A
Presentation was circulated as part of the agenda pack. Dr Tamara
Djuretic, Assistant Director of Public
Health and Shelley Shenker, Assistant
Director MH Commissioning – Haringey CCG, gave the first part
of the presentation on Mental Health and Wellbeing. The second part
of the presentation was delivered by colleagues from Barnet,
Enfield and Haringey Mental Health Trust: Dr Jonathan Bindman - Medical Director; Maria Kane - Chief
Executive and Katherine Edelman - Clinical Director of services for
Haringey. Following the presentation the Board discussed the
findings.
Some of
the key points raised in the presentation were:
- The
performance indicators for Ambition 9 were: Percentage of people
aged 18-69 on Care Programme Approach in employment and percentage
of people aged 18-69 on Care Programme Approach in settled
employment.
- Current
performance was noted as 76.8% of adults in contact with secondary
mental health services were in stable accommodation which was
similar to our statistical neighbours but was lower than the London
average and higher than the England average. 5.1% of adults in
secondary mental health services were in paid employment. 5.1% was
lower than Haringey’s statistical neighbours and both the
London and national average.
- 5.7% of
women in secondary mental health services were in paid employment,
compared to only 3.3% of men.
- The aim for
Ambition 9 was to increase the percentage of adults receiving
coordinated care who were in employment to 9.85%, which would be
top quartile nationally and to increase the percentage of adults
receiving coordinated care who were in settled accommodation to
80%, which would be in line with Haringey’s statistical
neighbours.
- The joint
CCG and LBH Mental Health and Wellbeing Framework was published in
March 2015 following extensive engagement and consultation. A whole
system approach was adopted in the definition of enablement adopted
in the framework: “...supporting people to meet
their potential to live independently, to have meaningful social
relationships, maintain good quality housing, find and/or maintain
employment and live a satisfying life.”
- The
proposed enablement outcomes were divided between outcomes for the
individual and outcomes for the system:
For the individual:
•
Strong social networks and reduced
isolation
•
Sustained employment, meaningful activity
•
Stable accommodation
•
Improved resilience and self-confidence
•
Resources are effective in achieving personal
goals
•
Improved physical health
•
Positive service user experience
For the system:
•
Reduced activity in intensive, high cost
resources/increased activity in low intensity, lower cost
resources
•
Pathways to and availability of resources understood
by all stakeholders
•
Improved mental health awareness and reduced
stigma
•
There was a choice of readily accessible resources
available that met a range of needs and preferences
- In order to
deliver these outcomes, an integrated, personalised and goal
orientated care approach would need to be adopted in order to
facilitate a life beyond diagnosis.
- The
delivery of more interventions at the earliest possible stage in
order to keep people well and supporting people with community
based services when they do become un-well was also a key aspect of
delivering the above outcomes.
- The need to
respond quickly and to deliver high quality interventions and
in-patient care was also highlighted to the Board, in order to
provide effective support and ensure early discharge.
- A shift in
the balance of resources to lower tiers of care was required so
that people were supported in a variety of settings.
Julie
Proudly, Manger for the Twining Enterprise service gave an overview
of the individual placement support model to the board, as an
example of a successful highly evidenced model of supporting people
with severe mental illness into employment. The key points
were:
- Delivery in
Haringey started in July 2015
- The model
involved the integration of employment specialists within health
teams so that employment became part of the health package and part
of the recovery package
- One
employment specialist was integrated into the Early Intervention
Services and one employment specialist was integrated into Recovery
Enablement Track which was in the process of being set
up.
- To date, 35
clients had been engaged in the process and 6 had been offered
jobs.
- The process
was based on 8 evidence-based principles including; a
client-centred approach to get patients the jobs that they want, a
paid work focus, ongoing in work support and employer
engagement.
- A similar
project was established in Barnet in January which had been
successful and Twining Enterprise hoped to be a centre of
excellence by March 2017.
- The process
involved an integrated approach involving a partnership between
statutory partners and the voluntary sector.
Ms. Shenker gave a
further example of successful enablement model, the accommodation
pathway, to the Board. The key points
were:
- The model was driven by a significant number of delayed
discharges from Mental Health in-patient beds.
- The partnership identified multiple challenges
including:
•
Lack of joined up approaches to early
assessment ensuring that housing needs were being addressed early
on.
•
Confusion about the range of available
accommodation options and approvals routes for health and social
care funding.
•
No clear escalation routes for when
blockages occurred.
•
No regular multi-agency forum for
resolving these issues proactively.
- A multi-agency steering group was established across health,
social care, housing and BEH to clarify the accommodation pathway
for people with mental health needs.
- This included the roles and responsibilities of key agencies
involved in a person’s care, and a guide for care
co-ordinators which was being trialled.
- The aim was to ensure effective and timely assessment, access to
least restrictive housing options which maximised independence for
people with mental health needs.
- The group was also developing an accommodation pathway dashboard
to outcomes.
The
Board was advised that key implications of adopting an enablement
approach were:
-
Harnessing the role of communities in offering
support and linking this to the primary care offer to maximise
well-being.
-
A need to pump prime to allow time for preventative,
primary care and strengthened community based mental health
services to be piloted and be shown to work with intent to release
resources from secondary care to fund longer term
developments.
-
Need to consider investment, capacity and skills in
voluntary sector organisations.
-
Consensus about management of clinical risk would be
vital as patients were empowered to manage their own
care.
-
Roles and responsibilities would need to be
clarified
-
Patients lived in the community and interacted with
others in a host of settings prior to presenting at mental health
services and resources should be utilised across the system in
order to keep people well.
In
support of the enablement approach, the Board were asked
to:
- Promote and support the whole system approach to developing and
implementing integrated enablement service model
- Advocate integrated commissioning approach based on the outcomes
and co-production models
- Hold the multiple stakeholders to account publicly to ensure a
system wide response
- Have oversight of risks to the programme and support risk
mitigation
- To monitor performance.
Dr Jonathon Bindman, Medical Director of BEH
Mental Health Trust (BEH MHT), provided an update to the Board on
the enablement approach from a clinical perspective.
- Dr. Bindman agreed with the
enablement definition given in the presentation.
- Dr. Bindman reiterated that where
people received their care and how that clinical risk was managed
was a crucial factor.
- Significant improvements had been made in community mental care
services but there were a number of cultural assumptions made
around mental health that remained and were problematic: That
mental health problems were lifelong; they were disabling and that
those problems made it impossible for people to work or engage
fully within the community.
- The existing community mental health system managed some aspects
of clinical care but didn’t do enough across the whole
spectrum of people’s lives, hence the notion that enablement
was about a life beyond diagnosis.
- BEH MHT’s official Enablement Programme launch was
launched in 2015 and created a new vision for the organisation:
Live, Love, Do.
- Enablement was an important transformation programme for BEH MHT
and required a transformation across the whole health economy. Dr
Bindman advocated that it was key that
the programme was led by commissioning and had buy-in from both
service users and the third sector.
- Dr. Bindman commented that a
significantly higher percentage of people with severe mental
illness who are on the Care Programme Approach could undertake
meaningful activities and paid work, than the current levels of
between 3-5%. The issue was that there were too many barriers that
got in their way.
- Dr Bindman advised that enablement
within secondary care was not just limited to recovery for people
with the most severe mental illness, instead for BEH MHT this meant
changing their approach right from the point they presented to
their services and across a range of diagnoses and
problems.
- Dr Bindman outlined a number of
enablement projects that were being taken by BEH MHT. The aim of
the projects was to challenge people’s expectations and
assumptions right from the point they came into contact with
services and then providing them with a different model for their
recovery and their support into independence.
- The name of the front end of the enablement intervention pathway
was being changed from triage to assessment service. It was at this
initial stage that the enablement principles needed to be rolled
out in order to counter some of the negative assumptions about
mental disorders that people may be exposed to at this early
stage.
- Dr Bindman advocated that the existing pathway could
sometimes encourage dependence and created unhelpful
patient expectations and that the
enablement approach sought to change this.
Ms Etheridge commented that she was pleased to see
how much progress had been made on enablement model and stated that
it was interesting to hear some of the different projects that were
being developed to facilitate some of the service users to live the
enablement model. Ms Etheridge commented that behind this was
funding from number of sources, which demonstrated the importance
of bringing budgets together.
Ms Etheridge asked what types of barriers needed to
be overcome as a system in order to make a whole systems approach a
reality for of the service users. In
response, Ms Shenker stated that the
enablement approach was in the process of being implemented and
that the CCG would be working with partners to look at a wider
array of projects that would deliver the outcomes that they were
looking for. As the implementation of these projects progressed and
as the shift in resources continued, it would be at this stage that
barriers would start to emerge. Ms Shenker elaborated that barriers would likely
emerge: At the point where people had anxieties or concerns about
clinical risk; if there was a failure to develop a co-production
model with service users and at the point at which movement of
resources was discussed.
Dr. Djuretic elaborated
that all of the relevant bodies were required to work together in
order to provide holistic support, and that whilst currently the
different bodies talked to each other they still delivered services
individually instead of as one package of care. This would require
a big cultural shift and for increased community
involvement.
Dr Bindman advised that
there were a lot of barriers involved and that services users were
heavily disadvantaged by changes to the welfare and benefits
system. Dr Bindman further advised that
any changes in the model and attempting to challenging dependence
would be difficult and would take a lot of time and hard work to
convince people of the advantages of this approach. The Board noted
that there were also barriers in changes to the NHS work force and
that this type of system transformation required a lot of changes
to working practices, and in some cases would be contrary to some
of the training that people had received.
Maria
Kane, Chief Executive BEH MHT, advised that a further challenge
would be how the primary care system was supported to become part
of the enablement approach, particular when taking in to account
the existing pressures facing GP’s. Ms Kane also commented
that some discussion would be required as to how the funding regime
would be developed, to potentially create longer contracts and how
funding would need to shift from secondary care to lower
tiers.
Paul
Leslie, Interim CEO HAVCO, commended the proposals. Mr Leslie also
enquired as to what the training and communication processes were
for voluntary sector organisations, and asked how some of those
gaps would be filled. Dr Djuretic
responded that the enablement approach would be taken to the
voluntary sector forum on the 5th October to begin a
dialogue on the role of the voluntary sector, and to establish what
capacity there was within the community and where the gaps
were.
The Board agreed to further consider its role in how it would
contribute to the delivery of a whole system approach.
The
chair thanked those present for their contributions.
RESOLVED:
I). That
the progress to date of the enablement approach be noted