House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Supplementary memorandum by the Department of Health (MH 1A)

After officials from the Department of Health gave evidence to the Committee on 23 March the Clerk of the Committee sent a letter to Dr Sheila Adam asking for a written response to some additional questions. This further memorandum consists of answers to the following questions:

1. Do you have any plans to extend the "duty of partnership" which the Health Act 1999 imposes on the NHS and local authorities to any other bodies such as the police or the probation service?

2. Do you have any plans to extend the ability to pool budgets with other services which overlap with the NHS, such as the prison medical service?

3. Do you have any estimates of the resource implications (both in terms of staffing and costs) of the tribunal structure proposed in the Green Paper?

4. "Home treatment" services are reportedly preferred by patients and may cost less than hospital-based services. Do you have any plans to commission research on why such services tend to be relatively short-lived?

5. The development of the kinds of services described in your memorandum (assertive outreach, crisis houses, early intervention, home treatment etc) implies a number of teams working in the same geographical area. Would you agree there is a danger of loss of continuity of care? What are the staffing implications of a number of teams serving the same area, given current difficulties in filling posts?

6. You mention in your memorandum the extra medium secure beds which are to be developed. Can you give us figures on the total number of beds that will be available once these extra beds have been provided? Will this still leave a shortfall on the number which are necessary for an adequate service? What role do you envisage in the future for the independent sector, which has traditionally provided many of these beds?

7. The Committee understand that the discharge of patients from the Special Hospitals, even where these have been agreed by Mental Health Review Tribunals, is impeded by the lack of alternative placements (particularly in long-term low and medium security). What firm plans do you have for ensuring that alternative placements are available? What is the timescale?

8. What plans do you have to improve services for people who have a "dual diagnosis", such as mental illness and substance abuse?

1. Do you have any plans to extend the "duty of partnership" which the Health Act 1999 imposes on the NHS and local authorities to any other bodies, such as the police or the probation service?

1. At present, there are no plans to extend the duty of partnership as outlined in sections 27 and 28 of the Health Act 1999.

2. The very specific requirement imposed by sections 27 and 38 on Health Authorities, Primary Care Trusts, and NHS Trusts, is to participate with their local authority in developing Health Improvement Programmes. Health Improvement Programmes are designed to improve the health of the local community. In many areas this will have involved the police and the probation services. However, the detail of the consultation and the programmes is decided at local, not national, level.

2. Do you have any plans to extend the ability to pool budgets with other services which overlap with the NHS, such as the prison medical service?

1. The Health Act 1999 dealt with the means to enable greater co-ordination between NHS bodies and local authorities.

2. The ability to pool budgets has already been extended from just involving social services and community health services to including most of the NHS and all local authority health-related functions.

3. There have been some indications that people are interested in possible further extensions. This drive has come in particular from Health Action Zones which have been interested in a broader range of partnerships, and from services, such as mental health services including those for children and adolescents, and Drug Action Teams, where they have argued the benefits of greater service integration.

4. The Department of Health is undertaking an evaluation process on the impact of the use of the flexibilities on both users of services and on organisations which become involved in the partnership arrangements. This evaluation will indicate the extent to which other services might usefully be included in any future powers.

3. Do you have any estimates of the resource implications (both in terms of staffing and costs) of the tribunal structure proposed in the Green Paper?

1. The Green Paper sets out several options for the new tribunal structure: more detailed modelling will be done in the light of consultation responses. We will need to develop full costings once this process has been completed. In the meantime, we are relying on provisional costings commissioned from Professor Martin Knapp of the London School of Economics in August 1999.

2. Professor Knapp was commissioned to undertake a study of the resource implications of the establishment of a new independent decision making process, involving the establishment of a new tribunal. This assessment was intended to:

— Take full account of the opportunity costs of the new system and opportunity savings of abolishing systems they replace;

— Advise on the practicalities of the proposals in terms of staffing the tribunals.

3. Professor Knapp's group has produced an impressively detailed, if provisional, set of costings for the new system and for the current system. They suggest that running costs (including costs to the Legal Aid Board) of the current system are about £38.2 million and that the new system would cost between £2.4 million and £6.3 million more per year to run. This represents an increase of roughly 6 per cent to 16.5 per cent.

4. The estimated increase in costs is lower than expected. This is partly explained by the high baseline costs that have been attributed to the current system. But this is an area where we do not have full information about unit costs or volume of activity. We think it likely that the current system costs less than Professor Knapp's group has calculated. Our preliminary adjustments suggest an envelope of between £3.5 million and £9.4 million may be a more accurate estimate of the increased cost of the new system.

5. These estimates are still necessarily very approximate and will be developed as our proposals become more concrete, We have made it clear in the Green Paper that the implementation of these proposals must not divert either money or staff time from patient care.

6. The main staffing implications identified by the group were an increase in the number of lawyers required to staff the new tribunals and a corresponding decrease in the number of doctors, approved social workers and community psychiatric nurses required. Costs could be further reduced by the use of salaried lawyers for tribunals and establishing a system of standard fees for lawyers representing patients.

7. If the tribunals are to be administered by the Lord Chancellor's Department, then it should be noted that most of the extra costs fall on that department or the Legal Aid Board rather than on the Department of Health. Professor Knapp's group suggests that there may even be net savings for the NHS and social services. However, this may well not be the case after further adjustments to their findings are made.

8. The main resource implications which are outside Professor Knapp's remit concern start-up and transition costs. We currently envisage a period of six months to a year during which the two systems would run concurrently. A relatively small number of long-term patients (probably mostly those in medium or high security units) would then make the transition from the old system to the new. Training staff in the workings of the new system would also have resource implications. We will do further costing work on these areas.

1. A review of Research and Development in mental health has recently been completed and its findings are summarised in the National Service Framework for Mental Health. Work is currently under way to assess priorities for further research in the light of the National Service Framework.

2. The main reason for home treatment failures has been that in the past they have depended on short-term funding and one or two champions for change. These champions often moved on, leaving no-one behind to carry on the work.

3. Research might be undertaken into why such services in some areas have been sustained over many years. For example, in Madison, Wisconsin, and in Sydney, Australia, model home treatment programmes have been running for 20 and 17 years respectively. Closer to home successful teams have been in operation for over six years in Northern Birmingham Mental Health Trust. There are six teams with 72 staff providing home treatment services around the clock.

4. In Northern Birmingham home treatment has expanded so much that it is the first line of response for all psychiatric emergencies. The Trust covers some 600,000 people.

5. The key to home treatment success is the full support of medical staff backed up by sufficient junior doctors. For example, in Northern Birmingham, all consultants now use home treatment as a normal part of their day-to-day work. Additional junior medical staff have been appointed to support them particularly out of hours. Each locality has a home treatment team and in five out of the six localities, the consultant psychiatrist responsible for the catchment area remains the responsible medical officer when people are on home treatment or subsequently admitted to hospital. This ensures continuity of care.

6. A recent article by Smyth and Hoult in the BMJ (29 January 2000) argued that the availability of home treatment in conjunction with hospital based services means that inpatient beds are readily available when needed. Rapid response can alleviate suffering and stem the patient's clinical deterioration and the escalation of social problems which commonly dictate admission to hospital. While endorsing home treatment in its own right, we consider that its ultimate usefulness is within the context of an integrated and comprehensive community services strategy.

1. We are aware that Members of the Health Select Committee have visited Birmingham and heard for themselves how the system works there. The Trust has arranged its services around six localities. Each locality has a primary care team, an assertive outreach team, and a home treatment team. The key to successful working is that each team has a senior team leader—all of whom are responsible to the locality manager for creating integrated packages of care. The other key feature which helps to ensure continuity of care and integration is that the catchment area consultant psychiatrist covers primary care and home treatment, as well as inpatient care. It is also important that teams focus on relapse prevention, family work and cultural competencies. In this system the only dedicated separate consultant works in assertive outreach. This is because the clients for assertive outreach require intensive input over very long periods. Each team of 10 staff only looks after 100 clients and because of the nature of their work and the client group they are looking after—people with a history of dangerousness, drug abuse and multiple compulsory admissions—it is felt advisable to have a separate consultant.

2. In the National Service Framework Standards 4 and 5, we make clear that the important issue is to ensure that each person with severe mental illness receives the range of services they need. We also emphasise the importance of ensuring that these people are engaged with and remain in contact with mental health services. It states that community mental health teams may provide the full range of community-based services themselves, or be complemented by one or more teams providing specific functions. New guidance on the Care Programme Approach makes it clear that many mental health service users have a range of needs that no one treatment service or agency can meet. A system that allows a service user access to the most relevant response is essential. Service users themselves should provide the focal point for care planning and delivery.

3. Although we are not aware that this has been researched extensively, morale in the new community teams appears to be high. The new teams give professionals other than consultants the opportunity to use their skills to the full. Furthermore, much community work, particularly assertive outreach, does not require a significant number of highly skilled professional staff. People with appropriate life skills can make a great difference to the quality of people's lives. The Workforce Action Team, chaired by Sue Hunt, has suggested the establishment of a sub-group to take forward work in recruiting and harnessing the skills and enthusiasm of professionally non-affiliated people. The sub-group will look at:

— The viability of training relevant graduates, with appropriate life skills, for work in mental health services;

— Ways in which mental health services can be encouraged to employ service users;

— The training needs of unqualified support workers.

4. We know that one of the major obstacles to delivering the National Service Framework is a shortage of suitably qualified staff. The Government's Human Resources Strategy Working Together sets out the framework for action across all staff groups. The Workforce Action Team will pay particular attention to the staffing needs for mental health services. National programmes targeting recruitment and retention are expected to improve staffing levels across all specialisms over the next five years.

1. By their nature medium secure psychiatric services are relatively expensive and for many health authorities relatively low volume. Because of this there is a need to manage the risk and that is why we have included these services in the arrangements for commissioning specialised services. Regional Specialist Commissioning Groups are in the process of developing service strategies, based on updated regional needs assessments, for the provision of medium and other levels of secure services. These needs assessments incorporate the high security hospital patients for whom Regional Specialist Commissioning Groups also commission services. The integration of commissioning for high and medium secure services at Regional Specialist Commissioning Group level will aid and inform the development of services required to facilitate the movement of inappropriately placed patients out of the high security hospitals.

2. In paragraph 13 of our earlier Memorandum, we mentioned the planned increase of 250 secure places in addition to the 221 planned for 1999-2000. These secure places cover not just medium secure but also low secure places as well as intensive care beds. Our current data show there are some 2,208 medium and low secure places in the NHS for people with a mental illness but we are in the middle of an exercise to confirm these figures. We will let you know the outcome which is expected shortly.

3. We are confident that the number of secure beds currently planned will be adequate to meet need on the basis of current predictions. But as explained above, it is for each Regional Specialist Commissioning Group to develop, and keep under review, a strategy for secure psychiatric services in their region. In developing such strategies Regional Specialist Commissioning Groups will be expected to take into account existing and predicted demand for new admissions to secure care, as well as the need to reconfigure existing secure and intensive care provision to ensure that people are not inappropriately placed. This is a complex process and there is no doubt that need for particular types of secure provision will continue to change over time.

4. The provision of medium secure services has to be seen in the wider context of Government policy towards the independent sector. The Government remains committed to the NHS as the main provider of healthcare. However, as the Prime Minister has himself confirmed, we do see a part for the independent healthcare sector working in partnership with the NHS. The Department of Health is currently exploring the opportunities for developing arrangements which would enable the most appropriate reciprocal use of intensive care, intermediate care and elective care facilities. In particular we would like to build such a partnership approach into local planning arrangements, but at the same time ensure that the NHS modernisation programme continues.

5. In terms of mental health and secure service provision, the expectation is that the NHS will continue to use the independent sector where this can be done as part of an integrated system of provision. For example independent sector provision might be appropriate for short term placement of a patient where a NHS place is temporarily unavailable, or where a particular type of very specialist treatment is needed.

6. There will probably always be a "niche" market for provision such as Thornford Park in Berkshire who look after a number of frail elderly patients who nonetheless still require conditions of security.

7. Standard 5 of the National Service Framework for Mental Health says "that care should be provided in an appropriate hospital bed which is as close to home as possible". This may be in an independent sector facility but the NHS should first explore what might be available locally in its own estate.

1. The devolution of responsibility for the commissioning of high and medium secure psychiatric services to Regional Specialised Commissioning Groups and the proposed mergers of the high security hospitals with NHS Trusts are, by better integrating the hospitals with the wider mental health system, intended to assist in addressing the difficulties in moving patients. Regional Specialised Commissioning Groups will be expected to assess the needs of patients from their regions and develop services accordingly. The National Oversight Group will maintain an overview and ensure co-ordination across regions. The National Oversight Group will attach great priority to developing plans to transfer the people who do not need high security into more appropriate facilities.

2. Funding of £896,000 has been made available for regions to develop clinical case management arrangements, leading to more effective patient transfers to more suitable settings. More places will therefore become available for the 140 or so people who have been assessed in the prison service as needing high secure hospital care, though it should be noted that not all of these people will necessarily be deemed suitable for transfer by the hospitals themselves.

3. To aid the process of moving inappropriately placed patients out of the high security hospitals, the Health Service Research Department at the Institute of Psychiatry (in collaboration with the Universities of Manchester and Nottingham) has been commissioned to undertake a comprehensive examination of patients' needs. A full report will be available by March 2001.

4. The study's aims are:

— To assess the treatment and placement needs of all patients currently in high secure hospitals;

— From these data establish a profile of patients rated for high, medium and low secure provision;

— To make recommendations for the types of care and treatment needed by these patients at each level of care in the foreseeable future.

5. This study is the first which addresses the needs of patients using multiple standardised instruments. It will inform future service provision and identify gaps in current provision. Interim reports will be produced, and will be considered by the National Oversight Group.

8. What plans do you have to improve services for people who have a "dual diagnosis", such as mental illness and substance abuse?

1. The needs of people with a dual diagnosis can best be met by partnership working between mental health and substance misuse services. The National Service Framework for Mental Health, together with the Government's Drugs Strategy and the forthcoming Alcohol Strategy, encourage individual services to plan for, and meet, the needs of people with a dual diagnosis. With proper co-ordination, integrated interventions from these specialist services can provide the right type of care at the right time for people who have multiple and complex needs.

2. The Mental Health National Service Framework recognises the challenging nature of this client group. Because people with a dual diagnosis can find it difficult to engage with traditional services, they will particularly benefit from the development of assertive outreach schemes (as described in the earlier Memorandum). The Framework makes it clear that staff assessing individuals with mental health problems, whether in primary or specialist care, should consider the potential role of substance misuse and ensure access to appropriate specialist input. The National Service Framework requires all health authorities to have protocols agreed and implemented between primary care and specialist mental health services for the management of drug and alcohol dependence by April 2001.

3. The Government's anti-drugs strategy Tackling Drugs to Build a Better Britain has treatment as one of its four priorities. One of the aims is to provide an integrated, effective and efficient response to people with drug and mental health problems. This is being promoted in various different ways.

4. In 1998-99 we allocated about £300,000 from our Drug and Alcohol Specific Grant to fund a dual diagnosis development programme supporting service development and evaluation in the voluntary sector specialist drug services. The Grant has also been used to fund a mapping exercise looking at multi-disciplinary and multi-agency working through local authorities and the voluntary sector. We are currently considering how best to disseminate what we have learned from the exercise to the field. Together with the King's Fund and the Sainsbury Centre, we are also funding the "Working Together in London Initiative". This initiative supports improvements in access and outreach to people with a dual diagnosis.

5. One of the aims identified by the Department for use of our Additional Drug and Alcohol Specific Grant is to support substance misusers including those with a dual diagnosis, in overcoming their problems and helping them to lead healthier, crime-free lives. In 1999-2000 we provided over £100,000 to several local, specific projects from the Drug and Alcohol Specific Grant, and funded several other projects which were also relevant to this area. These included an assertive outreach service in Kirklees which links drug agency workers with established mental health assertive outreach teams. Another tranche of projects will be funded this year, and we will continue to prioritise well-planned schemes for people with a dual diagnosis which meet an identified local need.

6. The Alcohol Strategy, which will be published later this year, will aim to develop services for problem drinkers most in need of treatment and advice, such as problem drinkers who also are experiencing a mental health problem.



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