Agenda item

To provide an overview and update on the progress of the community and mental health service reviews including how co-design and co-production have been embedded in the design and delivery of the core offers.

Cllr Connor opened this item and welcomed the NCL ICB colleagues and the local community groups that had joined the meeting.

Lauretta Kavanagh, Programme Director for Mental Health, Learning Disability and Autism at NCL ICB, introduced the report which provided an overview of the Core Offer programmes for Community and Mental Health services across North Central London (NCL) including improvements for residents made in the past year as well as the vision for delivery and challenges going forward.

Kay Isaac, Director of Operations at the Central London Community Healthcare NHS Trust, spoke about the investment into community services, the aim of which was to address health inequalities and reduce the ‘postcode lottery’ in terms of outcomes across the NCL area. The additional investment in 2023/24 included:

• £2.5m for children and young people’s services – priority investment areas included streamlined assessment pathways for autism, Children’s Looked After (CLA) service and CYP Special School Nursing.
• £1.9m for adult services – priority investment areas included work to reduce the length of hospital stays which had resulted in the average stay reducing from 34 days to 18 days. In addition, the time from referral to admission had reduced from 5 days to 3 days. Another priority area was faster responses for urgent care at home to help avoid the need for hospital admissions. Additional capacity had been provided for speech and language therapy.
• £6.9m for virtual wards – this investment had increased the number of virtual ward beds in NCL from 118 to 175, enabling more people to come out of hospital earlier and receive the same treatment at home.

Lauretta Kavanagh explained that 2023/24 was year 2 of the implementation of the core offer and that significant progress had been made with the additional investment made being generally against the tide of the wider financial pressures faced by the NHS. There was a lot of data to demonstrate increased access to services, increased workforce capacity and also work to level up the quality of services.

Jess Lievesley spoke about other major developments including the merger of the two Mental Health Trusts in NCL, which was expected to be completed by October 2024, the recent opening of a new inpatient facility at Highgate and the development of a single point of access for crisis mental health services.

A video presentation was played to the meeting about the transformation of community services and improved access to services in NCL. This video would be uploaded onto Youtube so that it could be accessed by a wider range of community groups and a booklet was also being produced for distribution. It was also suggested that the information could be promoted at the Mental Health Strategic Partnership in Barnet.

ICB officers responded to a range of questions and discussion points from Committee Members and community groups:

• On the issue of waiting time for autism diagnosis, Ruth Glover, Director of Open Door, commented that the process could often be complicated as young people with autism also had other conditions such as ADHD. She added that diagnosis was often important in gaining access to certain services and that Open Door had received some funding to provide support to young people pre, during and after diagnosis. Lauretta Kavanagh noted that there were some figures on waiting times on page 21 of the report in the agenda pack. She acknowledged that the pathways were too complex and that, from next year, there would be a programme of work to simplify them and to strengthen post-diagnostic support. The additional investment was particularly important due to the continued rising demand for autism services, among both children and adults. Cllr Connor noted that the Committee had previously highlighted waiting times for autism/ADHD diagnosis as an issue of concern at its meeting last year (Feb 2023) and suggested that, in addition to this, there should be closer communication between the NCL ICB and local organisations such as Open Door to ensure that the service offer met the needs of service users and that there was a joined up approach. (ACTION)
• Cllr Clarke noted that the waiting times for autism services were long in Islington although the cost per head was higher than other boroughs. She also expressed concerns about the impact of the long waiting times on early intervention. Lauretta Kavanagh explained that the spend in Islington was not as high when weighted according to need and that the aim of the current work was to equalise investment and outcomes across the NCL area.
• Cllr Revah expressed concern about young people potentially falling through the gaps of services and not being diagnosed until later in life. Jess Lievesley said that wait times for young people had come down significantly but had risen for adults as more people came forward later in life, but that the system was under pressure to cope with the additional demand from both cohorts. 
• Cllr Revah asked what support was provided to people while they were waiting for an assessment for autism/ADHD. Lauretta Kavanagh said that there was a programme of work available for adults to have a support offer across NCL rooted in the voluntary sector. This was both for people on the waiting list for autism/ADHD and also post-diagnosis. Around £500k of investment was being made available for this programme in 2024/25.
• Anne Essex from Camden Carers highlighted the feeling that some carers experienced of a lack of compassion when in contact with services and an emphasis on what cannot be done rather than what support could be provided. Jess Lievesley said that he was sorry to hear about this experience as this kind of support should be integral to how care was delivered. He added that there was high and rising demand for services on neurodevelopmental pathways, compounded by the need to provide ongoing support. The breadth of provision needed to be expanded, including to support people to move back into their lives and this meant a key role for the voluntary sector. Lauretta Kavanagh acknowledged the gaps in pathways and said that work was ongoing on how this could be improved next year, including by improving the availability of specialist mental health professionals across NCL. She added that, with the demand for autism/ADHD diagnosis so high, the challenge was to work with people earlier in the pathways and onto the right pathways so that resources were used wisely.
• Cllr Revah asked if any work was being done for carers who were worried about how a loved one with mental health conditions would be cared for after they themselves had passed away. Jess Lievesley said that he wasn’t aware of any specific work in this area but acknowledged that this could be a worry for people and that cases such as this would be best managed not just by the NHS but in partnership with local authorities and voluntary organisations working with carers.

• Peter Lyons, representing mental health carers, highlighted the lack of supported accommodation in NCL people with severe mental health issues. Lauretta Kavanagh responded that, while this was not a primary responsibility of the NHS, they did work closely with local authority colleagues in this area. She said that further details about this could be provided by Richard Elphick at North London Councils about this integrated work. (ACTION)

• In relation to the ambition to equalise service performance, Cllr Milne requested assurances that this would bring everyone up to top performing level rather than lowering performance in any areas. Jess Lievesley clarified that the ambition was to level up and not level down but that there were some excellent pockets of practice in NCL as well as some pockets of deficit and so the aim was to balance this.
• Asked by Cllr Chakraborty about the bottlenecks that were preventing the rapid implementation of the solutions that were being discussed, Jess Lievesley said that these were many and varied. As an example, he explained that, in relation to the neurodevelopment pathway, there was currently no exit pathway from secondary care to be discharged to primary care so therefore a relatively well patient would continue to sit with secondary care providers which limited their ability to take on new patients.
• Cllr Clarke referred to a written statement provided by the Stuart Low Trust, a charity supporting adults at risk due to mental health issues and social isolation. However, they had not been invited to participate in the Islington Care Partnership and felt that more investment was needed in the model of integrated care to include the value offered by smaller local providers. Lauretta Kavanagh agreed to consider with colleague how these arrangements could be strengthened.
• Cllr White noted that, while neurodevelopment assessment waiting times for young people had improved, they were still long and asked whether further investment to reduce waiting times could result in savings by reducing treatment costs in the future. Jess Lievesley responded that assessments took around three hours so the capacity required to do this was high and so workforce was a factor as was balancing the overall needs of mental health services. He explained that the current goal was to work towards 28-day access and that the rates for this had increased from around 40% last year to over 70% now. Additional capacity had been brought in from the independent sector to help improve access times. Cllr Connor noted that the 28-day target applied only to assessments and not the time to get to the treatment stage. Lauretta Kavanagh responded that the whole pathway was being reviewed.
• Peter Lyons said that, although there were promises to do things quicker and better, he wanted more clarity on how outcomes would be measured. He referred to an example of being on the phone for four hours to access crisis support. Jess Lievesley acknowledged that the process was convoluted and that there was a need for a single route to access crisis services and said that this would be changing as part of the ongoing work, in addition to addressing the issue of differential service provision across NCL. Adele McCormark explained that the outcome measures had historically focused on the time to access an assessment but that this had changed to a focus on access to treatment. There was a national 4-week wait standard with a number of metrics that had to be satisfied for this to be met, including a completed assessment and for the first stage of the care plan to be in place. This dataset would be made available for Trusts across the country. Lauretta Kavanagh added that there was a need to keep refining the population health and integrated care strategy for NCL by advancing inequalities work and deepening the understanding of the needs of patients, including in parts of the community that were not being reached. Outcome measure tools were also specified in much of the mental health commissioning work to help understand the improvement of patients. Cllr Connor requested that information on the outcomes data and metrics should be provided to the Committee as part of the next report on mental health. (ACTION)
• Asked about crisis cafes aligning with crisis services, Adele McCormark said that this was about co-producing to align together and that the current work on access to crisis services included looking at variations between different boroughs and where people could be best supported outside of an inpatient admission. Jess Lievesley added that there was also an issue around better matching service capacity to known peaks in demand.
• Asked by Cllr Atolagbe about staffing levels of crisis services, Jess Lievesley explained that services were not fully staffed but, because these services were critical, bank or temporary staff were used when required. There was also an issue to address about the five boroughs working in different ways which impacted on the ability to deliver a consistent service across NCL.
• Yasin Ahmed, Chief Executive of the Nafsiyat Intercultural Therapy Centre, welcomed the approach of working with the voluntary sector and spoke about the work of his organisation which provided intercultural services and therapy in up to 20 languages, but queried the current links with NHS talking therapies. Lauretta Kavanagh said that there were long waits in some areas for NHS talking therapies and that there was a conversation to be had in separating NHS talking therapies and other talking therapy services which may reach other parts of the local community. On a point from Yasin Ahmed about community link services which connected to housing or employment support, Adele McCormark said that primary care services were now looking to divert people to appropriate services such as this, as it was understood that mental health issues could often relate to specific challenges that a person was facing rather than requiring medication or psychiatric treatment.
• Sonja Scantlebury-Camara, from the Sewn Together community group, commented that there was no straightforward point of access when a group needed to get support for a service user in need of crisis services. While they had been provided with mental health first aid training by MIND, they were not qualified to deal with the sort of problems that required medical knowledge but it was very difficult to refer to services. She added that many service were still not racially appropriate with inadequate representation on language and culture. Jess Lievesley said that services were best accessed either through the 111 phone line or the crisis line. He agreed on the importance of cultural appropriateness and particularly on how services were not always able to access parts of communities that could be reticent to come forward with mental health concerns. This was often achieved better through voluntary sector organisations so there was an issue about how best to connect these organisations to the ICB. It was also important to intervene earlier as, for example, young black men had historically often come into contact with mental health services via the Police (under Section 136 of the Mental Health Act).
• Sonja Scantlebury-Camara spoke about a case of a young man who had died in a secure ward at St Ann’s hospital where there had not been anyone on the ward who could deliver CPR and highlighted that there were other similar cases. She said that there was still not enough conversation about racial disparities in this debate and that there was insufficient representation across the workforce. Jess Lievesley acknowledged these points and said that mental health services had to work harder to reach into communities but added that it wasn’t completely fair to say that they were not recruiting from those communities and that there was a broader representation of ethnicities in the workforce. The Chair and Chief Executive of the Mental Health Trusts were both from BAME backgrounds. This issue remained a high priority for the Board and change was happening but wouldn’t happen overnight but the regular check and challenge on this was important. Lauretta Kavanagh committed to report back on progress on the Patient and Carer Race Equality Framework. (ACTION)
• Sonja Scantlebury-Camara raised concerns about people with mental health problems in the community in Haringey who had been in the system for a long time and were not being adequately supported or included in the new community model (including from being misdiagnosed a long time previously or not having access to services such as talking therapies). Jess Lievesley agreed to look further into these concerns. (ACTION)
• Sonja Scantlebury-Camara expressed concerns about the implementation of the Dialog+ system which she said some staff were not confident about using. Adele McCormark said that there had been a national shift of focus onto outcomes, as discussed earlier, and that the DIALOG+ system enabled patients to communicate and record the outcomes that they wanted and for these to then be measured against. This was a massive cultural shift that would take time and it would be important to maintain dialogue with clinicians, patients and their families and to communicate better about the changes that had been made. It was suggested that this point about communications could be taken away as an action point. (ACTION) Jess Lievesley added that, while change often brought about complexity, at the heart of this process was a change in the power dynamic from outcomes being set by clinicians to outcomes being set by the patients themselves.
• Cllr Atolagbe noted that, according to page 17 of the agenda pack, “18% of people on the NCL mental health services caseload are Black/Black British, however, Black/Black British people accounted for 27% of NCL mental health inpatient admissions in 2019/20” and asked for more up to date figures on this to be made available. (ACTION)
• Asked by Cllr Atolagbe about the distress caused by the need for constant repetition of patient histories, Jess Lievesley agreed that patients were currently assessed too many times and that they needed to be able to tell their story once and then bring their care plan with them. Changes were being made on this but it would take some time for the transition to happen and the workforce to adjust. 
• FarisaNassiri, founder of the Yaran Women’s Club spoke about the work of her organisation which was established in 2021 to support women suffering from mental health problems, typically from asylum seeker/refugee background and often with a traumatic past and PTSD issues. The referrals often came from GPs and social prescribers and other local services and the Club provided activities such as yoga, meditation, mindfulness and emotional health checks. A challenge for the Club was sustainability of funding and having an appropriate venue to provide services and, without this, the service would have to close. Lauretta Kavanagh committed to having a conversation about this service (ACTION) but added that NHS budgets were particularly stretched at present with rising levels of demand. Cllr Connor commented that this was an example of a voluntary organisation that was engaging with communities that mainstream mental health services were not always able to reach, and suggested that a cost-benefit analysis could help to establish the effectiveness of funding organisations such as this. Cllr Revah added that the ICB had emphasised the value of working with the voluntary sector and that organisations such as this were looking for recognition of the work that they do.
• Ruth Glover from Open Door raised concerns about funding and the need for longer-term contracts which had brought up as an issue in previous reviews but which she felt had still not been properly addressed. This led to significant challenges for the voluntary sector in maintaining their workforce. Cllr Connor said that the Committee had previously made a recommendation in favour of longer commissioned contracts which was vital for the stability of voluntary organisations and asked what progress was being made on this. Lauretta Kavanagh said that there was a move to what was known as ‘3 + 2 year contracts’ but that she would need to consult with colleagues and provide an more detailed answer to the Committee in writing. (ACTION) Cllr Connor suggested that there should also be clarity on how this information should be communicated more widely to the voluntary sector in NCL. Cllr Milne added that, in addition to the length of the contracts, the lateness of the decisions on contracts could also have an adverse impact on the voluntary sector.
• Cllr Connor requested clarification on how voluntary sector organisations could access commissioners at the ICB. Lauretta Kavanagh noted that the ICB was currently going through an organisational change due to a national requirement to reduce operational costs by 30% and this meant that there were staffing changes in the units for each of the five boroughs with some disruption to continuity, but that there would be specific individuals who could liaise with voluntary organisations. Cllr Connor commented that it was sometimes difficult for voluntary and community groups to know who best to contact at the ICB to develop links with statutory services and suggested that there should be a clear single point of access. She requested that the next report to the Committee on mental health would include details of the new ICB structure following the organisational change with particular reference to the main contacts that voluntary organisations in each Borough were able to liaise with. (ACTION) Sonja Scantlebury-Camara suggested that the promotion of employment and training opportunities within the health and care sector should be part the communications with local communities.
• Allegra Lynch, Chief Executive of Camden Carers, suggested that, alongside the other pathways, there should also be a specific pathway for unpaid carers which could be supported by the existing carers organisations in each of the five boroughs and help with issues such as support for hospital discharge. Jess Lievesley agreed with this and emphasised that work to support carers had to work as a partnership with carers and also with local authorities. There would need to be consideration over how the offer to carers should be framed. It was agreed that this conversation would be followed up outside of the meeting and Cllr Connor requested that the Committee be updated on this as part of the next report on this topic. (ACTION)
• An audience members commented that highly skilled professionals were needed at all stages of the mental health pathway in order to avoid missed diagnoses and delays. Jess Lievesley agreed that there could sometimes be complex presentations which professionals had to assess and also noted that there were currently differential approaches across the NCL boroughs which would be addressed through the measures described in the report.
• Cllr Connor noted that the transition process from children’s services to adult services was an area that the Committee had previously monitored and requested further information about this as part of the next report on this topic. (ACTION)
• Cllr Connor noted that mental health support in schools had been mentioned in the report but that she was aware that this was not available in all schools in her borough (Haringey) so requested further details about the availability of this across NCL. Lauretta Kavanagh confirmed that no local authority areas anywhere in country had 100% coverage for this but that specific details of the coverage in NCL could be provided to the Committee. (ACTION)
• Asked by Cllr Connor how the Section 136 Hub and the 111 mental health line described in the report were accessed, Jess Lievesley explained that the Section 136 Hub was for Police only and assisted them in relation to their powers under the Mental Health Act. He added that the 111 line for the public would be available from April and that the launch communications for this were being managed nationally. In response to concerns from Cllr Cohen that many people found it difficult to navigate the system when they had concerns about someone, Jess Lievesley said that the 111 line would be the first port of call but added that routes of access for interventions needed to be improved overall.
• Asked by Cllr Atolagbe about the sharing of data, Jess Lievesley said that this was quite limited as the NHS could not share clinical records and could not access criminal records. He confirmed that Section 136 interventions would be recorded on the clinical records.
• Cllr Revah conveyed feedback from her local carers groups that some often found it hard to access information about the person that they were caring for. Jess Lievesley acknowledged that this could be challenging as individuals could sometimes withdraw consent, meaning that professionals could not share information, and that, in other circumstances, professionals may also ‘err on the side of caution’ and avoid sharing details unless they had explicit consent. The concept of the ‘triangle of care’ existed to try and bring this information together but this remained a challenge across the sector.

Cllr Connor thanked everyone for attending the meeting, highlighting the importance of working together, taking on board everyone’s concerns and accessing expertise across the local community.