This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Process improvement is what is needed in our NHS – not revolution.
Mental Health Services in West London in 2015/16 – and Beyond
I recently read the 147 page 2015/16 Annual Report of the West London Mental Health Trust (WLMHT). I also attended the WLMHT AGM on 28 September 2016 and the WLMHT Board meeting on 12 October 2016.
WLMHT is the largest Mental Health Trust in England. It provides mental health services for those who live in Ealing, Hammersmith, Hounslow and Fulham. An unusual feature of WLMHT’s responsibilities is that it also manages the Broadmoor High Secure Mental Hospital in Berkshire. The local population served by WLMHT totals around 750,000 – of which some 500,000 are adults. The WLMHT web site states that its service user population is 62,570. At less than 10% of the total population this is somewhat disconcerting. Estimates of adults suffering from mental health problems in England is 20% of the population. As for children it’s 10%. So it’s reasonable to presume that those in need of mental health care in the four towns number some 125,000.
In 2015/16 it cost £219.7 million to run WLMHT. The headcount as of 31March 2016 was 3,310. There is plenty of data in the report on expenses, income, staff, new buildings, governance, and some service performance metrics. However there is an amazing dearth of quantitative information about WLMHT ‘customers’ i.e. its service users and their experiences. What the report doesn’t tell us includes:
- What is the breakdown of diagnoses of service users using the DSM-5 classification? (DSM-5 BTW is the accepted worldwide classification of mental disorders)
- How many people have used the IAPT services? (Improving Access for Psychological Therapies is the NHS service for depression and anxiety)
- How many people were Sectioned under the Mental Health Act 1983?
- What were the numbers of people detained under Sections 2, 3, 4 and 5?
- How many WLMHT service users were discharged into Primary Care (i.e. GP surgeries)?
- How many who were discharged to Primary Care had to re-enter the WLMHT system?
- What was the profile of prescribed drug use? How many service users were prescribed Clozapine, Depot, SSRIs, Risperidome etc?
- How many psychologists and psychiatrists were employed?
- How many Acute mental health beds were in use?
- What was the average waiting time to begin a series of meetings with a psychologist?
- How many Registered Carers are there?
- How do all these figures in answers to questions 1. to 11. above compare with 2014/15 figures?
There is no mention in the report about the humiliating climb-down by WLMHT in November 2015 with regard to whistleblower Dr Hayley Dare. In 2013 Dr Dare revealed a culture of bullying and harassment in the Trust. However an Employment Tribunal found against her on the grounds that she had not acted ‘in good faith’. She had to pay £10,000 to WLMHT. Dr Dare appealed and in November 2015 WLMHT finally admitted that Dr Dare had acted in good faith. WLMHT repaid her £10,000 and its legal fees were £130,000. Also missing from the Annual Report were any details of the fraud investigation launched in 2015 when £millions of unbudgeted expenditure came to light.
There are also only sparse details in the report about the 2015 findings emanating from the 2015 CQC inspection. CQC assessed WLMHT as unsafe, ineffective and poorly led in three of five main areas. WLMHT Chair Nigel McCorkell had stood down in 2014 and Chief Executive Steve Shrubb retired in 2015.
I have been a member of the excellent volunteer run Carers’ Support Group (CSG) for five years. The CSG is based at WLMHT’s Avenue House in Acton. On 11 October 2016 I attended a meeting with over 20 CSG carers and the Trust’s Chief Executive and her Director of Nursing. On 25 October I attended a meeting of 20 CSG carers and two CQC inspectors. The biggest positive revealed at both these meetings by carers was the high quality of crisis intervention by WLMHT staff. The negatives raised included:
1.Many examples of very poor communication between WLMHT staff and careers.
2.Unsafe discharge of service users from hospital to home.
- Discharge of service users from WLMHT to GPs who displayed little empathy, mental health knowledge or interest in mental health
4.14 month waiting time quoted to carers for their loved ones to begin treatment with a psychologist
5.No adult Aspergers competence anywhere in the Trust
6.Very little support by the Trust for carers or carer support groups
- Only eight mental health support workers to support 80 Ealing GP surgeries housing over 200 Ealing GPs
- Some poorly trained Trust building receptionists – unfriendly and ‘head down’
- No Trust-maintained information resource for carers. What does the jargon mean? What does Sectioning mean? What are my expectations and rights as a carer?
- The Trust web site is ‘awful’. Some of the information on it is out of date.
- Why can’t appointments with clinicians be in the evening or at weekends? This is most important for service users who are managing to hold down daytime jobs
- Many carers have never seen Care Plans for their service users
- At a Work Capability Assessment in July 2016 the service user’s medical history was over three years out of date and did not include any details of his 2013 Sectioning.
In the ‘Future Plans’ section of the report there is a mention for the NW London Sustainability and Transformation Plan (STP). However no indication is given about the massive cost cutting STP agenda or the challenges inherent in STP’s aim of integrating mental healthcare with mental social care. I was pleased to see at least a mention of the work to come on Accountable Care Partnerships (ACPs). However no details or explanations are given about ACPs. The Trust is likely to be one of over ten NHS Trusts, NHS CCG, GP federations , Local Authorities, private and charitable care organisation partners all joined together in a private ACP consortium. This ACP will have a ten year fixed price contract to deliver mental care services to over 500,000 people. It will be the ACP and not WLMHT which will assign budgets, set priorities and determine strategy.
In November 2016, CQC will carry out a full on site inspection of WLMHT. This is unusual as a full inspection also took place in 2015. Let’s hope CQC finds significant improvements.
£1.1 Trillion Accountable Care Partnership Contracts to be Signed by 2021 – With No Parliamentary Mandate
Accountable Care Partnerships (ACPs) will be consortia of NHS Trusts, NHS CCGs, Local Authorities, GP federations, and private and charitable care organisations. ACPs are devices for care delivery being introduced in Sustainability and Transformation Plans (STPs). By 2021, apparently, all healthcare and social care services will be delivered by ACPs. The 44 STPs in England will collectively cut national annual care costs by £22 billion by 2021. ACPs, with 10 or 15 year fixed price contracts, will be the delivery vehicle for these cuts. The fixed prices will be determined by the ‘capitation’ method (more on this below).
At an NHS ACP briefing on 5 September 2016 I was told that in NW London there would be in total five ACPs serving specific populations of between 500,000 and one million. So let’s say one of the ACPs will serve the Primary Care needs of adults. There are around 1.6 million adults in NW London. In 2013 the annual per head healthcare budget for all patients in England was £2,350. Around 25% of that was for Primary Care. Now, taking cost cutting into consideration, let’s say the annual per head cost for ACP Primary Care for adults would be £500. So the capitated annual budget for this ACP would be £800 million. And the 10 year contract value would be £8 billion. Sadly you are unlikely to have read any of this in the latest version of the NW London STP.
The published NHS annual healthcare budget for 2016/17 for England is £107 billion. The 2016/17 social care and public health budget is £25 billion. Put these together and it comes to £132 billion. The target is to reduce that by £22 billion by 2021. So ACPs delivering all care services must have an annual contracts’ value of £110 billion. If all the ACPs are just 10 year contracts then the collective ACP contracts’ value would be £1.1 trillion.
None of these ACP arrangements has been discussed in Parliament. No Parliamentary Bill has proposed these STP /ACP mechanisms. No Act of Parliament mandates any of the STP/ACP or the astronomic use of public money to fund these ACP private partnership contracts.
Judicial Review anyone?
Young People Seeking Help for Anxiety Up Annually by 35%
The NSPCC’s Childline counselled 11,706 young people for anxiety in 2015/16. This was up 35% from 8,642 children in 2014/15. Seven times more girls than boys called about anxiety.
Number of Girls Cutting Themselves Annually Rises 385% to 2,311 in Ten Years
NHS England and NHS Digital reports that self-harm amongst children has risen dramatically over the last ten years. The biggest rises involve girls under 18 years of age. Poisoning is up 42% at 13,853 girls, cutting is up 385% and those attempting to hang themselves is up from 29 to 125. The number of boys cutting themselves also rose by 286% to 457.
One does wonder whether the increased incidence of self-harm amongst children reflects an increase in the reporting of such incidents by the children and by their parents and carers. Maybe it is caused by societal factors or maybe it reflects a failure in parenting, schooling and mental health and social care services. Young Minds, the UK’s leading children and young peoples’ mental health charity, blames inadequate specialist support. It cites cuts in social care workers, educational psychologists, parenting classes and mental health services in schools.
The Government has promised to invest an extra £1.4 billion into care for troubled children by 2020.
Police Use of Sectioning for Mental Health Patients Up by 50%+ in 10 Years
Police Officers used Section 136 powers 28,271 times to detain mentally ill people in 2015/16. This is an increase of more than 50% since 2005/6. The NHS mental health services are clearly massively under resourced because it is ideally these NHS bodies which should be Sectioning and detaining – not the Police.
Health Ombudsman Publishes Damning Report on Unsafe Discharge From Hospital
The Parliamentary and Health Service Ombudsman (PHSO) issued a report on unsafe hospital discharges in September 2016. The report is a follow-up of the May 2016 PHSO report on the most serious unsafe hospital discharge cases from 2014/15.
The new report’s conclusion is that the incidence of unsafe discharge from NHS hospitals is too high. Factors exposed in the report include:
+ The wholesale incompatibility between healthcare and social care funding
+ The inadequate funding of social care
+ Better Care Funding (for integrating healthcare and social care services) is not freely available as it is reliant on savings from the New Homes Bonus
+ Failure to involve carers and relatives in decisions to discharge patients
+ Night discharges are potentially dangerous
+ The relationship between early discharge and readmission
+ Variations in discharge procedures across England
+ Problems of delays in discharging older people
+ The Government’s policy and vision for comprehensive integration of healthcare and social care services is as yet unsupported by H.M.Treasury fiscal plans.
Perhaps the establishment of the Discharge Programme Board and the new Healthcare Safety Investigation Branch will help. However it’s clear to me that heroic local efforts alone will not of themselves eliminate unsafe hospital discharges. New Government care funding policy and new Government care funding are urgently needed.