Making a decision

The Journey

• Three in-patient care scenarios

• Two scenarios for the delivery of older people’s

services for Newcastle.

• We also gathered views on potential new or

enhanced community services

The scenarios

The challenge • Need for significant upgrade in specialist mental health

care in Newcastle and Gateshead – Reduced reliance on inpatient stay – Fewer avoidable admissions – Shorter average length of stay – Improved quality of inpatient experience

• Need for significant enhancement of community based support

• Two ‘pre-engagement’ phases that informed the scenario development

• Active involvement of the mental health programme board through Deciding Together Advisory Group

• Used new engagement methods including ‘participatory budgeting’ How would you spend the mental health pound?

• Large and wide reaching listening

• Recognised by external bodies as excellent practice through out all phases

The engagement process

• November 2015 to February 2016

– Focus groups

– An online survey (and paper based equivalent)

– A street survey with a representative sample of the public

– Letters, emails and other written submissions, including feedback from meetings with voluntary and community sector service providers

– Public consultation events

The formal consultation process

• In-depth interviews carried out by Northumbria University peer researchers

• Results independently analysed and reported by Kenyon Fraser

• Travel analysis carried out by North East Quality Observatory

• Full engagement programme managed by NECS

The formal consultation process

The legal duty The outcome of the consultation should be conscientiously taken into account (Gunning principle no 4) – the CCG should be able to demonstrate good reasons and evidence for it’s decision This does not mean that decision makers have to agree with the majority response, but where applicable, they should be able to set out why the majority view was not followed.

What we have heard • The most important basis of preference for all methods

apart from the public survey was around reducing the impact of travelling and maintaining close links with the community that patients are established within.

• For example, respondents to the consultation recognise the benefits of better accommodation for inpatients, but extra funds in the system is not a major persuader – minimising travel and maintaining links into the local community are more important.

What we have heard • The provision of in-patient services in Newcastle

appears to be favoured by respondents overall (it is worth noting that when the data is analysed further then Newcastle respondents favoured a Newcastle based inpatient provision and Gateshead respondents favoured a Gateshead based inpatient provision).

• However, responses through the online and paper surveys suggested that all three in-patient scenarios were favoured similarly in terms of respondents’ perceptions of a scenario’s ability to fully or partially meet their needs.

What we have heard • A preference for provision of older people’s services

from Newcastle was given by a significant and large majority of respondents to this question.

• The need for reassurances about staffing emerged - familiar faces and relationships are valued above the premises - and the lack of reference to this in the consultation documents was commented on.

What we have heard • The in-patient scenario T (NTW Trust-wide scenario) is less

popular with all but the street survey participants and a small number of focus groups, particularly if commitments to support travel were effectively in place.

• The argument that some in-patient scenarios will release more funds for improved and enhanced community services was less convincing for respondents to all methodologies apart from the large sample public survey.

In Depth Interviews The In Depth Interviews took place in January and February of this year and were led by service users and carers in partnership with academics from Northumbria University, using an interview tool designed and delivered by people who have first hand experience of services. The intent was to capture their lived experience • The participants ages ranged from 25 years to 70+. • Their length of time in service ranged from 1 to 15+ years.

11 participants had been in services for 15+ years

What we have heard • Participants wanted better facilities in inpatient settings,

including en-suite toilets and private areas for service users and carers to meet

• They wanted inpatient settings where activities reflected the diversity of their needs including reading, art, games and opportunities to be outdoors

• The availability of quality information particularly around transition points such as moving in and out of services or between children and adult services was reported as important

What we have heard • Targeted support over maintaining quality housing was

also stressed by participants. This would help avoid service users being discharged from hospital into unsuitable housing arrangements or becoming homeless.

• Ongoing conversations over mental health ‘recovery’ were reported as important in developing hope for both carers and service users.

The key issue - travel • Travel – measures outlining support to reduce the impact

of travel are in supplementary paper to CCG Governing body members following Governing Body development session in April 2016

• “Absolute commitment to support travel in any scenario where inpatient services are further away from local communities” in public consultation.

• Proposed “Travel Advisory Group” to be set up as part of Implementation Plans, with multi-stakeholder involvement

What we have heard - OSC • Regular attendance at individual OSC and joint

• Newcastle and Gateshead joint Overview and Scrutiny Committees (OSC) provided responses.

• The CCG presented the proposals to the joint Newcastle and Gateshead Overview and Scrutiny panel meeting. Both would find scenario N and scenario G acceptable. Gateshead OSC have reserved the right to refer to the Secretary of State if scenario T is chosen.

Professionals – primary care • The CCG has engaged with its member practices

throughout the Deciding Together process.

• Ongoing engagement and information has been shared since September 2014 via – weekly GP bulletins – Intranet – GP Teamnet.

Professionals – primary care – Attended existing meetings throughout 2015, including

the GP Commissioning Forums and GP Time In, Time Out sessions

– presentations given, comments and views were encouraged on the process and issues

Professionals – mental health Expert advisor, consultant psychiatrist from neighbouring trust reviewed scenarios as they were developed. NTW clinicians involved at all stages Benchmarked against: .

• A commission on the provision of acute inpatient and psychiatric care for England

• NHS England has also published a special task force into mental health – The Five Year Forward View for Mental Health which sets out the national priorities for the NHS in the next five years

Professionals – mental health • No Health Without Mental health – this sets out the

cross-government mental health outcomes strategy for people of all ages

• Closing the Gap – sets our Department of Health priorities for essential change in mental health

• Old Problems, New solutions: improving acute psychiatric care for adults in England

Clinical senate review Positive about the work Deciding Together process and the progress of the development of the scenarios and involvement from clinical teams and service users and carers. They summarised their findings in the 4 conclusions: 1 - The Review Team were impressed by the Deciding Together programme approach. 2 – The appropriate clinical interdependencies and risks have been identified, considered and mitigated.

Clinical senate review 3 – The programme is right to reduce the number of inpatient settings and rebalance the service with greater community provision closer to patient’s homes. 4 – The ultimate success of this programme will rely on the development and continued investment in services and sectors that are “out-of-scope” of this review. View that the Do-nothing scenario was not sustainable and therefore all other scenarios presented were deemed deliverable.

NHS England • Provide assurance against the service change gateways

including the four service change tests and national best practice tests – including: – Clinical sustainability – Financial sustainability – Strategic alignment and system impact – Involved at all stages of process – Stage 2 pre consultation partial assurance – Stage 3 pre decision – full assurance (clinical senate

review)

Mental Health Programme Board • At the centre of the CCG mental health agenda, reported

to throughout • Involved in two dedicated workshops for scenario

development • Undertook the non-financial option appraisal • Led for Deciding Together Advisory Group – overseen

the engagement activity

Decision making business case • Important that decision should be considered in the

context of ‘improving both inpatient and community services’, contributing to delivery of the CCG’s strategic plan objectives, which include:

– Increase the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community

– Reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital

Decision making business case • We want to ensure:

– Services are high quality and as efficient as possible, provided in the most appropriate, least restrictive environment, ideally supporting people well at home.

– Focus on supporting people to recover, and helping people with lifelong conditions to have fulfilling lives, so that every person can gain as much independence and control over their lives and their care as possible.

– This is in line with the national strategic direction for mental health services.

Decision making business case Option appraisal concluded:

Adult services - It is considered that scenario G (Gateshead) and the Do Nothing scenario can be removed from further consideration as they were ranked 3rd and 4th respectively in both non-financial benefits and the financial assessment. Therefore, scenarios (T) and (N) remain.

Older people – It is considered that the preferred scenario should be Scenario 1 (St Nicholas’ Hospital) as it delivers significantly higher non-financial benefits and better value for money than Scenario 2 (St. George’s Park)