Minutes:
The Chairman welcomed Iain Dimond, Chief Operating Officer – Oxleas NHS Foundation Trust (“Chief Operating Officer”) and Lorraine Regan, Service Director, Adult Community Mental Health/Adult Learning Disability – Oxleas NHS Foundation Trust (“Service Director”) to the meeting to provide an update on acute mental health pressures, community mental health within Bromley and the ‘Right Care, Right Person’ approach.
With regards to acute mental health pressures, the Chief Operating Officer advised that they were continuing to see considerable pressure across South East London, however the pattern of demand differed between the two providers (Oxleas and South London and Maudsley (SLaM)). Generally the Oxleas data showed a reduction in the number of people attending Accident and Emergency (A&E) in a mental health crisis. However, those that then required admission were waiting longer than they needed to – this was due to problems with flow and pressures within the acute bed system. It was noted that a recovery programme had been agreed, focussing on purposeful admissions and reducing delayed transfers of care. This work was underway, and an update could be provided at a future meeting of the Health Scrutiny Sub-Committee.
The Chief Operating Officer informed Members that as mental health demand was having an impact on A&Es across South East London, the ICB had commissioned a report from an external consultancy, Carnall Farrar. The conclusions had now been circulated to the ICB Executive – Oxleas and SLaM had drafted a response to this and would take forward any additional actions.
In response to questions, the Chief Operating Officer said that the trend being seen across the three boroughs was a gradual reduction in the number of people presenting in a mental health crisis at A&E – however, a greater proportion of those attending were unwell and need hospital admission. Due to the pressure on beds some were waiting longer than they should following the decision to admit them being taken. It was considered that fewer people attending in a mental health crisis was evidence that the decision taken by the Trust to invest more into community mental health was paying off. Data was collated regarding whether those attending in crisis were known to community teams; had been known to community teams; were waiting to see community teams; or were completely new – the data suggested that the majority were under the care of Oxleas, or waiting to come into their care. It was noted that part of the work being undertaken was to look at doing more to identify signs of relapse, and if someone was in crisis were their opportunities to do something different.
The Service Director advised that there had been a huge increase in demand for community mental health services since 2019 – this was impacted by both the COVID-19 pandemic and social circumstances. Referrals had increased significantly from 220 per month, pre-pandemic, to the current level of 400 per month. This activity meant that they were managing around 1,500 patients per month, which was an increase of 463. There were some mitigations in place, and a mental health hub had been established – this was a joint initiative between Oxleas and BLG Mind, which provided a new front door into adult mental health services. This was working well, enabling a different offer to be provided to people when first referred, and reducing waiting time for some treatment pathways – people were typically waiting 9-29 days for their first appointment (average of 20 days). This had been negatively impacted by urgent referrals, which needed to be seen within 2 days. Oxleas were 100% compliant with regards to urgent referrals but this created a knock-on to routine referrals, where the waiting times were longer than they would like. However, treatment times had decreased due to the interventions delivered through the hub. To increase contacts received by patients, a Care Teams approach in been implemented with new roles introduced – contacts within the psychosis pathway had increased by 35% and the dementia diagnosis rates had also been recovered, sitting just above the national target at 66.8%. It was noted that Bromley had the largest prevalence of dementia across SEL and therefore the figures represented a much larger group of people compared to neighbouring boroughs. Over the last six months the Helix Service had also been established. This was a maternal mental health service offering an opportunity for women who did not have a pre-existing mental health condition but suffered loss/trauma as a result of their birth experience to receive a rapid response from a mental health service.
In response to questions, the Service Director said it was complex in terms of identify the drivers for the increase in demand, but they were aware that a significant proportion of people sought their services due to their social situation – including lack of employment, finances, debt and relationship breakdowns. There needed to be further thinking undertaken regarding their relationship with primary care and ensuring the thresholds were right when patients moved between primary and secondary care. There was also a broader recognition within the community that it was okay to seek support for mental health which had led to an increase in demand for service. With regards to how staff were coping, the Service Director said it had been very difficult, but enough mitigation had been put in place. There had been investment through the Community Mental Health Transformation and they were currently in the third year of the programme.
With regards to the Right Care, Right Person (RCRP) approach, the Chief Operating Officer advised that the Metropolitan Police Commissioner had written indicating that he wished to implement this initiative which had previously been rolled out in Humberside. There were four main objectives:
- Police involvement in requests from health and social care providers for welfare checks;
- Police involvement when patients go absent without leave (AWOL) /missing from health care facilities;
- Police involvement in the conveyance of patients; and,
- The time taken to handover patients picked up by the police under Section 136 of the Mental Health Act and conveyed to a health-based place of safety.
It had originally been indicated that the RCRP approach would be implemented at the end of August 2023, however there had been a number of concerns raised regarding the way it was to be introduced and the time scale for implementation. In London, a Joint Mental Health Policing Group had been established – this brought together representatives from the police, mental health partners, London Ambulance Service (LAS), acute colleagues and special care providers. This group would oversee the safe implementation of the RCRP approach, with subgroups having been established to take forward the required work. Members were advised that the date of the RCRP implementation would now be the end of October 2023 which allowed more time for preparation. From the end of October the police would instruct call handlers to more robustly triage calls into their call centre and the ‘136 Co-ordination Hubs’ would be launched – these were already in train and would be the first point of contact for the police if they were considering detaining someone under a Section 136. The mental health providers would be able to give advice and direction, as well as indicate where there was capacity for patients which it was hoped would reduce handover times.
It was considered that there were still some risks created by this programme. The current policy stressed that the police should only be involved where absolutely necessary – however, they were involved quite routinely in welfare checks and when patients went AWOL. There would need to be an element of training and a culture change for health and social care providers in terms of the detail of the legal framework of what they were able to do if someone went absent without leave. It was noted that in Humberside they were three years into implementing the RCRP approach and this was still ongoing.
In response to questions, the Chief Operating Officer said that in terms of 136 handovers the hubs should provide some mitigation in reducing risks that may arise from the police withdrawing their officers once they had delivered a patient at a health-based place of safety. The environment allowed the person to be managed safely. The difficulty was when the police brought someone to A&E – this was a very different environment, which was very public, and it was difficult for staff to safely manage patients. This was an area of risk that needed further thought. With regards to requests for welfare checks and patients going AWOL, a new protocol for mental health providers would be drafted. Training staff and recalibrating the culture, so there was a shared sense between health and the police as to when they should be involved, would take time and would need to be monitored and reviewed. It was noted that a definite risk was that if health staff had to leave a ward to ascertain the whereabouts of a patient, this loss of resources was not built in and would need to be determined. Between now and the end of October they would continue to work around the policy, but as health and social care providers they would need to consider how the emerging risks were managed.
In response to further questions, the Service Director said that Oxleas were only providing physical health checks to their mental health patients, and they were continuing to work with partners to deliver broader physical healthcare. As part of serious mental illness annual health checks they were working with GPs – if these indicated any concerns, they would be followed up with primary care colleagues. Oxleas had a responsibility to monitor the physical health of its population and a number of nurses were employed to do so – most of the physical health conditions were linked to either a patient’s medication or their mental health, but this was being done in partnership with other organisations. It was agreed that this could be discussed in further detail following the meeting.
The Chairman thanked the Chief Operating Officer and Service Director for their update. Member requested that a further update be provided at the next meeting of the Sub-Committee.
RESOLVED that the update be noted.