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A step change

In 2017, south east London’s trio of mental health providers – Oxleas Foundation Trust, South London and Maudsley FT, and South West London and St George’s Mental Health Trust – took on specialised commissioning budgets for forensic and tier four inpatient mental health services, as part of the national new care model programme. 

Fourteen other providers have been granted responsibility over specialised commissioning budgets since 2017. NHS England has said it wants the country to be covered in these specialised budget holding groups by 2020.

However, the providers in south east London could go one step further. HSJ has learned the three trusts are in negotiations to take on responsibility for core mental health budgets – services which clinical commissioning groups are currently responsible for.

Technically, CCGs will still have statutory responsibility for commissioning the services, but, as with specialised commissioning and primary care, these powers can be delegated and or shared with providers.

If this goes ahead as planned, this will be a step change in the commissioning of mental health services. Arguments for the change will be that providers have the necessary clinical expertise in mental health services, unfair variation in services across the patch can be addressed and, as one chief executive put it, the “bureaucratic friction” can be reduced.

Deep-rooted problems

In the national risk register of local problems, the shortcomings in Lancashire’s mental health services and the knock-on effects for its emergency departments will be right up there.

The county has reported a jaw-dropping number of 12-hour accident and emergency breaches over the last year (around a third of all cases in England), most of which were mental health patients.

HSJ has obtained details of two reviews which diagnose system problems that have led to this issue. These include under-resourced community services, a lack of crucial bed capacity, inadequate support for patients in crisis, and overstretched A&E liaison psychiatry teams.

Alarmingly, the flow and capacity issues have also meant some patients were being detained illegally in seclusion rooms for more than seven days under section 136 of the Mental Health Act. This is despite the legislation only allowing for 24 hours of detention, with a possible 12-hour extension.

The reviewers were so concerned by these cases that they wrote Lancashire Care FT’s former bosses an urgent memo, well before they had finished their investigations.

The wider-looking of the two reviews is due to be published in full next week. It could raise difficult questions for commissioners and regional leaders over a lack of investment and effective intervention over many years.

It will also be used by the trust’s new leadership to finally admit the deep-rooted problems in the system, and to make a fresh start at addressing them.