WANDSWORTH CLINICAL COMMISSIONING GROUP PROGRESS REPORT TO THE CCG BOARD 8 JULY 2015 MENTAL HEALTH CLINICAL REFERENCE GROUP 1. Purpose This paper sets out, for Wandsworth Clinical Commissioning Group (WCCG) Board members, the progress in developing and implementing on-going and new initiatives to improve mental health services and outcomes for patients in Wandsworth. The report will focus on the last and the forthcoming twelve months and will seek to describe: The national context of Parity of Esteem key health outcome priorities and the associated commissioning and finance plans, Baseline and performance of current commissioned services (including quality measures) Key commissioning developments and achievements during 2014/15 Mental Health Clinical Reference Group work programme, key priorities and challenges for 2015/16 The CCG Board is asked to note the above and provide comment on the 2015/16 plans. It is noted that this paper is presented to the CCG Board alongside the Annual Public Health Report, with the focus on Mental Health, Happy and Thriving Communities. The two papers are intended to complement each other. 2. Parity of Esteem The Forward View into Action: Planning for 2015/16 published in December 2014 described the approach for organisations such as Clinical Commissioning Groups in fulfilling the vision of the NHS Five Year Forward View. An area of priority for operational delivery in 2015/16 was the need to achieve parity for mental health. The key areas described in the parity of esteem commitment are: Delivery of pre-existing NHS Mandate priorities in relation to improving access to psychological therapies (IAPT) service standards (15% of the population accessing services and at least a 50% recovery rate) and dementia diagnosis (a commitment separately managed through Wandsworth CCG s Dementia Clinical Reference Group and elsewhere reported to Board) Introduction of new access and waiting time standards in mental health, with plans in place for delivery and maintenance by April 2016. o 50% of people experiencing a first episode of psychosis to receive treatment within two weeks. To deliver this locally a Service Delivery and Improvement Plan (SDIP) is to be agreed as part of the Mental Health contract with South 1
West London and St. Georges MH NHS Trust with an additional 132K of ring fenced funding. o Within IAPT, 75% of adults to have first treatment session within 6 weeks of referral and 95% within 18 weeks of referral. A SDIP to support this achievement will be part of the Service Level Agreement (SLA) with the main provider of Mental Health (MH) services to the Wandsworth population, SW London and St George s MH NHS Trust (SWL&SGH). The CCG has identified an additional investment of 225K to meet this new target, alongside the existing national targets for access and recovery. Ensuring adequate and effective levels of liaison psychiatry services in acute settings. Additional funding has been made available across Wandsworth and Merton CCGs for St. Georges University Hospital NHS Foundation Trust s A&E service and is being managed with the SWL&SGH through the System Resilience Group (SRG). Ensuring that those experiencing a mental health crisis are properly supported. A response to this has been the development of the local Crisis Care Concordat Action Plan in conjunction with key local stakeholders including Wandsworth Borough Council, SWLSGH and the Police. The Action Plan delivery will form part of the MH CRG work programme. The Forward View funding requirements for 2015/16 sets out the need to ensure that mental health spend will rise in real terms in every CCG and grow at least in line with each CCG s overall allocation growth: for WCCG this is growth of at least 1.94%. In order to achieve the percentage growth required in the Operating Plan guidance, WCCG needed to identify priority services for additional investments to a minimum of 1.587M. The full list of new investments for 2015/16 is detailed in Appendix C.. 3. Key Health Outcomes, Commissioning and Finance Plans Key Outcomes, Identifying Need Commissioners have continued to work collaboratively across Health and Social Care through the Joint Commissioning Unit to deliver the Joint Commissioning Plan for Mental Health. The Joint Commissioning Plan 2014-2017 included a refreshed Needs Analysis compiled by Public Health and was a key driver in the identification of priority work streams for improving outcomes for patients. The identified priority areas in 2014/15 were: Prevention and Wellbeing Improving the Quality of services Integration through pathway redesign More detail is provided in Appendix B, the CRG Work Programme. 2
During 2014/15, the lead Public Health expert has worked alongside the Mental Health CRG in the development of the Annual Public Health report for Wandsworth Happy and Thriving Communities Commissioning and Finance Plans The projected Wandsworth Clinical Commissioning Group s spend in 2015/16 for mental health services is 49.78M per annum. A breakdown of the spend is as follows: Sector of Spend Amount ( 000) South West London and St. Georges Mental Health NHS Trust 40,052 Neighbouring NHS MH Acute and Community Providers 1,832 Independent Sector MH Placements 4,825 Other MH Projects (including young people, voluntary and third sector) 3,071 Cost Improvement Plans with South West London and St. Georges Mental Health NHS Trust (SWLSTG) As throughout the NHS, the SLA with SWL&SGH is required to follow the business rules that detail the approach to inflation and efficiency on an annual basis. As part of its five year Transformation Plans SWL&SGH agreed its second year of Cost Improvement Plans with commissioners across South West London to release 3.5% efficiencies. For WCCG this amounted to 1.3M and was identified across transformational domains including CAMHS, community services, acute care pathway, older people, administration and clerical and other productivity domains. Commissioning clinical leaders, as part of the Clinical Quality Review Group, quality assured all programmes, ensuring safety and clinical effectiveness. For Wandsworth, clinical leaders worked hard with SWL&SGH to ensure that, in particular, clinical quality and capacity within community settings were not compromised. Community Transformation Part of the cost improvement workstream has resulted in a number of planned transformational changes for community teams within Wandsworth including: A better defined assessment and recovery focus, A move from four Community Mental Health Teams (CMHTs) to three Teams, Clozapine & Depot clinics A centralised administration function. There is a separate reorganisation of capacity and roles in the CMHTs resulting from changes to the Section 75 arrangement between the Trust and Wandsworth Borough Council for social worker support to the Teams. The Wandsworth CMHT transformation process aims to streamline pathways to create efficiencies and improve patient outcomes and experience. 3
Investments for 2015/16 As part of the parity of esteem and the desire to support real transformation within mental health services a number of investments have been programmed across the mental health system in Wandsworth. The table in Appendix C details those investments currently planned. Although the current list of investments is in excess of the 1.587M specified as the minimum uplift, the CCG is anticipating some slippage on service investments which may enable further non-recurrent funding to be made available in year. It may be possible for a second round of investment bids to be considered in September 2015. 4. Performance and Quality (SWL&SGH MH Trust) Key performance indicators (KPI), as quality standards, are monitored on a regular basis (see Appendix A for contract management arrangements) The thirty-six key performance indicators are Red/Amber/Green (RAG) rated across the CCG contracts and for each individual CCG. Indicators showing a Red performance rating are investigated within the monthly performance meeting held with SWL&SGH and actions developed as necessary on across CCGs. A sample of indicators for Month 12 for 2014/15 includes: Indicator Definition Proportion of Service Users followed up within 7 days of discharge from I/P episode Proportion of service users entering an IAPT course of treatment Q4 Proportion of service users who have recovered following a course of IAPT treatment. % of caseload on CPA receiving either face to face or telephone contact within the Month" Length of wait for first access to the Child and Adolescent MH Service YTD YTD Comments & Actions Target Actual 95% 96% Exceeding target 15% 13.45% Overall WCCG has met the target for Q4 through the contribution of practice based counsellors. An Action Plan developed through local monitoring arrangements to improve SWL&SGH performance. Performance issues continue in Q1 2015/16. 50% 45.2% Improving performance through local Action Plan, as above. Consideration of cluster impact (WCCG has a higher percentage of complex patients using the IAPT service than national benchmarks) 80% 77% Target monitored through Performance Meeting. Including review of caseloads. 8 2.2 Meeting target. 4
(weeks) Face to Face Gatekeeping: Ratio of all informal admissions to the number which are gate-kept by CR/HT service (face to face contacts only)" 95% 100% Meeting Target South West London and St. George s performance in relation to their Key Performance Indicators remains solid. Within the most recent Quarterly and Monthly reporting 91% of their indicators were Green or Amber (88% during last year). Those indicators that are showing Red and Amber are picked up at the monthly Cluster Performance meetings and this process is developing well The Clinical Quality Review Group work plan includes the Quality Dashboard, Serious Incident reporting, Service User and Carer input, CQUIN monitoring, Safety Thermometer progress, Quality Account, complaints, Safeguarding, CIP Quality Impact assessment, Transformational plan progress, Medicines Optimisation, Equality and Diversity Assurance and Saville report progress. As reported previously, SWL&SGH were in the first wave of the CQC s Chief Inspector of Hospital Inspections of MH Trusts and this was undertaken in March 2014. The Report was published on 12 June 2014. Overall, the CQC found staff caring with good approaches to patient care. Inspectors found a number of areas of good practice which included the Behaviour and Communication Support (BACS) service in Wandsworth. Areas where improvements were needed included: a. Ensuring planning and delivery of care always met individual needs b. Ensuring suitable storage, recording and monitoring systems for medication c. Continuing to monitor mixed gender wards to ensure full compliance with national guidance. The full report can be accessed at http://www.cqc.org.uk/location/rqy01. The Clinical Quality Review Group continues to review and track actions against CQC reporting. 5. Mental Health CRG Work Programme & Key achievements for last 12 months (2014/15) The Mental Health Clinical Reference Group s work programme is detailed in Appendix B. The themes that have been developed are Prevention and Promotion of Wellbeing, Quality of Services and Integration of Cross Cutting Pathways Progress on the Priority Areas - Snapshot: Prevention - BME representation in MH Services. The BME Working Group including clinical leadership, service users and carers, community stakeholders, Public Health and provider representatives has continued to meet. Projects against the emergent themes of prevention and wellbeing, early 5
intervention, assessment and admission and discharge have been scoped and where necessary developed. These include: Community Network of Family Care. Funding of training in Family therapy to ten local Pastors (Stage 2 of training) and a new cohort of ten local Muslim faith leaders. The learning from this project is expected to be one of six examples of good practice in NICE Guidelines to be published in Community Involvement and Health Promotion: February 2016. Surviving to Thriving. Funding of support to a project to improve mental health awareness, reduce stigma and develop Community Champions within the BME community. Expansion of Place2Be (see S3 investments) Developing community links within CMHT and IAPT BME carer involvement at Care Programme Approach reviews Diversity training for Primary care and SWLTG Peer-lead Inpatient audit review and discharge peer befriending The work of the group was presented and discussed at Healing our Broken Village Conference on 9 October 2014. Improving the Quality of Services - Psychological Therapies and Primary Care. Intensive and collaborative work with Providers has taken place during 2014/15 to meet the national targets for access, recovery and waiting times for IAPT. With key contributions from the SWL&SGH IAPT Team, Big White Wall and GP based Counsellors, linked to additional funding, the key access target (1,650 new people entering treatment) was achieved in Quarter 4. Longer term plans for the IAPT service and the potential procurement options were considered by the MH CRG and these will be taken forward during 2015/16. Development of an optimal model of care in primary care has been fed into the thinking of IAPT service planning and the community transformation work with SWL&SGH. Suicide Prevention This work has been lead as a sub-group of the MH CRG by Public Health. The Group has undertaken a vast amount of work mapping services and has been working on an audit of Coroners Reports for the last 5 years (access to such reports in this way is almost unique nationally). The Group will report back to the MH CRG during 2015/16 and drive forward actions as part of this work. Improving the Quality of Services - Service User and Carer Experience. This continues to be a strong MH CRG priority with the development of a Patient and Public Involvement Action Plan for the Group to ensure a clear voice for service users and carers. Representation at the MH CRG and all sub-groups of service users and carers remains positive. Target metrics around service user and carer experience remain in relation to SWL&SGH s progress to Foundation Trust status. Improving Integration/Cross Cutting Pathways 6
Work has commenced to ensure that robust pathways are in place for those with a comorbidity of mental health and substance misuse problems. Liaison meetings have taken place with key clinicians from SWLSTG and the new Substance Misuse Provider (SLAM) and a clear pathway for referrers has been drafted. An increased focus on those with a dual diagnosis of Mental Health and Learning disability has also been evident in the Review of Learning Disability services which included within its scope the Mental Health Learning Disability Team and also the work in relation to Winterbourne View where WCCG achieved discharges from hospital to community of 62% against a national target of 50%. Alongside the priority areas the MH CRG continues to monitor all its work programme objectives at each of its bi-monthly meetings. A snapshot of other number of commissioned services and their achievements includes: Wandsworth Well Family Service. This Project is commissioned through Family Action and is a continuation into 2015/16 of the Project originally agreed in 2013/14. The annual value is 121K which includes the requirement for independent evaluation of the Project Benefits which is expected during 2015/16. Project provides direct work within identified Surgeries and Health centres to provide volunteer mentors, peer support, key work, workshops and self-help groups and contributes to the improving Primary Care response work programme objective Big White Wall. The Big White Wall online service was commissioned as part of the response to the Psychological Therapies work programme objective. The Project value agreed was 129K non-recurrent funding for 2014/15 and 2015/16. The investment will be used to extend and build on existing activity, including providing Support Network places for Wandsworth residents, with 24/7 support available from trained counsellors and providing Live Therapy sessions (each equivalent to a Cognitive Behavioural Therapy or counselling session) for Wandsworth residents. During 2014/15 there were: 791 people joining the Support Network (+15% from 2013/14) 974 sessions of Live Therapy commissioned. (+14% from 2013/14) As of December 2014, 54% Recovery rate achieved for IAPT referrals and 64% Recovery rate for direct GP referrals, using IAPT standard measures Perinatal Services Review. As part of the MH CRG review of mental health services for pregnant women and new mothers, funding has been secured ( 150K) to support additional outreach resource within the existing commissioned services at SWLSTG and CNWL. A revised service specification and collaborative care pathway has been agreed. Also additional input from IAPT for new mothers was achieved. Older Adults & Children and Young People 7
Achievements within mental health services for older adults and children are led by the Older Adults & Dementia CRG & the Children s Health Overview and Clinical Reference Group respectively, and these were reported to the WCCG Board separately. As part of the MH CRG s role in oversight of mental health across all age groups, an update on achievements and key priorities for 2015-16 will be presented to the MH CRG during 2015. Other achievements The Mental Health CRG has also been able to deal dynamically with other issues as they have presented themselves: Personal Budgets the MH CRG has supported the development of a separate working group lead by Service User representation which has brought together key providers, SWLSTG and Social Services representatives in order to resolve a number of ongoing issues. The Group has helped develop pathways and better understand any blockages in the process to improve uptake of personal budgets. This continues to be a key area for the MH CRG. Freedom Passes an issue was raised at the January CRG around withdrawal of Freedom Pass by end of March. Colleagues from Wandsworth Borough Council were able to follow up the issue during the meeting and arrange for re-issue of those prematurely cancelled and clarify the new process for re-application. This highlights the dynamic nature of the MH CRG and how all stakeholders are working collaboratively to make improvements and resolve issues in real time. Street Triage this project was piloted during the winter of 2014/15. It was seen as a success in reducing S136 admissions in Wandsworth and providing confidence to partners such as the Police in dealing with people in mental health distress. To this end it has been agreed as an investment for 2015/16. 6. Mental Health Clinical Reference Group work programme, key priorities and challenges for 15/16 a. The MH CRG has continued to plan its work programme as detailed in Appendix B. Alongside the existing work programme objectives and priorities, key areas for 2015/16 include: i. Crisis Care Concordat Action Plan this will be included in the work programme for 2015/16. Key action plan areas are early intervention and responsive crisis services, support before crisis, access to crisis care, recovery & staying well and operational development. ii. Review of rehabilitation services. This is following a report commissioned from CIVIS and will be a joint programme alongside Wandsworth Borough Council and SWL&SGH. The Review will look at improving outcomes for patients through a seamless, modernised, integrated rehabilitation pathway. iii. Community service transformation see s3, Investments for 2015/16 iv. Foundation Trust application SWLSTG continues to progress in its application to become a Foundation Trust. A shadow Board of Governors is now in place with Wandsworth CCG represented by Dr Beugelink. SWL&SGH currently await approval from the NHS Trust Development Authority to apply to Monitor for 8
Foundation Trust status. The Monitor assessment stage will take four to five months. v. Estates Modernisation updates on the outcome of the Consultation process have been presented separately to the Board and have been to Joint Health Overview and Scrutiny Committee in early 2015. Key messages from Consultation were: Taking account of the feedback and the clinical case for change, the recommendation was to support the preferred option of building two new centres of excellence at Springfield and Tolworth. A number of improvements to the proposals are recommended. These include keeping adult deaf services on the Springfield site, a commitment to investing in Home Treatment Teams in all five boroughs and working with service users and families to agree improvements to travel plans, as well as providing overnight accommodation at Tolworth for carers visiting children or specialised care patients. There is also flexibility around bed numbers with contingency for a seventh adult mental health ward built into development plans. The new hospitals would not open before 2021 and there will be clear collaborative work to have a more developed community services in place before this time. An initial milestone will be a Gateway Review in relation to bed proposals which will be considered in October 2015. vi. The South West London Clinical Design Group (CDG) for Mental Health is beginning to draw together a longer term strategy for mental health across the cluster, and in particular areas where commissioners can collaborate to enhance outcomes. This work will develop during 2015/16 and onwards. b. Key challenges for 2015/16 7. Conclusion As well as those priorities detailed above, some of the other key strategic challenges that will be faced during 2015/16 onwards are: i. The issue of South West London Lead Commissioner for Mental Health. This is currently undertaken by Kingston CCG and consideration will need to be given as to how this role might be developed further. ii. As mentioned above, the continuation towards Foundation Trust status and the Estates Modernisation work with SWLSTG (including the issue of the CAMHS School). iii. The continued pressure on SWL&STG to realise an increasingly demanding Cost Improvement Programme with proposals which are effectively and clinical safe. The Mental Health Clinical Reference Group continues to build momentum across a wide range of work streams within Mental Health services, with the constant aim of improving outcomes for patients through earlier intervention (prevention), high quality services to patients and integrated pathways and commissioning. 9
The committed contribution and leadership of the membership - spanning clinicians, commissioners, service users, carers and providers - ensures that the Clinical Reference Group can successfully tackle its challenging agenda. The clear and agreed work programme has assisted in maintaining the focus. It is accepted that there is still much work to do, but there are real opportunities both through the national agenda of parity esteem and local initiatives to bring meaningful transformation to mental health services to improve outcomes for the people of Wandsworth and their families facing mental health problems. 7. Recommendations The Wandsworth Clinical Commissioning Group Board is asked to: 1. Note progress of the Mental Clinical Reference Group. 2. Note and comment on the agreed Plans, Priorities and Challenges for Mental Health during 2015/16 10
Appendix A SWLSTG Contract Management Arrangements Wandsworth s largest single provider of Mental Health services is South West London & St. George s MH NHS Trust (SWLSTG). The contract is a multi-lateral NHS Contract across CCGs in SW London. The Governance and Contract Management Structure is set out below: Merton CCG Associate Commissioner Richmond CCG Associate Commissioner Sutton CCG Associate Commissioner Wandsworth CCG Associate Commissioner Kingston CCG Lead Commissioner Commissioning Support Unit (CSU) Contract Management Function Contract Performance Meeting Clinical Quality Review Group MENTAL HEALTH BLOCK CONTRACT - SWLSTG Monitoring of the SWLSTG MH Contract is undertaken through a combination of a Monthly Performance meeting and a Clinical Quality Review Group (CQRG). Both meetings are lead by Kingston but include key Wandsworth representation. The monthly Performance Meeting is attended by MH Commissioning Leads (non-clinical) from Wandsworth CCG and Wandsworth Local Authority. The Clinical Quality Review Group is attended by a Wandsworth GP Clinical Lead and the CCG s Quality Lead. Regular liaison and sharing of papers is undertaken by the respective leads to ensure that the key links across performance and quality are maintained. The Clinical Quality Review Group measures SWLSTG s performance in relation to quality against nationally and locally agreed standards, seeking to ensure that services commissioned from the Trust deliver the best health outcomes. The key objectives of the CQRG cover the five National Outcome Framework quality domains: Preventing people from dying prematurely Enhancing quality of life for people with long term conditions Helping people to recover from episode of ill health or following injury Ensuring people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm 11
APPENDIX B Mental Health CRG Work Programme Work Plan Groupings 1 Prevention/Promotion of Wellbeing: [Overarching requirement for co-production across all work-streams] MH promotion work streams BME over-representation in MH services, including adults and young people [Priority Area] Talking Therapies [Priority Area] Primary care, optimal model of care, map to WCCG. What this looks like and how it might be implemented. [Priority Area] Debt management Suicide prevention Joint Strategic Needs Assessment (refresh) Rationale: reduce the burden of mental ill health, reduce health inequalities, increase resilience, improve early intervention, Strategic fit with H&WB priorities 2 Quality [Overarching requirement for co-production across all work-streams] MH Clinical Quality Review Group (CQRG) Risk summit/cqc/quality Accounts/Serious Incidents Service User and Carer Experience and Engagement. To include transition and prevention. [Priority Area] Adult rehab model of care CMHT Review aim for 2014/15 Acute and community care performance Work-force development. Rationale: Key objective of the CCG to have high quality services. 12
Work Plan Groupings 3 Specialised/Cross-Cutting Care Pathways [Overarching requirement for co-production across all work-streams] CAMHS (joining up Tiers 2, 3 and 4) Other children s MH Personality Disorder Services (SUN Project) Dual diagnosis (substance misuse and/or LD) ADHD/ASD in adolescents and adults Rationale: Promote integration and seamless service for patients (priority of H&WBB) Prevent poor practice in silos etc. 13
APPENDIX C LIST OF MENTAL HEALTH INVESTMENTS Investment Amount Commentary Crisis and Home Treatment Team (including Street Triage) 325K To increase capacity to national benchmark to support work on the acute care pathway and proposed reduction in beds (see Estates Modernisation). Community Mental Health Teams (CMHT) Up to 300K Maintains the Street Triage function further to the pilot to improve crisis care. To support transformation to new community model Early Intervention Service 132K To support delivery of improved response to first episode of psychosis (Parity of Esteem) Improving Access to Psychological Treatment (IAPT) 225K Additional investment to support service development to meet access, recovery and new waiting times targets. Also to support infrastructure with community settings. Liaison Psychiatry at St. Georges 181K (tbc) Across Wandsworth and Merton CCGs. To be developed through Systems Resilience Group. Hearing Voices Group 22K Working with Wandsworth & Westminster MIND to deliver self-help group for those hearing voices. Mental Health physical activity programme 44K Working with Wandsworth Borough Council and MIND to deliver programme that increases physical activity levels of patients with moderate-severe mental health conditions. Service User Network (SUN) 50K To deliver a service for people with Personality Disorder ahead of review to mainstream functions. IAPT data collection 18K Supporting primary care based counsellors to contribute and support increased access to IAPT Place2Be 115K Support and expansion of a counselling service in Primary Schools. Linked to BME inequalities work stream. Dementia Behaviour & Communication Support service 282K Service to be further rolled out across contracted care and nursing homes (replacement of pilot funding with recurrent funding) 14
Memory Assessment Service 29K Additional funding to meet demand on existing service Other Dementia Projects 82K Includes a Joint Carers Support Service for self-management, specialist dementia training for carers and a voluntary sector mapping of dementia provision. Other Older Adult Community Teams TOTAL Up to 200K 2,005K Supporting additional transformation to complement the development of the Memory Assessment Service and Behaviour and Communication Support Team. 15