Mental health benchmarking and market analysis technical analysis

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1 Report prepared for: South West London CCGs Mental health benchmarking and market analysis technical analysis Draft Report Policy in Progress 18 th May 2012

2 CONTENTS TECHNICAL ANALYSIS INTRODUCTION Context and purpose of report Method Structure of report BENCHMARKING ANALYSES Service provision and activity Cost and productivity Service user feedback Staff feedback Regulatory compliance ANALYSES OF LOCAL DATA Outcomes Access and waiting Safety Use of services by population groups Service user feedback Costs and productivity Service utilisation MARKET INTELLIGENCE Structure of the mental health market Policy initiatives NHS provider portfolios Independent sector provider portfolios Case Studies SUMMARY OF LOCAL STAKEHOLDERS VIEWS Introduction Method Themes arising Perspectives on the FT application

3 TECHNICAL ANALYSIS 1. INTRODUCTION 1.1. Context and purpose of report South West London and St George s Mental Health Trust ( the Trust ) is currently the main provider of mental health services to the residents of five boroughs in South West London: Kingston upon Thames; Merton; Richmond upon Thames; Sutton; Wandsworth. As one of a small number of NHS mental health providers not yet to have achieved Foundation Trust ( FT ) status, the Trust is seeking support from its main commissioners for its application to become an FT. The local NHS commissioning system, in common with the rest of England, is at present in transition from one based on Primary Care Trusts ( PCTs ) to one based on Clinical Commissioning Groups ( CCGs. ) We will refer to this transitioning system as the commissioners for the purposes of this report, including in that term all of the PCTs and CCGs responsible for mental health care in the five boroughs concerned. The commissioners are keen to ensure they exercise due diligence in making this decision whether or not to support the Trust s FT application and therefore to make it within the wider context of an assessment of the current and potential market for mental health services for the residents of South West London. The commissioners also wished to secure an independent and objective perspective on the issue; this review was therefore commissioned with the following objectives: a) To benchmark the performance of the Trust against a wide range of indicators b) To analyse the range of current and possible future providers of community and inpatient mental health services for the five boroughs c) To identify, in the light of (a) and (b), of the potential organisational options for the future of the Trust, from a commissioning perspective d) To recommend to the commissioners a response to the Trust s prospective FT application, and to their future approach to procuring mental health services The scope of this project includes all of the mental health services provided by the Trust for the commissioners. It therefore does not formally include: Social care or other services commissioned by local authorities independently of the NHS Services provided by the Trust to residents of other boroughs or locations Specialist mental health services which are commissioned via regional or national specialist commissioning arrangements. We recognise, however, that the outcome of this review will have a bearing on all of these, and these wider implications are therefore taken into account where relevant Method The data which have informed this project can be considered in four main groups: a) Data about the Trust and its services which is publicly available for all of the mental health Trusts in England, and which can therefore be used as a means of benchmarking the Trust against those other providers 1

4 b) Data which the Trust maintains locally, not as part of a nationally mandatory data structure. This therefore cannot be benchmarked externally; it can however provide a means of internal benchmarking, by enabling differentiation of the situation between the five boroughs in a way which is not possible with the data at (a) c) Information about the general structure of the market for mental health services, and about important trends and factors within that market. This is contextual information which is very largely about other providers, not about the Trust itself. d) The opinions, experiences, and aspirations of local stakeholders These four groups have been drawn upon and used as follows: a) Benchmarking data. We have undertaken searches of the databases maintained by: i. The Care Quality Commission ii. The NHS Information Centre iii. The Department of Health reference cost framework We have also contacted the East of England Quality Observatory. In each case we have prepared analyses which attempt to synthesise the full range of data available, whilst drawing out those issues considered most significant by the commissioners. By agreement with the commissioners, we have used as benchmarks: i. The performance achieved by the full range of statutory mental health providers throughout England (an all-england comparison) ii. The performance achieved by the range of statutory mental health providers in London (an all-london comparison) iii. The specific performance of the four mental health providers whose main catchments neighbour those of the Trust: a. West London Mental Health NHS Trust b. Central and North West London NHS Foundation Trust c. South London and Maudsley NHS Foundation Trust d. Surrey and Borders Partnership NHS Foundation Trust b) Local data. We are pleased to record the ready co-operation of the Trust in supplying local data and materials to support this project. The Trust made available to us: i. A full anonymised record of service activity, for our analysis ii. An up-to-date statement of which beds of which types the Trust currently provides iii. The results of internally conducted patient surveys iv. Individual borough-based performance reports v. Costed activity schedules, again borough-by-borough vi. Submissions as to locally initiated quality improvements c) Market information. This material is based on: i. Financial mapping analysis of mental health services undertaken by MHS for the Department of Health each year since 2001 ii. Laing and Buisson s most recent (2011) market report on the independent sector in mental health care iii. A survey of market opinion undertaken by MHS earlier in 2012 for the NHS Confederation 2

5 iv. Web searches of the papers and publications of the identified organisations v. MHS s consultants general perspectives on developments in the mental health market d) Local stakeholders. During the course of this project, we interviewed 29 local stakeholders, adopting a semi-structured interview framework, to ascertain views on the strengths and weaknesses of local mental health services, and aspirations as to future service delivery arrangements. Stakeholders included commissioners, GPs, and local authority leads. We also: i. Attended a meeting of the local LiNks groups ii. Met representatives of the London specialist commissioners iii. Received copies of reports of service user consultations undertaken locally iv. Received copies of commissioners existing commissioning intentions v. Facilitated two workshops on 22 nd May, attended by [DN:number] local stakeholders, to consider this project s findings in draft. In all four cases, draft data analyses were shared and discussed with a steering group of commissioners, prior to preparation of the final versions included in this report Structure of report This technical analysis contains, in sections 2 to 5 respectively, presentations of the results of our analyses of the four sources of data described at 1.2. above. This is intended to form an essentially factual presentation of the range of evidence and information. We of course understand that it is impossible to present a wholly neutral analysis of this nature, as the choice of material for inclusion and the editing process inevitably requires the exercise of judgement. We have tried, however, to ensure that the technical analysis can be read as a balanced summary of available evidence about the Trust s performance, and about the wider market context in which it is operating so that a reader could form their own evidence-based view as to these. 3

6 2. BENCHMARKING ANALYSES Introduction In this section we benchmark the Trust s performance using a range of national data sets, looking at: Service provision and activity (2.1) Cost and productivity (2.2) Service user feedback (2.3) Staff feedback (2.4) Regulatory compliance (2.5) We have used a range of national data sets to benchmark the Trust. CQC survey of people who use community mental health services 2011 CQC mental health acute inpatient service users survey 2009 National NHS Staff Survey 2011 NHS Litigation Authority ratings 2011 Hospital Episode Statistics (HES) Reference costs CQC site visits We have compared the Trust with: English NHS mental health trusts London NHS mental health trusts the four mental health providers whose main catchments neighbour those of the Trust: o West London Mental Health NHS Trust o Central and North West London NHS Foundation Trust o South London and Maudsley NHS Foundation Trust o Surrey and Borders Partnership NHS Foundation Trust 2.1. Service provision and activity Spend per head of population We have compared spend per head of population for a range of key service lines using 2010/11 reference costs. Adult services Adult acute inpatient spend is comparable with the English average, and slightly lower than London trusts. It is low compared with its neighbouring trusts (figure 1). Adult CMHT and crisis resolution and home treatment teams spend are lower than the English average, other London trusts and the neighbouring trusts (figures 2 and 3). Assertive outreach team and adult A&E liaison service spend are higher than the English average, other London trusts and the neighbouring trusts (figure 4 and 5). 4

7 Adult outpatients, PICU and rehabilitation inpatients spend are higher than the English average and other London trusts, and the second highest compared with neighbouring trusts (figures 6, 7 and 8). Older adult services Older adult inpatient spend is similar to the English average and London trusts. Two neighbouring trusts have lower spend (figure 9). Older adult CMHT spend is lower than the English average, other London trusts and the neighbouring trusts (figure 10). Older adult A&E liaison service and outpatients spend are very high (figure 11 and 12). FIGURE 1: ADULT ACUTE INPATIENTS- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 FIGURE 2: ADULT CMHTS- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 5

8 FIGURE 3: CRISIS RESOLUTION AND HOME TREATMENT TEAMS- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 FIGURE 4: ASSERTIVE OUTREACH TEAMS - SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 FIGURE 5: ADULT A & E MENTAL HEALTH LIAISON SERVICES- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 6

9 FIGURE 6: ADULT OUTPATIENTS- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 FIGURE 7: REHABILITATION INPATIENTS- SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 FIGURE 8: PICU SPEND PER WEIGHTED POPULATION (18-64) Data source: Reference costs 2010/11 7

10 FIGURE 9: OLDER ADULT INPATIENTS SPEND PER WEIGHTED POPULATION (65+) Data source: Reference costs 2010/11 FIGURE 10: OLDER ADULT CMHTS SPEND PER WEIGHTED POPULATION (65+) Data source: Reference costs 2010/11 FIGURE 11: OLDER ADULT A & E MENTAL HEALTH LIAISON SERVICES SPEND PER WEIGHTED POPULATION (65+) Data source: Reference costs 2010/11 8

11 FIGURE 12: OLDER ADULT OUTPATIENTS SPEND PER WEIGHTED POPULATION (65+) Data source: Reference costs 2010/11 Ratio of spend on inpatients and community services In adult services the Trust spends a slightly higher proportion of spend on inpatient services than community services when compared with the English average. Its ratio of spend is the same as other London trusts (figure 13), but with a higher proportion of community spend than immediate neighbours. In older adult services the Trust spends a slightly higher proportion of spend on inpatient services than community services when compared with the English and London average (figure 14). FIGURE 13: RATIO OF SPEND ADULT ACUTE INPATIENTS AND CMHTS, CRHTS, AOT & EIP Data source: Reference costs 2010/11 9

12 FIGURE 14: RATIO OF SPEND OLDER ADULT INPATIENT AND OLDER ADULT CMHTS Data source: Reference costs 2010/11 Inpatient activity data We have used both reference costs and Hospital Episode Statistics (HES) to compare bed usage. HES data We have compared occupied bed days and average length of stay using HES data. HES do not differentiate bed types and include activity in the following NHS inpatient facilities: acute, rehabilitation, psychiatric intensive care and continuing care. Variation in bed use is likely to be due to a number of factors: Different mixes of inpatient facilities. The level of service provision. Those areas with relatively higher numbers of beds may be likely to attract more admissions. External factors such as the levels of homelessness and available accommodation. Different service models, clinical practice and performance. Adult mental illness The Trust has lower bed days than its neighbouring trusts except for Surrey and Borders, and is slightly higher than England average (figure 15). Average length of stay is significantly lower than the other comparators (figure 16). The variation in average length of stay may show more about the nature of the inpatient facilities than trusts performance, for example if one trust has high proportion of inpatient activity in a facility where long lengths of stay are the norm, their average length of stay would be high. 10

13 FIGURE 15: INPATIENT OBDS PER WEIGHTED 1,000 POPULATION (ADULT) BY TREATMENT SPECIALTY - ADULT MENTAL ILLNESS (710) FIGURE 16: INPATIENT AVERAGE LENGTH OF STAY BY TREATMENT SPECIALTY - ADULT MENTAL ILLNESS 11

14 Old age psychiatry The Trust s bed days are similar to the England, London Mental Health Trusts and Neighbouring Trusts (figure 17). The Trust s average length of stay is low (figure 18). FIGURE 17: INPATIENT OBDS PER WEIGHTED 1,000 POPULATION (OLDER ADULT) BY TREATMENT SPECIALTY - OLD AGE PSYCHIATRY (715) FIGURE 18: INPATIENT ALOS BY TREATMENT SPECIALTY - OLD AGE PSYCHIATRY Reference costs activity data We have compared occupied bed days per head of population using reference costs data 2011/11. Adult acute bed days are similar to the English average, and lower than other London trusts and most of the Trust s neighbours (figure 19). Rehabilitation bed days are very high compared to the English average, other London trusts and most of the Trust s neighbours (figure 20). 12

15 Older adult bed days are similar to the English average, other London trusts and the neighbouring trusts (figure 21). FIGURE 19: ADULT ACUTE OCCUPIED BED DAYS PER 1,000 WEIGHTED POPULATION (18-64) 2010/11 Data source: Reference costs 2010/11 FIGURE 20: REHABILITATION OCCUPIED BED DAYS PER 1,000 WEIGHTED POPULATION (18-64) 2010/11 Data source: Reference costs 2010/11 13

16 FIGURE 21: OLDER ADULTS OCCUPIED BED DAYS PER 1,000 WEIGHTED POPULATION (65+) 2010/11 Data source: Reference costs 2010/ Cost and productivity The Trust s 2011/11 reference cost index (RCI) is 104 after adjusting for market forces factor (MFF). This means that the Trust s costs are higher than the national average of 100. The Trust s RCI is higher than other London trusts and neighbouring trusts apart from West London (figure 22) FIGURE 22: OVERALL REFERENCE COST INDEX ADJUSTED FOR MFF 2010/11 Reference costs are recognised as a fairly crude way of measuring efficiency, for example the use of contacts as the activity unit for community teams is not a sophisticated way of measuring community team efficiency. 14

17 The Trust has included 130 million of costs in its reference costs. We have calculated that if their service line unit costs were at the national average, they would spend 6 million less, based on their recorded activity levels. Some service lines appear more expensive than the national average, while others appear cheaper. Figure 23 provides analysis for key service lines: Total spend RCI adjusted for market forces factor Overspend/ underspend (comparison of Trust unit cost and national unit costs based on Trust activity levels) Our analysis shows that: The Trust s relatively low unit cost compared with the national average means that the following service lines appear cheaper than the national average: Adult and elderly CMHTs Crisis resolution and home treatment teams Intensive care Rehabilitation inpatients Low level secure The Trust s relatively high unit cost compared with the national average means that the following service lines appear more expensive than the national average: Adult A&E mental health liaison services Early intervention in psychosis services Assertive outreach services Adult acute inpatients PICU Adult and elderly outpatients Children CMHTs Drug and alcohol community teams Medium level secure 15

18 FIGURE 23: TRUST REFERENCE COST ANALYSIS BY KEY SERVICE LINES 2010/11 16 MFF adjusted RCI Overspend / underspend ( '000s) Spend Currency Name Service Name ( '000s) Adult - A & E Mental Health Liaison Services Face to Face 2, Adult - A & E Mental Health Liaison Services Non Face to Face Adult - A & E Mental Health Liaison Services - Subtotal Adult - Early Intervention in Psychosis Services Adult - Early Intervention in Psychosis Services Adult - Early Intervention in Psychosis Services - Subtotal 2,778 1,045 Face to Face 2, Non Face to Face , Adult - Assertive Outreach Teams Face to Face 2, Adult - Assertive Outreach Teams Non Face to Face Adult - Assertive Outreach Teams - Subtotal 2, Adult - CMHTs Face to Face 6, ,892 Adult - CMHTs Non Face to Face Adult - CMHTs - Subtotal 6,875 3,180 Adult : Crisis Resolution Home Treatment Teams Adult : Crisis Resolution Home Treatment Teams Adult : Crisis Resolution Home Treatment Teams - Subtotal Face to Face 3, Non Face to Face , Adult inpatients Acute inpatients 22, Adult inpatients Intensive care 2, ,383 Adult inpatients Rehabilitation 12, ,681 Adult outpatients Adult outpatients Adult outpatients Adult outpatients Consultant Services (Outpatient Setting) - First Attendance Face to Face Consultant Services (Outpatient Setting) - First Attendance Non-Face to Face Consultant Services (Outpatient Setting) - Follow-up Attendance Face to Face Consultant Services (Outpatient Setting) - Follow-up Attendance Non-Face to Face 3, , , , Adult outpatients - Subtotal 10,262 4,982 Children inpatients Inpatients 1, Children - CMHTs Face to Face 7, ,129 Children - CMHTs Non Face to Face Children - CMHTs - Subtotal 7,815 2,285 Drug & Alcohol Community Team Face to Face contacts 4, ,135 Drug & Alcohol Community Team Non Face to Face contacts Drug & Alcohol Community Team - Subtotal 4,329 1,248 Drug & Alcohol Services -consultant Consultant Services (Community Setting) - First Contact Face to Face Drug & Alcohol Services -consultant Consultant Services (Community Setting) - First Contact Non-Face to Face Drug & Alcohol Services -consultant Consultant Services (Community Setting) - Follow Up Contact Face to Face

19 Currency Name Drug & Alcohol Services -consultant Drug & Alcohol Services -consultant - Subtotal Eating Disorder Services : Adult outpatients Eating Disorder Services : Adult outpatients Eating Disorder Services : Adult outpatients Eating Disorder Services : Adult outpatients Eating Disorder Services : Adult outpatients - Subtotal Service Name Consultant Services (Community Setting) - Follow Up Contact Non-Face to Face Consultant Services (Outpatient Setting) - Specialist Services First Attendance Face to Face Consultant Services (Outpatient Setting) - Specialist Services First Attendance Non- Face to Face Consultant Services (Outpatient Setting) - Specialist Services Follow-up Attendance Face to Face Mental Health Consultant Services (Outpatient Setting) - Specialist Services Follow-up Attendance Non-Face to Face Spend ( '000s) MFF adjusted RCI Overspend / underspend ( '000s) , , Eating Disorder Services : Adults inpatients Inpatients : Specialist Services 3, Eating Disorder Services : Children inpatients Inpatients : Specialist Services 2, Elderly - CMHTs Face to Face 2, Elderly - CMHTs Non Face to Face Elderly - CMHTs - Subtotal 2, Elderly day care Regular Attendances 1, Elderly inpatients Inpatients 10, Elderly outpatients Elderly outpatients Elderly outpatients Elderly outpatients Consultant Services (Outpatient Setting) - First Attendance Face to Face Consultant Services (Outpatient Setting) - First Attendance Non-Face to Face Consultant Services (Outpatient Setting) - Follow-up Attendance Face to Face Consultant Services (Outpatient Setting) - Follow-up Attendance Non-Face to Face 1, , Elderly outpatients - Subtotal 3,365 1,457 Local Psychiatric Intensive Care Units PICU 5, ,502 Low Level Secure Services Low level secure 4, Medium Level Secure Services Medium level secure 8,

20 2.3. Service user feedback CQC mental health acute inpatient service users survey 2009 Background The CQC carried out a national survey of survey users in mental health acute inpatient services in People were eligible for the survey if they were aged 16-65, had stayed on an acute ward or a psychiatric intensive care unit (PICU) for at least 48 hours between 1 July 2008 and 31 December 2008 and were not current inpatients at the time of the survey. It should be noted that this data is now fairly old, and the user experience may be different in The survey had 47 questions. Trusts were ranked against all other participating mental health trusts for each question as follows: Best performing 20% of trusts Intermediate 60% of trusts Worst performing 20% of trusts How did the Trust compare nationally? Overall the Trust performed badly in the survey, ranked in the worst performing 20% of trusts for 64% of the questions (figure 24). Patients were dissatisfied with their introduction to the ward, the ward environment, hospital staff, their care and treatment, their rights, and discharge procedures. How did the Trust compare to other London mental health trusts? Figure 24 compares the Trust with other London mental health trusts. While all trusts performed badly on some questions, South West London and St George s performed significantly worse. FIGURE 24: % OF QUESTIONS IN THE WORST PERFORMING 20% OF TRUSTS ALL LONDON MENTAL HEALTH TRUSTS 18

21 How did the Trust compare with its neighbouring trusts? Figure 25 compares the Trust with its neighbouring trusts. While all trusts performed badly on some questions, South West London and St George s performed the least well. FIGURE 25: % OF QUESTIONS IN THE WORST PERFORMING 20% OF TRUSTS NEIGHBOURING TRUSTS 19

22 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London FIGURE 26: CQC MENTAL HEALTH ACUTE INPATIENT SERVICE USERS SURVEY 2009 LONDON MENTAL HEALTH TRUSTS AND SURREY AND BORDERS KEY g a r Best performing 20% of trusts Intermediate 60% of trusts Worst performing 20% of trusts Introduction to the ward When you arrived on the ward, did staff make you feel welcome? r r a r r r a r r r When you arrived on the ward, did you feel that the staff knew about you and any previous care you had received? a r a r a r a r r a When you arrived on the ward, or soon afterwards, did a member of staff tell you about the daily routine of the ward, such as times of meals and visitors times? r r a a r r g r r a 20

23 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London About the ward During your most recent stay, did you ever share a sleeping area, for example a room or bay, with patients of the opposite sex? During your most recent stay, were you ever bothered by noise at night from hospital staff? g a a r g a a a r a a a a a a a r a a a During your most recent stay did you feel safe? r r r r a a r r a a How would you rate the hospital food? r r a a r r r r a a In your opinion, how clean was the hospital room or ward r that you were in? r a r r r a r r a How clean were the bathroom and toilets that you used in hospital? r r r r r r a a r r Do you feel the hospital helped you to keep in touch with r family or friends? r a a r a r r r a Hospital staff Did the psychiatrist(s) listen carefully to you? r a a r a a g a a a Were you given enough time to discuss your condition and treatment with the psychiatrist(s)? r a a r a a a a a a Did you have confidence and trust in the psychiatrist? r a a r r a a a a a Did the psychiatrist(s) treat you with respect and dignity? r a a r a r a a r a 21

24 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Did the nurses listen carefully to you? r r r r r r a r r a Were you given enough time to discuss your condition and treatment with the nurses? r r a a r r a r r a Did you have confidence and trust in the nurses? r r a r r r a r r r Did the nurses treat you with respect and dignity? r r a r r r a r r a Your care and treatment Did the hospital staff explain the purpose of this medication in a way you could understand? Did the hospital staff explain the possible side effects of this medication in a way you could understand? Were you given enough privacy when discussing your condition or treatment with the hospital staff? Were you involved as much as you wanted to be in decisions about your care and treatment? During your stay in hospital, did the provision of talking therapies meet your requirements? If you had talking therapy during your stay in hospital, did you find it helpful? During your most recent stay, were there enough activities available during the day on weekdays? During your most recent stay, were there enough activities available during evenings and/or weekends? During your most recent stay, did you have any medical tests about your physical health? r a r r r r a r r a r a a r r a r a r a r r r r r a a r r a r a a r a a a a r a r a a a a a a a a a g r a a r r a a r a a a a a a r a a r a a a a a g a r r r a a r a a r r g r During your most recent stay, do you feel that enough care was taken of any physical health problems you had? r r a r a a a r a r 22

25 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Your rights When you were detained (sectioned), or soon after, were your rights explained to you in a way that you could understand? During your most recent stay, were you made aware of how you could make a complaint if you had one? During your most recent stay, do you feel that you were treated unfairly for any reason? r a a r a r a a r a r a a a r r a r a a a r r a r r a r a r Leaving Hospital Do you think you were you given enough notice of your discharge from hospital? Once you were due to leave hospital, was your discharge delayed for any reason? Did hospital staff take your family or home situation into acount when planning your discharge from hospital? Do you have the number of someone from your local NHS Mental Health Service that you can phone out of office hours? Before you left hospital, were you given information about how to get help in a crisis, or when urgent help is needed? About how long after you left hospital were you contacted? a a a g a a a a r r a a a r a a a a r a r a a a a a a r r a a r r a r r a r a r r r r r a a a r a r r r a g a a r r r r 23

26 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Overall Overall, how would you rate the care you received during your recent stay in hospital? r r r r r r a r r r 24

27 CQC survey of people who use community mental health services 2011 Background The CQC carried out a national survey of people who use community mental health services. The survey comprises a sample of service users aged 16 and over who had been in contact with NHS mental health services in the three month period 1 July 2010 to 30 September 2010 and who were receiving specialist care or treatment for a mental health condition. The survey had 48 questions. Trusts were ranked against all other participating mental health trusts for each question as follows: Best performing 20% of trusts Intermediate 60% of trusts Worst performing 20% of trusts How did the Trust compare nationally? The Trust was in the worst performing 20% of all mental health trusts for 27% of the questions (figure 27). They scored in the upper 20% of all mental health trusts for 10% of the questions. Users expressed dissatisfaction with the way they were treated by health and social care workers. Care planning is a major problem, as is access to crisis care. In contrast users were far more positive about the care provided by talking therapies. How did the Trust compare to other London mental health trusts? The Trust had a higher percentage of questions in the worst performing 20% of trusts than other London mental health trusts (Figure 27). FIGURE 27: % OF QUESTIONS IN THE WORST PERFORMING 20% OF TRUSTS LONDON MENTAL HEALTH TRUSTS 25

28 How did the Trust compare with its neighbouring trusts? Both the Trust and Surrey and Borders had higher proportions of questions in the worst performing 20% of trusts than other neighbouring trusts. FIGURE 28: % OF QUESTIONS IN THE WORST PERFORMING 20% OF TRUSTS NEIGHBOURING TRUSTS 26

29 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London FIGURE 29: CQC SURVEY OF PEOPLE WHO USE COMMUNITY MENTAL HEALTH SERVICES 2011 LONDON MENTAL HEALTH TRUSTS AND SURREY AND BORDERS KEY g a r Best performing 20% of trusts Intermediate 60% of trusts Worst performing 20% of trusts Health and Social Care workers Did this person listen carefully to you? r a a a a a a a a a Did this person take your views into account? r a a a a a a r a a Did you have trust and confidence in this person? r a a a a a r r a a Did this person treat you with respect and dignity? r a r a a a r r a a Were you given enough time to discuss your condition and treatment? r a a a a a a a a a Medications Do you think your views were taken into account in deciding which medicines to take? a a a r a a a g r a Were the purposes of the medications explained to you? g a r r a a a a a g Were you told about possible side effects of the medications? a a r r g g a a a a 27

30 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Were you given information about the medication in a way that was easy to understand? Has a mental health or social care worker checked with you how you are getting on with your medication? a a a r g a a r a a a a a a a a a g a r Talking therapies Did you find the NHS talking therapy you received in the last 12 months helpful? g a a a g g a a a a Care Coordinator Do you know who your Care Co-ordinator (or lead professional) is? Can you contact your Care Co-ordinator (or lead professional) if you have a problem? How well does your Care Co-ordinator (or lead professional) organise the care and services you need? a a a g a r a a a r r r a r a r a a r a a a a r r r a a r a Care Plan Do you understand what is in your NHS care plan? r a a r a a a r a a Do you think your views were taken into account when deciding what was in your NHS care plan? r a g a r a a r a a 28

31 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Does your NHS care plan set out your goals? r a a r a a r a a a Have NHS mental health services helped you start achieving these goals? g a g a g a a a a a Does your NHS care plan cover what you should do if you have a crisis? r g a a r a a a a a Have you been given (or offered) a written or printed copy of your NHS care plan? r a a g a a a a g a Your Care Review In the last 12 months have you had a care review meeting to discuss your care? Were you told that you could bring a friend, relative or advocate to your care review meetings? a g a g a a g a g a a a a r r a r a a a Before the review meeting, were you given a chance to talk to your care co-ordinator about what would happen? a a g a a a a a a a Were you given a chance to express your views at the meeting? g g a a a g a r r a Did you find the care review helpful? a g g r a a a a r g Did you discuss whether you needed to continue using NHS mental health services? a a g a a r a a r g 29

32 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London Crisis Care Do you have the number of someone from your local NHS mental health service that you can phone out of office hours? The last time you called the number did you have any problems getting through to someone? The last time you called the number, did you get the help you wanted? a a r g r a a a g r r r r a a g a a r a a g g r g a a g a a Day to Day Living Has anyone in NHS mental health services ever asked you about your alcohol intake? Has anyone in NHS mental health services ever asked you about your use of non-prescription drugs? In the last 12 months, have you received support in getting help with your physical health needs? In the last 12 months, have you received support in getting help with your care responsibilities? In the last 12 months, have you received support in getting help with finding or keeping work? In the last 12 months, have you received support in getting help with finding and/or keeping your accommodation? g a a r g a a a a r a a a a a g a a a a a g g r a a a a a r r g a r a g g a a a a a g g a a a a a a a a g a a r a r a a 30

33 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London In the last 12 months, have you received support from anyone in NHS mental health services in getting help with financial advice or benefits? a a g a a r a a a a Overall Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months? Have NHS mental health services involved a member of your family or someone else close to you, as much as you would like? a a a a r r a a a r a r a r a a r r r r 31

34 2.4. Staff feedback National NHS Staff Survey 2011 Background The national NHS staff survey presents the results of the staff questionnaire in the form of 38 Key Findings. Trusts are ranked against all other participating mental health trusts for each Key Finding as follows: Best performing 20% of trusts Better than average Average Worse than average Worst performing 20% of trusts Where there has been a statistically significant change in a Key Finding since the 2010 survey, this is also shown. How did the Trust compare nationally? 42% of staff at the Trust took part in the survey. This response rate is in the lowest 20% of mental health/learning disability trusts in England, and compares with a response rate of 45% in the Trust in the 2010 survey. 34% of the Trust s Key Findings were in the worst performing 20% of trusts. 50% of the Trust s Key Findings were worse than average or in the worst performing 20% of trusts. Key areas of concern focus around patient and staff safety, and equality and diversity. The Trust scores more strongly on staff personal development. 84% of the Key Findings have not changed since the 2010 survey. The Trust showed improvement for four Key Findings: % appraised in last 12 months % having well structured appraisals in last 12 months % appraised with personal development plans in last 12 months % having equality and diversity training in last 12 months The Trust showed deterioration in performance for two Key Findings: % using flexible working options Staff motivation at work How did the Trust compare to other London mental health trusts? Several London trusts had a higher proportion of Key findings in the worst performing 20% of trusts than the Trust. 32

35 FIGURE 30: NHS STAFF SURVEY 2011 PERFORMING 20% OF TRUSTS LONDON MENTAL HEALTH TRUSTS - % OF KEY FINDINGS IN WORST How did the Trust compare with neighbouring trusts? The Trust had the second highest proportion of Key findings in the worst performing 20% of trusts, when compared with its neighbouring trusts. FIGURE 31: NHS STAFF SURVEY 2011 NEIGHBOURING TRUSTS - % OF KEY FINDINGS IN WORST PERFORMING 20% OF TRUSTS 33

36 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London FIGURE 32: NATIONAL NHS STAFF SURVEY 2011 LONDON MENTAL HEALTH TRUSTS AND SURREY AND BORDERS KEY g ag a ra r Best performing 20% of mental health trusts Better than average (2nd quintile) Average (3rd quintile) Worse than average (4th quintile) Worst performing 20% of mental health trusts STAFF PLEDGE 1: To provide all staff with clear roles, responsibilities and rewarding jobs. KF1 % staff feeling satisfied with the quality of work and patient care they are able to deliver KF2 % staff agreeing that their role makes a difference to patients KF3 % staff feeling valued by their work colleagues KF4 Quality of job design (clear content, feedback and staff involvement) ag g g ag g ag ra ag g ag ag g g ag r ag ra g g ag ag ag ag ra r r ra ra g ag g g g ag g ag ag g g ag KF5 Work pressure felt by staff ag ag ag r ag r ag ag g ag KF6 % staff working in a well structured team environment ag g ag ag r ag ag ag g ra 34

37 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London KF7 Trust commitment to work-life balance r ag ag r r r ag ag g r KF8 % staff working extra hours r r r r ag r ra ra ra ag KF9 % staff using flexible working options r ra ag ra r r r ag r ag STAFF PLEDGE 2: To provide all staff with personal development, access to appropriate training for their jobs, and line management support to succeed. KF10 % staff feeling there are good g g g ag ag r ra ag g ag opportunities to develop their potential at work KF11 % staff receiving job-relevant training, learning or development in last 12 months g g ag r ra ag ra g g r KF12 % staff appraised in last 12 months g ra r g ag ag g ag ra r KF13 % staff having well structured appraisals in g last 12 months g ag g g g g g g r KF14 % staff appraised with personal development plans in last 12 months g ra r ag ag ag g g ag r KF15 Support from immediate managers ra ag ag ag r r g ag g r STAFF PLEDGE 3: To provide support and opportunities for staff to maintain their health, well-being and safety. KF16 % staff receiving health and safety training r in last 12 months ra ag ra ag r r ag ag ag KF17 % staff suffering work-related injury in last ag 12 months ra ag r ra ag ag ag r r KF18 % staff suffering work-related stress in last ra 12 months g ag r g ra ag r g ag 35

38 KF19 % saying hand washing materials are always available KF20 % staff witnessing potentially harmful errors, near misses or incidents in last month KF21 % staff reporting errors, near misses or incidents in last month KF22 Fairness and effectiveness of incident reporting procedures KF23 % staff experiencing physical violence from patients/relatives/members of public in last 12 months KF24 % staff experiencing physical violence from staff in last 12 months KF25 % staff experiencing harassment, bullying or abuse from patients/relatives/members of public in last 12 months KF26 % staff experiencing harassment, bullying or abuse from staff in last 12 months KF27 Perceptions of effective action from employer towards violence and harassment KF28 Impact of health and well-being on ability to perform work or daily activities KF29 % staff feeling pressure in the last 3 months to attend work when feeling unwell r r r ag r r r r g ra r ra ra ag r r r ag ag ag ra ag ag g ag ra r r ra r r ag ag ag ra ag r ag g ag ag ag r ag ra ra r ag ag g ag ag ag ag r r r ra ra r r ra r ag r ra r ag g g ra ag ra ag r ra ag r g ag r ag ag ag ra r r ag g ra ra r ra g ag ra ag g r ag ag ag g ra r ra r r g ra 36

39 SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London SWL&STG CNWL SLAM Surrey & Borders West London BEH Camden & Islington East London Oxleas North East London STAFF PLEDGE 4: To engage staff in decisions that affect them, the services they provide and empower them to put forward ways to deliver better and safer services. KF30 % staff reporting good communication between senior management and staff KF31 % staff able to contribute towards improvements at work ra g ra ag ag ra ag ag g ag g g g ra r ra ra g g ag ADDITIONAL THEME: Staff satisfaction KF32 Staff job satisfaction ag g g ag r r r ag g r KF33 Staff intention to leave jobs r ag ag r r ra r r g r KF34 Staff recommendation of the trust as a place to work or receive treatment ag g g ra ag r r ag g ra KF35 Staff motivation at work ag g ag ra ra g r ag g ag ADDITIONAL THEME: Equality and diversity KF36 % staff having equality and diversity training in last 12 months KF37 % staff believing trust provides equal opportunities for career progression or promotion KF38 % staff experiencing discrimination at work in last 12 months r ra r ag ag ra r ag g ag r r r r r r r r g ra r r r r r r r r ag ag 37

40 2.5. Regulatory compliance CQC site visits The table below shows the ratings given by the CQC to each unit in London (and Surrey and Borders). In each case a green box indicates that all standards were being met when they last checked. A grey box indicates that at least one standard in this area was not being met when they last checked and they required improvements. A red box would indicate that at least one standard in this area was not being met when the CQC last checked and they had taken enforcement action, however this outcome did not occur within any of the units below. The table only shows those units where Mental health featured in the unit type description. Five of the Trust s ten sites have at least one grey box. The majority of other London trusts and Surrey and Borders have no grey boxes. West London, Barnet, Enfield and Haringey and South London and Maudsley all have one site each with a grey box. 38

41 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management FIGURE 33: CQC WARD VISIT INSPECTION RESULTS Trust Unit Type South West London and St Addison Unit - George's Mental Health HMP NHS Trust Wandsworth South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust South West London and St George's Mental Health NHS Trust Barnes Hospital Haydon House Old Church Queen Hospital Springfield University Hospital Thrale Road Tolworth Hospital Mary's Mental health, learning disability or substance misuse hospital service, Prison health service Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Long-term conditions service, Mental health, learning disability or substance misuse hospital service 39

42 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type South West London and St Trust George's Mental Health Headquarters NHS Trust South West London and St George's Mental Health NHS Trust North East London NHS Foundation Trust North East London NHS Foundation Trust North East London NHS Foundation Trust North East London NHS Foundation Trust North East London NHS Foundation Trust North East London NHS Foundation Trust North East London NHS Foundation Trust West London Mental Health NHS Trust Westmoor House Brookside Hawkwell Court Mascalls Park Nasebury Court Sunflowers Court Trust Head Office Woodbury Unit Broadmoor Hospital Community service, Mental health community service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Community service, Mental health community service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service, NHS and/or Private doctor 40

43 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type West London Mental Mental health, learning disability or Cassel Hospital Health NHS Trust substance misuse hospital service West London Mental Health NHS Trust West London Mental Health NHS Trust West London Mental Health NHS Trust West London Mental Health NHS Trust Hammersmith & Fulham Mental Health Unit and Community Services Lakeside Mental Health Unit & Hounslow Community Services St Bernards and Ealing Community Services The Limes Hospital, Mental health community service, Mental health, learning disability or substance misuse hospital service Hospital, Mental health community service, Mental health, learning disability or substance misuse hospital service Hospital, Mental health community service, Mental health, learning disability or substance misuse hospital service, NHS and/or Private doctor, Prison health service Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service Oxleas NHS Foundation Trust Atlas House Oxleas NHS Foundation Trust Banbury House Mental health community service Oxleas NHS Foundation Bexleyheath Mental health community service 41

44 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Trust Centre Bracton Centre Oxleas NHS Foundation Mental health, learning disability or Medium Secure Trust substance misuse hospital service Unit Bracton Oxleas NHS Foundation Community Trust Psychiatric Mental health community service Nursing Team Oxleas NHS Foundation Green Parks Mental health, learning disability or Trust House substance misuse hospital service Oxleas NHS Foundation Trust Oxleas NHS Foundation Trust Oxleas NHS Foundation Trust Oxleas NHS Foundation Trust Oxleas NHS Foundation Trust Barnet, Enfield and Haringey Mental Health NHS Trust Greenwood and Hazelwood Highpoint House Memorial Hospital Oxleas House Woodlands Unit Barnet General Hospital Mental health, learning disability or substance misuse hospital service Mental health community service Mental health community service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health community service, Mental health, learning disability or substance misuse hospital service 42

45 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Barnet, Enfield and Haringey Mental Health NHS Trust Barnet, Enfield and Haringey Mental Health NHS Trust Barnet, Enfield and Haringey Mental Health NHS Trust Barnet, Enfield and Haringey Mental Health NHS Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Chase Hospital Edgware Community Hospital Farm St Ann's Hospital Trust Headquarters 3 Beatrice Place 7a Road Woodfield CNWL Trust Headquarters Community health service, Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Community health service, Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health community service, Rehabilitation (illness or injury) Community service, Mental health community service, Prison health service 43

46 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Collingham Child & Family Centre Hillingdon Hospital Mental Health Site Horton Haven Kingswood Centre Max Glatt Unit Northwick Park Mental Health Centre Park Royal Centre for Mental Health Seacole Centre Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service 44

47 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust Central and North West London NHS Foundation Trust South London and Maudsley NHS Foundation Trust South Kensington and Chelsea Mental Health Centre St Charles Mental Health Centre Stephenson House The Butterworth Centre The Butterworth Centre The Hospital Gordon Ladywell Unit Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Community health service, Community service, Mental health community service, Prison health service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service 45

48 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type South London and Lambeth Maudsley NHS Foundation Hospital Trust South London and Maudsley NHS Foundation Trust South London and Maudsley NHS Foundation Trust East London NHS Foundation Trust Maudsley Hospital The Bethlem Royal Hospital Adult Mental Health Services - City and Hackney Directorate Mental health, learning disability or substance misuse hospital service Care home with nursing, Community service, Care in your home and supported living, Diagnostic and/or screening service, Long-term conditions service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury), Urgent care service Care home with nursing, Community service, Care in your home and supported living, Long-term conditions service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury), Urgent care service Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) 46

49 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Adult Mental Mental health community service, Mental East London NHS Health Services - health, learning disability or substance Foundation Trust Newham misuse hospital service, Rehabilitation East London NHS Foundation Trust East London NHS Foundation Trust East London NHS Foundation Trust East London NHS Foundation Trust East London NHS Foundation Trust Directorate Adult Mental Health Services - Tower Hamlets Directorate Child and Adolescent Mental Health Services (CAMHS) Forensic Services Directorate Mental Healthcare for Older Persons Directorate Trust Headquarters - East London NHS Foundation Trust (illness or injury) Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or 47

50 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type injury) East London NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Warehouse K - Management Building Ethel Close Oakglade Fairmead Farmfield Bailey and Farnham Road Hospital (Mental Health Unit) Mid Surrey Assessment and Treatment Service Community health service, Community service, Diagnostic and/or screening service, Long-term conditions service, Mental health community service, Remote clinical advice, Rehabilitation (illness or injury) Care home with nursing, Mental health, learning disability or substance misuse hospital service Care home with nursing, Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service 48

51 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Surrey and Borders Mental health, learning disability or Partnership NHS Oaklands substance misuse hospital service Foundation Trust Surrey and Borders Old School Mental health, learning disability or Partnership NHS House substance misuse hospital service Foundation Trust Surrey and Borders Ridgewood Mental health, learning disability or Partnership NHS Centre substance misuse hospital service Foundation Trust Surrey and Borders Mental health, learning disability or Partnership NHS St Ebbas substance misuse hospital service Foundation Trust Surrey and Borders Mental health, learning disability or Partnership NHS St Peter's Site substance misuse hospital service Foundation Trust Surrey and Borders Community service, Care in your home Trust Partnership NHS and supported living, Mental health Headquarters Foundation Trust community service, Prison health service Surrey and Borders West Park Mental health, learning disability or Partnership NHS Epsom substance misuse hospital service Foundation Trust Surrey and Borders Willows, Woking Mental health, learning disability or Partnership NHS Community substance misuse hospital service Foundation Trust Hospital 49

52 Standards of treating people with respect and involving them in their care Standards of providing care, treatment and support that meets people's needs Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management Trust Unit Type Camden and Islington NHS Foundation Trust Camden and Islington NHS Foundation Trust Camden and Islington NHS Foundation Trust Camden and Islington NHS Foundation Trust Highgate Mental Health Centre Queen House St Hospital Mary's Luke's St Pancras Hospital Care home with nursing, Care home without nursing, Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Prison health service, Rehabilitation (illness or injury) Mental health, learning disability or substance misuse hospital service Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) Care home with nursing, Community service, Mental health community service, Mental health, learning disability or substance misuse hospital service, Rehabilitation (illness or injury) 50

53 NHS Litigation Authority ratings as at March 2011 The core of the NHSLA risk management programme is provided by a range of NHSLA standards and assessments. Most Healthcare organisations are regularly assessed against these risk management standards which have been specifically developed to reflect issues which arise in the negligence claims reported to the NHSLA. There is a set of risk management standards for each type of healthcare organisation incorporating organisational, clinical, and health & safety risks. All the NHSLA Standards are divided into three levels : one, two and three. Organisations at level 1 are assessed against the relevant standard(s) once every two years and those at levels 2 and 3 at least once in any three year period, although organisations may request an earlier assessment if they wish to move up a level. The mean for English mental health trusts is 1.35, and for London mental health trusts Figure 34 shows the ratings for neighbouring trusts. The Trust is rated as 1. FIGURE 34: NHS LITIGATION AUTHORITY RATINGS AS AT MARCH 2011 West London Mental Health 1 Surrey and Borders Partnership 1 South West London and St George's 1 South London and Maudsley 2 Central and North West London 2 51

54 3. ANALYSES OF LOCAL DATA Trust data has been analysed under the following headings: Outcomes (3.1) Access and waiting (3.2) Safety (3.3) Use of services by population groups (3.4) Service user feedback (3.5) Costs and productivity (3.6) Service utilisation (3.7) 3.1. Outcomes We have no data on outcomes. There are a number of measures in the Trust reports which relate to quality processes, which could drive improvements in outcomes. These are described below Quality processes The Trust Local CQUIN 2011/12 Closure report notes: Recovery goals The Trust has developed its own recovery goals form, which can be used to inform the care planning process and measure progress over time. The Trust met the target to ensure that 30% of people on CPA in clusters 12, 13, 16 and 17 have two of these forms recorded. Physical health high mortality codes (QOF register). The Trust missed the 90% target for achievement of this indicator, reaching 71% by the end of March (2,742 people being discussed with GPs). This was influenced by the late starting of the project (in September) due to efforts to reach agreement with the commissioners on the CQUIN and the design of the data entry tool. Relevant physical health checks in primary and secondary care - The Trust just missed the 60% target of people on CPA to have a relevant annual physical health check, achieving 59% by the end of March. Medicines reconciliation within 72 hours of admission this target was met. Discharge summaries to be sent to GP within 7 days of discharge this target was met. Smoking cessation all 3 targets met (Data recording of smoking status, recording the number of referrals to Stop Smoking Services, Setting and recording the number of smokers referred who set a quit date). The quarterly contract report for the 2011/12 year end notes: The Trust met the target for the proportion of those on CPA reviewed in at least the last 12 months. 96% of service users who required a CPA review had an up to date CPA review present at the year end (for service users on CPA for 12 months or more). The Trust reports that this is an improvement over the over the end of the previous year where only 92% of service users who should have had a CPA review did so. The monthly contract report for March 2012 shows that: The Trust met the target for the proportion of service users followed up within 7 days of discharge from inpatient care. 52

55 The Trust met the delayed discharged target in all boroughs except Kingston (amber). The Trust reports that it continues to perform well on this KPI month on month. In March only 2% of Trust occupied bed days were due to delayed discharges of care. This is an improvement compared with 2010/11 (5%) and well below the Monitor target of 7.5%. The Trust was rated amber for the two KPIs measuring the percentage of CMHT caseload receiving face to face or phone contact with a care co-ordinator in the month (actual was 71% for service users on a CPA and 31% not on a CPA). The Trust has provided us with a draft copy of the Mental Health Trust Quality Profile developed by Quality Intelligence East and North East Quality Observatory System. We have not used data from the Profile as it is in draft form, and has not yet completed national validation Trust quality initiatives The Trust has also drawn our attention to the following quality initiatives: The Recovery College Specialist services directorate Forensic services IAPT Smoking Cessation services Older people s intensive home treatment team Older people s challenging behaviour service Sutton and Merton Self-directed support and personal budgets Adult safeguarding 3.2. Access and waiting Access to services can be measured in a number of ways. We start by looking at the services available to local residents, by comparing the level of investment in the Trust mental health services by PCT, and the spend per head of population for adult and older people s services. We then review some of the Trust s KPIs with respect to some of their services. Level of investment in South West London and St George s by PCT Figure 35 shows the four PCTs total mental health budget (across all providers) and the value of their investment in the Trust for The PCTs budget also covers London Specialist Commissioning Group contributions, and contracts with other providers. FIGURE 35: PCT PLANNED INVESTMENT IN MENTAL HEALTH (,000) Total mental health budget per PCT Budget Books Spend with the Trust outside SLA Total investment in the Trust % of mental health budget spent with the Trust SLA with PCT the Trust Kingston 25,127 16, , Richmond 27,111 15,105 1,638 16, Sutton & Merton 52,464 30,851 1,200 32, Wandsworth 66,260 40,143 2,934 43, Total 170, ,246 5, ,

56 60% of the planned investment is in adult and older people services. Planned investment per head of population shows some variation between the PCTs (figure 36). FIGURE 36: PLANNED INVESTMENT IN THE TRUST IN ADULT AND OLDER PEOPLE S SERVICES 2012/13 Adult '000 Weighted population * Spend per weighted adult Older People '000 Weighted population * Spend per weighted older adult Kingston 7,843 94, ,086 17, Richmond 6, , ,720 19, Sutton & Merton 14, , ,458 25, Wandsworth 18, , ,031 18, Total 47, , ,295 80, Data source: 2012/13 PCT SLA costed activity schedules. Excludes CQUIN * Adult population for Kingston and Richmond is 18-64, for Sutton & Merton and Wandsworth Older people population for Kingston and Richmond is 65+, for Sutton & Merton and Wandsworth 75+. Access to community mental health teams The March 2012 monthly contract report rates the Trust red for waiting times to CMHTs (non-urgent cases). 20% of patients were not assessed within 28 days of referral (target was 10%). The Trust reports that this is an improvement over last year (23%). All boroughs were rated red except for Wandsworth (amber). Kingston shows deterioration on 2011/12 with 36% of patients not assessed within 28 days of referral. The Trust notes that the target levels for 2011/12 were optimistically set at less than half of the 2010/11 waiting times which was over ambitious. Access to crisis resolution and home treatment teams The March 2012 monthly contract report shows that all boroughs have had more home treatment episodes recorded in 2011/12 compared with 2010/11 and the KPI is green rated. The Trust s target for the ratio of all informal admissions to the number which are gatekept by the CRHT service (face to face only) was red rated with a year end figure of 60%. The Trust reports that the Trust and all boroughs continue to improve on this year to date indicator following its introduction in September. The 90% Monitor target has been consistently met for Sutton and Merton PCT clients since November. In February and March, over 90% of Richmond PCT clients received face to face gate keeping. This KPI is red for these boroughs as it is a cumulative (YTD) figure and includes the measurement when the face to face requirement was still being embedded in these boroughs. Access to Early intervention in psychosis services The monthly contract report measures the extent to which Early Intervention Services provided meet the national standards by considering the number of users on the caseloads. The March 2012 target is amber rated. The Trust reports that the KPI provides information on the PCT caseload rather than the managed caseloads of the teams. After discussion with local commissioners it has been agreed that next year s performance reports will monitor the managed caseload of each borough s funded service. The number of new cases accepted by the teams was green rated. 54

57 Access to Assertive outreach teams The monthly contract report has one KPI to measure whether the Trust has comprehensive coverage of assertive outreach services which meet the national standards. The March 2012 target is amber as the Trust had lower numbers on the caseloads than the target. All boroughs were rated green except Sutton and Merton which was rated red. Access to CAMHS The March 2012 monthly contract report rates the CAMHS target red. The length of wait for first access to CAMHS was red rated in all boroughs expect Sutton and Merton which was green. Access to IAPT The Trust provides IAPT services for all boroughs except Richmond. The March 2012 monthly contract report rates the two IAPT KPIs green. All boroughs have had more service users enter a course of IAPT therapy and had more service users recover after the course of therapy compared to last year. In numbers, the Trust overall saw 619 more service users entering a course of IAPT therapy (an increase of 7%) compared to the previous year and 670 more service users recover following a course of IAPT therapy (an increase of 41%). The number of active referrals who waited more than 28 days from referral to first treatment/ therapeutic session at the end of each quarter in 2011/ 12 are show in figure x. FIGURE 37: NUMBER OF REFERRALS TO IAPT WHO WAITED MORE THAN 28 DAYS FROM REFERRAL TO FIRST TREATMENT/ THERAPEUTIC SESSION PCT 2011/12 Q1 Q2 Q3 Q4 Kingston Sutton and Merton Wandsworth Safety Serious Untoward Incidents In June 2011 the Trust was issued a performance notice regarding the 60 overdue serious incident investigations for NHS London. The Trust reports that it has worked hard to resolve both the number of overdue incidents and any system issues that may have led to such a backlog of investigations. This has resulted in the lifting of the performance notice in January The Trust reports that recent figures from NHS London show: A continuing reduction in overdue investigations. As of the 27 April 2012 the Trust only had 7 overdue investigations. The Trust has zero serious incidents overdue by over three months as of the 27 April. The quarterly contract report for the 2011/12 year end notes that 74 SUI were reported to NHS London in 2011/12. Figure x compares the number with 2010/11 and shows the split by PCT. 55

58 FIGURE 38: NUMBER OF SUIS REPORTED TO NHS LONDON 2010/ /12 change Kingston Richmond Sutton & Merton Wandsworth Other TOTAL Absent without leave (AWOL) The quarterly contract report for the 2011/12 year end notes the number of episodes of absence without leave (AWOL) for the number of patients detained under the Mental Health Act Overall there were 47 AWOL events in 2011/12 compared with 47 in 2010/11. While the Trust achieved its target, there was variation between boroughs. Both Kingston and Richmond are red rated with higher number of AWOLs than their target. Complaints The quarterly contract report for the 2011/12 year end rates the number of Trust complaints as red with 318 complaints made. There is variation between the boroughs. Kingston and Richmond are both rated red, Wandsworth is amber, and Sutton and Merton are green. The Trust notes that it has been actively promoting the use of the complaints process resulting in increased numbers of complaints for the past three years. The time to respond to a complaint is rated amber. All boroughs are measured as amber, except for Richmond which is rated red. The percentage of complaints that received a first time resolution is rated green. The Trust notes that the number of complaints that were referred to the ombudsman has halved (from 15 to 8), illustrating improvement in the handling of complaints despite the significant increase in volume. They also note that six out of the eight complaints referred to the ombudsman required no further action (the remaining two are still pending an outcome). CQC Quality and Risk Profile The Trust has provided us with a summary of its CQC Quality and Risk Profile as at 2 April 2012 (figure 39). The Trust note that the CQC cannot explain their rationale for colouring the various boxes, which seem to move in a particularly random and peculiar way from month to month. It cannot be used for benchmarking purposes because the CQC do not release the whole set for scrutiny. The Trust has asked us to include the following from Trish Morris-Thompson and Andrew Mitchell s letter of the 20 th April which says that the Trust s work signals a clear commitment by the Trust to address the issues which were identified and shows that significant effort is being applied and that progress is being made. The Trust had two green rated indicators and two red rated indicators. The remaining indicators were either amber or not marked due to insufficient data to calculate risk. 56

59 FIGURE 39: CQC QUALITY AND RISK PROFILE AS AT APRIL 2ND 2012 Outcomes Involvement Information and 1. Respect and involvement 2. Consent to care and treatment Insufficient data to calculate risk Personalised care Safeguarding safety and 4. Care and welfare 7. Safeguarding 5. Meeting nutritional needs 8. Cleanliness and infection control 6. Co-operating with other providers 9. Management of medicines 10. Safety and suitability of premises 11. Safety, suitability and availability of equipment Suitability of staffing 12. Requirements relating to workers 13. Staffing 14. Supporting staff Quality management and 16. Assessing and monitoring quality 17. Complaints 21. Records 57

60 The Trust s comments on the green and red indicators are as follows: Currently the Trust has two green rated indicators: Outcome 7 Safeguarding people who use services from abuse The Trust received positive comments about its safeguarding procedures from the CQC following their review of compliance visits to five of the Trust sites. Following a visit to the Trust s Springfield Hospital site the CQC noted Staff whom we asked to describe what constituted vulnerable adult or child abuse demonstrated a good understanding of the various types. Other staff, to whom we gave a fictional scenario involving suspected and/or witnessed abuse, were very clear about their safeguarding role and whistle blowing responsibilities. Outcome 21 Records The Trust achieved an overall score of satisfactory for its Information Governance Toolkit in March 2012 (Trusts can achieve satisfactory or not satisfactory ). The Trust scored Level 2 or higher in all of the 45 requirements. The Trust also has two red rated outcomes in its latest QRP: Outcome 2 Consent to Treatment This red rated outcome follows the CQC concerns that the consent of people using the service is not being consistently obtained and acted upon. Outcome 4 Care and Welfare of People who use Services This red rated outcome follows concerns that proper steps are not in place to ensure that the planning and delivery of care and treatment is always centered on the individual, developed with them and meets their needs. We have compared the April CQC Quality and Risk Profile with the March Profile. The differences between the two months are: March profile April profile Meeting nutritional needs Amber Insufficient data Safeguarding Yellow Green Cleanliness and infection Insufficient data Yellow control Management of medicines Yellow Amber Safety and suitability of Yellow Insufficient data premises Supporting staff Insufficient data Yellow Records Yellow Green The Quality Board report dated 22 March 2012 provides further information on CQC Moderate and Minor Concerns (figure 40) 58

61 FIGURE 40: CQQ MODERATE AND MINOR CONCERNS Essential Standards for Quality and Safety Tolworth Springfield Queen Marys Barnes Old Church Outcome 1: Respecting and Involving People who use Moderate Moderate Moderate Moderate Minor (x2) Services Minor (x2) Minor (x2) Outcome 2: Consent to Care and Treatment Moderate Moderate Not Reviewed Not Reviewed Not Reviewed Outcome 4: Care and Welfare of People who use Moderate Moderate Moderate Moderate Moderate Services Outcome 5: Meeting Nutritional Needs Minor Minor Minor Minor Minor Outcome 6: Co-operating with Providers Not Reviewed Compliant Not Reviewed Not Reviewed Not Reviewed Outcome 7: Safeguarding People who use Services from Not Reviewed Compliant Compliant Compliant Compliant Abuse Outcome 8: Cleanliness and Infection Control Not Reviewed Compliant Compliant Compliant Compliant Outcome 9: Management of Medicines Not Reviewed Minor Not Reviewed Moderate Minor Outcome 10: Safety and Suitability of Premises Moderate Compliant Compliant Minor Compliant Outcome 11: Safety Availability and Suitability of Not Reviewed Compliant Minor Not Reviewed Not Reviewed Equipment Outcome 12: Requirements Related to Workers Not Reviewed Compliant Not Reviewed Not Reviewed Not Reviewed Outcome 13: Staffing Minor Minor Minor Compliant Compliant Outcome 14: Supporting Workers Moderate Compliant Compliant Moderate Minor Outcome 16: Assessing and Monitoring the Quality of Not Reviewed Compliant Compliant Compliant Compliant Service Provision Outcome 17: Complaints Not Reviewed Compliant Not Reviewed Minor Not Reviewed Outcome 21: Records Not Reviewed Compliant Not Reviewed Not Reviewed Not Reviewed Source: Trust Quality Board Report 22 March 20 59

62 3.4. Use of services by population groups Inpatients Age Virtually all bed days in adult acute, PICU, rehabilitation and forensic services inpatients were between the age of 18 and 64 in 2011/12. 9% of adult acute bed days were aged 65+, with the majority of these bed days being in Richmond and Sutton and Merton. Nearly all bed days in older adult inpatients were 65+. Gender There is an equal mix of adult acute beds days by gender. 63% of older adult bed days are female. proportion of men to women is higher for PICU (75%), rehabilitation (76%) and forensic services (85%). The Ethnicity 61% of adult acute bed days are White (figure 41). There is significant variation between PCTs. Wandsworth bed days have a different mix to the other PCTs with 47% White and 35% Black. Kingston and Richmond have very few Black bed days. The picture is different for older adult bed days (figure 42). 89% of bed days are White. Wandsworth has a higher proportion of non White bed days compared with the other PCTs. 53% of PICU bed days are White (figure 43). There is significant variation between the PCTs, but the smaller sample size means that more detailed analysis should be viewed with caution. 57% of rehabilitation bed days are White (figure 44). There is significant variation between the PCTs. Compared with Kingston and Richmond, Wandsworth and Sutton and Merton have significantly fewer White bed days (44% and 33%). 50% of forensic bed days are White. There is again a marked variation between PCTs, with Wandsworth and Sutton and Merton having significantly fewer White bed days (31% and 54%). 60

63 FIGURE 41: ADULT ACUTE OCCUPIED BED DAYS BY ETHNICITY 2011/12 FIGURE 42: OLDER ADULT OCCUPIED BED DAYS BY ETHNICITY 2011/12 61

64 FIGURE 43: PICU OCCUPIED BED DAYS BY ETHNICITY 2011/12 FIGURE 44: REHABILITATION OCCUPIED BED DAYS BY ETHNICITY 2011/12 Community services Age Virtually all service users on adult CMHTs, assertive outreach teams, early intervention teams, addictions and psychotherapy were between the ages of 18 and % of home treatment service users were older than 65+ due to a number of older service users in Sutton and Merton and Wandsworth. Virtually all service users on older people s community teams were over the age of % of service users in daycare were between the ages of 18 and 64, with the remaining 25% aged 65+. All CAMHS service users were under the age of

65 Gender There is an equal mix of service users by gender in adult CMHTs, home treatment teams and day care. There is a higher proportion of male service users than female service users on assertive outreach teams (75%) and early intervention teams (62%). The same applies to addictions services (62%). There is a higher proportion of female service users than male service users in older people s community teams (65%), psychotherapy (74%) and CAMHS (60%). FIGURE 45: ADULT CMHTS SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER FIGURE 46: HOME TREATMENT SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER 63

66 FIGURE 47: OLDER PEOPLE SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER FIGURE 48: ASSERTIVE OUTREACH SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER FIGURE 49: EARLY INTERVENTION SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER 64

67 FIGURE 50: DAYCARE SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER FIGURE 51: ADDICTIONS SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER FIGURE 52: PSYCHOTHERAPY SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER 65

68 FIGURE 53: CAMHS TIERS 3 & 4 SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY GENDER Ethnicity 70% of service users on adult CMHTs are White (figure 54). The mix varies between PCTs with Wandsworth having a significantly lower proportion than the other PCTs (55%). There is a similar pattern for home treatment teams (figure 55) and assertive outreach teams (figure 56). Older people s teams show a different picture to adult services. 90% of all service users are White and 78% for Wandsworth (figure 57). 50% of service users on Early intervention teams are White (figure 58). 22% are Black and 14% are Asian. The picture is different again for day care services (figure 59) and addictions services (figure 60), where nearly 90% of service users are White. For both services the proportion is lower in Wandsworth. 80% of service users in psychotherapy are White (figure 61). In CAMHS 74% are White (figure 62), with a lower proportion in Wandsworth. FIGURE 54: ADULT CMHTS SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY 66

69 FIGURE 55: HOME TREATMENT SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY FIGURE 56: ASSERTIVE OUTREACH SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY FIGURE 57: OLDER PEOPLE SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY 67

70 FIGURE 58: EARLY INTERVENTION SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY FIGURE 59: DAYCARE SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY FIGURE 60: ADDICTIONS SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY 68

71 FIGURE 61: PSYCHOTHERAPY SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY FIGURE 62: CAMHS TIERS 3 & 4 SERVICE USERS ON CASELOAD AS AT 31 MARCH 2012 BY ETHNICITY 3.5. Service user feedback Inpatient services The Trust Local CQUIN 2011/12 Closure report notes that internal surveys of inpatient service users were undertaken by Quality Health in 2011/12. According to the report the surveys showed some improvement in inpatient experience, with deterioration against previous results in the welcome to the ward and the experience of nursing care. The report does not provide detailed results of the surveys, as they were not made available. The Trust reports that, after a poor national inpatient survey result in 2009, it has invested in inpatient kiosks to provide real time-feedback. The initial pilot has recently been completed. The roll-out is expected to take the majority of 2012/13. As a result of the inpatient survey results last year, the Trust has created a service development plan. The plan notes that the Trust will bring together key stakeholders to agree a blueprint for better inpatient 69

72 services across adult, older adult and specialist services. The blueprint will specify the future state of inpatient wards in terms of structures, processes, technology, location, practice and outcomes. Part of this blueprint will be the safe reduction of bed numbers and possibly acute wards to invest in further community services. The programme will plan where and how these beds can be reduced appropriately to ensure any reduction is supported by stakeholders, is managed safely and is sustainable in the long term. The plan s milestones are: Coordination and simplification of current short term projects April 2012 Project Board approve project plan May 2012 Initial stakeholder meeting to agree approach, roles and timescales June 2012 Blueprint development workshops - June August 2012 Finalise blueprint Oct 2012 Develop implementation plan Dec 2012 The plan notes that it has not yet been discussed with commissioners. Community services The Trust Local CQUIN 2011/12 Closure report notes that internal surveys of community service users were undertaken by Quality Health in 2011/12. According to the report the community surveys showed that there had been improvement in the proportion of people with a care review. However, there is significant under performance in the quality and content of the review, of care planning and the experience of care coordination. The report does not provide detailed results of the surveys, as they were not made available. Specialist services The Trust commissioned its own survey of its specialist service wards in March The survey involved face to face interviews, and had a response rate of 71%. The survey used the 15 questions from the Real Time Feedback inpatient survey to enable the wards to be benchmarked against the Trust s average and the national average in a number of areas. The Trust report does not state what the Trust or national benchmarks included within figure x are based on. The survey covered the following wards: Type of ward Name of ward Number of beds Eating disorders (adults) Avalon Ward 24 Deaf (adults) Old Church 16 Medium secure Halswell Ward Ruby Ward Turner Ward Low secure Hume Ward 16 OCD (adult) Heather Ward

73 FIGURE 63: SPECIALIST SERVICES INPATIENT SURVEY RESULTS MARCH 2012 Question Specialist Services Inpatient survey results March 2012 Scores out of 5 Trust Av Ha 2012 He 2012 Hu 2012 Ol 2012 Ru 2012 Tu 2012 SS 2012 T 2012 Nat Av Trust Variance National Variance 2 Do you currently feel safe on the ward? When you arrived on the ward, or soon afterwards, did a member of staff tell you about the daily routine of the ward, such as times of meals and visitors times? Have you been made aware of how you could make a complaint if you have one? Do the psychiatrists treat you with respect and dignity? Do you have enough time to discuss your condition and treatment with your psychiatrist? Do the nurses treat you with respect and dignity? Are you given enough time to discuss your condition and treatment with nurses? Do you think your views are taken into account when deciding your care plan? In the last 12 months, have you had a care review to discuss your care plan? How would you rate the hospital food? In your opinion, how clean are the hospital rooms, toilets and bathroom on the ward you are in? (If detained under the Mental Health act) Have your rights been explained to you in a way that you could understand? Overall, how would you rate the care you receive in hospital?

74 3.6. Costs and productivity Cost improvement plan The Trust s cost improvement plan delivered 79% of its target savings for , before adjusting for current and non-recurrent mitigating action. It shows slippage in a number of areas, amounting to 2million (figure 64). This represents about 1% of the annual budget. FIGURE 64: COST IMPROVEMENT PLAN Target Actual Variance YTD M12 YTD M12 k k k SIP CAMHS Community Services e-rostering Older People inpatient P&P PICU Older People Community Older People Sutton & Merton SIP sub total QIPP K&R Fuschias QIPP K&R Rehab/Rose(or Riverside) QIPP S&M Day QIPP S&M Sutton QIPP Southbank QIPP WW CHTT QIPP WW OP Day (CDW) QIPP WW OP Day (JDH) QIPP WW Return of Placements QIPP WW Seacole QIPP WW WRC/CAP CHG Sector QIPP sub total Barnes Closure Catering CIP Facilities CIP Maintenance CIP Facilities CIP sub total Capital Charge revaluation Corporate Costs Corporate Planning Finance Governance Human Resources IM&T Medical Director

75 Nursing Directorate Service Improvement Therapies Trust Board/Secretariat Corporate CIP sub total Placements & Rehab Specialist Svs Growth Total Savings/Income Growth Mitigating Action Non Recurrent Mitigating Action Recurrent Grand Total Reference costs As noted in section 2, the Trust s reference costs index for was 104. The Trust notes that while it has made efficiency improvements, it does not know how this will affect its reference costs index for 2011/12, as other mental health trusts will also have made efficiency improvements. The Trust reports that: Reference costs should not be taken in isolation as a measure of efficiency because:- Nationally they have been used for information only, rather than as a baseline for producing tariffs for contracting purposes (as per Acute sector), and as such there have been queries around the incentives to achieve consistency and accuracy. Analysis shows huge levels of variation from Trust to Trust that is not easily be explained by just market/environment and that there is no contextual analysis to help determine how or why any Trust appears higher cost or lower cost in any area. It should also be noted that reference costs do not allow for contact duration, inpatient length of stay, quality of care and outcome measures, number of contacts or cost per episode or different care pathways. PbR clustering The Trust was involved in a benchmarking comparison of PbR Cluster based tariffs prior to last year s PbR Reference Cost exercise. The Trust reports that it compared favourably against other London Providers in terms of: Cost per day in cluster Episode length per service user Overall Cost per Service user It is too early to draw any conclusions from this data, as the Trust has reported to us that they only introduced care clusters during 2011 and they expect to improve the accuracy during 2012 in time for their formal use in The same applies to other London mental health Trusts. We have therefore made no use of care cluster-based data in this report. 73

76 DNA rates The quarterly contract report for the 2011/12 year end measures some of the Trust DNA rates as amber: Adult CMHT first appointment Older people first appointment Adult follow up CAMHS follow up All other monitored service lines met their targets Service utilisation There are three sections to service utilisation: Bed numbers Bed numbers and some comparative benchmarking of inpatient activity from the Audit Commission Benchmarking Club report Inpatient activity Community activity The Trust reports that as at May 2012 it had 455 beds in various hostels and wards. Figure 65 provides an analysis of bed numbers by type and ward. 74

77 FIGURE 65: TRUST BED NUMBERS AS AT MAY 2012 Bed capacity Services Category Ward/Unit Capacity Borough Site Acute Lilacs 23 Kingston Tolworth Acute Lavender 23 Richmond QMH Acute Jupiter 23 Merton SPH Acute Ward Three 20 Sutton SPH Adult and PICU Beds Acute Rose 23 Wandsworth SPH Acute Laurel 23 Wandsworth SPH Acute Ward Two 18 Wandsworth SPH PICU (F) External Provider 3 All Boroughs External PICU (M) Ward One 13 All Boroughs SPH 169 Rehabilitation Rehabilitation Phoenix 18 All but predominately Wandsworth SPH Rehabilitation Riverside Lodge 12 Kingston, Richmond and Hounslow Barnes 30 Rehabilitation Norfolk Lodge 11 Merton Hostels Rehabilitation Westmoor Hse 12 Wandsworth Rehabilitation Haydon Hse 12 Wandsworth Rehabilitation Thrale Rd 11 Wandsworth Community 46 Older Adult Assessment Azaleas 20 Kingston and Richmond Tolworth Assessment Magnolias 21 Merton, Sutton and Wandsworth Tolworth 41 Older Adult Continuing Care Continuing Care Fuchsias 8 Kingston Tolworth 8 75

78 Forensic Eating Disorders Deaf Medium Security Halswell 16 All Boroughs SPH Medium Security Ruby 10 All Boroughs SPH Medium Security Turner 18 All Boroughs SPH Low Security Hume 16 All Boroughs SPH Rehabilitation Shaftesbury MSU Rehab Flat 1 All Boroughs SPH 61 Adult Avalon 24 All Boroughs SPH Child Wisteria 10 All Boroughs SPH 34 Adult Old Church 16 All Boroughs + National SPH Child Corner Hse 6 All Boroughs + National SPH 22 Tier 4 CCMHS Child Aquarius 10 All Boroughs SPH 10 OCD Adult Heather 20 All Boroughs + National SPH 20 Learning Difficulties Adult Jasmines 14 Merton and Sutton + Any Others SPH 14 76

79 The Trust reports that there has been a 10% increase in referrals to secondary adult and older people s services from 2008/09 to 2011/12, but at the same time a decrease in the use of beds. The Trust has reduced the number of beds significantly over the last 10 years with reductions of more than 40% in adult acute and PICU beds and a reduction of more than 75% for older adult and continuing care beds. There has been no use of overspill beds for acute patients. In March 2012 local commissioners commissioned the Beacon Report which reviewed the needs for acute adult and older people inpatient psychiatry beds across South West London. The report suggests that a reduction of at least 20% inpatient beds could be achieved through reviewing the way that inpatient care is currently provided, such as infrequent Consultant Psychiatrist reviews and lack of communication with other entities involved in the patient s care. The Trust notes that some of the data used in the Beacon Report was dated at the time of publishing. The Audit Commission Mental Health Benchmarking Club report dated December 2011 compares the Trust s use of inpatients with 47 other mental health trusts in England, based on quarter /12 data. The Audit Commission report shows that Trust adult acute beds per head of weighted population were in the upper quartile (figure 66). The Trust notes that at the time of the data collection the Trust had 156 adult acute beds ( now 153), but the audit used a figure of 180. Occupied bed days per head of weighted population were in the upper quartile (figure 67). The median length of stay was in the lower quartile (figure 68), but the percentage of patients with a length of stay of more than 3 months on the census date was near the upper quartile (figure 69). FIGURE 66: ADULT ACUTE BEDS PER HEAD OF WEIGHTED POPULATION QUARTER /12 Source: Audit Commission Benchmarking Club report December

80 FIGURE 67: ADULT ACUTE OCCUPIED BED DAYS PER HEAD OF WEIGHTED POPULATION QUARTER /12 Source: Audit Commission Benchmarking Club report December 2011 FIGURE 68: ADULT ACUTE MEDIAN LENGTH OF STAY INCLUDING OUTLIERS, EXCLUDING LEAVE QUARTER /12 Source: Audit Commission Benchmarking Club report December

81 FIGURE 69: PERCENTAGE OF ADULT ACUTE INPATIENTS WITH LENGTH OF STAY OF MORE THAN 3 MONTHS ON CENSUS DATE Source: Audit Commission Benchmarking Club report December 2011 The Audit Commission report shows that Trust older adult acute beds per head of population were at the median (figure 70), while occupied bed days per head of population were at the lower quartile. The median length of stay was at the median (figure 72), while the percentage of patients with a length of stay of more than 3 months on the census date was above the median (figure 73). FIGURE 70: OLDER ADULT ACUTE BEDS PER HEAD OF POPULATION QUARTER /12 Source: Audit Commission Benchmarking Club report December

82 FIGURE 71: OLDER ADULT ACUTE OCCUPIED BED DAYS PER HEAD OF POPULATION QUARTER /12 Source: Audit Commission Benchmarking Club report December 2011 FIGURE 72: OLDER ADULT ACUTE MEDIAN LENGTH OF STAY INCLUDING OUTLIERS, EXCLUDING LEAVE QUARTER /12 Source: Audit Commission Benchmarking Club report December

83 FIGURE 73: PERCENTAGE OF OLDER ADULT ACUTE INPATIENTS WITH LENGTH OF STAY OF MORE THAN 3 MONTHS ON CENSUS DATE Source: Audit Commission Benchmarking Club report December 2011 Inpatient activity Using data provided by the Trust, we have compared inpatient activity between boroughs as well as producing an overall picture for the Trust. Our focus has been on those bed types with higher numbers of occupied bed days (OBDs). Our analysis shows: Occupied bed days for 2010/11 and 2011/12 Occupied bed days per head of population Occupied bed days by diagnosis Referral source for all ward spells in 2010/11 and 2011/12. A ward spell is a continuous period of stay on one ward. All patients admitted to a ward during the financial year have been included. Patients are counted more than once when they have been discharged from one ward and admitted to another ward during the financial year. Length of stay to date in a bed type for those service users who were inpatients as at 31 March 2011 and 31 March This includes patients who were on leave. Overview of bed types Figures 74 provides an overview of occupied bed days for all bed types for 2011/12. Detailed analysis has been carried out for those bed types highlighted in yellow. 81

84 FIGURE 74: OCCUPIED BED DAYS 2011/12 Ward Type Kingston Richmond Sutton and Merton Wandsworth Trust Addictions ,260 1,469 4,387 Adult Acute 8,139 8,225 15,501 20,551 52,416 CAMHS Tier ,269 Deaf Services ,030 2,114 Eating Disorders ,897 Forensic Services 1,811 2,438 7,394 10,730 22,373 Learning Disabilities , ,411 Older People 3,962 3,374 2,404 3,494 13,234 Older People Continuing Care 2, ,547 PICU 1, ,744 1,593 5,288 Rehabilitation 2,500 6,074 3,130 17,226 28,930 Grand Total 21,044 23,012 35,107 57, ,866 ICD10 codes to note when interpreting data The Trust has advised us that the ICD10 code (diagnosis) is 98.8% complete for unique admissions during the period. The few records that remain un-coded mainly relate to current short stay patients and these are coded at finished consultant episode. Patients with no diagnostic code are shown as no recorded diagnosis in the charts. In collaboration with the Trust we have bundled the ICD10 codes (ie diagnoses) into a number of categories: Mood (affective) disorder Neurotic, stress and somatoform disorders Behavioural syndromes Psychosis CAMHS Personality disorder Substance misuse Organic No specific domain No recorded diagnosis Adult acute inpatients Figure 75 shows the number of occupied bed days for 2010/11 and 2011/12, excluding leave. Overall bed days have decreased by 13%. While bed days have decreased for three of the PCTs, they have slightly increased for Kingston. 82

85 FIGURE 75: ADULT ACUTE OCCUPIED BED DAYS FOR 2010/11 AND 2011/12 Occupied bed days 2010/11 As % of total Occupied bed days 2011/12 As % of total Increase / (Decrease)% Year-on-year Kingston 7,998 13% 8,139 16% 2% Richmond % % (14%) Sutton and Merton 18,772 31% 15,501 30% (17%) Wandsworth 23,839 40% 20,551 39% (14%) Total 60,209 52,416 (13%) All analysis has been carried out using occupied bed days excluding leave. Figure 76 compares occupied bed days including and excluding leave for acute adults. The proportion of leave days is the same for 2010/11 and 2011/12. FIGURE 76: OCCUPIED BED DAYS INCLUDING AND EXCLUDING LEAVE FOR ADULT ACUTE 2010/11 AND 2011/12 Acute adults Acute adults 2010/ /12 Occupied bed days including leave 71,635 62,539 Occupied bed days excluding leave 60,209 52,416 Days of leave 11,426 10,123 Leave as % of bed days including leave 16% 16% Figure 77 compares the occupied bed days per weighted population for 2010/11 and 2011/12. Sutton and Merton has significantly lower bed days. Kingston and Richmond have the highest bed days. FIGURE 77: ADULT ACUTE OCCUPIED BED DAYS PER WEIGHTED THOUSAND POPULATION 2010/11 AND 2011/12 Note: Adult population for Kingston and Richmond is 18-64, for Sutton & Merton and Wandsworth Figure 78 and 79 compare occupied bed days by diagnosis for 2010/11 and 2011/12. 56% of bed days were for psychosis, and 24% were for mood (affective) disorders. There is no significant change between 83

86 the two years for the Trust, although there is some movement for Kingston, Richmond, and Sutton and Merton. FIGURE 78: ADULT ACUTE OCCUPIED BED DAYS BY DIAGNOSIS 2010/11 FIGURE 79: ADULT ACUTE OCCUPIED BED DAYS BY DIAGNOSIS 2011/12 84

87 Figures 80 and 81 compare referral source for all ward spells in 2010/11 and 2011/12. 40% of referrals are transfers from another ward, and about 30% are from A&E. There is little change between the two years. This is indicative of the service operating as a common bed pool across South West. FIGURE 80: ADULT ACUTE REFERRAL SOURCE FOR ALL WARD SPELLS IN 2010/11 FIGURE 81: ADULT ACUTE REFERRAL SOURCE FOR ALL WARD SPELLS IN 2011/12 85

88 Figures 82 and 83 compare the length of stay to date for service users who were inpatients as at 31 March 2011 and 31 March As at 31 March % of service users had been on an acute ward for more than one month. This is a slight increase from 2011 (51%). Less than 10% of all service users had been on the ward for more than six months. FIGURE 82: ADULT ACUTE - LENGTH OF STAY TO DATE AS AT 31 MARCH 2011 FIGURE 83: ADULT ACUTE - LENGTH OF STAY TO DATE AS AT 31 MARCH

89 Older people Figure 84 shows the number of occupied bed days for 2010/11 and 2011/12, excluding leave. Overall bed days have decreased by 32%, with the most significant reduction in Richmond (51%). FIGURE 84: OLDER PEOPLE OCCUPIED BED DAYS FOR 2010/11 AND 2011/12 Increase / (Decrease)% Year-onyear Occupied Bed Days 2010/11 As % of total Occupied Bed Days 2011/12 As % of total Kingston 5,088 26% 3,962 30% (22%) Richmond 6,950 36% 3,374 25% (51%) Sutton and Merton 3,212 17% 2,404 18% (25%) Wandsworth 4,118 21% 3,494 26% (15%) Total 19,368 13,234 (32%) Figure 85 compares the occupied bed days per weighted population for 2010/11 and 2011/12. There are very large differences between the PCTs. FIGURE 85: OLDER PEOPLE OCCUPIED BED DAYS PER WEIGHTED THOUSAND POPULATION 2010/11 AND 2011/12 Note: Older people population for Kingston and Richmond is 65+, for Sutton & Merton and Wandsworth

90 Figures 86 and 87 compare occupied bed days by diagnosis for 2010/11 and 2011/12. About 40% of bed days were organic, and approximately 30% were mood (affective) disorders. There is little change in the Trust average between the two years. The proportion of mood (affective) disorders reduced significantly in Kingston in 2011/12 (56% to 36%) but they had a higher proportion of bed days with no recorded diagnosis in 2011/12. FIGURE 86: OLDER PEOPLE OCCUPIED BED DAYS BY DIAGNOSIS 2010/11 FIGURE 87: OLDER PEOPLE OCCUPIED BED DAYS BY DIAGNOSIS 2011/12 88

91 Figures 88 and 89 compare referral source for all ward spells in 2010/11 and 2011/12. About 20% of service users were referred by community health services. In 2010/11 20% of service users were referred from A&E. This increased to 26% in 2011/12. FIGURE 88: OLDER PEOPLE REFERRAL SOURCE FOR ALL WARD SPELLS IN 2010/11 FIGURE 89: OLDER PEOPLE REFERRAL SOURCE FOR ALL WARD SPELLS IN 2011/12 89

92 Figures 90 and 91 compare the length of stay to date for service users who were inpatients as at 31 March 2011 and 31 March About 45% of all service users had been on an older people s ward for less than a month. In % had been on an older people s ward for more than 6 months. This increased to 16% in There is considerable variation between the PCTs for each year and between years. FIGURE 90: OLDER PEOPLE - LENGTH OF STAY TO DATE AS AT 31 MARCH 2011 FIGURE 91: OLDER PEOPLE - LENGTH OF STAY TO DATE AS AT 31 MARCH

93 PICU Figure 92 shows the number of occupied bed days for 2010/11 and 2011/12. Overall bed days have increased by 6%. Kingston bed days have substantially increased (71%) while Richmond bed days have decreased by 17%. FIGURE 92: PICU OCCUPIED BED DAYS FOR 2010/11 AND 2011/12 Occupied bed days 2010/11 As % of total Occupied bed days 2011/12 As % of total Increase / (Decrease)% Year-on-year Kingston % 1,043 20% 71% Richmond 1,096 22% % (17%) Sutton and Merton 1,680 34% 1,744 33% 4% Wandsworth 1,585 32% 1,593 30% 1% Total 4,971 5,288 6% The Trust has informed us that the PICU occupied bed days include s136 patients who are not inpatients but who are brought in by police to be assessed but then may be sent home (in the case of drunken behaviour for example). We have been advised to identify s136 patients by looking at the length of stay. All those patients who were admitted to PICU from outside the Trust and who have a length of stay of one day or less are assumed to be s136 patients. The bed days attributable to s136 patients represents 3% of total bed days (Figure 93). There were no s136 patients on PICU on either of the two census dates (ie 31 March and 31 March 2012). FIGURE 93: PICU OCCUPIED BED DAYS ATTRIBUTABLE TO S136 PATIENTS CCG 2010/ /12 Kingston Richmond Sutton and Merton Wandsworth Grand Total

94 Rehabilitation Figure 94 shows the number of occupied bed days for 2010/11 and 2011/12, excluding leave. Overall bed days have decreased by 16%. Kingston bed days substantially decreased (62%), while Wandsworth bed days increased by 11%. FIGURE 94: REHABILITATION OCCUPIED BED DAYS FOR 2010/11 AND 2011/12 Occupied bed days 2010/11 As % of total Occupied bed days 2011/12 As % of total Increase / (Decrease)% Year-on-year Kingston 6,512 19% 2,500 9% (62%) Richmond 8,378 24% 6,074 21% (28%) Sutton and Merton 3,918 11% 3,130 11% (20%) Wandsworth 15,573 45% 17,226 60% 11% Total 34,381 28,930 (16%) Figure 95 compares the occupied bed days per weighted population for 2010/11 and 2011/12. Sutton and Merton is very low compared with the other PCTs. Both Kingston and Richmond had a significant reduction in 2011/12, while Wandsworth had a slight increase. FIGURE 95: REHABILITATION OCCUPIED BED DAYS PER WEIGHTED THOUSAND POPULATION 2010/11 AND 2011/12 92

95 Figure 96 and 97 compare occupied bed days by diagnosis for 2010/11 and 2011/12. Virtually all bed days are psychosis. FIGURE 96: REHABILITATION OCCUPIED BED DAYS BY DIAGNOSIS 2010/11 FIGURE 97: REHABILITATION OCCUPIED BED DAYS BY DIAGNOSIS 2011/12 Figures 98 and 99 compare the length of stay to date for service users who were inpatients as at 31 March 2011 and 31 March % of the service users had been on a rehabilitation ward for over a year. FIGURE 98: REHABILITATION - LENGTH OF STAY TO DATE AS AT 31 MARCH

96 FIGURE 99: REHABILITATION - LENGTH OF STAY TO DATE AS AT 31 MARCH 2012 Forensic services Figure 100 shows the number of occupied bed days for 2010/11 and 2011/12. Overall bed days are very similar, but there is significant movement by PCT. Kingston and Sutton and Merton bed days have reduced by 15% and 13%, while Wandsworth bed days have increased by 17%. FIGURE 100: FORENSIC SERVICES OCCUPIED BED DAYS FOR 2010/11 AND 2011/12 Occupied bed days 2010/11 As % of total Occupied bed days 2011/12 As % of total Increase / (Decrease)% Year-on-year Kingston 2,124 10% 1,811 8% (15%) Richmond 2,302 10% 2,438 11% 6% Sutton and Merton 8,520 39% 7,394 33% (13%) Wandsworth 9,163 41% 10,730 48% 17% Total 22,109 22,373 1% 94

97 Figure 101 and 102 compare occupied bed days by diagnosis for 2010/11 and 2011/12. About 80% of bed days are psychosis. FIGURE 101: FORENSIC SERVICES OCCUPIED BED DAYS BY DIAGNOSIS 2010/11 Sample size = 62 FIGURE 102: FORENSIC SERVICES OCCUPIED BED DAYS BY DIAGNOSIS 2011/12 Sample size = 53 95

98 Figures 103 and 104 compare the length of stay to date for service users who were inpatients as at 31 March 2011 and 31 March % of service users had been on a forensic ward for more than a year as at 31 March This was a slight increase from 2011 (56%). FIGURE 103: FORENSIC SERVICES - LENGTH OF STAY TO DATE AS AT 31 MARCH 2011 FIGURE 104: FORENSIC SERVICES - LENGTH OF STAY TO DATE AS AT 31 MARCH

99 Community services Using activity data provided by the Trust, we have compared community teams between boroughs as well as producing an overall picture for the Trust. Our focus has been on those teams with larger caseloads and greater contact activity. Our analysis provides a snapshot of the main community teams as at 31 March 2011 and 31 March 2012 showing: Number of service users on caseloads as at 31 March 2011 and 31 March 2012 Analysis of caseloads by diagnosis as at 31 March 2011 and 31 March 2012 Length of stay to date for those on caseload as at 31 March 2011 and 31 March 2012 Analysis of service users on caseload for more than 3 years as at 31 March 2012 by diagnosis and care cluster. We also compare the number of contacts per service user per year for the two financial years 2010/11 and 2011/12. Overview of community teams Figures 105 and 106 provide an overview of all community teams. Detailed analysis has been carried out for those teams highlighted in yellow. FIGURE 105: NUMBER OF SERVICE USERS ON CASELOADS BY TEAM TYPE Team Type Caseload 31st March 2011 Caseload 31st March 2012 Addictions 1, Adult CMHT 5,098 4,947 Art Therapy Assertive Outreach BCPU CAMHS Tier CAMHS Tier 3 & 4 2,551 2,263 Day care Deaf Services Early Intervention Eating Disorders Forensic Services Home Treatment Learning Disabilities Liaison Neuro Psychiatry Older People 3,209 3,356 Other Psychotherapy PTSD Total 15,377 14,075 97

100 FIGURE 106: TOTAL NUMBER OF CONTACTS BY TEAM TYPE Team Type Total contacts Total contacts Addictions 31,393 23,049 Adult CMHT 97, ,787 Art Therapy Assertive Outreach 18,022 8,582 BCPU 2,556 2,369 CAMHS Tier 2 1,770 2,277 CAMHS Tier 3 & 4 28,986 28,952 Crisis Intervention Daycare 13,306 8,223 Deaf Services 1,789 2,089 Early Intervention 15,237 15,591 Eating Disorders 6,132 5,625 Forensic Services 1,656 1,950 Home Treatment 27,533 33,560 Learning Disabilities 3,515 3,470 Liaison 7,028 5,325 Neuro Psychiatry NULL 5 0 Older People 48,859 51,083 Other 5,539 18,209 Psychotherapy 12,705 9,815 PTSD 1,522 1,516 Total 326, ,188 PCT populations Figure 107 shows for reference the share of population by PCT. We have summed the 2008 mid-year estimate populations for the four PCTs, and calculated their share of the total population. FIGURE 107: PCT POPULATIONS Kingston Richmond Sutton and Merton Wandsworth Share of population % 19% 41% 24% % 17% 37% 30% % 19% 42% 22% All age 16% 18% 38% 28% Share of weighted population % 14% 36% 37% 98

101 ICD10 codes to note when interpreting the charts The Trust has advised us that the ICD10 code (diagnosis) is missing for 16% of the patients. Patients with no diagnostic code are shown as no recorded diagnosis in the charts. We have used the same diagnosis categories as for inpatients. Adult community mental health teams (CMHTs) Figure 108 shows the number of service users on caseloads as at 31 March 2011 and 31 March There is little change between the two years in terms of the overall number of service users or the split between the PCTs. FIGURE 108: ADULT CMHTS - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar-11 As % of total Caseload 31-Mar-12 As % of total Increase / (Decrease)% Year-on-year Kingston 1,027 20% 1,015 21% (1.2%) Richmond % % 0% Sutton and Merton 1,433 28% 1,351 27% (6%) Wandsworth 1,649 32% 1,592 32% (3%) Total 5,098 4,948 (3%) Figure 109 and 110 compare the case mix of caseloads by diagnosis. There is little change between 2011 and About 30% of the service users on the Trust caseloads had mood (affective) disorders. Richmond had the highest proportion of service users in this category, while Wandsworth had the smallest proportion. FIGURE 109: ADULT CMHTS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

102 FIGURE 110: ADULT CMHTS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figure 111 and 112 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 113 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a CMHT caseload for more than two years. This was a slight reduction from 2011 (38%). The proportion of service users with a length of stay of more than two years is significantly lower for Wandsworth service users. Figure 113 shows that while the number of service users on a CMHT caseload for more than two years has reduced in Kingston and Wandsworth between 2011 and 2012, there has been no change in Richmond or Sutton and Merton. FIGURE 111: ADULT CMHTS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

103 FIGURE 112: ADULT CMHTS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2012 FIGURE 113: ADULT CMHTS - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS 101

104 Figure 114 provides further analysis for those service users who have been on the caseload for more than three years. The charts show that a lower proportion of Wandsworth service users had mood affective disorders compared to the other PCTs. FIGURE 114: ADULT CMHTS - ANALYSIS OF SERVICE USERS ON CASELOAD FOR MORE THAN 3 YEARS AS AT 31 MARCH 2012 BY DIAGNOSIS Figure 115 compares the number of contacts per service user for and The Trust average increased by 11%. Kingston and Sutton and Merton show the greatest variation between the two years: Kingston contacts per service user decreased by 19% Sutton and Merton contacts per service user increased by 31% FIGURE 115: ADULT CMHTS - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 102

105 Home treatment teams Figure 116 shows the number of service users on caseloads as at 31 March 2011 and 31 March The number on caseloads increased by 27% from 2011 to The highest increase in service users is in Wandsworth. FIGURE 116: HOME TREATMENT TEAMS - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 Caseload 31-Mar- 12 Increase / (Decrease)% Year-on-year As % of total As % of total Kingston 17 18% 21 17% 24% Richmond 17 18% 20 16% 18% Sutton and Merton 32 33% 36 29% 13% Wandsworth 31 32% 46 37% 48% Total % The following analysis should be reviewed with caution as the number of service users on a caseload at a point in time is small. The analysis provides a snapshot, but may not demonstrate service use month by month. Figure 117 and 118 compare the case mix of caseloads by diagnosis. There is little change between 2011 and About 35% of the service users on the Trust caseloads had mood (affective) disorders. FIGURE 117: HOME TREATMENT TEAMS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

106 FIGURE 118: HOME TREATMENT TEAMS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figure 119 and 120 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March As you would expect with a home treatment service, all service users in 2012 had been on the caseload for less than 6 months in FIGURE 119: HOME TREATMENT TEAMS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

107 FIGURE 120: HOME TREATMENT TEAMS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2012 Figure 121 compares the number of contacts per service user for and The Trust average increased by 37%. Sutton and Merton show the greatest increase (64%). FIGURE 121: HOME TREATMENT TEAMS - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 105

108 Older people community mental health teams Figure 122 shows the number of service users on caseloads as at 31 March 2011 and 31 March There is little change between the two years in terms of the overall number of service users or the split between the PCTs. FIGURE 122: NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 As % of total Caseload 31-Mar- 12 As % of total Increase / (Decrease)% Year-on-year Kingston % % 2% Richmond % % 18% Sutton and Merton 1,139 35% 1,201 36% 5% Wandsworth % % (11%) Total 3,209 3,356 5% Figure 123 and 124 compare the case mix of caseloads by diagnosis. There is little change between 2011 and About 68% of the service users on the Trust caseloads had an organic diagnosis. The proportion of service users with an organic diagnosis is slightly higher in Sutton and Merton. FIGURE 123: OLDER PEOPLE - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

109 FIGURE 124: OLDER PEOPLE - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figure 125 and 126 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 127 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a caseload for more than two years. This was a slight increase from 2011 (34%). The proportion of service users with a length of stay of more than two years is significantly lower for Richmond service users. Figure 127 shows that while the number of service users on a CMHT caseload for more than two years has reduced in Kingston between 2011 and 2012, there has been a slight increase in the other PCTs. FIGURE 125: OLDER PEOPLE - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

110 FIGURE 126: OLDER PEOPLE - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2012 FIGURE 127: OLDER PEOPLE - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS Figure 128 provides further analysis for those service users who have been on the caseload for more than three years. About 70% of all users have an organic diagnosis. FIGURE 128: OLDER PEOPLE - ANALYSIS OF SERVICE USERS ON CASELOAD FOR MORE THAN 3 YEARS AS AT 31 MARCH 2012 BY DIAGNOSIS 108

111 Figure 129 compares the number of contacts per service user for and The Trust average decreased by 3%. Kingston and Wandsworth show the greatest variation between the two years: Kingston contacts per service user decreased by 17% Wandsworth contacts per service user decreased by 16% FIGURE 129: OLDER PEOPLE - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 Assertive outreach It would appear that the service ceased (as a separate service) in several boroughs during Figure 130 shows the number of service users on caseloads as at 31 March 2011 and 31 March There is little change between the two years in terms of the overall number of service users or the split between the PCTs. FIGURE 130: ASSERTIVE OUTREACH - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 Caseload 31-Mar- 12 Increase / (Decrease)% Year-on-year As % of total As % of total Kingston 59 50% 59 48% 0% Richmond 60 50% 63 52% 5% Total % 109

112 Figure 131 and 132 compare the case mix of caseloads by diagnosis. The vast majority of service users have a psychosis diagnosis. FIGURE 131: ASSERTIVE OUTREACH - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2011 FIGURE 132: ASSERTIVE OUTREACH - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

113 Figure 133 and 134 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March At 31 March % of all service users had been on a caseload for more than two years. This is similar to Over 50% of Kingston service users had been on the caseload for more than five years, while none had in Richmond. FIGURE 133: ASSERTIVE OUTREACH - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2011 FIGURE 134: ASSERTIVE OUTREACH - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

114 Figure 135 compares the number of contacts per service user for and Kingston contacts reduced by 8% in FIGURE 135: ASSERTIVE OUTREACH - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 Early Intervention in Psychosis teams Figure 136 shows the number of service users on caseloads as at 31 March 2011 and 31 March There is a 10% decrease between the two years in terms of the overall number of service users. The split between the PCTs remains similar for the two years. FIGURE 136: EARLY INTERVENTION IN PSYCHOSIS - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 Caseload 31-Mar- 12 Increase / (Decrease)% Year-on-year As % of total As % of total Kingston 80 17% 75 17% (6%) Richmond 72 15% 61 14% (15%) Sutton and Merton % % (11%) Wandsworth % % (10%) Total (10%) 112

115 Figure 137 and 138 compare the case mix of caseloads by diagnosis. There is little change between 2011 and The large majority of service users have a psychosis diagnosis. About 20% have mood (affective) disorders. FIGURE 137: EARLY INTERVENTION IN PSYCHOSIS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2011 FIGURE 138: EARLY INTERVENTION IN PSYCHOSIS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

116 Figure 139 and 140 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 141 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a caseload for more than two years. This was a slight increase from 2011 (30%). The proportion of service users with a length of stay of more than two years is higher in Wandsworth and lower in Sutton and Merton. FIGURE 139: EARLY INTERVENTION IN PSYCHOSIS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2011 FIGURE 140: EARLY INTERVENTION IN PSYCHOSIS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

117 FIGURE 141: EARLY INTERVENTION IN PSYCHOSIS - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS Figure 142 provides further analysis for those service users who have been on the caseload for more than three years. The majority of service users have a psychosis diagnosis. Over 20% of Kingston service users have mood (affective) disorders. FIGURE 142: EARLY INTERVENTION IN PSYCHOSIS - ANALYSIS OF SERVICE USERS ON CASELOAD FOR MORE THAN 3 YEARS AS AT 31 MARCH 2012 BY DIAGNOSIS 115

118 Figure 143 compares the number of contacts per service user for and The number of contacts per service user between PCTs varies considerably. Richmond contacts are significantly lower than the other PCTs. The Trust average increased by 11%. There is significant variation for all PCTs: Kingston increased by 21% Richmond increased by 36% Sutton and Merton increased by 20% Wandsworth decreased by 22% FIGURE 143: EARLY INTERVENTION IN PSYCHOSIS - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 Day care Day care covers a range of services. The 2012/13 Trust service directory lists: Newent This service offers treatment, assessment, psychotropic medication, mood/behaviour assessment, group programmes, anxiety and depression management, recreational activities, art therapy, nurse clinic, care planning and risk assessment. This service is for people aged 65 and over experiencing mental health problems. Downs Day The day hospital is for clients with dementia and is there to provide respite to carers. This service is for patients who are 65 and over. Amy Woodgate The service assesses and treats older people with organicrelated mental health needs. Purchaser Kingston Sutton Kingston 116

119 This service is for those who are aged 65 and over Richmond Recovery The Richmond Recovery Support Team is a communitybased borough-wide service. Referrals are made through secondary care (CMHTs). Roselands Access Team The team offers intensive day care as an alternative to (and to assist) rapid discharge from acute psychiatric wards. Richmond Kingston This service is for adults aged 18 to 65. (We note that there is no service listed as sited in Wandsworth, but that there is a substantial volume of Wandsworth activity recorded.) Figure 144 shows the number of service users on caseloads as at 31 March 2011 and 31 March The number of users has decreased by 34% over the two years. This is due to a large reduction in Sutton and Merton. As at 31 March 2012 the majority of service users were in Kingston (18%) or Richmond (78%) with very small numbers in the other two PCTs. FIGURE 144: DAY CARE - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 As % of total Caseload 31-Mar- 12 As % of total Increase / (Decrease)% Year-on-year Kingston 50 15% 40 18% (20%) Richmond % % 4% Sutton and Merton 99 29% 4 2% (96%) Wandsworth 24 7% 5 2% (79%) Total (34%) Figures 145 and 146 compare the case mix of caseloads by diagnosis. There is little change between 2011 and About 35% of the service users on the Trust caseloads had mood (affective) disorders. Sutton and Merton and Wandsworth results for 2012 should be viewed with caution as the caseload sizes reduced to very small numbers over the two years. FIGURE 145: DAY CARE - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

120 FIGURE 146: DAY CARE - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figures 147 and 148 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 149 compares the % of patients who have been on a caseload for more than two years. The proportion of service users on caseload for more than two years has slightly reduced for both Kingston and Richmond, ranging from 10 to 17% in FIGURE 147: DAY CARE - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

121 FIGURE 148: DAY CARE - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2012 FIGURE 149: DAY CARE - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS 119

122 Figure 150 compares the number of contacts per service user for and Overall the number of Trust contacts decreased by 23%. The number of contacts increased in Kingston by 22%. FIGURE 150: DAY CARE - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 Addictions Figure 151 shows the number of service users on caseloads as at 31 March 2011 and 31 March The number has reduced by 43% from 2011 to This is due to a significant reduction in caseload in Wandsworth. FIGURE 151: ADDICTIONS - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 As % of total Caseload 31-Mar- 12 As % of total Increase / (Decrease)% Year-on-year Kingston % % (28%) Richmond 119 9% 95 13% (20%) Sutton and Merton % % (10%) Wandsworth % 29 4% (94%) Total 1, (43%) 120

123 Figures 152 and 153 compare the case mix of caseloads by diagnosis. Virtually all cases are substance misuse. FIGURE 152: ADDICTIONS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2011 FIGURE 153: ADDICTIONS - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

124 Figures 154 and 155 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 156 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a caseload for more than two years. This was a slight increase from 2011 (26%). The number of service users on caseload for more than two years has increased most significantly in Kingston and Richmond. The proportion of service users with a length of stay of more than two years is lowest in Kingston. FIGURE 154: ADDICTIONS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2011 FIGURE 155: ADDICTIONS - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

125 FIGURE 156: ADDICTIONS - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS Figure 157 compares the number of contacts per service user for and The Trust average decreased by 20%. The PCTs with the greatest variation between the two years are Sutton and Merton and Wandsworth: Sutton and Merton contacts per service user decreased by 19% Wandsworth contacts per service user decreased by 29% FIGURE 157: ADDICTIONS - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 123

126 Psychotherapy Figure 158 shows the number of service users on caseloads as at 31 March 2011 and 31 March Numbers have reduced by 34%. The split between PCTs for both years has not changed much. FIGURE 158: PSYCHOTHERAPY - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 As % of total Caseload 31-Mar- 12 As % of total Increase / (Decrease)% Year-on-year Kingston % 90 22% (30%) Richmond % 82 20% (44%) Sutton and Merton 92 15% 51 13% (45%) Wandsworth % % (26%) Total (34%) Figures 159 and 160 compare the case mix of caseloads by diagnosis. Over 20% of service users had no recorded diagnosis. In Kingston over 30% of service users had no recorded diagnosis as at 31 March About 38% of service users had neurotic, stress or somatoform disorders, or mood (affective) disorders as at 31 March This reduced to about 32% as at 31 March About 30% had personality disorders in both years. FIGURE 159: PSYCHOTHERAPY - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH

127 FIGURE 160: PSYCHOTHERAPY - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figures 161 and 162 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 163 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a caseload for more than two years. There is no significant change between the two years. A greater proportion of service users have been on a caseload for more than two years in Kingston and Sutton and Merton than on the other two PCTs. FIGURE 161: PSYCHOTHERAPY - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

128 FIGURE 162: PSYCHOTHERAPY - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2012 FIGURE 163: PSYCHOTHERAPY - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS 126

129 Figure 164 compares the number of contacts per service user for and The Trust average increased by 1%. The number of contacts per service user varies significantly between PCTs with the highest numbers in Kingston and Richmond. Kingston and Sutton and Merton show the greatest variation between the two years: Kingston contacts per service user decreased by 20% Sutton and Merton contacts per service user increased by 56% FIGURE 164: PSYCHOTHERAPY - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 Child and adolescent mental health services Tiers 3 and 4 Figure 165 shows the number of service users on caseloads as at 31 March 2011 and 31 March Numbers have reduced by 11%. There is little change in the split between the PCTs. FIGURE 165: CAMHS TIERS 3 & 4 - NUMBER OF SERVICE USERS ON CASELOADS AS AT 31 MARCH 2011 AND 31 MARCH 2012 Caseload 31-Mar- 11 As % of total Caseload 31-Mar- 12 As % of total Increase / (Decrease)% Year-on-year Kingston % % (2%) Richmond % % (5%) Sutton and Merton 1,093 43% % (11%) Wandsworth % % (25%) Total 2,551 2,263 (11%) 127

130 Figures 166 and 167 compare the case mix of caseloads by diagnosis ( CAMHS refers to a broad range of developmental disorders of children and adolescents). A significant proportion of service users have no recorded diagnosis. FIGURE 166: CAMHS TIERS 3 & 4 - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2011 FIGURE 167: CAMHS TIERS 3 & 4 - ANALYSIS OF CASELOADS BY DIAGNOSIS AS AT 31 MARCH 2012 Figures 168 and 169 show the length of stay to date for service users who were on the case load as at 31 March 2011 and 31 March Figure 170 compares the % of patients who have been on a caseload for more than two years. At 31 March % of all service users had been on a caseload for more than two years. This was slightly lower than at 31 March There is significant variation between PCTs: Richmond has considerably higher lengths of stay ( 30% of service users were on the caseload for more than 2 years for 2011 and 2012) Kingston has low lengths of stay (less than 10% of service users were on the caseload for more than 2 years for 2011 and 2012) 128

131 There is little change between the two years, expect for Wandsworth. In % of service users were on the caseload for more than two years. This decreased to 9% in FIGURE 168: CAMHS TIERS 3 & 4 - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH 2011 FIGURE 169: CAMHS TIERS 3 & 4 - LENGTH OF STAY TO DATE FOR THOSE ON CASELOAD AS AT 31 MARCH

132 FIGURE 170: CAMHS TIERS 3 & 4 - % OF SERVICE USERS ON A CASELOAD FOR MORE THAN TWO YEARS Figure 171 compares the number of contacts per service user for and The Trust average decreased by 11%. Wandsworth shows the greatest variation between the two years with a decrease of 20%. FIGURE 171: CAMHS TIERS 3 & 4 - NUMBER OF CONTACTS PER SERVICE USER PER YEAR FOR 2010/11 AND 2011/12 130

133 4. MARKET INTELLIGENCE This section of the report is presented in five subsections: Structure of the mental health market Analysis of the overall structure of the national market mental health services broken down by market segment, provider type and SHA region. National policy initiatives with a bearing on the development of the mental health market NHS provider portfolios Analysis of the organisational structure, service portfolios, and planned service developments of the neighbouring mental health trusts to South West London and St George s. Independent sector provider portfolios - Analysis of the organisational structure, service portfolios, and planned service developments of the largest national independent sector providers of mental health services Case Studies Analysis, through case studies, of the process and experiences in other areas that have re-tendered the full portfolio of mental health services Structure of the mental health market Overall structure The market for mental health services is the single biggest within the NHS, and encompasses a huge diversity of types of provision, from a handful of psychotherapy sessions to year-long stays within secure care, and from treatment of children with behavioural problems to care of older people with dementia. Although the NHS is comfortably the largest provider, it is organised via distinct (and sometimes competing) provider organisations; and there are numerous independent organisations, across almost the full spectrum of provision. These range from large national chains, to small local charities and social enterprises. Despite this plurality of provision, many mental health services still operate on a constabulary model, whereby a statutory organisation sees itself as having default responsibility for all services in a given territory. Some mental health services do require this systems for ensuring oversight of compulsory treatment, for example but many do not, and the concept of choice is only beginning to have an impact. This contrasts strongly with the situation in social care, where developments in personalisation have seen far greater opportunities for genuine choice beginning to emerge, and where the importance of choice in promoting recovery is a much more established principle. The mental health market is concentrated with statutory NHS providers, with non-statutory providers primarily competing at the two extremes of the care continuum. In the financial year 2010/11 the total investment of PCTs in adult and older people s mental health services was reported to be 7.19 billion. Of this investment 77% ( 5.57) billion was reported to be with NHS providers, with 22% ( 1.56 billion) with non-statutory providers, and 1% with local authorities. There is some variation by SHA region with NHS providers overall market share ranging from a high of 86.1% in London, to a low of 71.6% in the North West. 131

134 FIGURE 172: STATUTORY AND NON-STATUTORY MARKET SHARE ACROSS THE MENTAL HEALTH CARE CONTINUUM Non-statutory providers have a significant market share Non-statutory providers have a significant market share The above figure illustrates the overall pattern of the market. There is firstly a core service market, consisting of acute inpatient and generic community mental health services. This core market: Operates on a local constabulary model of provision, with a clear sense of default responsibility for the mental health care of a particular community Is managed almost entirely via block contracts, and is relatively uncompetitive, both between NHS providers and other agencies, and within the NHS Has been in long-term decline, in terms of the proportion of overall mental health investment it receives There is secondly a specialist market (in reality a series of sub-markets) for services which are either short-term and episodic in nature, or which are based around specialist inpatient beds. This specialist market: Contains many services operating to regional or national catchments, with much weaker local ties Is managed via a mix of cost and volume contracts, named patient placements, and contracts arising from competitive tenders. It is more competitive, both between NHS providers and other agencies, and within the NHS Has been in long-term growth, in terms of the proportion of overall mental health investment it has received The figures below give the detail of overall national investment patterns. 132

135 FIGURE 173: TOTAL PCT INVESTMENT IN ADULT AND OLDER PERSON MENTAL HEALTH SERVICES -2010/11 ( 000S) SHA Region NHS Non- Statutory Local Authority Total NHS North East 317,467 87,393 14, ,168 NHS South Central 357, , ,964 NHS South East Coast 392,971 99, ,440 NHS East Midlands 415, , ,377 NHS East Of England 538,203 95,425 4, ,171 NHS South West 464, , ,937 NHS Yorkshire and Humber 533, ,433 9, ,508 NHS West Midlands 576, ,620 16, ,015 NHS North West 744, ,320 10,693 1,039,563 NHS London 1,231, ,414 2,464 1,429,225 ENGLAND 5,572,107 1,560,370 58,890 7,191,366 FIGURE 174: TOTAL PCT INVESTMENT IN ADULT AND OLDER PERSON MENTAL HEALTH SERVICES -2010/11 (%) Data Source: Mental Health Finance Mapping 2010/ Contracting Structures Through a survey of contracting structures undertaken with PCTs we estimate that 75% of the total investment in mental health services is via block contracts. There are, however, marked differences between market segments. Secure services are mostly organised via regional specialist commissioning, and there is a large presence of cost and volume and named patient contracts in eating disorders and in CAMHS. These differences in contract structure mirror the differing presence of the independent sector the greater the independent sector role, the smaller the use of block contracts. The principal contracting structures used in mental health are summarised in the figure below. 133

136 FIGURE 175: TYPES OF CONTRACT STRUCTURE Contract Type Block Contract Cost and Volume Agreement Cost per Case Agreement Named Patient Contract Payment by Results Definition A service is purchased at a fixed price over a set period of time (usually 3 years). The contract will normally include a specification, or equivalent schedule, detailing the service requirements. Payments will not vary according to the volume of service actually provided. Cost and activity are linked. Providers receive a sum for a specified base-line of activity (e.g. number of cases, treatments etc..). Beyond or below that level of activity funding will rise or fall on a cost per volume formula. The commissioning authority agrees an allocation for each patient treatment provided. Payment is made based on the cost of services provided. Services are purchased for an individual at an agreed price which may be by reference to an agreed price list or negotiated individually. The contract is only for that individual. PbR is the payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient s healthcare needs. PbR uses a national tariff of fixed prices that reflect national average prices for treatment procedures. Patient treatments within a cluster of diagnoses and procedures that consume the same level of resources are assigned to a Healthcare Resource Group. Specialist Commissioning The price for a particular procedure is called the reference cost and is standardized across the NHS with adjustments made for market forces. Although most services in the NHS are currently commissioned by local Primary Care Trusts (PCTs), there are different arrangements for commissioning specialised services. A specialised service is defined as a service which covers a planning population (catchment area) of more than a million people. Each PCT contributes some of its budget to funding specialised services. Specialist services are normally lower volume higher cost cases. Examples in mental health include secure services, inpatient eating disorders and Tier 4 CAMHS. 134

137 Local structure Figures 176 and 177 below detail the investment of each the South West London PCTs in adult and older people s mental health services. Across the four PCTs 75.8% of the investment was reported to be with NHS providers, and 23.7% with non-statutory providers. The highest proportionate investor with nonstatutory providers is Wandsworth at 27.2%. FIGURE 176: TOTAL PCT INVESTMENT IN ADULT AND OLDER PERSON MENTAL HEALTH SERVICES -2010/11 ( 000S) Provider Type ( 000s) Commissioner NHS Non- Statutory Local Authority Total Richmond 17,971 2, ,748 Kingston 20,814 6, ,701 Sutton and Merton 33,992 11, ,016 Wandsworth 43,810 16, ,222 TOTAL 116,586 36, ,688 FIGURE 177: TOTAL PCT INVESTMENT IN ADULT AND OLDER PERSON MENTAL HEALTH SERVICES -2010/11 (%) Data Source: Mental Health Finance Mapping 2010/11 135

138 Common Mental Health Problems - IAPT Non-statutory providers have a significant share of the market for IAPT services. In 2010/11 PCTs invested 168 million investment in IAPT services, of which 26% ( 44 million) was reported to be with non-statutory providers and 123 million (73%) was reported to be with statutory NHS providers. The highest proportionate investors with non-statutory providers are the North East, East Midlands and Yorkshire SHA regions. Over half of the NHS investment (53%) in IAPT services in the North East was with non-statutory providers. In the East Midlands and Yorkshire regions over 30% of the investment in IAPT services is with non-statutory providers. Across the London region 24% of the total investment in IAPT services in 2010/11 was with non-statutory providers. FIGURE 178: TOTAL PCT INVESTMENT IN IAPT /11 ( 000S) Provider Type ( 000s) SHA Region NHS Non- Statutory Local Authority Total NHS West Midlands 6,795 1, ,154 NHS North East 6,062 6, ,842 NHS South East Coast 11,158 1, ,055 NHS Yorkshire and Humber 9,739 4, ,545 NHS South Central 11,145 3, ,637 NHS East Midlands 9,474 5, ,220 NHS South West 15,103 4, ,858 NHS East of England 16,226 5, ,688 NHS North West 18,440 3, ,049 NHS London 19,014 5, ,991 ENGLAND 123,156 44, ,041 FIGURE 179: TOTAL PCT INVESTMENT IN IAPT /11 (%) 136

139 Figures 180 and 181 below detail the investment of each the South West London PCTs in IAPT. Across the four PCTs 87.2% of the investment was reported to be with NHS providers, and 12.8% with non-statutory providers. All of the investment of NHS Richmond was with non-statutory providers. FIGURE 180: TOTAL PCT INVESTMENT IN IAPT /11 ( 000S) Provider Type ( 000s) Commissioner NHS Non- Statutory Local Authority Total Richmond Kingston Wandsworth 1, ,750 Sutton and Merton 1, ,867 TOTAL 3, ,389 FIGURE 181: TOTAL PCT INVESTMENT IN IAPT /11 (%) Data Source: Mental Health Finance Mapping 2010/11 137

140 Serious and Enduring Mental Illness - Community Analysis of investment in core community services for serious and enduring mental illness (community mental health teams, assertive outreach teams, crisis resolution home treatment and early intervention in psychosis) shows that nationally 97.6% of the just over 1 billion NHS (PCT) investment is with statutory NHS providers. The North West and West Midlands SHA are the highest investors with non-nhs providers, albeit both spend over 90% with NHS providers. In the London region 99% of investment in these services is with NHS providers. FIGURE 182: TOTAL PCT INVESTMENT IN CMHTS, AOTS, EIPS AND CRHTS ( 000S) Provider Type ( 000s) SHA Region NHS Non- Statutory Local Authority Total NHS North East 54, ,051 55,635 NHS East Midlands 67, ,780 NHS South Central 68, ,246 NHS South East Coast 76, ,619 NHS South West 85, ,289 NHS Yorkshire and Humber 93,416 1,469 1,869 96,753 NHS East of England 101, ,945 NHS West Midlands 101,906 1,464 5, ,214 NHS North West 142,592 6,868 3, ,734 NHS London 192, ,197 ENGLAND 984,885 11,048 12,479 1,008,412 FIGURE 183: TOTAL PCT INVESTMENT IN CMHTS, AOTS, EIPS AND CRHTS (%) 138

141 Figures 184 and 185 below detail the investment of each the South West London PCTs in adult community services for serious and enduring mental illness (CMHTs, AOTs, EIPs and CRHTs). Across the four PCTs 98.3% of the investment was reported to be with NHS providers. No investment was reported with nonstatutory providers. FIGURE 184: TOTAL PCT INVESTMENT IN CMHTS, AOTS, EIPS AND CRHTS ( 000S) Provider Type ( 000s) Commissioner NHS Non- Statutory Local Authority Total Richmond 1, ,986 Kingston 2, ,519 Sutton and Merton 4, ,166 Wandsworth 7, ,335 TOTAL 15, ,006 FIGURE 185: TOTAL PCT INVESTMENT IN CMHTS, AOTS, EIPS AND CRHTS (%) Data Source: Mental Health Finance Mapping 2010/11 139

142 Serious and Enduring Mental Illness - Inpatient As regards inpatient services for serious and enduring mental illness, 94.4% of NHS (PCT) investment in adult acute inpatient services is with NHS providers, with just 5.6% with non-statutory providers. (It should be noted that this figure does not include the commissioning of residential rehabilitation services from the independent sector). The SHA with the highest percentage investment with non-statutory providers is the North West (10.6%). The London SHA region invests 93.5% with NHS providers and 6.5% with non-nhs providers. FIGURE 186: TOTAL PCT INVESTMENT IN ADULT ACUTE INPATIENT SERVICES -2010/11 ( 000S) Provider Type ( 000s) SHA Region NHS Non- Statutory Local Authority Total NHS North East 32, ,958 NHS South Central 33,394 1, ,188 NHS South East Coast 37, ,291 NHS East Midlands 44, ,502 NHS South West 49,825 2, ,520 NHS Yorkshire and Humber 60,416 2, ,681 NHS East of England 63,364 2, ,147 NHS West Midlands 63,621 6, ,991 NHS North West 83,604 9, ,572 NHS London 145,792 10, ,854 ENGLAND 614,403 36, ,705 FIGURE 187: TOTAL PCT INVESTMENT IN ADULT ACUTE INPATIENT SERVICES -2010/11 (%) Data Source: Mental Health Finance Mapping 2010/11 140

143 Figures 188 and 189 below detail the investment of each the South West London PCTs in adult acute inpatient services. Across the four PCTs 78% of the investment was reported to be with NHS providers, and 22% with non-statutory providers. Only Wandsworth reported any spend with non-statutory providers ( 2.6 million). FIGURE 188: TOTAL PCT INVESTMENT IN ADULT ACUTE INPATIENT SERVICES -2010/11 ( 000S) Provider Type ( 000s) Commissioner NHS Non- Statutory Local Authority Total Kingston 1, ,178 Richmond 1, ,186 Sutton and Merton 3, ,910 Wandsworth 2,962 2, ,570 TOTAL 9,236 2, ,844 FIGURE 189: TOTAL PCT INVESTMENT IN ADULT ACUTE INPATIENT SERVICES -2010/11 (%) Data Source: Mental Health Finance Mapping 2010/11 141

144 Secure / forensic services In 2010/11, PCTs in England invested 925 million in secure services (PICU, low secure and medium secure). Of this investment, 34% ( 315 million) was reported to be with non-statutory providers, and 66% ( 610 million) was reported to be with NHS providers. In two SHA regions over half of the investment was reported to be with non-statutory providers: East Midlands (58%) and the West Midlands (51%). The region with the lowest proportionate investment with non-statutory providers is London SHA (10%). FIGURE 190: TOTAL PCT INVESTMENT IN PICU AND LOW & MEDIUM SECURE SERVICES /11 ( 000S) SHA Region Provider Type ( 000s) NHS Non- Statutory Local Authority Total NHS South East Coast 22,380 9, ,520 NHS North East 31,749 10, ,227 NHS South Central 36,710 14, ,310 NHS East Midlands 28,036 38, ,069 NHS East of England 43,834 26, ,273 NHS South West 47,660 34, ,406 NHS Yorkshire and Humber 58,441 36, ,124 NHS West Midlands 67,142 70, ,492 NHS North West 100,022 55, ,357 NHS London 173,764 19, ,851 ENGLAND 609, , ,630 FIGURE 191: PCT INVESTMENT IN PICU AND LOW & MEDIUM SECURE SERVICES /11 (%) Data Source: Mental Health Finance Mapping 2010/11 142

145 Figures 192 and 193 below detail the investment of each the South West London PCTs in secure services. Across the four PCTs 46.9% of the investment was reported to be with NHS providers, and 53.1% with nonstatutory providers. The highest proportionate investor with non-statutory providers is Kingston at 65.6%. FIGURE 192: TOTAL PCT INVESTMENT IN PICU AND LOW & MEDIUM SECURE SERVICES /11 ( 000S) Provider Type ( 000s) Commissioner NHS Non- Statutory Local Authority Total Richmond 1, ,255 Kingston 1,153 2, ,350 Sutton and Merton 3,120 3, ,226 Wandsworth 5,180 6, ,008 TOTAL 10,707 12, ,839 FIGURE 193: PCT INVESTMENT IN PICU AND LOW & MEDIUM SECURE SERVICES /11 (%) Data Source: Mental Health Finance Mapping 2010/11 Although the independent sector has a significant presence and market share in the national market for forensic mental health services, this provision is concentrated with a relatively small number of providers. 77% of independent sector medium secure beds are provided by 4 providers. Furthermore, a single provider (Partnerships in Care) has a 33.6% market share as summarised below. 143

146 FIGURE 194: INDEPENDENT SECTOR NATIONAL MARKET FOR MEDIUM SECURE BEDS (%) Data Source: Laing and Buisson Mental Health and Specialist Care Services, Trends in investment analysis by type of service Trend analysis of investment in adult mental health services shows that there has been a marked change in distribution over the past decade. As shown in figure 195 below there has been a growth in secure services and psychological therapies matched by a decline in investment in more traditional inpatient services, CMHTs and day services. FIGURE 195: CHANGE IN NATIONAL DIRECT SERVICES INVESTMENT 02/03 TO 10/11 Data Source: Mental Health Finance Mapping 2002/03 to 2010/11 144

147 4.2. Policy initiatives In this section of the report we assess the impact of current NHS policy initiatives on the mental health market. The analysis is divided into two sections: i) general health policy; and ii) mental health specific policy. It should be stressed that this section does not present certainties, but rather Mental Health Strategies judgement as to the potential main implications of current policy initiatives General Health Policy Health and Social Care Act 2012 Policy issue Establishment of Clinical Commissioning Groups (CCGs) Establishment of commissioning support structures Establishment of Public Health England Establishment of Healthwatch Establishment of Health and Wellbeing Boards Implications for the mental health market Delays in commissioning decisions during the transition process. Greater weight given to views of GPs in local commissioning processes potential for greater priority to be given to services for mental health problems more commonly seen in primary care. Subject to CCG support, potential for wider-scale aggregate commissioning of some mental health services than currently, particularly specialist services (high-cost low-volume). Creation of a new focus for expertise and activity in epidemiological analysis, and in the identification and promotion of factors which are protective against mental health problems. A new route for the involvement of service users and carers in monitoring and influencing the planning and delivery of services, alongside existing national and local voluntary organisations. Potential for the influence of local authorities direct influence to increase over commissioning strategy mental health services could well be an area of particular interest in many local authorities Quality, Innovation, Productivity and Prevention (QIPP) Policy issue Delivery of 20 billion of efficiency savings by Focus on acute care pathway Focus on out of area treatments Focus on acute and mental health integration Implications for the mental health market Mental health services are expected to contribute an appropriate proportion of this saving, placing a strong emphasis on services cost-effectiveness and cost-efficiency The longstanding process is likely to continue of reducing lengths of acute stay, closing acute beds, and developing alternatives to admission, including crisis resolution/home treatment and more community-based short-stay residential services There is likely to be a substantial pressure to reduce both existing and new high-cost low-volume placements Service growth areas are likely to include acute hospital psychiatric liaison services (including, but not limited to, A&E liaison); and integrated provision of mental health and physical care in the management of long-term conditions, such as diabetes, COPD, and long-term neurological disorders. 145

148 Any Qualified Provider (AQP) Policy issue Qualification and registration process Commissioners setting of local pathways and referral protocols Referrers choice offering Competition on quality, not price Adoption for IAPT services Implications for the mental health market Requirement for all providers to meet equal quality standards Shift of balance of decision-making as to care pathways from providers to commissioners likely to be of greatest significance in the more short-term and episodic aspects of mental health care. Greater clarity as to the range of providers and services which are available in a given area for each type of mental health problem. A new opportunity to increase the extent to which mental health care can be self-directed Pressure to improve the capturing and publication of data about services outcomes and effectiveness Potential for increasing diversity in the type and range of providers offering IAPT services and an increase in the existing tendency for these services to be relatively un-integrated with other mental health services in their area Personal Health Budgets Policy issue Current evaluation of extension of personal budgets to healthcare Implications for the mental health market Potential to reinforce the bite of the any qualified provider policy, as the financial mechanisms would give more direct control to the service user. Potential for some mental health service users to prefer non-healthcare applications of their funds for example on support to access physical access, green spaces or training/employment in preference to medication or psychological therapies Mental Health Specific Policy National Mental Health Strategy Policy issue Shift to outcomesfocussed commissioning Emphasis on community wellbeing Emphasis on recovery Implications for the mental health market Expectation that providers will be able to demonstrate more clearly the benefits to service users of what they are providing; including social and vocational outcomes as well as health outcomes such as symptom reduction The potential for a shift of some attention and resources away from mental health services and towards mental health promotion activities mostly not likely to be provided by traditional mental health service providers Expectation that providers will demonstrate how they are supporting service users to achieve greater independence from services, and greater control over their own process of recovery notwithstanding, in some cases, continuing illness 146

149 Emphasis on safety Aim to reduce stigma and discrimination Providers will need to demonstrate that their governance processes both reduce the risk of, and respond appropriately to serious untoward incidents Both commissioners and providers have the opportunity to act as local champions on this issue, in the way they recruit and support staff, and in the way they engage with their local communities Mental Health Payment by Results (PbR) Policy issue Care clustering Costing of care clusters Agreement of care pathways by cluster Agreement of local tariffs Movement towards a national tariff Implications for the mental health market An important first step in improving transparency in the market as to what types of mental health problems are being treated by which teams and services in which locations. This could lead to service redesign, and to refinements of the clustering process. Enables an understanding of providers cost structures not only by service block, but also by service user type. Given NICE s involvement and guidance, a potentially important step in standardising approaches to the delivery of mental health care, and reducing current substantial variation between localities. In the short-term, likely to be of modest significance, given expectations that commissioners and providers agree arrangements to give some assurance of stability of income for the provider and of stability of expenditure for the commissioner. In the medium term, with data in which local parties have confidence, this could support increased competition between providers, in those areas and for those services where there is a more competitive market. If this happens, it will create incentives for: providers to improve their cost-efficiency; providers to attract and undertake a greater volume of work; commissioners to reduce referrals; providers to distinguish themselves by their quality NICE Guidance The National Institute for Health and Clinical Excellence (NICE) publishes a range of guidance and materials that influence the commissioning and provision of all health services, including mental health. The key role / functions of NICE are summarised in the table below. Role / Function of NICE Guidelines NICE develops evidence-based guidelines on the most effective ways to diagnose, treat and prevent disease and ill health. All of the guidelines, including those for mental health, can be accessed at: Key clinical guidelines for mental health include: Anxiety: Bipolar Disorder: Dementia: Depression: Schizophrenia: 147

150 Supporting commissioners of health services Recent reforms have introduced a role for NICE to work alongside the NHS Commissioning Board, and professional and patient groups, to develop a commissioning outcomes framework (COF). This will measure the health outcomes and quality of care achieved by clinical commissioning groups. NICE also produces commissioning guides. These are topic-specific, web-based resources. Each commissioning guide comprises a series of text-based web pages that signpost and provide topic-specific information on key clinical and service-related issues to consider during the commissioning process. Each guide contains a commissioning and benchmarking tool, which is a resource that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions. In addition, NICE provides: A library of 150 quality standards A technology appraisals programme Public health guidance Guidance on medical technologies NHS evidence, an online library of guidance and research All of this is likely to lead to an increasing standardisation of the NHS s expectations as to good practice, with commissioners role being to secure the best local implementation of best practice models, and to monitor their performance and delivery. 4.3 NHS provider portfolios This subsection contains provider portfolios for the four mental health trusts that neighbour South West London and St George s: i) Central and North West London; ii) South London and Maudsley; iii) Surrey and Borders; iv) West London Central and North West London NHS Foundation Trust Type of Provider - Summary Type of Trust NHS Foundation Trust Health / Social Care Provider of mental health and social care services Core Services Mental Health Learning disabilities Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered Central and North West London NHS Foundation Trust is the main provider of health care services for people of all ages with mental health problems and substance misuse problems across a number of London boroughs. They provide a full range of adult, older adult and CAMHS services in the boroughs of Brent, Hillingdon, Harrow, Kensington & Chelsea, and the City of Westminster. In addition, they provide substance misuse and eating disorder services in Ealing, Hounslow and Hammersmith & Fulham. Community health services are provided by the Trust in Barnet, Camden and Islington, and learning 148

151 disability services in Enfield. As a whole, they provide services in 12 London boroughs, including responsibility for offender care in 8 of those. The Trust employs 5,000 staff across more than 100 sites, serving a population in the region of 1.8 million. They operate at over 150 sites, providing services to around 40,000 people. The Trust reported an operating income of 284.9m in 2010/11 and 278.4m in 2009/10. Brief History The Trust was formed on 1 April 2002, following the merger of Brent, Kensington & Chelsea and Westminster Mental Health NHS Trust and Harrow & Hillingdon Healthcare Trust, in addition to the substance misuse service previously provided by Hounslow & Spelthorne Community and Mental Health NHS Trust. They have gradually taken on further services from the boroughs they serve, including; Hillingdon CAMHS (2003), Brent substance misuse (2005), the remainder of services in Hillingdon and Harrow CAMHS (2006), Enfield LD inpatient services (2009) and community health services in Camden (2011) They received Foundation Trust authorisation on 1 st May Service Portfolio Community and inpatient mental health services for adults and older adults with severe and/or complex illnesses (including CMHTs, CRHTs, AOTs) Community and inpatient mental health services for children and adolescents Community and inpatient drug and alcohol services for adults. Children & adolescent and adult eating disorder services. Children & adolescent and adult complex care. Community healthcare (physical) Learning disability services Offender healthcare services Service Developments / Plans New service developments/plans at the Trust are summarised below: Adult Mental Health Services Inpatient Plan to develop services which would allow repatriation of patients currently in high-cost out of area placements. Refurbishment of Northwick Park Hospital. Adult Mental Health Services Community Redesign of community services in Harrow, Hillingdon and Westminster, to facilitate better integration of services. Older Person s Mental Health Services Plan to develop services which would allow repatriation of patients currently in high-cost out of area placements (similar to adult services) Other Continued focus of potential acquisition of community health services in other boroughs. Data sources: Trust website: Annual Report 2010/11: 149

152 4.3.2 South London and Maudsley NHS Foundation Trust Type of Provider - Summary Type of Trust NHS Foundation Trust Health / Social Care Provider of mental health services Core Services Mental Health Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered South London and Maudsley NHS Foundation Trust is the main provider of health care services for people of all ages with mental health problems and substance misuse problems across South London. They provide a full range of services in the London boroughs of Croydon, Lambeth, Lewisham and Southwark. In addition, they provide drug and alcohol services in Bexley and Greenwich, and CAMHS services in Kent. A number of national services are also provided by the Trust. The Trust employs 4,800 staff across more than 150 sites, serving a population of 1.1 million. Inpatient services are provided from three main sites at Bethlem Royal, Lambeth and Maudsley Hospitals. They have more than 100 community sites, providing services to around 40,000 people. The Trust reported an operating income of 372.3m in 2010/11 and in 2009/10. Brief History The Trust was formed on 1 April 1999, bringing together Bethlem & Maudsley NHS Trust, Lambeth Healthcare NHS Trust and Lewisham & Guy s Mental Health Trust. They became the 50 th Foundation Trust in England on 1 st November Service Portfolio The Trust provides a range of health and social care services as summarised below: Community and inpatient mental health services for adults and older adults with severe and/or complex illnesses (including CMHTs, CRHTs, AOTs) Community and inpatient mental health services for children and adolescents Community and inpatient drug and alcohol services for adults. Children & adolescent and adult eating disorder services. Children & adolescent and adult forensic mental health services. Mother and baby unit at Bethlem. Older adult acute liaison services Broad range of specialist and national services for children & adolescents and adults, including ADHD, mood disorders, chronic fatigue and brain injury. Renowned research department, in partnership with King s College (as part of King s Health Partners academic health sciences centre) Service Developments / Plans New service developments/plans at the Trust are summarised below: Adult Mental Health Services Inpatient 1m investment to modernise inpatient services in Lewisham. Maudsley Hospital site. Comprehensive plan to reduce lengths of stay. Adult Mental Health Services Community Rationalisation of community estate, including plan to dispose of 34 properties over the next 3 years, and extend opening hours of other properties to me patient demand. 150

153 Older Person s Mental Health Services Developing memory assessment service in Lewisham, as part of an overall strategic aim for introduces services across their area. CAMHS and Eating Disorders Recently awarded contract to provide tier 4 CAMHS services in Kent and Medway, leading to the opening of 24-bed Woodland House in Staplehurst. Data sources: Trust website: Annual Report 2010/11: Annual Plan 2011/12: Surrey and Borders Partnership NHS Foundation Trust Type of Provider Summary: Type of Trust NHS Foundation Trust Health / Social Care Provider of health and social care services Core Services Mental Health Learning Disabilities Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered Surrey and Borders Partnership NHS Foundation Trust is the main provider of health and social care services for people of all ages with mental health problems, drug and alcohol problems and learning disabilities in Surrey and North East Hampshire. The Trust delivers care across 200 services, all of which are registered with the Care Quality Commission. The Trust employs 2,800 staff across 77 sites, serving a population of 1.3 million. Services are provided in community settings, hospitals and residential homes with an emphasis on providing local treatment and support close to home. The Trust reported an operating income of 170,128 in 2010/11 and 174,613 in 2009/10. Brief History The Trust was formed on 1 April 2005 following the merger of Surrey Hampshire Borders NHS Trust, Surrey Oaklands NHS Trust and North West Surrey Partnership NHS Trust. The Trust achieved Foundation Trust status on 1 May Service Portfolio The Trust provides a range of health and social care services as summarised below: Community and hospital mental health services for adults and older adults with severe and/or complex illnesses (including CMHTs, CRHTs, AOTs) Community mental health services for children and adolescents Community and hospital drug & alcohol services for adults in Surrey & Portsmouth Community and residential learning disability health care services in Surrey for people of all ages Assisted living and residential learning disability social care services for people in Surrey, Hampshire and 151

154 Croydon Community eating disorder services for young people and adults in Surrey Prison mental health services in Surrey Community forensic mental health services in Surrey Foetal Alcohol Spectrum Disorder clinic, national referral service The provision of services by geography is summarised in the table below: North Service Surrey Hamphsire Adult learning disabilities Y Children and young person s LD Y Working age adult mental health Y Y Older persons mental health Y Children and young person s mental health Y Forensic mental health Y Prison in-reach mental health Y Eating disorders Y Y Drug and alcohol Y Service Developments / Plans New service developments /plans at the Trust are summarised below: East Adult Mental Health Services Inpatient Planning permission has been granted to build four new wards at Farnham Road Hospital. The new development will include a psychiatric intensive care ward and a Section 136 suite. Building work is scheduled to start in summer 2012 and adult inpatient services will be relocated to the Abraham Cowley Unit in Chertsey and Ridgewood Centre in Frimley, This is expected to be for approximately 2 years during building works. Adult Mental Health Services Community The Trust has restructured adult from 17 CMHTs to 11 Community Mental Health Recovery Services. The specialist psychology service has been reconfigured as part of the adult community mental health services redesign programme and is now being delivered within the new Community Mental Health Recovery Services Older Person s Mental Health Services The Trust is in the process of implementing key changes to their older people s services: Developing comprehensive older person s community mental health services based on guidance from the Royal College of Psychiatrists and with a single point of access Merging the remaining community day hospitals into the older person s CMHTs Merging of two dementia units in West Surrey into a single service CAMHS and Eating Disorders The adult eating disorder service is being integrated into the children and young person s service to help ease the transition of adults with this condition. Data Sources: Trust Website (service developments) Annual Report 2010/11: 152

155 4.3.4 West London Mental Health NHS Trust Type of Provider - Summary Type of Trust Health / Social Care Core Services Age Categories NHS Trust *The Trust is currently in the process of applying for an NHS Foundation Trust equivalent status and is scheduled to submit their NHS FT application in January Provider of health and social care services Mental Health Addictions (Drug and Alcohol) CAMHS Working age adults Older people s services Size of Organisation and Geography Covered The Trust provides care and treatment for around 20,000 people each year and serves a local population of approximately 737,000 residents. The Trust is the main provider of services to 3 London boroughs: Ealing; Hammersmith and Fulham;Hounslow. The Trust provides specialist services to a wider catchment population. These include: Forensic and low secure services Services for people with emerging and serious personality disorders Gender identity services The Trust is also licensed by the Secretary of State to provide high secure services at Broadmoor Hospital. Broadmoor is one of only three high secure hospitals in England. The Trust employs approximately 4,300 staff from 28 sites all registered with the CQC. The Trust has a total of 914 inpatient beds. The Trust reported an income of 251,788 in 2010/11 and 253,744 in 2009/10. Brief History West London Mental Health Trust was formed in 2001 from the merger of Ealing, Hammersmith and Fulham and Broadmoor Hospital Authority and was further expanded by the absorption of Hounslow mental health services in Service Portfolio The service portfolio of the Trust includes a wide range of services as summarised below: A&E liaison Adult inpatient services Adult community services (including CRHT, CMHT, AOTs, day services) IAPT, Psychology and Psychotherapy Rehab services Residential services Older person s services - inpatient and community (including memory services) community services (including memory services) Forensic services (low and medium secure, community forensic) Personality disorder services Cassel Hospital Services (national specialist service for personality disorders) Prison mental health services (Feltham Young Offenders Institute) 153

156 High secure services (Broadmoor) Child and adolescent mental health (community and outpatient) Early intervention Eating disorders (community and outpatient, adults and CAMHS) Drug and alcohol services Service Developments / Plans St Bernard s Site The St Bernard s site is based in Southall and is home to the Trust s medium and low secure forensic services, as well as inpatient wards for the London Borough of Ealing and a number of other community based services. In October 2010, The Trust Board supported the recommendation to build a new medium secure unit on the current site of the John Conolly Wing (JCW). This will result in a consolidated, forensic male campus in a single area, allowing staff and services to work together effectively together. In February 2012 the planning application for this project was submitted to Ealing Borough Council. The Trust expects the Council to make its decision in May Data Source: Broadmoor Redevelopment The Trust is planning to redevelop Broadmoor Hospital to create a more modern secure setting. Constructed within the existing grounds, the new Hospital will contain 234 beds, providing accommodation for 210 patients and space for 24 flexible beds. In March 2012 the planning application was passed by the Council and work is scheduled to start in Autumn It is intended that it will house patients from the end of Data Source: Reconfiguration of Community Services Community mental health services are being reconfigured in Hounslow and Ealing to implement a new model of care. The new model of care in each borough will be based around the following: One Assessment Team The single assessment team will provide assessment with short-term interventions. It will be the first point of contact for all service users via a single point of assessment. Recovery Teams Two recovery teams will work with people that need treatment for a longer period. The teams will provide a step down service, working with primary care to discharge people, when suitable. Single Cognitive Impairment and Dementia Team The team will be dedicated to supporting people with cognitive impairment. The aim of the service will be to identify dementia as early as possible and support the patient and their family for the rest of their life. Data Sources: Community Services in Hounslow v1_1.pdf Community Services in Ealing 154

157 4.4. Independent sector provider portfolios This section of the report details a sample of provider portfolios for national independent sector providers of mental health services. We have selected four of the largest national providers that either that have hospitals in South West London area or the wider London region. Figure x below provides a summary, extracted from the CQC website, of all of the independent mental health hospitals identified within a 30- mile radius of South West London and St George s HQ (Springfield Hospital Tooting) Care UK Type of Provider Summary: Type of Provider Non-Statutory (For Profit) Health / Social Care Provider of health and social care services Core Services Mental Health Learning Disabilities Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered Care UK provide mental health and social care services, as part of their wider healthcare portfolio, across the UK. They offer a full range of mental health care, including inpatient care, residential care, supported living, secure services, in addition to specialised eating disorder and self-harm services. In London services are provided from Avesbury House in Edmonton (low secure step-down) and Tariro House in Hackney (continuing care and rehabilitation). Their specialist eating disorder and self-harm facility, Rhodes Farm, is sited in Mill Hill. Across the country, the group also operate a number of care homes and homecare services to older people. They operate services for learning disabilities, through 18 sites providing respite care, and homecare. They are also responsible for providing primary care in 17 prisons, in addition to operating some NHS drop-in centres. The company reported revenues of 443.6m for the 2010 financial year. Brief History Care UK was founded in 1982, and was floated on the London Stock Exchange in The company has achieved growth throughout its history through a combination of acquisitions, and development of new service internally, such as their move into providing primary care services. In 2010 the company was bought by private equity firm Bridgepoint, and subsequently de-listed from the LSE. Service Portfolio The Trust provides a range of health and social care services as summarised below: Inpatient mental health services for adults with severe and/or complex illnesses Inpatient eating disorder services for young people and adults. Secure and forensic services. Step down and supported living facilities. Care homes for older people with organic mental illnesses. Support services for those with learning disabilities. Service Developments / Plans Most of Care UK s recent developments have come in the social and health care field, rather than in mental health. Most recently, they took on 27 former Southern Cross care homes, along with new 155

158 developments in primary care services. Their mental health division acquired the Rhodes Farm Clinic (North London) in 2011, which provides specialist eating disorder services, to complement a similar facility already operated by the group in Gloucestershire. The company also plans to open new care homes specialising in care for older people suffering from dementia, beginning with a site in Hailsham, Sussex, due to open in mid Data Sources: Care UK website: Annual report to Bondholders (to year end 30 September 2011): der_annual_report_2011.pdf Cygnet Healthcare Type of Provider Summary: Type of Provider Non-Statutory (For Profit) Health / Social Care Provider of health and social care services Core Services Mental Health Learning Disabilities Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered Cygnet Healthcare is a provider of a wide range of mental health and social care services across England. In addition to a full range of acute inpatient services, they also operate a number of secure services, as well as specialised eating disorder and other services such as offering mental healthcare in prisons. In and around London, the company has a number of sites, with their hospital in Harrow providing a range of acute inpatient, secure and addiction services. There is a single-sex site for women with complex mental needs at their Beckton hospital. The Ealing site offers specialist services for eating disorders and personality disorders. Secure services are provided at Blackheath, and step-down services at Blackheath, Lewisham and Kenton (Middlesex). Nationwide, the group also operate education facilities for children with special educational needs and care homes for older people with organic mental illness. Their estate totals 19 properties. The company reported revenues of 81.7m for the 2010 financial year. Brief History Cygnet was founded in 1988, and they have worked closely with NHS commissioners in that time. Their focus is on being able to provide a full integrated care pathway, with their latest venture, Cygnet Supported Living, seeing them partner with housing associations. Service Portfolio The Trust provides a range of health and social care services as summarised below: Inpatient mental health services for adults with severe and/or complex illnesses Inpatient mental health services for children and adolescents Inpatient and outpatient drug and alcohol services 156

159 Inpatient eating disorder services for young people and adults. Secure and forensic services. Step down and supported living facilities. Care homes for older people with organic mental illnesses. Facilities for children with special educational needs. Service Developments / Plans Much of the company s recent service developments have focussed on improving and maintaining quality, with them achieving nationally recognised standards, such as Investors In People, at some of their sites. They also achieved 100% compliance with CQUIN indicators for quarter 3 this year. Within the last 12 months, they have opened new services at their Sevenoaks facility (male low secure), Beckton (low secure for women with learning disabilities) and significant changes at their Stevenage Hospital. Data Sources: Cygnet Healthcare Website: Partnerships In Care Type of Provider Summary: Type of Provider Non-Statutory (For Profit) Health / Social Care Provider of mental health services Core Services Mental Health Addictions Age Categories Working age adults Size of Organisation and Geography Covered Partnerships In Care specialise in secure mental health services for adults. They operate services from 23 sites across the UK treating people who have severe mental illness and/or personality disorders. They also offer services for people with learning disabilities, and rehabilitation for people who have suffered brain injury. Services in London are provided at the North London Clinic in Edmonton, which has 61 beds in a medium secure setting. The company reported revenues of 186.6m for the 2010 financial year. Brief History Partnerships In Care have been providing services for more than 25 years, and provide services to the majority of NHS commissioners in England. They have recently developed a service offering training in the management of aggression and violence. Service Portfolio The Trust provides a range of health and social care services as summarised below: Inpatient mental health services for adults with severe and/or complex illnesses Secure and forensic services. Rehabilitation services Specialist brain injury services Learning disability services Step down residential Service Developments / Plans A refurbishment of the North London Clinic was completed in the summer of A new secure unit recently opened at The Dene Hospital in West Sussex. The company have developed good relationships with relevant authorities in order to ensure that referrals from prisons are handled in an expedient 157

160 manner. Data Sources: Partnerships In Care Website: Annual Half Year Statement 2011: Annual Report 2010: Priory Group Type of Provider Summary: Type of Provider Non-Statutory (For Profit) Health / Social Care Provider of health and social care services Core Services Mental Health Learning Disabilities Addictions Age Categories CAMHS Working age adults Older people s services Size of Organisation and Geography Covered Priory Group is a provider of a range of mental health and social care services across the UK. They operate mental health and addiction inpatient, outpatient and day patient services at 17 sites across the UK, for both adults and younger people. In and around London, they operate a range of services from both Roehampton and Southgate, in addition to sites in Bromley and Woking. They operate a secure unit in Charlwood, Surrey, and a step down unit in Walton on the Hill, Surrey. Nationwide, the group also operate education facilities for children with special educational needs and care homes for older people with organic mental illness. The company reported revenues of 256.7m for the 2010 financial year. Brief History Priory Group was founded in 1980 with its first site at the Roehampton Hospital, and has since grown through both acquisition and development of its own services. The company moved into specialist education services in 1993, and care homes for the elderly in In 2010 they acquired Affinity Healthcare, whose properties included Manchester s Cheadle Royal Hospital saw them acquire the Craegmoor Group who specialise in learning disability services. Service Portfolio The Trust provides a range of health and social care services as summarised below: Inpatient and outpatient mental health services for adults with SMI Inpatient and outpatient mental health services for children and adolescents Inpatient drug and alcohol services Inpatient eating disorder services for young people and adults. Secure and forensic services. Care homes for older people with organic mental illnesses. Schools for children with special educational needs. Service Developments / Plans Acquisitions in the last two years have significantly increased the size of the group. The purchase of Craegmoor Group boosted Priory s standing in the market for learning disabilities. Though much smaller, the acquisition of Affinity Healthcare gave Priory a significant foothold in the market in the North West, with the Cheadle Royal Hospital, which treats patients from all over the country. 158

161 Recent developments have focussed around the opening of new care homes, supplementing the company s fast growing care home division. Data Sources: Priory Group website: Local Independent hospitals Figure x overleaf details all independent hospitals registered with the CQC that are within a 30 mile radius of Springfield Hospital (Trust HQ). For those hospitals that have been inspected by the CQC, summary scores are provided based on the following: All standards were being met when we last checked. (If this service has not had a CQC inspection since it registered with us, our check may be based on our assessment of declarations and evidence supplied by the service itself.) At least one standard in this area was not being met when we last checked and we required improvements. At least one standard in this area was not being met when we last checked and we have taken enforcement action. 159

162 FIGURE 196: INDEPENDENT HOSPITALS WITHIN A 30-MILE RADIUS OF SPRINGFIELD HOSPITAL (TRUST HQ) 160

163 161

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