THURSDAY 17APRIL 2008 at 10.00 A.M.


Author: Catherine Swaile, Service Development Manager, Mental Health

(Adults of Working Age)

Tel: 01438 843232

  1. Purpose of Report

To provide the Joint Commissioning Partnership Board (JCPB) with a review of the performance of Working Age Mental Health Services over the past year and to present the key objectives and challenges facing Working Age Mental Health over the coming year.

  1. Summary: Points arising from the Annual Review Report to the Strategic

Commissioning Group

As agreed at the last JCPB, new reporting arrangements are now in place so that this report is first seen by the Strategic Commissioning Group (SCG) for Working Age Mental Health for comment and in order that they might highlight to the board any areas of particular note.

This annual report was included in SCG’s discussion on the 4th March and SCG would like to highlight the following areas for the particular attention of the Joint Commissioning Partnership Board:

  • Pressures on acute inpatient services

(Please reference 3.20 and 3.21)

SCG were concerned at the high level of bed occupancy. It was noted that the commissioners have no current commitment to any further reduction in beds and need to keep bed capacity under close review. It was discussed that further investment in community services might relieve the current situation and that an investigation of crisis accommodation as an alternative to admission should be carried out.

  • Performance and Planning

SCG would like the overall 2007/08 analysis for Serious Untoward Incidents (SUIs) to be included in the next report to JCPB and are anticipating looking more closely at the following performance areas in the coming year:.

  • Eating Disorders Services
  • Carers Assessments
  • Psychological Therapies
  • Voluntary Sector
  • Investment Planning

3.Annual Review Report Background Information

3.1Autumn Assessment

This year’s assessment process is currently underway. The themed review for 2008 is ‘Commissioning Mental Health Services for the Future’. The assessment process will utilise the local knowledge of the four Local Implementation Teams (LITS) which will be fed into the Strategic Commissioning Group which functions as Hertfordshire’s LIT to compile the information.

3.2Practice Based Joint Commissioning

As board members will recall from the November JCPB report this is the first initiative of its type in the country. Following completion of a Needs Assessment, the Stevenage Locality Cluster Group has agreed the service specification, the model of care being a single point of access to provide rapid triage and signposting of referrals. It is expected that the model will be rolled out to all Stevenage practices by October 2008.

3.3Specialist Personality Disorder Service

The service specification for the Personality Disorder Service has now been agreed and Hertfordshire Partnership Foundation Trust(HPFT) is currently recruiting in order to staff the new service. HPFT currently have an Assistant Psychologist in post who is scoping the caseload of current services. HPFT are now interviewing for the Head of Service post and service-users have been engaged throughout this recruitment process. It is expected that this service will be operational by autumn of 2008.

The service will be a dedicated specialist multi-disciplinary team and will be consistent with the approach described in ‘No longer a diagnosis of exclusion’ and incorporated in the Eastern Specialist Mental Health Commissioning Group ‘Personality Disorder Framework (2005)’. The team will be a county-wide resource and will configure itself so as to provide the most effective level of provision to individuals and those who may care for them within their communities.

The service will seek to work with those persons within existing mental health services and new referrals into the service that are assessed as having a high degree of need associated to their diagnosis of Personality Disorder.

In practice this will translate as follows (in no particular order):

  • High Level of Risk to Self and/or Others
  • High Degree of Multiple Service Use
  • Limited Response to Service Intervention
  • Repeated Crisis Presentation

3.4Impact of Saving Measures

The Joint Commissioning Team (JCT) have continued to monitor the impact of the 2006/07 savings. As reportedat the last JCPB there is no concrete evidence that the savings have impacted detrimentally on the voluntary sector, though work will continue to monitor this. Bed occupancy will also continue to be monitored closely.

3.5Delivering Race Equality

The Delivering Race Equality (DRE) Project Board, previously titled the Black and Minority Ethnic Project Board is a multi agency group chaired by HPFT’s Director of Nursing and Performance and supported by Care Service Improvement Partnership. The aim of the Board is to improve access, experiences and outcomes for black and minority ethnic mental health service users. A comprehensive project plan supports the work of the Board.

To ensure common understanding of the role of Community Development Workers (CDWs) by partner organisations a service specification has been prepared for consideration by the DRE Board. Work is also being organised to map relevant services and organisations that CDWs will need to link into, providing a directory of information across the county.

Going forward into 2008/09 the Board will continue to oversee the work of the CDWs as well as promoting and sharing best practice. In order to ensure that the work of the Board remains relevant a workshop is being organised for early summer to discuss current activities and achievements to-date. The workshop will also focus on identifying local needs and promoting the DRE agenda.

HPFT has been contacted by the Healthcare Commission as an example of best practice in this area, with service user involvement supported by Viewpoint.

3.6Enhanced Primary Mental Health Care (EPMH)

HPFT are currently preparing a report detailing options to facilitate the accelerated roll out of the Enhanced Primary Mental Health Care Teams across Hertfordshire. The Practiced Based Commissioning (PBC) groups are currently taking proposals to develop EPMH services in Hertsmere and Dacorum to the respective PBC Governance meetings with a view to EPMH services beginning in these areas in July and October respectively. Links with the PBC structures are working increasingly well and a mental health leads meeting has been established to assist with this.

3.7Improved Access to Psychological Therapies (IAPT)

As the Board will be aware Hertfordshire is one of eight national pathfinders site for Improved Access to Psychological Therapies (IAPT). In conjunction with Hertfordshire Partnership Foundation Trust, four pilot sites have been set up across Hertfordshire. The pilot sites also cover special interest groups which include Long Term Conditions, Older People and Perinatal. The service model is based on the Stepped Care Model approach and, where possible, carried out in a primary care setting so that the service is seen as a community service rather than being linked to a secondary care acute service. This is to increase local access as far as possible and reduce the stigmatisation of the service as being seen as an intensive mental health service. The pilots deal in general with mild, and moderate cases of depression and anxiety generally referred to as Tier 2 and Tier 3 type services of the stepped care model. Tier 1 is generally dealt with in primary care and Tier 3 and Tier 4 are more intensive secondary care services. The principal is to treat and maintain as many people as possible within primary care. It is envisaged that there will be a shift of resources from secondary care to primary care to support this service along with significant investment from the government who will be providing an extra £170million to set up local community based psychological therapy services nationally. This funding is currently earmarked for staff and training only. There is no current funding nationally available for premises. Under the national guidelines it is suggested that a population of 250,000 should be covered by 40 workers. Hertfordshire would therefore require 160 workers within this field. This presents the county with a significant manpower and training issue which is being addressed in conjunction with HertfordshireUniversity. The accommodation issue has still to be resolved and discussions have begun to try and work this through.

3.8Health Care Commission Targets

We remain on course to achieve the target for this year as shown below

Indicator / Target 07/08 / Current Position / Projection for end of 07/08
Community Development Workers / 10 WTE by 31st December 2007 / 10 WTE in post / 10 WTE in post
Early Intervention in Psychosis- New Cases / 150 New cases a year / 163 New Cases / 170 New Cases
Crisis Assessment and Home Treatment / 1636 / 2207 / 2864 Service Users
7 Day Follow up / 90% of all admissions / 90.8% / 90.8%
Suicide Audit Group / Monitor PCTs progress to reducing suicide rate by 20% by 2010 / First meeting of Suicide Audit Group has been held- actions agreed / Will be completed on time

3.8.1Community Development Workers

Hertfordshire has achieved the target of 10 whole time equivalent community development workers (CDWs). The CDWs are currently based within HPFT (5.5 WTE including the lead CDW), the voluntary sector (3.6 WTE) and Hertfordshire County Council (0.9 WTE).

3.8.2Early Intervention in Psychosis Service

The Early Intervention Service has continued to recruit in-line with the growth in caseload and the Team are now working to increase GP awareness and engagement with the service. The target of 150 new cases per year by April 2008 has now been achieved. Additional funding has been agreed by the PCT to fully finance the Early Intervention Service from 2008/09.

3.8.3Crisis Assessment and Home Treatment

The Crisis Assessment and Home Treatment (CAT) Teams continue to provide intensive support for people in mental health crises within the community. The target for 2007/08 has now been far exceeded.

3.8.4Care ProgrammeApproach (CPA) 7-day follow up

This relates to the timely post discharge follow-up of ‘at risk’ service users and is being closely monitored by HPFT and the JCT.

3.8.5Suicide Audit Group

The Suicide Audit Group has now met and agreed the actions necessary to complete the suicide audit. A second meeting has been arranged and it is envisaged that the group will complete the audit on time.

3.9Day Opportunities

Following the review of multi-purpose day centres a specification was designed for the provision of community based recovery oriented services in the South East in partnership with service users. The contract for this provision has now been tendered out and awarded to Herts Mind Network. This service will provide for people of working age with a diagnosis of or suspected mental health problems who have been using King Arthur Court or Bishops House multi-purpose day centres. It will also re-provide for service users currently using the Community Bridge Builders run by Rethink in Ware. The contract will run from April 2008 and work is currently being undergone to ensure a smooth transition for current service users. Work on rolling out the transfer of mental health clients from multi-purpose day centres to the West will begin later in the year and will be informed by learning gained through the process in the South East.

3.10Prison Mental Health In-Reach

The In-Reach team was awarded by the prison ‘In recognition of the team’s outstanding recent performance and integration into the establishment’. The prison has not previously awarded an external team and the team were extremely pleased to have their good work recognised.

Training for staff continues weekly at The Mount by the team. The training is well received and the target set by the prison service of 34 officers trained has been exceeded as the figure is 71 to date. The training is used to promote the sharing of information.

3.11Voluntary Sector

The Joint Commissioning Team continue to work in partnership with a wide range of voluntary organisations, with consistent and meaningful engagement of the third sector in service planning and needs analysis for adults with mental health problems. A robust contract management and monitoring system operates to ensure that investment within the voluntary sector is targeted towards identified need. The voluntary sector offer a wide reaching spectrum of services ranging from day provision, meaningful occupation, respite opportunities for service users and carers, training opportunities, supported volunteering and befriending services and drop in sessions.

3.12Accident and Emergency Liaison Service

An Accident and Emergency Liaison Service is currently operational at both the Lister in Stevenage and the QEII in Welwyn Garden City providing triage and liaison with the in-patient wards and ensuring access to a mental health service for people who present or are admitted to these two District General Hospitals. Disparity has been found between this and the current level of service in West Herts, as the service has not yet been fully developed in Watford. Work is currently being done to examine the model currently operating inEast and North Herts and to assess the plausibility of developing the service in the West. Work will also need to include plans for the future to provide these services in the new urgent care centres.

3.13Mother and Baby Mental Health Services

The Thumbswood Unit continues to provide specialist provision to mothers with mental health problems caused by or parallel to pregnancy and birth. HPFT are meeting with the PCT Children’s Services Commissioner and acute hospital regarding the links that Thumbswood needs with the acute and primary healthcare to ensure that mother and baby are given access to the necessary physical health checks, immunisations, emergency care, rehabilitation and support back into their community.

3.14Eating Disorder Services

From April 2006 HPFT have been providing a community specialist service working across Hertfordshire through two multi-disciplinary teams. Work is currently ongoing to assess the current model for delivering Eating Disorder Services in Hertfordshire. Bed occupancy rates are higher than anticipated and scoping work is being done to examine the best use of resources to meet the needs of current and future service users.

3.15Mental Health Grant

The announcement of allocations to local authorities in December 2007 provided information on the Mental Health Grant allocation over the next three years.

£’000 / (Reduction)/Increase
£’000 / %
2007/08 / 2,205
Uplift 2008/09 (2.5%) / 55
2007/08 Allocation with uplift / 2,260
2008/09 Allocation / 1,997 / (263) / (-11.92%)
2009/10 Allocation / 2,104 / 107 / 5.36%
2010/11 Allocation / 2,211 / 107 / 5.09%

The Hertfordshire allocation will be reduced by £263,000 in 2008/09. It has therefore been necessary to find savings to support this reduction in grant income.

Two options were agreed at the last SCG meeting; either to top slice voluntary organisation funding or to top slice both HPFT and voluntary organisations to fund the deficit. However it has been possible to find sufficient savings without doing this.

The PCT has agreed that some initiatives that have been supported by the Mental Health Grant but which are priorities for health can be supported from the increase in mental health investment in 2008/09 – this relates to CDWs and the CATT worker in Hertsmere.

There are savings expected from the re-provision on the Higgins Walk and the telephone line services. The re-provision of the Higgins Walk service will not result in full year savings in 2008/09 because the new service is not expected to start until July. The day service schemes that are supported through this budget will be reviewed and it is expected that some savings will be achieved.

Total full year savings from the voluntary organisation funding identified is:

Transfer to health funding£136,720

Higgins Walk re-provision£ 50,000

Telephone line re-provision£ 8,392

Day service review£ 18,000


ACS has agreed that they will accept this potential overspend on the budget for 2008/09 but that the full savings must be achieved for 2009/10.

3.16Supported Capital Funding

The full £318,955 allocation has now been committed to support 35 different projects. Each bid was assessed as contributing to the following priorities as identified by SCG and the local LITs.

  • Enhanced primary mental health services
  • Exercise and physical health promotion
  • Red Areas in Autumn Assessment: Graduate Workers, STaR Workers and

Mental Health Promotion (NSF Standard One)

  • Vocational
  • Promotion of social inclusion

Just over £218,000 of this funding was allocated to the 20 voluntary sector projects that were successful, with the rest going to support enhanced primary mental health services or toHPFT to make improvements to current secondary care provision.

3.17Respite Provision

Direct payments are now being used for everyone meeting the criteria for respite, ensuring increased choice and control for service users and carers. Forresters has remained a key provider of this respite but by aiding service users to access this resource by using their direct payment it means that those for whom it is not suitable can use their payment to make other arrangements.


The uptake of the self-help books available in the libraries has been good, largely due to the innovative displays and promotion of the scheme within the libraries. However there is little evidence of prescriptions being issued by GPs. Work is now being done to promote the scheme within primary care and encourage GP engagement.

3.19Specialist Treatments

This budget is currently projecting a spend of £247,000 against a budget of £213,000, largely due to a higher than average level of activity being provided by the South London and Maudsley NHS Foundation Trust. However the cost pressure this year will be met through under-spend in other budgets areas within Working Age Mental Health.

3.20Pressures of Acute Inpatient Services

The percentage of people being held on section in the acute inpatients units has increased over the last year. This has meant that not only are the wards at capacity but that the service users are more demanding requiring more monitoring and observation. Staff are endeavouring to continue to offer therapeutic interventions and life and social skills work, however this is becoming more problematic and JCT are increasingly aware of the pressures being placed on these resources.