Archived decisions

PROPOSALS TO CREATE A SINGLE MENTAL HEALTH AND LEARNING DISABILITIES TRUST FOR SURREY AND NORTH EAST HAMPSHIRE

Background to the Joint Health Select Committee

1. The Health and Social Care Act 2001 makes statutory provision for local authorities with social services responsibilities to extend their overview and scrutiny functions to cover Health. An Overview & Scrutiny Committee may review and scrutinise any matter relating to planning, provision and operation of health services in the area of its local authority. It places a duty on the NHS to involve and consult patients and the public in developing and considering proposals for change. NHS organisations are also required to consult the Overview and Scrutiny Committee (OSC) or committees of the relevant local authorities on any proposal for a substantial development or variation to health services.

2. In July 2003 the Secretary of State issued a general direction to local authorities with Social Care responsibilities requiring them to appoint joint overview and scrutiny committees for the purposes of responding to consultations by local NHS bodies involving a substantial development of the health service or a substantial variation in the provision of such service where it spanned more than one overview and scrutiny area.

3. The Health Select Committee of Surrey County Council together with members of the Hampshire County Council Health Review Committee have a responsibility `to review and scrutinise matters relating to the health service in the authority's area, and make reports and recommendations on such matters.' This Joint Committee was formed to scrutinise the proposal to create a single Mental health & Learning Disability Trust for Surrey and north east Hampshire.

It has a core membership of seventeen councillors.

TERMS OF REFERENCE

4. To understand the implications of a single Mental Health (MH) & Learning Disability (LD) Trust in terms of the pattern of service and how it will be applied in Surrey & North East Hampshire.

· To ensure equality of service provision and standards across the county;

· To ensure that the new service arrangements comply with Standards set out in the Mental Health National Service Framework, and the NHS plan;

· To reach an informed view on the choice of a single MH & LD Trust across Surrey and North East Hampshire from NHS management, professional staff, users' and carers' and voluntary organisations' perspectives.

Scope

5. All aspects of Mental Health Services for adults of working age including home and community-based care and hospital care but excluding secure facilities such as prisons;

· Implication of changes in service organisation in respect to LD Services and others.

· Funding for Mental Health services.

Methodology (Timescale & Process)

6. In December 2003 the Committee was made aware of the DRAFT NHS document concerning `Outcome of Discussion and Consultation on Mental Health Services in Surrey and North east Hampshire' which recommended the establishment of a Surrey and north east Hampshire Mental Health & Learning Disability Trust.

7. Arrangements were immediately made for a meeting between the respective Chairmen and Vice Chairmen of Surrey & Hampshire County Council Select Committees to meet together with Officers on 22 December 2003 in order to consider the `Outcome'.

8. On 24 December 2003 a letter was sent to the Chief Executive and Joint Chair of the Mental Health Strategy Steering Board expressing concerns relating to the proposed establishment of a single trust for the whole of Surrey and north east Hampshire. It raised the question as to whether it was in the interests of all those affected and, if so, whether the document adequately demonstrated that in a way which could be clearly understood.

9. It was felt to be clearly in the public interest that the two County Councils were seen to be actively involved in consultations over these service changes, working together through a joint Health Select Committee. Surrey and Hampshire did not feel able to do justice to their health scrutiny roles without meeting representatives of the local health bodies, and hearing from some of those affected by the changes, both in the east of Surrey and in north east Hampshire.

10. An additional period of consultation was therefore required to run until 29 February 2004 so that local people have a proper opportunity to consider and respond to this issue.

11. A formal hearing took place at Guildford Borough Council on the 18 February 2004, at which the Joint Select Committee heard from chief executives and executive officers representing:

· Surrey & Sussex Strategic Health Authority

· Guildford & Waverley Primary Care Trust

· Surrey & Hampshire Borders NHS Trust

· North West Surrey Mental Health Partnership Trust

· East Surrey Primary Care Trust

· Surrey Oaklands NHS Trust

· Blackwater Valley & Hart Primary Care Trust

· Surrey County Council

· Senior NHS Management from Secondary and Primary Care Trusts

· National Institute of Mental Health South East

· Staff Representation

· Service Users & Service User Group Representatives (Mental Health)

· Carers and Carer Representatives (Mental Health & Learning Disability)

· Voluntary Organisation (Mental Health MACA & Learning Disability Services MENCAP)

12. Witnesses were all given evaluation forms to enable them to feedback to the Joint Health Select Committee on their experience in attending the meeting and speaking to the Committee.

Summary of Evidence Received

13. The Joint Committee is most grateful to have had the benefit of the following written submissions;

· `Discussion and Consultation Document on Mental Health Services in Surrey and North East Hampshire'.

· Draft & Final `Outcome of Discussion and Consultation on Mental Health Services in Surrey & North East Hampshire'

· Letter from Mr & Mrs Galbraith

· Hampshire County Council Social Services.

· Letter from Mr & Mrs Austen

· Communication from Mr D Hagger

· Communication Mr & Mrs R Syme

· Letter from St Ebba's Parents and Relatives Group

· Letter Mr M Stannard

· Letter from Ms S Beavis

· Letter from Mrs V Halstead

· Communication Mr M Stanley

· Written Submission for Heads of Professions at Surrey oaklands NHS Trust

· Written submission from the Royal Mencap Society

· Letter from Mrs H Homan, Mrs J Forker, Mr D Capon

· Written Submission on behalf of members of UNISON

· Written Submission on behalf of members of GMB

· Letter from Advocacy Partners Mrs M Ronksley

· Written submission from London Borough of Croydon

· North West Surrey Mental Health Partnership NHS Trust `Developing our Vision.'

· North West Surrey Mental Health Partnership NHS Trust Service Plan 2003-2004.

· North West Surrey Mental Health Partnership NHS Trust Annual Report & Financial Statement 2002-2003.

· The Integrated Mental Health Service - A report focusing on the integration of health and social care in East Surrey (2003).

· Mental Health Services for Adults of Working Age, Surrey County Council (2003).

· A Strategy for User Involvement, Mary Francis Trust (2003).

· Priority Processes, an external analysis of the process of user-focused monitoring of Priority Enterprises.

· User Focused Monitoring User Views on Priority Enterprises.

· Review of Mental Health Services in north west Surrey (North West Surrey Mental Health Partnership Trust.

· Written submission on behalf of the Learning Disability Partnership Board in Surrey on issues relating to learning disability

· Patient & Public Involvement Forums.

· Letter from Mrs Muriel Brook

· Letter from Mr & Mrs Coxhill

Findings of the Joint Committee

14. The members of the Joint Health Select Committee would like to express their sincere appreciation and thank all those who have made such a valuable contribution to the overview and scrutiny process.

15. The Committee is aware that "Keeping the NHS Local" is the Department of Health guidance about the process for configuring health services and the NHS has to apply its principles when developing future service models. There is a tension between providing choice for patients and the constraints of the NHS Plan, the performance management framework and the National Service Frameworks. It highlights the need for stronger partnerships to find high quality, sustainable solutions for local health services. The "closer to home" model of care recommended by the National Beds Inquiry in 2000 highlighted the potential to deliver care in smaller settings than previously thought possible. The guidance challenges the "big is best" philosophy, acknowledging that with new resources available and new models of care being developed, "small can work". It sets out three principles to be followed:

· Developing options for change with people not for them - another publication called "Strengthening Accountability" provides guidance to the NHS about how to achieve this.

· Focusing on redesign not relocation - meeting local needs and expectations.

· Taking a "whole system" view of care - exploiting the contributions of hospitals, primary, intermediate and social care.

16. The guidance recognises that in the past the process of change has often been confrontational, without real community engagement and without putting forward any real alternatives to the solutions preferred by the NHS. Change in the future must be patient-focused and in tune with community needs.

17. Organisational Service Model It is noted that the case put forward for a single Trust has some merits. The desire to set up a more sustainable long term organisational model that can ensure that mental health and learning disability services are well represented in setting the agenda of the overall health economy was accepted.

18. The implications for people using the services to be provided for this Trust however were not clear. This was a cause of considerable concern to the committee as well as service users and carers.

19. Consultation A key question for the committee was the adequacy of the consultation process. The committee considered that the case made for implementing an option for service delivery that had not been subject to proper consultation was seriously flawed.

20. The original scope of the consultation focused on adult mental health services, discussed a service model and consulted on changes in the east of Surrey. Additionally the appraisal process explicitly discounted the option being proposed . NHS management comments confirmed that those using the learning disability service had not had an opportunity to comment on this option, similarly those that responded to the discussion/consultation document could not have given a view on the service configuration that is now being suggested. This point was strongly endorsed by service users, carers and voluntary sector representatives in the afternoon session and is reflected in the letters sent to the SHSC following to publication of the decision to pursue a single Trust model.

21. The committee is most concerned that NHS management has lost a great deal of credibility in terms of its ability and willingness to undertake genuine consultation with users carers and other stakeholders.

22. Although the committee welcomes the work currently in hand to explain the case for change to the people affected, there is a perception that this process is just a rhetorical exercise.

23. The committee has therefore carefully weighed the benefits of formally asking for further formal consultation, or referring the matter to the Secretary of State under section 4, paragraph 5 (a) of the overview and scrutiny regulations. There were however a number of points raised during the day that suggest that this may not be in the interest of local people or the NHS..

24. Staff Recruitment Development & Retention There appears to be a considerable degree of pressure and uncertainty for front line staff regarding the future organisational arrangements of these services. Recruitment and retention has been adversely affected as a result with an increase in demand from support from the voluntary sector.

25. NHS management highlighted economies of scale achieved through merger would bring about major improvements in this area. However issues concerning staff morale and development opportunities need to be addressed. This includes the perception of frontline staff that they will have less choice and less influence within a larger Trust.

26. There appears to be a widespread staff perception that a single trust will mean that senior management and the board will be too remote from the front line to have a proper understanding of the numerous services which are provided over the many sites and diverse population. Therefore there will need to be another layer of management. This could erode intended economies of scale.

27. Staff were also said to have serious concerns that some services were already being diluted to point whereby they were not able to provide a safe and effective services for either clients or themselves.

28. The Joint Committee remains unclear about the perception of clinical staff at primary care level. For example what is the requirement in terms of recruitment and retention, education and training of clinical staff at a primary care level, and plans for making the best possible use of existing staff, recruiting new staff, raising morale.

29. Finance The difficulty of the financial situation within the Health economy is appreciated but it was not made clear to the committee how the establishment of a single trust would be implemented in a climate of 4% efficiency savings for 2003/4.

30. The committee were not informed of any specific safeguards which would be put in place to ensure that the health community of Surrey and north east Hampshire will not have money diverted from mental health and learning disability services to relieve cost pressures.

31. It was not explained how services would be commissioned across the six Primary Care Trusts or on what basis. i.e. block contract, individual billing for different services, lead PCT Investment, or individual PCT independent provision.

32. Nor was it clearly explained how the integrated service between Health and Social Care concerning Mental Health funding translated for Learning Disability services across Surrey, north East Hampshire and the London Borough of Croydon. It was not clear whether there would be a requirement to pool budgets.

33. In terms of Surrey Oaklands there is a reduction in overall budget for 2003/2004. It was not clear if this will impact on the creation of a new single mental health and learning disability service.

34. `The Patient Experience' Service Improvement & Equality User and carers involved with mental health services have expressed serious reservations regarding the level of service that they will have from the establishment of a single trust. The fear that services will deteriorate rather than improve should not be ignored. This matter was previously addressed by the Surrey Health Select Committee report in October 2003.

35. Concern has also been expressed that there will only be a requirement for single Patient and Public Involvement Forum for an area serving the Mental Health and Learning Disability needs of a population of 1.5 million people.

36. The emphasis on locality working across the communities served needed to be safeguarded together with clarity about the range and scope of service to be provided.

37. Voluntary Organisations have expressed an interest and capacity to provide more services if consistent funding could be made available.

38. Learning Disability Services The committee is well aware that the Valuing People agenda has set a challenging programme of change for learning disability services. It was not clear from NHS management how the setting up of a single Mental Health and Learning Disability Service would facilitate the accomplishment of this agenda.

39. The Committee heard concerns expressed by carers of those using learning disability services that they feared further dilution of both management and clinical capacity and capability since they felt they would have even less influence over priorities set by a single mental health and learning disability trust which covered such an wide area.

40. The fact that the Surrey Oaklands NHS Trust was the largest provider of learning disability services in the country and would not fit easily with the other two Mental health trusts was also an issue for many carers. Concerns regarding how staff uncertainty and poor morale might affect standards of care for service users were also raised.

41. Concerns were raised about the lack of progress that was being made by Surrey Oaklands NHS Trust in implementing its `Social Care Change Programme' and it was feared that more senior management changes might simply exacerbate the problem.

42. Voluntary Sector Service Provision There is considerable good will across the voluntary sector that can be harnessed to secure the provision of high quality services and the Committee heard that some providers might find it easier to work with a single Trust.

43. Local Authority The Committee heard that there is a commitment to partnership working across the localities that is sensitive to the different needs of the communities served. However concern was expressed that, given the NHS Agenda for change, there might not be enough capacity and capability if senior staff attention was being diverted to the establishment of a single Trust. This might have a consequence of adversely affecting the social care agenda.

Conclusions and Recommendations

The Committee accept the case for a single Mental Health and Learning Disability Trust subject to the following recommendations.

1. Consultation That efforts are made to ensure that future proposed changes, their alternatives and their benefits are communicated to stakeholders more effectively. The Committee expects to receive early referral on all matters relating to Section 11 of the Health and Social Care Act 2001. Therefore proposals to develop or vary services will need to be discussed with the relevant Overview and Scrutiny Committee (or Joint Committee) at the earliest opportunity.

2. User and Carer Involvement That protocols be agreed for involving and engaging service users and carers across the localities affected. This will fully reflect the requirements and spirit of Section 11 of the Health and Social Care Act.

3. That arrangements be made to ensure that during the merger process there is an appropriate input from service users and carers across the services affected (with appropriate support and training).

4. A Steering Group is set up to oversee the merger process: this shall include input from services users and carers across the services affected with appropriate support and training. That consideration be given to the membership of the new Trust Board in order to provide reassurance to users and carers both for mental health and learning disability and professional clinicians regarding representation of their interests.

5. Transport That the Steering Board address the concerns of users and carers regarding access to services, especially for those in receipt of state benefits. The Committee would like to see evidence of the Steering Boards' progress in addressing this matter.

6. Service Delivery Outcomes That an area-wide evaluation process be agreed, with clearly defined outcome measures which are user and carer focused and user-led and which allow the effects of any changes to be evaluated on a `before and after' basis.

7. Learning Disability Services That options for the organisation of services for people with learning disabilities be assessed and discussed with users and carers.

8. That an appropriate range of robust mental health services enabling improved quality of life outcomes be available to a person with learning disability, as they would be for any other person.

9. That the NHS bodies acknowledge that the needs of people with learning disabilities and those with a mental health problem may be different. The Committee would like to see evidence of explicit arrangements put in place throughout all levels of the service to allow these different groups to influence service provision. This should include evidence in terms of a `care pathway' and an early statement of what can be expected from these services and the point of contact for users and carers should this not be delivered, This should also cover the learning disabilities services purchased by the Croydon PCT.

10. Front-line Clinical and Social Care Staff That the NHS bodies acknowledge the importance of ensuring that the service model proposed is supported by GPs and clinicians, particularly with respect to the provision of community support as set out in tiers one and two of the model described in the original document.

11. That it is suggested that an area-wide health and social care staff survey be carried out to monitor the high level of staff vacancies in key staff groups and concerns regarding poor staff morale, and sickness (short and long term). This should also enable an evaluation of the effects of change on staff on a `before and after' basis.

12. Strategic Outline Case That the business case supporting the establishment of the single Trust be published, together with the anticipated savings and targets for recruitment and retention. This should include details of where specialist services will be based, an assessment of accessibility for the population served and details of the care pathways that will be set up within the services to be provided by the Trust.

13. That the local NHS bodies confirm that the organisational arrangements put in place would be stable and enduring. This should be communicated to all staff and users and carers and the voluntary organisations.

14. That the Committee be kept informed of all Primary Care Trust commissioning arrangements for the purchase and provision of mental health and learning disability services.

15. That the Committee to be made aware of the NHS and local authority resource allocation concerning mental health and learning disability services across the six Primary Care Trusts.

The Committee would like a response to its recommendations by (28 days from sending). It can then consider any further action it wishes to take, and any additional monitoring that will be required to ensure that the actions taken have been followed through.

pp.

Diana Bowes Dr Ray Ellis

Chairman Vice Chairman

Joint Health Select Committee 27 February 2004

Lead Officer (Surrey) Health Advisor (Surrey)

Peter Edwards Derek Cunningham

Tel: 0208-541-9007 Tel: 0208-541-7591

e-mail: [email protected] e-mail: [email protected]

County Hall County Hall

Kingston upon Thames Kingston upon Thames

Surrey KT1 2DN KT1 2DN

Health Review Manager (Hampshire)

Denise Holden

Tel: 01962-847338

E mail: mailto:[email protected]