BOARD MEETING 25 FEBRUARY 2015 AGENDA ITEM 2.1 ADULT MENTAL HEALTH NHS MANAGEMENT ARRANGEMENTS Report of Paper prepared by Purpose of Paper Action/Decision required Link to Doing Well, Doing Better: Standards for Health Services in Wales Link to Health Board s Annual Plan Acronyms and abbreviations Director of Nursing (Lead Director for Mental Health) Assistant Lead Director for Children/ Strategic Lead for Mental Health & Project Manager To agree the extent to which NHS adult mental health services should be directly managed within Powys and next steps. To approve This paper supports the standards Promotes Health & Wellbeing Continuously Improves Safety, Effectiveness & Patient Experience Captures the Benefit of Integration Adult - adults of all ages from 18 th birthday to end of life LPMHSS - Local Primary Mental Health Support Service CMHT - Community Mental Health Team CRHTT- Crisis Resolution Home Treatment Team AMHP - Approved Mental Health Professional CAMHS - Child and Adolescent Mental Health Services DSU - Delivery Support Unit WG - Welsh Government TUPE- Transfer of Undertaking (Protection of Employment) CCIS - Community Care Information Solution PICU Psychiatric Intensive Care Unit Page 1 of 10
ADULT MENTAL HEALTH NHS MANGEMENT ARRANGEMENTS INTRODUCTION A strategy to improve the mental health of the people of Powys was published by PtHB and Powys County Council in January 2013. A service model was developed with stakeholders and approved by PtHB at its meeting on the 16 th October 2013. The Board initiated work to identify the best delivery arrangements for the model, including re-consideration of arrangements involving three neighbouring health boards. An advisory option appraisal involving partners was undertaken in December 2013 and reported to the Board in February 2014. In response to this and subsequent Board discussions a Project Board was established, in September 2014, chaired by the Deputy Chief Executive, to focus on NHS management arrangements (involving the employing health boards working in Powys, PtHB directors, Powys County Council and GP representatives). This paper presents the conclusions of the Project Board which has been endorsed by the Transformation Board. Further detail is provided in the Summary Report at Annex 1. It: recommends the extent to which NHS adult mental health services should be directly managed by Powys teaching Health Board; assesses the impact of the recommendation; and provides an outline implementation plan. It is recommended that PtHB seeks to directly manage NHS adult mental health service staff working in: Local Primary Mental Health Support Services within Powys Community Mental Health Teams within Powys Crisis Resolution Home Treatment Teams within Powys Mental health wards within Powys hospitals (for adults of all ages) and associated clinical psychologists and occupational therapists. It is important to stress that the proposed changes are to NHS management arrangements. The proposed recommendation is not about changes to the location or range of existing patient services and thus is not subject to public consultation requirements. STRATEGIC CONTEXT The strategic context shows that a great deal has changed since 2008. Mental health services are no longer in-patient led there is a much greater focus on what can be delivered through primary and community services. Clinical governance has been strengthened across the NHS. PtHB and partners have developed a robust strategy and service model which is attracting medical and other staff interested in developing services outside hospital. Page 2 of 10
Powys already manages physical health services and other hospital based services within the county. In order to rise to challenges, such as dementia, it needs to be able to manage services to meet patients needs coherently. PtHB and partners are driving forward an ambitious programme for mental health which combines local priorities with Welsh Government s new mental health laws and 10 year strategy. Powys aims to excel in delivering services in or close to home. Its model for adult mental health services is about enhancing access within primary care; providing alternatives to admission at home; ensuring services for adults are based on needs not age; and integration. Powys is predicted to have one of the highest rates of people with dementia in the UK. Dementia is already the leading cause of death amongst women. People with dementia are often frail elderly people with other conditions. It is vital that their physical, mental, social and spiritual needs can be considered together. This is important both in the early days of the condition and at the end of life. The sustainability of services in highly rural areas lies with more integrated working between local agencies. NHS management arrangements for adult mental health need to be simplified in order to improve safety by reducing complexity within the county. Thus, Powys needs NHS management arrangements for adult mental health services which will help deliver the approved strategy and service model; will enable it to develop strong primary and community services including alternatives to hospital at home; breakdown barriers to access through new ways of working; and ensure care is closely co-ordinated with local agencies such as social services and the police. The Summary Report (Annex 1) sets out the services PtHB would seek to directly manage (and associated functions) and those it would continue to commission. PtHB would continue to commission specialised services such as psychiatric intensive care. BACKGROUND TO CURRENT ARRANGEMENTS PtHB has highly unusual and complex arrangements for NHS adult mental health services. Around 250 NHS staff delivering such services in the county are employed by three other health boards. However, there has been increasing concern about the effectiveness of the arrangement and whether it is appropriate for the future in light of the strategy already agreed for mental health. In 2008 the Clinical Governance Support and Development Unit (CGSDU) undertook a review of mental health services provided by PtHB. It was thought that larger organisations would be better able to improve medical staffing; standardise admission rates; reduce delayed transfers of care; reduce the isolation of in-patient units; improve joint working with the local authority; ensure clear lines of accountability; ensure participation in appraisal; strengthen clinical governance; improve supervision; ensure robust on-call arrangements; and drive forward modernisation. No other health board wished to provide adult mental health services across the whole of Powys. Subsequently, mental health services were transferred from PtHB to Page 3 of 10
Abertawe Bro Morgannwg University Health Board (ABMUHB), Aneurin Bevan Health Board (ABHB) and Betsi Cadwaladr University Health Board (BCUHB). This is known as the 3 health board arrangement (although the situation in Powys actually involves more health and NHS Trusts than this). The scale of the challenge for provider health boards was not equal, for example AMBUHB was asked to take on 8% of the population in the Swansea Valley; whilst BCUHB, already spanning a huge geographical area, was asked to cover half the population of Powys as well. The initial transfer of service was based upon co-operation between integrated health boards in Wales which was consolidated in a Governance Framework for Transferred Mental Health Services in 2010. Later a provider/commissioner relationship was developed. However, the basis of this was challenging at times, particularly as health boards had not sought to provide the service. Difficulties had rapidly emerged at the interface between PCC and four health boards working within one county (including PtHB). This was the case for joint work with the police also. There were multiple planning fora; multiple information systems; different working methods and care management approaches. As set out in Annex 1 improvements have been uneven. The unit which was experiencing difficulties with medical staffing has continued to be reliant on agency locums for lengthy periods. Mental health beds for people with dementia managed by neighbouring health boards within Powys hospitals have the highest rates of delayed transfer of care in Wales. PCC is having to work with more than half the health boards in Wales including trying to navigate 4 different delayed transfer of care policies. Recent spot checks of dementia wards have shown variations across the county and indicate some staff remain isolated although there is also good practice. Clinical governance has been strengthened across the NHS since 2008 (including in Powys). There have been improvements, for example, in the specialist supervision of some staff groups. However, there have also been areas of deterioration since transfer, such as access to psychology. On-call has not been consistent across the county. Furthermore, ensuring pan-powys modernisation within the current arrangements has been a challenge. PCC, PtHB and Dyfed Powys Police (DPP) have a close working relationship. However, four health boards working in one county has adversely affected clarity of accountability; coterminosity; safety (due to the sheer complexity of the arrangements); effective use of resources; integration; consistency; effective multiagency working; robust information at the individual and strategic level; pan Powys clinical leadership; and equity. PROCESS UNDERTAKEN IN REACHING RECOMMENDATION The process for reaching this recommendation is summarised below. Strategy: Hearts and Minds - Together for Mental Health in Powys was published by Powys County Council and Powys teaching Health Board following engagement of stakeholders. The priorities it contains were subject to formal public consultation within One Powys Yn Un. Page 4 of 10
Adult Mental Health Services Model: The service model was developed through a multiagency Project Board and engagement of a wide range of stakeholders. Advisory Option Appraisal for : This was independently facilitated by Public Health Wales (PHW) and involved a wide range of stakeholders including people using services and those close to them; Community Health Council representation (CHC); Powys GPs; three neighbouring health boards providing adult mental health services within Powys; Powys County Council (PCC); Dyfed Powys Police (DPP); Powys Domestic Abuse Forum (PDAF); Powys Association of Voluntary Organisations (PAVO); and Powys teaching Health Board (PtHB). The mix of experience included: people using services and those close to them; clinicians (included GPs, psychiatrists, nurses, therapists); social workers; police; operational managers; third sector; planners and commissioners; and the Community Health Council. The results of the Advisory Optional Appraisal were reported to the Powys Mental Health Partnership Board. Additional views of people using services were gathered by PAVO supported by PHW and submitted to PtHB. The results of the Advisory Option Appraisal were reported to the of PtHB in February 2014. Adult Mental Health Services NHS Management Project Board: The Project Board included employing health boards and directors of PtHB (together with PCC and GPs). It was supported by a Project Team including the operational managers in neighbouring health boards providing clinical services within Powys. The Project Board agreed to tackle the work in two Phases: Phase 1 - to make a recommendation to the Board of PtHB about the extent to which NHS adult mental health services could return to direct management within Powys; Phase 2 to develop a detailed implementation plan, subject to the Board s approval of the recommendation. The work of the Project Board has included: a self-assessment against essential national published standards for adult mental health services and a specification drawn from LTAs, externally assured by Public Health Wales (PHW), considering the risk of deterioration and the opportunity for improvement an impact assessment - including possible actions to mitigate risk an outline implementation plan Annex 2 and Annex 3 contain technical papers and are embedded into the electronic version of these papers with some copies being made available at the Board meeting. Page 5 of 10
ASSESSMENT AGAINST ESSENTIAL NATIONAL STANDARDS An assessment against essential national standards was considered for risk of deterioration or improvement if the NHS management arrangements changed. PHW provided independent assurance for this process. The assessment and impact assessment included managers from PtHB and the three neighbouring health boards; social services; and clinical in-put. It drew from an integrated performance report regularly submitted to the Board s Risk Assurance Committee for Mental Health Services. Annex 2 includes the information considered (excluding that which has the potential to be identifiable even though anonymised). IMPACT ASSESSMENT Following the self-assessment against essential national standards the mitigating actions for risks were identified. These are summarised in Annex 1, with further information provided in Annex 2. DEVELOPMENTS REQUIRED TO SUPPORT IMPLEMENTATION OF THE RECOMMENDATION PtHB needs to ensure that an appropriately resourced long term robust leadership, management, professional and governance infrastructure is place to ensure the delivery of a safe and high quality service. Strengthen Clinical Leadership and Management: PtHB would appoint a Clinical Director for Mental Health to ensure strong clinical leadership. The post holder would ensure that there was effective job planning, appraisal, development, support and supervision arrangements in place for staff. The post-holder would help negotiate local agreements, such as for on-call. The post holder would collaborate with other clinical leaders and provide a Powys voice in all-wales meetings. PtHB will also ensure robust operational management on a pan Powys basis. At present there is no clinical director or operational manager covering the whole of Powys. In line with the successful model for maternity services there would be leadership on clinical governance within the service structure. These would be early interim appointments to help PtHB make the preparations for the direct management of services. Furthermore, a robust management infrastructure is required that supports the effective operational management of the service. Strengthen Governance: It is being proposed that the Mental Health Committee is strengthened to ensure Board level focus, assurance and leadership. The Committee would have access to independent advice. Furthermore, specific managerial arrangements focused on governance (audit, policy and practice development, legislation compliance) will be established. Staff development and support: Appropriate arrangements for specialist supervision would be maintained for staff groups including psychologists, nurses and occupational therapists. This would be commissioned externally if necessary. Staff would be supported to continue participation in research and development. Staff would be Page 6 of 10
encouraged to participate in clinical networks on a regional and sub-regional basis. Staff would participate in appraisal and development arrangements. Appropriate training would be provided. There would be a positive induction process. Shared information and consistent approaches: PCC and PtHB will be early adopters of the new Community Care Information Solution, which would enable staff to use the same information system. There would be consistent policies and procedures, referral processes and integrated working with PCC across Powys. FINANCE The recommendation to directly manage adult mental health services delivered within Powys would affect approximately 10.3million of the 10.7million spent with neighbouring health boards to provide such services. (This is about half of the PtHB adult mental health budget.) The exact cost of services which would remain commissioned would be subject to the usual LTA negotiation process.) (Annex 1 includes financial schedules. These do not include provision which is already, and would remain, in separate LTAs, for example, in-patient services in Wrexham and Redwoods. Whilst there would be transitional costs associated with transferring the employment of approximately 250 staff to PtHB, the medium term aim would be greater direct control to tackle the effectiveness and equity of expenditure across Powys. Cost pressures (which would be experienced regardless of whether the service is commissioned or directly managed) have been taken into account in the budget setting for 2015/16 and beyond. Annex 1 sets out transitional costs for Phase 2 of just under 78k - excluding existing resources. (Full year costs have been given but would be reduced by implementation before December 2015). Sums for corporate support of mental health services within existing LTAs would be re-invested within PtHB. However these would only be released following transfer back to Powys. Resources secured for CCIS implementation should include a mental health work stream. There would be the continuation of existing Project Management arrangements (which are funded from existing resources within the Programme Management Office and the Mental Health Department Budget). Interim arrangements within the PtHB Mental Health Department would continue. THE IMPACT OF NOT SUPPORTING THE RECOMMENDATION Strengthened commissioning and governance of services secured from neighbouring provider health boards and other providers would continue within either scenario. However, the interim arrangements would need to be made sustainable. It is thought that all the current neighbouring provider health boards would continue to provide services if the recommendation is not supported. However, the scope for integrated working with the local authority and the implementation of the new model Page 7 of 10
of care would be severely limited. Most of the identified risks would still need to be tackled such as improving the mental health estate and ensuring robust medical cover. This would need to be achieved within extremely complex arrangements which have not worked well, on a pan Powys basis, to date. OUTLINE IMPLEMENTATION PLAN (PHASE 2) Annex 1 provides an outline implementation plan. The aim would be to ensure appropriate engagement of staff; compliance with statutory TUPE requirements; to keep other stakeholders informed of progress; with an estimated date for returning to PtHB management of services of no later than 1 st December 2015. A mid year transfer is not without problems. LTAs and financial agreements would be for part of a year only. Whilst an April 2016 start date would be the most straightforward this would; leave staff in a prolonged period of uncertainty affecting recruitment and retention; extend the period of risk; delay re-investment within PtHB; and further delay the development of integrated working with PCC and defer service improvements which need to be the focus of activity in 2016/17. STATUTORY CONSULTATION Public consultation is not required as no changes to the location or range of patient services are recommended. The CHC would be one of the key stakeholders to keep informed about progress. Staff engagement and consultation in line with statutory TUPE requirements as part of changing management arrangements will be necessary. An Equality Impact Assessment has been undertaken. SUPPORT The advisory option appraisal, involving a wide range of stakeholders, showed little support for the NHS Management arrangements remaining as they are. No partners in the Project Board dissented from the proposed recommendation. The Chair of the North Powys GP cluster has written to the Chair of PtHB in support of the proposal. PHW after a thorough review of the papers suggested some helpful amendments on points of detail. They found the documentation to be extensive and comprehensive with a strong rationale for the recommendation. They found the judgements in the selfassessment to be fair, but noted difficulties due to international deficits in the evidence base for mental health services. The impact assessment was found to be extensive with no obvious omissions. CONCLUSION PtHB must ensure appropriate NHS management arrangements are in place in order to deliver the agreed strategy and service model for adult mental health services in Powys. The current arrangements, with four different health boards working within one county, are too complex and are holding back integration (with PCC and between physical and mental health services). The complexity of the arrangements adversely affect safety, equity, strategic development and accountability. The arrangements are rooted in what was needed in 2008. A great deal has changed since then with mental health services now delivered in or close to home wherever possible including as an Page 8 of 10
alternative to hospital admission. Clinical Governance is central to the work of PtHB. Powys must have in place the arrangements needed for excellence in primary and community care as it rises to meet challenges, such as the growing number of people living locally with dementia. PtHB holds the risks within the current arrangement regardless of whether it commissions or directly manages services. A careful self-assessment of essential standards involving senior managers in Powys and provider bodies has concluded that current risks are unlikely to deteriorate if there was a change to the current NHS management arrangements and that it would provide a platform for further improvement. RECOMMENDATION The Board is asked to: A) Approve the recommendation that it seeks to directly manage staff in: i) Local Primary Mental Health Support Services within Powys ii) Community Mental Health Teams within Powys (including for older people) iii) Crisis Resolution Home Treatment Teams within Powys iv) Mental health wards within Powys hospitals (for adults of all ages) v) including associated clinical psychologists and occupational therapists; B) Work with employing health boards to initiate engagement and consultation with the staff affected; C) Receive up-dates against a detailed Phase 2 implementation plan at following Board meetings. Report prepared by: Clare Lines Assistant Lead Director for Children and Strategic Lead for Mental Health Presented by: Carol Shillabeer Lead Director for Mental Health & Director of Nursing Background Papers Adult Mental Health Services Model, Powys teaching Health Board October 2013; Hearts and Minds: Together for Mental Health in Powys, Powys Teaching Health Board December 2012 Hearts and Minds: Together for Mental Health Annual Report, Powys Teaching Health Board December 2014. Mental Health (Wales) Measure 2010 Page 9 of 10
Commission on Public Service Governance and Delivery January 2014 Annex 2 & Annex 3 technical documents Annex 2 Adult Annex 3 Adult Mental Health NHS Mental Health NHS M Financial Impact Other Resource Implications The complexity of the current arrangements for adult mental health services has resulted in structural weaknesses in terms of governance and financial control. The current financial position is set out in Annex 1 and the paper includes the likely financial impact. These are set out in the Impact Assessment in Annex 1 Engagement An independently facilitated advisory option appraisal was held with stakeholders in December 2013. Participants included people using services and those close to them; the Community Health Council; GPs; staff from PtHB, BCUHB, ABMUHB and ABHB (including psychiatrists, therapists and nurses); third sector organisations; Powys County Council and Dyfed Powys Police. The results were reported to the Powys Mental Health Planning and Development Partnership. PAVO co-ordinated additional views from people using services which were submitted to PtHB. The underlying strategy involved extensive engage was established in September 2014 involving the employing organisations. The Project Board has been supported by a project team involving operational managers responsible for clinical services with clinical in-put to assessment and risk mitigation work. PHW has provided independent assurance of the self-assessment and impact assessment. Page 10 of 10