Contact: Graham Collingridge, County Manager (Mental Health Strategy)

Telephone: 01962 847277

1 Introduction

This report describes the progress made in developing proposals for integrated line management of mental health services and seeks authority to take the process further.

2 Background

2.1 The previous report on the integration of mental health services (30 July 2001) described an organisational model proposed by the Social Services Department that had been subject to some initial discussion with NHS colleagues. This included:

1. A joint Strategy and Performance Board with a performance management function

2. Joint Management Board to oversee the operational management of a joint health and social care adult mental health service

3. Integrated locality management with jointly appointed managers from NHS Trusts and Social Services

2.2 The scope of integration proposed includes the joint operational management of mental health and substance misuse services for adults across Hampshire. It includes services provided through contracts with voluntary sector services providers. The current proposals exclude services for older people and children with mental health problems, which will require separate consideration. The scope also excludes the structural integration of commissioning with Primary Care Trusts.

3 Progress

3.1 An integration project board was established in July 2001. This is chaired by the Assistant Director Hampshire County Council Social Services and has representation from Southampton City Council/Southampton City PCT, West Hampshire NHS Trust, Surrey Hampshire Borders NHS Trust, Portsmouth Health Care NHS Trust, Portsmouth City PCT/Social Services, East Hampshire PCT, New Forest PCT, and Rushmoor and Hart (Shadow) PCT (to be called Blackwater Valley and Hart PCT from April 2002, see section 6 below).

3.2 The following progress has been made by the Integration Board

(i) Commissioning of a Consultation exercise by the Sainsbury Centre for Mental Health

(ii) Draft proposals to establish joint operational management boards

(iii) Indicative timescales for integration

3.3 NHS Trust reconfiguration has had a major bearing on progress to date and will continue to do so. One of the major consequences of major organisational change occurring according to different timescales is that the integration of mental health services also needs to occur at different paces across Hampshire. The NHS organisational changes include:

(i) The establishment of West Hampshire Trust as a new organisation in April 2001 and subsequent development of new management arrangements

(ii) The merger of the Loddon Trust with Surrey Hampshire Borders NHS Trust in April 2001 and the possibility of further organisational change by April 2003 (see Section 6 below)

(iii) The dissolution of Portsmouth Health Care NHS Trust with the transfer of adult and mental health services to the West Hampshire Trust and substance misuse services to Portsmouth City PCT from April 2002.

3.4 The Social Services Department has also gone through a process of remodelling to enable it to meet the modernisation agenda more efficiently. For adult mental health services this has included the establishment of a County Manager (Operations) to manage specialist mental health service managers and to establish integrated services with NHS Trust mental health providers; and a County Manager (Strategy) to lead on strategic developments and commissioning.

4 Integration Project Board

4.1 The Sainsbury Centre for Mental Health was contracted to undertake a staff consultation exercise across all the affected agencies and develop a project plan for the integration process. A report on the outcome of staff consultation and a project plan is expected by the end of March 2002. Emerging findings from the consultation include the following:

(i) a positive attitude towards further integration

(ii) the need for the development and communication of a clear joint vision for mental health services

(iii) the identification of a number of resource and systems issues that need to be resolved.

(iv) a desire to see more user and carer involvement in the integration process

(v) anxieties about the pace of change (too fast) and the need for more staff involvement in the process

(vi) greater clarity on proposals for substance misuse services

4.2 As indicated above, the integration process is going to need to progress at a different pace according to the NHS Trust concerned. West Hampshire NHS Trust is a new organisation in the process of appointing staff and implementing new arrangements (see below). Surrey Hampshire Borders NHS Trust has an existing structure in place, but is subject to review and consequent uncertainty. Joint integration project groups are being established for each social services department and NHS Trust to develop a more detailed project plan.

5 West Hampshire NHS Trust

5.1 West Hampshire Trust currently provides mental health services to the populations served by Mid Hampshire PCT, Eastleigh TVS PCT (to be formally established from 1 April 2002), and New Forest PCT. It also provides services to Southampton City. An organisational structure reflecting these localities has been developed and recruitment to locality manager posts is currently underway. From 1 April 2002 services for adult mental health commissioned by the PCTs for the populations of Fareham and Gosport, and East Hampshire will also be provided by West Hampshire Trust. Proposals to develop joint locality management here will need developing in due course. It has been agreed between by the Director of Social Services and Trust Chief Executive that, following the conclusion of appropriate redeployment processes within the Trust, locality manager posts in Hampshire will be available to staff from both organisations to apply for. These posts will be jointly accountable to both organisations. Staff will remain with their current employer with staff from Hampshire County Council in a secondment arrangement. In the early stages of joint appointments social services managers will remain accountable for and will continue to manage all social services budgets. Once a partnership agreement is in place, locality managers, regardless of employer, would be expected to have responsibility for staff and resources under their management.

5.2 Proposals to identify an integrated management structure beneath the locality manager are still being developed. This will include social workers in Community Mental Health Teams, in-house day services and the management of contracts with voluntary sector providers held by the Social Services Department.

5.3 It is hoped for West Hampshire Trust and Hampshire Social Services that a detailed joint organisational structure based on PCT localities, together with accountability and governance arrangements should be in place by April 2003 subject to the outcome of consultation, and possibly in advance of this timescale.

5 Surrey Hampshire Borders NHS Trust

6.1 Surrey Hampshire Borders NHS Trust (SHBT) serves a Hampshire population whose NHS services are commissioned by North Hampshire Primary Care Trust, and Rushmoor and Hart (Shadow) Primary Care Trust. It also provides mental health services in West Surrey. It has recently been agreed that Rushmoor and Hart (Shadow) Primary Care Trust will be called Blackwater Valley and Hart PCT from 1 April 2002, and will have delegated duties for the Surrey Heath population, thus crossing the boundary between County Councils and Strategic Health Authorities.

6.2 Partnership arrangements with SHBT need special consideration, first because the needs of the Blackwater Valley population require an approach to service delivery across the County boundary with Surrey, and secondly because of a review of the configuration of mental health services in East and West Surrey and the implications this has for Hampshire residents. Work is currently underway, led by East Surrey Health Authority, to develop options with the implementation of any new arrangements from April 2003, subject to formal consultation and Ministerial approval. As a result of this, two issues in particular may need consideration by Members: first the implication of establishing the joint management of services across the County boundary with Surrey (the Blackwater Valley), and secondly the future configuration of mental health services in Hampshire. It is not possible to proceed with confidence towards integrated operational arrangements until some of these issues are resolved.

6.3 Under current arrangements, Hampshire County Council and Surrey County Council Social Services Departments have separate management arrangements and approaches to partnership with Surrey Hampshire Borders NHS Trust. It is increasingly being recognised that the needs of the Blackwater Valley population in Hampshire and Surrey could be better met by a more integrated approach to service delivery. The networks of health, and to some extent social, care operate across the boundary. This includes access to an adult inpatient unit in Camberley (with plans to move this to Guildford in due course). There is an increased emphasis in health and social policy that services should be based on the needs of local communities and care pathways, and that organisational barriers should not impair service delivery. Subject to further consideration and consultation, one option for integrated mental health services for the Blackwater Valley population is that a joint arrangement to manage adult mental health services is developed by Surrey Hampshire Borders NHS Trust, Hampshire County Council, and Surrey County Council. Any proposals for joint management would need to ensure that accountability and scrutiny arrangements for the respective County Councils and Strategic Health Authorities were in place.

6.4 Members have previously indicated (Adult Services Sub Committee of Social Services Committee, 7 April 2000) their desire to see a County wide mental health provider. The reasons for this include the need for economy of scale, consistency, specialist management and the management of risk. Specialist mental health Trusts are the preferred organisational arrangement identified in the Mental Health National Service Framework in most circumstances. One of the implications for the current review of mental health service configuration is that options could include one in which the Blackwater Valley population is served by an organisation serving largely a Surrey population, with alternative arrangements e.g. West Hampshire Trust, providing services for the North Hampshire Primary Care Trust area currently served by Surrey Hampshire Borders NHS Trust. This would mean that West Hampshire NHS Trust could provide mental health services for all of Hampshire County Council residents except for those in the Blackwater valley where the special considerations of a natural community across the County boundary and access to services in Surrey apply.

6.5 The issue of service delivery to the Blackwater Valley is relevant not only to users of adult mental health services but to the whole population and the range of services they require, and may have policy implications that Members wish to consider. It is therefore proposed in this report that the Social Care Policy Review Committee scrutinise proposals for the future organisational configuration of mental health services for this locality, including proposals for joint integrated management by the Trust, Hampshire County Council and Surrey County Council.

7 Financial and Capital Implications

7.1 Revenue. The revenue budget for adult mental health social care services for 2002-03 is over £9 million. The first stage of developing an integrated mental health service with West Hampshire NHS Trust will involve the joint management of over £3 million of social services resources. Until a robust partnership agreement is in place that satisfies both agencies requirements, authorisation and control of expenditure remains with the originating authority.

7.2 Capital. The development of an integrated mental health service also has capital implications, particularly for accommodation, that will need to be addressed in partnership agreements. There are a number of localities where integrated working is hindered by a lack of suitable accommodation. This is most notable for the population served by East Hampshire Primary Care Trust, where there are as yet no integrated Community Mental Health Teams (CMHTs), although £500,000 Joint Finance Capital has recently been identified for this purpose. The issue is also significant in Gosport, where £100,000 Mental Illness Supplementary Credit was been awarded to the County Council for 2001-03 to develop facilities, but adequate accommodation is yet to be identified. There is also a need for suitable accommodation for Romsey CMHT and Day Services. There will also be a need for additional accommodation for staff as new services are developed in accordance with the National Service Framework such as assertive outreach, and crisis resolution and home treatment teams.

7.3 The County Council has previously made significant capital investment e.g. Junction Road, Andover, to assist in the development of Integrated Day Services with a CMHT. It is suggested that the County Council could develop costed options with Primary Care Trusts and Mental Health NHS providers to facilitate the acquisition and development of suitable accommodation for integrated mental health services. Sources of capital finance available to the County Council include application to the Department of Health for Mental Illness Supplementary Credit Approval in addition to consideration in the County Council's Capital Strategy.

8 Human Resource Implications

8.1 The full extent of the human resources issues will be identified as part of the project planning arrangements. Work is currently underway to develop a partnership agreement that identifies the range of issues that need to be considered, and draws on the best practice recommended by professional bodies and the experience of existing partnerships across the country. Partner agencies will need to consider when it is appropriate to agree to adopt the policies and procedures of one of the partners, and when current arrangements require significant adaptation to meet the requirements of an integrated service. Among the issues needing to be considered include the following: recruitment procedures, the case for seconding staff to an NHS Trust, different approaches to pay and conditions, and a joint approach to relationships with Trades Unions. Other issues include the need to develop a shared organisational culture that embraces the values and strategic objectives of the partners and other `softer' issues that are a challenge to capture in formal agreements but are essential for successful partnerships to develop e.g. good understanding and relationships.

8.2 It should be noted that local NHS organisations have a different approach to certain issues such as job evaluation, pay and conditions, and recruitment, although the NHS nationally is aiming for a more standardised approach over the next few years. The implications of developing an integrated single line management structure between the Social Services Department and NHS Trusts will also need to be considered as part of the County Council's approach to implementing "Employment in Hampshire County Council". Additional considerations will apply if it is agreed to jointly manage services with Surrey County Council and the NHS across the Blackwater Valley.

8.3 The recruitment and retention of Approved Social Workers, who carry out the County Council's statutory responsibilities under the Mental Health Act 1983 continues to be a challenge. This is a national and local issue but is particularly noticeable in the Blackwater Valley locality. The Social Services Department has identified an additional £35 000 for the 2002 - 03 budget to address this issue.

9 Conclusion

9.1 Progress with developing more detailed proposals for an integrated adult mental health service has been slower than expected but steady. There is a continuing commitment to develop integrated mental health services, and a better understanding of the organisational complexities that impact on the process, given the wholesale changes in the health and social care system. Work to date suggests that separate organisational partnership boards need to be established between Hampshire County Council Social Services Department and its NHS partners to enable integration to be taken forward at an appropriate pace taking into account other factors such as further possible organisational change.

9.2 Advantage is being taken of the need to implement a new organisational structure in West Hampshire Trust to bring in interim joint management arrangements with safeguards prior to a detailed partnership agreement being in place. Integration in other localities in Hampshire will proceed at an appropriate pace dependent on development of the appropriate agreements and subject to the possibility of further organisational change.

9.3 Integrated working between the Social Services Department and NHS Trusts can be hindered by the lack of appropriate accommodation in which to locate social services and NHS staff together. It is therefore proposed to develop costed options that can be considered for capital investment.

9.4 Options are currently being developed for the configuration of mental health services in Surrey, and those parts of Hampshire currently served by Surrey Hampshire Borders NHS Trust. Options are likely to include:

i) joint arrangements to manage services to the population of the Blackwater Valley with Surrey Hampshire Borders Trust, Hampshire County Council and Surrey County Council

ii) West Hampshire NHS Trust providing services for the residents served by North Hampshire PCT

It is proposed that Social Care Policy Review Committee considers these proposals.

10 Recommendations

1. That the County Council Social Services Department proceeds with the current proposal to develop an integrated management structure with partnership boards established with the relevant NHS provider Trusts.

2. That the Social Services Department develops options for the joint use of accommodation with NHS mental health providers.

3. That proposals for NHS provider arrangements for mental health services are referred to the Policy Review Committee.

Section 100D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extend in the preparation of this report and attached appraisal.

NB the list includes

1. Published works.

2. Documents which disclose exempt or confidential information as defined in the Act.

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