Contact: Graham Collingridge 01962 847277 [email protected]

1. Summary

This report summarises the findings of the Autumn Monitoring of the Mental Health National Service Framework (NSF) 2003. Good progress has been made across a range of service areas and in the context of significant financial challenges to the health and social care economy. However, a majority of key NSF targets remain to be met, including the need for crisis resolution and home treatment teams (one per locality), an early intervention service operating across Hampshire, additional staff in Primary Care, and an integrated mental health electronic information system. Additional capacity is also required in low secure inpatient services. Members are asked to comment on the findings of the Autumn Monitoring and advise the Executive Member of any issues that they consider merit further attention by the County Council.

2. Introduction

2.1 At the 28 November 2003 meeting of the Social Care Policy Review Committee Members reviewed progress in implementing the Mental Health Commissioning Plan 2003/06. It was noted that significant progress was required against a substantial number of target areas in the 2002 Autumn Assessment, and that there were relatively low levels of mental health investment in most PCT's Local Delivery Plans (LDPs). The following was requested:

2.1.1 A report on the outcome of the Mental Health National Service Framework (NSF) Autumn Assessment 2003.

2.1.2 A progress report on investment in Mental Health services in January 2003 following the refreshment of LDPs in December 2003.

2.1.3 A revised Social Services Mental Health Commissioning Plan in Spring 2004 with confirmation of LDP investment in key targets.

2.1.4 A progress report in January 2004 on the development of services with a dual diagnosis of mental health and substance misuse problems.

2.2 Successful implementation of the Mental Health NSF will support the aims of the Corporate Strategy in a number of ways. Aim 4, Building Strong and Safe Communities, is achieved through service developments that reduce risk to individuals with mental health problems, and in some cases to other people. Aim 5, Improving Services, is the main aim of the National Service Framework. Aim 6, Developing Councillors and Staff, will be achieved through the training and workforce developments required by the NSF.

2.3 The contents of this report have been shared with representatives from PCTs, West Hampshire NHS Trust and Surrey Hampshire Borders Trust, and the Strategic Health Authority.

2.4 This report contains a number of acronyms used in mental health services. These are summarised in Appendix 1.

3 Background

3.1 The Mental Health (NSF), published in 1999, describes the range of services required for a modern mental health service, and spells out a ten year programme for modernisation. It has been accompanied by additional national investment and proposals for new Mental Health legislation. Specific targets have been set in the NHS Plan and accompanying guidance. They include Assertive Outreach Teams (by December 2003), Crisis Resolution and Home Treatment Teams (by 2005) Early Intervention Teams (by 2004), carers support (2004) and additional staff in primary care (2004). There are other targets for prisons and secure services, inpatient beds, services for women and black and minority ethnic groups, and development of Support Time and Recovery (STR) Workers. There is also a target to reduce the suicide rate by twenty per cent by 2010.

3.2 Performance in delivery of the Mental Health NSF contributes to PCT and Mental Health Trust Star Ratings; and also to Social Services Star Ratings and therefore the County Council's Comprehensive Performance Assessment.

3.3 The Mental Health Component of the Social Services Delivery and Improvement Statement (DIS) is relatively small because information for the DIS is supplemented by the Autumn Monitoring. The DIS focuses on:-

3.3.1 Investment in the social services element of key NSF targets: Assertive Outreach, Crisis Resolution, Early Intervention, Carers, Black and Minority Ethnic Development Workers.

3.3.2 Level of engagement in the preparation of the LDPs.

3.3.3 Local Strategic Partnerships (LSPs) including whether mental health is an LSP priority, and funding obtained through the LSP for mental health related projects.

3.3.4 Implementation of information system requirements and the deployment of Mental Health Supplementary Credit Approval (Capital).

3.4 Local responsibility for the implementation of the NSF is held jointly by PCTs and Social Services, with Local Implementation Teams (LITs) being the primary vehicle for achieving this. Hampshire and the Isle of Wight LITs are based on PCT localities. Implementation follows a national programme set by the Department of Health, with performance monitored locally by Strategic Health Authorities and the Social Services Inspectorate.

3.5 The current report describes the outcome of the Autumn Monitoring 2003 of the NSF in Hampshire and the Isle of Wight, with particular reference to the seven LITs within the County Council's boundary. Autumn Monitoring included the following activities:-

3.5.1 Self-assessment against 45 target areas.

3.5.2 A review of each LIT against new national standards

3.5.3 Service Mapping, with data input to a national website.

3.5.4 Financial mapping

3.6 The overall process was steered by the Strategic Health Authority (SHA) through the Hampshire and Isle of Wight Mental Health Network. The network aims to ensure consistency of interpretation of national requirements, peer support, learning, and co-ordination of activities which need to occur across more than one LIT. The network is also supported by the South East Development Centre (SEDC) of the National Institute for Mental Health England (NIMHE). The network has developed with the SEDC a performance management framework to assist monitoring and delivery of progress against the forty five targets.

3.7 The outcome of the Autumn Monitoring for each LIT was reviewed by the SHA and the SSI. Each LIT received a summary report outlining key achievements and areas for development in 2004/05.

4. Outcome of Autumn Monitoring

4.1 Self Assessment

In 2003 LITs assessed progress against 45 indicators (four more than in 2002), rating each one Red, Amber or Green according to national guidance. The outcome (with the 2002 assessment for comparison) is shown in Appendix 2. The indicators are divided into themes: Key Services (1-13), Care Co-ordination (14-19), Local Planning (20-24), Service Integration (25-28), Underpinning Programmes (29-37), and Other Priorities (39-45).

4.2 Key Messages

The key messages from the self assessment are:-

4.2.1 Key Services A significant number are red, and this shows consistency across the SHA area: Crisis Resolution and Home Treatment, Early Intervention, Primary Care Gateway and Graduate Primary Care Workers. Assertive outreach is now being implemented. Full implementation requires additional resource to meet national guidelines or DOH approval for a variation from national requirements. This is an issue for rural localities who have judged that full compliance to a national model is not necessary.

4.2.2 Care Co-ordination Good progress has been made from 2002. The Blackwater Valley locality is red due to inadequate information systems and the need for linkage with Surrey based systems.

4.2.3 Local Planning Good progress has been made from 2002 and there are no reds in this section. The County Council has not used the Health Act Flexibilities for its joint commissioning with PCTs. However, the County Council has integrated management arrangements with West Hampshire and Surrey Hampshire Borders Trusts, where jointly appointed managers can access NHS Trust and Social Services budgets. The DOH has advised that these arrangements should be interpreted as a pooled budget for some discrete services.

4.2.4 Service Integration There are no reds in this section.

4.2.5 Underpinning programmes All localities were red for the integrated mental health electronic record. This is due to the ending of the Pan Hampshire Mental Health Information System (PHaMHIS) Project following the introduction of the National Programme for IT (NPfIT). Contingency arrangements are now being implemented, including the use of the Hampshire Social Services SWIFT system in Community Mental Health Teams. A number of other indicators were red in Blackwater Valley and Hart. Funding is red in the New Forest due to the relatively small investment (£96,000) identified in the LDP for 2003/04.

4.2.6 Other Priorities One or two localities were red for these indictors due to local and/or historical factors e.g. single sex accommodation (Blackwater Valley and Hart), suicide prevention (Blackwater Valley and Hart), and North Hampshire), dual diagnosis (Mid Hampshire); Access Booking and Choice (Blackwater Valley and Hart), and Mental Health Act Place of Safety (East Hampshire and Fareham and Gosport).

4.2.7 Progress There has been progress in a large number of indicators between 2002 and 2003. The major areas for development are the key NHS Plan targets requiring significant investment and/or service redesign, such as crisis resolution and home treatment, early intervention is psychosis, developments in primary care, and an integrated mental health electronic record. The progress is as follows:

4.2.8 In Autumn 2002 most LITs reported sixteen reds. By Autumn 2003 most LITs reported five or six (there were also four more indicators).

4.2.9 In Autumn 2002 most LITs reported twenty ambers. By Autumn 2003 most LITs reported an average of twenty two ambers (range between eighteen and twenty seven).

4.2.10 In Autumn 2002 most LITs reported five greens. By Autumn 2003 most LITs reported an average of fifteen greens (range twelve to twenty one).

4.2.11 Performance against the integrated mental health electronic record indicator moved to red due to the ending of the PHaMHIS project.

4.3 LIT Review

The key messages from the LIT review were:-

4.3.1 Improving links with the Workforce Confederation, and the Drug Action Team

4.3.2 Establish formal links with Local Strategic Partnerships

4.3.3 Establish clear accountability arrangements with Hampshire County Council in addition to the PCT Board

4.3.4 The LIT should be involved in priority setting for the LDP

4.3.5 The SHA should attend the LIT annually

4.3.6 A few LITs needed to strengthen primary care or psychiatrist input, and their communication strategy

4.4 Service Mapping

A key national objective of the service mapping is for Government to identify progress in terms of the number of teams etc, in place in each SHA area. The information is contained on the Durham website (www.dur.ac.uk/service.mapping/amh), and in the publication Mental Service Provision for Working Age Adults in England 2002. A copy of this is in the Members Library. This electronic map can be converted into a local service directory if required.

4.5 Financial Mapping

A summary of the financial mapping is in the process of being developed and will be available later in 2004. A map of the 2002 information, and a provisional local map for 2003 is contained in a file in the Members library, but the latter is subject to validation. Financial mapping will be reported nationally by Mental Health Strategies (www.mentalhealthstrategies.co.uk).

4.6 SHA and SSI Validation

A copy of the individual letters to each LIT are in the Members library. Many of the key messages from the validation meetings between the SHA, SSI and each LIT are contained within this report. There is a need to ensure senior and Board / Member engagement in the mental health agenda and to strengthen the accountability arrangements for delivery of the NSF. There is also a need to ensure that the LITs can establish effective links with other planning frameworks, and that they can access the resources available within the broader health and social care system that are available for modernisation.

4.7 Audit Commission

The Audit Commission has been conducting a national audit of investment NHS Plan targets, by SHA area, including those for mental health. This will complement the Autumn assessment. The Audit Commission report is expected to be reported to the SHA Board early in 2004 and a copy will be made available to Members.

5 Next Steps

5.1 Each LIT is developing an improvement plan for the forty five indicators in the self assessment, and the issues identified in the LIT review. Progress will be monitored by the SHA using existing performance mechanisms. The Hampshire and Isle of Wight Mental Health Network has developed a programme to address those issues that require work across the SHA area e.g. plans for Early Intervention in Psychosis, and improving links with the Workforce Confederation, Drug Action Teams, and Local Strategic Partnerships. Some LITs have planned or completed a fundamental review of local services to address the service redesign issues that need to accompany service improvements. It is recognised that some significant changes may need to be made in the way services are delivered to meet the requirements of a modern mental health service, and that some of these changes are not dependent on additional resources.

5.2 The review of the LITs identified a number of improvements in joint commissioning, and the need to link with other planning frameworks e.g. the DAT and LSPs. The County Council has a lead role in each of these and will need to continue to develop its partnership working in these areas.

6 Local Delivery Plans

6.1 Recent guidance from the SHA to PCTs notes that that all mental health targets are at risk based on progress so far. The DOH have made it clear that a "refreshed" LDP which fails to deliver on the major mental health targets is unacceptable. The SHA has therefore suggested that plans are required to deliver these services by the final year of the LDP (2005/06). Social Services is involved in the LDP process through its involvement in the LITs, and with Partnership Managers on the PCT Professional and Executive Committees (PECs).

6.2 The table in Appendix 3 summarises the current position regarding investment in Mental Health for 2003/04. At the date of this report the outcome of the refreshment process is not available.

6.3 The County Council is reliant on the LDP process to identify growth in revenue funding for the social care component of new services. There has been no growth in Mental Health Grant to Local Authorities since 2001/02, with all new mental health investment directed through the PCTs. The County Council's Mental Health Grant allocation has remained at £2.4 million since then, although the County Council has continued to fund inflationary pressures on this grant and the base budget (total investment in adult mental health is £10.1 million in 2003/04). The DOH is expected to announce a phased end to the grant over the next four years with funds being included as part of the Personal Social Services FSS allocation.

6.4 The SSI has noted that it has been a challenge for Social Services across the country to ensure that the social care component of new services is funded through PCTs. The availability of adequate funding continues to be a significant challenge locally, but most PCTs now accept the need to build the social care element into new proposals. For example, at the date of this report plans are at an advanced stage to recruit to a Crisis Resolution Service in the Blackwater Valley, including social work input. There is also broad acceptance that PCTs will need to fund the costs of social work input to a new low secure inpatient service to serve the Hampshire and Isle of Wight population, and this will need to be included in the refreshed LDPs. Estimates for additional social care staff were included in Social Services workforce plan for 2003/04, identifying those posts that would need to be funded through LDPs.

7 Dual Diagnosis

7.1 Autumn monitoring identified a need to strengthen links between the LITs and the Hampshire Drug Action Team (DAT). This is a national requirement, in recognition of research showing that up to fifteen percent of users of specialist mental health services misuse drugs, alcohol and other substances. National guidance recognises the particular challenges of providing appropriate treatment and support because of the often fragmented system of care from mental health teams, substance misuse teams, and other services in the statutory and voluntary sector. Guidance recommends that `individuals with these dual problems deserve high quality, patient focussed and integrated care. This should be delivered within mental health services.' This is referred to as `mainstreaming' and should avoid people being shunted between services.

7.2 It is routine for Community Mental Health Teams (CMHTs) and inpatient staff to deal with people with a dual diagnosis as part of their day to day work. Specialist Dual Diagnosis posts in some parts of the County have been created to support mental health staff. At present the West Hampshire NHS Trust employs one fulltime post in Fareham and Gosport, and one in East Hampshire. These are mental health nursing staff, funded by the DAT, who focus on liaison and consultation work and training, rather than carrying full caseloads as they are a scarce resource. In Surrey Hampshire Borders NHS Trust there is a nurse consultant in the substance misuse service who has a lead for dual diagnosis.

7.3 The Hampshire DAT has now allocated a further £100,000 recurring pooled treatment budget for additional dual diagnosis workers. Funding will be allocated across the New Forest, Eastleigh/Test Valley South, Mid Hampshire, North Hampshire and Blackwater Valley and Hart to recruit dual diagnosis workers to adult mental health teams. These workers can come from a range of professional backgrounds, including social work, and provision has already been made in the workforce plan for this.

7.4 National guidance requires a number of other actions to strengthen links between mental health and substance misuse services including the following:

7.4.1 Establish LIT project groups for dual diagnosis to include staff from mental health and substance misuse services

7.4.2 Map local services and needs

7.4.3 Develop a local definition of dual diagnosis

7.4.4 Develop care pathways for this user group

7.4.5 Devise a training strategy for all staff, especially those in Assertive Outreach Teams

7.4.6 Designate a lead clinician where this is not already in place.

8 Conclusion

8.1 The Autumn monitoring of the Mental Health NSF 2003 identifies the progress that has been made across Hampshire in implementing many of the requirements of the National Service Framework. This has been achieved in the context of financial challenges to the health and social care economy. Whilst there continue to be improvements that can be made within existing resources, the majority of major gaps in services require significant additional investment. The priorities for investment are for crisis resolution and home treatment teams (one per locality), an early intervention service operating across Hampshire, additional staff in Primary Care, and an integrated mental health electronic information system, plus additional capacity in low secure inpatient services.

8.2 Service developments in these areas will require PCTs to identify funding in their refreshed LDPs. There will also need to be significant service redesign in some localities to modernise services within available resources. Members will want to keep appraised of these developments, and where it would add value, to consider the option to refer particular issues to the Health Review Committee. An appropriate opportunity to consider this would be in the Spring when the Social Care Policy Review Committee and the Executive Member for Social Care considers the Mental Health Commissioning Plan for 2004/05, and the outcome of the LDP refreshment process.

9 Recommendations

9.1 Members are asked to comment on the contents of this report and advise the Executive Member for Social Care of any issues that require further action

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.

Mental Health National Service Framework: Autumn Monitoring 2003

File in the Members library containing the following items:

1. Self Assessment across Hampshire and the Isle of Wight, 2002 and 2003

2. Service Mapping

3. Financial Mapping 2002

4. Financial Mapping 2003 (provisional figures)

5. SHA/SSI validation letters to Mental Health LITs

Appendix 1 - Glossary

Appendix 2 - NSF Self Assessment: 2002 and 2003 (see key on next page)

2.1 NSF Self Assessment 2002 ( =LIP4)

Key:-

(for when printed in black and white) PCTS

2.2 Self-Assessment 2003 (AAI)

Appendix 3

Summary Investment by PCTs for the Adult Mental Health chapter of the LDP 2003/04

*Figures provided by Strategic Health Authority as of May 2003.

Information from the refreshed LDPs for 2004/05 and 2005/06 is not yet available.