Adult Mental Health Services in the Community an Update Report by Healthwatch Isle of Wight November 2015 How to contact us Visit us in person at the IsleHelp Hub: 7 High Street NEWPORT, I.W. PO30 1SS … or online – www.healthwatchisleofwight.co.uk Phone us – 01983 608 608 Write to us - FREEPOST RTGR-BKRU-KUEL Healthwatch Isle of Wight Riverside Centre, the Quay NEWPORT, I.W. PO30 2QR E-mail us - enquiries@healthwatchisleofwight.co.uk Facebook - www.facebook.com/HealthwatchIOW Twitter - @HealthwatchIW 2 1 Contents Page no. 1 Acknowledgements 4 2 Summary 5 3 Background 6 4 What Healthwatch Did 9 5 What Healthwatch Found 10 6 Conclusions 14 7 Recommendations 15 8 Glossary 16 9 References 17 10 Appendices 18 3 1 - Acknowledgements Healthwatch Isle of Wight would like to thank those who have shared positive experiences of recovery and of using a range of mental health support services on the Isle of Wight. Healthwatch Isle of Wight is grateful to all those who have helped paint a picture of how local mental health services work today, and how they are changing. This includes people with experience of using specialist services, those active within communities to promote support and wellbeing, and paid professionals working in the statutory sector and third sector. 4 2 - Summary Healthwatch Isle of Wight carried out a consultation with local groups and the public in the summer of 2014 to help decide its priority themes for the following year. Through this, adult mental health services in the community was set as a Healthwatch priority theme for 2014-15. Healthwatch Isle of Wight undertook targeted engagement work, and liaised with service providers to learn about the way services work, how people experience them, and about planned changes. Several new third sector groups have begun delivering services over the last two years, based around mutual support and developing confidence. The Recovery Model has informed much of this growth. As well as providing opportunities for individuals, a model of positive engagement is being offered to the wider mental health sector. In June 2015 Healthwatch Isle of Wight held an engagement event jointly with the Isle of Wight Recovery Partnership. The event celebrated recovery stories and gave opportunities for participation for people throughout the mental health sector, primarily for people with experience of using mental health services. This report presents the outcomes of the engagement event, summarises feedback on mental health services 2013-15 and makes recommendations based on the findings of Healthwatch Isle of Wight. 5 3 - Background Healthwatch Isle of Wight is one of 148 local Healthwatch organisations across England. It is a “consumer champion” for people who use health and social care services. It has a Board and a team of paid workers. Authorised volunteers help in evaluating services and in other activities. Healthwatch Isle of Wight took the place of the Isle of Wight Local Involvement Network (LINk) in April 2013. Healthwatch Isle of Wight asks local people about their experiences, and several topics are highlighted each year to be looked at closely. In 201415, community-based mental health services for adults was chosen. Recovery Model For some time it has been agreed that adult mental health services on the Isle of Wight need to focus on the concept of “recovery”. The Mental Health Foundation has explained “recovery” in this way1: “For many people, the concept of recovery is about staying in control of their life despite experiencing a mental health problem. Professionals in the mental health sector often refer to the ‘recovery model’ to describe this way of thinking. “Putting recovery into action means focusing care on supporting recovery and building the resilience of people with mental health problems, not just on treating or managing their symptoms.” The Recovery Model’s emphasises the individual “becoming an expert in your own self-care”2. Self-help, mutual support and the pursuit of individual hopes and aspirations are therefore central, alongside the traditional ideas of treatment and rehabilitation3. Shared learning is at the heart of this approach, supporting active decision-making and choice. 6 Consultations, Surveys and Strategies With this in mind, two “Have Your Say” workshops were organised in summer 2010 by the Island’s NHS and the Isle of Wight Council. This was to outline ideas for change and seek service user views. A new approach was envisaged, that would provide a clearer route through specialist services and beyond4. In 2012 the former Isle of Wight LINk carried out a survey, receiving responses from 126 people using adult mental health services5. The report that followed was named “Into the Future”, the intention being to help service planners implement the service changes, due to be put into effect around that time. The LINk’s 2012 report identified inconsistent quality from community services, with a lack of clarity around care planning and crisis planning. Amongst the recommendations (a full list is given as Appendix A of this report) was for a fresh approach to service user involvement, and a renewed commitment to interagency work, to include the third sector fully. Appropriate accommodation choices were also noted as being central to positive mental health. In response, local NHS organisations stressed that the introduction of specific, focussed interventions would offer a clear pathway through treatment. These would be adopted in a new “payment by results” structure. “Re-ablement” would prepare people for new accommodation options if they had over time lost skills of independence. In 2014 a five-year Mental Health Strategy for the Isle of Wight6 was published. It is a broadly-based document outlining multi-agency work to promote positive mental health and to combat stigma around mental illhealth. It re-iterates ideas around “payment by results” and re-ablement, as well as stating an intention to develop a Service User and Carer Forum. One of its three main priorities is “Improved recovery and access to mental health support” (p.16). 7 Immediate context Feedback to Healthwatch Isle of Wight in 2013 and 2014 suggested that issues remained around moving into, through and beyond specialist mental health services. This was also raised during Healthwatch Isle of Wight ’s priority-setting, which led to the decision in June 2014 to include Community Mental Health Services in the forthcoming year’s workplan. Concerns around community mental health provision were underlined in a report published by the Care Quality Commission (CQC) in September 20147. Although staff were compassionate, it found there were long waiting lists, high caseloads, infrequent staff supervision, inadequate risk assessment and inconsistent service-user involvement in care planning. During 2015 Healthwatch Isle of Wight has kept in touch with service developments via the Head of Mental Health and Learning Disabilities for the Isle of Wight NHS Trust. Since the CQC report, there have been changes to parts of the community service, with a reduced caseload for professional staff. The outcome of a major service review was announced in September 2015. Future plans include a single route for referrals and quicker response times. A clearer format is intended for care planning and crisis support, to increase involvement of people who use the service. Whilst local authority services retain much of their traditional structure and approach, a range of third sector groups have emerged, fostering mutual support, often under the impetus of people who themselves have experience of mental ill-health. Examples of initiatives include social networking, vocationally-based approaches, and accommodation options for people in crisis. Some of these groups and organisations have come together form the Isle of Wight Recovery Partnership. The “My Life a Full Life” programme (a joint initiative between the Isle of Wight Clinical Commissioning Group and the Isle of Wight Council) has funded the Isle of Wight Recovery Partnership to set up peer-led recovery courses. Under the name “Recovery College” these have begun in Newport, with the intention of future expansion to other Island locations. 8 4 - What Healthwatch Did Community Engagement When Community Mental Health was identified as a Healthwatch Isle of Wight workplan topic, targeted engagement work began. This took place in various places, to find out more about people’s experience of mental health services. A summary of all feedback it received, relating both to the community and hospital, is given as Appendix A of this report. Interagency Liaison A range of networking activity took place by the Healthwatch Isle of Wight team to understand how the “whole system” of mental health provision is working at present, and any ways in which it may be changing. A number of key individuals were identified to be a virtual “reference group” for the Healthwatch Isle of Wight workplan. Conversations took place with these people periodically for updates, clarification and additional insights. Voices of Experience Healthwatch Isle of Wight aims to put the voice of people using services at the heart of all that it does. The growth of recovery-based activity in the third sector opened up possibilities to work together on a participation event. Healthwatch Isle of Wight and the Isle of Wight Recovery Partnership therefore held “Working Together – Listening and Recovery in Action” at Newclose Cricket Ground in June 2015. The task was to explore collaborative working between people who have used mental health services, unpaid carers and professional workers. Presentations and discussion gave an opportunity to exchange ideas and find practical and positive ways forward. 9 5 - What Healthwatch Found “Working together” The partnership event at Newclose was an important landmark in the adoption of recovery-based approaches on the Isle of Wight. As intended, most people there had experience of using mental health services. A number of carers and paid workers attended, including service managers. A welcome was extended to all, with informal mingling taking place before and between the structured sessions. The informal start of the “Working Together” event at Newclose A positive tone of co-operation was set, which promises much for the future. It was notable that a number of service managers attending the unstructured opening session chose to stay to the end, and spoke positively when invited to give their reactions. People from various agencies voiced optimism that a move to a recovery focus could lead to positive change throughout all services. 10 The event was a celebration of the stories of people with experience of mental health services, and demonstrated how sharing these can form a basis of peer support. This is in keeping with the Recovery Model where education is a primary concept alongside treatment. A key idea is that people become “experts by experience” in managing all aspects of their own lives, with a mental health condition being one part of this. One of the speakers at the “Working Together” event at Newclose The first structured sessions of the day saw several speakers describe their life histories and their experience of recovery. Each one had discovered talents which had been used to assist others on their own recovery journey. The power of such stories in providing inspiration and in re-focusing the minds of service planners should not be underestimated. As part of this event, it put across from the outset the importance of listening to accounts of lived experience. In group discussions, reservations were expressed about the label of “service user” as this could foster dismissive attitudes and a diminished sense of self. Keeping sight of positive achievements is very important. Inequities were highlighted between healthy living provision for those with physical conditions and a mental health condition, as well as lack of coordination between children’s and adult services. The importance of considering the needs of unpaid carers was also raised. 11 Group discussions during the “Working Together” event at Newclose To close the event, managers from NHS mental health services were invited to give their reaction to what they had heard. Managers spoke of being moved and inspired by the experiences shared, and recognised the need to be sensitive in use of terminology. A commitment was given to work with third sector recovery-focussed groups and to listen to people who use services as equal partners. Service change The emergence of a more confident voice amongst those who have used services coincides with the Island NHS’s plans to launch a revised service model. The Isle of Wight LINk’s 2012 report quotes contrasting feedback on the quality within and between different community teams. Given the likelihood of teams merging, it is an important time to hear the service user and carer voice. In the spirit of continued engagement, Healthwatch Isle of Wight is pleased to share a summarised version of the feedback it received from April 2013 to July 2015. It may be used with other sources of feedback to inform service change. Whilst the focus of this report is on Community Mental Health, feedback for other parts of adult mental health provision is included alongside. Transition from one service has an important bearing on experiencing another. Full summaries appear as Appendix A. 12 Feedback to Healthwatch Isle of Wight Striking amongst the feedback on Community-based services is the level of support from staff. Whilst two comments reflect a positive picture, four indicate a negative experience. In Miscellaneous /other feedback, there were seven negative comments on this. Alongside, there were two pieces of feedback about reduced levels of support to staff. This feedback anticipates the later CQC report’s7 observation about levels of caseload supervision. This may illustrate a relationship between support levels for staff and a positive experience for people who use services. Feedback also pinpointed access to psychological therapies for people receiving secondary care community mental health services. Five comments raised concerns about the length of wait and other barriers. Another theme occurring several times was that of communication and correspondence, around information about treatment. Communication issues were also noted between hospital and community team and between G.P.s and secondary services - medication and diagnosis being mentioned in particular. In Miscellaneous / other feedback enquiries were being made about employment, benefits and legal issues, suggesting a need for advice and information provision in these areas. One area of particular focus was in discharge from hospital. These centred largely on levels of risk assessment prior to discharge. Comments cast doubt on processes gauging people’s ability to manage their condition in a community setting, and on the capacity of the Crisis Resolution Home Treatment team to support individuals at home. Other feedback on hospital discharge related to Accommodation. Instances included people being effectively homeless on discharge or going to settings not conducive to their mental health. Examples were quoted of community placements not being sustained as a result. Figures from Public Health England indicate the Isle of Wight having the lowest percentage (25.1%) in the Southeast of adults aged 18 – 69 on the Care Programme Approach in settled accommodation8. The 2012 LINk report5 13 recommended closer links between mental health services and housing, and whilst a specific “re-ablement” project is underway for people leaving long-term care, Healthwatch Isle of Wight has not been made aware of increased broader liaison between mental health services and housing. Feedback about engagement centred around four comments about the complaints process and one on service-user engagement. The latter related to what appeared to be a punitive response from a service to a comment made in an involvement forum. This underlines the importance of feedback processes independent of service provision, to foster a culture of confidence in sharing experience so as to improve services. Improving Access to Psychological Therapies (IAPT) is not part of the secondary care mental health service, so is outside this report’s main focus. However, it is part of the overall picture, so feedback is included in Appendix A. There was positive feedback on quality of treatment, with one negative experience quoted of staff telephone manner. 6 - Conclusions Since the publication of the Isle of Wight LINk’s 2012 report, there have been major developments in third sector mental health activity, largely at the behest of people with experience of using services. This has helped foster a more active and confident pattern of self-help and mutual support, inspired by the Recovery Model. Feedback to Healthwatch Isle of Wight indicates that inconsistencies and concerns remain within NHS community mental health provision. Whilst progress towards organisational change has so far been less swift than anticipated, a service review signals major change to come. Such a review offers opportunities for people with experience of using services to say what works best for them. It could also set a new tone for “experts by experience” to be involved in service delivery and planning. 14 7 - Recommendations A. That commissioners of mental health services further support the development of recovery-based third sector groups and organisations, which can be more responsive in developing and maintaining services as circumstances change. B. That all partners work together to ensure as far as possible that support to recovery-based third sector groups and organisations is sustained securely into the future. C. That the review of NHS Community Mental Health services, due to be launched in September 2015, uses specific mechanisms to engage people who have used services. Future service blueprints should state how proposals for each element of the service have been shaped by listening to service-user and carer experience. D. That recovery-focussed groups are expanded to provide trainings in service-user and carer involvement. These trainings should be: a) offered to people with experience of using services, and carers, to equip individuals for involvement in service delivery, planning, staff recruitment and training, research and a range of other functions. b) required for all service providers, to equip them for full inclusion of the service-user and carer voice. E. That current initiatives in re-ablement be supplemented by a broader collaboration between mental health services and housing. This should address people’s need for accommodation conducive to good mental health. Its brief should include the provision of advice and the hospital discharge process. 15 8 - Glossary Initials CCG Explanation Organisation that acts as the commissioner for health services on the Isle of Wight A public organisation or department that decides which services will be funded, and how much money will be spent on them CQC Care Quality Independent organisation that inspects health Commission and social care services in England and gives them a rating, e.g. “inadequate”, “requires improvement” or “good” Healthwatch Isle of A local “consumer champion” for Health and Wight Social Care services, formed in April 2013 IAPT Improving Access to NHS service providing counselling support to Psychological people not felt to require the intensive mental Therapies health treatments offered in secondary care Isle of Isle of Wight Local A local health and social care “watchdog” that Wight Involvement Network existed until March 2013 and has now been LINk replaced by Healthwatch Isle of Wight I.W. NHS Isle of Wight The main provider of NHS services on the Isle Trust National Health of Wight, including specialist mental health Service Trust services in community IWC Isle of Wight Council Local authority for the Isle of Wight. It is the commissioner for social care services and provides some social care services itself. It has responsibilities for housing vulnerable people Re-ablement An intensive service to equip people with skills for daily living Recovery Staying in control of life, and leading a meaningful life, despite a mental health problem Secondary Care Specialist NHS services that family doctors make referrals to. These may be in a hospital or the community. Third Sector A collective term for non-commercial independent groups and organisations, formed to benefit communities or the environment 16 Name Clinical Commissioning Group Commissioner 9 - References 1. The Mental Health Foundation Website: “Recovery” 2. Implementing Recovery through Organisational Change – Recovery Colleges: Rachel Perkins, Julie Pepper, Miles Rinaldi and Helen Brown, Centre for Mental Health 2012 p. 2 3. Recovery in Mental Illness: Ann McCranie, in The Sage Handbook of Mental Health and Illness, Sage 2011 p. 475 4. Have your Say – Modernising Mental Health Community Services: NHS Isle of Wight, August 2010 5. Into the Future – Report on Community Mental Health Services for Adults: Isle of Wight LINk, October 2012 6. Isle of Wight Mental Health Strategy 2014 - 2019 – No Health without Mental Health, Everybody’s Business p. 21 7. St Mary’s Hospital (Mental Health Management) - Quality Report: Care Quality Commission, September 2014 pp. 83 - 90 8. Public Health Profiles for Mental Health, South-East England – Public Health England 2015 17 10 - Appendices Appendix A Recommendations from “Into the Future”: Report by former Isle of Wight Local Involvement Network (LINk), 2012 1 The Isle of Wight LINk recommends that processes are put in place to ensure a more consistent service user experience across all services. Each area covered by these recommendations should be clearly monitored so that any issues can be addressed and consistency maintained. 2 A clearer pathway is required through treatment and towards recovery. Clear information is required for individuals on how they can be involved at different stages of the process. 3 A more consistent approach to Care Planning needs to be adopted. This should include moves between hospital and community care. Service users need support in becoming more aware of the process, and being more involved in it. 4 An energetic approach is needed for an immediate overhaul of Crisis Planning. This should include definite timetables to improve consistency, and clear definitions of what constitutes a Crisis Plan, available to and understood by service users. 5 If community teams are re-organised, the higher quality demonstrated by the smaller teams should not be diluted. Good practice should be kept and adopted by larger teams. There needs to be clear plan of action for achieving this. 6 A fresh approach is needed to service user involvement. It should be co-ordinated independently from current service providers. Activity should include training for individuals and support for small groups of service users. The voice of service users needs to be heard across agency boundaries. 7 Inter-agency work should be pursued with renewed vigour, to support the progression of service users towards recovery. All agencies, including the Third Sector should be enabled to play a full part. 8 Ways should be found urgently to make connections between mental health services and housing. Joint work should be done to identify which settings are conducive to recovery. Clear communication routes should be in place with the Isle of Wight Health & Well-Being Board. 9 It is recommended that changes to Community Mental Health services are formulated swiftly and with a clear timetable, to end the climate of uncertainly that has existed for service users over the last two years. 10 The LINk recommends that its successor body, HealthWatch Isle of Wight, assess progress on the above recommendations no later than October 2013. 18 Appendix B Feedback to Healthwatch Isle of Wight on Adult Mental Health Services: April 2013 – July 2015 Overview and origin A total of 83 items of feedback have been received on adult mental health by Healthwatch Isle of Wight since its inception in 2013 until July this year. These are presented below under four headings. Hospital services and Improving Access to Psychological Therapies (IAPT) have 16 and 4 items respective. The Community Mental Health Team (CMHT) received 32 items and miscellaneous/other received 28 items. Where more than one topic is covered within one contact these have been listed as separate items of feedback. Feedback on Adult Mental Health Support Improving Access to Psychological Therapies (IAPT) Hospital Services (including Crisis Team) Community Mental Health Team (CMHT) Miscellaneous / other 0 Negative 5 Neutral / mixed 10 15 20 25 30 35 40 Positive 19 Services and topics Improving Access to Psychological Therapies (IAPT) Quality Staff Community Mental Health Team (CMHT) Hospital Services (including Crisis Team) Access to services Equality & diversity Patient choice Patient pathway Quality Safety Service monitoring Staff Miscellaneous / other Access to services Equality & diversity Access to services Finance Fit for purpose Patient choice Patient pathway Quality Patient pathway Quality Service monitoring Staff Equality & diversity Legal issues Service monitoring The majority of feedback related to patient pathway or quality. Feedback about access was more numerous in CMHT and Miscellaneous categories, whilst both Hospital Services and CMHT included items on patient choice and equality & diversity. Feedback on hospital services included one item on safety. The “miscellaneous” category featured a greater spread across topics. This reflects requests for information on advice, advocacy and making complaints, as well as enquiries to the CAB regarding housing or financial issues. General comments about current provision or changes needed to mental health support are also included, as well as more specific comments about services. 20 More detail on feedback themes Improving Access to Psychological Therapies (IAPT) Quality & effectiveness Telephone manner of staff Positive Negative 3 1 Negative Negative Negative Neutral Negative Negative Negative Negative Negative Negative Positive Mixed 1 1 1 1 1 5 1 1 1 2 1 1 Negative Neutral Negative Negative Mixed Positive Negative Negative Negative Positive Negative Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Negative Positive Negative 1 1 1 3 1 2 1 2 1 2 4 1 1 1 1 1 1 5 1 1 1 1 1 1 Hospital Services, including Crisis Team Arrangements around detention Choice of service provider Communication with deaf people Complaints process Crisis team Discharge Interaction with ethnic minority service users Liaison with GPs Liaison with unpaid carers Medication issues Quality and effectiveness Staff manner Community Mental Health Team (CMHT) Access to services (general) Clinic building Communication and correspondence Complaints process Daytime activity Diagnosis issues Employment and benefits Level of support from staff Liaison with GPs Liaison with in-patient unit Liaison with unpaid carers Medication issues Provision of information Psychological therapies, access Service to those with autism Service to those with substance misuse issues Service-user involvement Staff attitudes Waiting times (general) 21 Miscellaneous / Other Access to information Accommodation Complaints process Contact information for services Diagnosis issues Employment and benefits Finance issues Legal issues Level of support from staff Level of support to staff Medication issues Prison healthcare Psychological therapies, level of availability Psychological therapies, waiting times PTSD support Public awareness Unclear Waiting times, general 22 Neutral Negative Neutral Negative Unclear Negative Negative Neutral Negative Neutral Unclear Negative Negative Unclear Negative Negative Negative Negative Neutral Negative 2 4 2 1 2 1 1 2 1 1 2 7 2 1 1 1 2 1 1 1 1 23