TRANSFORMING MENTAL HEALTH SERVICES Consultation 22 June 15 September 2017 FREQUENTLY ASKED QUESTIONS / KEY ISSUES RAISED DURING THE CONSULTATION PERIOD (updated 7 September 2017) Q1. Why has some documentation changed? The documentation has not changed significantly. As a result of our ongoing conversation with our public about 'Transforming Mental Health', some of the supporting documentation has been updated in order to provide further clarity or detail where considered necessary. We are advising people to make sure they are reading the latest versions, all of which are available on our website www.hywelddahb.wales.nhs.uk/mentalhealth Q2. When the changes are up and running what will it mean for me? If you need access to mental health services there will be a single point of contact available 24/7. Services will be more streamlined and there will be provision of localised support as and when required. Care will be closer to home and you will see the right person in the right place at the right time. There will be more integrated working between services and organisations including health, social care and voluntary sector providers. Q3. Are the changes about saving money? The focus of the change is on improving and modernising the mental health services we provide. There is no intention to reduce the resources allocated to mental health services, but instead to reinvest in an improved model of care. Q4. Can I choose where I receive services? The revised service model aspires to enhance services that are currently available on a locality level. However, if for any particular reason an individual preferred to receive that service elsewhere within the University Health Board, this would be considered and every effort made to accommodate this. Q5. Will I have to travel further to receive services? It is recognised that some residents within the University Health Board area already have to travel a considerable distance to receive certain services as they are currently provided. Although an assessment and treatment unit will be centrally located there will be a focus on delivering an enhanced service in the local communities in line with the concept of care closer to home. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 1
Q6. Will it be more difficult to access inpatient services? Bed numbers will not be reduced within the proposed model. The purpose of the new service model is to move away from hospital admission and treatment to help people during periods of mental distress and crisis. Our model provides a range of solutions in relation to the provision of beds, including beds provision at our Community Mental Health Centres to address short term crises, assessment and treatment beds in a centralised location with in-reach support. Q7. Will there be local walk in and drop in facilities and increased support for groups and projects that already exist as well as the main Community Mental Health Centres? Our current proposals include the ambition to provide more accessible local services to people wherever they live including our rural areas. We are planning how we can use existing community resources such as village halls, church halls, etc to help us provide local services as well as helping to keep vital community resources alive. We will continue our commitment to work with other voluntary organisations and agencies to enhance our services where they provide meaningful activity and assistance to people experiencing mental health difficulties. Q8. Will there be facilities for out-of-hours assessment in each of the three counties? There will be assessment services accessible to all 24 hours a day 7 days a week. Q9. How is the single point of contact going to be managed? The single point of contact will provide a first point of call for people wanting to get in touch with adult mental health services and it will be operational 24 hours a day, 7 days a week, 365 days a year. It will: enable those using mental health services to call one number, or to contact one point for general advice, care and, if required, an assessment by skilled mental health practitioners who will refer people on to the most appropriate mental health service or local service provided by other agencies; enable health, social care professionals and voluntary organisations to call one number for advice on referrals and for a central place to accept and direct referrals into mental health services; provide a better, more responsive service delivered by specially skilled and trained staff. The service will be developed so that general enquiries can also be raised from those not in regular or direct contact with mental health services, such as carers, relatives or members of the public. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 2
This will be an inclusive, accessible and supportive service, delivered within a rigorously tested and evidence based model of care (please see Data and Evaluation technical document for supporting evidence of this model). As part of our consultation we are asking whether people would prefer one single, centralised point of contact or one single point of contact per county. We are also asking how people would prefer to access the single point of contact e.g. via phone, email, text etc. Please see consultation questionnaire for more detail. Q10. How will transport be managed in the new model? As part of our aim to transform services, our Mental Health and Learning Disabilities (MH&LD) Services plan to have an Assessment Unit in Carmarthen on Morlais Ward at Glangwili Hospital and a Treatment Unit in Llanelli on Bryngofal Ward at Prince Philip Hospital. This means that all individuals needing admission for assessment will need to travel to Carmarthen. It is proposed that whilst there will be no traditional inpatient unit in Pembrokeshire, small hospitality facilities will be available within the 24 hour Community Mental Health Centres (CMHCs). Within the proposed model, people may come to hospital through a variety of means, depending on their needs and potential risks involved during transport. Scheduled admissions and discharges will be within normal working hours and more urgent, unplanned admissions can occur in and outside normal working hours. The table below describes this in more detail (this does not include inter-ward transfers): Admission type Risk level No. of people to accompany Planned Low One person. May be family member, carer, volunteer or mental health professional. Urgent, Low / 1-2 people. within normal medium Volunteer or mental working hours health professionals. Urgent, outside normal working hours Emergency Low / medium Higher risk, may include immediate concerns about safety 1-2 people. Ambulance or mental health professionals. 2-3 people. Mental health, police, ambulance or secure transport professionals. Transport type Own transport or volunteer transport. Own transport or volunteer transport. Welsh Ambulance Service NHS Trust, St John s Ambulance, Health Board transport. Emergency ambulance or secure transport vehicle. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 3
Healthcare clinicians are currently used more than they should be to help get people to and from hospital. This is not the best use of valuable clinical time. Our partner agencies, such as the police and local authorities also undertake more transportation than they should; again this is not the best use of their resources and is not always the most appropriate transport method. Taxi services or private transport arrangements are also used, though these may not always be the most appropriate or cost effective forms of transport. We are proposing to work with the transport and voluntary sectors to develop a solution, based on the above table, that will best meet the needs of our staff, service users and carers. The costs of providing transport within the new model have already been worked out and are within our budget (please refer to the Transport document in our Technical and Supporting Documents section on our webpage: www.hywelddahb.wales.nhs.uk/mentalhealth). Any transport services commissioned by us will be commissioned with a clear specification of the service that is being delivered, for example: if we commission the voluntary sector for transport arrangements then there will be a clear expectation that the staff are appropriately trained, supervised and adhere to the same confidentiality agreements as health board staff, they must also within their contract specification be able to always provide the service that we have commissioned from them. As part of this consultation we are asking for your ideas to help us improve this and provide a consistent approach for everyone across the three counties. An example of a taxi service can be seen at the link below: http://www.wales.nhs.uk/sitesplus/862/news/45062. Q11. Will there be a loss of beds? Bed numbers will not be reduced within the proposed model. The purpose of the new service model is to move away from hospital admission and treatment to help people during periods of mental distress and crisis. Our model provides a range of solutions in relation to the provision of beds, including beds provision at our Community Mental Health Centres to address short term crises, assessment and treatment beds in a centralised location with in-reach support. Q12. Will beds be available in each of the three counties? It is intended that beds will be provided within the three counties. These beds will be available for those individuals who require enhanced levels of community support, or for those coming out of more formal inpatient admission units. Q13. In several documents, it states: It has proved difficult to be able to provide a bed for everyone referred for admission for many months. On several occasions in recent months all the available beds were full. This has resulted in some people having to be admitted outside of the Hywel Dda TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 4
area and sometimes a very long distance from their home and family. One factor in this was the number of people awaiting discharge due and the time taken to ensure the most appropriate support was in place. In April and May there has been a significant improvement in reducing arranging care and treatment to enable discharge. In our proposed co-designed model we will not be reducing the number of beds but we will instead provide a range of beds to suit peoples needs and improve the service provision. The crisis and recovery beds will be run flexibly, meaning people could stay for a few hours, overnight, or for longer if needed. They will be a place of safety for people detained by the police under Section 136 of the Mental Health Act and we will offer support to families, carers and friends as well as service users. Further the crisis and recovery beds could be used as a bridge facility for people to go to after a hospital stay and before they go home. The Central Assessment Unit will be based at Glangwili Hospital in Carmarthen and will be open 24/7. It will have 14 assessment beds and two dedicated beds for people detained under Section 136 of the Mental Health Act, to ensure capacity for people from across the three counties. The Central Treatment Unit will be based at Prince Philip Hospital in Llanelli. It will be open 24/7 and will have 15 beds. It will be run by specialist nursing, medical and support staff including occupational therapists, psychologists and a range of mental health workers from the voluntary sector. The team will be assisted by peer mentors and family support workers, as well as social care professionals, with connections to community services to help plan care for service users after a hospital stay. Q14. Do you have figures to support this? Does difficult mean appropriate beds were not available? What alternative provision is in place should a bed not be available? How many, and in which areas, were these difficulties? Our current systems would be able to provide an overall bed occupancy figure but not numbers going out of area. However, we are working to develop our systems to be able to track out of area beds and costs to the Health Board of these. The transport document states that additional costs in commissioning voluntary sector and St John Ambulance services when dealing with predicted transport needs would be 80,993. Q15. What is the current cost to the health board for dealing with these existing transport needs? It is currently difficult to predict actual transport costs. This is because we use a combination of means that come from different budgets. Healthcare clinicians are currently used more than they should be to help get people to and from hospital. This is not a good use of valuable clinical time. Our partner agencies, such as the police and local authorities also undertake more transportation than they should. This again is not a good use of their resources and not always the most appropriate transport method. We may TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 5
also use taxi services or private transport arrangements as needed. Again, these may not always be the most appropriate or cost effective. We propose to develop a more coherent transport strategy that best meets the needs of our population and that provides appropriate cost effectiveness. Q16. The document also states many individuals currently admitted to Bryngofal or St Caradog may live closer to Carmarthen and this would reduce costs. On what data does the health board make this assumption? Are figures available for where patients admitted to both sites in the last year are travelling from? We looked at all admissions to Bryngofal, Morlais and St Caradog in 2016 and then apportioned them to either Carmarthen, Llanelli, Pembrokeshire or Ceredigion by looking at which surgery they were registered with. Q17. On page 9 of the Transport document, it also states: The Health Board should consider whether our partner agencies can contribute to these costs. Who are these partner agencies? When we talk about partner agencies in the document we are referring to statutory organisations which help us deliver care, the local authorities, Dyfed Powys Police and the Welsh Ambulance Service Trust. Q18. In the transport document, it states 82 inpatient admissions were made in 2016 were people who lived in Ceredigion. Do you know how many of these were transferred to Bro Cerwyn or Bryngofal? Please see below for a breakdown of the 82 inpatient admissions from Ceredigion in 2016: Bryngofal: 21 Morlais: 41 St Caradog: 20 Q19. Given that 242 admissions were made to Bro Cerwyn in 2016, compared to 168 from Bryngofal, why is it proposed that Pembrokeshire s staffing budget be cut above other locations? There is no plan in place to reduce the staffing budget in Pembrokeshire the service model proposed will be different and it is likely that there will be some changes in roles for staff who work within the service. With regards to the numbers of admissions it is anticipated that providing a more responsive service will reduce the requirement for individuals to be admitted to hospital. Additionally, many admissions are for very short periods of time which would suggest that different alternatives or solutions could have been put in place to prevent the admission in the first instance. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 6
Q20. In the Our Finances - Total Expenditure on Mental Health Services document, on pages 2, 3, 4 and 5, the top line of each refers to Community Mental Health Centre Pembs. To which site does this refer? This refers to the Mental Health Medical Staffing budget currently historically aligned to Pembrokeshire. Q21. How will the new model be staffed? The proposed new way of working will ensure the service meets the needs of our local population. All three counties will have the same number of crisis and recovery beds with the appropriate level of staffing to deliver a more joined up and holistic service model that will improve access and timely responsiveness at the time of need. The new model present opportunities for staff to develop additional skills, work in new and extended roles and receive additional training. Training needs will be assessed as part of this process to ensure that all staff have the skills required to deliver these services. There will be no job losses and all staff changes will be handled through the organisational change policy. Those staff affected by the change will be offered 1:1 discussions as part of the change process. Staff meetings are held on a regular basis to update staff on progress with the proposed model and developments. With regard to staffing in Pembrokeshire county specifically, the proposed new service model has already had a positive influence on the recruitment of two excellent psychiatric consultants in Pembrokeshire. Q22. On each page, it is proposed that two staff members be cut, bringing a saving of 206,000. Am I right in thinking this would mean the loss of a consultant and speciality doctor based in Pembrokeshire? The proposed co-designed consensus model will ensure the service model meet our local population needs and is underpinned by the aforementioned 4 key principles. An essential component of the service model is the enhancement of the 24/7 community provision with the increase from 42 to 43 adult mental health beds, with the focus on delivering our community and inpatient services based on the National and International best practice evidence. All three counties will have the same number of crisis and recovery beds with the appropriate level of staffing to deliver a more joined up and holistic service model that will improve access and timely responsiveness at the time of need. A clearly defined phased implementation plan will be developed collaboratively with all the stakeholders involved within the Transforming Mental Health Programme, including West Wales Action for Mental Health, Service User representatives and Carer Representatives. The future medical model is supported by the Multi-stakeholder Programme Group and the Senior Medical Body within the Mental Health Directorate and will be carefully implemented through a robust phased approach. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 7
It is important to note that the proposed co-designed consensus service model has already had a positive influence on the recruitment of two excellent Consultants in Pembrokeshire - quotes are included at Appendix 1. Q23. Am I right in thinking that proposed additional staffing costs across the whole health board (assuming staffing in Ceredigion and Carmarthen remain the same, but with the addition of staff/full-time contract in the proposed admission and treatment centres) totals 260,000? The current model of care is delivered by 307.39 Whole Time Equivalents (WTE) whilst the proposed new model of care depending on whether it s a single point of contact for the whole Health Board or 1 in each county will be delivered by either 339.92 WTE or 342.74 WTE. The figure you refer to equals 206,000. Q24. Near the bottom of the four pages mentioned above, it refers to open non medical pay budget, with figures of ( 288.89) and ( 10,829,767). Can you clear up what this budget covers, and confirm that this would mean a saving of 10,829,767? The opening non medical pay budget refers to all staffing budgets except medical staffing that have been included in this service review, so it will include the budgets for nurses, health care support workers and occupational therapists. The 10,829,767 does not equate to a saving. For the new model the budget and WTE have been shown in the areas they will sit in the new model of care for example Community Mental Health Centre or Central Admission Unit. Q25. Are services being closed before the consultation has ended? No. Services currently in existence will remain in place until after the consultation process has been fully completed. Changes to be made as a result of implementing the proposed new model will be communicated widely at the appropriate time. In the meantime, we wish to reassure anyone who may be concerned about Awel Deg and Hafan Hedd facilities, that these operate as follows: Awel Deg: Opening hours are 9am-5pm, Monday to Friday. This is currently office accommodation occupied by administrative staff responding to telephone enquiries. There are no clinical facilities in this building and service users have never been seen in this building. Hafan Hedd: Opening hours are 9am-5pm, Monday to Friday. Service users are seen by appointment within the clinical facility here. A receptionist provides full-time support during opening hours. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 8
Q26. Will the proposed service model support all current stakeholder organisations providing support in the community? We already commission the voluntary sector to deliver mental health services. Hywel Dda University Health Board is focused on working in partnership with key stakeholders to make the best use of resources available. Our proposals include joint training opportunities, shared provision of services and better outreach to rural communities. Q27. Will all key stakeholders and partners have an opportunity to influence the proposed future service model, including service users and their carers? We have developed our proposals by talking and listening to staff, service users, carers and stakeholders. A project group has been established comprising a broad range of stakeholders from statutory and third sector services as well as service users and carer representation who have worked together to develop the proposed model as outlined in the consultation. Q28. In the CMHC document, it states: Voluntary organisations will be commissioned to assist in the staffing and management of the hospitality beds. Reliance of volunteers in helping run cafes etc at centres, and in providing transport, is also mentioned in various documents. To what extent are the health board s proposals reliant on support from the voluntary sector? The Health Board already works very closely with voluntary organisations through a number of commissioned schemes. The Transformation of our services will mean that we will continue to work with those organisations but in a far more joined up and collaborative manner. The Transformation is not reliant on voluntary organisations to deliver services but builds upon and strengthens existing partnerships to enhance and extend current provision. Q29. Have your proposals been tested? The main areas that we are consulting on are based on examples of the best practice from within and outside the UK. We have based our ideas on examples of working models that has proved to be effective and safe. None of our proposals include testing something new for the first time. These ideas have been shown to work in both urban and rural areas so we have confidence that they will work for us in West Wales. Q30. How will you manage the implementation? We have a number of workstreams already in place that include people from different statutory agencies, service users, carers and the voluntary sector who work with us to ensure the different aspects of our proposed co-designed model are planned, reviewed and evaluated throughout any implementation. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 9
Any changes we make will be piloted in one area before being implemented across the three counties to ensure that we have a robust system in place. Our existing services will continue to run whilst any changes are made. Q31. When will the changes happen? The project group, which is overseeing the transformation of services, will need to agree all the details, protocols, operational procedures and staffing requirements to deliver this new model. As soon as timelines are available the University Health Board will ensure they are communicated widely to staff, stakeholders and the wider community. Q32. How will you know that the changes are safe? The provision of a service that is responsive and safe is of paramount importance. In its current configuration, there are times when there is a dependence on bank and agency staff to sustain the service. This poses a potential safety risk, hence the requirement to revise our service model. Hywel Dda University Health Board will monitor any service changes continuously in order to manage any potential increased risk as well as measuring improvement in service delivery and service user and carer experience. Q33. What do we tell patients who are asking about the changes to our services? This FAQ document can be printed off to give to patients and they can access the main consultation document and summary version online www.hywelddahb.wales.uk/mentalhealth. This is available in Welsh and English and alternative formats. Throughout the consultation Hywel Dda University Health Board will deliver events to ensure members of the public fully understand the proposals. Q34. What about the needs of people with protected characteristics? At Hywel Dda University Health Board, we are committed to ensuring that all people are treated fairly and equitably, without unlawful discrimination because of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief (including no belief), sex and sexual orientation. We know that some groups are disproportionately represented among service users and will seek to ensure that our new service model and delivery will be equitable. We are keen to hear everyone s views on our proposals and how they may affect our service users, staff, friends, family and the wider community to help us achieve this. We have included a set of Questions about you in our consultation which will help us know if we have been successful in gathering views from those who will be most affected by the changes. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 10
Questions received relating specifically to St Brynachs, Pembrokeshire Q35. What services have historically been provided at St Brynachs/over what days/times etc? A day hospital has been in situ in differing configurations within Pembs Older Adult Community Mental health Team for several years. In April 2015, a referral process was initiated as prior to this no standard referral process existed. Prior to April 2015, four days per week were allocated to day hospital attendance two days for clients with advanced dementia presentations (where respite was being provided to a maximum of 10 people per day) and two days for clients with functional mental health presentations or mild to moderate dementia (where day care was provided to a maximum of 20 people per day). By September 2016 referral rates were approximately three per month, with only needs related to time-limited assessment and intervention for mild to moderate dementia being referred for. In combination with the referral needs and review of those in attendance on Mondays, Tuesdays and Thursdays, it became clear that by the end of 2016 there would be no one in attendance for three out of the four allocated day hospital attendance days. This further diminished to between five and eight attending on a Friday only at the beginning of 2017. As it was noted that demand for the service seemed to be changing a review was instigated. The review was carried out from a multidisciplinary team (MDT) perspective, including day hospital staff, doctor, CPN / care coordinator, individual and family members, and they were asked to consider local needs and what would make better use of the resource for people with dementia and their families. Q36. Is the day hospital to close, or has it already? The day hospital has not closed and there are no plans to close it. As noted above, demand has changed and as such the service needs to adapt to meet current needs. Q37. If so, where will these services be offered from now/in future? See response to Question 36 above. A review of what else the service could provide to better meet people s needs identified the following: Carers and family members were consistently and repeatedly asking for help in understanding changes in behaviour as individual progresses through dementia. The memory service reported having a post diagnostic group, Memory Strategies. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 11
There was a need for the development of a carers / relatives group focusing on challenging and changing behaviours. Two groups were then made available, Understanding your Relatives Dementia and Strategies for Relatives. The groups will be run at Bro Cerwyn utilising the St Brynach s Day Room. The service continues to run but on some days acts as a day hospital and on other days provides group interventions to support carers and families. Feedback from the groups that have been introduced has been very positive. Q38. If not, what changes if any have been made/are to be implemented? I.e. what services will continue to be offered from St Brynachs? Please see responses to Questions 37 and 40. Q39. If changes or closure have been agreed, what is the rationale behind this decision? When was this decision made? Has any decision been included in the ongoing mental health transformation consultation? Please see earlier responses. The level of changes are proportionate with changes in demand and are designed to ensure better use is made of the facility over coming years. Q40. How many patients currently use the day hospital per week/month? Members of the groups fluctuate, but at present there are four specific groups: Anxiety management between 8 and 10 for 8 weeks Memory strategies group - approx 8-10 for 5 weeks Relative support group - once a month, with over 40 participants (relatives and patients) Start Group - 8 people, run over 8 weeks. The groups are delivered on a rolling programme. As mentioned in the response to Question 37 above, feedback from those accessing the groups has been very positive. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 12
Appendix 1 Personal quotes referred to in Answer to Question 22 Community Consultant in Pembrokeshire Adult Mental Health Services: My experience of the TMH Programme is that it has been a very transparent and professional process. The extent of public and stakeholder involvement has been impressive. I have always felt that the process was driven by a realisation that mental health services in West Wales are not really fit for purpose and that there is a need for wholesale change. Managing change is of course difficult but tinkering around the edges would not be sufficient. Taking ideas from elsewhere and seeing how they can be applied to West Wales is an inspired idea and has demonstrated that even though there are large areas for improvement there are certain areas where we do very well. My involvement with TMH and the prospect of working in a stakeholder-influenced, newly-designed, fit for purpose service was a key factor in my decision to return to Hywel Dda for a Consultant post. Adult Mental Health Inpatient Consultant in Pembrokeshire: My personal perspective is from a relative newcomer to the health board and therefore the programme, but it is fair to say that the TMH agenda attracted me to working in the area and actually spurred me to make the move to Pembrokeshire earlier than I had intended. For me, the messages underpinning the work are clear and consistent and represent a true modernisation of mental health services. From the outside the work was visible and attractive and enthusiasm for it was evident. The international perspective added colour and vibrancy and this seemed reflected in the staff from whom I heard about it. Since I have been working in the Health Board that enthusiasm and commitment to the programme has continued to be shown by my colleagues and I have been impressed by the apparent understanding of the changes throughout a wide range of roles and seniority. I am looking forward to contributing to the TMH agenda and the expected subsequent improvement in access to appropriate mental health input at the right time from the right healthcare professional for the people served by the Hywel Dda Health Board. I really feel that these changes could lead the way for Wales as a whole, and feel privileged to be able to participate and contribute to this innovation. I very much hope that the TMH will serve to attract staff to work in the mental health service in this part of the country for this reason, and with a desire to be part of this exciting and invigorating effort. From a Pembrokeshire perspective I hope that the population will be able to see that longer journey times for the relatively small number of in patients and their relatives to Carmarthen would be counterbalanced by enhancement of community resources which will benefit the wider community and enhance the experience of the vast majority of people coming into contact with MH services. In patient treatment as an option is necessary for a very small number of patients, and remains in the proposed model, but I hope that it will not be seen as the gold standard or always the safest option. In my view robust community treatment can have better and longer lasting positive outcomes for those suffering with mental disorders, and certainly for those facing life crises and situational difficulties leading to mental disturbance. TMHS Frequently Asked Questions Version 4 - Updated 07.09.17 13