Agenda item

Review of mental health provision in Herefordshire

To consider reports and presentations on the provision of mental health services across Herefordshire. This will include updates on the progress of the current community mental health services transformation programme. This will also address the impact of Covid19 on the mental health of local people. And the contribution Talk Community can make to mental wellbeing in Herefordshire.


The chairperson advised that the purpose of this item was to consider the provision of mental health services across Herefordshire.


1.           Introduction


Ewen Archibald (Head of community commissioning and resources) outlined: recent structural changes in terms of NHS Herefordshire and Worcestershire Clinical Commissioning Group (HWCCG) and the transfer of Herefordshire mental health and learning disability services from 2gether NHS Trust to Herefordshire and Worcestershire Health and Care NHS Trust (HWHCT); further changes going forward in relation to the Integrated Care System and the mental health collaborative; efforts to understand the impact of COVID-19 on mental wellbeing, and how services and support in the community could respond to the needs of local people; the potential impact of other societal changes and events, such as flood emergencies; the development and extension of the role of Talk Community; and the review of the arrangements under Section 117 of the Mental Health Act 1983 relating to the provision and funding of support to people who have previously been detained in hospital.


2.           Presentation slides on Mental Health Services in Herefordshire


Presentation slides by HWCCG and HWHCT were included in the agenda (pages 39-44) on ‘System changes’, ‘Impact of COVID-19’, ‘Transformation of Community Mental Health Services’, ‘New developments’, and ‘Planning for 2021-22’. 


The slides were presented at the meeting by Jenny Dalloway (Lead for Mental Health, Learning Disabilities and Children, HWCCG), Susan Harris (Executive Director of Strategy and Partnerships, HWHCT) and David Thomas (Deputy Associate Director Primary Care and Community Mental Health Services, HWHCT).


3.           Contribution on behalf of the Primary Care Networks (PCNs)


Dr Simon Lennane, (Clinical Director for South West Herefordshire Primary Care Network, Mental Health GP Lead for HWCCG, and Trustee of Ross-on-Wye Community Development Trust) commented on: the significant increase in GP consultations; the impact of lockdown measures on people with cognitive difficulties; and the importance of preventative mental health, including through the work of the Talk Community programme; and issues associated with loneliness, lack of connections, and loss of confidence in communicating.


4.           Questions (part one)


The chairperson invited questions and comments from attendees, focussing on the transformation of mental health services.  The principal points of the discussion included:


a)           A committee member, noting historic difficulties with joint arrangements between Herefordshire and Worcestershire, questioned how impact would be monitored, especially in terms of the issues associated with rural sparsity and distribution of services.


Jenny Dalloway commented on: investments in Herefordshire; how access to specialist services benefitted both counties; the detailed information available to the CCG to monitor services where they were delivered; Herefordshire had a separate place identity to Worcestershire; PCNs were helping the system to understand population needs at the GP practice level; and how support could be accessed at a GP practice or a GP practice could refer people into a service.


Alicia Lawrence (Chief Executive Officer, Herefordshire Mind) added that the alignment of the transformation project with the PCN areas enabled greater reach in rural areas.


b)           The chairperson questioned how Herefordshire residents who did not have a Herefordshire GP could access services.


Dr Lennane advised that some services were based around localities and others were tied into practices and it was recognised that this was an ongoing issue, particularly given the differences between the systems in England and Wales.


c)           A councillor in attendance expressed a view that the transfer of services to HWHCT had not been good for many patients and asked about the morale of frontline workers.


Jean Hammond (Community Services Manager, HWHCT) acknowledged that the combined effect of the transfer of services, COVID-19 and the transformation project had been very challenging.  An overview was provided of the measures put in place to support staff members, including regular update and question sessions, and individual one-to-one discussions.


David Thomas said that key locations had been visited and meetings had been held with as many staff members as possible.  It was recognised that there were undoubted challenges but there was also a sense that HWHCT was ‘turning a corner’ and moving on to the next stage.


In response to a further question about patients, Susan Harris said that mental health services had not stopped but had been adapted during the pandemic.  The transformation of community mental health services provided capacity to see more people earlier and HWHCT was working with system and voluntary sector partners to develop pathways.  The integrated care agenda would provide further opportunities to maximise resources to ensure that potential patients reached the right service as quickly as possible.


d)           In response to questions from the vice-chairperson, Dr Lennane commented on: the shift in care closer to home; how GPs helped many patients with mental health conditions but it was helpful to have quick access to specialists as and when needed; morbidity in terms of untreated mental health conditions; and the overlap between mental and physical health.


e)           In response to further questions from the vice-chairperson: Jenny Dalloway provided assurance that the majority of additional funding received for the transformation of services would be recurrent; Susan Harris said that the refurbishment of the Stonebow Unit to single occupancy would not reduce the bed base because the footprint of the building would be increased (outline plans would be shared with committee members), Herefordshire and Worcestershire had some of the lowest uses of out of area placements, and investments had been made in crisis support and improved home treatment; and David Thomas recognised that there were challenges with some of the estate inherited by HWHCT and there would be further conversations with system and voluntary sector partners about opportunities to reach out to patients in different settings and deliver services in ways logistically.


f)             In response to questions from a committee member, Dr Lennane said that: the issues around rurality were recognised and confirmed that the Borderlands Rural Chaplaincy was involved in work on suicide prevention; there were concerns about the economic effects of Brexit, especially the agriculture community; the full impact of COVID-19 was uncertain but there was a degree of community resilience arising from shared purpose and understanding; people should be encouraged to mix safely during the summer, as modelling suggested further waves of infection to come; and there had been a significant focus on mental health in schools, although it was suggested that more work was needed on lower level prevention.


g)           A committee member noted that ‘Each GP surgery will have a number of allocated assessment slots into which they can make appointments for patients’ (page 32) and asked for clarification on the arrangements.  Jean Hammond said that this was a developing service and GPs had been able to book assessment appointments directly initially but it was found that this could result in delays where the mental health worker subsequently identified that a further onward referral to an appropriate consultant was necessary.  The revised approach involved an assessment of all the referrals received from GPs each day by experienced advanced clinical practitioners to determine the most appropriate place for the patient to be signposted to.  In parallel, a pilot was being run with four practices whereby an advanced clinical practitioner would facilitate a weekly face-to-face discussion with a GP to examine the referrals for the previous week.  Information was being gathered to assess the most beneficial approach for patients going forward.


h)           The chairperson expressed concern about the challenges with Section 12 and Section 136 assessments under the Mental Health Act 1983, as identified in paragraph 8 of the report (page 34).


Dr Lennane explained that it was necessary to involve a second ‘Section 12 approved’ doctor in determining the need for someone to be detained but it was difficult to persuade doctors to undertake this extra work, especially given current workloads.  It was confirmed that this was a long-standing issue prior to the pandemic.


Jenny Dalloway advised that thought had been given to digital solutions and a software application had been commissioned; this would provide frontline workers with a list of available Section 12 approved doctors, enable doctors to confirm that they had provided the work, and assist the CCG in making payments.  It was noted that there were some issues with the national guidance in terms of remuneration and training.


Jenny Dalloway explained that it was usual practice for people to be taken to the nearest local place of safety for mental health assessments under Section 136, with reciprocal arrangements with other counties.  The chairperson noted that there was a risk currently that demand could outstrip availability until the prevention agenda gained traction. 


Mandy Appleby (assistant director for adult social care operations) provided an overview of a particular situation that had arisen with the Worcestershire Section 136 suite and the adjustments that had been put in place to reduce the impact on Herefordshire (or vice-versa) in a similar situation going forward.  In response to a question from a councillor in attendance, it was noted that the means of transport to the local place of safety would depend on the circumstances.


i)             The chairperson, noting the value of the whole person approach and the making every contact count philosophy, commented on unresolved grief being experienced by people who had not been able to go through the usual functions and rituals due to pandemic control measures and the potential for this to lead to problems later on.


Dr Lennane said that this was a valid point and commented that there were a number of bereavement support groups.  The chairperson noted that GPs were uniquely positioned to signpost people to sources of information and support.


j)             The chairperson questioned the extent to which new services, such as the eating disorders service for adults, joined up to public health initiatives, such as healthy eating campaigns.


Dr Lennane briefly commented on post-lockdown anxieties for children returning to school and for young carers which could result in eating disorders or self-harm, adding that it was important to recognise the emotional context of eating behaviours and address upstream issues.


k)           The chairperson noted that the theme of Mental Health Awareness Week 2021 was ‘connect with nature’, that there was an All-Party Parliamentary Group for Nature which was looking at the positives that came from a healthy natural environment, and that there were other national projects on outdoor activities and mental health.  It was questioned how the ‘natural capital’ of Herefordshire could be utilised to support health and wellbeing, including through social prescribing.


Dr Lennane commented on: the significant environment assets in the county; high levels of Vitamin D deficiency; the grant award secured by Ross-on-Wye Community Development Trust to increase social prescribing interventions; the connections being developed by Talk Community to support social prescribing; and the benefits of outdoor activities and active travel for physical and mental health.


l)             A committee member felt it unfortunate that a representative was not present from the children and families directorate given the comments about eating disorders and self-harm.


The democratic services officer drew attention to an item considered by the children and young people scrutiny committee on 23 March 2021 in relation to ‘Children and Young Peoples Mental Health’.


m)         Mr Stead said that: Healthwatch Herefordshire had been involved in the transfer of mental health and learning disability services at an early stage; the new provider had welcomed the views of Healthwatch on the issues in the county and its ideas for engagement and patient involvement; the recent investments in Herefordshire would not have occurred without the link with Worcestershire; restructuring usually had some impact on the morale of staff members but the situation had been compounded by the pandemic which had a consequential impact on the support that could be put in place; and, whilst Healthwatch was positive about the way forward, there was a concern about the practicalities of combining the mental health budget and management for both counties under the Integrated Care System.


n)           Ewen Archibald reported that a self-harm working group was being established across multiple agencies and involved a number of community organisations. 


It was also reported that the system was focussing on ‘multiple complex vulnerability’ which included people that were vulnerable as a result of issues such as mental health, homelessness, substance use, experience of the criminal justice system, and a range of other needs.  The chairperson requested that a briefing note be provided to the committee in due course.


5.           Contribution on behalf of Herefordshire Mind (HM)


Alicia Lawrence (Chief Executive Officer, HM) provided an overview of the ‘crisis café’ safe haven service, the main points included: it had opened just before the first lockdown, for three then four evenings per week; it was funded through HWCCG and additional funding had been secured to expand opening to seven evenings per week from the end of June 2021; 194 people had been seen in total, with 101 seen since the start of 2021; support was provided online initially, with face-to-face appointments available from June 2020; the ability for people to book appointments for later in the day was a key benefit; there were two paid members of staff and a number of volunteers that supported the service; the intention was to relieve some of the strain on the emergency services, although there were nine occasions when emergency services had to be involved; and support was also available by telephone, email, and a new website would enable instant messaging.


An overview was also provided of the involvement of HM with the HWHCT transformation team in relation to voluntary service, working in parallel with counterparts in Worcestershire.  It was reported that four full-time equivalent staff had been recruited; comprising six link workers on part-time and full-time hours, and a part-time manager.


Zoey Groves (Link Worker, HM) explained the role of link workers, including: working flexibly to meet client needs; linking people into community groups; some link workers had come from other sectors, some had volunteered at HM previously, and some had lived experience; the range of the work undertaken was illustrated through an example; a number of clients had been affected by flood emergencies; and peer support groups were being set up in communities.  Alicia Lawrence added that link workers were also supporting people in non-clinical ways to engage in activities and would link in with Talk Community hubs as lockdown measures eased.


6.           Overview of Talk Community Mental Health by the assistant director Talk Community


Presentation slides were included in the agenda (pages 46-55). 


Amy Pitt (Assistant director Talk Community programme) reported that: Talk Community was about all aspects of wellbeing and independence, working in partnership with communities, the voluntary sector and health partners to bring Herefordshire together and connect people; Talk Community Mental Health would work with communities to equip them to support people with low level needs or to signpost people with higher level needs to formal services; funding had been allocated to train community leaders in mental health and mental health first aid; other elements of the programme included debt and financial management support, and Talk Community hubs.


Amy Pitt also reported that a health and wellbeing survey had been commissioned, with 1100 people surveyed; it was anticipated that the results would be published at the end of May 2021.  Some of the key findings in relation to mental health were outlined, including: 28% said that they were talking less to their family and friends; 27% were talking less to their neighbours; 30% were not sleeping very well; 33% were a lot less active; 28% had high levels of anxiety, 35% had low levels of anxiety; and 12% felt better in terms of general health but 24% felt worse.


7.           Questions (part two)


The chairperson invited further questions and comments from attendees, focussing on community mental health.


o)           The vice-chairperson commented on the need for HWHCT and HWCCG to work with Talk Community in a holistic way, and on the importance of enhancing the healthy environment offer.


Susan Harris outlined: how the Talk Community programme and HWHCT developments had lined up during the last year; ongoing discussions around communication and engagement; the potential to bring together volunteering elements; system partners wanted to work together and maximise resources; and efforts to minimise the medicalisation of the impact of COVID, such as through the ‘Now We’re Talking’ campaign to encourage people to access mental health structures.  It was noted that some of the key challenges included keeping pace with changes in demand and tacking health inequalities.


Jenny Dalloway said that: HWCCG was a membership organisation of GPs and their practices; HWCCG worked with the PCNs to understand how it should be linking the services it commissioned with other provision, including Talk Community; feedback from the PCNs about the impact of Talk Community was positive and there was awareness of the potential benefits in terms of non-clinical support for individuals; and HWCCG would work to ensure that the services it commissioned were linked to and complemented the Talk Community offer.


p)           A committee member expressed concern about hidden mental health issues, particularly amongst the older population and illustrated this through three recent examples.  The need for everyone to play a part in identifying problems associated with isolation and mental health was emphasised, and the potential for Talk Community to promote and coordinate such activities was noted.


q)           A committee member thanked Amy Pitt for the work of Talk Community in the Bromyard area.  It was commented that the police were often the ‘gatekeepers for the mental health system’ and the extent of liaison with West Mercia Police was queried, including on mental health first aid. 


The chairperson said that: it was perhaps helpful to consider mental health first aid in terms of physical first aid, i.e. dealing with minor injuries and trauma rather than serious conditions; a national company had implemented mental health first aid and this had resulted in fewer absences and increased productivity; and there were a diverse range of communities, i.e. a community was not just a geographic location.


Amy Pitt said that Talk Community Mental Health would not be proscriptive and would work with community leaders in various communities.  It was reported that Talk Community Business was engaging with local employers on the health and wellbeing of workforces.


Ewen Archibald reported that: a number of local providers offered training on mental health first aid; there were mental health first aiders within the council; some partners had established programmes in place, such as Balfour Beatty Living Places; it was understood that a number of police officers had been trained on mental health first aid; a mental health professional was travelling with police officers, in parts of the county at certain times of the week, to provide a joined up mental health emergency response; for the mental health first aid model to be safe and effective, it was not just an issue of training but also about ensuring that there were networks of support and mentoring in place, with appropriate signposting routes to wider support in the community or to specialist NHS services; and system partners were working closely with the police on various agenda.


A councillor in attendance commented on the need to promote and coordinate training opportunities for councillors and others on mental health issues.


r)            Paul Smith (Assistant director all ages commissioning) commented on: the mobilisation of resources by Talk Community during a flood emergency; the meaningful contribution from Herefordshire Mind which demonstrated the potential to transfer skills from other sectors and lived experience into community mental health; strategic commissioning in the future should explore what could be done collectively, and how to facilitate communities and individuals to help themselves, before looking at formal clinical services; and the value of bringing together a broad range of services and treating mental health with the same parity as physical health.


s)           A committee member made reference to the ‘Here Youth Can’ day-long conference for young people aged between 16 and 25 to be held on 1July 2022.


t)             The chairperson welcomed the practical perspective that people needed help sometimes, it did not necessarily mean that they were helpless, and this in turn could enhance resilience.  The chairperson also welcomed the positive direction of travel in terms of joining up local community activities and questioned the extent to which this was being mapped.  In view of the potential for post-traumatic stress disorder amongst first responders and key workers, it was suggested that the expertise of military personnel could be utilised in some way.


Amy Pitt reported on the intention to position a Talk Community development officer in each PCN, acting as a key link with parish councils, community leaders and system partners, and developing the intelligence for each area.


Alicia Lawrence commented on the role of HM link workers in connecting people to different groups, helping to support recovery journeys, and the merits of having a mix of access options and services available to suit individual needs.  Zoey Groves provided an example of support provided by a church community group.


8.           Recommendations


The committee discussed draft recommendations arising from points raised during the debate, with input from other attendees. 


In addition, the chairperson noted that the Agriculture Bill had set out how farmers and land managers in England could be rewarded with public money for ‘public goods’ and suggested that consideration be given to a piece of work around access to nature and its therapeutic benefits.  The Leader of the Council commented on the potential for a dialogue around the mental wellbeing of farmers but also how they could help other communities.  Ewen Archibald provided an overview of ongoing work with representatives of the agriculture community.


Resolved:  That


a.           A spotlight review on the progress with the transformation of community mental health services be undertaken in nine to twelve months, including progress addressing the identified Section 12 and Section 136 issues;


b.           Herefordshire and Worcestershire Health and Care Trust be asked to provide further details regarding the refurbishment of the Stonebow Unit;


c.           The adults and communities directorate be asked to provide a briefing note on emerging project work on the mental health needs of people with multiple complex vulnerability;


d.           The results of the health and wellbeing survey be circulated to all councillors when available;


e.           The Talk Community programme be invited to consider additional linkages and signposting opportunities to environmental and activity groups, particularly in relation to access to nature and the facilitation of groups to support social prescribing; and


f.            Consideration be given to engaging further with the agriculture community on mutually beneficial arrangements with other communities in terms access to nature and its therapeutic benefits.

Supporting documents: