To provide an update on Herefordshire and Worcestershire Health and Care NHS Trust’s Adult Mental Health Inpatient and Rehabilitation Services Redesign.

The Chairperson invited representatives from the Herefordshire and Worcestershire Health and Care NHS Trust (the trust) to update the committee on Adult Mental Health Inpatient and Rehabilitation Services Redesign.

The principal points of the discussion are summarised below:

1. The Chief Operating Officer referred to two related schemes as referenced in the report: 1. Quality improvement scheme that is focused on the improvement of patient pathways on acute mental health wards with the outcome of eliminating inappropriate out-of-area placements. It was noted that this scheme is coming to an end and does not have an immediate bearing on services provided in Herefordshire. 2. Longer-term piece of redesign work for mental health rehabilitation.

2. The Cabinet Member for Adults, Health and Wellbeing welcomed the improvements at Stonebow and inquired about any potential future uses for Hill Crest.

3. The Chief Operating Officer responded to note that there are two main challenges with the Hill Crest building; the first is that it is not big enough to provide en-suite accommodation and; second, the building’s carbon footprint is non-compliant with modern building standards.

4. The Director of Strategy and Partnerships added that Hill Crest is not empty and it is currently providing community services out of the front.

5. In response to a question about why investment in suitable buildings had not occurred earlier, the Chief Operating Officer explained that national capital funding had been limited. The types of schemes that enabled the rebuilding of the Elgar Unit and Stonebow had exhausted the available capital limits, requiring the Trust to wait for new national funding opportunities. Regarding rehabilitation services, the Trust was prompted to act following the publication of new national guidance, as well as insights from its own benchmarking.

6. The Chief Operating Officer noted that in terms of overall strategic outcomes they are about preventing long-term disability for people with severe mental health problems. The people that are brought through rehabilitation, if they do not receive the right type of support, they end up with far worse outcomes than the general population and end up in residential and nursing care. A successful rehabilitation programme can help people back down to supported housing and often into their own tenancy with community support.

7. The Chief Operating Officer explained that, in relation to benchmarking, the GIRFT programme establishes various benchmarks, examining aspects such as the nature of local service provision, the number of people placed out of area, and whether those individuals should be brought back into local services. In some cases, the findings indicate that local provision does not align with the needs profile of the community. National guidance on commissioning mental health inpatient services defines what should be available at each level, revealing existing deficits. One such deficit is the lack of community-based rehabilitation services, as funds that might otherwise support community services are instead tied up in inpatient unit beds. Another significant gap identified is that individuals requiring intensive support often have to travel considerable distances to access it.

8. In response to a request for the trust providing access to GIRFT pre-consultation engagement reports and other relevant reports, the Chief Operating Officer confirmed that this could be provided.

9. In response to a question about which option is the best, the Director of Strategy and Partnerships noted that the three options are being developed before going to Clinical Senate and the more feedback that can be received will be helpful to be included as part of the process.

10. In response to a question about which option would be best, the Director of Strategy and Partnerships explained that all three options are still being developed and will be presented to the Clinical Senate. It was emphasized that gathering as much feedback as possible is valuable for informing the process.

11. In response to a question about the possibility of constructing a purpose-built facility on the Herefordshire-Worcestershire border to prevent patients from needing to travel out of county, the Chief Operating Officer confirmed that the Trust had undergone an extensive consultation process. As part of this, they explored whether a new facility could be built or whether an existing building or site could accommodate a large new structure or adaptations. However, factors such as the time required for land acquisition and planning, along with the significant capital costs involved, meant that this option was limited in feasibility.

12. In response to a question about whether it is realistic to expect to deal with every patient in every degree of mental health in the trust itself, the Director of Strategy and Partnerships confirmed that the trust does have similar arrangements in mental health. For example, the trust does not have eating disorder beds, but they sit in the regional portfolio and the trust has to work well with providers of those beds.

13. The Chief Operating Officer added that there are usually at least fifteen patients who are requiring level two rehab but cannot have it locally. 

14. In response to a question about how prevalent external providers are in providing level two rehab, the Chief Operating Officer confirmed that there are a good range of providers that provide level two rehab. There is a variability in the cost, quality, and outcomes. The trust is entering into an exploration of which providers are local enough and are willing to have a conversation about consolidating block-contracting and to meet the standards required for a rehabilitation unit.

15. In response to a question about whether Stonebow is classified as level one or level two, the Chief Operating Officer explained that Stonebow comprises three wards, and the clinical decision was to rebuild them as modern wards. One ward serves older adults with functional mental illness, another cares for older adults with organic conditions, and the third accommodates working-age adults in Herefordshire experiencing acute mental illness.

16. In response to a question about whether any analysis has been conducted to understand the reasons for patient admissions, the Director of Strategy and Partnerships stated that several case studies have been utilized in developing the available options.

17. In response to a question about how the changes will enhance patient outcomes, the Chief Operating Officer explained that community rehabilitation services are currently underdeveloped in the two counties. By reducing inpatient beds through the closure of Cromwell and the reduction or closure of Oak House, staffing resources can be redeployed into the community to deliver community-based rehabilitation, creating a step-down pathway from acute care.

18. In response to a question about how patients with mental health issues in rural areas are supported, the Chief Operating Officer explained that the proposed options primarily focus on individuals already known to the trust, many of whom have experienced multiple acute episodes and repeated admissions to the Stonebow unit and require extended support. Regarding community accessibility, there has been significant investment from central government over the past five years to enhance community services, and considerable collaboration with GPs aims to keep access as open as possible, with 97% of referrals from GPs being accepted. It was also noted that the previous government set a target for a one-third increase in the number of people receiving mental health care in the community, a goal that has been surpassed in both counties.

19. The Director of Strategy and Partnerships added that she chairs the Better Adult Mental Health Partnership, where valuable discussions take place about key priorities and areas of focus.

20. In response to a question about the level of involvement of the Primary Care Network, the Chief Operating Officer confirmed that they have been closely engaged throughout the entire process.

21. In response to a question about which specific key performance indicators (KPIs) will measure the success of the redesign and how they will be monitored over time, the Chief Operating Officer explained that the trust established overall objectives at the outset of the programme, serving as primary lead indicators. Once the level one and level two model is finalised, a secondary set of KPIs will be defined, encompassing various social outcome measures such as overall length of stay and successful securing of tenancy, among others.

Resolved:

1. That the Herefordshire and Worcestershire Health and Care NHS Trust should set out the pros and cons of each of the three redesign options against the six “and we” criteria in the NHS Commissioner Guidance for adult mental health rehabilitation inpatient services.