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