discussion about the move away from a medical model to provide holistic and person-centred support. More information was sought in how this would take place and how the VCS would be involved and develop their services. Eleanor Cappell explained the significant staff training over a four-year period and cultural shift away from a medical model. This gave parity between medical and other aspects like housing and employment. The work with social care had helped to move to a strengths and asset based model, which had seen changes in policies, processes and continual training. The work with experts by experience had been informative in showing the value and outcomes which could be achieved. The journey would continue. Reference also to the inclusion of VCS in the Care Collaborative. They provided a valuable role, were closer to their communities and could sometimes deliver services in a more cost-effective way. It was confirmed that clinicians were supportive of the new service model, recognising that patients had a range of needs when unwell. A related question concerned the DIALOG questions shown in the slide pack, used to assess an individual’s satisfaction with a range of domains. These were scored by professionals and repeated periodically to give a holistic view and an indication of the person’s wellbeing.
• Councillor Holland commented that this committee could help to join up services. He used a scenario to show how a delay in providing effective mental health services for an individual could impact on their family and consequential costs for a range of other organisations. Another example was providing suitable premises and support to assist self-help groups.
• The Chair suggested that several briefing notes could be circulated after this meeting to add further detail on the areas discussed.
• Reference to the co-production of the new models of care.
• It was noted that the former waiting lists for psychologists were lengthy. There was a multi-disciplinary approach with a stepped care model, which tailored the support and interventions dependent on the patient’s needs. The use of group support would help some. The co-production had been transformational, involving a range of different health professionals including GP doctors. The value of experts by experience was emphasised. These former service users, now employed by the charitable partners had a significant impact in shaping the new services and access to them. This had been recognised by a national award for public engagement in transformation.
• It was noted that the day hospitals had previously been used as a location for blood tests. Patients could now have their blood taken at a range of settings including hospitals, a GP surgery or even at home. This provided more flexibility than previously. 
• On crisis care and visits to home, a risk-based approach was taken, with two staff attending if there were any risks to them. In other cases, lone working was feasible if there were no risks to staff. There were a range of contact methods used by staff when arriving and leaving each visit.
• A councillor previously employed in this service area spoke of the benefits of the collaborative approach which was being reintroduced. The model seemed like the successful approach used when she worked with dementia patients. She considered this approach to be patient centred.  Alastair Penman confirmed the similarities in this model from his previous experience, the benefits of the approach and it was now much more locality based. He drew a comparison to the primary care network approach and becoming more population based.
• Healthwatch Warwickshire (HWW) welcomed much of the report, especially the flexibility to meet patients’ needs and the way the collaborative had been developed with significant patient and public input. HWW would test the effectiveness of the NHS 111 services based on the lived experience of people trying to use it and would report their findings. Referring to current patient feedback, there seemed a disconnect between what should be happening and the lived experience. This may take time to reset, building relationships, trust and credibility. People with a serious mental illness being placed on a general medical ward was still an issue which had an impact for both that person and other patients. There was a need to support carers too.
• The Chair welcomed HWW’s positive input and their continued monitoring of this area. It would take time for people to understand the new arrangements and pathways, with some still struggling to access services. It would be helpful for members to know the pathways and if NHS111*2 proved successful she would publicise this widely.
• A councillor referred to the slide showing key areas of focus. He asked about the investment required to build the multi-disciplinary teams and whether the existing funding model was sufficient to meet the challenges ahead. He suggested a minor change to the wording of the slide on learning to date and what the trust ‘will’ change. This was agreed.
• Alastair Penman confirmed the funding was tight and it was a case of repurposing the money. Some services needed to be undertaken by senior clinicians. For others, multi-professional approved clinicians (MPAC) could receive appropriate training to undertake those services, freeing up the consultants to specialise and focus on the most complex roles. He drew a comparison to the shift in primary care where other clinicians undertook roles instead of the GP doctor. There had been significant investment in mental health services, but in the main, it was repurposing the existing funding, achieving cost savings and reinvestment of those savings.  Richard Onyon confirmed that compared to 2020 when the transformation started, additional funding of around £12m per year had been invested in mental health services for Coventry and Warwickshire. There were 200 more staff working in the services, giving more responsive and holistic care, which included staff employed by VCS partners.
• The Chair asked if the MPAC approach could extend to providing child and adolescent mental health services (CAMHS), through triage. There were a range of new roles. The MPAC approach enabled other clinicians to undertake roles previously delivered by a consultant psychiatrist. Health and wellbeing practitioners were trained to deliver psychological interventions, including for CAMHS patients, giving a broadening of the workforce.  
• Discussion took place on the transition of care for young people to the adult mental health services. The services for children and adults were delivered by different teams. There was a recognition that most serious mental illnesses started in adolescence. Reference was made to the feedback from experts by experience. It was recognised that the transition could be difficult for some, so there were various arrangements in place to support people. Medically, there were different qualifications for child and adult psychiatrists, so they could not continue to provide the care but could seek to make the transition as smooth as possible.  People transitioned when aged 17-18. CAMHS tended to be more psychologically driven and therapeutic, whereas adult services were likely to be intervention led. Alastair explained the ongoing discussions about a youth service project to support people aged between 16-25, which would link well with the local authority’s arrangements, especially for care leavers. This would move the transition point to 25. People aged 17-18 could vary significantly in terms of their emotional development and a range of other factors were reported. The ability to flex the pathway rather than it being based on a specific age was helpful and should be driven by the individual’s needs. There was use of technology too with a mobile telephone application, with chat functions and a menu of options, which was more attractive to many younger people than an appointment with a clinician.

The Chair thanked the presenters for this useful item and reminded members of the report recommendations. It was agreed that the Committee:

1. Notes the content of the report and presentation and the steps being taken to strengthen access to community mental health support for adults and older adults, across Warwickshire.

2. Supports the recommendations that the pre-existing day service units are permanently closed as they represent a duplication of services now delivered in alternate ways.

Councillor Holland abstained from voting on this item.

Pete Sidgwick spoke briefly about the Section 75 agreement in place with CWPT and the very good working relationships between that organisation and the Council.