This week’s HSJ Local Briefing investigates the changing picture of mental health services across the South East Coast region
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Issue: The South East Coast region contains three large and ambitious mental health providers. They are in the midst of evolving their structures and services in order to meet the challenges of providing mental health and learning disabilities care in the new NHS landscape.
Context: Kent and Medway NHS and Social Care Partnership Trust is entering a crucial phase of the foundation trust pipeline and is embarking on major programmes to modernise its estate and invest in expanding its community services.
Meanwhile, Surrey and Borders Partnership Foundation Trust is working to slash its sites, with a view to focusing on prevention and early intervention. It recently won a joint contract with a charity to run drug and alcohol dependency services in part of London and plans further partnerships.
Sussex Partnership Foundation Trust is already well advanced in running services outside its borders, especially in London. It wants to develop more opportunities of this kind and is also seeking to bid for national contracts to run specialist services.
Outcome: Each of the three organisations has its own strategy to develop in different ways. However, all are looking to win contracts in new specialist or geographical areas and in partnership with third sector partners.
The South East Coast could prove to be an important test-bed in mental health for the government’s policies on use of competition and alternative providers as a means to improve services.
The South East Coast health economy and its bordering areas have become a highly competitive environment for mental health services. Service design and delivery is evolving fast, with potential lessons for the rest of the sector.
The region contains three large mental health providers largely corresponding with the boundaries of the three counties that it covers.
Each of them has been pursuing or is embarking on major programmes of service and structural change, in an effort to modernise their services in line with clinical and policy direction.
They have also embraced the opportunities presented by the increased competition in the NHS to develop new services – often beyond their own traditional areas – but at the same time are changing or transferring some of their previous services.
All three are also having to deal with the challenges of a new commissioning environment, in which they are having to build working relationships with many more local organisations than previously.
One of the largest mental health trusts in the country, Sussex Partnership Foundation Trust has a turnover of £240m and employs 5,000 staff.
Its most high profile development so far this year has been the partnership deal it agreed in March with private provider Care UK to develop rehabilitation and recovery-based care.
Thought to be the first partnership of its kind in the UK, the two organisations have formed a joint venture company, Recovery and Rehabilitation Partnership. It has taken over the running of a 32-bed facility in Gosport and will develop a new home for 24 people in Horsham.
Trust chief executive Lisa Rodrigues noted it already had a number of joint ventures and subcontracting relationships with charities.
She said: “We work with CRI, a third sector organisation, which provide substance misuse services; we work with Turning Point, which provides some of our primary care mental health services; and we work increasingly with local branches of Mind to provide some local services.”
She told HSJ the joint venture with Care UK would also be used to try and develop “other opportunities”, adding that the trust would seek further partnerships. “We’ve got to be more plural in our approaches,” she said.
“For commissioners, presenting oneself as a package is more attractive than them having to go out and buy the different sections of the service. They don’t want a service where you’ve got X providing the medical cover and Y providing the nursing cover and Z providing the social care.”
The trust is also working closely with acute and community service providers in Sussex. As well as established liaison services in accident and emergency departments, it is starting to offer equality of human rights training – it came top in March in Stonewall’s first Healthcare Equality Index for delivering services to the lesbian, gay and bisexual community.
In addition, it is beginning to co-locate services, especially around dementia care, with Sussex Community Trust. However, any talk of a merger between the two organisations has been muted by positive noises from the NHS Trust Development Authority about the community trust’s ability to gain foundation status as a standalone organisation.
Ms Rodrigues noted that Sussex Partnership would also have to stop doing some of the things it provided in the past, most notably residential services, which were “better placed” with other organisations.
“People don’t want to live in a house run by the NHS. I think we’ve sorted it out for learning disabilities but we’ve a way to go for mental health.”
The trust is already working with clinical commissioning groups to invest in personality disorder services, with a new service in Brighton and Hove due to formally open in May.
Ms Rodrigues added that the trust would also be looking to expand its secure services, and children and young people’s mental health service because of national capacity shortages in both areas. “We’ve got a number of things in the pipeline,” she said.
As well as its service provision across Sussex, the trust has also extended its reach into the surrounding health economies. It provides inpatient services to East Surrey, substance misuse services in Kent and south London, inpatient detoxification for five south-west London boroughs, and children and young people’s mental health services in Hampshire and in Kent and Medway.
Ms Rodrigues said: “Thirty per cent of my income is coming outside of the seven CCGs in Sussex and we see that increasing. It’s going to go 50:50, I would have thought.
“Increasingly, we’re not expected to think of the geography that our name suggests, and I think that applies to all my colleagues [across the South East Coast]. The system isn’t set up for that any more. We have to think more broadly.”
Surrey and Borders
The £128m-turnover Surrey and Borders Partnership Foundation Trust has been an FT since 2008 and is the main provider of mental health services for Surrey and also north-east Hampshire. It employs 2,400 staff across 74 sites, and serves a population of 1.3 million.
The trust is at the tail end of significant changes to its service provision for learning disabilities, which has seen it transfer some of its social care services to third sector providers and move the remainder away from residential care to a supported-living model – in line with government policy.
Likewise, the trust is attempting to transform its estate for mental health services. It is about a year into a major strategy to modernise and rationalise its built environment.
At the end of 2011-12 the number of trust sites stood at 65, almost half the 127 sites it had in 2005. Its ultimate aim is to reduce its sites to about 28 by 2016.
According to director of quality and nursing Jo Young, the trust is adopting an approach based on more early intervention and prevention, building on its existing liaison services in local acute trusts.
For example, she highlighted that it was training teachers at 200 schools in East Surrey to spot emerging mental health problems and had funded healthcare staff for the county’s 10 specialist schools to help manage the early signs of mental distress.
Ms Young said: “Our 10-year strategy has talked about a shift in moving away from a see and treat-style model to a more consultative and preventative-style approach.
“[We are] putting our expertise into care pathways and the way services are organised and designed – spreading the work that we can, reaching as many people as we can with the resource that’s available.”
Like Sussex Partnership, Surrey and Borders has taken successful advantage of greater competition and recently been winning contracts both inside and beyond its traditional borders.
In April 2012, it started a new treatment and recovery service for people with drug and alcohol dependency problems in the London borough of Hounslow.
The service is provided under the banner of the iHEAR Partnership by a consortium of Surrey and Borders and the drug and alcohol charity Cranstoun. The service marked a shift away from several individual contracts for adult community and criminal justice substance misuse services in Hounslow to an integrated and coordinated treatment system and service.
Director of finance Clive Field said the trust was “very excited” about the new service and that working in partnership with third sector organisations was increasingly important to it.
“It was a joint tender, the idea of taking the strength of what they do alongside the strengths of what we do. They are the lead partner in the contract and we support them,” he said.
“We genuinely see that as the way forward, giving the best of both worlds to commissioners.”
Mr Field added: “We also have contracts for other services with Berkshire and with Sussex. It’s like a lot of things, the way some health economies work, the fact there happens to be a county border in the middle is immaterial.”
Ms Young noted that the trust was also engaged in partnership working with the Alzheimer’s Society on early diagnosis of dementia.
“All our memory clinics are partnered with the Alzheimer’s Society so we can try and give a more complete package when people come and receive a diagnosis,” she said. “That’s the other big partnership that we’ve just started work on and will continue on into next year.”
In addition, the trust has been accredited though any willing provider as Surrey’s provider of IAPT (improving access to psychological therapies), the primary care-based early intervention programme favoured by the government.
The service went live this month from 14 sites and the trust has recruited 40 whole-time-equivalent staff to run it. But Mr Field admits that trying to gauge demand for the new service has been difficult, because it involved a “far more nebulous and amorphous group of people” than, for example, learning disability services.
The trust estimates 15,000 people in Surrey could benefit from IAPT services each year. But Mr Field said: “We know the type of care we want to provide, [but] we have no idea how many people need to use these services, how many will contact us in preference to other providers – we won’t know what their needs are.”
Kent and Medway
Like its neighbours, Kent and Medway NHS and Social Care Partnership Trust is one of the country’s largest mental health providers. With an income of £178m, it employs about 3,500 staff to provide services from almost 90 sites to a population of 1.6 million people.
However, it is the only one of the three yet to attain foundation status. It began an initial assessment process with Monitor in March 2009 but a series of delays and retirements among key directors led it to withdraw its initial application.
The trust is currently being quality assessed by the NHS Trust Development Authority and expects to make significant progress along the pipeline this year.
Chief executive Angela McNab said: “We’re expecting some time in the next three to six months to successfully complete that stage and move on to the Monitor stage.”
The trust’s latest tripartite formal agreement, signed in September 2011, noted issues to address, including an “ambitious” service redesign programme to reconfigure services to “meet future demands and expectations”; and issues relating to providing high quality services in some areas where “estate is compliant but not ideal for service users”.
Ms McNab, who has been with the trust since this time last year, said it had achieved an “enormous amount” in 2012-13. “We are fulfilling our strategy and we’ve got a very exciting year coming,” she said.
The trust also finished a year-long consultation last October on a major programme to solve the problems posed by its estate by setting up three “centres of excellence” – Canterbury in the east, Maidstone in the west and Dartford in the north.
In preparation it completed a £10m purpose-built inpatient unit in Canterbury last October, featuring two 18-bed wards.
The achieving excellence in mental health crisis care programme is intended to allow it to dispense with “wholly unsuitable” premises, Ms McNab said – most notably two wards in Medway Maritime Hospital. The plans were rubber-stamped by NHS Kent and Medway at its meeting in February.
In addition, she said the trust was investing heavily in community teams so that more older patients, especially those with dementia, could remain at home. Seven community “hubs” are planned, of which three are now open and four more are due to be completed by October this year.
Ms McNab described the centres of excellence and community hubs as the two “big headlines” that the trust was working on at present.
“We had good services, we had excellent staff, but we had a whole range of quite disparate bases across a very wide geographical patch,” she said. “Inevitably the consistency of service delivery and the integration between different services and teams was probably not as good as it should be.”
She added: “We had a large number – we still have quite a large number – of buildings right across the county… some of them out of date, some of them in poor condition and some of them just unsuitable because the models of care have moved on.
“What we’ve increasingly got and we will have even more of in another 12 months is a smaller number of really excellent facilities and much more connectivity between all our teams.”
Despite its lack of FT status, the trust is developing strongly in a number of specialist service areas in a similar way to its counterparts in Surrey and Sussex.
For example, it has recently secured funding to expand its police custody liaison and diversion service across Kent and develop a new county-wide court liaison and diversion service.
In common with other mental health trusts in the region, it recently established a partnership agreement with Cygnet Healthcare. A joint service will expand the provision of low and medium secure services in Kent and Medway, with the trust providing a consultant psychiatrist and social worker, and the private provider supplying physical resources and other frontline staff.
“It’s early days but it’s going very well,” Ms McNab told HSJ. “I anticipate there will be more partnerships in the future, not just with the private sector but a whole range of partners.
“It’s important we use the range of skills that we’ve got in the most effective way and particularly in times of recession when it makes sense for us to bring our skills and our resources together.”
For example, she said the trust had met with local housing associations this month to try and garner interest in new partnerships to develop new intermediate care models, where patients might need short-term crisis care but did not require admission to an acute inpatient unit.
All three mental health providers are having to cope with the formal change this month from dealing with a small group of primary care trusts to a large group of clinical commissioning groups.
Surrey and Borders had largely been co-terminus with NHS Surrey, with the obvious exception of its services in part of Hampshire.
Mr Field, the trust’s finance director, said: “It will be interesting… we’ve always been able to discuss with NHS Surrey about how we ensure equality of service across the whole county. But CCGs by definition are far more concerned about what services look like in their locality.
“They’ve published commissioning intentions documents, we’ve had discussions and as such there have been constructive talks about how we take the whole service forward. How that evolves as the CCGs get settled into what they are doing, it’s really difficult to tell how this will work.
“If one in the east starts pushing for a different priority to one in the west… that might be something we get into as they develop,” he added.
Similarly, Sussex Partnership chief executive Ms Rodrigues expected “big changes” now that she had to deal with seven separate CCGs across the county rather than working largely with one PCT, which led on mental health commissioning for Sussex.
“It’s going to take at least a year to settle down but we’re preparing ourselves for working with the new arrangements,” she said.
“We’ve got many more clinicians involved in senior management roles [on a part-time basis]. Doctors want to talk to doctors, so we’ve completely revamped our management structure so we can work with the CCGs in the right way.”
She added: “There’s also the national commissioning arrangements, under NHS England, such as secure and forensic services, which is a big part of what we do – and some of our more specialist mental health services and inpatient children and young people’s mental health services.”
Meanwhile, West Kent CCG has agreed to take the lead commissioner role for mental health services with Kent and Medway.
Ms McNab said: “We’ve still got good links across all of our CCGs, but the commissioning lead is with West Kent and that’s working extremely well.”
She hoped it would lead to much closer working with primary care on mental health services, adding that some of the trust’s staff had already been seconded to local CCGs.
A competitive environment
All three providers have signalled their intention to compete with each other for contracts across the South East Coast region and beyond, noting that traditional trust boundaries are less important in the modern NHS.
Ms Rodrigues, from Sussex Partnership, said: “I can’t speak for the other trusts but it is a competitive environment. My driver is always: ‘Can I do this really well for the amount of money that’s on offer?’
“That means, do I have the expertise and can I get the people together to provide a great service? If I can I’m going to bid for it, and if I can’t I’m not. That’s my approach,” she told HSJ.
Mr Field, from Surrey and Borders, echoed the point that quality was a key driver behind its decisions to bid for contracts outside its boundaries.
“We probably share the same agenda around quality of care [as the other trusts]. Beyond that, in terms of strategic intent and where the other organisations are, essentially we focus on what our strategy is,” he said.
“We’re not seeking to establish services in Surrey just to compete with Sussex. We’re seeking to establish services that will provide the care that’s required as per the needs of the population.
“We work as closely as we possibly can with each other, but recognising that we are separate organisations,” he added.
Kent and Medway’s Ms McNab highlighted that, while not yet an FT, her organisation was a “large well-established trust” with “growing services”.
“There will be a range of organisations across the south and no doubt we all have something slightly different that we offer,” she said.
“I’m sure there will be times when we work together and times perhaps when we are competing, but that’s good for the population of the south.”
Mental health services in the South East Coast region will be increasingly delivered where possible from fewer, but more modern, sites. These will be backed up by expanded community teams, greater use of primary care and a range of new care models.
Increasingly, the three trusts will move outside their traditional areas, filling gaps in niche services by developing their own specialist expertise but also vying with each other to win tenders.
They will increasingly work in partnership with charities and private sector organisations to provide services they might have been unable to develop or run on their own.
In contrast to their structure as county-wide providers, they will work with an increasing number of local and national commissioners, including their own CCGs, neighbouring CCGs and NHS England.
“It’s a very exciting time for mental health trusts,” Ms McNab stated. “I think everybody recognises that getting parity with mental health and physical health is a strong ambition and I think it’s a very exciting time to be progressing these services.”