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“A Sense of Belonging” Edinburgh Mental Health and Wellbeing Redesign and Development Stakeholder Event 11 June 2014

Stakeholder Report

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Edinburgh Mental Health and Wellbeing Redesign and Development

Stakeholder Event 11 June 2014

Contents Introduction, since we last met and outlining the m odel

3 – 7

Table Top Discussions

7 - 8

Key themes

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Table Top Discussions: Key Points

9 - 33

Information Overload

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What’s great; what’s missing

34 – 37

Ending today

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Appendices One: The Programme Two: What we spend

38 - 40

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1. Introduction, since we last met and outlining th e model 1.1 On 11 June 67 people attended the second stakeholder event to discuss the redesign

and development of Edinburgh’s mental health services. Attendees came from a range of backgrounds: • people who use or have used Edinburgh Mental Health Services • representatives from the third sector • individual advocacy providers • practitioners from social work • clinicians working in Edinburgh Community Mental Health services • clinicians working in acute mental health services and senior managers • managers working in statutory and 3rd sector agencies

1.2 The purpose of the day was to update stakeholders on progress made since the last

stakeholder meeting on 17 September 2013 and to discuss further ideas and plans for the redesign and development.

1.3 The day ran from 10am to 4pm and was chaired by Colin Beck (Senior Manager, The

City of Edinburgh Council and Chair of the Edinburgh Mental Health forum). 1.4 Kirstin Leath from NHS Lothian’s Mental Health and Wellbeing Programme Team gave a

brief summary of what has happened as a result of the discussions at the last Stakeholder event and the staff survey. There has been a particular focus on a number of “big themes” and a series of actions are underway to address these:

Theme One: How can we improve services for people using them? People wanted:

Work underway

• Greater continuity of care • Flexible services • Clearer information on what’s

available • The option to self refer • Improved waiting times • Better services for people with a

diagnosis of personality disorder

• Ensuring people can access volunteering and meaningful opportunities

• Connecting Community and Inpatient Mental Health Services

• Improving how people get to where they need to be

• Investigating new ways to access psychological therapies

• Spreading the word about new ways to get information

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Theme Two: How can we improve things for staff working in Edin burgh Community Mental Health Services

People wanted: Work underway

• Training & Development opportunities

• Specialisation opportunities • Supervision • Clear roles & responsibilities • Clear management/leadership • Clear referral criteria • A pleasant work environment • Resources • Sharing IT/Information • Administrative Support

• Opportunities for training and development

• Advanced Nurse Practitioner roles • Formal psychological therapies with

supervision and governance from Psychology

• Psychological Therapies Training and Supervision framework agreed

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Theme Three: Are there issues around referrals that we can impro ve? People wanted: Work underway

• Clear referral criteria • A faster process/feedback • A named contact on the

community mental health team • Consistency • Appropriate use of technology

• GP referral sub group established • Rewriting Refhelp • Named mental health link worker

identified for each practice • Consistent referral guidelines • Revising clinical letters • Discussion with substance misuse

services about onward referrals and people requiring joint input

• Theme Four Can we improve how we work with our partners?

People wanted: Work underway To work more closely with:

• Social Work – especially Mental Health Officers

• Other professionals in a multidisciplinary team

• Welfare and Housing services • Substance Misuse services • Key Third Sector Partners •

• Social Work embedded in locality partnerships

• Continued Multidisciplinary Team • Housing Trial in SW Edinburgh • Key third sector partners working with

the locality partnership • Consultation on Joint Commissioning

Plan

1.5 Linda Irvine, Strategic Programme Manager and Chair of the Edinburgh Redesign Group

spoke of the ethos of “A Sense of Belonging” with its focus on the central importance on social relationships and communities; the relationship between client and worker and how we collaboratively work together to build people’s capacity to live well with socially supportive systems that people can return to time and again.

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Linda summarised current work underway relating to each of the four commitments to change areas with the strategy:

Tackling inequalities

Recovery and Living Well

• Safe Place, self harm and safe place to be

• Autism – working with local authority colleagues to improve the care pathway for people with autism

• Early years- Psychology of Positive Parenting (PoPP)

• Focus on Looked after and Accommodated Children and Young People

• “see me” – participation in recent national event ; focus on rights and discrimination

• Mitigating the impact of welfare reform

• Pilot Peer Support Course at Edinburgh College – formal evaluation expected in June

• Peer Support Potential – because it makes sense!

• Learning Education and Recovery Network - LEARN - WRAP

• Mad People’s History and Identity new module just delivered Employment Opportunities – Individual Placement Support Model

• What is our organisational commitment to recovery?

• How do we promote citizenship and participation?

Building social capital and wellbeing

Improving services for people: specific conditions

• Growing participation in the arts and film festival

• Stress Control - 93% participants would recommend to a friend

• Guided selfhelp in Midlothian and Edinburgh

• Healthy Reading across Lothian with growing focus on different age groups and conditions

• Individual Placement Support Model

• The importance of education and life long learning

• People’s History and Identity • Branching Out; Greenspace; Men in

Sheds • Importance of space and our

environment – places to be; places to play

• Service user led research • Supporting carers, friends and

families • Small ADHD team now established • People who may have attracted a

diagnosis of personality disorder – matched care model – community; day programme and inpatient unit

• Closer working with colleagues working in substance misuse services

• Improving access to psychological therapies

1.6 Linda also spoke of the potential of the green space : art space Public Social

Partnership for the Royal Edinburgh Hopsital with the four cocoons on • growing and eating • environmental participative arts and craft • Integrated art green exercise • green play and design

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which all have a focus on maximising opportunities for volunteering. Peer support, paid employment, social firms and therapeutic spaces all underpinned by understanding and building the evidence base of What works for whom?.

1.7 The next section detailed the importance of understanding how are current financial

resources are used. A summary of this is included in Appendix One. 1.8 The Locality Partnership Model was then presented.

Composition informed by local population needs

North WestLocality Partnership Model

South EastLocality Partnership Model

General Mental Health

Services delivered City Wide

South WestLocality Partnership Model

Specialist Services

population; condition;

all with named

contactsto the LPMs

North EastLocality Partnership Model

rehab?

1.9 The ethos and potential further opportunities that locality working offers in terms of

delivering on the ethos of “A Sense of Belonging” were presented. This covered a focus on • ““help me” rather than fix me • Local by default- Understanding people and families in their own contexts • Helping people to help themselves – focus on strengths • Purpose not outcomes – the purpose of the service from the users’ point of view • Enabling learning and improvement • Managing value not cost • Moving from risk to knowledge management • Greater emphasis on interpersonal, organisational and problem solving skills as key

attributes needed for understanding and helping people to rebalance their life 1.10 Linda queried if the locality partnership model could address “Failure demand” caused

by a failure do something right for the client. Failure demand entails: • Progress chasing - what is happening with my case? • Rework – because of bureaucratic complication • Not only within but across multiple services • A focus on unit costs rather than end to end costs of service provision • The assessment activity become the service response?

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• Assess – Do – Refer • Screening out – criteria and thresholds • Assessment does it amplify demand rather than control it • Repeated screening • Episodic view – “Treat as new”

1.11 She used as an example whereby a client may present stating “I’m behind with my

rent” this could actually mean • I need to help to manage my money • I need help with my benefits • I need help to get back to work • I need help to move to a place I can afford • I’ve split up with my partner – I’m really depressed and lonely • I need help to deal with my alcohol / drug problems • I need to find affordable childcare

Locality working gives organisation an opportunity to view that statement within the context of a person’s lived experience and living circumstances.

1.12 Linda ended this session discussing the attributes of systems that fail as opposed to

those that help:

Systems that fail

Systems that help

• Assess • Transact • Refer on • Prescribe packages of activity • Identify needs • Increase resource consumption

• Understand • Build relationships • Take responsibility

• Consider what improves a life • Identify strengths • Build self sustaining support systems

that increase agency

2. Table Top Discussions 2.1 In the morning and afternoon there were two sets of table top discussions focused on key

issues and strands of the redesign. 2.2 The table topics were:

• Getting where you need to be – Self referral, open access, staying in touch, local priorities

• Different ways to deliver psychological therapies • Connecting Community and Inpatient • Volunteering, employment and meaningful activities • Wayfinder - What could be different? • Places to be • Acute Care – different paths for the future • Self directed support – expectations, opportunities and relationships

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2.3 Each table had several facilitators who gave a short (5-10 minute) introduction to the work completed and ongoing in their topic area. The tables then had 25 minutes to ask questions, discuss the issues and give feedback. Each table was covered in paper tablecloths – this allowed people to record key discussion points. It also meant that anyone who didn’t feel comfortable voicing their opinion could write their thoughts down – we hoped that this would ensure that a broad swathe of opinion was captured.

2.4 There were a total of four table top chat sessions in two blocks – so everyone had the

opportunity to find out about and contribute to four strands of their choice.

3. Key themes 3.1 A number of issues and topics emerged in several or all of the table top discussion.

These have been identified as key themes and are summarised in this section. 3.2 Self Referral, Open Access, Easier Access

• Keeping in touch – making it easier for people to ‘get back in’ when they need to • Self referral to episodic support • Not solely self referral – multiple routes to services

3.3 Single assessment/screening/point of referral

A place where people can be referred or self refer to to find out the best solution - a trial of screening assessments where people can be directed to the best service for them – which may, or may not, be community mental health services.

3.4 Peer support

• Peer support being more than just meeting for coffee - more than “just Starbucks’ • how peer support could enhance community mental health services • Properly supporting peer support groups to ensure greater provision of ‘low level’

support 3.5 Where am I in the system?

• The importance of understanding where you are in a service/referral process • Feeling like someone has an overview of the process • Feeling informed

3.6 Older People

• Why do people get a different response when they turn 65? 3.7 Clear Roles, Responsibilities and Criteria

The importance of clearly defined: • Professional roles • Service remits • Criteria and definitions

3.8 Information – front page shared notes and asses sments

• Shared assessments • Shared Notes • A front page of key information in notes

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3.9 “Going where people are” • Looking at delivering services and supporting people in non traditional spaces.

3.10 Information

• Clear information on what’s available – for people referring and people being referred. • People feeling overwhelmed by wide range of current options

4. Table Top Discussions: Key Points

This section details the key points and feedback from each of the table top discussions.

4.1 Getting where you need to be - Self referral, open access, staying in touch, reflecting local priorities Kirstin Leath and Anne Crandles began by describing the he work that’s taken place since the last stakeholder event in September to improve transitions between services and ensure that people get smoothly into the service that’s best for them. They then spoke about improving the GP referral process: • The sub group meeting to bring together GPs from across Edinburgh and staff from

Mental Health Services and Substance Misuse • Work done to improve Refhelp and referral criteria into mental health services • Named workers for GPs to contact with queries in their CMHT • Ways of improving feedback to people and their GPs

Anne introduced Headroom – a new initiative where GPs in SW Edinburgh are considering mental health services that they work with and how they can shape and improve those services and their own practice.

We also spoke about how people have told us they would like to access services and asked the tables to consider self referral, open access and how being referred to a service should feel

Self referral/ Access There was a lot of discussion about self referral/ a greater range of routes to access services. Much of this conversation circled the idea that self referral and a greater range of routes into services could be beneficial but that self referral should be one of a range of routes in and wasn’t suitable for all services:

“Lots of doors” to services rather than “the door” – different models of referral.

Should be open access self referral for group therapies (e.g. for anxiety and depression) – maybe not apt for all services”

“The greater the emphasis on self referral the more likely a service is to exclude disadvantaged and stigmatised groups who lack the confidence/ knowledge/ awareness/ means to self refer.”

“Open access – not for everyone, accessibility, confidence in referring self”

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Staying in touch There were several comments and a lot of discussion on ‘staying in touch’. It was linked to self referral and the idea of being able to self refer back to a service that you’d previously used

Information overload – GPs

Screening appointments This table had a lot of discussion about the possibility of mental health screening appointments that GPs could refer to. Rather than a gate keeping mechanism to Edinburgh Community Mental Health Services these would be an opportunity for someone to discuss options and refer, or sign post someone to the most appropriate option – which may or may not be Edinburgh Community mental Health Services.

Self referrals back to service that worked for you before (and service knows you) = fast track for CMHT

Staying in touch exists currently in ANITT also in CMHT for 2 years – Not PCLT

“Now more websites than there were referring options several years ago!”

Is it a GP jobs to know every service that’s out there? If someone has an upper GI problem I know where to refer them – I’m not expected to know every treatment option available. Maybe it’s not a GPs job to know all services available in an area.

Could there still be a pilot of self referrals to initial assessment centre

Should there be a trial of screening appointments in CMHT? People could have an appointment with someone and either be referred into the CMHT or to other services, third sector partners available.

There was a pilot of screening 6 years ago with an advice clinic. It wasn’t very well used but might be if it took place in a GPs surgery. Screens would need to

happen promptly shouldn’t be too much delay – equivalent to emergency GP appointment. For screening to work there couldn’t be a long wait for an appointment.

Could there be self referral like optometry where you turn up to a specialist – get booked in on info sent to GP if though relevant go on to other service

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Where am I in the system? This table also discussed information available to people on waiting lists – that people wanted to know where they were in the process – or to know that there was someone who did who they could contact.

Clear roles and responsibilities and criteria – 12 Another much discussed topic was the need for clear roles, responsibilities and criteria for services and referrers.

Where are you ‘in the system’? Someone being able to see an overview or knowing where you are.

Answer phone services – picking up numbers. Want to know where you are. So if it’s an answer phone “You will be called back today” or within 3 days or in 10 minutes. Just knowing where you are and where you stand. Know that you can turn up and people will

care about you, that there’s someone to call who knows what’s going on, someone to walk you through the process – have a name while you wait.

Definitions – what is “urgent”, what is “emergency” – should be consistent

Self referral – unmet need. People who don’t meet the criteria – how would we provide it?

How narrow are the criteria

People not fitting criteria for a service “too well”

People may not fit the criteria but they’re still getting something from therapy/support. It might be hugely beneficial for their mental health

Appearing competent but still requiring support –

People slipping between cracks

Clear roles and responsibilities

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Low level service and support

Other themes Relationships • Capacity – don’t have time to meet people and build relationships • Relationships between professionals – more likely to refer if you have a relationship –

something gets lost in translation in a letter/email • Relationships/control • between person using a service and the ‘professional’ • between ‘ professional groups’ Nature of referral • Referral vs. signposting – the nature of ‘referral’ – passing responsibility – people

getting lots and missed between services • Can you have appropriate referral if you don’t have appropriate info sharing? • Advanced directives in referrals GP concern • If a GP really wants someone to attend a service directing them to self refer might not

be appreciated – might be worrying for the GP Information • Email information and referrals • Need to be alerted to key info –changes etc. Info to be visible – A&E attendance • Notes – how people are written about in notes and how that’s taken in to account in

referral and referral letter Episodic care • 3 session of focussed therapies – would know what’s around • Bursts of therapy • Episodic care • “Just in case” getting back in post discharge

Supporting online communities , peer support groups etc to keep running with admin support etc – continuous, more reliable more likely to refer/sign post people to them

Range of low intensity services for emotional difficulties – e.g. life coaching

Filling the gaps – people building communities online – how can we support the gaps?

Low level service? Supporting people with life experience – training etc taking peer support seriously. Do we tie people’s identity to mental health issues?

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4.2 Different ways to deliver psychological therapi es

Patricia Graham and Mo McKenna began their discussion on thinking about different ways to deliver Psychological Therapies: can we start to think differently in terms of time to deliver and how long psychological therapy lasts? They used a bus as an analogy – thinking about being on a journey but also thinking about the delivery of Psychological Therapy; could we deliver from a bus, encouraging people to self-refer. A Psychological Therapist on a bus could deliver a range of advice and sign posting and if relevant, could provide some psychoeducation and offer, say, 3 sessions of brief psychological therapy which may have an immediate impact and therefore serve a preventative function.

We considered who delivers what to whom and for how long. Do we always need to see people for an hour?

Open access and easier referral The major theme of this table was that of open access, self referral back into services and how this might link to “short bursts” of therapies.

Base of the pyramid should allow for open access to services to prevent later use of more advanced and expensive services

Self referral for top –up

Self-referral for counselling services and stress control

Offer evening and weekend appointments to improve access

Need to be able to “top-up” on therapeutic techniques i.e. CBT worked in the past but just need to readdress it with practice; the patient is not necessarily resistant to CBT Questions about

ethics in providing care more quickly

Access blocks

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Linked to self referral and access was the need for more access at lower intensity

Groups and Peer Support

Linked to comments about different types of input t hat could be available • Active listening • Suggested use of life-coaching • What constitutes therapeutic input? Therapies delivered by all staff

More access to psychology at mild/moderate Not ‘mental health’ badge - reduce stigma - Group work – peer support fits prevention agenda

Robust use of matrix levels – solid base/low level

Perhaps use of voluntary measures or no measures for services at bottom of pyramid; however, lack of measurement makes it difficult to justify use of services

Group work – peer support fits

Counselling in existing groups

Group work should be done throughout the pyramid

Active listening – affirmation of these, skills sharing –e.g. legal rights, Crewe 2000

Groups – add different dimensions – safely using techniques

Need to continue using peer support workers for listening and counselling; suggestion of applying social worker skills for peer support workers

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Stress Control and Management

The need for clear Roles and criteria

Targets and Outcomes

Stress management link on work intranet

Need for workplace recognition of stress Suggested use of a

stress control class

Offer stress control seminars after hours at university

“Who is driving the bus?”

Locality patient model may not clarify individual roles and responsibilities

Need to determine role of public health in terms of prevention

Unclear criteria

Stress control – access

Continue collection of outcome measures after each session to visualize progress

Need for whole service targets rather than individual targets

Need to define the interpretation of outcomes for treatment; success does not necessarily mean a score of 0; Distress may have to increase for treatment to work

Need to look at mental health in a holistic way

What does the target say about the quality of care?

12 week access target

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Integrated response and preventative services

Medical model/ stigma

Additional Themes

Accommodation and alternative spaces • Mental health does not seem to be a priority in healthcare • Need for better access, rooms, and more suitable buildings • Look to how substance abuse and partners manage care by providing services in the

same building; creates informal peer support through communication among staff members

Need for increased integration of health and social care and reduce fragmentation between services

Preventative interventions psychology – real awareness

Need for an integrated response from council, 3rd sector, and NHS

Prevention agenda

Use of preventive services to stop waiting lists from increasing when it is avoidable Integrated response

Problems with use of medical model for mental health

Could add value to normalise the situation

Removes negative stigma or connotation attached to “psychopathology” and “mental illness” that might currently be barriers for some individuals

Need for a change in the language to help people recognize when they need treatment

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• Suggested use of rooms at universities, hospitals, and schools after hours that are currently empty (places with spare capacity that are already open for other reasons in the evening)

• Need to open up access to more psychological therapy through different points of delivery

• In schools that are open/universities/colleges

Information • Need improved advertisement of mental health information • Need for improved education about treatment options to prevent patients and

referrers from always recommending CBT • Film re PT and what it is and isn’t – in GP practices? • Suggestion to use a film that plays in GP offices to explain what to expect from

therapy

Paperwork • Reducing Paperwork • Paper light for initial contact • Need to reduce paperwork and stress for administrative staff; Phone calls was

suggested as a substitute

Assessment • Use impersonal, brief 30 minute assessment (CAPM Model) to reduce patient feeling

like a bond was formed during assessment only to be passed along to someone else for treatment

• Explain to patient during assessment that they will need to tell their story a second time after assessment; this has shown to increase attendance

• Brief assessments – not initially about story

Communication while waiting • Need for communication after referral before treatment while on waiting list • Who remains in contact with patient while they are waiting? • There is an opportunity for patient to get lost while on waiting list.

Technology • Safely using technologies • Desire to invest in technology to reduce redundancies and improve efficiency • We need more investment – reinvestment? In technology to make services easier

and patients can own their own data

Staff development • Protected time for staff training to help facilitate developed and sustainable skill mix • Opt- in • “Opt-in” is viewed as a positive by staff • Opt-in - a barrier vs. screening

Other • Need for increased buy-in from team and staff • Need improved relationships between colleagues to engage in informal discussion of

patients to hear point of view and gain feedback • Offer flexible hours for community staff

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• By the time a patient reaches the top of the pyramid, there are problems of assuming that a particular treatment option was offered to a patient lower in the pyramid, and as a result, did not work; however, this is not necessarily an accurate assumption.

• Both relationship and model of care are equally important • Stepped model of arts therapies, arts in health, wellbeing and inclusion

4.3 Connecting Community and Inpatient Mental Health Se rvices

Anne Langley, Mike Reid and Ihsan Kader described a process where capacity in CMHTs would be committed and this would enable commitment to deliver on three stages of an admission to REH:

• Within 24-72hrs of admission, all paperwork is complete which includes a discussion

with SW, CMHT and potentially housing. Ward Band 6 would lead on this and ensure all is complete. Ensure reason for admission is clear and what needs to change to discharge patient again.

• On 2 occasions per week ( we said Wednesday & Friday), each ward would hold an

“Options” meeting which would be attended by representatives of the Ward team, led by the Ward Charge Nurse and staff from CMHT, IHTT and Social Work. . All new admissions would be discussed, completed paperwork presented by ward team. A decision would then be made regarding requirements for follow up for assessment for whatever service(s) is deemed suitable. Staff could jointly assess after the meeting.

• If patient requires CPN (CMHT or IHTT), CPN/ ward Band 6 take a lead in

coordinating discharge arrangements.

Social Work Connecting with social work in wards and in the community.

More availability/access to SW on the wards!

Social work admission on referral (screening)

Initial screening on admission should include consideration of social need/issues that could be contributing to the patient’s mental state.

In creating capacity in CMHTs can north teams have same S.Work resource as in south – (day a week input)

Social work pack/resource – developed a few years ago – review and use.

Social work involved in discharge

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Third Sector Connecting 3rd sector and inpatient services – particularly regarding discharge.

Care Programme Approach

CPA for everyone – Accountability

CPA for all in-patients for a time

All inpatients to go on CPA (broader criteria) – has to be same documentation

Replace ward rounds with regular CPA meetings – no duplication of paperwork/assessments

CPA admin

How best to link 3rd sector and wards – (working GP?) Colin Evoc/Anne Community connector from Ward?

Third sector being used more creatively – patients in the past saw the REH as a buffer to community – now that things are more focussed on stabilisation rather than recovery when in hospital patients need to have an ongoing sense of safety, security and being understood throughout the journey.

Discharge meetings include 3rd sector previously used or introduce a 3 sector “community support” option.

3rd sector on discharge need to have it coordinated

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Information sharing and systems – 10

Systems and Services • Improve IT systems • Consistent paperwork

Discharge referral meeting

1 set of clinical notes to go with patient – avoid repetition/duplication

IT – some of ICP to be available electronically and enable update/review without starting all over again – e.g. risk assessment.

We need to ensure information is explicit, concise and helpful rather than ‘multiple’

Reduce replication of paperwork

Consistent paperwork

Assessments passed on inpatient <-> community

DVD re teams and what’s there

Patient history – (at front of clinical record – just update and ‘events’) - static info e.g. family history, would reduce repetition, summary of each episode of care

What is relationship with “ward round” and this new single discharge/referral meeting?

Review all meetings – same day as ward rounds?

Support visits to community services – could this link to band 3 role of therapeutic activities coordinator?

Advocacy available at referral meeting times

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Assessment/screening More comprehensive assets based assessments.

Additional Themes Peer and group support

• Discharge groups to prepare folk for moving – peer support • “Transitional Object” Discharge support group

Inpatient link to community support • Ensure “inpatients” continue to attend community services and support does not

cease if the patient is admitted to hospital – psychotherapy, VIP, contact point, Stafford centre, advocacy

• Can treatment continue while in hospital (i.e., psychological therapy?) Admin support

• Increased ward clerk time to organise DPM etc • Ensure band 6 (c.lead) has admin support for ensuring minutes are accurately

taken Volunteers • Role for existing volunteer within REH or new opportunity • Role of VCE in providing bridging activity and support from inpatient care to

community REH volunteer hub • VCE’s Health and Wellbeing Team • Marion to discuss with REH volunteer hub – is there a way of providing “Community

Connecting” “Talking Noticeboards” on wards Other • Capacity in IHTT/CMHTs • Consultant roles and in reach across the city. • Designated B&B • Self directed support – choice – huge impacts • Could the same model be used in IHTT? • An integrated care pathway should start with universal services, community support,

intensive community support, intensive bed based support, recovery and aftercare • Day management allows for early identification of SW incidents this has been a gap • Define key worker group roles

Advance statements, personal statements, WRAPs – third sector facilitate -> hospital on admission

Need for staff to take an assets based approach in assessing patients- e.g. personal strengths which can be drawn on for volunteering

More comprehensive assessment – find out about housing, welfare etc needs on admission to give time to prepare for discharge.

Understanding holistic view

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4.4 Volunteering, employment and meaningful activit ies Margaret, Sarah and colleagues detailed some developments that are happening in the City. The Activity Information Fair is a new initiative providing a monthly 1.5 hour walk-in session for clients recovering from mental health problems and seeking activity. Specifically the session offers open access to a range of information and service providers on education, volunteering, employment, physical social and recreational activity in Edinburgh. The Fair is scheduled to roll out as a city wide monthly event once centrally located accommodation is identified. Employability services are planning an event later in the year to look at optimising its interface with mental health services. The Works continue to supply a valuable service to our clients with a good degree of employment success with the IPS model. Some discussion about whether funding could be redirected to further support a focus on 'wellness' schemes such as activity and social inclusion.

Information

Overload of places/ projects to get involved with volunteering/ employability stuff. Options like activity info fair are out there to get this info out.

EdSpace/Health in Mind Resource centre

ALISS – link up separate resources and websites.

New intranet activities link for staff in NHS Lothian – enabling signposting of clients

Need for regular newsletter circulating info to workers and clients

Value of one stop city centre resource versus community based hubs with their own resource hub

Living it up website resource for people with long term

LOOPS – c/o elderly info resource model

Talking info/notice board” – volunteers in GP surgeries and hubs to help sign post people o community activities

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Good Models

Relationships and links • How do city wide services ensure they link into local areas, forums and hub? • A stepped model of arts in inclusion and recovery • Importance of role of local forums – cross sector representatives • Professionals having a relationship with individual services tends to lead to more

referrals – how to encourage and protect time – easier done with local community • Can this be rolled out across city – replicate models that work well? Tasters • WAVE” Ways to Volunteering Experience – short course run by VCE and YPU for

young people & MHP for past 9 years – Bridge to volunteering involved taster placements with support.

• Possibilities of ‘taster’ volunteer placements? Volunteering values • Responsibility of VCE to uphold values of volunteering and ensure there is clarity that

volunteering is not mandatory activity directed by DWP e.g. new community work placement

• Need to not be taken advantage of • PR – Do people see volunteering and volunteers as a cheap alternative, unqualified,

unprofessional? Are peer support services seen in the same way? Need for positive PR

Department of Work and Pensions • Volunteering but anxious about benefits – don’t feel they can tell the benefits office as

they’ll try to argue I’m fit for work

Replicate substance misuse model having a cross sector alliance for volunteering employability and meaningful activity

% post code lottery – community connecting done at link up women’s group: support group, lunch group etc

LEAP – substance misuse recovery peer support workers helping people look into move into and engage with services – great model!

Wellness (wellbeing) hubs (centres): Wouldn’t know from outside looking in if you were accessing support for mental health addictions etc etc – some specialist

Activities Info fair - -- investment in aftercare needed - - is money being invested in the right

places Activity information fair is working well – 50

visitors in 1.5 hours for the last 3 fairs. Could this also provide a link to a variety of supports to help folk engage with the info – e.g. peer support groups or 1-1?

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Meaningful • How are we defining “meaningful” – why does everything* have to be “meaningful”?

(*that people with lived experience of mental health issues do) • Meaningful activity versus helping people makes real connections. Time limits • Services and activities not being tied to an external defined “recovery” path – not

having time limits, how long they can stay involved in an activity Funding • Problem of year to year funding makes it difficult to keep up current providers and

services • End year to year funding- c/o wasted money starting up and winding down services • Funding of preventative services essential – keeping well • Redirect monies from illness to wellness • Resources and support needed to help get people to activity and continued to help to

engage with that activity Peer support • Peer support workers to support activity fair to help people look into and engage in

selected activities • Why is peer support model not being developed more? Outcomes • Progression rather than outcomes. Signposting is not always enough. People step

back and forth – learning can be achieved though relapse (Richter) Recover – being able to move from being a client, to peer support volunteer, volunteer ambassador, peer support worker, to colleague – but able to link back into support as and when needed.

Other • NHS/council: role for them to provide supported volunteer and employment

opportunities within NHS and Council • Health inequality cross sector service hubs

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4.5 Wayfinder - What could be different? Michele Harrison detailed the history, progress and current focus of Wayfinder.

The Wayfinder Partnership is a knowledge transfer partnership between NHS Lothian and Queen Margaret University. The aim of the Wayfinder Partnership is the redesign of rehabilitation services for people with complex mental health needs. The Wayfinder Graded Support Model was generated from a stakeholder event held in August 2013, incorporating findings from a systematic review of literature, research into what service users reported facilitated recovery within current services, and a review of current support and accommodation using the Residential Environment Impact Scale, which assisted in understanding how current support and accommodation provision meets the needs of this service user group.

The Wayfinder Graded Support Model comprises of three areas: • Graded support: Stakeholders wanted to see the provision of a range of support and

accommodation, where support is timely and flexible and having a secure base is important.

• Person Centred Choice: Stakeholders wanted services to identify people’s needs not problems and to have services which enable positive risk taking.

• Meaningful Days: Stakeholders wanted people to have meaningful activities, including those which support activities of daily living and which would connect people with the community they live in for example through work or being involved in local groups.

The Wayfinder Graded Support Model has been separated into 6 grades of support. Grade 1 describes a person living in the community, receiving support from their friends, family, work colleagues and peers. The model moves its way towards Grade 6, identifying increasing levels of support. Grade 6 is described as highly intensive rehabilitation provided in a hospital setting. Grade 5 provision is not currently available and a group of stakeholders from the NHS, the council and third sector are working to design this type of provision. The graded support model describes a range of support for people with complex mental health needs which incorporate Rehabilitation currently provided within rehabilitation services and rehabilitation provided within community adult mental health services.

Coordination

Time between identifying need and getting support required

- social care model which supports this kind of approach

- -step up/step down - -tighter on how care packages are

reviewed to free up resource.

Coordination – who does it?

Patient meetings

Coordination of a persons needs

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Teams and people working together

Meaningful days • Meaningful days are really important in a person’s recovery journey

Passing on information • Communication of info access to info at assessment

Purpose of a rehab ward? • Are the rehab wards are sufficiently different in tone, support and opportunities than

acute wards? • What is their purpose?

Prevention

• Where is the finance for prevention of admission and increasing ability to discharge from hospital?

• Prevention agenda stepped up – stepped down

Risk • Risk aversion – risk assessment vs. signs of safety (Turnell) There’s an unchallenged

assumption that we need to have risk assessments.

Capacity and flow • Bed numbers are a concern • Capacity – need for education in the community, so that community can best support

recovery processes • Beds ‘blocked’ for improving the pathway of care • Influence movement of clients

Eating disorder services • Where do EDS fit – how can they refer into this?

Can CMHT get a similar arrangement CRT and 3rd sector have? What would need to happen to facilitate? It would increase capacity and is a more appropriate skill set.

Building relationships between Health/social care and third sector resources

Coproduction of new services/model

Access for rehab team across diagnosis

Including people in assessment and plans – not tokenistic – culture change important

How do we make this work across community services – peer worker connections, community connections?

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Peer working • Peer working within system/services

Community Rehabilitation Team in the community • CRT should be available to clients within the community without the need for re-

admission to a rehab ward for assessment of appropriate resource

Branding • “It starts when you are branded” – how do we change the culture – this is key to

change • How do we organise without ‘branding/labelling’?

Other • Recent experience referral to CRT Expected – to carry out assessment and locate

somewhere else for the person to receive intensive support. Actual – assessed for admission to hospital rehabilitation – not what expected.

• CMHT ACC Panel – feedback not received about what outcome is • Prioritisation or reference between IP rehab and community referral. • To easily access grade 5 from hospital currently significant delay • Is role of staff at grade 6 to assist sustaining grade 4/5? • 65, what is the impact on older age group? • Settings must respond to needs • “Resetting” of purpose of CMHTs • Rehab model vs. intensity/active skill building needs • Family group conferencing model for adults and children

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4.6 Places to be Michelle Mason introduced this session by asking participants to think about what supports a person’s sense of belonging – and what kind of place feels welcoming; how people are supported to go to places they want to go.

Go where people are Taking information and support to non traditional locations.

What could places feel like ?

Welcomed/support

Do places need to be labelled mental health?

Direct open access

Somewhere to be yourself – safe place

Health all round – drop in daily sounds like the wellbeing centre

Sense of identity – is that important?

Places to be – where I need to be, satisfy a need, sort myself out

Contact point

Safe comfortable enjoyable somewhere I want o be not need to be

Take over the local chippies “a by the way conversation”

Use social network sites as clinical opportunity

Staff trained in McDonalds in ASIST – social responsibility

“Clinic in the playground”

Why can’t we use places we like?

Know where people are – referred to be there – colleges, universities, playgrounds, community centres

Redefining where people get help

Other ways to communicate GPs, supermarkets, communities

Stafford centre on the road with other partners

Serenity Cafe

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Self directed support (SDS)

Information – What’s Out there? People feel overwhelmed by the amount of information available.

Will open door services choose because you will need new SDS? assessment

Talking about increasing access how does that sit with SDS – hearing stories from people who are using SDS

SDS as flexible SDS – A cover for

privatisation?

If a GP doesn’t know how will a peer know?

If people don’t know then they can’t tell others Leaflets through

the door on what is available for people

Human contact takes far more than websites Too much

information – how do you select – how do you know?

People don’t know where you can go

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Collaboration and Power Sharing

“Open” access

Additional Themes

Peer working • Peer support – “not just Starbucks”

Using different media • “Use social media in a much better way - Get with the programme” • Connecting through media – different to see – easier engagement – pluses and

negative

How do we remove the need for competition between 3rd sector orgs so that we can truly collaborate?

Power and connection between groups

Get caught up with who is delivering – do we have to still define ‘mental health service’ – is it wellbeing services?

Community champions working with GPs – make that community connection

“Introducing sofas” and shared toilets

Shifting of power – how do we do that – culture changing – “signs of safety”?

How do we truly share power?

Send invites – first week of the month - with a support worker – open anyway

Permission to enter a place if not over the threshold

Not be refused – direct access, open access

Amanda – anxiety management groups – self referral since 2003 – name and a person to contact

Not jump through hoops – is there somewhere to go?

Open door in Morningside

No refusal

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• Where should be sharing these stories – use social media, twitter, facebook

Contact with people • Importance of contact with human • Screening by phone – is face to face better • How do you access – home and name. Before you go to a place have a named

person to meet you. • Lots of people isolated and lose connections • People connect and feel better

Who’s holding who to account • Who is holding people to account are we all reinforcing? What we say and do can be

different things – difference between practice and rhetoric • Fear and blame – who is holding people to account

Meaningful • Meaningful - a drop-in what do you get there?

Communities • Communities means different things – your friends, a group, social media contacts, a

place

Choice • Choice & personalisation

Early services • Impact on a young person • Early intervention and early detection • Services know where people are (early onset) • Building early services and inclusive services – connected

Communities • How do we maintain communities? • Supportive communities • Places as community resources

Risk • Risk should not be stopping you doing something • How do we create a culture where it feels safe to take risks? And safe to support

others to take risks • Managing risk vs. what you get out of it • Personal responsibility and risk

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4.7 Acute Care – different paths for the future Peter Lefevre summarised the developing acute model of care and how the wards could be configured in the new build

4.8 Self directed support – expectations, opportuni ties and relationships

Karen Alexander from Health and Social Care led this discussion. She explained that Self-directed support is a flexible way of providing services and support to individuals who have been assessed as needing support in the community. It will give the individual more choice over how support is arranged and managed. The process of identifying needs and goals is achieved by working in partnership with the individual. Once you have agreed what support is needed we will develop a support plan with you. As part of the new way of working the Local Authority must offer individuals a range of 4 options in which support can be arranged and this offers much more choice than most people have been offered in the past.

Option 1 The council provides you with a direct payment to buy support yourself. Option 2 You choose the support you want and ask the council or another party to organise this on your behalf. Option 3 You ask the council to choose and organise the support you need, which is how most services and support is managed just now. Option 4 Is a combination of the 3 options discussed.

Couldn’t sustain 2/3 for 4/5

Why did it change - inpatient: community 30:70?

Assertive Bed management – both at high level but also on an individual patient basis

Senior Nursing staff decision making – not relying solely on consultants Staff as key workers or

case manager follow the patient into or out of the ward

Measure the number of Edinburgh patients that have been in Hermitage under IHTT Consultant – look at outcomes and how many went to IHTT?

Assessment ward model – Bed manager patient flow dedicated post needed – ‘with- authority’

Need to maintain contacts with CMHT and sector wards

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Collective Champions debunking “the mountain” of SDS

In reach &Outreach

Come to the Stafford centre for day workshop on SDS

Role of advocacy

Staff rotation

Involve peer support in the car planning and assessment stage

How do we respond to fluctuations of need?

How quickly can a support plan

If health OT identifies client’s aspirations/goals with them can the service provider just carry them our as opposed to reassessment with feedback from pt

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5. Information Overload

5.1 In addition to the two sets of table top discussions there was brief presentation by Kirstin on the just published Scottish Association of Mental Health (SAMH) Survey of GPs in Scotland. The key findings were:

• 85% of GPs thought there were gaps in service provision for people with mental health problems in their area

• 73% of GPs would like more information on non-pharmaceutical treatment options for common mental health problems

• 50% of GPs said they last undertook accredited training on any aspect of mental health more than a year ago

5.2 The statement made by one GP as part of the survey - The main difficulty is keeping up to date with locally available services – knowing what is available at any one time” resonated with a lot of what we have heard from our GP colleagues in Edinburgh.

5.3 Screenshots of three online resources were demonstrated to stakeholders:

• Edinburgh Choices - www.edinburgh .gov.uk/edinburghchoices • EVOC’s Red Book - www.evoc .org.uk • ALIS - www.aliss .org Information is available but people sometimes need support to access it.

6. What’s Great, What’s Missing 6.1 The last session of the day asked people to consider what was great about today and

what was missing.

What was great? What’ was missing?

Meeting the 3rd Sector

How is this going to progress?

Hearing the genuine connection to real people from strategic planning

Communication with the GPs

Diversity of People here

More people with lived experience

‘the bus’

Enough milk

This venue

Info could have been clearer

Openness about finances Some organisations e.g. GPs ; 3rd

sector representation Gaining a wider perspective

Early intervention, prevention

Gaining knowledge on what’s happening Do we try to solve what does not work or create new problems

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Common themes identified

Do we have a timeline for events?

Financial Statements Willingness to work together

No clear statement about what’s financially available e.g. over next 3 years

Lots of ideas at table top discussions

Employability, economic development –

People feel passionate about services they are in

nothing in isolation e.g. criminal justice, housing,

What’s happening – relevant – all new ideas Clear Leadership

Confirming to hear about the amount of change in other areas/Services

Community learning and Development,

Lots of inter – disciplinary agreement at discussions

Rehab colleagues

Uplifted – listened to

More GPs present

Meet People genuinely seem to care

Vision of LPN in actuality

GP here

Working pens

Making contacts

Consultants few present

Right people here (except student med/HSC profs or their colleges

Impact of Integration

Opportunities to meet/Network/share Open front door into MH(A+E, GP OOH)

All “on same page” Easy read – Plain English…….Including diagrams

Communication Equality impact assessments b4 not after, but diagrams, pictures work well to communicate

No “Criticism” Quiche and Biscuits

Talk Positive – Improvements of Care

Uncertainty

Skill merging – possibilities for Partnership Translation into action on the frontline of services

Constructive Challenging Consistency of service across Edinburgh

Thinking outside the Box

Access to services in your local area

Agreements to start “Practical steps”

Joined up - ness

“Person” Centred Thinking/Solutions Common directions but no common purpose

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Opportunity to learn about what’s going on, what’s being planned, what’s been achieved

Struggle to join together

Identifying gaps Those people who did not elect to attend today

Range of experiences – opportunity to share and participate

Detail

Commitment to partnership working. But how does it break down. Financial constraints

How to do it?

Opportunism despite limitations

Hurdles to break down

Enthusiasm to get it right Need to make whole system better – great we have investment in hospital but how to support all other these things

Enthusiasm for partnership Join up between hospital and community – process to achieve this

Statutory and non stat services The join up with older people Why have the barrier with 65

Talking to each other

How realistically to give choices

Turning our thinking

Knowledge of choices

Real Partnership between 3rd sector, NHS and councils

We do it by working quicker,

All work helps to achieve if we do it together

We do need to change things to make it better for people

We can’t do this on our own

Emphasis on choice – it can be realistic

Quicker, easier access – everyone wants this

Respect all contributions – other contributions

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6.2 Word clouds were made from all these comments: What’s great…

What’s missing?

7. Ending today 7.1 Linda thanked everyone for participating so enthusiastically today and to the members of

the core group and colleagues for facilitating the table top discussions. Linda gave a few key dates which would focus attention of next steps including the completion of the REH Phase One Full Business Case for REH: which begins formal governance approval route on 19 June. The Edinburgh Core Group: are due to meet on 26 June 2014 and they key topics to progress with are the locality partnership arrangements for accommodation, new roles and management. The Core Group would also sign off on the stakeholder report from today’s event and this will be distributed to all by early July.

7.2 Linda concluded by reflecting on the centrality of relationships which has been a key

theme of today and the opportunity to build a locality partnership model where relationships have • Generosity • Trust • Confidence • Love • Benevolence • Commitment • Involvement • Delight • Allegiance • Esteem • Accord • Admiration • Curiosity1

1 Fox, 2003

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Appendix One: Programme

“A sense of belonging” – A joint strategy for impro ving the mental health and wellbeing of Lothian’s population 2011 -2016

Second Stakeholder Meeting Redesigning and Developing Edinburgh Mental Health Services

Date: Wednesday 11th June, 2014 Time: 9.30 registration for 10.00 am start, finis hing at 4.00 pm Venue: Creative Scotland Event Space, 1st Floor, W averley Gate, 2-4 Waterloo Place 9.30 Coffee and Registration

10.00 Welcome and Programme for Today

10.10 What have we been doing since last September?

10.45 How can we make this affordable?

11.15 Break

11.30 Session 1: Table top presentations and discussions

• Volunteering, employment and meaningful activities

• Places to be

• Connecting Community and Inpatient

• Self directed support – expectations, opportunities and relationships

• Wayfinder – what could be different?

• Different ways to deliver psychological therapies?

• Getting where you need to be - Self referral, open access, staying in touch, reflecting

local priorities

12.45 Lunch

1.30 Information Overload

1.45 Session 2: Table top presentations and discussions

• Connecting Community and Inpatient

• Self directed support – expectations, opportunities and relationships

• Wayfinder – what could be different?

• Different ways to deliver psychological therapies?

• Getting where you need to be - Self referral, open access, staying in touch, reflecting

local priorities

• Acute Care – different paths for the future

3.00 Break

3.20 How do you feel about what you’ve heard? - discussion and questions

• What have you heard that you really like?

• Is anything missing?

3.50 Closing Words

4.00 End

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Appendix Two: What we spend

NHS Specialist Community £1.268m 23 WTE

NHS Rehab Community and Inpatient £4,086m

NHS Acute Inpatients: £6,398m 177 WTE Staff

NHS Community Mental Health: £9,333m 218 WTE Staff

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