Agenda item

Ian Ayres (Accountable Officer, NHS West Kent CCG), Dave Holman (Head of Mental Health Programme Area and Sevenoaks Locality Commissioning, NHS West Kent CCG), Lisa Rodrigues (Chief Executive, Sussex Partnership NHS Foundation Trust), Lorraine Reid (Managing Director, Specialist Services, Sussex Partnership NHS Foundation Trust), Simone Button (Divisional Director, Children and Young People’s Services, Sussex Partnership NHS Foundation Trust) and Jo Scott (Programme Director, Sussex Partnership NHS Foundation Trust) were in attendance for this item.

(1)       The Chairman welcomed the guests of the Committee and asked them to introduce the item. Mr Ayres began by acknowledging that the Committee had given NHS West Kent CCG and Sussex Partnership NHS Foundation Trust (SPFT) a challenging time at the previous meeting particularly in regard to the length of wait for an initial assessment. The CCG had recognised at the January meeting that CAMHS was not a good service when it was taken over by SPFT; the Trust had a significant task to turn around the service. The CCG and SPFT had taken HOSC’s recommendations seriously and had spent a long time working together to improve the service. By the end of August, the following targets should be met: referral to assessment within 4 – 6 weeks; urgent referral within 24 hours; and referral to treatment within 8 – 10 weeks.

(2)       Mr Ayres had been assured by the CCG’s clinical team that once an initial assessment had been held, the quality and performance of the service was good. SPFT had not fully recruited in Kent however, the full time vacancy rate was low enough for temporary staff to be recruited. The CCG had been working with Steven Duckwork from NHS England’s South East Coast Strategic Clinical Network. He was supporting the CCG to review Tier 4 services and their interface with Tier 3 and identify a best practice CAMHS service to benchmark against services in Kent. CAMHS was recognised as a national challenge, a number of national reviews had been launched and the CCG and SPFT were involved with those.

(3)       The CCG now had an agreement with KCC and NHS England to reintegrate the commissioning of CAMHS with a lead commissioner and single specification for the service. It was acknowledged that it had not been sensible for different sections of the service to be commissioned by three different commissioners. The Kent Health and Wellbeing Board had approved this direction of travel. The CCG were also working with the Police to commission a Section 136 place of safety for children which had not been commissioned under the previous arrangement. The CQC were inspecting safety and safeguarding arrangements in NHS West Kent CCG and NHS Dartford, Gravesham and Swanley CCG with a focus on CAMHS during the week of the meeting. No emergency findings had been identified at the time of the meeting; an emerging view from the CQC would be published within a month.

(4)       Mr Brookbank noted that he had received letters expressing concerns with CAMHS in Kent from The Rt Hon Greg Clark MP and Julian Brazier TD MP. He had also received an email from Patrick Leeson and Andrew Ireland regarding the integration of CAMHS commissioning.

(5)       Ms Rodrigues commented on SPFT’s decision to bid to run CAMHS in Kent. CAMHS was an important service which SFPT already delivered in East Sussex, West Sussex and Brighton and Hove. The Trust was under no illusion about the challenge it had taken on when it bid for the contract. SPFT agreed with the commissioners that a three year improvement plan would be needed to improve CAMHS in Kent. SPFT were now 18 months into the plan; they had increased the number of whole time equivalent staff to 274; carried out a number of geographical moves; made improvements to IT and mobile communication systems and introduced a 24 hour service; in addition to running the existing service. In July 2013, the average wait for an initial assessment was 32 weeks; by February 2014 the wait had been reduced to 7 weeks. However the number of referrals particularly urgent referrals was higher than anticipated.  In February 2014, 79 of 112 emergency referrals had been out-of-hours and were all assessed within 24 hours. The number of standard referrals had increased from 772 in February 2013 to 952 in February 2014.

(6)       Ms Rodrigues highlighted the challenges to SPFT and their staff. Referrals had increased with improved access; in addition to a 10% national increase. NHS England was conducting a rapid review into the national increase. With three different commissioners; it was easier for children and young people to access higher level services rather than lower tier services. Staff were feeling beleaguered following negative media coverage which contained anecdotal and historic allegations; there was an unrealistic expectation in the press of what the service could achieve in the time that SPFT had been responsible for the service. Ms Rodrigues stressed that SPFT would continue to make improvements and was committed to improve the service in Kent.

(7)       Mrs Whittle was invited to comment. She explained that the Health and Wellbeing Board would be looking at the commissioning arrangements for all CAMHS tiers. She had concerns with the referral pathways and waiting times for tier 2 and 3 services. It was important that children and young people could access the correct treatment at the right time particularly with the increased demand. She felt that the provider had been set up to fail with the backlog they had inherited; however both KCC and the PCT were not aware of the backlog at the time of commissioning. She acknowledged that the services were performing much better than three years ago. Mrs Whittle suggested that the Health and Wellbeing Board report regularly to this Committee about the progress of reintegrating the commissioning arrangements.

(8)       Members of the Committee then proceeded to ask a series of questions and make a number of comments. A Member enquired if referral to routine assessment was the same as referral to treatment. Mr Ayres explained that if performance in the contract was being met, a child or young person would be assessed within 6 weeks and treated within 10 weeks. The wait for assessment was currently 7 – 8 weeks which compressed the time available for treatment. Ms Reid noted that an assessment often had an element of treatment with homework tasks being set for the next appointment.

(9)       A Member acknowledged and expressed sympathy with SPFT staff working in challenging circumstances; the Member proceed to ask what lessons had been learnt about the commissioning process. Ms Rodrigues explained that SPFT had experience of taking on a number of services. When a service was re-tendered like the CAMHS contract in 2012, it suggested there were issues with the original contract. It was reported that SPFT had a similar experience in Hampshire three years ago; the Trust had benefitted from this experience and were able to implement change much faster in Kent than in Hampshire. Ms Reid added that SPFT inherited staff with low morale; some of who had tendered for the CAMHS contract on behalf of their previous organisation. She explained that it took at least 18 months for staff to settle into a new organisation and sign up to the new model. Further, when SPFT took up the contract, all the commissioning arrangements changed too. Ms Reid stated that discussions with HOSC regarding CAMHS had been very helpful; the commissioner and provider were working more closely together.

(10)     In regards to lessons learnt, Ms Reid expressed that she would have introduced a less complex management of change but would have still implemented the same model. Mr Ayres stated that the CCG should not have undertaken the procurement with a commissioning team who had no knowledge of running the service. The CCG also recognised that there had been an information vacuum in the transition from the old to the new provider. Knowledge capture would be built into reviews for future contracts. Mr Ayres explained that neither the contract nor provider of CAMHS were poor. Both the commissioner and provider, initially, had not dealt with problems fast enough; things are beginning to be turned around. Most of the actions from the last HOSC meeting had been enabling actions rather than delivering results.

(11)     A question was asked about the transition to adult mental health services. Ms Scott explained that it depended on the issue; the majority of young people did not need to transfer to the adult section if they had been successfully treated beforehand. Children with continuing needs were transferred to adult services which began six months before the young person’s 18^th birthday with the adult and children services working together. Adult mental health services in Kent were provided by Kent and Medway NHS and Social Care Partnership Trust (KMPT). The CCG sets both KMPT and SPFT transitional targets. Mr Holman acknowledged that transition had always been a problem. From a contract view, it was important for the contract to align with SPFT and KMPT to ensure a smooth transition. Transition would be part of the integrated commissioning review.

(12)     A number of comments were made about the recent KCC Select Committee on Commissioning, joint commissioning and the importance of performance management. A Member questioned the NHS’ experience in commissioning. Mr Ayres admitted that the NHS was not good at commissioning and contracting; every three years the NHS was restructured which had prevented the development of good commissioning teams. For West Kent CCG, he explained that it would take another year to build a confident commissioning team; external expertise would be brought in. The amount of CAMHS activity in Kent had been higher than anticipated in the contract. If the CCG had been dealing with a commercial provider, a cost premium would have been associated with the additional activity. Cooperation between partners in the NHS, such as the CCG and SPFT, was very helpful as there was recognition that a child needed to be seen rather than an associated cost. Mr Ayres was keen to improve joint working with Kent County Council to ensure clearer interactions with education and young peoples’ services; and to learn from their expertise with commissioning and procurement.

(13)     A further question was asked about the provision of information given to bidders during the tendering process. Mr Ayres acknowledged the information given to the provider had been poor. The CCG had discovered that with the former block contract, counting activity had been poor; therefore information given to the bidders was flawed. In addition, Mr Holman explained that there was a growing need for CAMHS in Kent; providers needed to be kept informed about the additional services required.

(14)     A Member expressed concerns that SPFT performance had got worse since the January meeting; the Member referenced figures provided by The Rt Hon Greg Clark MP. Ms Rodrigues clarified that the figures provided in the report to HOSC were correct. In response to Mr Clark’s letter to SPFT, Mr Ayres explained that if the contract was broken down into very small areas, some areas performed better and worse over time. The contract did not set out individual targets for small geographical areas. A Member expressed their disappointment that waiting times by area had not been included in the report; this information had been provided at the last meeting in January.

(15)    A number of questions were asked about the use of inpatient beds and the development of a Section 136 suite in Kent. Ms Scott explained that Kent and Medway had a high number of bed users due to the historic set up of community services. A home treatment service to look after children and young people in their homes had recently been introduced. This had reduced the number of children and young people who required an inpatient bed. There was a national shortage of beds with a one in, one out system. The home treatment service also facilitated early discharge from an inpatient bed as children and young people can be supported at home. Mr Holman acknowledged that it was not acceptable for children to be going out of county to a Section 136 suite. A place of safety was being developed in Dartford; it was due to open on 1 May 2014 as an interim arrangement. It had the support of the Police and South London and Maudsley NHS Foundation Trust (SLaM); a place of safety in Kent would relieve bed pressure for SLaM.

(16)    In response to a specific comment about KCC’s duty to safeguard Looked After Children as part of its corporate parenting role, Ms Rodrigues acknowledged that it was very important to safeguard Looked after Children as they were more likely to need the support of the CAMHS service There were a large number of Looked After Children in Kent with London Boroughs’ placing children in the county.

(17)    A series of questions were asked about mental health funding and staffing levels at West Kent CCG. Mr Holman explained that funding for mental health services as a whole was low. Funding for children and young people was even lower despite 75% of first mental health difficulties happening between the ages of 14 – 24 years. Mr Ayres noted that staffing had increased from 6 – 60 staff at West Kent CCG since April 2013. The transition to CCGs had been very disruptive for the whole of the NHS; 54 of the CCG’s staff had moved from within the NHS.

(18)    Members enquired about staff morale, feedback on the effectiveness of treatment and appointments in school holidays. Ms Reid explained that morale was a very important issue for SPFT. There had been a significant programme of change, negative media coverage and an increased demand for services which had increased stress and lowered morale. To boost morale, SPFT had engaged staff in the business continuity plans, improved the physical working environment and increased the number of staff. SPFT were also expert providers of mindfulness training which had been made available for staff.  Ms Reid stated that the Trust received lots of feedback from children and young people about their treatment. Children and young people were also involved in advising on treatment programmes. All treatments were based on NICE guidance. Ms Rodrigues explained that SPFT ran services all year round including the school holidays. The CCG had asked SPFT to be tougher on patients who were offered an appointment in the holidays and then cancelled them.

(19)    A Member highlighted a case which had been brought to their attention. A child who was originally referred for Tier 3 services was escalated to Tier 4 inpatient bed. The child had received extremely good treatment. The child was subsequently discharged on the understanding that one-to-one treatment would be continued at home. There has been no contact with the child since being discharged. Mr Ayres encouraged the parent or carer to complain. Ms Scott asked for the Member to pass her the contact details, with the parent’s permission, outside of the meeting and said that it would be looked at immediately after the meeting.

(20)    In response to a specific comment about SPFT being set up to fail, Ms Rodrigues explained that this was not the case. The Trust was confident that they would meet the needs of children and young people in Kent and Medway. The Trust was 18 months into their three year transformation programme and staff were working very hard. Ms Rodrigues welcomed the opportunity to return to the Committee to update them on progress in six months.

(21)     RESOLVED that:

(a)        this Committee continues to be concerned for the CAMHS service in Kent and recommends that the commissioning of this service is investigated by KCC and West Kent CCG.

(b)        West Kent CCG be asked to give due regard to the recent KCC Select Committee on Commissioning. 

(c)        West Kent CCG and Sussex Partnership colleagues be invited to the Committee meeting in 6 months’ time and the CCG submit two monthly update reports to the HOSC.