Agenda item

The Board received a presentation on the Whole System Approach to Adult Mental Health in South Tees.

The presentation provided information on the following services that are delivering Adult Mental Health Services across South Tees.

·        Changing Futures

·        Impact

·        Primary Care Practitioners/ARRS

·        Community Mental Health Framework

·        Voluntary and Community Services

South Tees Changing Futures (STCF)

·        The STCF programme has mental health and substance misuse as the two, main underpinning factors of issues relating to ‘multiple vulnerabilities’

·        Majority of people in STCF scope but with primary issue of Drug/Alcohol, criminal justice-related or acute housing issue are significantly affected by mental health and alcohol/drugs

·        The Board contains director-level representation from both TEWV and South Tess Public Health

·        Collaboration from the bid stage and throughout at every level

·        Greater understanding of common issues – personal, geographical, societal

·        Lived Experience Network developed and invaluable

·        Developing system improvements as a result

·        Operational level includes frontline support and advocacy, harm reduction and plans to get keyworkers addressing unmet needs

Impact on Teesside

·        Previous Improving Access to Psychological Therapies (IAPT) provision provided by 5 separate organisations

·        Impact launched 1^st April 2020

·        1 service covering North and South Tees

·        Partnership – Alliance Psychological Services and Middlesbrough and Stockton Mind

2022-23 Challenges

·        National trend for increased sessions post Covid

·        Loss of staff to remote only contracts and NHS IAPT providers, cost of living crisis has exacerbated this

·        Starting the service in April 2020 with a large inherited waiting list of approximately 6000  cases which are still impacting on current waiting times

·        Reduced GP surgery and other primary care room capacity

·        Difficulty recruiting qualified staff to fill vacancies – national trend

·        Support for client’s who fall between primary and secondary care

2022-23 Achievements

·        Variety of options and choice in addition to IAPT and range of modes of delivery i.e. 1:1, online, face to face, groups, portal, SilverCloud

·        Reduction in 1:1 waiting times and numbers through group work expansion

·        Improved joint working, communication and collaboration with statutory and voluntary organisations (e.g huddles)

·        Impact Resource Hub

·        Launch of service user involvement forum and volunteer support within pathways

·        Largest number of high intensity and low intensity trainees recruited and qualified so far

·        Increase in Mental Health Support Worker team to free up therapists to take on additional clinical work

·        Increased integration into mental health offer across Tees through robust networking, promotion and engagement work

Mental Health Primary Care Offer ARRS Roles across Teesside Primary Care Networks

2021-2022 – Year One ARRS/PCN roles

·        The National Health Service Executive (NHSE) announced the mental health roles and funding [50/50] through the additional role reimbursement scheme- April 2021 for one mental health practitioner per Primary Care Network (PCN)

·        Overall aim to improve the quality of care for people struggling with Severe Mental Illness and/or complex needs who are too complex for IAPT services and not complex enough for secondary care mental health services by access to specialist mental health advice in their local GP surgery.

·        Regular reporting through the Clinical Directors meetings to facilitate dialogue with PCNs and ensure they were fully informed and helped shape the implementation/ model

·        Advanced Nurse Practitioner posts agreed for the year one posts

·        Ensure autonomy in clinics

·        Promote non-medical prescribing and the positive impact this would have on accessing treatment/ reviewing treatment

·        Provide clinical leadership to future ARRS Mental Health Practitioner roles.

·        Job plan agreed - 20-minute appointments, with the option to double book for complex cases/ reasonable adjustments

·        Where mental health nurses are non-medical prescribers also review patients’ long-term medications and reduce or stop these where appropriate

·        Most PCNs had a practitioner in post for summer 2021

2022-2023 – Year Two ARRS/PCN roles

·        NHSE/I further funding [50/50] became available through the additional role reimbursement scheme- April 2022. The scope of who could be recruited into these roles expanded.

·        A new post created called Mental Health and Wellbeing Coaches (MHWC) agreed for the year two posts:

·        Hybrid role between social prescriber/health training/support-time recovery worker

·        To deliver: psychoeducation, graded exposure, behavioural activation, grounding strategies etc

·        Enrol on Trainee Mental Health and Wellbeing Practitioner course; trained to deliver CBT based psychological interventions, trained on risk management and caseload management for patients with a severe mental illness and/or complex emotional needs.

·        Started in October 2022 and following an induction program began clinical work in November 2022.

·        Anticipated start date of course is March 2023 for 7 MHWC and October 2023 for the remaining 4 MHWC .

Successes

• Furthermore, a review of patients referred by GPs to TEWV services resulted in some patients being brought back into the care of their local GP surgery with the support of the local mental health nurse
• The general interface between TEWV mental health services and GPs improved
• The ARRS roles allow for quicker access to mental health professionals for those with SMI and complex needs in primary care.
• Patient feedback and satisfaction rates have been high, and remain high
• GPs are reporting seeing improvements in patient health and well being
• The practitioners are active participants in the PCN MDT, working closely with roles such as link workers and pharmacists and they also access the mental health MDT e.g access team huddles
• The practitioners promote more non-pharmacological approaches
• The practitioners have a range of skills including CBT, DBT, clinical management and there are a number of non-medical prescribers employed
• There is a dedicated programme lead in TEWV appointed to help troubleshoot difficulties experienced by the practitioners
• The practitioners document straight into GP clinical system and use TEWV clinical system to ensure notes can be readily updated, ensuing patient safety e.g. if a medication is changed or a risk is identified
• The practitioners understand the criteria for referral into mental health services, supporting practice teams to make the right referrals to the right place

Challenges

• Most PCNs have been happy to work with TEWV, but there are a few who would have preferred to employ the roles directly
• Whilst the 50/50 split in funding welcomed, the process by which the Trust claims the 50% funding from the PCNs does lead to considerable administrative burden for both parties.
• IT systems not talking to each other e.g., separate clinical systems across practices in primary care and within the Trust, poor WiFi signal impacting access to systems.
• Differing expectation of the role within Primary Care and what the role can offer e.g., job plan requires longer appointment times than a standard 10-minute appointment
• Release of staff for training and development due to limited number of  ARRS roles in each PCN
• Working across a complex system and the communication across these settings e.g., multiple practices, voluntary care and other commissioned organisations
• Estates and the housing the workforce [PCNs are completing estates strategies but this is an immediate pressure]
• Where staff have worked remotely this has hampered building relationships within PCNs
• Each PCN works different- e.g., clinical systems in practice might not be the same across the PCN

Community Transformation

·        Integrated services delivering collaborative pathways which meets the needs of the population

·        Empowering individuals to choose and manage their own personalised recovery, as experts in their own mental health

·        Introduction of community navigators (In post)

·        Expansion of peer workforce (Lead peer role developed options appraisal alongside partners for implementation early 2023)

·        Physical Health hubs – introduction of lead pharmacy role to develop future service offer

·        Organisational change process initiated (move to hub and treatment team offer)

·        Funding in place to increase access to psychological therapies in secondary care (Treatment Team) – ongoing recruitment

·        Local systems groups established including LA, VCSE and TEWV colleagues (funding distributed to support system wide delivery)

CMHF and Changing Futures

Similar to previous dual diagnosis roles but with broader inclusion criteria

• 3 x FTE roles funded by external grants, including Project ADDER
• Initially Middlesbrough but recently expanded team to also cover Redcar & Cleveland
• South Tees PH and TEWV have also improved work into urgent/emergency care by match-funding additional roles within the HILT team @ JCUH:

• 1 x FTE Project ADDER-funded Team Leader with remit to improve pathways to community provision
• 1 x FTE TEWV Transformation-funded MH Lead Keyworker

• Additional funding has been secured in R&CBC to provide 1 x FTE Adult Social Worker with mental health as their primary focus – this role is being recruited but will provide a conduit between ASC, substance misuse services and TEWV.

Benefits of Community Mental Health/Substance Misuse Teams, Mental Health Dual Diagnosis Role

Middlesbrough START Team (Substance, Treatment and Recovery Transformation)

·        Aim - Reduce gaps and promote the integration of mental health and substance use services in Middlesbrough

·        Trauma Focussed Care Approach -  support clients who have historically been difficult to engage or have declined support from mental health services

·        Assertive Outreach Approach - offer different way of working – offering appointments at various locations in order to provide timely assessments and care planning

·        Drop in clinics - weekly  clinics in the Live Well Centre and The Depaul Centre - providing a service in a familiar setting/ promoting joint assessment/engagement -  Further clinics to run within Foundations and Recovery Connections to offer joint appointments/advice/support

·        Access - supporting with Access referrals to reduce waiting times for Dual Diagnosis clients and offering specialist advice/support 

·        Pathways - collaborative shared care pathways for people with co-existing mental health and substance use needs in Middlesbrough

·        Documentation – currently working towards gaining access to CPD to access/share information for clients alongside recovery services

·        Case discussion Form - new client discussion form to collect essential information including date of birth, risk and current area of need in order for the team to plan support 

Virtual Hub

• Members Growing Week on Week  - Voluntary & Statutory Services – Shared Goal
• Case Discussions Around Clients Who May repeatedly assessed or “Bounced Around Services” or May Need More Than One Service Involved – Joint Working – Shared Skills & Knowledge
• Education Around Appropriate Referrals To Reduce repeat referrals and Disappointment   Help to get people to the most appropriate service
• Stepped Care Model  - Recovery and Step 3+ Pathways
• Care Navigators To Continue To Make Links With Wider Communities In Preparation For Move To Physical Hubs (Jan/Feb 23)

Access

• Ongoing Work To Explore Referrals & Waiting Times – bridge the gaps
• Initial Needs Review Offered To Ascertain Clients Needs and Who Is Best Place To Offer Service
• Aim Is To Reduce ‘Rejections’ And To Ensure Clients Get To Where They Need To Be And How We Can Facilitate This – No Wrong Door – Warm Handover

Co-location of community teams

• Live Well East at Berwick Hills will be operational in Qtr 4 22/23
• People in East Middlesbrough will be supported closer to their homes
• The former housing office will be the main Middlesbrough community base for both the TEWV Community and Substance Misuse co-ordination teams
• Co-location will facilitate improved collaboration, including
• Joint reviews/meetings with patients
• Improved co-ordination of co-existing MH/substance-related issues
• Increased number of MDTs, including with wider agencies
• Potential joint prescribing reviews
• Once the former library is also available, it will create the opportunity for a community/VCS offer to be developed

Contributions from the Voluntary Sector

Community Mental Health Transformation in Middlesbrough

·        NHS CMH Framework is explicit about role of VCS – recognising importance of quality of life and VCOs as service providers

·        In Middlesbrough, a partnership of 9 organisations has come together to integrate their existing provision with the CMH offer

·        Initial partners – Mind, My Sister’s Place, Arch Teesside, Recovery Connections, Open Door North East, Hope Foundation, Breckon Hill Community Centre, MVDA, Youth Focus North East

·        Not adding new provision, but building capacity in existing, effective VCOs and their services – we’re already in the community working alongside people

·        Keys to success – developing relationships and clearer, deeper understanding; strengths-based approach; transparency in decision making; local ownership

·        System challenges still to overcome – culture; capacity; capability; resistance to change, inequity.

Social Prescribing Link Workers in GP Practices

·        In Middlesbrough, provided by Middlesbrough and Stockton Mind

·        Grown from 7 staff on 1 April 2020 to 23 staff across 3 PCNs

·        Supporting non-medical needs in primary care – responding to referrals for 1:1 support; delivering early intervention to targeted groups as part of population health management

·        Working with more than 3,000 people per year - majority of people have emotional or mental health difficulties alongside physical health and life issues

·        System challenges -  

·        Signposting and referring to wider VCS is crucial part of effectiveness- where’s the support for these activities/organisations?

·        We now have so many different ‘navigation’ services – why? How well are these working together?

ORDERED: The Live Well South Tees Board noted the work that was being delivered and thanked the presenters for the sharing the information