NHS GRAMPIAN Board Meeting 01.06.17 Open Session Item 8 Local Delivery Plan - Mental Health and Learning Disability Services 1. Actions Recommended The Board is asked to: Note the context regarding the development of a national Mental Health Strategy; Review the actions taken to redesign the Child and Adolescent Mental Health Services to improve access (Appendix A); and Consider the changes and innovative practices being implemented within the four teams presenting on behalf of the Mental Health and Learning Disability Services Perinatal Mental Health, Older Persons, Adult Mental Health and Child and Adolescent Mental Health Services. 2. Strategic Context At the end of March 2017, Mental Health in Scotland a 10 year vision was published setting a commitment over the 10 years of the strategy to achieve parity between mental and physical health. This is the first national strategy in health and social care since the establishment of the new Integration Joint Boards (IJBs) and will provide new opportunities for local areas to develop their own approaches, to innovate and to work across service boundaries to meet the needs of the local population. This strategy aims to make clear the scale of the ambition over 10 years, to focus national actions to support local delivery, to remove barriers to change, and to make sure that change happens The scale of the challenge to achieve parity of mental and physical health is considerable: Only 1 in 3 people who would benefit from treatment for a mental illness currently receive it, on current estimates. People with life-long mental illness are likely to die 15-20 years prematurely because of physical ill-health. People with a mental health problem are more likely than others to wait longer than 4 hours in an Emergency Department. Over the 10 years of this strategy, a commitment has been given to measuring the following for mental health compared to physical health: Equal access to the most effective and safest care and treatment: Demonstrated by increasing the proportion of people who receive treatment for a mental illness, who would benefit from that treatment. This will also require improvements in prescribing and follow up care. 1
Equal efforts to improve the quality of care: Demonstrated by achieving the same level of access to services and the same efforts to improve standards, infrastructure and staffing in mental healthcare as in physical healthcare. Allocation of time, effort and resources on a basis commensurate with need: Including addressing higher rates of premature mortality by targeting efforts at higher smoking rates and improving access to physical healthcare for people with a mental illness. Equal status within healthcare education and practice: Demonstrated by supporting core skills and competencies in mental health for a variety of staff. Equally high aspirations for service users: Recognising service users as equal partners in their own healthcare and emphasising expectations of good health and a good life. Equal status in the measurement of health outcomes: Met by robustly measuring people s responses to treatment, and people s experiences of mental health services, just as in physical healthcare. Improvements will be supported by increasing resources for mental health, including an increasing share of the NHS frontline revenue budget, and investing in innovation in services. Plans for investment twinned with reform to help deliver the best mental health outcomes possible will be targeted as follows: Primary Care Transformation: supporting the development of new multidisciplinary models of supporting mental health in primary care to deliver ask once, get help fast. That will necessitate models that allow access to information about what help is available; information about what people can do to look after themselves; signposting and support to access facilities in the community and information about who is available to provide support so they can make informed decisions about what is best for them. Urgent Care Transformation: prioritisation of mental health pathways for people who need urgent care, including in emergencies in A&E. This means that when somebody has a mental health problem out-of-hours, they know how to, and are able to, access support as easily as they can for a physical health problem. This will include improving the range of support available through NHS24; ensuring that staff in A&E are able to support people in distress; and ensuring there is good access to specialist mental health support when it is needed. Child and Adolescent Mental Health Services (CAMHS): Demand for this specialism is continuing to increase and services could work together more effectively, or to intervene early. This will look at the whole system, recognising the importance of specialist services but also the importance of early interventions at tiers 1 and 2. This includes providing support for families through parenting programmes where appropriate. 2
3. Key matters relevant to recommendation In NHS Grampian community adult mental health, older adult mental health, learning disability and substance misuse services are integrated within the three Health and Social Care Partnerships (HSCPs). All inpatient services, other specialist services and CAMHS are managed by the Health Board as a hosted Mental Health and Learning Disability Service (MH&LDS). The hosted MH&LDS and the 3 HSCPs are working very closely to ensure that patient pathways and good governance are maintained and there is a joint focus on delivering a high quality patient centred care service. This includes minimising access times to care. In terms of meeting the national commitments set out in the Mental Health in Scotland 10 year vision, we would highlight the following: 1. Access to effective and safest care and treatment As a result of a low staffing establishment and some recruitment difficulties the services for Child and Adolescent Mental Health Services (CAMHS) and psychological therapies have been unable to meet the Local Delivery Plan standard of access within 18 weeks for all. We continue to take action to deliver improvement and work with the NHS Scotland Mental Health Access Improvement Support Team to ensure all that can be done is done. In terms of improving access to services we would highlight the following actions, with further details in relation to the CAMHS service set out within Appendix A. We will continue to use the Choice and Partnership Approach (CAPA) model in CAMHS and undertake routine demand and capacity checks, including individual practitioner caseload reviews, across all psychological therapy services. We will consider the local demographic shift and population projections to establish potential future service demand and to inform development and redesign. We will continue to implement our CAMHS service redesign and our inpatient adult mental health redesign. These design processes include provision of psychological therapies. 2. Improve the quality of care The MH&LDS is committed to continuous improvement and improving quality of care. Two key developments that have been progressed in the last six months are: The National Managed Clinical Network for Perinatal Mental Health was launched in Aberdeen on 20th January 2017. A Mental Health Work Programme Group for HM Prison (HMP) Grampian was established in March 2017 following an HM Inspectorate Prisons for Scotland inspection report that identified issues regarding the provision of mental health care in HMP Grampian. 3
3. Equal status within healthcare education and practice Staff development, training and education is key to creating and maintaining a robust and pro-active workforce and remains high priority. We will ensure NHS Grampian continues to link with NHS Education for Scotland (NES) and the three further and higher education institutes in Aberdeen. We will continue to look at innovative ways of attracting skilled and experienced staff and update workforce plans to increase skill mix. We have created posts that support new ways of working, e.g. Clinical Associates in Applied Psychology (CAAPs) and Psychology Practitioners are now in post. We will continue to work with primary care and other partners to increase mental health and wellbeing service capacity in these areas to offer alternatives for cases not requiring specialist mental health provision (i.e. ongoing development of Mastermind Project / Beating the Blues and use of link workers). Workforce and vacancies Whilst the consultant vacancy rate is broadly in line with NHS Scotland figures and has been a generally improving position, the significant challenge has been in filling the medical staff grades below consultant, including trainees and specialist doctors. The current position for consultant posts is noted below, with similar challenges being presented in relation to filling training grade posts. Consultant (FTE) Consultant Vacancies General Psychiatry 30.5 7.9 Child and Adolescent Psychiatry 8.7 12.4 1.9 Forensic Psychiatry 3.0 3.5 1.5 Old Age Psychiatry 10.4 2.0 Psychiatry (Learning disability) 2.0-3.0 2.0 Psychotherapy 2.0 - Nurse staff recruitment remains a continuing challenge with vacancy levels having been approximately 50 or 7% of total nursing workforce for the last 24 months. Due to further staff retirements and leavers, the nursing staff vacancies are forecast to increase over the coming months, in advance of the next intake of students being able to take up post later this calendar year. With high levels of demand within Royal Cornhill Hospital, work is being undertaken with the three HSCPs to review options for continuing to offer access to safe and high quality in-patient specialist services and seek solutions for patients who are clinically ready for discharge. We have welcomed the additional resource being made available by the Scottish Government. We are working with the three HSCPs in Grampian to agree the model of care for all people suffering from a mental illness and are developing primary care based psychological therapies. Most of the funds will be used for level one and two services with some additional capacity for levels three and four being made available in years three and four. We will continue to work with NES and Mental Health Access Improvement Support Team (MHAIST). 4
We will continue to deliver a range of capacity building training programmes to the wider workforce e.g. Scottish Mental Health First Aid (SMHFA), SafeTalk, Mentally Healthy Working Lives, stress awareness, mindfulness and relaxation courses. We will continue to support and work with the IJBs, acute, community, voluntary and private sectors to provide and improve inequality sensitive mental health improvement services through awareness raising, training and development activities by focusing on 6 equality strands. 4. Allocation of time, effort and resources on a basis commensurate with need Smoking cessation has been a key focus in mental health inpatient services with the encouragement for patients to switch to nicotine replacement therapy as appropriate. There have been many challenges in the attempts to make the sites of Royal Cornhill Hospital and Dr Gray s Hospital smoke free. The emphasis on improvement of physical health is welcomed with plans to develop further primary care initiatives including the creation of primary care workers offering psychological interventions in primary care. We are also undertaking a review of the Mental Health unscheduled care team and liaison psychiatry team to make best use of this resource, working closely with colleagues in Acute Emergency Departments, Police Scotland, GMED Out of Hours service and primary care. 5. Equal status in the measurement of health outcomes A suite of 30 new Key Performance Indicators (KPIs) is being introduced to Mental Health Services which will include measures across 6 quality dimensions personcentred, safe, effective, efficient, equitable and timely. Some items are already routinely collected by MH&LDS and some are not. Our internal auditors are currently working with MH&LDS to establish what data is already being collected and to establish a plan to gradually introduce the routine collection and reporting of data for these KPIs. Commitment to quality and improvement In terms of the Board meeting, there will be an opportunity for members to have a question and answer sessions with representatives from the MH&LD service covering the following areas: Perinatal Mental Health - pregnancy is challenging for many women; however, for a minority of women it can be overshadowed by mental illness. The establishment of the national managed clinical network for Scotland this year was an important step forward in recognising the importance of perinatal mental health provision Older Adult Services focussed on Older Adult Liaison Psychiatry service and early onset dementia. Strathbeg Ward at Royal Cornhill Hospital is a demonstrator site for the implementation of dementia standards in hospital settings 5
Adult Mental Health primarily focused on raising awareness of the Adult Mental Health Re-design Process the psychology links between primary & Secondary Care Services Child and Adolescent Mental Health Services providing further details on early Intervention, CAMHS Choice and Partnership Approach model (CAPA), North of Scotland Tier 4 network and Family Based Treatment (FBT) & Patient Involvement. 4. Risk Mitigation The risks and opportunities that the service has actions to mitigate are as follows: Implementing the requirements of the national mental strategy and striving to achieve parity between mental and physical health Improving access to mental health services and early intervention; in particular child and adolescent mental health services Redesign of services to address the challenges around workforce and the introduction of new models of care based on multi professional and multi agency working. 5. Responsible Executive Director and contact for further information If you require any further information in advance of the meeting please contact: Responsible Executive Director Alan Gray Director of Finance alangray@nhs.net Contact for further information Jane Fletcher Head of Hosted Mental Health & Learning Disability Services janes.fletcher@nhs.net 24 May 2017 6
Appendix: Child and Adolescent Mental Health Services Background Evidence suggests that nearly 5% of children aged 5-10 years and 10% of children aged 5-18 years suffer from a clinically diagnosable mental health condition and up to one in five 15 year olds say they self harm. These children and young people are more likely to continue to have or develop associated problems later in life. Therefore, while identifying and treating mental health problems in early life is important in terms of avoiding serious consequences for children s emotional, behavioural and educational development in the short term, it also offers an opportunity to reduce problems in later life and to reduce the burden of these often costly issues on public services. Robust evidence shows that effective interventions which improve outcomes for children and young people across a range of mental illness do exist. Indeed, when these are deployed, measurable savings in future spend, not only in health but across the range of other public sector provision, occurs. In terms of demand for the service there is a growing year on year increase in referrals to CAMHS in Grampian. Referral rates are increasing on average by 10% per year. 4000 3500 3000 2500 2000 1500 1000 500 0 CAMHS referrals received by year 2011/12 2012/13 2013/14 2014/15 2015/16 2011/12 2012/13 2013/14 2014/15 2015/16 Moray 427 455 482 539 601 Royal Aberdeen Children s Hosp. 1020 1431 1414 1543 1605 Young Persons Department 893 1030 1282 1301 1398 Total 2340 2916 3178 3383 3604 7
Patients Waiting Performance As reported to the Board through the regular performance reports, the CAMHS service has been unable to meet the Local Delivery Plan standard of 90% of children being seen in an 18 weeks referral to treatment for specialist Child and Adolescent Mental Health Services. Performance over the last six months is noted below: Patients Waiting - CAMHS 18wk Target 120.00% 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month >18 wks Workforce The largest service pressure we have for Psychological Therapies is in the delivery and support of evidence based interventions at Tiers 3 and 4 and support, training and supervision to Tier 2. These staff pressures arise mainly as a result of vacancies and overall capacity within the service. The position regarding vacancies as at May 2017 was as follows: Medical Consultant Psychiatrists Clinical Psychology Nursing and Allied Health Professions Other 2.0 WTE 4.3 WTE 0.5 WTE None We have recently had confirmation of 337,000 additional funding from the Scottish Government to improve service access and also new funding from NES and arrangements are now in place to recruit 8 additional clinical staff. Sustainability and achieving a much needed reduction in overall numbers of patients waiting will only be possible as staffing levels increase and the CAMHS redesign and service development plans are implemented. 8
Service redesign In response to the demand and capacity gap, the service has undergone a service redesign and developed a workforce plan to enable increased access to CAMHS locally to address needs and service gaps. Initially the focus of the workforce plan will be on recruiting to vacant posts, with a longer term aspiration to increase the overall workforce to meet the growing demand for services. 1. Consultation In light of continuing challenges in providing access to the service and continuity of care for children and young people across Grampian, it was essential to enter into a phase of consultation with stakeholders. The aim was to ensure the service can work collaboratively with partners to meet shared strategic objectives (including optimising the mental health of our children and young people and future adult population), meet our joint statutory Corporate Parenting responsibilities, make sure children and young people can access appropriate (levels of) services to support their mental health needs, and create a safe, sustainable and equitable future service. The agreed model of care evolved from a series of workshops with stakeholders, children and young people and their families, and members of staff.this commenced in September 2015 with an appreciative inquiry which asked all participants to reflect on the current state and imagine the future state of CAMHS. 2. Option appraisal The outputs from this fed into the full option appraisal process, which had staff representation from across the CAMHS localities and included an open invitation to stakeholders. Six delivery care models were then identified and judged according to the benefits each would bring across a set of predetermined factors. 3. Priorities The following were identified as the priority areas to be addressed through the redesign and with additional funding in the longer term: consistency of care from 0-18yrs with no transitions; equality in waiting times across the service regardless of age and location of the family; capacity to be responsive to the needs of looked after and accommodated children (LAAC) across the localities and in A&E departments; residential care, foster care and adoption consultation and advice for children and young people who have emerging or known mental illness a consultative model of support to school team leaders for children and young people with complex and challenging behaviour; early psychosis intervention and psychosocial educational programmes focussed on illness management and recovery; 9
availability of AHPs to support complex out-patients needs and address gaps in care pathways for specific disorders, such as exercise models for chronic low mood and for Eating Disorders that do not respond to the Family Based Therapy approach; Tier 4 outreach to families where cases are complex, in order to manage risk in the community (these cases require more than one person more than once a week). Provision would also be required to support consultation, teaching/training and supervision to Tier 2 colleagues for early intervention, prevention and care. 4. Status of redesign The redesign is now largely complete having been undertaken in the following phases: Phase 1: Clinical Psychology and Admin & Clerical Phase 2: Nursing and clinicians Phase 3: Psychotherapists, medical and management Improving access Whilst the redesign will not result in an immediate improvement in the access performance, it will enable the Tier 3 and 4 services to provide evidence based treatment/interventions with a staffing complement which over time (and with additional investment) matches demand and need. This includes both the provision of direct intervention where appropriate for those referred, and being an available and accessible partnership agency for those children and young people suspected of having a mental disorder. The specialist CAMHS will require to be a full partner in a multi agency response to children and young people with mental health needs and we welcome the ongoing work that continues with our three local authority partners in terms of supporting the development of the Tier 1 and Tier 2 services. Mitigation of risk Whilst there continues to a gap between demand and capacity the service continues to implement the following actions to mitigate where possible risks to children referred to the service: All emergency and urgent patients will continue to be seen in a timely manner Continue to prioritise patients with the longest waits and monitor those waiting for patient symptom escalation Specific actions in relation to addressing the staffing issues within Moray. 10