Agenda item

·         Barnet, Enfield & Haringey Mental Health NHS Trust

·         Camden & Islington NHS Foundation Trust

Cllr Pippa Connor introduced the session noting that the two mental health Trusts represented at the meeting were expected to merge in October 2024. However, at present there were still two separate quality accounts reports for the Barnet, Enfield & Haringey Mental Health Trust and the Camden & Islington NHS Foundation Trust. The two Trusts were currently represented by one shared executive team as what was currently known as the North London Mental Health Partnership (NLMHP).

Amanda Pithouse (Chief Nursing Officer), Vincent Kircher (Chief Medical Officer), Andrew Wright (Chief of Staff) and Caroline Sweeney (Partnership Director of Nursing – Quality Governance) introduced the draft quality accounts of behalf of the NLMHP.

Amanda Pithouse set out the NLMHP strategy which had the stated Purpose of “Working with our communities to improve mental health” and a Vision of “Better Health. Better Lives. Better Communities.” The four aims of the strategy were:

• Aim 1 – We will provide consistently high quality care, closer to home.
• Aim 2 – With our partners in North London and each Borough we will ensure equity of outcome for all.
• Aim 3 – We will offer great places to work, providing staff with a supportive environment to deliver outstanding care.
• Aim 4 – We will be more effective as an organisation by pioneering research, Quality Improvement and technology.

Some key developments over the past year had included:

• The publication of a new clinical strategy which had included service user, carer and partner input.
• The development of a new values and leadership framework which had involved over 600 staff and was aimed at supporting the merging of the workforces of the two Trusts.
• The publication of a new People and Organisational Development Strategy which aimed to make the organisation a great place to work and to attract and retain the best possible staff.
• The Partnership Board had signed up to a Sexual Safety Charter and Anti-Racism Statement and Action Plan.
• A new 78-bedded inpatient facility had opened at Highgate East.
• A new Mental Health Crisis Assessment Service had opened at Highgate West, providing 24/7 emergency mental health care across North London.
• New community mental health facilities had been opened at Lowther Road in Islington.
• A new section 136 pilot had been launched with the Metropolitan Police resulting in a 27% reduction of inappropriate detentions, a 38% reduction in people attending A&E and a 32% reduction in Police time spent attending mental health emergencies.
• A new mental health option had been added to the NHS 111 phone service with around 150-200 calls per week so far.
• The continuation of the Community Mental Health Transformation Programme which involved strengthening community services to keep more people out of hospital.

The NLMHP officers then responded to questions from the Committee about the Quality Accounts report for Barnet, Enfield & Haringey Mental Health Trust:

• Cllr Connor referred to an issue that had been raised at the previous year’s scrutiny of the Quality Accounts about support for people with serious mental health issues after discharge. It had been noted at the time that a particular problem was the lack of supported housing for people in such circumstances and that this would require funding and further partnership working with local authorities. Vincent Kircher said that there had been no real progress since then in this area but that the problem was escalating with more people medically ready for discharge but without a place to go to. He added that this was a systems-wide problem but that it would be difficult to justify using NHS resources on housing. He added that there were regular multi-agency discharge events which provided a forum to discuss cases that were difficult to resolve. Andrew Wright noted that the shortage of suitable accommodation was a national issue. Amanda Pithouse commented that the Care Quality Commission (CQC) had recently outlined a systems approach to regulation with the intention of picking up system-wide issues that individual organisations could not address. However, this approach was currently paused due to the upcoming General Election.
• Cllr Revah highlighted long waiting times for mental health services and suggested that details of this should be included in future Quality Accounts reports. Vincent Kircher noted that this information was provided in the Board’s integrated performance reports which were in the public domain. There was an ambition to reduce waiting times and there was now a 4-week wait standard from referral to treatment which was a challenging target to meet. He added that waiting times for children had been improving. Cllr Connor requested that a link to this information be provided to the Committee. (ACTION)
• Cllr Connor noted that the Committee had previously recommended that data should be provided on the monitoring of people being provided with support or signposting to other services following calls to the Crisis Helpline. Vincent Kircher confirmed that outcome data was recorded and that this could be provided to the Committee. (ACTION)
• Cllr Revah asked about follow-up work with housing organisations to support residents post-discharge as Councillors were aware of problems emerging through casework and often found it difficult to find the appropriate contact at the right service to obtain help for people in these circumstances. Vincent Kircher referred to the community transformation work which involved neighbourhood teams working in an integrated way with primary care, local authorities and the voluntary sector which would provide those links. He noted that this work was still developing across North Central London (NCL) so there was still some way to go in some areas and that it would be beneficial for everyone to know who the core team was in their area with responsibility for these types of cases. This information was available online. (https://www.northlondonmentalhealth.nhs.uk/services)
• Cllr James referred to page 35 of the agenda pack which stated that 100% of service users felt that they did not receive enough support from their CAMHS team when moving from Children’s Services to Adult Services compared to a national average of 54%. Vincent Kircher said that transition services were provided to help people in this change which could be difficult as the support provided by Adult Services was very different from CAMHS. Transitions had been specifically included as part of the clinical strategy, including by replicating services such as Mind the Gap in Camden elsewhere in NCL, but overall this was an area where improvements were required.
• Cllr Milne asked if there was a higher threshold required for Adult Services when compared to Children’s Services because of a higher number of patients. Vincent Kircher said that, if anything, the opposite was the case because Children’s Services were under so much pressure with high demand. However, there was also broader support provided through schools, including workers based in schools, to try and help those with less severe mental health needs through early intervention.
• Cllr Revah requested further details on how the proposed merger of the two Trusts would improve services and waiting lists. Amanda Pithouse explained that the two organisations had worked on this for some time, including through a strategic alliance some years ago before then becoming a partnership with one executive team which enabled the best elements and pockets of work from both Trusts to be scaled up. There was evidence that having engaged and happy staff improved outcomes for service users and the feedback from staff was that they wanted the opportunities to develop and work in different services. Having a single bed base across the five NCL boroughs would also help to keep patients closer to home. Andrew Wright added that having a stronger voice for mental health would be another benefit of the merger. He also noted that more detailed information would be provided to the JHOSC at a meeting in the autumn.
• Cllr Connor referred to page 10 of the agenda pack which referred to the importance of local community organisations and noted that a common concern raised by organisations such as this was the short-term nature of their contracts which impacted on their stability and financial planning. Vincent Kircher noted that a lot of the shorter contracts tended to be from local authorities and that the Trusts were in a position to offer longer contracts of up to three years which they felt was beneficial as it enabled the organisations to focus on service delivery. Cllr Milne commented that another common concern was that contract renewals were often not confirmed until very close to the end of the contract. Andrew Wright said that both Trusts typically started the renewal process two-thirds of the way through a contract so this shouldn’t be the case. Cllr Connor noted that these concerns may also need to be directed to the local authorities in NCL.
• Referring to the details of the CQC inspection on page 11 of the agenda pack, Cllr Connor noted that the Trust had been rated as ‘Good’ and that a robust improvement plan had been delivered to address the actions raised by the CQC. Asked if there were still any outstanding areas of concern, Amanda Pithouse said that the safety domain remained at ‘Requires Improvement’ for both Trusts and this related largely to staffing issues which was an ongoing challenge. Estates was also an issue and, although new state of the art buildings such as Highgate and Blossom Court had recently opened, there were other buildings in areas of Enfield and Barnet that were old and required more work. There was investment in estates across the Trust through the capital programme but often the actual fabric of the old buildings was a problem. Andrew Wright added that a new Estates Strategy was being developed and, as the decisions on how capital was allocated was now decided through the ICB, the case was being made for further improvements. Overall, the action plans from the CQC inspection had been delivered, but it was important to ensure that these were sustainable. This aim was supported by initiatives such as the Brilliant Basics programme as outlined on page 12 of the agenda pack.
• Asked by Cllr Connor about the progress against the CQUIN goals on page 30 of the agenda pack, Vincent Kircher provided further details:

o   CCH15b (Routine outcome monitoring in CYP and perinatal mental health services) – this was Amber due to performance against access targets. The locally agreed target was 7% which was being met but the higher national target of 10% was not being met. It was clarified that the 7% related to all births rather than mental health cases. Cllr Connor requested that data on the number of actual cases that this related to be provided to the Committee. (ACTION)

o   CCG15a (Routine outcome monitoring in community mental health services) – this was also Amber as the figures were improving but not where they would ideally be. Further work and action planning on this was ongoing.

• Cllr Clarke referred to the section on participation in clinical research on page 29 of the agenda pack and requested further details on the funding and the specific studies. Vincent Kircher explained that the two main sources of funding were the local Clinical Research Network (CRN) and Research Capability Funding (RCF). In Barnet, Enfield & Haringey around £27k of RCF was received but in Camden & Islington around £900k was received so if research could be spread across the NCL area in future then more could be achieved. He also clarified that the Short Names in the table referred to specific projects and that the PPIP2 project related to research on the withdrawal of anti-psychotic medication. There was a strong relationship with University College London with joint appointments of clinical academics who were able to then bring research evidence into clinical practice to improve standards.
• Cllr Milne referred to the section on learning from deaths on page 35 of the agenda pack which stated that 263 service users had died in 2023/24 and requested further details on the 47 investigations carried out. Caroline Sweeney explained that mortality incidents were reviewed by a Panel and that all deaths had an initial review which would assess what further level of investigation was required. The 47 investigations referred to in the report were the cases where a full level of investigation was carried out, usually over a 60-day period. Vincent Kircher added that the cases requiring further investigation were often those that were unexpected, such as a suspected suicide for example. These figures did not indicate a particular trend in the figures in either direction.
• Cllr Connor requested further details on the section about Serious Incidents on page 35 of the agenda pack which stated that there had been 14 Serious Incidents in 2023/24 compared to 33 the previous year. Caroline Sweeney explained that the government had recently implemented the new Patient Safety Incident Response Framework which had changed the incident reviews and speeded up the learning process. This also meant that Serious Incidents were categorised in a different way, with some cases now dealt with through a different process. This accounted for the significant change in the figures.
• Asked by Cllr Connor about any other areas of particular risk, Vincent Kircher said that there was a risk register with various areas closely monitored and that the areas previously highlighted by the CQC report, such as estates, were high of the list of priorities. 

Cllr Connor summarised some of the key issues raised during the meeting as communications over mental health casework in the community, including a direct point of contact for Councillors and others, addressing supported housing needs post-discharge and support during the transition from Children’s services to Adult services. She also noted that there would be further discussions with the Committee on the upcoming merger between the two Trusts. Cllr Revah suggested that all questions from the scrutiny of the Quality Accounts the previous year should also be followed up with the answers circulated to the Committee. (ACTION)

The NLMHP officers then responded to questions from the Committee about the Quality Accounts report for Camden & Islington NHS Foundation Trust:

• Asked by Cllr Clarke about work on early intervention and talking therapies, Vincent Kircher said that early intervention and prevention was an overarching priority in the clinical strategy because this was essential to meet the rising demand on services. Early intervention applied to various different conditions and was part of the work of the integrated community teams. Talking therapies was aimed at mild to moderate common conditions such as depression and anxiety. These were successful interventions that treated a large number of people. In response to a query from Cllr Clarke about the lower proportion of people completing talking therapies treatment moving to recovery, illustrated in the graph on page 86 of the agenda pack, Vincent Kircher said that the figure of 45% was within the normal range but had recently improved back up to the target figure of 50%.
• Cllr Clarke noted that only “suitable cases” were admitted for talking therapies treatment and asked how this and the length of treatment was determined. Vincent Kircher explained that the treatment length was pre-determined, starting with six sessions and then following a stepped approach, with up to six further sessions and then referral to secondary care services if required. He added that the eligibility criteria were based on whether the person had a treatable condition. Other issues such as alcohol/drug misuse or conditions such as psychosis required treatment from different services.
• Asked by Cllr Clarke about equal access to talking therapies, Vincent Kircher said that the Trust’s track record on access to services for people from BAME backgrounds was good when compared to national figures and there was also a diverse staff group.
• Asked by Cllr Clarke about the effectiveness of Electroconvulsive Therapy (ECT) services, Vincent Kircher said that this was a treatment for people who were very unwell and, while there was no specific data in the report on this, it may be possible to provide some data to the Committee. (ACTION)
• Asked by Cllr Revah for an update on services moving from St Pancras Hospital, Vincent Kircher said that there was a decant plan and that there were no longer any 24-hour units remaining as these had all moved to the Highgate site. Some other day services were still on site which would be moved over a period of time. He added that they were mindful of the destabilising effect for the teams, but the long-term aim was for an improved estate for the services.
• Cllr Revah commented that people caring for those with mental health problems often reported that services did not share information with them. Amanda Pithouse said that this was a historic problem which she agreed was frustrating as it was important to involve carers in decision making. Professionals were often in a difficult position when a service user did not want family members to be involved, for example because of difficult relationships or because of issues relating to their condition. Without this permission from the service user, the information could not be shared with carers. She added that a Carers Strategy from both Trusts was currently being developed which would include best practice and training in this area and carers would be involved in this process, but there was no easy solution to this problem.
• Cllr Connor asked whether specific conversations could be had with both the patient and the carers just before discharge took place to see what information could be shared and arrangements put in place. Vincent Kircher said that there was close contact with families and an ongoing conversation over a period of time as the Trust was acutely aware of the importance of involving families but noted that, in some cases, families were not involved or the patient did not give permission for information to be shared.
• Asked by Cllr Milne about recruitment and retention, Amanda Pithouse said that the situation with the recruitment of registered nurses had improved compared to previous years through new measures to attract staff. However, there were certain teams that it was more difficult to recruit to such as crisis teams. The Trust worked with Capital Nurse Programme, a regional programme run by NHS England which helped with recruitment and retention issues including international recruitment. Other initiatives included apprenticeships and the use of peer support workers. Vincent Kircher highlighted a care leaver recruitment programme and the recruitment of local people. He added that Camden & Islington had a good record of recruiting doctors with low reliance on locum doctors, though the situation was more difficult in Barnet, Enfield & Haringey so there was an active programme to recruit international medical graduates.
• Asked by Cllr Clarke about children’s services provided out of the NCL area, Andrew Wright said that there was a long-term aspiration to ensure that the new organisation resulting from the merger would provide all of the mental health services for children and young people in NCL. At present, there were other providers which added complexity to the service provision, including in transitions.
• Asked by Cllr Connor if there were any outstanding areas of concern from recent CQC reports (other than the issues of staffing and estates which had been discussed), Amanda Pithouse highlighted that the acute wards pathway had improved according to the most recent inspection with the rating in the Effectiveness domain rising from ‘Requires Improvement’ to ‘Good’, with service users no longer being sent out of area.
• Cllr Connor referred to Aim 1 (Providing consistently high quality care, closer to home) of the Quality Priorities on page 79 of the agenda pack and described local cases that Councillors were aware of relating to people with serious mental health problems in the community, including those who appeared to be at risk of becoming violent. She explained that Councillors, GPs and members of the public did not typically know who to contact to provide assistance. Vincent Kircher said that all GP practices should know who their community consultants and teams were and that these details had been circulated to all team managers and were also on the website. He added that the crisis team had a four-hour response time and were not set up to respond to life-or-death emergencies. Building local relationships was important to this community approach so it was agreed that there was more to do on this.
• Referring to the section on Quality and Safety Reviews on page 82 of the agenda pack, Cllr Connor requested further details on the areas that required improvement. Caroline Sweeney said that there was an action plan for each service and that reports were made to the Quality & Safety Committee every two months to identify issues and trends. Specific issues included the challenge of the estate, the quality of food and patient issues such as patients not feeling that they know enough about their medication. Cllr Connor suggested that it would be useful to see an example of a team action plan in the Quality Accounts as it was not easy to understand just from the general description in the report.
• Referring to the section on Mental Health Community Service User Survey on page 90 of the agenda pack, Cllr Connor noted:

o   That the proportion of service users getting the help they needed when they last contacted the crisis team was 42% and that, while the national comparison was 43%, this appeared to be low. Vincent Kircher said that the Trust wanted this figure to be higher, but it was complicated as it was a measure of how people felt who were experiencing mental distress. Caroline Sweeney added that this data was based on high level feedback and that there was greater depth in the full management report. There was also benchmarking data across the London Trusts.

o   That 43% of service users did not have a Care Plan. Amanda Pithouse noted that this was based on a survey that went to community service users rather than inpatient services users and had only a 17% response rate. Vincent Kircher explained that the Care Plan was a specific document that not everyone had, but that the aim was for every service user to be included in the new Dialog+ care planning.

Cllr Connor thanked all those from the NLMHP for attending the meeting and noted the follow up actions that had been agreed.