Agenda item

The Committee to receive a report from the West London Trust providing operational information about the Mental Health Integrated Network Teams, and including details of the recently redesigned services.

6.1           Councillor Richardson welcomed Dr Chris Hilton and Helen Mangan from West London Trust. This was a follow up report to one that was provided at the previous meeting of the committee and provided members with insight into the MINT service provision for H&F residents.  Although a brief was agreed, it was explained that unfortunately health colleagues were only able to meet this in part, due to severe Covid-19 related service pressures.  It did not cover transitional mental health care for children and young people, to adult services, which was subject to ongoing transformation work and Dr Hilton assured the committee that he would explore this further with members at a future meeting. In addition, some demographic information had only been superficially covered, focusing on the ethnic coding of individuals accessing the MINT service.  Dr Hilton commented that MINT represented a new community mental health service reconfiguration.  Referencing page 19 of the report, he accepted that the detail of this had lacked clarity for service users. The MINT service offered a different, geographical configuration replacing the previous service pattern.  What was primary care mental health, accessible as part of the SPA set of services, included treatment and recovery teams, had been augmented.  They now geographically aligned with the north and south centres of the borough to integrate more closely with the local primary care networks.

6.2           Co-optee Keith Mallinson commented that the report lacked clarity about the SPA issue and did not address the previous concerns identified by the committee.  In his experience, individuals who suffered a mental health episode and need to be seen urgently, or a relative who needed urgent support and information, required clear guidance and direction towards the SPA.  The reality was that this was not the experience of many service users who felt “pushed” towards Accident and Emergency (A&E).  He felt that streamlined, SPA services focusing on service users was required to help navigate mental health pathways.

6.3           Dr Hilton acknowledged that navigating the SPA could be confusing and referenced page 24 of the report, which set out service details.  He explained the Trust’s SPA provision, which was intended to run 24 hours a day, seven days a week, offering an advice and support line for patients and carers. The SPA did not itself deliver services but helped to identify the appropriate care service, including crises care. This was a freephone service, open to all H&F residents, and in particular, for those individuals requiring immediate assistance. Dr Hilton apologised for the confused messaging and frustration for service users that this had caused. A review was currently underway to avoid individuals from being passed between multiple teams and a SPA would help improve capacity.  The SPA, however, was primarily for planned referrals as well as an advice and support line and distinct from MINT, which offered planned care. 

6.4           Councillor Richardson observed that the issue of the SPA raised questions about the consistency of care provided and the advice offered by staff. Dr Hilton explained that the SPA was a service that was distinct from MINT, and that it was a call centre function, offering advice and support for patients, managed and based within the call centre, delivered by a team of mental health advisors and clinicians.  Dr Hilton clarified that clinicians were specially trained to provide interventions and telephone calls were recorded for training purposes.  The SPA received thousands of call each month covering a range of issues, with some individual callers calling in distress.  These also included referrals and calls from emergency services.  Dr Hilton assured the committee that consistency in customer service was a priority for the Trust and welcomed further feedback on how it could be improved.

6.5           Jim Grealy welcomed the report which he felt contained more information than the previous paper, despite the significant pressures experienced by the Trust.  He commented on the issue of ethnic coding highlighted in section of 5 of the report and felt that this offered more clarity.  He asked what strategic plans were in place to understand the reasons for this.  The borough also had a low rate of dementia diagnosis and a second question was about the report’s connection between dementia in older people and mental health which was never fully examined.  Further information was sought about the correlation between the mental health of men and dementia.  National figures indicated that there was a growth in dementia rates in this cohort, and he asked how hoped to plan the Trust future dementia services.  On a further point, Jim Grealy welcomed the inclusion of staffing numbers as this highlighted concerns about recruitment and how this could impact on the successful delivery of the MINT programme.  A final point was about the role of GPs within this new configuration.  Given that many people currently had little opportunity to see their GPs, he observed that Imperial College Healthcare NHS Trust were seeing increased numbers through A&E and urgent care centres.  There were a range of cases that presented with physical symptoms but these sometimes disguised underlying mental health conditions.  The structure of this was important as the integrated care system (ICS) developed.

6.6           Dr Hilton concurred with the concerns about ethnic coding, not dissimilar to H&F or NWL, and work was being undertaken to address, for example, the Ethnicity and Mental Health Improvement Programme (EMHIP, page 29 of the report).  The intention was to understand the different reasons populations have for coming into contact with mental health services and that support was culturally competent. It was acknowledged that there was little information about older people in the report as the brief was focused on MINT.  In addition, dementia services were delivered by a different part of WLT. It was hoped that WLT could develop similar models for older people within the next year and additional investment had been received to support better integration of the older person’s experience. Dr Hilton described the organisation of dementia services in H&F and within the WLT, led by Mr Nevil Cheeseman, consultant and clinical director, with oversight of cognitive impairment and dementia services.

6.7           Dr Hilton acknowledged that there was a concern about the significant level of vacancies in the organisation. An increase in new vacancies had been prompted by additional investment, resulting in greater recruitment challenges which were also reflected across the NHS.  The Trust hoped to invest in recruitment and grow services. New initiatives included apprenticeship routes into nursing and identifying new roles such as peer support workers and graduate mental health workers, who were often psychology graduates seeking a career in mental health. Overseas recruitment was another initiative and these formed part of a collective approach to improve recruitment and retain staff.  Commenting on the interface between GP and hospitals, Dr Hilton agreed that were concerns about this.  Declaring his clinical interest as a consultant liaison psychiatry, Dr Hilton explained that he saw patients in a general hospital setting.  There were a number of structures with NWL’s acute hospitals such as the NWL Urgent Care Board for Mental Health, which monitored mental health presentations across A&E departments.  The Board also monitored the use of alternative pathways, including those provided by MIND.

6.8           Jim Grealy welcomed Dr Hilton’s response but pointed out that colleagues who regularly attended meetings of the NWL clinical commissioning group (CCG) meetings reported that reports on mental health were not considered and enquired how this might be addressed within the implementation of the ICS.  Dr Hilton agreed that mental health services should be well represented within the ICS and was concerned that reports might not be reaching the Board, which he agreed to follow this up with Carolyn Regan, Chief Executive Officer, WLT.  It was confirmed that information was being provided to the ICS executive team.

6.9           Jo Baty reported that she had been working with Peggy Coles, H&F Dementia Action, to deliver dementia friend sessions across the Adult Social Care department and the wider council. One new social worker, (within the mental health team) was unclear as to dementia pathways, where it sat within their sphere of work and how it connected to MINT.  It was clear that further work was required to raise the profile of dementia and this was an opportunity to undertake joint workforce development with WLT.

6.10        Councillor Lloyd-Harris enquired about service pathways and the response times and whether this was consistent with times reported by other trust providers, depending on an individual’s episodic experience and treatment pathway and the follow up contact they might receive. Dr Hilton explained that there were two key pieces of information about this and the first was referenced page 24 of the report. There were a number of different pathways, including the 4 to 24 hours crises team and the MINT service, which responded within a routine response time of one day or up to 28 days, standardised and measured against national response time targets. The implementation of response time standards was a recent introduction for mental health services to ensure greater accountability. A third response time indicator was a waiting time of up to three months for a routine appointment which the Trust aimed to reduce to one month.  This was a challenging target that reflected work in progress, given the increased ratio of referrals to discharges.  This was being monitored and measures had been implemented to ensure timely and adequate triaging and assessment.  In response to a follow up query, Dr Hilton explained that the programme was modelled on the level of approximate demand expected, with a forecast that would reduce following the transition period (pandemic related) and which was informed by the Trusts staffing model.  An added difficulty was the current number of staff vacancies which compounded the issue.

6.11        Merrill Hammer, HAFSON, thanked Dr Hilton for the report which raised a number of further questions. This was the beginning of genuine dialogue and engagement which she found very helpful. One particular concern was the separation of older people from those that were employed, which was regarded as an unhelpful dichotomy.  While it was accepted that the SPA was not part of MINT, this remained an area that lacked clarity, particularly around the awareness of what was available and how this data was collected, analysed and applied in modelling the service. Dr Hilton indicated his agreement to a future report and welcomed opportunities to engage with HAFSON and the committee. There were concerns about the use of a broad, ethnic coding framework and how further refinement of the categories would better inform mental health services so that these could be more responsive.

6.12        Helen Mangan responded to points about the SPA and ethnic coding which she acknowledged was blunt and not good enough. It was possible to provide data on the total number of calls but this lacked contextual details about the calls.  A detailed review of telephony services was currently underway with a view to upgrading existing provision.  At the same time as a review of the functionality of the service, the review would also examine the functions of the workforce underpinning the service.  It was noted that there was a distinction between different functions and that these need to be separated out more clearly, for example, a dedicated crises line, and another helpline which facilitated therapeutic interventions.  Dr Hilton added that the services were being further developed to include an older people’s pathway within MINT and the further engagement that had been discussed. While this was not dissimilar to the one used within the council, Dr Hilton agreed that a further refinement of the ethnic coding categories was warranted. 

6.13        Co-optee Lucia Boddington sought further clarification around waiting times (up to 90 days in some cases) and whether there was a correlation with staff shortages or increased demand. She enquired when the Trust envisaged that they would to be able to meet the 28 day target and if there was a fast track pathway, querying if there was a process of identifying urgent referrals or those that present through the SPA.  She also asked how quickly people would be discharged from MINT, and the length of time it would take to be re-referred.  Dr Hilton explained that the target of 28 days had not been possible for some time and was regarded as a ‘new’ target that they hoped to meet. The target of 90 days was in place but Dr Hilton acknowledged that some wait times exceeded this.  Extensive work was required to meet the 28 day target but it was deliverable within the available resources. In respect of the assessment process, Dr Hilton explained that there were at least three steps in the initial assessment: triage and how the patient had been referred, followed by clinical contact with either the referrer or the individual to understand their current presentation and any psychiatric history; and a risk of self-harm assessment and whether their mental health condition was likely to deteriorate. This information would indicate whether a crises or routine intervention was required. There were mechanisms in place to support individuals where the condition deteriorated and tools to help guide triaging and decision making.  Discharge times would vary according to patient need but some people remained in the service for a long time.  The benefit of MINT meant that it could respond to the needs of both short and long term patients.

6.14        Dr Hilton clarified that the CAMHs (Children and adolescent mental health service) to adult mental health services was a separate, national piece of work around transitions services for young people aged 16-25 years which WLT was involved with and that co-production work with this cohort across NWL had been undertaken.

6.15        Carleen Duffy enquired whether how a discharge process was managed where the patient was homeless and how they might be readmitted if in crises.  Dr Hilton confirmed that there were strict protocols that the Trust adhered to, which ensured that individuals who were homeless received the support they were entitled to, based on any details linked to their last known address and where they had presented.  The mental health trusts across London were part of a compact with agreement about the support provided to this cohort with targeted investment to support rough sleepers. 

6.16        Councillor Coleman welcomed the report and the Trust’s positive efforts in providing information.  In response to a number of questions, Dr Hilton welcomed  the suggestion to identify a date by which the 28 day target might be achievable aspiration, given Councillor Coleman’s concern about a 90 day waiting time, in some cases. On the issue of mapping demand, Dr Hilton responded that provision had been based on demand projection data from multiple sources, but he welcomed a suggestion for further joint work with the ICP and the council’s Business Intelligence Unit to collectively analyse data, including the Joint Strategic Needs Assessments (JNSA) policy. The work around transition services was welcomed and it was noted that this had this information had not been requested as part of the brief for the report.

6.17        On a final point, Councillor Coleman questioned the government’s formula for calculating the registered population, given that the actual population figure for H&F was 190,000. The differential had significant implications for resourcing for the borough across range of areas.  In terms of demand projections, it was expected that this would be impacted by Covid and modelling of the MINT was being developed to include monitoring data from the SPA. The suggestion of a mystery shopping exercise was welcomed and an offer from Healthwatch to support this was also welcomed, together with further engagement with Dementia UK and the input of Peggy Coles and the council.  Referencing page 26 of the report in the context of denominators for vaccination, Dr Hilton noted that the figure provided as the registered population by the CCG was 341,178 and that this incorporated the patient numbers for GP at Hand (Babylon).  A large portion of this number would affect the figures given as open to WLT mental health services (7461), and of which were adults age of 18 years (6538).  Most of the MINT services were for residents rather than GP registered patients.

6.18        Jim Grealy referred to the immense work undertaken to date on the co-production of services for people with disabilities and one of the groups most affected by the pandemic and mental health pressures.  He asked how closely WLT was working to co-produced tailored provision with the borough’s mental health team and across neighbouring boroughs, and the extent to which this would form part of the framework of the MINT pathway.  Dr Hilton responded that there was insufficient engagement with disabled groups and welcomed opportunities to have conversations with the disabled community, facilitated through the ICP mental health campaign, and the council’s co-production network of contacts.  Jo Baty added that, together with Helen Mangan, they aimed to develop a consistent approach to co-production and engagement, through the mental health campaign and across the ICP and build on the work of the council’s Disability Commission, and Dementia Strategy.  The importance of having diverse conversations with communities that were often furthest away from decision making was noted.

ACTIONS:

Please see the attached appendix for a list of the actions.

RESOLVED

That report, comments and actions were noted.