1. Summary

This report describes proposals for changing the organisational arrangements for the delivery of mental health services to the populations served by North Hampshire and Blackwater Valley and Hart Primary Care Trusts (Appendix 1 and Appendix 2). It also includes a draft response (Appendix 3) to `A Consultation Document on Mental Health Services in Surrey and North East Hampshire.' The proposals, if implemented, would result in the West Hampshire Trust providing adult mental health services for most Hampshire County Council residents. The majority of the population of Blackwater Valley and Hart (also known as North East Hampshire in the Discussion and Consultation Document) would receive services from a West Surrey based provider. Members comments are requested on the proposals for inclusion in the County Council's formal response.

2. Introduction

2.1 The majority of specialist mental health services for Hampshire County Council residents are currently provided by two mental health Trusts, West Hampshire NHS Trust, and Surrey Hampshire Borders NHS Trust. They provide mental health services for adults ( including those who misuse substances), people with learning disabilities, and older people. The exceptions to this are in South East Hampshire, where substance misuse services for Fareham and Gosport and East Hampshire are provided by Portsmouth City PCT, and older people's services by East Hampshire PCT.

2.2 It has been recognised for some time that further organisation change will be required with the Mental Health Trusts in Hampshire and Surrey. North Hampshire PCT has indicated its intention to commission services from West Hampshire Trust. In Surrey change is required in the Mental Health Trusts to provide long term financial viability.

2.3 On 31 May 2002 the Social Care Policy Review Committee considered these issues and indicated its support for arrangements whereby the West Hampshire Trust provided services for most of Hampshire; and for a largely Surrey based provider to provide services for the Blackwater and Hart population (with the exception of Western Hart, who would be served by West Hampshire Trust). It should be noted that in the current Discussion and Consultation Document, Blackwater Valley and Hart is referred to as North East Hampshire.

2.4 The grounds for support of the expansion of West Hampshire Trust include consistency of approach and arrangements that support integrated working with the County Council. The grounds for supporting and different arrangement for North East Hampshire include that its population forms part of a natural community that crosses into Surrey; and this population uses services in Surrey e.g. inpatient beds. It is generally recognised that good practice requires integrated working between community and inpatient mental health services, and arrangements that organised services by the County boundary would break this link. Commissioning and local management arrangements have now been established that cross the County boundary. This requires joint working between Blackwater Valley and Hart PCT, Woking PCT, Hampshire County Council and Surrey County Council.

2.5 Working across a County and Strategic Health Authority boundary raises important issues regarding accountability. Members have previously emphasised the need to ensure that the needs of Hampshire residents are properly addressed in a Surrey led health system where the provider is accountable to the Surrey Sussex Strategic Health Authority, as well as Blackwater Valley and Hart PCT. Appropriate accountability arrangements need to be in place for Hampshire services, whilst recognising that the needs of patients should come before the convenience of organising services along administrative boundaries.

3. The Current Proposals

3.1 Consultation

There is a statutory duty on the NHS to consult on significant changes in NHS provision. The current changes involve two separate processes, led by North Hampshire PCT and Blackwater Valley and Hart PCT for their respective populations. These are summarised below. PCTs currently have a duty to consult with Community Health Council, which will continue until December 2003. There is also a requirement for significant changes in NHS provision to be referred to Overview and Scrutiny Committees, and a new requirement for joint committees to be established where services cross local authority boundaries. Surrey County Council's Health Select Committee had already established arrangements for scrutiny of the changes to mental health services in Surrey, and following the issue of new regulations for joint scrutiny, invited Hampshire County Council to participate in their arrangements.

3.2 North Hampshire

The case for services for North Hampshire being provided by West Hampshire NHS is described in a North Hampshire PCT Board Report, Appendix 1. The County Council has supported proposals for a Hampshire wide Mental Health Trust since April 2000 when a previous consultation was conducted. North Hampshire PCT will be conducting some public consultation through local Community Health Council (CHC) locality forums and service user and carer groups. The CHC has agreed that it is not necessary to produce a formal consultation paper since the proposals concern management changes and will not change the range of services being provided.

3.3 Surrey and North East Hampshire

3.3.1 The `Discussion and Consultation Document' regarding the issues in these localities is contained in Appendix 2. The nature of the process for Surrey and North East Hampshire is more complex because of the range of issues involved. In addition to meeting statutory requirement for consultation on organisational changes (North East Hampshire and West Surrey) and services changes (East Surrey), the Surrey Sussex Strategic Health Authority wants to use the process to open up a discussion on the service model and strategic direction of adult mental health services. From a County Council and Blackwater Valley and Hart PCT perspective, the main purpose of the consultation is to secure the necessary support for organisational change. This would result in a single mental health trust for West Surrey and North East Hampshire. The new organisation will be a partnership trust. It will be formed using the establishment order of North West Surrey Mental Health Partnership Trust but it will be renamed. Further details are contained on pages 14-16 of the Discussion and Consultation Document.

3.3.2 The County Council's draft response is enclosed as Appendix 3.

4. Conclusion

4.1 The net result of the proposals outlined in this paper is to extend the provision by West Hampshire Trust of adult mental health and substance misuse services, NHS learning disability services and older people's services to North Hampshire (and West Hart). The benefits of this change include the opportunities for improved efficiency, consistency and partnership in service delivery.

4.2 Similar NHS services for the North East Hampshire population will be provided by a West Surrey and North East Hampshire partnership trust. The benefits of these changes include those listed above, and also provide for some longer term organisational and financial stability, and the benefits for services users and staff that this brings. For this proposal to be successful it requires effective partnership working across a County and Strategic Health Authority Boundary.

4.3 Members are asked to comment on these proposals and identify any other issues to be included in the County Councils formal response.

5. Recommendation

1. That the Social Care Policy Review Committee comments on the proposals.

Background Papers

Section 100D - Local Government Act 1972 - Background Documents

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

N.B. The list excludes:

1 Published works.

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

NONE

APPENDIX 1

North Hampshire Primary Care Trust

Report to: North Hampshire Primary Care Trust (NHPCT) Board

Tuesday, 24^th June 2003

Subject: Revised Commissioning arrangements to support greater

coterminosity for the delivery of Mental Health Services

for North Hampshire.

Author: Peter Kelly, Director of Performance and Commissioning

Purpose of Report: To present proposed revised Commissioning arrangements

Recommendation: The Board is asked to support the proposal or to agree

alternative action.

1. Context

1.1. The provision of specialist Mental Health Learning Disability Services in
north Hampshire is currently undertaken by Surrey Hampshire Borders
Trust (SHBT). This Trust also provides services to part of Surrey and
the north east area of Hampshire.


1.2. Mental Health Services for North Hampshire transferred to SHBT in
April 2001 following the dissolution of Loddon NHS Trust. When the
decision to transfer services to SHBT was taken in 2000, West Hampshire
NHS Trust did not exist.


1.3. West Hampshire NHS Trust (WHT) was established on 1^st April 2001 and
provides services to a large proportion of the population of Hampshire,
i.e..to the population of six Primary Care Trusts: New Forest; Eastleigh &
Test Valley South; Mid Hampshire; Southampton; Fareham & Gosport and
East Hampshire. It is anticipated the name of the Trust will change from
April 2004 to reflect its wider catchment area across Hampshire.


1.4. The existence of WHT and its wider catchment area, now provides a
platform which will enable service users, carers and staff in the North
Hampshire area to continue to enjoy the benefits of critical mass that a
large Mental Health and Learning Disability Specialist Trust brings.
Furthermore, it offers the potential to realise the benefits of greater
coterminosity with Hampshire County Council.


1.5. Some of the advantages of Specialist Trusts are described in Annex 1.


1.6. Proposals are being developed for changes to the current providers of
mental health and learning disabilities to the populations of west Surrey
and north east Hampshire. These proposals are to be considered through

public consultation commencing in July.

2. Proposal

2.1. It is proposed to transfer responsibility for the provision of specialist
mental health and learning disability services in North Hampshire
to the West Hampshire Trust.


2.2. This change would become effective from 1^st April 2004. However, this
proposal should not jeopardise the stability of Surrey Hampshire Borders
Trust and consequently, can only be finalised in conjunction with any
changes to the Surrey providers.


2.3. These changes will also cover services provided from north Hampshire
based services to the population of West Hart, which is served by
Blackwater Valley & Hart Primary Care Trust.


2.4. The proposed change will mean that West Hampshire Trust will provide
services to the majority of the population of Hampshire. As stated above,
this will give greater coterminosity with partner organisations across
Hampshire. Benefits will include:

· Improved coterminosity with Hampshire County Council Social
Services leading to improved effectiveness of integrated provision
of adult health services and substance misuse services; as well as
joint working with regard to the provision of elderly mental health
services and learning disability services.

· Greater potential for staff working in north Hampshire to
influence and benefit from the investments made by Hampshire
& Isle of Wight Workforce Development Confederation.

· Greater focus from the Hampshire & Isle of Wight Strategic Health
Authority on the population of North Hampshire and the performance of Trusts providing these specialist services to this population.

· Efficient implementation of the new Pan Hampshire Adult Mental
Health Information System. The Trust reconfiguration will build on
the joint work that is currently underway in developing and acquiring
the new mental health information system.

· Improved coterminosity with the Wessex Deanery. There already is a
common Junior Doctor Training Rotational Programme between
North Hampshire and Mid Hampshire. That training programme being
under the "management" of a single employer NHS Trust would
improve the efficiency and effectiveness of that rotation.

· The new South East Development Centre is "patch based", focusing
on the geographical area covered by each Health Authority. Thus the
greater coterminosity of the Trust with the Hampshire and Isle of
Wight Strategic Health Authority boundary will be helpful in
ensuring that local services benefit from the contribution and support
of the SEDC.

· The improved coterminosity with Hampshire County Council will
help ensure that the scrutiny function that has become the statutory
responsibility of the Local Authority will be enhanced. It will be
easier for the Local Authority to undertake its role regarding mental
health and learning disability services.

· Improved opportunities for support from the Modernisation Agency.
The NHS Modernisation Agency is increasingly devolving resources
to each Strategic Health Authority.

· The larger critical mass of West Hampshire Trust will facilitate the
development of specialist services, e.g. forensic, low secure and
psychiatric intensive care unit services.

· The opportunity to develop joint commissioning and mental health
services which can be achieved as part of a wider Hampshire
approach to the development of integrated mental health services.

3. Impact on Service Provision

3.1. The changes that are set out in this proposal describe the benefits to the
provision of service through a change in management arrangements; they
are not about any reduction in the level or quality of service to the local
population of north Hampshire.


3.2. The services that are currently provided to the north Hampshire
population will continue to be provided at Parklands Hospital and the
Community Mental Health Centres in Tadley, Basingstoke and Bordon.


3.3. Developments for north Hampshire will build on the "localness" which
influences the way that services are delivered. Services will continue to be
provided on a locality basis with locality based arrangements that involve
clinicians in the management and leadership of the provision and
development of local care. Services will continue to be based in their
current locations.

The change of the Trust that is responsible for the provision of services
will ensure:

· Locally managed services
· Local i.e. Hampshire based standards of service
· Local i.e. Hampshire scrutiny of services
· Local commissioning of services will continue to be undertaken
predominantly by the North Hampshire Primary Care Trust
· Local partnership will continue and indeed be enhanced by having
more integrated working arrangements with Hampshire Social
Services
· The ability to develop specialist services on a local i.e. Hampshire
basis will be enhanced.

4. Public and Staff Engagement

4.1. Public

We are committed to engaging and informing the public about the
proposed changes. We are, therefore, proposing the following approach
to public engagement:

· Presentation to July Community Health Council Meeting
· Presentations to all Locality Health Forums
· Presentations to all (shadow) Patient Forums
· Engagement/presentations to local Mental Health User and
Carer Forums

These will take place over a four month period commencing in July 2003.


4.2. Staff

An agreed joint programme of staff engagement and consultation between
Surrey Hampshire Borders Trust and West Hampshire Trust will give staff
the opportunity to discuss the proposal. If the transfer is agreed this will
be continuous until the statutory transfer of staff has been completed and
will include formal consultation with the individuals affected.

5. Engagement with Partner Organisations

5.1. Hampshire Social Services Policy & Resources Committee have
previously agreed in principle to these proposed changes. However, it
is understood they would wish to endorse the detail at a meeting to be
held in the early Autumn as will the Social Care Executive Cabinet
Member.


5.2. These proposals will be considered by the respective Boards of Surrey
Hampshire Borders Trust and West Hampshire Trust in July 2003.

6. Conclusion

6.1. The Board are asked to support the proposed change in commissioning
arrangements to take effect from April 2004, subject to the detail set out
in Section 2.

Annexe 1

The Benefits of a Specialist Trust

· An NHS Trust devoted solely to the needs of mental health and learning disability users and carers, is able to concentrate its efforts on these disciplines. It can raise the profile and influence of mental health and learning disabilities issues and services fight to reduce stigma and campaign for more resources.

· A specialist Trust ensures that the `mental health and learning disability service improvement agenda' is represented at the highest levels in the health and social care community in which the Trust provides services.

· Staff working in mental health and learning disability can engage with other staff in the Trust at all levels, in getting help and support by people who understand and are knowledgeable about the services.

· Mental Health and Learning Disability Trust works in partnership with Primary Care Teams, Social Services, service users and carers and the voluntary sector to develop high quality locality based mental health and learning disability services.

· Staff who are devoted solely to mental health and learning disability services bring greater commitment, clear vision and innovative service improvement.

· The standards, targets and milestones set out on the NSF for Mental Health and NHS Plan are challenging and demanding - they are most likely to be met by a Mental Health & Learning Disabilities NHS Trust with clear lines of accountability, a unified vision and the capacity for developing and implementing major plans for severe change.

· A large specialist NHS Trust would be able to make economies of scale and reduce duplication of support services.

· A large specialist NHS Trust is able to make better overall provision for education and training, and research and development. The Trust is an NHS Teaching Trust building strong links with Southampton University.

· A larger organisation could use its staff in a more flexible way, and would be better able to attract and retain well-qualified staff by offering them opportunities for career development, access to training and to specialisation.

· A Mental Health and Learning Disabilities NHS Trust is better able to plan and provide services for the minority of people with severe mental illness who present a risk to themselves or to others.

· The Trust would be better placed to develop a wider range of specialist services and to reduce reliance on out-of-area services.

· A large specialist NHS Trust, while taking account of local priorities, could nevertheless reduce inequalities of provision across different areas and services by all means other than cross subsidization.

A large specialist NHS Trust could provide more effective treatment and support for people with a learning disability, and could set up more responsive and therapeutic services for people with complex needs as a result of dual diagnosis, for example, a mental health problem which is accompanied with a drug or alcohol problem, a learning disability, or personality disorder

APENDIX 3

DRAFT

HAMPSHIRE COUNTY COUNCIL

Response to `A Discussion & Consultation Document on Mental Health Services in Surrey and North East Hampshire

Question 1. What are your views on the model of service outlined in this document?

Adult Mental Health Services

This model, which is applied to mental health services for adults of working age, has received support in the North east Hampshire and Surrey Health Mental Health Local Implementation team. The National Service Framework (NSF) requires the establishment of new services such as Crisis Resolution and Home treatment; Assertive outreach, and Early intervention in psychosis; and additional staff e.g. carers support workers, ethnic minority community development workers, and graduate primary care staff and gateway workers. It would be helpful if the model could explain the relationship between these new services and existing ones e.g. CMHTs (Community Mental Health Teams) and inpatient units; and the interface with other services e.g. substance misuse and child care.

Question 2. What are your views on the strategic direction of travel for these services across Surrey and North East Hampshire

2.1 Views expressed by people who use services, carers, partners, and staff.

The controlling principle of modern services is that they are shaped around the needs and preferences of the people who use them, their families and carers. The underlying principles of the current discussion and consultation document should reflect this emphasis. Currently the document does not make this the primary concern.

National research has identified those issues most of concern to people who use adult mental health services:

a. satisfaction with accommodation

b. employment or other purposeful activity

c. sufficient income to support themselves

d. participation in social and leisure activities

e. self respect in social roles, family and work

f. not feeling a burden upon family carers

g. a sense of partnership with their paid carer

h. achieving a balance between risk and safety in everyday life

i. a level of clinical symptoms that does not unduly restrict social functioning

Services need to be organised to enable people to achieve these objectives. This requires a `social model' of mental health that recognises the priority given to addressing the social factors in a person's life, rather than a `medical model' that emphasises the person as a patient and the treatment of psychiatric symptoms.

People who use services in the United Kingdom are increasingly talking about a `Recovery Model' of mental health. The idea of Recovery emphasises hope, personal development, self esteem and identity, without necessarily meaning restoration of full functioning without support. Hampshire County Council Social Services is promoting the dissemination of this model in adult mental health services including a major conference in 2004. Anthony Sheehan, Chief Executive of the National Institute for Mental Health, and other leading speakers on Recovery, have agreed to participate.

National guidance gives recognition to the widespread cultural changes that need to take place within organisational culture and professional practice. The County Council will, through its Social Services Department, contribute resources towards this process.

2.2 Partnership working

The implications of 1. above is that a great deal more needs to be done in partnership working to ensure that service objectives are met. This includes the needs of people with mental health problems to be addressed in local community strategies and through local strategic partnerships, as required as part of the implementation of the National Service Framework. Hampshire County Council has played an active part in Local Strategic Partnerships, in addition to establishing a Hampshire LSP, and will work with partners to ensure that mental health needs are addressed.

2.3 State of `preparedness' of organisations to meet the requirements of the NSF

In addition to the comments above, the County Council is committed to working with Blackwater Valley and Hart PCT to implement the findings of the recent review it commissioned by the Health Advisory Service to assist in NSF implementation.

2.4 Developing the involvement of people who use services.

Service user involvement requires a stronger base in order for people who use services to participate effectively in the planning, running and monitoring of services. The County Council will be working with the Hampshire and Isle of Wight Strategic Health Authority and the South East Development Centre on an initiative to develop user involvement, in addition to its continued support for current initiatives within Surrey Hampshire Borders Trust and Blackwater Valley and Hart PCT. Evidence from other areas suggests that some aspects of user involvement may need organising on a County wide basis, including innovative approaches such as the establishment of social firms run by people who use services, to provide effective support.

2.5 PCTs as commissioners and providers of mental health services.

2.5.1 The County Council is yet to be convinced that it is appropriate for PCTs to provide the majority of adult mental health services. Special considerations apply for these services, including:

- the need for a specialised focus on adult mental health to counterbalance the stigma associated with mental health, and the risks of marginalisation when managed alongside other services

- the need for, and scarcity of, skilled management of services

- the management of clinical risk. The consequences of responding to serious untoward incidents and inquiries demands focused attention from senior staff and the Chief Executive. This is unlikely to be available within a PCT with a broad range of responsibilities.

2.5.2 The County Council would support developments to strengthen the commissioning of mental health services for older people jointly with the Social Services Department. The County Council's preferred position is for these services to be provided on a PCT basis because of the growing incidence of mental health problems of older people in the general population. However the County Council does not wish to see further destabilising structural change unless this would result in substantially increased beneficial outcomes.

2.6 The development of joint commissioning

2.6.1 The County Council would like to see further developments in the joint commissioning of adult mental health services and is currently engaged in a series of consultations with Hampshire PCTs about this.

2.6.2 The issue of pooled budgets requires further consideration. Although promoted by the Department of Health, the case for their extensive use has yet to be proven. They are a means not an end to joint commissioning, and considerable progress can be achieved through the use of partnership agreements and transparency of resources without formal pooling under the Health Act.

2.6.3 Mental Health Local Implementation Teams are the core component of joint commissioning, and this has recently been endorsed by national guidance. The role of the LIT needs greater prominence in the mental health strategy than is reflected in the current consultation.

2.7 Medium and longer term changes e.g. care trusts and foundation trust developments

The case for further structural change e.g. the establishment of care trusts has yet to be established in Hampshire, including the implications of a Care Trust that might incorporate services for North East Hampshire. Similarly it is too early for the implications of foundation trust status for a partnership mental health trust to have been assessed.

2.8 Strategy development work for more specialist services e.g. forensic services, eating disorders, substance misuse and cross boundary working.

2.8.1 The main interest of the County Council in specialist commissioning is through the Wessex Consortium, a joint commissioning forum for Forensic Services for Hampshire, the Isle of Wight and West Dorset. This addresses the needs of specialist adult mental health, learning disability and CAMHS services.

2.8.2 The current document says little about substance misuse services. The new Trust would need to work closely with the Hampshire Drug Action Team (DAT) and its Joint Commissioning Group to implement service developments in North East Hampshire. This will build on the partnerships developed by the Acorn substance misuse service with the Hampshire and Surrey DATs .

2.9 The impact of hosting arrangements (NHS Direct, shared services, social care learning disability services)

No comment

2.10 The impact of medium to longer term changes due to strategic development work on child and adolescent mental health and older people's services.

The issues regarding older person's services have been addressed in 2.5.2. The County Council has recently been selected to be a pathfinder Children's Trust for Child and Adolescent Mental Health Services. The new Trust will need to build links with Hampshire childcare systems and engage with the County Council in working through the implications arising from the forthcoming Green Paper on children's services.

Question 3. Do you support the formation of a single mental health and learning disability provider trust for the west of Surrey and north east Hampshire, and what do you think should be included in the vision and values of the new organisation.

3.1 The County Council supports the proposal for a single mental health and learning disability provider trust for West Surrey and North East Hampshire. This proposal, which has been expected for some time, has important implications for service users and for the development of partnerships between the county Council and the NHS. The Social Care Policy Review Committee considered this issue on 31 May 2002, and again on 12 September 2003. They advised the Executive Member for Social care of their support for a proposal that adult mental health services in North East Hampshire could become part of a Surrey Mental Health Trust. The May 2002 meeting also signalled support for a proposal that adult mental health services in north East Hampshire and Surrey heath could be jointly managed as a single locality, and this has now been implemented.

3.2 The County Council notes that `efficiency savings of 4% will need to be delivered in 2003/04,' (paragraph 48). We will be seeking clarification of how this will be achieved, and the apportionment of the deficit into the successor Trusts.

3.3 The vision and values should include the following (not an exhaustive list):

a) Services designed and delivered around the needs of those who have to use them, their families and carers

b) To provide non stigmatising services that promote maximum independence consistent with personal safety and that of the community: this would be monitored by adopting local performance targets for the numbers of adults in full time employment, permanent accommodation, and user and carer satisfaction (using nationally accredited measures e.g. Carers and Users Experience of services / CUES)

c) To provide the best mental health services in the Country

d) To develop effective partnerships across Surrey and Hampshire with service users, carers, statutory, voluntary and independent sector agencies in order to deliver on service outcomes. Hampshire County Council should be regarded as an equal partner and consulted and involved in all significant matters of policy and practice affecting the management of the Trust and its services.

e) Accountability arrangements

f) Best Value for services

g) Promoting best practice and supporting the workforce

3.3 The consultation rightly observes that there are particular accountability issues to be taken into consideration when establishing services and partnership arrangements that cross a County Council and Strategic Health Authority boundary. It is crucial that there is explicit acknowledgement of this, but that the challenges should not prevent the delivery of integrated and well co-ordinated services to local populations. Among the accountability issues that need to be addressed are:

a) A Partnership agreement for the integrated management of adult mental health services in North East Hampshire that describes the accountability to Hampshire County Council Executive Member, Director of Social Services etc for Hampshire Services, and the establishment of a partnership board.

b) A partnership framework to address the approach to managing services across the County boundary e.g. management of resources, policies and procedures, links with other County Council services and planning frameworks, performance management and reporting. This could include establishing a regular `strategic exchange' between senior staff of the Partnership Trust, The County Councils (including the Drug Action Teams) and BlackwaterValley and Hart PCT to address issues in adult mental health, learning disability and older people's services.

3.4 The name of the new Trust should reflect its partnership with Hampshire Services. One suggestion is that it should be called `The Surrey Hampshire Mental Health Partnership Trust.'

Question 4. Do you support the changes to the way in which services will be delivered in the east of Surrey?

There do not appear to be any issues that affect service provision for Hampshire residents.

Prepared by :Graham Collingridge

County Manger Mental Health Strategy

23 July 2003, revised 2 September 2003