Inpatient mental health services in south west London. Healthwatch Wandsworth response to public consultation. Introduction

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1 Inpatient mental health services in south west London Healthwatch Wandsworth response to public consultation Introduction This consultation nominally focusses on a clear and limited question, namely the choice between a two site and a three site option for the location of inpatient mental health services in south west London. But it can only be considered against the background of the future evolution of both inpatient and community mental health services, about which there is a great deal of uncertainty at this stage. It raises issues which are complex and beyond the knowledge and expertise of most members of the public (and most members of Healthwatch), although service users, their carers and families no doubt have personal experience which they can bring to bear on some aspects. This response inevitably represents the thinking of only a small number of Healthwatch Wandsworth members who have been actively following developments in mental health policy and service provision. But we have been alert to views expressed within various sectors of the Wandsworth community, including at the preconsultation meeting of the Healthwatch Assembly at Queen Mary's Hospital on 3 September, the public meeting held at Springfield Hospital on 19 November. The case for change In our view the case for change, as amply documented in the consultation document of September 2014 and elsewhere, is overwhelming and indeed overdue. The need to modernise (ie rebuild in conformity with up to date clinical and other standards) much of the existing inpatient facilities, dating back in some cases to the Victorian era, is clear and in line with the principle of "parity of esteem" for mental health services which has been adopted as a national priority. While reconstruction may impose strains for a number of years on local traffic and the local environment more generally, it should bring clear long term benefits to Wandsworth residents in terms of safety, clinical effectiveness and the inpatient experience as well as contributing to improved efficiency and sustainability of services. As the consultation document recognises, to do nothing is not a real option.

2 Funding The opportunity to fund the reconstruction programme from the proceeds of the sale of surplus land and buildings in accordance with the planning consents already obtained is clearly an important one at a time of financial stringency and on balance in the best interests of the south west London population as a whole. Avoidance of borrowing costs is clearly highly desirable in the interests of longer term viability and seems the right basis for plans to be made on at this stage. But quality of care should be the paramount priority and, depending on the situation as the project is implemented, funding options may need to be reviewed. Bed numbers This is the issue which has attracted the most interest, even concern, among Wandsworth residents. It needs to be seen in context. The recent and future evolution of mental health services, as of other branches of the NHS, is widely seen as involving an increased emphasis on prevention and of treatment at home or in community settings with a consequent reduction in the use of hospital inpatient treatment. As well as offering greater efficiency in the overall use of scarce public resources, this is generally preferable in terms of the impact on the lives of service users and their families. South West London and St George's Mental Health Trust with the support of their commissioners, the local CCGs, are already pursuing policies of staffing and deployment (under the banners of the Acute Care Pathway, Community Modernisation, the Older People's Services review and the the Children's and Adolescents' Mental Health Services remodelling) designed to this end. Effectively, the suggested equation is that investment in strengthened Home Treatment and other Community teams will yield in time a reduction in demand for inpatient beds via more use of alternatives to admission, reduced rates of admission and more rapid discharge. This reduction has crucially been factored into the plans for the reconstruction of inpatient facilities whether at two sites or three. The problem for those outside the circle of decision-makers is that we are required to take all this on trust. The strengthening of the Wandsworth Home Treatment team is only just starting. The future shape and location of the Wandsworth Community Mental Health teams is said to be under discussion between the Mental Health Trust and the CCG but no details

3 have been made public, while the tenor of recent decisions affecting the CMHTs has been to make budgetary savings rather than invest. Such figures as have so far been publicly presented in connection with the current consultation, eg the expected reduction in the number of inpatient admissions by 2020 (in a paper submitted to the joint Overview and Scrutiny Subcommittee of the five Boroughs) and the substantially greater proportionate reduction in the number of adult acute and older people's beds implied by the reconstruction proposals, do not appear to match very well. This situation, while not particularly comfortable, is perhaps inevitable at this stage in what is likely to be an 8 to 10-year process. It has led some Wandsworth residents to fear the worst and to point out that facilities once lost can be difficult to recover. In recent years Wandsworth has (in part as a result of efficient bed management by the Trust) been relatively fortunate in avoiding a shortage of mental health beds of the kind experienced in some other parts of the country. What clearly would be unforgivable would be for decisions to be taken now which resulted further down the line in patients being discharged prematurely to make way for new admissions or people being sent to hospitals in distant areas away from their families, friends and familiar places. Against this background Healthwatch must urge the Trust and the commissioning CCGs: - to take the utmost care in making their forward plans for mental health services and in monitoring implementation and its impact; - to avoid taking decisions to reduce existing levels of bed provision until it has become clear that the level of demand has reduced to permit this; - to make appropriate contingency plans from the outset to provide the possibility that demand does not reduce to the expected extent; - to develop and publish a "road map" identifying key milestones, review opportunities and decision points; - and to report publicly on progress at regular intervals. Issues for particular services (i) Adult acute wards

4 These represent the largest service group, divided between borough directorates (an arrangemant which we understand may not continue following the reconstruction). The current total of adult acute beds appears to be 161 (74 at Springhield, 54 at QMH and 23 at Tolworth). the reconstruction proposals envisage 6 wards of between 12 and 18 beds, giving a maximum of 108 beds, a reduction of 33%. A reduction in demand of this magnitude seems to us a hignly ambitious target for a Trust which already boasts good bed management and has one of the lowest average lengths of stay in the country. But it should not be ruled out as unachievable if the commissioners are prepared to put sufficient additional resources on a continuing basis into Home Treatment and other Community teams as well as perhaps into more innovative alternatives to hospital admission. But in any case there need in our view to be contingency plans to bring into service (or keep in service) at least one additional adult acute ward, should demand prove irreducible. (ii) Older adults' wards The proposals envisage an even more drastic reduction of older adults' ward from two to one. We were told at the meeting on 19 November that community services for older adults in Wandsworth are effective and have already reduced admissions to 11 iast year, although there may be more scope for other boroughs to catch up. But, more importantly, we have been told that the approach to older adults' treatment is changing: arrangements are being explored on a partnership basis (ie involving resources outside the Mental Health Trust) to provide, as a clearly preferable alternative to hospital admission, exceptional levels of nursing support in the community, eg in suitable nursing homes, for the two categories of older adult with arguably the highest need, ie those with extreme manifestations of dementia and those exhibiting serious mental illness alongside physical frailty; for older adults with serious mental illness but more robust physical health it is considered that they can satisfactorily be treated in general adult wards (where they would represent an additional, if small, element of demand - see (i) above). If these apparently tentative plans materialise successfully, then one older adults' ward may indeed prove sufficient for south west London. But prudence suggests that contingency plans for a second ward need to be maintained at this stage. (iii) Children's and younger people's services

5 A report was submitted to the meeting of the joint overview and scrutiny subcommittee of the 5 south west London boroughs on 18 November by the Director of Education and Social Services for Wandsworth (who is now responsible for children's services) arguing that the future location of children's and young people's mental health services, including inpatient wards, should remain at Springfield Hospital where the creation of an up to date and award-winning "young people's campus" has already begun to be implemented, rather than at Tolworth as the consultation document proposes. The same case was briefly but effectively argued at the public meeting on 19 November by a senior Wandsworth education professional. Healthwatch Wandsworth find this case compelling and urge the CCGs and the Trust to revise their plans accordingly. (iv) Deaf people s services We understand that Springfield has been a centre of excellence for deaf people s mental health services for some years and that as a result both service users and highly specialist professionals have established roots in the local community such that the transfer of the services to Tolworth as proposed in the consultative document would be very disruptive and could put the continuing quality of services at risk. A sizeable number of deaf people attended the public meeting on 19 November and gave an example to the rest of us of committed involvement. Their deliberations were presumably recorded although not shared in detail with the rest of the meeting. While recognising that the planning consents so far received limit the overall footprint of reconstruction at the Springfield site, Healthwatch Wandsworth believe that the needs of the deaf community should be given special weight in determining priorities for the location of services at this site. Two sites or three We have saved our comments on this, nominally the overall focus of the consultation, to the end of our response as in our view it needs to be considered against the background of the other important issues arising for the future of inpatient services in south west London. Clearly the retention of adult acute wards at Queen Mary s Hospital, Roehampton, holds attractions for people in the west of our Borough as to their neighbours further west. From the point of view of convenience of access for Wandsworth service users and their families, the three site option with adult wards at QMH and Springfield is clearly preferable to the two site option which removes half the adult ward to Tolworth. But against this

6 have to be weighed the undoubted clinical, safety and other benefits of newly designed and built facilities as well as the question of access for other people in other boroughs. This is an issue of overall balance which the collective south west London commissioners will have to take and answer for. Healthwatch Wandsworth are not in a position to come down firmly on one side or the other but believe that Wandsworth residents can be satisfactorily served under either option, given the right decisions on the other issues we have highlighted. In any case as mentioned above we believe that a clear road map is needed setting out the main stages to be gone through to make the inevitably complex transition from the present facilities to the reconstructed ones, with appropriate provision for reviews and contingency plans. The final decision whether or not to surrender some or all of the wards at QMH is in our view likely to be one that needs to be kept open until a later stage in the reconstruction process. 16 December 2014