Community Mental Health Service changes to be discussed by Brent Cabinet tonight

Plans to restructure Brent Community Mental Health services are on the already crowded for tonight's Cabinet.  The current budget is £5.4m and the proposals account for £350k of the £500k reduction tabled for 2015-16.  The model is the outcome of partnership wotk between Brent Council, Central and NW London NHS Foundation Trust and NHS Brent CCG.

The Report LINK gives the views of users and staff:

USERS

· The service needs to be genuinely holistic, taking into account all health and community support needs. 


· The service needs to be person-centred, with the service user setting their own goals. 


· Better information should be available at the point of referral about what services are available, and how they are accessed. 


· Assessment and Brief Treatment needs to be improved – assessments aren’t timely enough and brief treatment is not always provided. 


· Community services for those who are not in acute crisis need to be improved so that support doesn’t drop away when an individual’s mental health starts to improve. 


· The service needs to be better linked with the third sector in order to address broader needs. 


· There needs to be clear information for service users on what they should do if they go into crisis and they need emergency support. 


STAFF

· There should be fewer handoffs between teams and service users should move less between teams. 


· There should be clarity around third sector services in Brent and how service users can access them. 


· The single front door, with senior people carrying out the first assessment, should be more effective than it currently is where services find they are “playing catch up” with the core assessment – eliminate the need for more than one assessment. 


· Bureaucracy should be reduced in the new model

· The advantages and disadvantages of generic care coordinators should be considered – new skills have been learned, even if social care assessments aren’t as good. 


· The continuity of care should be improved. 


· Staff may feel unsettled if they don’t like the new structure – Brent already has 
recruitment and retention issues 


· The service should have sufficient capacity to manage demand 


· Links to other services, such as Housing, need to improve 


· Effective discharge planning with service users is essential. 


· The implementation plan has to be well thought through. The impact on service 
users has to be considered as services are reorganised and staff moved around. 


· Ensure specialist functions aren’t lost in the reorganisation. 


· Interfaces shouldn’t be replicated elsewhere, such as between Primary Care Plus 
and the secondary service 


The report recognises that a change of culture is required in the proposed new model:

Changing the operating model and the size and structure of teams will help to improve services, but this also needs to be accompanied by changes to culture and working practices if there is to be genuine transformation. As well as making changes to the teams staff work in, work will take place with staff to change the way they work. There is more to do in terms of changing what people do, as opposed to the teams they work in. Ideas which need to be taken forward include – 

 

  · Better recognition of social breakdown and the contribution it has to a person’s mental health at the initial assessment stage. Multi skilled workers are required, people who can perform a health and social care role and recognise when social factors are the cause of mental ill health. There needs to be a range of services available for staff to refer people to so that social issues are addressed, rather that in the absence of anything else, people have to be accepted into the secondary service. Referrals to supporting people services, day services, the use of direct payments, third sector and peer support services have to become the main tools for the service and available to staff for their work with service users. Commissioning these services to improve the mental health system will be essential. 


        

· The service should focus on a period of intervention, not on keeping cases open indefinitely. Developing and implementing a recovery pathway, where people are not kept in the service indefinitely in case they should relapse, will be central to the new model. There will be a strong focus on outcomes, which services users will be encouraged to work towards during their time in the secondary service. The service will not be judged on time spent with service users, but on the results it delivers. 


· Named case workers should be allocated to the most difficult cases so that there is a clear contact and named person to call if there is a problem with a particular service user. Accountability for cases will be clearer. 


· Better management of urgent referrals is a key priority and, with staff, plans will be put in place to help prevent a backlog of referrals building up as they have in recent months. 


· For people discharged to Primary Care there will be, for an agreed period of time, the ability to get support from secondary services without having to re-refer back to the SPA. Links to primary care need to be improved, to bring about a more cohesive mental health system. The community mental health service will only work effectively if its links with other parts of the system are effective. 


The Report gives an outline of the new model and new service standards:

Single Point of Access 


3.26  This is summarised earlier in the report, but the North West London single point of access will provide an access point for all new referrals to the Brent Mental Health service. 


3.27  Recovery Service 


3.28  A Brent Recovery Service will be established, split into two network groups which will deliver a range of functions including –

       ·  Responding to referrals and providing brief treatment as required – providing an initial response to referrals, particularly a face to face response within four hours for urgent access, pending Trust-wide work on the development of a HRRTT model, which will be crucial for the networks. 


       ·  Assessment Function – a full Core Assessment, Risk Assessment and Carer’s Assessment will be carried out in network groups following referral from the screening service. 


       ·  An outcome based Care and Support Plan will be put in place for each person, with progress reviewed against this plan on a regular basis by the Care Coordinator. Working towards discharge from the secondary service back to primary care will be a key function of the service. 


       ·  The service will engage with people to ensure they are involved with Employment Support Services, training and other activities designed to promote independence and recovery and to avoid social isolation. 


       ·  The functions of the Rehab Service will be carried out within the network teams. Care for service users in residential care and supported accommodation services will happen from the networks. 


       ·  A “Staying Well Plan” for each service user will be put together at the point of discharge. This will be personalised for each service user, so they are aware of the services available to them in primary care and the voluntary sector, and what to do if they feel they are relapsing. 


3.29  One of the key service standards that will be introduced is based around length of time in the Recovery Service. The team has to start thinking about how long it is appropriate for someone to stay in recovery. Of the 869 service users allocated to the 
 current Recovery Team, 457 have been in the service for five years or more. This has been challenged and progress made in reviewing and discharging people who don’t need to be in the service. A new model with clear standards and expectations for staff, as well as stronger links with other parts of the system will deliver further progress with this issue. The service is moving towards a model where working with service users on the basis of a maximum of a two year period for recovery is the ambition. It is acknowledged that a step-down to primary care services will be impacted upon by the implementation and monitoring of agreed and not yet agreed shared care protocols and the current lack of specialist services such as Personality Disorder Service, Community Forensic Service, and Dual Diagnosis Services in Brent, as well as the lack of clear commissioning streams/budgets for service users with complicated needs such as ADHD, Autism, Brain Injury etc. This will be reliant on better commissioning between the council and CCG.

3.30  Early Intervention Service 


3.31  The Early Intervention Service (EIS) works with people under the age of 35 experiencing their first episode of psychosis. It is a time-limited service, focussed on intensive interventions and recovery. By delivering sustained support over a three year period, the possibility of an individual developing a long-term condition is minimised. There is a strong focus on social support networks and support is also offered to the families of service users, to try to ensure relationships are maintained. 


3.32  Because there is a national directive, based on strong evidential support for the effectiveness of Early Intervention Services, the EIS will remain a standalone team, but will be hosted within one of the network teams. The importance of recognising the EIS clinical pathway and service standards for those experiencing their first episode of psychosis is such that it will remain a separate team providing borough wide coverage. The key service standard that has been introduced since April 2015 is that all those referred to and accepted into the service shouldn’t have to wait longer than 14 days from referral to treatment. 


3.33  Mental Health Act Team 


3.34  The Mental Health Act Team is a council funded team, made up of Approved Mental Health Act Practitioners (AMHPs). AMHPs are responsible for carrying out Mental Health Act assessments and can deprive people of their liberty if it is felt that this is required for treatment for their illness. It is a specialist role that is governed by legislation. At present all of the AMHPs in Brent are social workers, and those who work in the Mental Health Act Team don’t carry a caseload, their focus is on Mental Health Act work. 


3.35  For the time being it is proposed that the Mental Health Act Team remains as a stand alone team, providing coverage across Brent. This includes AMHPs based at Brondesbury Road and Park Royal, who are to be brought together as one team. In time it is proposed that AMHPs are integrated into the Recovery and Rehab Services leaving only a core Mental Health Act Team, of one AMHP manager and one permanent AMHP. AMHPs will provide coverage on a rota basis as this evolves. The Mental Health Act Team will continue its interface with the EDT, to ensure that there is Mental Health Act coverage 24 hours a day in the borough. 


3.36  Service Standards 


3.37  As part of the work in developing a new operating model, an audit of case files has been undertaken to look at strengths and weaknesses in practice and to help clarify 
 service standards which will guide working practice and the implementation of a recovery model. There are some clear issues that have been identified from the audit as well as analysis of the current case load data and work with service users which has led to the development of the service standards set out below –

· Monthly contact as a minimum with all service users 


· Urgent referrals seen and assessed within four hours; routine referrals seen 
within 28 days 


· Targets for length of time people are in the secondary MH service – two years as 
a maximum, based on the point that it isn’t a service for life and that the primary 
goal is recovery 


· Uniform approach to discharge planning including a “staying well plan” - pro- 
active management to avoid the need for crisis intervention, jointly agreed with 
GPs 


· Better interaction between secondary and primary care based on “staying well 
plan” to ensure people can access secondary support even when in the 
community 


· Reduced hand offs between teams - smaller teams based on two networks – 
better links with primary care and the local community 


3.38  For staff, the service standards and service capacity will mean that each of the 51 care coordinators in the service will be expected to do –

· 1 service user review per week 


· 1 new assessment per week 


· 11 “contacts” with service users on their caseload (2.5 hours is set aside for each 
contact), so that every service user is contacted every 3 weeks 


3.39  Each care coordinator will have a caseload of around 35 people. Cases will be segmented into one of 4 zones, depending on the complexity of the persons’ illness –

· Reablement: 1-12 weeks – It is expected that 40% of cases will be included in this zone 


· Targeted treatment: 2-6 months - 15% of cases will be included in this zone 


· Continued Care: 3-9 months - 15% of cases will be included in this zone 


· Complex needs: 9 months plus - 30% of cases will be included in this zone 


3.40  There will be 51 care co-ordinators in the service, 22 of which will be social care funded social workers. The community service will be able to manage a caseload of 1,500 service users at any one time. This is a reduction from the 1,800 currently in the service, but reflects the changes that are happening in the system – the development of Primary Care Plus and discharge of service users to that service, as well as a better focus on service user recovery. 


The report notes that  there are employment issues to be dealt with in the near future if the model is to work:

Analysis of staff who work in the service has uncovered one striking feature that stands out - the age of staff. Only 13 of the 61 council staff are aged under 40. Twenty six are aged 51 to 60 and five are aged 61 to 70. Over 50% of the staff are aged 50 or over. This could have had implications for the operating model work, but savings will be taken from vacant posts rather than existing staff. However, this will be an issue for the service and it will need to take steps to ensure experienced members of staff are replaced as they leave in the future