Lambeth/Southwark Statutory Joint Health Scrutiny Committee
Scrutiny of South London & Maudsley Mental Health NHS Trust’s proposals for review of crisis mental health services
December 2005 – March 2006
CONTENTS Chair’s Foreword Acknowledgements 1. 2. 3. 4. Executive Summary [recommendations] Background to the review Context: provision in Lambeth and Southwark Key findings and recommendations 3 4 5 8 11 19
Appendix A Appendix B Appendix C Appendix D Appendix E
List supporting documents Committee membership and TORs Scrutiny consultation questions Joint Committee schedule Process flowchart
39 41 44 45 47
This is the first time that either Lambeth or Southwark Councils have set up a formal cross-borough Joint Committee since local authority councillors gained the powers to scrutinise health and local health services. The experience of undertaking the review has been a learning curve for all involved as we have sought to understand the nature of mental health provision and need across both boroughs, actively engage with a wide range of stakeholders and deliver our findings within the required three month timescale. On behalf of the committee I would like to thank all the individuals and organisations that have contributed to the review either by speaking to the committee, contributing views in writing or given their time to participate in sessions or visits. Mental health services support some of the most vulnerable people in our society. Over recent years there has been a significant shift away from an institutional based model of care towards services that seek to support and treat people where possible within their home community. Whilst this review of mental health crisis services has focused largely on proposals by the South London and Maudsley NHS Mental Health Trust, we recognise that the Trust is just one part of the jigsaw that requires integrated working across many sectors. Through the scrutiny process the committee has gained a wider understanding of the pressures placed on health service managers to whom we have spoken, as well as the role which non-health providers such as the police are often required to take on. We have also heard the sometimes distressing experiences of individuals who experience mental ill health and for whom direct access to specialist mental health services can be so crucial. The committee’s findings and recommendations are set out in the Executive Summary. We strongly believe that all our residents deserve excellence in all aspects of health provision and whilst we have not been able to support the proposals put forward by SLAM we do wish to find a local resolution on this matter and want to work with local health providers on the issue.
Councillor Angie Meader Chair of Joint Lambeth/Southwark Statutory Health Scrutiny Committee March 2006
The Joint Committee would like to thank all those people who gave their time to assist with the review by providing information, attending meetings and submitting written evidence. Some individuals have requested that their comments remain anonymous, however all contributions were greatly appreciated and of great importance to the committee. Isobel Morris (Southwark Service Director SLAM), Patrick Gillespie (Lambeth Service Director SLAM), Denis O’Rourke (Assistant Director Service Strategy and Commissioning Lambeth PCT), Tamsin Hooton (Joint Commissioner Southwark PCT), John Roog (Assist Director Adult Services Lambeth Council), Rod Craig (Joint Head of Services for Older People & People with Physical Disabilities Southwark PCT), Michael Casey (Emergency Clinic Manager, SLAM), Catherine Seymour (Manager A&E St. Thomas’), Adrian Hopper (Head of Service Delivery Unit St Thomas’), Victoria Glen-Day (Psychiatric Liaison Nurse A&E St Thomas’), Liz Martin (Clinical Nurse Manger A&E St Thomas’), Phil Watson (Partnership and Planning Manager Guys & St Thomas’), Aidan Slowie (Modern Matron A&E KCH), Briony Sloper (Operational Performance Manager A&E KCH), Ed Glucksman (Consultant KCH), Liz Wells (KCH), Teresa Priest (Southwark MIND), Silvio Couthino (SLAM Patient and Public Involvement Forum), Mike Hartley (Rethink), Anna Tapsell (Lambeth Community Police Consultative Group), Chief Inspector Suzanne Wallace (Lambeth Borough Police), Superintendent Simon Smith (Southwark Borough Police), Mary Roberts (Lambeth Mental Health and Disabled People’s Action Group), Cathy Thorpe (Lambeth User Voice), Les Elliot (Lambeth service user). And all the individual service users who attended the informal discussion session with the committee or gave their views in writing. The committee would also like to thank the scrutiny teams at Southwark and Lambeth Councils, and in particular Lucas Lundgren and Elaine Carter for their support throughout the review and Sarah Feasey (Legal, Southwark) and Alison McKane (Legal, Lambeth).
In December 2005 Lambeth and Southwark Councils established a statutory Joint Health Scrutiny Committee to consider consultation proposals by the South London and Maudsley NHS Trust (SLAM) on the future of crisis services for people with mental health problems in Lambeth and Southwark. In outline, the proposals subject to public consultation by SLAM are to • Cease the walk-in function at the Emergency Clinic [EC] at the Maudsley Hospital whereby patients with mental health problems can self-present in times of a mental health crisis • Create five Clinical Decision Unit (CDU) beds in the EC for service users with complex mental health needs and who may, for example, be waiting for screening by the Home Treatment Team, discussions by the Community Mental Health Team or awaiting admission to hospital • Accept into the EC service users with complex needs who are finding it difficult to wait in A&E or whose behaviour is difficult to manage in A&E. This would be by referral to the EC by the relevant medical professionals rather than by direct selfpresentation at the EC by the patient. The Joint Committee was established with the remit to: a) consider the proposals of SLAM in relation to crisis care provision from the perspective of all those likely to be affected or potentially affected by those proposals and to consider whether the proposals for change are in the interests of the health of local people; b) consider SLAM’s consultation including: how the consultation options have been formulated whether the health Trust has taken into account the views of patients, the public and other stakeholders in developing the proposals whether the formal consultation process is inclusive and comprehensive c) take account of the evidence and views of stakeholders to consider what impact the proposed changes will have on patients, carers and the public.
Set out below are the key findings and recommendations of the Joint Committee. •
The Committee is not satisfied that the proposed changes to mental health crisis services, particularly the withdrawal of the self-referral, 24 hr walk-in facility at the Maudsley Emergency Clinic, as set out in the South London and Maudsley (SLAM) NHS Trust’s ‘Lambeth and Southwark mental health crisis care review’ consultation document, are in the interests of the health of local people in Lambeth and Southwark.
The Joint Committee does not support the proposed option for change for the following reasons: 5
1. The committee recommends that a whole system approach to mental health crisis services is needed across both boroughs – with shortcomings in the existing system addressed, and key parts of the system strengthened before any reconfiguration is progressed. (see paragraphs 93-99) 2. Committee members, many service users, and some staff at St Thomas’ and Kings A&Es expressed serious reservations about the capacity and appropriateness of A&E facilities to provide quality crisis care for people in mental distress and to contain any increased pressure of demand for services. The committee would like to see the situation for patients attending and waiting at A&E addressed regardless of the outcome of the trust’s crisis services review. (see paragraphs 100-125) 3. Although forming part of the trust’s overall plan for the future of local crisis mental health services, the committee would like to see increased commissioning emphasis on non-medical model services such as services which could provide informed support and valuable social contact, particularly out of hours. (see paragraphs 126-131) 4. The committee supports the need for a properly resourced, targeted and userfriendly telephone advice service and notes the service user preference that this be provided independently of SLAM. (see paragraphs 132-136) 5. The committee would like to see the trust and other delivery partners working closely with non-statutory organisations to ensure provision of clear and timely information to assist navigation around existing and future local provision. This should be available to service users, potential users of services, carers, those responsible for making referrals to services and the wider local community. (see paragraphs 137-143) 6. The concerns of the Mental Health Act Commissioner in November 2005 were reported to the committee. However, the committee would like to see the trust exploring alternative options by which these might be addressed, other than closure of the EC. (see paragraphs 144-151) 7. The committee believes that a self-referral, walk-in, 24 hour specialist mental health facility should continue to be available locally, in whatever form. (see paragraphs 152-167) 8. The committee is concerned that SLAM’s proposals for reconfiguration may impact disproportionately on BME communities. The committee recommends that the impact of EC closure across the local system is subject to a full Equalities Impact Assessment before any reconfiguration is progressed. (see paragraphs 168-176) 9. The committee considers that SLAM’s consultation process including the way in which consultation options were formulated have been less than ideal, because: • the views of non-SLAM members of the crisis services review steering group (i.e. service users, carers and other relevant voluntary and statutory agencies, including the police) appeared not to have been significantly
reflected in SLAM’s final consultation option for public consultation; and the perception of service users and user groups was that their contributions played no meaningful role in the outcome of the trust’s consultation processes. The Joint Committee recommends that the trust addresses concerns raised by the JC in respect of this consultation in order to ensure that its consultation process and practices are inclusive and comprehensive in future. (see paragraphs 177-199)
Background to the Review
1. In late 2004, health scrutiny councillors in Lambeth and Southwark were contacted by local mental health service user groups campaigning against closure of the Emergency Clinic (EC) at the Maudsley Hospital. The EC is run by the South London and Maudsley NHS Trust and provides a self-referral, 24-hour, walk-in, emergency mental health service. Primarily providing support to residents of Lambeth and Southwark, the clinic is also attended by non-borough residents with mental health problems when in crisis. The Lambeth and Southwark directorates of SLAM provide the EC jointly although mental health services are commissioned independently by both Lambeth and Southwark PCTs on behalf of their respective residents. Campaigners were concerned that the future of the clinic was under threat due to option proposals by SLAM’s Lambeth directorate to withdraw its annual funding share of £200,000 to make efficiency savings required by Lambeth PCT. Representatives of SLAM and the PCTs were invited to discuss the matter with health scrutiny sub-committees of both boroughs, each body being advised that no decision had been taken on the future of the Emergency Clinic. In addition the committees were advised that the proposal from Lambeth PCT to withdraw its annual funding share had been withdrawn and that any proposals to make changes to crisis services would be cost neutral. However, in view of the significant investment in mental health crisis care services in recent years and a commitment to providing targeted, preventative help to people before they reached crisis, SLAM had initiated a review of its crisis services across both boroughs. An Emergency Services Review Group had been established as part of the review to formulate options for change and was a joint venture with stakeholders including the Acute Trusts, PCTs, Social Services Departments, service users and carers. In line with statutory Government consultation guidance, significant change in NHS service cannot occur without proper consultation first being undertaken with stakeholders and the resulting proposals being subject to a formal three-month consultation period. Under section 11 of the Health and Social Care Act 2001, NHS bodies have a specific duty to consult and involve patients and the public in the planning and development of services and in relation to decisions that might affect services. In addition, regulations under section 7 requires that NHS bodies are separately required to consult relevant Overview and Scrutiny Committees (OSC) on any proposals they may have under consideration for any substantial development of the health service in their area or any proposals to substantially vary service provision. Where proposals affect more than one area, all the relevant OSCs for the area(s) in question must be consulted and if more than one of these OSCs consider that the issue is substantial for their area they must establish a statutory Joint Committee to consider and respond to the proposals.
If as a result of the review a Joint Committee or an individual OSC concludes that the proposed change is not in the best interests of the health of the local population, and no agreement can be reached locally on the proposals, it has the power to refer the matter to the Secretary of State. The extent of public involvement in the development of the proposals can be taken into account in making any such referral. A joint briefing was held for Lambeth and Southwark health scrutiny members in March 2005. Each committee had independently agreed at an early stage that reconfiguration of local crisis care services was likely to have a substantial impact on their local populations. During 2005 both committees received regular updates from SLAM on the development of its proposals and constitutional arrangements for establishing a statutory Joint Committee were discussed across both boroughs. The patient profiles provided by SLAM suggested that attendance at the Emergency Clinic was overwhelmingly by Southwark and Lambeth residents [an audit recorded this as 52% and 31% respectively]. Having confirmed that no other borough had expressed an interest in participating in scrutiny of the proposals, Lambeth and Southwark established a statutory Joint Committee. Lambeth and Southwark Councils subsequently agreed that the membership of Lambeth’s Health Scrutiny Sub Committee and Southwark’s Health and Social Care Scrutiny Sub-Committee comprise the Joint Committee and appointed members to this joint body. The membership of the Joint Committee was as follows: Lambeth Members: Cllrs Donatus Anyanwu, Irene Kimm, Angie Meader, Robert McConnell and Helen O’Malley Southwark Members: Cllrs Alfred Banya, Eliza Mann, Lisa Rajan, Veronica Ward and Sarah Welfare
In December 2005 SLAM published its consultation documentation on the review of mental health crisis services in Lambeth and Southwark and announced that public consultation would run until 17 March 2006, the preferred option recommended by SLAM being to change the role of the Emergency Clinic to a five-bed Clinical Decisions Unit for people with complex mental health needs and service users awaiting assessment or admission. Thus direct access, self-referral to the Emergency Clinic would cease and individuals who would have selfpresented in a crisis to the EC would have to access crisis services via other access points including A&E, Community Mental Health Teams [CMHTs] and their GPs. Details of these access points are set out in detail in the body of this report. Throughout SLAM’s informal consultation service users made it clear that they could not support an option that did not contain the walk-in service currently provided by the EC. An option proposed by Lambeth and Southwark service user campaign groups for continuation of the self-referral alongside the development of the Clinical Decision Unit [CDU] beds was circulated with the SLAM preferred option.
The Joint Lambeth and Southwark Statutory Health Scrutiny Committee formally started its work on 20 December 2005. Councillor Angie Meader (Lambeth) was appointed chair and Councillor Sarah Welfare (Southwark) vice chair. At the first meeting SLAM presented its formal change proposals to the committee and answered questions alongside colleagues from Lambeth and Southwark PCTs. A further four meetings were held at which a range of stakeholder witnesses including service users, health professionals and A&E staff, Lambeth and Southwark Police and representatives from voluntary and community groups gave their views on SLAM’s proposals. In addition, the Committee visited the Emergency Clinic and A&E facilities at both St Thomas’ and King’s College Hospitals [KCH] and held an informal discussion session to gather feedback from service users. The committee also invited written comments on the SLAM proposals, these key questions being set out at Appendix C. The Joint Committee’s position in relation to SLAM’s proposals, and its reasons for this position are set out in the following report. The committee has heard very strong views on the value that service users attach to the self-presentation aspect of the Emergency Clinic and has also considered the concerns of local health partners, including the local acute trusts. The committee hopes that SLAM and its partners will take on board the strength of these feelings in considering how to provide crisis services to the people of Lambeth and Southwark. The Joint Committee wishes to work with local health providers to find a locally acceptable solution on this issue. However, should local resolution not be achieved the committee has the right to refer the matter to the Secretary of State.
Context for local service delivery
16. 17. Context: provision in Lambeth and Southwark Responsibilities for provision of health services across Lambeth and Southwark and commissioning and delivery of mental health services in particular are complex. This introduction is designed to give an overview of the local context within which the Joint Committee has undertaken its review and made its recommendations and provide an outline understanding of the concepts used within the body of the report. Lambeth Lambeth is the largest inner London borough with a resident population of 266,170 (2001 Census). The borough has a young age profile compared with the rest of the country (almost half of the population - 45% - is between 20 and 40) and an ethnically diverse population. 62.5% of Lambeth’s residents are white whilst 25.8% are of black origin, 4.8% mixed race and 4.6% Asian. Chinese and Other groups make up 2.5%. Southwark Southwark’s population numbers 256,000 (2001 Census). Demographically, the borough’s population is a relatively young one, 53% of people being between 1644 years, with the mean age of residents being 34.1. The age at which first psychotic episodes occur is on average 22 years of age, reportedly. Geographically, Southwark sits between Lambeth and Lewisham. Both the Maudsley Emergency Clinic and King’s College Hospital A&E are located within Brunswick Park Ward near the centre of the borough. 62.9% of Southwark’s residents are white, 24.1% black Caribbean or black African, 3.7% mixed race, 3.5% Asian, 1.8% Chinese. Other groups account for 2.9%. In total, black and minority ethnic groups represent 37% of the population. In 2004 only 60% of the borough’s working-age population were working, compared to 75% in Great Britain overall, and 67% in Southwark five years previously. The 2001 Census indicated that of the borough’s total unemployed 18% had either never been in work or were long term unemployed. Common factors: social exclusion and deprivation A wide range of economic, social and environmental factors (Dahlgren & Whitehead 1991) are known to affect people’s health throughout their lives and can create a differential health status (health inequalities) within a population or community. In terms of both Lambeth and Southwark’s demographic make-up, there are several factors with particular relevance to outcomes in respect of mental health and therefore local service provision. Lambeth’s Mental Health Promotion
Strategy identifies a range of social exclusion and social isolation determinants as potential risk factors for mental health, these being • Unemployment • Severe life events • Long term carers of highly dependent people • Women with a history of depression in pregnancy 28. 29. Demographics: implications for service delivery Anna Tapsell, Chair of Lambeth Police and Community Consultative Group and a Non-Executive Director of Guy’s & St Thomas’ NHS Foundation Trust, in her evidence to the committee referred to recent work in response to a Lambeth review of mental health and policing, that appeared to indicate that local deprivation, drug and alcohol abuse and that borough’s young population all contributed to incidence of mental ill-health locally. Lambeth and Southwark are boroughs with high levels of deprivation but there is considerable variation between Wards within both boroughs. Social exclusion, discrimination and poverty are likely to lead to poor health outcomes and therefore inclusive and culturally appropriate service provision is necessary to address these factors. Across both boroughs a diversity of languages are spoken which can make the delivery of services more complex. And both London and Southwark are amongst the top London boroughs that support asylum seekers with Lambeth ranked in 4th place and Southwark in 9th. Analysis at electoral ward level of the 2004 Index of Multiple Deprivation rankings record Coldharbour, Vassel and Tulse Hill as the most deprived wards in Lambeth (ranked at 26th, 53rd and 86th across a total of 624 London wards). For Southwark these are Livesey (30th), Camberwell Green (38th) and Peckham (39th).
Mental healthcare: current pathways to care Acknowledging the debate around appropriate terminology, this report uses the term severe mental illness (SMI) to refer to schizophrenia, psychotic experiences and bi-polar disorders. Common mental illness (CMI) refers to non-psychotic depression and anxiety. Primary care pathways The most common mental illnesses are depression and anxiety, with 90% of people experiencing these conditions being treated in primary care settings with talking therapies, medication, self-help and social support. Primary mental healthcare includes “Treatment and preventative and promotional interventions conducted by primary care professionals including GPs, nurses and staff based in primary care clinics providing diagnostic, treatment and referral services.
GPs, nurses and other workers making home visits for the management of mental disorders.” [WHO, 2003] 37. Primary care is for most people the first point of contact with services, the place where the majority of people receive treatment and is a referral point to secondary mental health services for those with more serious problems. It has been suggested that there is less stigma attached to seeking help via primary care for mental illness. GPs and referral route via primary care Mental healthcare provided in primary care settings [National Service Framework Standards], includes GP referral to secondary services including Community Mental Health Teams [CMHTs]. Primary care access targets are generally 48 hours, as compared to A&E 4-hour targets. South East London Doctors Co-operative [SELDOC] provides 24/7 telephone advice from an on-call doctor, referral to a primary care centre or home visit across Lambeth, Southwark and Lewisham. Secondary care pathways Secondary mental health services are those that provide care to people referred by a GP to a psychiatric outpatient clinic or local community mental health team. People with conditions including severe mental illnesses [psychotic illnesses including schizophrenia and bi-polar illness], depression that is resistant to treatment, eating disorders, obsessional compulsive disorders [OCD], personality disorders and complex conditions involving for example a dual-diagnosis [drug/alcohol problems and psychosis], or mild learning disability alongside psychosis are referred to secondary mental health services. Schizophrenia is a psychotic illness with disturbances in thinking and perception which can result in changes in personality, behaviour and social functioning. Symptoms include disturbances in thinking, delusions (false ideas), hallucinations (false sensations usually in the form of voices) and problems with feelings, behaviours, motivation, and speech. Whilst the exact cause is unknown stress can exacerbate symptoms and possibly trigger the illness. Many patients do not have insight and find it difficult to accept they are unwell. Some people may recover completely from schizophrenia while others will have symptoms which occur from time to time or which are present all the time. Treatment and management of schizophrenia is provided in relation to three phases, i.e. initial treatment received at the first episode, acute phase and measures promoting recovery. The Joint Committee heard that levels of mental ill health were high in Lambeth and Southwark and that residents suffered more in general from mental illness than in some other parts of London and significantly more so than compared with the country as a whole. Specific figures for those receiving help with common and severe mental illness within combined primary and secondary care is sketchy but Directors of Public Health in both Lambeth and Southwark estimate that at any one time at least 37,000 adults in Lambeth (13.9%) and 30,000 in
Southwark (11.7%) are experiencing common mental illness, with around 1 in 20 people experiencing severe or clinical depression. Lambeth’s Director of Public Health in her 2004/05 annual report estimates that in that borough alone ‘possibly 3000 people will experience severe mental illness but some research estimates that local rates for severe mental illness may be three times higher than this’. 46. 47. Community Mental Health Teams The Community Mental Health Teams (CMHTs) in Lambeth and Southwark provide assessment, treatment and continuing care via two specialist systems: the Care Programme Approach (CPA) and care management. The Care Programme Approach was introduced in 1991 as a means by which an individual’s social, medical and nursing needs are met and coordinated by agencies responsible for providing them in the community. CPA applies to everyone with serious mental health problems who is accepted as a client of specialist mental health services. Following an initial assessment, Care Plans are delivered at either standard or enhanced levels, according to various factors including an individual’s ability to self-manage, number of agencies involved in care, frequency and intensity of support required and level of cooperation with services. A key worker should be appointed to monitor and review how each plan is effected. Crisis plans set out actions needed if the user becomes very ill or their mental health deteriorates rapidly and are a required element within enhanced CPA. It is good practice for those on standard CPA to have crisis plans. Social service departments ensure that people referred to them are assessed for social problems and have their problems addressed through the process of Care management, which process should work in conjunction with CPA to meet an individual’s social and medical needs. This calls for close working between health and social service professionals around an individual’s package of care. CMHTs are community based, comprising psychiatrists, community mental health nurses, social workers and occupational therapists and psychology. They will take urgent referrals from GPs or other agencies for assessment of people not already known to services and these people will be seen the same working day/48 hours [Southwark]. Lambeth’s Rapid Response Teams can make assessments within 6 hrs. Existing clients of CMHTs can arrange home visits or appointments. Southwark has four CMHT’s teams and Lambeth has three. Both boroughs provide services between 9 am – 5.00 pm Monday to Friday. CMHTs are described as the “hubs” of local mental health care provision, and it is expected that they are the first point of contact within the system for people who are already in contact with mental health services when in crisis. The World Health Organisation notes that such formal community services promote community integration by enabling many people with severe mental illness to continue living in the community and work best when closely linked with primary care services and informal service providers working in the community [WHO, 2003].
Crisis services Crisis services are community services targeted to people in severe mental health crisis who would otherwise be admitted to hospital, however people with both common and severe mental illness may use crisis services. As such they are a means of addressing situations where an individual’s mental health has deteriorated to the extent that they might harm either themselves or other people, and intensive treatment and/or support is indicated. In-patient treatment is provided at five acute psychiatric wards across the trust, including a psychiatric Intensive Care Unit at the Maudsley Hospital and another at Lambeth Hospital. Currently, crisis mental health services are offered at A&E departments of both St Thomas’ and KCH, the Emergency Clinic at the Maudsley at Denmark Hill and Community Mental Health Teams which provide Assessment & Brief Treatment taking referrals from GPs, and Continuing Care. SLAM self-defines crisis services offered within Southwark and Lambeth as comprising: • 24/7 access to A&E departments at St.Thomas’ and King’s College Hospital; • walk-in access to the Emergency Clinic at the Maudsley Hospital; • out of hours GP services via SELDOC; • Social Services Emergency Duty Teams in Lambeth and Southwark; • assessment of patients brought in by Police under section 136 of the Mental Health Act at section 136 suites at Lambeth Hospital and the Emergency Clinic; • urgent assessments carried out by Community Mental Health Teams between 9.00 am and 5.00 pm in Southwark and by the Rapid Response Teams in Lambeth; • 24/7 access to NHS Direct telephone advice • Home Treatment Teams (Lambeth) • Crisis Resolution Team (Southwark) CREST/HTTs Southwark’s Crisis Resolution Teams [CREST] and Lambeth’s Home Treatment Teams [HTT] assess individuals presenting at any of the crisis services access points outlined at paragraph 41 above and give intensive treatment at home where appropriate. HTT and CREST services are not open access but require referral via A&E, the EC or the Community Mental Health Teams. (However, the committee heard that not all clients referred to these teams are accepted.) There are two Home Treatment Teams in Southwark [CREST North and South]. Each team comprises mental health nurses, social workers and support staff and a consultant psychiatrist covers both teams. The team provides intensive home treatment to clients suffering a severe crisis as an alternative to admission and can visit up to three times a day. The teams assess all patients with acute mental health problems at A&E, the Emergency Clinic and at the request of CMHTs. The team provides services 7 am – 10 pm. Approximately 30 – 40 patients are
supported by CREST and the average length of support by the team is around 30 days. 60. The two Home Treatment Teams in Lambeth (North and South) operate similarly. However the HTT service in Lambeth is available on a 24/7 basis. Accident and Emergency provision Emergency psychiatric assessment is available at A&Es at St Thomas’ Hospital in Waterloo and at KCH in Denmark Hill, Camberwell. Psychiatric Liaison Nurses at each of these acute trusts, managed by SLAM, are available 24/7 to provide assessment for deliberate self-harm patients, mental health intervention for patients presenting to A&E, and education on mental health issues to general hospital staff in A&E and wards. KCH A&E is supported by an on duty dedicated Senior House Officer [SHO] and on-call consultant psychiatrist. KCH has a private interview room where people may wait for assessment. KCH and SLAM are currently developing a Safe Transfer Policy governing transfer to the Maudsley CDU from A&E. St Thomas A&E service is supported by a Senior House Officer Friday-Monday. Provision is nurse-led, with eight nurses working three shifts 8 am-9 pm. One nurse is on duty between 9 pm-8.15 am. The team is supported by an SHO except Tuesday, Wednesday Thursday. Individuals who are brought to A&E by friends or other agencies [including the Police] wait within A&E until triage and further assessment by a Psychiatric Liaison Nurse where mental ill health is believed to be the reason for presentation and treatment is not required for physical illness or injury. A&E departments are required to meet 4-hr targets for presentations, mental health presentations making up the longest breaches. CDU beds are not subject to the 4hr target, however. Emergency Clinic The Maudsley Hospital Emergency Clinic is located directly across Denmark Hill, 5 minutes away from KCH’s A&E department. It provides assessment for people self-presenting and those referred there by GPs. Until March 2006 it was able to receive Section 136 presentations via Police [during the period of the scrutiny review this function was transferred to Eileen Skellern 1 ward at the Maudsley Hospital]. It is the only 24/7 self-referral service of its kind in the UK and has been open since the 1950s. In addition, the EC offers follow-up assessment and brief treatment, support to service users waiting for admission, and operates as a back-up to KCH A&E by providing facilities where people with complex presentations can wait for assessment by HTTs or admission to inpatient psychiatric wards. The current configuration of the EC includes one room where one person may be accommodated overnight. If this happens, the walk-in clinic must close to presentations, however.
Currently, the EC is staffed by psychiatric nurses, a staff grade psychiatrist, a psychiatric senior house officer and supervised by a part-time consultant psychiatrist. The Emergency Clinic is not subject to the same 4 hour performance target as A&E. In 2004/05 3,503 service users attended the EC, 1,831 [52%] from Southwark and 1095 [31%] from Lambeth. Users also included people from other London boroughs and elsewhere in the UK. Lambeth Hospital Lambeth Hospital is home to one of two 136 suites for assessment of people brought in by Police under Section 136 of the Mental Health Act – this is managed by SLAM. South East Doctors Co-operative [SELDOC] SELDOC runs a 24-hour answering service and provides a duty doctor service between 6:30pm and 8:00am weekdays and 24-hours on weekends and bank holidays. This service covers Lambeth, Southwark and Lewisham and handles approximately 59,622 calls per year. Following initial patient contact by telephone, details of symptoms are taken and passed to a duty doctor who then calls the patient back to discuss. Most calls are concluded with advice, but patients may need to attend a primary care centres at Dulwich Hospital or Lewisham Hospital, or a mobile doctor may visit at home. The National Service Framework for Mental Health The NSF addresses the mental health needs of working age adults up to 65 years and sets national standards and defines service models for promoting mental health and treating mental illness in six key areas. For the purpose of this review the most relevant standards are standards two, three, four and six: Standard Two • Any service user who contacts their primary health care team with a common mental health problem should i. have their mental health needs identified and assessed ii. be offered effective treatments, including referral to specialist services for further assessments, treatment and care if they require it Standard Three • Any individual with a common mental health problem should i. be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care ii. be able to use NHS Direct as it develops for first-level advice and referral on to specialist helplines or to local services Standard Four • All mental health service users on the Care Programme Approach (CPA) should
i. receive care which optimizes engagement, prevents or anticipates crisis, and reduces risk ii. have a copy of a written care plan which: • includes the action to be taken in a crisis by service users • their carers and their care co-ordinators • advises the GP how they should respond if the service user needs additional help • is regularly reviewed by the care co-ordinator iii. be able to access services 24 hours a day, 365 days a year 81. Standard 6 • All individuals who provide regular and substantial care for a person on CPA should: i. have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis ii. have their own written care plan, which is given to them and implemented in discussion with them.
Key findings and recommendations
82. 83. Summary of and rationale for SLAM’s consultation proposals In December 2005 SLAM published its formal public consultation proposals for the future of mental health crisis services in Lambeth and Southwark. The consultation follows a service review carried out between July 2004 and September 2005, the review involving a wide range of stakeholders including service users, the police, Kings College Hospital NHS Trust, Guys and St Thomas Foundation Trust and Lambeth and Southwark PCTs. A stakeholder steering group was set up to oversee the review and develop proposals. The steering group commissioned a range of work which included an audit of presentations to mental health crisis services and a stakeholder event. SLAM initiated the review for a range of reasons including The risk of duplication of services across the crisis mental health services which was not considered to represent value for money • The multiple points of entry to the current system which could be confusing for service users • The need for a greater emphasis on preventing crisis rather than managing it • The EC is increasingly providing a service to patients with serious and complex problems who need to remain in the clinic overnight to allow a full assessment of their needs to take place Both Southwark and Lambeth PCTs and SLAM have advised that the review was not initiated by a need to find savings but to address problems in the crisis care system as a whole. In the last four years about £3.2 million has been invested in improving crisis services in Lambeth and Southwark. This has led to the expansion in mental health A&E services at Kings and St Thomas and the introduction of four Home Treatment Teams in the two boroughs. A study of adult Acute Crisis Services in Southwark commissioned by SLAM’s Acting Commissioner and undertaken in September and November 2004 by consultant Stephen Niemiec had already highlighted the fragmentation of services in that borough, observing that “Feedback from staff across the service confirms findings that there is very little joined up approaches [sic] to care within the adult acute areas. The service is fragmented. All staff and service users I met with held this perception”. 87. The PCTs have stated that any recommendations from the review need to be achievable within existing resources. The proposal put forward by SLAM is that the EC will be refurbished to provide a five bedded clinical decision unit. SLAM considers that this will • provide back up to A&E departments for people who are awaiting admission to hospital or a further assessment
provide better facilities to care for users with complex needs overnight and be supported in an environment offering greater privacy and dignity than at present allow more time to support service users through their crisis and give more choice and flexibility about the best course of action.
The principal disadvantage identified by the trust is that the EC would no longer be available to self presentation and people would therefore need to use the other forms of crisis care available in the two boroughs. It also recognises that some of the current users of the EC would be likely to attend A&E instead which would increase the workload there. However it states that both A&Es have experienced psychiatric nurses and psychiatrists available around the clock and that the proposals meet national policy requirements. The trust has additionally stated that the Mental Health Act Commissioner has expressed concerns about the legal position of patients in the EC subject to detention. Legal advice to the Trust reportedly is that the EC should only accept admissions to a discrete and staffed area, separate from walk-in facilities. Conclusions of the Joint Committee
Given the complexity of the existing system this report does not seek to explain existing provision in minute detail, as in any case this was not its remit, but rather to explain the committee’s position in relation to SLAM’s formal proposals for change and to make system-wide recommendations for improvement that it would expect all key partners to take on board together, recognising that whatever changes are ultimately made to the existing local system the co-operation of all other partners will be vital to its success. The Joint Committee does not support the proposed option for change because it is not satisfied that the proposed changes to mental health crisis services, particularly the withdrawal of the self-referral, walk-in, 24 hour facility at the Maudsley Emergency Clinic, as set out in the South London and Maudsley (SLAM) NHS Trust’s ‘Lambeth and Southwark mental health crisis care review’ consultation document, are in the interests of the health of local people in Lambeth and Southwark. The Joint Committee reached its conclusions as follows. MAKING THE EXISTING SYSTEM WORK BETTER [RECOMMENDATION 1] The committee recommends that a whole system approach to mental health crisis services is needed across both boroughs – with shortcomings in the existing system addressed, and key parts of the system strengthened before any reconfiguration is progressed. “ The system is like a giant jigsaw puzzle. If the EC goes, the whole of the rest of the system will have to cope with the impact”. [service user]
The stated starting point for SLAM’s own review of crisis services in both
boroughs between July 2004 and September 2005 was to consider how well services were working together, to identify how well they were meeting key stakeholder needs and to consider options for service improvement [SLAM, 2005] 95. During the scrutiny review the JC invited input and received feedback on the proposals from key stakeholders involved in local service delivery including the Primary Care Trusts of both boroughs, the police, Social Services, police and community consultative bodies, the local voluntary sector, and interested individuals who either received services or cared for others who did. As part of their work, JC Members observed SLAM’s consultation sessions with healthcare staff and attended several user-led consultation sessions. Prior to SLAM’s formal consultation period Members and scrutiny support attended the trust’s Emergency Services Steering Group meetings. SLAM’s consultation proposal document acknowledged that the way in which the current system was configured and used by those delivering and receiving services was complex and that duplication occurred. The trust and users both gave examples of its negative impact on quality of care including individuals having to undergo repeated assessments by different parts of the system before accessing services and instances of less than effective communication between parts of the system that should have been working together better to support service users. That the various parts of the current system did not always work together effectively to the benefit of service users, staff and other parts of the system was borne out by information from key local stakeholders during the review. Also during the review the JC heard that an Unscheduled Care Strategy for both physical and mental health was in development, the purpose of the strategy being to reduce the need for crisis care by increased emphasis on early intervention and a more integrated approach between PCTs, Social Services departments and other providers. Community Mental Health Teams [CMHTs] 99. SLAM reported that 60% of users presenting to A&E were known to CMHT’s and that in the event of EC closure the trust anticipated these people would instead approach CMHT’s when in crisis. However, the Committee was not able to satisfy itself that analysis of current CMHT workloads nor capacity to meet the needs of additional patients redirected from the EC had been carried out, a concern reflected in the submission of one of the acute trusts. This was concerning to the JC given CMHTs role as gatekeepers to other secondary mental health services, locally. Service users described using CMHTs as “a lottery” and several, including those already known to CMHTs and with the service as an agreed element within their Care Plan, reported that the service had on occasion been insufficiently responsive when they were in crisis, leading them to endure long waits for CMHT help. CMHTs 9-5 pm weekday opening hours and lack of weekend opening was problematic to users. In addition to reported inconsistencies in service to known users, the Committee was also concerned
about how potential users not yet known to services might fare if the CMHTs were expected to deal with an increase in demand for their services, given no additional resources. Members also heard from users that not all individuals referred to CMHTs were accepted by the service, however the Committee did not receive further evidence on this point. 101. Southwark MIND and Lambeth Mental Health & Disabled People’s Action Group both expressed concern that many people in contact with these groups neither knew their CMHT representative nor had a Care Plan. In the Healthcare Commission 2005 Patient Survey of Mental Health Trusts SLAM scored in the worst performing 20% of trusts for patient understanding of and involvement in deciding the contents of individual Care Plans. Furthermore, implementation of SLAM’s proposals would require all existing care plans in which the EC was an element to be amended/updated to re-direct people to CMHTs. The potential for confusion across the system about new arrangements caused concern to the committee. The committee thought that the high percentage of presentations to the EC by existing service users might indicate that CMHTs [with whom existing users were already expected to make contact under the existing system] might not be sufficiently meeting the needs of these people and that users might therefore be “voting with their feet” for the service that they felt best met their needs in preventing crises. In his report on Southwark, commissioned by the Emergency Services Steering Group, Steve Neimiec described how CMHTs had experienced difficulties with referrals to CREST resulting in their own work becoming focused on addressing urgent crises rather than continuing care, and believed this “perverse capacity circle” encouraged EC use. SLAM was upfront about this being a rationale for its reconfiguration. However, evidence to the committee appeared not to support this. Scrutiny heard that EC acts as a safety net for the system and is unique in being an open-access gateway to other services. Many service users told the committee that they would not be prepared to attend A&E in any event. SLAM assured the JC that its Community Mental Health Teams across both boroughs were currently being reviewed, which review was focused on increasing responsiveness and increasing support to GPs through Home Treatment Teams. The committee has heard that a range of service delivery improvements will be introduced to address existing inconsistencies in crisis mental health services. However, the committee was not presented with an implementation plan or timetable to indicate when and how these might be brought about, or how it was intended to dovetail these with proposed changes to the EC. Care Plans 107. A common concern raised consistently with the JC was that although CPA applies to everyone with serious mental health problems who is accepted as a client of specialist mental health services, there was anecdotal evidence that
some people did not have a Care Plan, despite these being key to accessing CMHTs and the secondary mental health services to which they provided referral. In addition, there were reports from user groups of very varied levels of understanding amongst individuals of their care plans and their roles/involvement in them. Some users with whom the JC spoke commented that those on Standard rather than Enhanced CPA received less support from CMHTs, despite believing they were just as likely to experience crisis, and thus to need access to preventative services.
[RECOMMENDATION 2] Committee members, many service users, and some staff at St Thomas’ and Kings A&Es expressed serious reservations about the capacity and appropriateness of A&E facilities to provide quality crisis care for people in mental distress and to contain any increased pressure of demand for services. The committee would like to see the situation for patients attending and waiting at A&E addressed regardless of the outcome of the trust’s crisis services review. The National Service Framework for Mental Health is one of the key national policy drivers for mental health policy. Standard three requires that any individual with a common mental health problem should:
be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care be able to use NHS Direct as it develops for first level advice and referral on to specialist help lines or to other local services
At its initial meeting the committee discussed with SLAM whether the proposals met the NSF. It was confirmed that all the core standards were being met including the provision of a 24 hour service via A&E at KCH and St Thomas’. However following visits to both A&Es, discussions with medical professionals at the hospitals and comments from service users the committee has serious concerns that A&Es are currently able to deliver quality and timely care to people experiencing a mental health crisis alongside individuals who are seeking medical help for physical problems. This is not to imply any criticism of staff but intended to focus attention on the appropriateness of the facilities and circumstances in which patients suffering mental distress await treatment at A&E. The committee made an afternoon visit to the A&E department at St Thomas’ and went to KCH in the early evening. During both visits members discussed the patient pathway for a client with mental health problems attending A&E in a crisis and the pathways when an individual either self-presents, is brought in by ambulance or arrives escorted by police. In addition the committee discussed with these trusts about the potential impact of the proposals on A&E should the EC close to self-presentations. Both Kings and St Thomas’ anticipate that the net effect of closure of the EC would be a significant increase in the number of patients with mental health problems attending their A&Es and an increase in complexity in the nature of the problems to be dealt with. The committee heard that many of those who
attend at A&E are patients who self harm or require medical support and the perception was that those who attend the EC direct have more complex mental health problems. 113. Between April 2004 and April 2005 St Thomas’ saw an average of 207 mental health presentations each month. Based on a monthly audit of those presenting to the EC between April 05 – June 05 and a patient’s recorded place of residence, the mental health liaison team estimate that an additional 40 people suffering from mental health problems/in crisis would attend at St Thomas’ A&E each month. KCH currently has on average 5 attendances per day. The expectation is that this would increase to 10 per day or 150 per month. Comparative statistics from other A&Es for mental health attendances were not obtained but the location of St Thomas’ [in particular] and KCH close to central London brought the increased likelihood that non-borough residents would use these facilities in addition to patients brought there by emergency services based outside Lambeth and Southwark. Both departments expressed concern about the impact of the potential increase in presentations on patient waiting times and on hospital targets. At present little has been identified by way of resources to support the increase in potential attendances resulting from A&Es becoming the only 24 hour emergency entry points for mental health services. Both A&Es currently experience difficulties in meeting the national 4-hour waiting targets for A&E attendance for people with mental health problems. The most recently available borough-based figures record that 21.4% of Lambeth patients attending A&E and 20.5% from Southwark wait more than 4 hours from the point of arrival to the point of leaving the department. [This compares to 8.8% in Lewisham and 4.6% Croydon – the two other boroughs covered by SLAM services]. It was further reported that on occasion more serious 12 hours waits have been breached in A&E. Breaches can be for a number of reasons but in general would involve patients with the most complex needs waiting assessment and requiring admission. Both trusts were of the clear view that A&E was not an appropriate environment for patients to be waiting for a long time for treatment or assessment. The long waiting time to be seen and the perceived lower priority given to patients with mental health problems was consistently raised by service users as a key reason for choosing to self-present to the EC where an individual could be assured they would be seen by a specialist mental health professional. Service users also cited how difficult it could be when in crisis to deal with the reception and initial triage stages involved in presenting at A&E. Most individuals attending the discussion session arranged by the committee quoted that their experience of A&E was not good and considered it to be a service geared to provide for physical ill health in an emergency rather than mental ill health. This was reflected in written submissions to the committee. Patients who self-present were free to leave the A&E at will and whilst the A&E teams advised that they would follow up on those who ‘did not want treatment’ service users mentioned that those who are quietly unwell and not causing a disturbance would often slip out unnoticed and before receiving
treatment. There are no holding powers at A&E although under common law if the circumstances can be established that a patient lacks key competences and is at risk/vulnerable in a serious way the hospital has a duty of care to act in the patient’s best interest and aim to keep on the premises, including being physically restrained and held as necessary. The EC also has no powers to detain individuals but in the view of service users provides a more secure environment to those who attend [in comparison to A&E] in that people presenting there cannot simply walk out of the clinic without asking a staff member to open the door for them. In the absence of the EC service users feared a situation in which self-presenting patients might leave A&E and potentially do themselves harm or commit suicide. 118. Patients awaiting treatment at A&E for mental health problems are required to wait in the general reception alongside those patients seeking medical help. It was recognised by health staff that this was not a satisfactory situation and in particular that the circumstances at A&E did not provide an environment conducive to calming patients with psychotic symptoms. For patients the experience of waiting alongside the physically injured when suffering from paranoia or mental illness could exacerbate their distress; it was also raised that it would be an equally distressing experience for physically unwell patients to wait alongside people in crisis or distress. There are no containment facilities at A&E so those deemed at risk to themselves have to be managed in the general A& E environment. The issue of the need to manage and restrain disturbed clients at A&E was raised as one of the challenges for staff. As for patients the use of security staff to restrain patients at A&E, the intimidatory nature of A&E when in crisis (as well as being ‘too loud, too scary’) and unsympathetic behaviour and lack of knowledge by some non-mental health specialist staff. The problem of providing privacy and dignity at A&E to clients suffering acute mental distress was cited by both health professionals and service users. KCH had carried out a review of the environment and a private interview room, ‘the blue room’, had been created where people could sit and relax prior to assessment (although this was also used for other clients). Lack of space at both A&Es and financial resources limited the capacity to make further changes to the environment. Staff reported that all areas of A&E were currently working over capacity and based on the evidence heard the committee can only conclude that this situation would become worse should the EC be closed and the number of presentations to A&E increase. Medical staff also raised instances in which the police brought patients in a disturbed state to A&E despite this not being a recognised place of safety, although subsequent discussion with Southwark and Lambeth police on this issue revealed that this was not the protocol to which local police worked. In addition, and St Thomas’ had developed good practice guidelines for police presentations to A&E. It was thought that other forces in the London area and the London Transport Police might take patients to A&E in this situation, however. The view that A&E is not an appropriate place to treat mentally ill or mentally distressed people because it neither provides a place of safety nor a specialised mental health service was voiced by Lambeth Community-Police
Consultative Committee and was reflected in its submission to the recent Metropolitan Police Authority review on policing and mental health. 122. Whilst SLAM has stated that higher numbers of clients attend at A&E than the EC, it was informally raised by the SLAM Patient & Public Involvement Forum that the figures for A&E attendances do not contain an analysis of how or why patients attend in a crisis and may reflect that some patients are taken there by emergency services, rather than indicating individual choice. Similarly, service users commented that the EC is not well publicised and committee members considered that the service is not well signposted to potential users as a walk-in, 24 hour resource. Whilst SLAM are of the view that the provision of a CDU will alleviate the pressures of complex presentations at A&E the committee heard strong reservations from A&E staff as to how this would work in practice based on the current proposals and lack of additional resources. These reservations have also been stated in the draft written submissions to SLAM made by the trusts. St Thomas in particular questioned how the CDU model would be of benefit to its service provision. The limited bed capacity of the CDU, its location close to Kings and the distance from St Thomas led the trust to think that it was likely the facility would be of more benefit to KCH. In addition the proposal does not make clear how CDU beds would be allocated – St Thomas suggested that some beds might be ‘ring fenced’ to each Trust; at the consultation session for Southwark SLAM staff it was indicated by managers that Lambeth would have 2 of the 5 beds and Southwark the remaining 3. From discussions with the acute trusts the committee is concerned that significant details still needs to be worked up with key partners as to how the CDU would operate in practice and complement the work of neighbouring acute trusts without creating additional problems at A&E. The issue of transporting patients between facilities was also of concern to both trusts and requests by the committee for further information on the proposed patient safe transfer policy as well as an outline implementation plan for the reconfiguration of the service has not been made available to the committee despite requests to SLAM.
[RECOMMENDATION 3] Although forming part of the trust’s overall plan for the future of local crisis mental health services, the Committee would like to see increased commissioning emphasis on non-medical model services such as services which could provide informed support and valuable social contact, particularly out of hours. It was raised by SLAM that relatively stable people present themselves at the EC because the clinic offers a welcoming environment where they know the staff. In the committee’s discussions with service users there was some acknowledgement that, for those people who know about the EC, its very
existence and the direct access to staff who understand mental ill health provides comfort to those who need support which might not be overtly medical. Sometimes those enduring a less severe crisis needed medical intervention but that more drop-in provision and access to support services, particularly out of hours was needed. 129. Whilst the provision of accessible non-medical support services was an issue for service users in both boroughs it appeared to be a greater problem for Lambeth clients. It was considered that fewer day services existed in Lambeth than Southwark to which clients had access, either because of the withdrawal of funding to day centres in recent years or the need for an individual to have a care plan to access such services. The Lorrimore was cited on several occasions as a service to which Lambeth clients no longer had easy access, as was the change in service at the Shore Centre. It was not the remit (nor within the capacity) of the committee to focus on what model non-medical provision should take. However SLAM’s consultation documentation notes that at its Stakeholders Day the issue of gaps in provision of social and psychological care was noted – service users expressed a wish for more out of hours day care, a help line and access to out of hours counseling services. The existing gaps in service provision and the need to extend the drop in model for out of hours provision beyond the medical model of service delivery was accepted by the PCTs and SLAM in their respective capacity as service commissioners and provider. In December 2005 the PCTs advised the committee that each borough had submitted a Local Delivery Plan funding bid for £50,000 to pump prime some of the non-medical service initiatives which service users had requested. By the end of the consultation period it was not established whether this funding has been agreed nor the detail of what services might be expected to follow. The committee cannot therefore be assured that this will come on stream. Whilst accepting that finances are finite, the committee again strongly feels that there are too many aspects of the proposals associated with the service change at the EC which are insufficiently robust or worked through. The extension of such services is something the committee strongly supports, however.
[RECOMMENDATION 4] The committee supports the need for a properly resourced, targeted and user-friendly telephone advice service and notes the service user preference that this be provided independently of SLAM. The subject of a 24-hour telephone support and advice service has been proposed by SLAM for some time. Service users have supported the idea that such a service is provided and that it be independent of SLAM. In January 2005 the SLAM briefing to Lambeth Health Scrutiny Sub Committee advised that a proposal was “being considered for the provision of a 24 hour help line via a voluntary sector organization”. During the review the committee heard from Rethink, a national charity that works with mental health service users, carers and professionals. The
organisation manages a number of services across the UK including a 24hour helpline that is integrated with crisis services. The helpline can be used to agree a plan of action with the service user to fast track them into accommodation without having to go to A&E. As Rethink does not operate a self-referral service the helpline is the main way to get in touch with the organization’s service. Research undertaken by Rethink and commissioned by the Department of Health/National Institute for Mental Health in England was provided to the committee. One of the main characteristics of the helpline service was the usefulness as a local resource for service users in need of listening, emotional and social support. 135. However during the review the committee was given to understand that any helpline would be provided via existing health services due to cost limitations. The committee welcomes the introduction a 24 hour telephone advice service but urge that its delivery be subject to further consideration following discussion with service users and health providers. In particular SLAM should consider the benefits of wider partnership working with voluntary organisations. Moreover St Thomas’ has expressed concern about the prospect of the SLAM service offering immediate consultation in A&E with a psychiatric liaison nurse. This could overstretch the PLN team and, as the telephone support and rapid psychiatric assessment are effectively new services would need to be resourced accordingly.
[RECOMMENDATION 5] The committee would like to see the trust and other delivery partners working closely with non-statutory organisations to ensure provision of clear and timely information to assist navigation around existing and future local provision. This should be available to service users, potential users of services, carers, those responsible for making referrals to services and the wider local community. Despite its complexities, many current service users appeared to have come to a working understanding of the local system, both through their own experience, through local service user networks and mental health voluntary organisations. It was clear however that there was a much better level of knowledge generally about the Emergency Clinic not only amongst local service users but those within South East London and more widely across the rest of the UK. The committee heard how one user had been brought for help by a member of her family to the EC from North East England, because she had heard of its reputation. “It makes me wonder about all the people who just need to make short term use of mental health services. How do they find their way through the system?” [service user]
SLAM has acknowledged that the local system is complex and cites service duplication as one justification for the proposed changes. This being the case, there appear to be few concrete plans being developed by the trust to try to
address this information gap, for example an information strategy targeted towards explaining the current system to existing users, let alone a strategy to disseminate information locally through the whole system about major system change. The committee was particularly concerned about how the trust would ensure that not only existing users but potential services users, GPs, and other delivery partners, would be informed about the changes proposed, to the benefit of the local population. 141. The committee believes it is important that individuals are given information to explain the current system, their relationship with it, service standards they can expect and where they should go for help in a crisis. The committee did not, however, receive information about how long it would take for the trust to update all individual crisis plans within care plans, nor a timetable for doing so. During the scrutiny, local mental health voluntary organisations and user groups demonstrated their ability to disseminate information effectively and widely about the trust’s proposals to their networks and the work of scrutiny review. The committee suggests that the trust and other delivery partners might develop appropriate partnerships with non-statutory organizations to ensure that information enabling navigation around the local system is available to service users, potential users of services, those responsible for making referrals to services and the wider local community.
THE CURRENT PROPOSALS FOR CHANGE [RECOMMENDATION 6] The concerns of the Mental Health Act Commissioner in November 2005 were reported to the committee. However, the committee would like to see the trust exploring alternative options by which these might be addressed, other than closure of the EC. The Committee heard that the Mental Health Act Commissioner had raised concerns regarding the EC in a report. Although the committee did not see the report from the Commissioner which referred to the EC, it was presented with a management briefing paper for the Trust Board indicating how the trust might act on the concerns reportedly raised around the legal position of patients in the EC subject to detention. The trust suggested that the physical environment of the EC was such that patients with complex needs to be accommodated overnight at the EC were not afforded adequate privacy and dignity in the current building. In addition, SLAM stated that to comply with the provisions of the Mental Health Act 1993 the CDU and walk-in assessment areas would need to be physically separate. Whilst no evidence was presented to suggest this was not practically possible, the trust stated that management of two discrete areas posed safety/risk management problems if undertaken within existing staffing levels.
SLAM told the JC that it had seen a trend for service users with complex needs being brought to the EC from KCH A&E and needing overnight accommodation [30% of additional service users with complex needs] to wait for further assessment by HTTs or admission and that this was as a consequence of SLAM supporting KCH to simultaneously manage people with mental health problems and meet 4-hr A&E targets. The trust acknowledged that its proposals would result in a walk-in facility no longer being available, but put forward the argument that it needed to address duplication in the system, provide a satisfactory level of service to people with complex needs and said it therefore planned to convert the EC to a Clinical Decision Unit order to provide better facilities for those needing overnight accommodation. In her paper to the Board the Deputy Director of Nursing concludes that “Allocating clinical decision beds is acceptable if such beds are clearly separated from the walk-in facility of the clinic”. In view of the strength of feeling about the reconfiguration of the EC the committee strongly recommends that SLAM and the PCTs explore alternative options by which the concerns of the Commissioner can be met, other than withdrawal of the walk-in, self-referral facility.
[RECOMMENDATION 7] The committee believes that a self-referral, walk-in, 24 hour specialist mental health facility should continue to be available locally, in whatever form. Consistently throughout the committee’s scrutiny of SLAM’s proposals, in evidence given at meetings, in the service-user feedback session held by the committee, in written submissions from individuals, a local ward councillor, and service user organisations, the clear message was that the Emergency Clinic in its current form is a greatly valued service. The EC’s defining benefits are that it is available 24 hours a day, seven days a week, without referral and it is a specialist mental health service. That the EC is multifunctional is used by SLAM as justification for the proposed reconfiguration, rather than apparently being seen as a strength of current provision. In addition to its defining benefits, SLAM acknowledges that the Emergency Clinic provides support to the rest of the local system, including enabling assessment of people with complex needs from KCH A&E, and providing a point to which police may bring individuals in crisis. The EC as it currently operates appears uniquely to be a service that is: • Preventative – acts to prevent users reaching crisis – its very existence reportedly provides a level of day-to-day confidence to existing users with severe mental illness • Accessible - is a place to which anyone can self refer or be taken when in crisis • Specialist – the Emergency Clinic is perceived by service users and recognised by other parts of the system as having the necessary specialist
knowledge and skills to address the needs of people in crisis. Service users have confidence in the Clinic as a safe space to go when they feel they may be approaching crisis. Responsive – service users report being able to get the help they need more easily via the Emergency Clinic than by other routes extant.
It was almost inevitable that with an existing service under threat, opinions expressed during the review would be polarised. The Committee heard the trust’s concerns about its ability to offer proper privacy and dignity to users at the EC in its current physical configuration, and heard that the EC regularly had to close to walk-in presentations if an individual required overnight accommodation at the EC. Despite the limitations of the clinic’s physical environment, which Members visited during the review, service user feedback indicated that it was still preferred to A&E as a point of access. The message appeared to be that the EC is more than the sum of its less than perfect parts. In the context of the committee’s terms of reference it is important to remember that although the EC is used regularly by a number of local longterm service users, it is a potential resource for everyone who needs it across all boroughs in which SLAM operates, i.e. Lambeth, Southwark, Lewisham and Croydon. In addition the committee heard that the clinic is used by people from other parts of the UK. For the committee to support SLAM’s proposal it would need to be satisfied that the needs of these people would be served elsewhere in the system. As part of the scrutiny review the committee invited feedback from a wide range of stakeholders on current services and SLAM’s proposals. The committee invited people to make their own recommendations about how the system might be improved. These key questions are set out in Appendix C. Firstly, the EC’s accessibility “out of hours” sets it apart from other local mainstream services. For example, CMHT services are not available outside office hours, and as users pointed out the times at which crises occurred were often unpredictable and as such did not align with service availability, other than that provided at the EC currently. This is significant in relation to whether the health of local people would be served by SLAM’s proposals for change. Both Lambeth and Southwark Primary Care Trusts are broadly supportive of the drive to modernise mental health services locally but during the review indicated that their support was subject to action being taken to strengthen the entire local system in particular through extended service hours and better connectivity between emergency and community services to support people with mental health problems. The committee considered whether A&E might be considered an appropriate alternative as an out of hours service for people in mental health crisis. It visited A&E departments at KCH and GSTT and spoke with the police, local mental health voluntary organisations, user groups, individual users and representatives from both acute trusts and Lambeth’s Community-Police Consultative Group. Whilst there was nothing to suggest lack of professionalism on the part of any A&E staff, it was apparent that existing demands on these busy A&E departments left little capacity within which to
find the space or flexibility needed to address mental health crisis. The Committee was told that people attending A&E with mental health problems often led to acute trusts breaching 4-hour waiting targets in A&E. 162. Individuals shared their experience of attending A&E when in crisis. This indicated to the Committee that in relation to people experiencing symptoms of severe mental illness, there exist very real barriers to this service being a viable option for support for those in crisis. Users who had sought help at A&E in a crisis voluntarily or who were brought there by police were well aware that A&E was expected to deal with a range of emergencies, of which mental health crisis was only one. Several people said that they were likely to leave A&E before being seen because waiting to be triaged in the busy atmosphere of the emergency department was likely to actively increase their distress. Service users felt there was a real danger that those leaving A&E before being seen by medical staff might potentially cause themselves harm. Service users acknowledged that restraint was sometimes needed when they were in crisis. The committee heard from one user however who felt security guards at A&E were perceived to be utilised too readily when people in crisis were loudly vocal as a result of their distress. The committee was made aware that Lambeth and Southwark PCTs and local NHS trusts were developing an Unscheduled Care Strategy one of the aims being to reduce demand for [physical and mental health] 24/7 crisis care through earlier intervention but details of the strategy were not discussed in depth by those bringing evidence to scrutiny. A specialist mental health service “I need specialised services that can cope with me in a crisis” [Service user] 165. SLAM’s proposals that people in crisis should contact their CMHTs or attend A&E elicited strong responses from service users not least of these being that when compared to the EC, these other services had either insufficient specialization or insufficient flexibility to be considered equivalent services. Southwark Mind argued very clearly for the need for self-referral, preferably via the Emergency Clinic in its current form, and if this was not possible suggested SLAM operate a scaled-down CDU with three rather than five beds, operated alongside a restricted hours walk-in facility. In addition, at a consultation session for service users co-ordinated by Southwark MIND the meeting unanimously agreed the following: “The participants in these workshops have no confidence in SLAM’s consultation process and strongly request the Joint Lambeth & Southwark Health Scrutiny Committee to refer this matter to the Secretary of State and in doing so, to make clear what the experiences and views of service users are and to present the option for public consultation which was drawn up by users.”
[RECOMMENDATION 8] The committee is concerned that SLAM’s proposals for reconfiguration may impact disproportionately on BME communities. The committee recommends that the impact of EC closure across the local system is subject to a full Equalities Impact Assessment before any reconfiguration is progressed. The Race Relations (Amendment) Act 2000 places a duty on public authorities to promote race equality. Some authorities also have specific duties including a requirement to collect and publish specific information relation to staff ethnicity and the impact of their services and policies on the promotion of race equality. There is evidence nationally indicating that disproportionate numbers of people from all ethnic groups are represented in mental health services and that certain ethnic groups may be at increased risk of developing mental health problems than their non-BME counterparts. An audit of crisis presentations undertaken by the trust in November 2004 indicated that of people presenting to local services in a crisis, fewer people from black minority ethnic groups presented to A&E [12%] than presented to either the Emergency Clinic [22%] or Community Mental Health Teams [42%]. This seems to suggest that when there exists a degree of choice between access points, A&E is the least preferred option by BME service users in a crisis. SLAM also acknowledges that BME people generally experience poorer outcomes having accessed mental healthcare via emergency services when compared to access help via primary care pathways. Within this in mind, replacement of a preferred non-emergency pathway with one that is neither a specialist mental healthcare pathway, preferred by service users, nor takes account of known health inequalities experienced by BME people in relation to mental health, seems somewhat perverse. The recent report Breaking the Circles of Fear [Sainsbury Centre for Mental Health, 2003] suggested that BME people are less likely to access mental healthcare through primary care pathways. It would appear that the local system needs to find out how primary healthcare might be made an option of choice for BME people seeking help for mental health problems, whilst retaining preferred local access points until such time as the entire system better meets their needs. The committee was advised that both boroughs are reportedly Focused Implementation Sites for implementation of Delivering Race Equality [DRE] in mental health services, which initiative aims to reduce admission and sectioning rates within the BME community. Whist SLAM’s formal consultation document included a Race Impact Assessment of Option 2 [the trust’s preferred option] no comparative analysis of current configuration or the user option was presented. The committee was therefore unable to draw any comparison between the options in respect
of their impact on promotion of race equality. 176. The committee is not convinced that SLAM has undertaken a full Equality Impact Assessment of the current configuration and the previously proposed user configuration. The committee recommends the Trust undertakes such assessment in order that comparisons can be better drawn between options for service development, and the potential impact on all sections of the local community known to experience inequalities in service outcomes better understood. The committee recommends that all local trusts undertake EIAs of all future proposals for change presented to health scrutiny committees locally. CONSULTATION [RECOMMENDATION 9] The Committee considers that SLAM’s consultation process including the way in which consultation options were formulated have been less than ideal, because: the views of non-SL&M members of the crisis services review steering group (i.e. service users, carers and other relevant voluntary and statutory agencies, including the police) appeared not to have been significantly reflected in SLAM’s final consultation option for public consultation; and the perception of service users and user groups was that their contributions played no meaningful role in the outcome of the trust’s consultation processes. The Joint Committee recommends that the trust addresses concerns raised by the JC in respect of this consultation in order to ensure that its consultation process and practices are inclusive and comprehensive in future. 178. NHS health Trusts have a specific duty to consult with stakeholder groups on changes to service provision, as well as a separate duty to consult the relevant overview and scrutiny committee/s. At the inception of this review the committee was clear that it did not wish to duplicate the formal stakeholder consultation being undertaken by SLAM (indeed we specifically wished to avoid stakeholders experiencing the notion of ‘consultation fatigue’). During the review the committee sought assurance that SLAM’s consultation had been inclusive, accessible and robust. The committee had particular concerns about changes to SLAM’s formal consultation timetable and formal sessions occurring late into the consultation timetable. For example, no carer specific events were included within the trust’s initial consultation plan, despite their valuable role in providing support to those with mental illness. In our discussions with different stakeholder groups we have sought their views firstly on involvement in the initial development of the proposal options that are the subject of consultation and secondly their experience of SLAM’s formal three-month consultation process.
At an early stage of the crisis review process, SLAM in partnership with Southwark and Lambeth PCTs hosted an open event for stakeholders to explore what constitutes a good crisis service. The report from the event in January 2005 formed part of SLAM’s consultation documentation and it is understood that the feedback from the workshop was to be one of the key strands used by the Crisis Review Steering Group in deciding what recommendations to make about the future of crisis services. It is worth noting the brief description of a good crisis service highlighted in the workshop report and provided by one of the discussion groups: An easily accessible, responsive, holistic, user-led service where the patient is treated with dignity and respect The report goes on to state that ‘a recurring theme of the workshop was the importance of giving more attention to the views and contributions of people who use crisis services, and their families and carers. Pay attention to your customers’. Whilst the committee fully accept the problems with creating a wish list of services for which funding may not be available, we are disappointed that in presenting its consultation proposals SLAM has focused solely on the issue of changing the role of the EC to a CDU. It would seem that the views reported from the workshop (attended by approximately 100 people) bear little relation to the final proposals and have been drawn up without sufficient consideration or evidence as to how other elements of the system (including non-medical models) may be developed or introduced to deliver improved integrated services rather than simply the loss of a valued service. Crisis Services Steering Group
182. 183. 184.
More importantly we were not assured that in developing the option for consultation the Crisis Service Steering Group has paid attention to the voice of its customers or the range of interests represented on the group. We heard from Lambeth User Voice that the Crisis Services Steering Group which included service users, and belatedly a carer from Southwark, had worked hard together to form four initial consultation options including a service user option which had the EC at its centre. Despite support for this option at wider discussions in May 2005, the option was subsequently rejected by SLAM management in favour of a consultation option that was not supported by users. LUV asked the members of this committee to consider what this indicated about user involvement in the process. Southwark Mind also considered that service users had little impact on the final consultation proposals once the preferred user option for self-referral was removed. SLAM has stated that it has reacted to the strong opposition by users to the closure of the clinic by retaining the EC but focusing the service on the needs of service users with the most complex problems. We cannot overstate the view that has been given to the committee consistently by users that the key
element of the EC is the ability to self-present in times of crisis to mental health specialists. Without this self-presentation element service users do not consider the proposed reconfigured service to be providing the same function as the EC and therefore represents a fundamental change (and loss) of service. Users recognise the value of a CDU but not at the expense of the EC. 190. The committee also questioned other invited witnesses on their experience of the Steering Group and its outcome. Chief Inspector Wallace (Lambeth Police) confirmed that she had been a member of the Group but stated that none of the police input was evident in SLAM’s final proposals. Each of the health trusts in Lambeth and Southwark were also members. Whilst the PCTs have given broad support to the reconfiguration services their draft responses (as seen) have identified significant concerns and contain detailed requirements that should be in place before the EC is closed. Kings has stated that it is unable to support the proposal in its current form. Guys and St Thomas (draft response) is supportive in principle of the proposed changes but in conclusion the trust states: ‘The Trust has some significant concerns that, unless parallel improvements in the way that Community Health Teams work and clear agreed operating policies for the CDU are put in place, the closure of the EC could have a detrimental effect on mental health patients in crisis and on the A&E at St Thomas Hospital’ 191. In view of the above we must question whether the final preferred option reflects the membership and views of the group set up to oversee the process and whether the proposal has been sufficiently worked up in inception before becoming the subject of public consultation. Consultation documents 192. We would also wish to comment briefly on the quality of the consultation papers published by SLAM and its formal consultation process. We hope that these comments may be taken into account in any future consultation undertaken by the trust. The committee received a copy of SLAM’s consultation document at the start of the formal process (it had access to the draft before the consultation began) and received updated copies from SLAM of its consultation plan. Despite the long lead in period before the consultation process began in December 2005, the committee was at that point still asking SLAM to clarify how elements of the process would be managed. In particular there was little detail provided as to proposed arrangements for pro-active engagement and information with service users, carers and other stakeholders of the proposals beyond circulating copies of the consultation documents at the start of the formal consultation. The committee held an informal service user only discussion session to gather views in confidence on 21 February, as well as a formal meeting on the same evening for public submissions. The discussions attended by
approximately 25 individuals focused on experience of current mental health services, views on the SLAM crisis care proposals and the consultation process. The committee also invited written submission and received 12 individual responses as well as a submission from the Lorrimore signed by 18 people. 195. At the session and throughout our review the committee heard complaints about the inaccessibility of SLAM’s consultation information. Creative Routes was just one voice that said that there had been no publicity about the consultation. Another individual felt that rather than circulating sufficient hard copies the proposals had been ‘just dumped on the Internet and users were left to find it for themselves.’ Individual clients had heard about the consultation only as information had ‘filtered through’ about the potential closure of the EC. In essence it appeared to the committee that cascading information further than the key statutory and voluntary organisations appeared to be largely the responsibility of voluntary groups rather than via any direct contact from SLAM. This perceived inaccessibility of consultation documentation extends beyond where and how information was made available to the format and language used within it. Whilst the committee has found the supporting information published with the main documentation helpful as background to this review, neither the key document nor separate executive summary were written in a way that was easily understood by a layperson, nor was it immediately clear what the proposals involved. The committee did not become aware of any leaflets or posters advising that the consultation was underway or how stakeholders might become involved. It was mentioned to the committee at its session with service users that there was no information available at the Emergency Clinic and staff at Kings informally mentioned that no leaflets etc had been provided to place in A&E. However an article in the February edition of Southwark Mind by the SLAM Southwark Director was timely to coincide with the Southwark MIND event. It has already been mentioned that the committee did not intend to run a consultation process to replicate SLAM’s own processes nor has it been possible for the committee to hear directly from all stakeholders whose views it may have wished to be informed. Members of the committee attended as observers a session arranged by Southwark Mind and also sat in on a consultation session with SLAM staff (primarily CREST) in Southwark. We were disappointed that no similar sessions appear to be have been held in Lambeth at which members could hear from CMHT/HTT. At the committee’s final session on 8 March, SLAM was questioned about the response so far to the consultation proposals. It appeared at that stage that minimal submissions had been received. Whilst it is usual that responses are often received close to the deadline, the committee will be interested in how inclusive SLAM has been in its consultation arrangements and the breadth of views expressed. Conclusion
The committee has heard very strong views on the value that service users attach to the self-presentation aspect of the Emergency Clinic. The committee has also considered the concerns of local health partners, including the local acute trusts. The committee hopes that SLAM and its partners will take on board the strength of these feelings in considering how to provide crisis services to the people of Lambeth and Southwark. The Joint Committee wishes to work with local health providers to find a locally acceptable solution on this issue. However, should local resolution not be achieved the committee has the right to refer the matter to the Secretary of State.
Background Papers and Supporting Evidence DOCUMENT TITLE • • • • • • • • About SLAM NHS Trust Lambeth & Southwark Crisis Care Review Review of mental health crisis services in Lambeth & Southwark Lambeth & Southwark mental health crisis care review: summary Crisis Care review consultation plan (update circulated 8/2/06) Report on SLAM Mental Health Trust Report from Workshop January 2005 - What counts as a good crisis service? Emergency Clinic – Results of Southwark Mind Survey AUTHOR SLAM CIRCULATED TO JC MEMBERS 12/10/05 (Background briefing) 20/12/05 (agenda papers)
SLAM “ “ Stephen Niemiec
Patient Survey Report: Mental Health Survey 2005 SLAM National Service Framework – Mental Health • Report of Psychiatric Crisis in Southwark & Lambeth • Two week review of mental health crisis services in Southwark and Lambeth: summary Information from the Mental Health Liaison Team (inc. pathway for patient care) Briefing document for Joint Committee & pathway for patients through A&E for patients with mental health problems • Unscheduled Care Strategy in Lambeth (briefing paper July 2005) • Unscheduled Care – July 2005 PCT Board Meeting Key Performance Indicator Report • Quarter 1 April – June 2005 • Quarter 2 Apr – Sept 2005
Healthcare Commission Department of Health SLAM
20/12/05 20/12/05 23/01/06
(agenda papers) St Thomas Hospital 20/01/06
Kings College Hospital
Southwark PCT SLAM 20/12/05 2/02/06
DOCUMENT TITLE Submission to the MPA Joint Review into mental health and policing • • • • Do helplines help? Crisis Services Research Best Practice Briefing Cedar House Crisis Accommodation Public written submissions (service users & user organisations) 12 submissions from individuals and response from the Lorrimore signed by 18 people and from Lambeth Mental Health and Disabled Peoples Action Group Emergency Clinic and the Mental Health Act - Briefing Paper for the Trust Board Mental Health Act Briefing
AUTHOR Lambeth Police – Community Consultative Group (Mental Health Working Party Rethink
CIRCULATED TO JC MEMBERS 8/02/06
Service users & user organisations
15/02/06 and later
Lambeth Mind MentalHealth Directory 2006 Guys and St Thomas NHS Trust Lambeth User Voice
Guys and St Thomas NHS Trust – Draft Response to SLAM Service User Review Group Statement to the 10 year review project Board and SLAM Board (Jan 04) Service User Workshop – Notes SLAM/Staff Consultation Event Notes Report to Lambeth PCT Board 13 March 2006
Joint Health Scrutiny Committee Joint Health Scrutiny Committee Lambeth PCT
2/03/06 2/03/06 8/03/06
Full copies of supporting documents listed above, the agendas, reports and minutes of all meetings of the joint committee are available from: Elaine Carter Lead Scrutiny Officer Lambeth Town Hall Brixton Hill London SW2 1RW Tel: 020 7926 0027 Email: firstname.lastname@example.org Lucas Lundgren Scrutiny Project Manager Southwark Council Scrutiny Team Room 3.09, 3rd Floor, Town Hall Peckham Road London SE5 8UB Tel: 020 7525 7224 Email: Lucas.Lundgren@southwark.gov.uk
Joint Lambeth/Southwark Statutory Health Scrutiny Committee Membership and terms of reference Membership of the joint committee was: Councillor Angie MEADER [Lambeth] (Chair of Joint Committee) Councillor Sarah WELFARE [Southwark] (Vice-Chair of Joint Committee) Councillor Donatus ANYANWU [Lambeth] Councillor Alfred BANYA [Southwark] Councillor Irene KIMM [Lambeth] Councillor Eliza MANN [Southwark] Councillor Robert McCONNELL [Lambeth] Councillor Helen O’MALLEY [Lambeth] Councillor Lisa RAJAN [Southwark] Councillor Veronica WARD [Southwark] SUBSTITUTE MEMBERS: Councillors BATES [Southwark], BENNETT [Lambeth], CLARKE [Lambeth], DERING [Lambeth], DIXON-FYLE [Southwark], GRAHAM [Southwark], HUBBER [Southwark], McCARTHY [Southwark], SERWAA [Lambeth] and YATES [Southwark] 1. Terms of Reference 2. To discharge the health scrutiny functions of the London Boroughs of Southwark and Lambeth in relation to the changes in crisis care provision proposed by the South London and Maudsley NHS Trust (SLAM) in November 2005. 3. The Joint Health Scrutiny Committee is set up under the July 2003 Direction under section 8 (4) of the Health and Social Care Act 2001 and regulation 10 of the Local Authority (Overview and Scrutiny Committees Health Scrutiny Functions) Regulations 2002. 4. The Joint Committee will: 5. consider the proposals of SLAM in relation to crisis care provision from the perspective of all those likely to be affected or potentially affected by those proposals and to consider whether the proposals for change are in the interests of the health of local people 6. consider SLAM’s consultation including: • • • how the consultation options have been formulated, whether the health Trust has taken into account the views of patients, the public and other stakeholders in developing the proposals whether the formal consultation process is inclusive and comprehensive
7. take account of the evidence and views of stakeholders to consider what impact the proposed changes will have on patients, carers and the public.
8. prepare, agree and publish a report of the Joint Committee setting out the evidence received and considered and its recommendations to SLAM and other parties as appropriate. 9. consider the response of SLAM and other parties to the Joint Committee’s report, and consider SLAM’s final decision and make a formal response as necessary. 10. report to the Secretary of State in the event that the Joint Committee: (i) is not satisfied with the content of the consultation with the Joint Committee; or (ii) is minded that insufficient time has been allowed for consultation; or (iii) is minded that reasons given for not carrying out consultation are inadequate; or (iv) that the proposals are not in the interests of the health service locally. 11. following the conclusion of scrutiny, evaluate the Joint Health Scrutiny Committee process for future good practice and guidance and make suggestions on how scrutiny and local NHS Trusts might improve engagement in future consultation on NHS substantial variations. 12. MEMBERSHIP 13. The Joint Committee shall consist of 11 members comprising • 6 members of the Health and Social Care Scrutiny Committee, London Borough of Southwark • 5 members of the Health Scrutiny Sub Committee, London Borough of Lambeth 14. Substitutions/reserves shall be permitted according to the arrangements in force within each respective authority. Continuity of attendance throughout the review is strongly encouraged, however. 15. TERM OF OFFICE 16. The Joint Committee’s term of office will be for (a) the period of formal consultation on SLAM’s Crisis Care Review, and (b) for such subsequent period(s) as may be necessary following the period of formal consultation to respond to SLAM’s final decision and consultation thereon. 17. CHAIR & VICE CHAIR 18. The Committee shall formally elect the chair and vice chair at the first meeting of the Joint Committee. The Committee shall seek to appoint the chair from one authority and the vice chair from the second. 19. QUORUM 20. The quorum of the meeting of the Joint Committee will be three members of whom at least one shall be from Southwark Health and Social Care Scrutiny SubCommittee and one from Lambeth Health Scrutiny Sub-Committee 21. VOTING 22. Members of the Joint Committee should endeavour to reach a consensus of views. In the event that a vote is required each member present will have one vote up to a maximum of five votes per authority.
23. In the event of there being an equality of votes the Chair of the meeting will have a casting vote. 24. FINAL REPORT 25. The Joint Committee shall hear evidence and reach its final report within the defined time period of the statutory formal consultation. 26. On completion of the scrutiny review by the Joint Committee, it shall produce a single final report, agreed by consensus and reflecting the view of both local authority committees involved. 27. MEETINGS 28. Meetings of the Joint Committee will be normally held in public and will take place at venues within either Southwark or Lambeth. However, there may be occasions on which the Joint Committee may need to meet witnesses or hold site visits outside of the formal Committee meeting setting. 29. The Committee may meet informally to discuss and draft its recommendations. 30. Meetings shall last for up to two hours from the time the meeting is due to commence. The committee may resolve, by a simple majority, to continue the meeting for a maximum further period of up to 30 minutes 31. SUPPORT 32. Administrative and research support will be provided by the Scrutiny Teams of Southwark and Lambeth Councils working together.
Scrutiny consultation questions 1. Mental Health Crisis Services (a) What is your opinion/experience of the crisis mental health services currently available in Lambeth and Southwark (e.g. attending A&E; contacting crisis resolution/home treatment teams, Maudsley Emergency Clinic) and how might these be improved? Have you used the Maudsley Emergency Clinic in a crisis? Is so, please tell us why you used this service rather than another crisis service (e.g. A&E; crisis resolution/home treatment teams). If you have not used the Maudsley Emergency Clinic but have used another service in a crisis why was this? The next question is to people with personal or professional experience of A&E services for people in crisis. What are the best and worst aspects of attending A&E when in crisis, and how might this be made easier for individuals and professionals?
SLAM’s proposals for change What are your views on the SLAM proposals for crisis care, including the future of the Emergency Clinic?
Consultation (a) (b) Are you aware of SLAM’s proposals? If you are aware of the proposals, how did you find out about them and when? Have you been involved in any formal/informal consultation events in respect of the proposals? Were you invited to take part? If you have attended an event what was it and what was your experience of it?
Joint Committee – working schedule Date Event Purpose/People
SLAM Board agree consultation options 29 November 2005 Consultation Document to be published 1 December 2005 and be distributed to stakeholders w/c 5 December . Consultation Timetable runs 1/12/05 – 17/3/06 20 DECEMBER First formal meeting of the JC Administrative/constitutional: Formally Agree terms of reference, Agree Chair/Vice-Chair and arrangements; Agree future JC dates, initial timetable, possible site visits Evidence: • SLAM to formally present consultation document. • Initial discussion on the consultation process and proposals under scrutiny with SLAM/PCT - Presentation & member questions • Invite written comments on the options from stakeholder groups [proforma letter] Potential delegated actions • Attend/observe consultation meeting/s organised by SLAM; • Site visits and discussion with health staff [20/1 & 23/1] • Visit other good practice examples
During formal consultation period:
Date 20 January 23 January
Event Member site visit to St Thomas’ A&E Second formal meeting of JC
Third formal meeting of JC
Fourth formal meeting of JC
Member site visit and witness session discussion with health professionals – crisis care and impact of option proposals in practice SLAM EC Kings A&E Witness session - discussions with stakeholders. Invited: Police Community Police Consultative Group/Mental Health Carers Advocacy/Vol orgs Witness session discussions with service users
Fifth formal meeting of JC
SLAM/PCTs response to JC’s points of concern Members consider draft recommendations Submit response to SLAM
BY 17 MARCH Following formal consultation SLAM publishes report, makes public its proposed decision & formally makes decision on proposal Formal meeting of JC
Following formal announcement of decision on proposal
JC considers SLAM’s decision and the adequacy of both Section 11 & Section 7 consultation JC decides whether to accept proposals, have further discussions or refer matter to Secretary of State
If JC doesn’t refer proposal to SoS
SLAM implements proposal and continues [Section 11] consultation with patients and public JC reconvenes at future date [tbc]
To monitor implementation of scrutiny recommendations/SLAM proposal(s)
Statutory process flowchart from point of scrutiny report submission
Joint Lambeth/Southwark Health Scrutiny Committee responds to SLAM formal consultation
SLAM responds to Joint Committee report [within 28 days of receipt] • Indicating whether trust accepts JC recommendations; and if so • Indicating how these will be implemented
JC recommendations accepted by SLAM
JC recommendations not accepted by SLAM
Recommendations implemented by trust
JC and trust must seek to reach local agreement on disputed issues • Informal advice is available [to trust and JC] from the office of the Independent Reconfiguration Panel
NO RESOLUTION ACHIEVED
JC has option to refer proposals to Secretary of State
NHS trust cannot implement proposals until SoS has determined the outcome