LaurettaKavanagh (Kent and Medway Director of Commissioning for Mental Health and Substance Abuse, NHS Kent and Medway), Helen Buckingham, (Deputy Chief Executive and Director of Whole Systems Commissioning, NHS Kent and Medway), Sara Warner (Assistant Director Citizen Engagement, NHS Kent and Medway), David Tamsitt (Director Acute Services, Kent and Medway NHS and Social Care Partnership Trust), Rosarii Harte (Assistant Medical Director – Acute Services, Kent and Medway NHS and Social Care Partnership Trust), Adrian Lowther (Head of Communications, Kent and Medway NHS and Social Care Partnership Trust) and Kevin Skinner (Commissioning Consultant, NHS Kent and Medway) were in attendance for this item.
(1) Along with the reports contained within the Agenda, Members had before them copies of a 158 page paper due to go to the Board of NHS Kent and Medway later in the month. This provided an additional level of detail which Members of the Committee would be able to study. Reference to parts of this additional paper was made during the meeting as giving additional information underpinning the answers to specific questions from Members of the Committee.
(2) Representatives of the NHS began by explaining that they welcomed the opportunity to bring their proposals to the Committee (JHOSC). They saw the role of the JHOSC as being to hold the NHS to account in ensuring that the appropriate process was carried out and looked forward to asking the Committee to approve their plans to proceed to a full public consultation. In discussion the consensus was that a second meeting of the JHOSC would be required once the NHS had completed the consultation and subsequent deliberations, but this did not preclude Members taking an active interest in the intervening period.
(3) In 2010, the Secretary of State for Health set out 4 tests. When carrying out any service reconfiguration, it would be incumbent on the NHS organisations involved to demonstrate the plans had met these tests. These are: strong clinical evidence base; support of GP commissioners; appropriate patient choice was maintained and strengthened; and strong engagement with service users, staff and other stakeholders such as local authority Members.
(4) The current plans had been developed by NHS Kent and Medway as the commissioners with the main provider of mental health services, Kent and Medway NHS and Social Care Partnership Trust. A lot of detailed analyses of changes in the way services have been used and the profile of patients who accessed them, along with engagement events with stakeholders and clinicians had led to 4 proposals which would define the outcome sought by service reconfiguration.
(5) Firstly, there was a need to strengthen Crisis Resolution Home Treatment Teams (CRHT). Several years ago there was often no choice but to admit people to hospital out of hours and at weekends when Community Mental Health Teams (CMHTs) were not available. CRHT were able to deliver acute services in people’s homes and act as gatekeepers to acute care. The plan was to enhance these with additional Support Time Recovery Workers (STRWs). STRWs would be able to provide more support to enable people to remain at home. There was a connection here with the Liaison Psychiatry service available 24/7 in East Kent which was due to be enhanced in Medway and West Kent.
(6) Secondly, there was a desire to establish 3 centres of excellence for acute mental health inpatient services. This would allow therapeutic services to be enhanced and lead to measurable improvements in outcomes. This was connected to the misalignment of the current location of beds with need. In effect there were too few beds in East Kent which meant that patients from East Kent could be sent to West Kent, were there was capacity. This broke the connection between a patient and local services and led to an increased length of stay and impaired recovery. It also connected with long-standing concerns about A-Block in Medway Hospital. Although the staff were hard working and dedicated, the building itself was not fit for purpose. For example, the women’s ward on the first floor had no easy access to outside spaces. Line of sight for safely monitoring patients was also regarded as inadequate. The analogy was given of the recent centralisation of angioplasty at William Harvey Hospital in Ashford which had seen improved outcomes despite longer travel times.
(7) Thirdly, there was a desire to extend Psychiatric Intensive Care Outreach (PICO) teams. This was a peripatetic service which was able to serve acute wards and reach into intensive care. This service was already well established in West Kent but needed to be rolled out across East Kent.
(8) Fourthly, there was a need to consolidate Psychiatric Intensive Care Units (PICU) from 2 to 1. The plan was to have a second ward at Little Brook Hospital in Dartford to consolidate the services. This would mean the PICU at Dudley Venables House at St. Martin’s Hospital in Canterbury would be relocated to Dartford, enabling an increase in 8 acute beds in Canterbury.
(9) These 4 proposals in turn underpinned the Options for service change set out in the Agenda paper and to be included in the consultation paper. The first option was to do nothing and leave the status quo. The other 3 Options all involved the relocation of beds available for Medway patients from Medway to Little Brook Hospital. The choice was between patients from Swale and Sheppey going to Priority House in Maidstone, Little Brook Hospital or St. Martins. Excluded from this were patients from Faversham who would continue to access beds at St. Martin’s.
(10) NHS representatives set out the argument that maintaining the status quo was not an option. All 8 of the current Clinical Commissioning Groups (CCGs) in Kent and Medway had approved the large Board paper which Members had before them. This had been supplemented by 2 GP practice engagement events. Much of the clinical evidence was based on the changing nature of service use and patient profile. The average length of stay in acute inpatient care had decreased but the acuity of the conditions seen had increased. One third of patients were detained under the Mental Health Act and accounted for over half the total number of bed days. It was explained that this trend was mirrored across England. There was a measure of scepticism on the part of a number of Members about the data which had been presented with the view expressed that data can be selected and presented to demonstrate something which might not be the whole story. There were a number of requests for specific information that NHS representatives undertook to provide in order to address these concerns.
(11) Allied to this discussion was a broader one about possible future increases in demand for mental health services. The current economic climate did mean there was likely to be a rise in cases of depression but that this would not lead to an increase in demand for acute inpatient services but rather psychological therapies, in which there was investment planned. The other main area of predicted increased demand would involve dementia and again there were specific services being enhanced here.
(12) A core focus of discussion was around the closure of A-Block at Medway Hospital. Members of the Committee generally agreed that there were issues at A-Block which needed addressing and which meant it was not truly fit for purpose. However, given the concentration of population and the high proportion of people on Incapacity Benefit with mental health needs in Medway, the view was expressed by a number of Members that for Medway to lose a facility seemed counter-intuitive. The issue of demand for acute beds in Medway was raised and the question posed as to whether there had been a shortfall in the period 2008-2012. Information on the number of patients from Medway accessing services in other areas was requested because this would determine the level of past demand for a local service.
(13) NHS representatives understood this argument and indicated that the Board paper set out the background to the search for a suitable location in Medway. The location would need to be suitable for the purpose to enable a quality service to be delivered. It also needed to be a facility which would allow recruitment and retention of staff as well as being within an appropriate ‘cost-envelope.’ More generally on the question of finances, cost-saving was not given as a prime driver for the changes, with the overall cost of the changes being about the same or even more than the status quo. However, the budget was not limitless and there were constraints on staffing numbers as well. The NHS undertook to provide the site requirements to Members and write to them formally with a promise to examine any location brought to their attention.
(14) The possible future location of services directly connected to a number of concerns and questions from members about the issue of transport. Along with general concerns about the accessibility of services, some Members expressed the view that there was a tension between centralising some services and the idea that the recovery process was improved when services were part of an integrated local pathway and patients were not separated from their support networks of families and friends. NHS representatives responded by arguing that the proposals taken together would mean more people treated at home and due to the proposed increased in provision in East Kent more people would be treated in their local area. A number of appendices in the Board paper related directly to transport. It was explained that the Kent and Medway Transport Group was being reconstituted and would involve local authorities and NHS commissioners and providers looking at transport issues across the board. Members commented that from the perspective of Medway and Swale patients, Bluewater was easier to get to than either Maidstone or Canterbury, but they had concerns about the next stage of the journey to Little Brook Hospital by public transport, particularly outside regular business hours.
(15) In the context of the discussion around the future of Medway A-block, concerns were expressed about the impact any relocation of inpatient services would have on the sustainability of CRHTs in the area if there was a lack of a local base.
(16) Part of the response to the transport issue for staff and visitors from the NHS involved the use of mobile technology. For example, supported by the voluntary sector, Skype could be used to talk to patients. On the subject of transport, one Member made the offer that if he could be persuaded that transport from his area on the coast of Kent (Deal and Walmer) could be addressed to his satisfaction, he would promote the proposals and this could help make the case as his area was the furthest place in Kent from Little Brook Hospital. It was added that there was adequate car parking for staff and visitors at Little Brook.
(17) This issue was raised of the knock on effect of the changes to the viability to Acute Trusts across Kent and Medway. NHS representatives responded by saying that recent events in South East London has meant an increase in activity in Darent Valley Hospital, but not Little Brook. The development of Liaison Psychiatric services at Darent Valley was geared to enhancing the capacity of Darent Valley in responding to any increase in presentations of mental health issues at accident and emergency. The services at Medway A-Block were provided by KMPT, but if they were moved this would mean Medway Foundation Trust had two additional wards. No discussions about any possible reconfiguration of services at Medway Hospital this may allow would take place until a final decision had been made.
(18) A specific question was asked about the potential impact of the proposals on Priority House in Maidstone. There were 34 beds here, and it was explained that over the last 4 years, demand was such that 10 fewer beds were required. This meant that the 7 beds required each year for Sheppey and Sittingbourne patients could be available.
(19) On the question of finances, it was explained that work was going on to introduce Payment by Results (PbR) in mental health. As this replaced the old-style block contracts, integrated pathways of care would be more viable.
(20) Members of the JHOSC had been given the opportunity to visits Medway A-Block and Little Brook Hospital the week before the meeting and those Members who had been able to attend expressed their thanks to the patients, staff and others they had met. There was an enthusiastic response to the suggestion that further site visits be arranged in the intervening period before the next formal JHOSC meeting.
(21) Regarding the details of the consultation process itself, the NHS explained that information on the proposals would be available in as many places as possible, such as GP practices and hospital sites. It was conceded that there was a limit to how much background detail could be contained in a consultation document, but all the supporting evidence would be available online. In addition to 6 public meetings, staff would go to as many other events as possible where people interested in the proposals were likely to be, which was a tactic adopted during the recent East Kent maternity services consultation. As had happened with the recent consultation on Older People’s Mental Health Services, there are established routes to involving carers and users of mental health services and those directly affected do make up the majority of respondents.
(22) To assist the deliberations of the Members of JHOSC, representatives of the NHS undertook to provide the following:
· Information on the numbers of Medway residents accessing acute mental health inpatient services outside of Medway, and the associated costs in the last 4 years.
· Details of the levels of staffing at Medway A-Block over the last four years along with an analysis of the changes which could have affected demand.
· Details of the staffing of the different CRHTs across Kent and Medway, with the location of the new and proposed Support Time Recovery Workers indicated clearly.
· CQC reports of all the sites involved in the plans.
· Provide Members with the criteria/site requirements for an alternative to A-Block in Medway and formally write to Members promising to examine any alternative site brought to their attention, giving details of all the options in Medway which have been considered and rejected
(23) The Chairman proposed and the Vice-Chairman seconded the following motion:
· That the Committee approves the NHS decision to take the proposals in the report to three months public consultation between late July and late October 2012 and looks forward to a consultation document which will take into account the concerns expressed at this meeting and that these concerns will also be addressed by the further information to be provided and the further site visits to be arranged.
(24) RESOLVED that the Committee approves the NHS decision to take the proposals in the report to three months public consultation between late July and late October 2012 and looks forward to a consultation document which will take into account the concerns expressed at this meeting and that these concerns will also be addressed by the further information to be provided and the further site visits to be arranged.