To review the performance of 2gether NHS Foundation Trust in providing mental health and learning disability services in Herefordshire in the light of the recent Care Quality Commission (CQC) Inspection.

 The director for adults and wellbeing introduced the presentations, which would give the commissioner and the service perspectives. Members were encouraged to focus on care provided in Herefordshire, given that the trust also covered Gloucestershire.

The programme manager, NHS Herefordshire Clinical Commissioning Group (CCG), outlined in terms of the CQC’s inspection, the trust was rated over all as “good”, with some areas that were found to be outstanding and others which required further improvement. The trust should be commended for their response to the findings and improvements made. The CCG monitored the trust’s performance and found that 80% of the performance indicators were met. In some cases, performance exceeded national targets, such as for waiting times for children and young peoples’ services and also for dementia assessments. Those areas that had not been achieving the required standards were being addressed, and it was noted that low levels of access to some services, such as “let’s talk”, were partly due to the stigma attached to mental health issues. This was being addressed with public health, and members were encouraged to work with constituents to encourage up take.

The chair of 2gether NHS Foundation Trust commented on the context of the CQC rating. Those areas that were found to be outstanding were in the top four best services nationally. There were opportunities for improvement but in recognising areas of excellence, she thanked those who contributed to the achievements.

The trust’s director of engagement and integration presented a summary of a guide to the trust, the CQC’s findings, and a specific focus for scrutiny in Herefordshire. She highlighted that the trust aimed to be part of the community and tackle stigma so that people would be encouraged to access services. The CQC inspection in October 2015 was very rigorous, so the positive feedback that acknowledged the contributions of staff and partners was welcomed.

In response to an observation from the chairman regarding there being no health-based place of safety provided by the trust, the medical director explained that this was a place defined by the Mental Health Act for someone with a mental disorder to be taken to keep them safe. There was a facility at the unit in Hereford which was unstaffed due to the requirement for police presence and which had implications for policing capacity.

A member commended the trust for its CQC rating. However, the presentation gave the impression there were no major concerns with regard to service provision in Herefordshire, although the member noted a number of points from the CQC report that were absent from the presentation. These included: staffing concerns in relation to high sickness absence rates; comments from staff about not having access to regular clinical or managerial supervision and appraisals; that staff reported feeling stressed and unsupported; and decisions made over resources that had an impact on acute services at the hospital.  

Responding to the concerns regarding resources, the trust’s locality director explained that the arrangement to host social care had come to an end and this had an impact on the sustainability of services, which were re-organised. In terms of the sickness absence rate, this had reduced to 4.3%. The previously higher level was partly as a result of gaps left in the management structure but turnover was more stable and an action plan was in place to provide stronger leadership. The director for adults and wellbeing commented on the dissolution of integrated services, explaining that the decision was driven by concerns regarding quality of care and funding.

The trust’s director of quality added that it was crucial that staff felt supported. The supervision policy had been reviewed and regular updates were provided to the CQC inspector, who did not believe there were systemic issues.  The trust’s chairman added that the CQC reported differences between the two counties due to differing approaches in commissioning, and that both counties benefited from different experience and expertise.

The member reiterated her comment regarding staff feeling stressed and unsupported as reported by the CQC. The director of quality explained that the issue was challenged by staff and there was rigorous monitoring in place. The trust’s chairman added that there was learning to be taken from the inspection’s less positive feedback and there were action plans in place to address.

In response to a member’s observation that the crisis team and learning disability service were not in place, the CCG programme manager explained that the level of need was under assessment and that there was support in place from the community learning disability team. People were not considered to be vulnerable as agencies were working together to manage support. The medical director added that relatively small numbers needed this level of support as there were strategies in place to support people to avoid crises, which reduced demand on crisis support.

A member asked what implications the NHS’s new requirement for a five year sustainability and transformation plan (STP) had for the trust, both in general terms and in relation to the local footprint. The director of quality outlined that the chief executive was a member of the project group for the local footprint and the trust was leading on aspects of the triple aims (population health, service quality, financial balance) at the heart of the STP process to support trusts to come out of special measures. Senior colleagues from the trust were leading on the mental health work stream.

The vice-chairman commented on hidden issues within schools and colleges and the need for engagement with young people to raise awareness on mental health. The locality director explained that there was regular and active engagement with young people on mental health issues.  The trust hosted a support group, the crucial crew, supporting emotional wellbeing, and during mental health week this year, hosted a ‘strong young minds’ event at Hereford College. The public also took part in the recruitment of a consultant psychologist.

In response to a question from the chairman regarding better access to child and adolescent mental health services (CAMHS), members were informed that there were two new consultant psychiatrists and a psychologist in the team. The service was more stable and waiting lists had reduced to 4 weeks, which was better than the national average.  It was noted that there were national issues affecting admissions to child and adolescent inpatient services, with admissions going out of the county where medical care was required. As far as possible, admissions were to the nearest service, which was in Birmingham. There had been difficulty accessing beds due to regional commissioning but the trust had good links with local general paediatric services which provided support.  ‘Tier 3.5’ services, which would provide a hospital outreach service, were not currently commissioned, although the evidence base for this was being monitored. 

Acknowledging the improvements in CAMHS, a member commented on its role in supporting young people. It was important to tackle stigma and increase resilience and the engagement of service champions supported this. The director for engagement and integration added that the trust was proud to engage with experts by experience and to learn from them. 

In response to a question regarding what role scrutiny could take in facilitating further improvements to services, it was identified that members could help further by encouraging people to understand the services,  to challenge stigma and encourage access to services.  The trust was promoting its services through creative advertising and developing use of social media and an app.  It was also important to forge stronger links between services and members were asked to support the role of psychiatric liaison as a mental health speciality which would work between mental health and other services in an enabling role, for example to facilitate discharge from other services.

The chairman asked what the action the trust had taken to improve the facility at Oak House which had been in poor condition. This had been noted by the CQC and the director of quality confirmed that the trust was working with the CCG to with regards refurbishment or alternative provision.

A member asked about the resources available for responding to accident and emergency attendance and arrests of people with mental health issues. The CCG programme manager explained that as people presented to different places, consideration was being given to commissioning a flexible workforce in order to respond to need wherever people presented.  A resource pack on mental health first aid was being developed for professionals along with development of essential skills. Experts by experience were helping to test the pathways for this new approach. In terms of numbers, there had been two adults with mental health care needs in custody in the past year.  The member further commented on the number of drug and alcohol related issues in the county, explaining that services needed to join up to address this.

Commenting on the culture of the organisation in closing remarks, the trust chair cited a patient who had described the quality of overnight care in psychiatric intensive care services in the county as comparable with the day-time services. She added that CQC inspectors made the point that they had confidence in the trust when compared with services in the rest of the country.

The chairman thanked trust representatives for attending. She added that it was important to ensure that as well as looking at rural-proofing the county, the county also needed to be mental-health proofed.

RESOLVED

That:

(a)             the performance of 2gether NHS Foundation Trust be noted; and

(b)             for ongoing monitoring to inform any future items for scrutiny.