Agenda item

·         Barnet, Enfield & Haringey Mental Health NHS Trust

·         Camden & Islington NHS Foundation Trust

Cllr Pippa Connor introduced the meeting, highlighting a useful definition of Quality Accounts set out on page 57 of the supplementary agenda pack as “an annual report including information about the quality of the services provided to service users and other stakeholders by the Trust.”

Amanda Pithouse, Chief Nurse for Barnet, Enfield & Haringey Mental Health Trust (BEH-MHT) and Camden & Islington NHS Trust (C&I), presented slides on the Quality Accounts for the two Trusts, highlighting key points which included:

• The partnership between the two Trusts had been further developed with a single Chair, Chief Executive and Executive Team. A five-year joint strategy with four key strategic aims had been developed in consultation with staff, service users and others.
• The redevelopment of St Ann’s Hospital in Haringey had been completed.
• A new inpatient building at Highgate East and a new community building at Lowther Road were due to open in late 2023.
• Progress was continuing in transforming community mental health services across all five boroughs.
• Enfield Community Services were transferred to North Middlesex University Hospital (NMUH) in April 2023.
• Specific actions taken on Quality Priorities at BEH-MHT and C&I including reductions in restrictive practices, suicide prevention, building the workforce around people with lived experience, launching a Recovery Strategy, supporting staff well-being and improving service experience and involvement.
• The ‘Brilliant Basics’ initiative was aimed at getting the fundamentals of care right for every person every time.
• The Partnership Quality Priorities identified for 2023/24 were patient safety, patient experience and clinical effectiveness.

Amanda Pithouse, Vincent Kirchner (Chief Medical Officer), Andrew Wright (Chief of Staff), Caroline Sweeney (Director of Nursing) and David Curren (Deputy Director of Nursing) then responded to issues raised by the Committee:

• Cllr Connor referred to the £25m three-year project to develop a new model of community services and wraparound care which every resident was expected to have access to by summer 2024 (page 55 of supplementary agenda pack) and asked what residents could expect to experience. Vincent Kirchner explained that this was a population health model with place-based community mental health teams that get to know their local populations and statutory/voluntary partners in that area. This involved working with people with complex needs but also had a social health aspect, helping to link people to appropriate services and networks as well as early intervention/prevention while considering the social determinants of mental ill-health. These multi-disciplinary teams include psychiatrists, psychologists and social workers but would also refer to housing, benefits or other staff where appropriate.
• Cllr Revah expressed concern about support for people with disabilities and mental health problems. She noted that some centres that provided acute services and drop-in centres in North Central London had been closed in recent years and queried how people dependent on such services would be supported. Vincent Kirchner explained that the model had been shifting towards providing services in the community rather than requiring people to come to far away clinics and this involved choices about where to spend limited resources. The new model included seeing people at home where appropriate and also linking in via the voluntary sector to communities that had not always been reached very well in the past. He also noted that some of the centres that had closed had been local authority run.
• Asked by Cllr Revah about services for people from the deaf community, Vincent Kirchner agreed that this was a community that was under served at times and that St Georges was typically the only point of access for deaf people. He confirmed that access to sign language services could be provided when required.
• Cllr White queried whether all residents felt that they had sufficient access to mental health services when they needed it, including mild to moderate anxiety and depression issues, and whether this was linked to insufficient funding. Vincent Kirchner acknowledged that funding was always an issue as the demand for mental health services was so high, but said that, since the Covid-19 pandemic, an increase in the severity of mental health had been seen. He added that sometimes people escalated to a point of crisis before they reached the threshold to get access to mental health services. However, the NHS talking therapies service (previously known as IAPT) was aimed at those with mild to moderate mental health problems and people could self-refer to this service (unlike other types of mental health services). He agreed that people experiencing mental health problems for the first time would not necessarily know about the range of services, but they would typically go to their GP in the first instance for advice on this.
• Cllr Atolagbe observed that not all residents would necessarily visit their GP to speak about mental health and suggested that there should be greater visibility about services in community settings, such as schools/play centres to reach parents for example. Vincent Kirchner said that tackling health inequalities was an important priority in NCL and the aim was to think more creatively, including to reach communities in different ways. There were workers in schools as part of the children and young people’s mental health approach and this was also part of the community ‘place-based’ approach that was previously mentioned. This also involved stronger collaboration with the voluntary sector and being spread out further across the local community. Cllr Revah suggested that other settings including community centres and food banks could also be considered. (ACTION)
• Cllr Milne added that, with GP appointments being difficult to obtain at present, some people suffering from mental ill-health might not persevere in getting the necessary appointment. Vincent Kirchner acknowledged that this was an issue but noted that there was also a crisis line that people could access as an alternative point of access to services.
• Cllr Atolagbe asked about the monitoring of in-patients and the serious incidents referred to in the report. Caroline Sweeney explained that, when admitted to services due to a mental health crisis, there were a team of nurses that were present 24/7 as well as a range of specialist staff available during the week. Overall, the teams would have treatment and care plans for individuals and the monitoring would depend on specific needs. Serious incidents could include a deterioration of someone’s condition in inpatient care resulting in harm or a completed suicide in the community for example. There was NHS England guidance on how to manage and report on such incidents and a focus on learning from them, including the involvement of service users and carers in incident reviews.
• Asked by Cllr Milne about recruitment and retention challenges, Vincent Kirchner said that there was a real shortage of mental health medical workers at present, not least because of the expense of living in the North Central London area. Efforts were therefore being made with staff wellbeing initiatives, recruiting further afield, bringing in international medical graduates and building the physician associate workforce as they could perform tasks that reduce the workload of doctors. In relation to nursing, Amanda Pithouse said that there had been a number of initiatives, including peer support workers and nursing associate roles with pathways for development into nursing. She added that some newly qualified nurses were sometimes lost at the end of the first year so there was more work to be done to support people during that period of time. The wellbeing strategy would help to support this.
• Cllr Connor said that the feedback she had received on the NHS talking therapies service was that, if the person was deemed to have risk factors relating to suicide/self-harm, then they were told that the service was not appropriate for them. In contrast, people contacting the crisis line were often not admitted to services unless their mental health crisis was deemed to be sufficiently serious. This led to some groups of patients being turned away from services and potentially having to go back to their GPs before any support would be provided. Vincent Kirchner acknowledged the risk of some patients falling between the middle of these types of service but said that this was an issue that the community mental health teams were designed to be able to address and to direct people to the right services (e.g. referral to a psychologist or other types of support).
• Cllr Connor requested further details on how the performance of services was monitored. Vincent Kirchner said that there were clinical strategies setting out how services should work along with a governance structure, performance indicators and deep dives into service delivery. Amanda Pithouse added that a recent CQC inspection had been carried out on BEH-MHT crisis services which had recognised recent improvements in staffing with more manageable caseloads. Cllr Connor said that, in future reports, it would be useful for details to be included about how these deep dives worked, how evidence was captured about how people were using services and how issues were identified when things were going wrong. (ACTION)
• Cllr Connor said that she was aware of concerns about access to mental health support for asylum seekers, including for PTSD, and their lack of access to translators when trying to access services. Vincent Kirchner said that interpretation services were made available to asylum seekers but that this was an issue that could be taken away for further consideration if there were concerns that the services provided were not sufficient. He also acknowledged that it could be difficult to meet the demand for services from people who had experienced trauma in conflict zones. (ACTION)
• Cllr Connor referred to the new 78-bed Highgate East facility which would replace the wards at St Pancras Hospital and asked whether this represented an increase in the number of beds available. Vincent Kirchner explained that, though there were fewer beds at Highgate East compared to St Pancras, the refurbishment work at Highgate West meant that the overall number of beds was not being reduced.
• Asked by Cllr Milne for further details about the reduction in restrictive practices and the definition of this, Amanda Pithouse explained that, in some circumstances, restrictive practices were unavoidable included restraint and tranquillisation. A regional conference had recently been held which involved looking at new ideas to reduce the use of restrictive practices.
• Asked by Cllr Milne about longer term funding streams for voluntary sector organisations, Vincent Kirchner said that three-year contracts were now being provided.
• Referring to the ambition to reduce the average length of stay at acute wards (page 82 of supplementary agenda pack) and, given that this was usually for people with severe mental health issues, Cllr Connor asked how they would be supported following discharge. Vincent Kirchner noted that this was a national ambition set by the NHS Long Term Plan that the Trusts were aiming to meet. He explained that one of the concerns relating to discharge was the lack of supported housing available for people and that, if they were placed in a hostel instead, then this could be a difficult place from which to recover from a serious illness such as psychosis. Asked by Cllr White about the reasons for this, Vincent Kirchner explained that the provision of supported housing was a responsibility of local authorities but that the provision was quite limited, particularly for younger people. While local authorities were usually sympathetic to these concerns, the availability of resources to invest in this area was not typically available. Cllr White observed that investment in this area would arguably save both the local authority and the NHS Trusts money in the long-term, as well as improving quality of life. (ACTION)
• Cllr Connor noted that the Metropolitan Police had recently indicated that they were aiming to reduce their responses to mental health cases and asked what alternative arrangements were being put in place. Vincent Kirchner said that various places of safety were provided, including at Highgate East, and added that there was also a mental health crisis assessment service. Amanda Pithouse added that Police officers no longer take S136 cases to police cells. Cllr Connor said that a clearer understanding of how this was all joined up would be useful to see in future Quality Account reports. (ACTION)
• Referring to the section on suicide prevention and the involvement of carers in risk assessment and care planning (page 96 of supplementary agenda pack), Cllr Connor noted that some carers felt that they were kept out of the loop and were the last to know about ongoing concerns. Amanda Pithouse explained that the main challenge here was on consent and confidentiality because patients sometimes did not want certain information to be shared with their carers. However, improved practices on engagement and involvement where possible was the objective.
• Cllr Revah highlighted the long waiting lists for mental health services, both for adults and for children & young people and requested  that details of waiting times, and the progress against previous years, be provided in future Quality Accounts reports. (ACTION) Amanda Pithouse said that this information could be shared with the Committee and added that an integrated performance report, which included information on waiting times, could be found the Trust’s public board papers. Cllr Revah said that it would be helpful for Members if it was clearer about where information such as this could be found.
• Referring to the section on the Local Clinical Audit Programme (page 75 of supplementary agenda pack, Cllr Atolagbe requested clarification on the point that “the carenotes outage affected the completion of several audits”. Vincent Kirchner explained that a cyberattack on a provider of electronic patient records had meant that performance reporting could not be completed in that period.

On behalf of the Committee, Cllr Connor thanked the NHS Trust’s officers for their attendance. She commented that a longer meeting would be required in future years as the time allotted had not been sufficient to scrutinise the Quality Accounts in full. With regards to this year’s reports, she added that further questions from the Committee would be submitted to officers in due course. (ACTION)

Statement provided from JHOSC to Barnet, Enfield & Haringey Mental Health Trust and Camden & Islington NHS Trust

The Joint Health Overview and Scrutiny Committee for North Central London (NCL) would like to thank Barnet, Enfield & Haringey Mental Health Trust and Camden & Islington NHS Trust for their engagement and assistance regarding the Quality Accounts including the sharing of draft versions of the reports and attendance at a scrutiny meeting of the Committee.  In recognition of the further development of the partnership between the two Trusts, which now has a single Chair, Chief Executive and Executive Team, the Committee considered the two Quality Accounts reports together and this statement addresses issues relevant to both documents.

The Committee also wishes to place on record its thanks for the hard work of staff throughout both Trusts in 2022/23 in delivering positive health outcomes for our residents at a time when the NHS is under considerable pressure.

As part of our scrutiny, the Committee emphasised the need to continue to improve access to services for people with disabilities and mental ill-health, for people from the deaf community and for asylum seekers (including the availability of interpreters and difficulties in communicating via the helplines because of language barriers).

With regards to the monitoring of the performance of services, it was explained that there were clinical strategies setting out how services should work along with a governance structure, performance indicators and deep dives into service delivery. The Committee recommended that, in future Quality Accounts reports, it would be useful for details to be included about how these deep dives worked, how evidence was captured about how people were using services and how issues were identified.

While acknowledging that supported housing was an area of responsibility for local authorities rather than NHS Trusts, the Committee advocated increased provision of supported housing for people with serious mental health difficulties following discharge from hospital as provision was currently too limited, particularly for younger people. The Committee recommended that there should be further discussions between the Trusts and the NCL local authorities on how greater supported housing provision could be achieved, with details of these discussions and any progress made provided to the Committee and other scrutiny committees in NCL.

The Committee welcomed the shift towards a community ‘place-based’ approach to mental health services and would support additional visibility and presence throughout the community, including settings such as community centres and food banks. Additional points of access to services would also be welcome as, while people can self-refer to talking therapies or through the crisis line, not everyone with mental health issues necessarily meet the criteria for admission to these services (for example someone who was not deemed to be an immediate suicide risk but was nonetheless suffering from serious mental health issues). In addition, the current difficulties with obtaining GP appointments means that some people suffering from mental ill-health may be less likely to seek help via their GP.

The Committee highlighted certain areas where additional information could be included in future Quality Account reports. In particular, the Committee suggested that details of waiting times for mental health services both for adults and for children & young people, be provided along with the progress against previous years. In addition, the Committee recommended that details of the arrangements to support people detained under the Mental Health Act be provided including liaison with Police, places of safety and the mental health crisis assessment service. This was felt to be particularly relevant due to recent changes in the Metropolitan Police’s approach in this area. Finally, the Committee felt that data should be provided on the monitoring of people being provided with support or signposted to other services following calls to the Crisis Helpline.

Other issues and areas of concern raised by the Committee included the monitoring of mental health inpatients and serious incidents, recruitment and retention challenges, the number of beds at the new Highgate East facility, efforts to reduce restrictive practices, longer-term funding streams for voluntary sector organisations and the involvement of carers in risk assessment and care planning.

The Committee looks forward to further engagement with the Trusts on these issues in 2023/24 and through the scrutiny of next year’s Quality Accounts report.