Item 12.1 Appendix 1 A FIVE YEAR STRATEGY FOR NHS TAYSIDE MENTAL HEALTH SERVICES INTRODUCTION This document sets out a five year strategy for Mental Health Services provided by NHS Tayside, covering the period 2011 to 2016. It relates to the provision of mental health services to adults over 18 years of age, but does not address services for people with dementia. The purpose of the strategy is to set the priorities and provide the overall direction for the modernisation of NHS Tayside s Mental Health services. Four priorities are identified and these will be used to underpin NHS Tayside s annual commissioning plans. These priorities have been developed in the context of our partnerships, progress with delivering previous local and national plans for Mental Health Services, the information available to us from the national and local Mental Health benchmarking work, progress with the development of the mental health commissioning plans endorsed by NHS Tayside over the past three years and advice and support from senior clinicians. The strategy is intended to support the overall strategic aims of NHS Tayside and to provide the context for the development of annual commissioning plans and service development plans. It will be reviewed periodically and refreshed when necessary to reflect progress with delivery and any changes to the wider strategic aims of NHS Tayside. There are important links and relationships between this strategy and other NHS Tayside plans. The principal of these are the Health Equity Strategy, the Child Health Strategy and the local action plans to implement Towards a Mentally Flourishing Scotland. If we are able to address inequalities, improve early years development and develop personal and community resilience through the delivery of these plans this will have a very significant impact on the prevalence of mental health problems. The four priorities are inextricably linked with each other and no individual priority has precedence over the others. The delivery of these priorities will be fundamental to NHS Tayside s annual commissioning plan, most obviously in the mental health section of the plan but in other parts such as public health commissioning and long term conditions. THE STRATEGIC PRIORITIES FOR NHS TAYSIDE FROM 2011-2016 1. Improving Quality of Care and the Patient s Experience It perhaps seems hardly necessary to state that NHS Tayside wishes to provide good quality services and that patient s experience of treatment and care should be a positive one. However developing and sustaining high quality services requires the attention of all parts of the organisation and it is important to be clear about the specific improvements that are expected. The following four areas are therefore to be sustained and developed: a) The engagement and involvement of patients in their own care and treatment will continue to be a mainstay of NHS Tayside s approach to improving our mental health services. We will continue to solicit feedback on the care and treatment people receive and we will act on that feedback. We will work to develop models of care that support a self management approach and place patients at the centre of care planning. We will continue to actively encourage and provide practical support for people to be involved in and to influence changes to mental health services. This approach to engagement and involvement will also apply to people who care for others with a mental health problem.
b) The greatest determinant of the quality of care that we deliver is the individual and collective skills of our staff. Investing in the clinical skills of nursing staff and allied health professionals will be an explicit component of our approach and in particular we will look to improve and enhance the delivery of psychological and behavioural skills among front line staff. Similarly the re-validation of medical practice among psychiatrists will be fundamental to the delivery of high quality medical interventions. c) Ensuring that front line staff are supported to develop and deploy their skills appropriately and effectively is at the core of a clinically effective service. Appropriate systems of clinical supervision across mental health services will be developed and maintained. d) Ensuring patient safety, particularly for those whose illness or disability makes them more vulnerable, remains a priority for NHS Tayside. Supporting the development and maintenance of robust clinical governance arrangements and the support and sponsorship of specific patient safety initiatives will remain a priority for mental health services. 2. Prioritising What We Do and How We Do It Services will naturally be expected to undertake all of their activities to the best of their abilities and to meet or exceed national or local standards. However, to provide a structure to this and to enable us to prioritise the work that is undertaken the following approaches will be adopted:- a) In recognition of the volume of Mental Health problems that present to and are managed within Primary Care, we will improve the capability and capacity of primary care to assess and treat or refer on patients as appropriate. And to have access to resources that will help them respond to patients experiencing emotional distress and who require support but not medical intervention. This will build on the existing work to develop a matched psychological model of care with social prescribing, access and support for self-help, and access to a range of psychological therapies. b) The adoption of condition specific models of care clarifying the interventions that will be provided by General Practitioners and primary care services and those that will be provided by specialist Community Mental Health Services. Such an approach will utilise NHSQIS standards for condition specific Integrated Care Pathways (ICPS) and other relevant professional guidelines. The development of such models of care will build on the approach first set out in the mental health commissioning plan of 2009 in relation to Obsessive Compulsive Disorder. c) NHS Tayside Health Equity Strategy highlights the benefits of an approach called coproduction. The underlying principle of this approach is that people s needs are better met when they are involved in an equal and reciprocal relationship with professionals and others to get things done 1. This resonates with the features of a mental health service that is focussed on recovery and builds upon individuals strengths; develops partnerships with its patients; involves patients in the management of their own care and treatment; and works to build individuals resilience and recognises the benefits of peer support. This principle should become embedded in how services approach the delivery of care and treatment. Examples of good practice already in existence in Tayside such as the embedding of peer support workers in community mental health teams, adopting a recovery focussed approach to care planning supported by the provision of recovery focussed training to our frontline staff, will be extended so they become the norm and other opportunities to embed a focus on recovery will be pursued. 1 Right Here, Right Now, Taking Co-production into the Mainstream : Boyle, Coote et al, London 2010
d) The wider implications of the Health Equity Strategy relate to the longer term mental health and well being of the population of Tayside. There is growing evidence to link the prevalence of mental health problems and poorer treatment outcomes with social deprivation. There is also clear evidence that people with mental health problems have poorer physical health and have poorer outcomes in relation to these health problems. The intent to tackle inequalities and to make a positive impact on the environmental factors which often underpin or exacerbate common mental health problems such as anxiety or depression should reduce the burden of mental health problems, particularly on primary care, and contribute to better outcomes for patients with chronic illnesses. We will work to develop and deliver local action plans in collaboration with our Community Planning Partners which aim to reduce inequalities and improve mental health and well being. We will also work to improve the management of mental ill-health for those with physical health problems. 3. Measuring and Improving Clinical Effectiveness It has become clear that, although we have improved our information and intelligence surrounding our resource use, activity levels and service efficiencies, our ability to measure the clinical effectiveness of our services and interventions remains weak. This is not a problem peculiar to Tayside and, although there are strong evidence bases for the treatment and interventions that are provided, we struggle to routinely produce regular information on the clinical effectiveness of the various psychiatric services. With the development of new mental health information systems across Tayside there is an opportunity to improve this position and to build on existing work in Tayside. Therefore the following approaches will be developed:- a) Development, endorsement and roll out of the IT enabled clinical effectiveness project, piloted within psychological therapies to all psychiatric sub-specialties. b) Adapting the approach used within the Substance misuse services to produce and endorse a local outcome framework relevant to each of the psychiatric subspecialties and for the treatment of mental illness within primary care. c) Ensuring that variance reporting from agreed Integrated Care Pathways is collected and reported. Each of these developments can then be used by individual services to monitor and improve services. Improving our ability to measure the clinical effectiveness of our services naturally leads to an expectation that this knowledge will be used to underpin the annual commissioning plans. It is therefore proposed that the strategic plan sets out the intent that reliable information on the effectiveness of interventions and the ability of services to deliver them will be used to do the following through the annual commissioning plan : d) Specify particular developments or improvements within individual or groups of services. An example of such targeted commissioning would be to specify a timeframe for services to demonstrate that the requisite skills were being used to assess the need for and the delivery of particular interventions e.g. the availability of psychological treatments. This would build upon the previous work to develop condition specific commissioning. e) To identify activities or interventions that should be reduced or ceased entirely. f) Further develop the use of targeted performance indicators that would have a focus on clinical and patient outcomes in addition to those that have a focus on service efficiency.
4. Making Best Use of Our Resources The national benchmarking work 2 indicates that NHS Tayside continues to spend more per capita on general psychiatry services than other Health Boards in Scotland when that population is weighted for social circumstances, demographic profile and population density. However the proportion of that expenditure that is for community services remains below the Scottish Average. NHS Tayside employs more staff per head of population in General Psychiatry than any other Board apart from NHS Borders and by far the highest number of hospital staff per head of population. Our information on expenditure on psychiatry of old age is less well developed, largely due to the difficulty of differentiating between expenditure on dementia services and general psychiatry services. However there remains significant variance between NHS Tayside and other health Boards in the use of its resources and our services remain high cost. 3 Although less easy to measure and compare it would appear that NHS Tayside is making improvements in the effective use of its resources e.g. reductions in the average length of stay in hospital which are below the Scottish mean and the median. 4 The immediate prospect for public sector spending in Scotland will following the Scottish Government s Public Spending Review is that while NHS budgets will not face the same reduction as many other public services there will be a real term reduction in available resources each year for at least four years. Financial planning in NHS Tayside based on this assessment will require savings from the Mental Health Services of 4.6M by 2014/15. Delivering the strategic plan for mental health will therefore not only have to be delivered without any additional investment but also that improvements and efficiencies in resource use will be required to meet this target and ensure a sustainable and effective service is provided. It is therefore proposed that three issues relating to our resource use are prioritised within the strategic plan as follows:- a) Further revisions are made to our in patient provision to ensure the maximum benefit is gained from the investment in the new facilities at Murray Royal and Stracathro and adaptations at Carseview. These revisions would lead to the inclusion of in-patient facilities for over 65s from Dundee and the Tayside Alcohol Problems Service. There will also be a requirement for these revisions to ensure we are able to meet the needs of patients with more challenging behaviour and provide low secure care for women. The impact of this would be to reduce the overall numbers of beds. The scale of reduction will be determined by a combination of benchmarking the NHS Tayside level of provision with other comparable systems and recognised national guidelines and from the experience gained from the development of local community services and tests of change in our ways of working. 2 Mental Health Benchmarking Implementation Project Update 2008/09, ISD Feb 2010 3 National Mental health benchmarking project- NHS Tayside Benchmarked against the Scottish average- Summary Report, Directorate of health strategy May 2010 4 Mental Health Benchmarking Implementation Project Update 2008/09, ISD Feb 2010
b) To review and revise our staffing radically in relation to the overall numbers, the deployment between hospital and community and in the training and skills of our staff. This review would have the goal of achieving a staffing profile that is comparable to NHS boards with populations of a similar size and composition and that is able to effectively deliver clinically appropriate care. c) To examine and revise our internal service boundaries between the various psychiatric sub-specialties. The aim of this will be to ensure that we are able to provide the necessary clinical expertise to meet the needs of our patients and to ensure that there is equitable access to a service irrespective of a person s age or where they reside. A balance will need to be struck between shifting workloads between sub-specialties and ensuring that the necessary clinical expertise is available to meet particular needs e.g. co-morbid psychiatric problems and physical problems associated with ageing. SUMMARY Significant progress has been made in developing and improving mental health services in Tayside over the past decade and significant additional investment has been made. We need to build on these achievements and this strategy should provide the backcloth to achieving improvements to the health of the population, and the further modernisation of the mental health service to achieve a shift in the balance of care, improvements to the quality of care and more efficient use of our resources. Successful delivery of this new strategy will be dependent upon the development of our annual commissioning plans and supporting resource and workforce plans. The strategy also needs to be integrated with other plans. The stepped changes required will most obviously be articulated in the mental health section of the commissioning plan but should also appear in components of the public health, older peoples and long term conditions sections. Neil C. Fraser Mental Health Commissioner