The providers of services for people with schizophrenia in Liverpool saw ISIP as a great chance to bring the NHS and local authority together, as Helen Mooney explains
In May 2006, Liverpool primary care trust and Liverpool city council decided they needed help. They had identified a gap in local mental health service provision and decided to establish a slicker, more integrated partnership to address the needs of one group of users.
The opportunity to bid and become a pilot site for the NHS Integrated Service Improvement Programme seemed an ideal chance to help integrate the local provision of mental health services for people with schizophrenia.
Established in 2005 by a group of strategic health authority service improvement directors, the programme aimed to marry the workstreams, initiatives, policies and programmes coming out of the Department of Health.
The initiative addressed the technical, workforce and process reform of these differing policies and aimed to help communities make them work across health and local government.
Liverpool PCT mental health director Debbie Nixon played a key part in bidding for help from the programme team and then working towards outcomes.
"We were already doing a big programme of work across mental health in the North Mersey area and we saw a real opportunity in ISIP to bring the NHS and the local authority together," she explains.
In Liverpool, the joint commissioners decided to focus specifically on service users with schizophrenia. The aims were to:
develop an agreed model of care for service users and develop integrated care pathways to enhance patient outcomes and experience;
develop inclusive services to promote positive mental health and reduce stigma and health inequalities;
strengthen primary community services and integrate medical, psychological and self-management components of care;
develop specialist home treatment services to provide a real alternative to service users who would otherwise be admitted to hospital.
The Liverpool team also hoped to explore the possibility of a tariff for mental health services across the patch.
"[The programme] was about introducing joint commissioning to Liverpool and we identified mental health as a particular challenge because of the lack of tariff," says Ms Nixon.
"But we tried to establish a methodology and work across the care pathway to help us all achieve the outcomes we wanted as part of the wider Year of Care programme."
The programme brought together a range of stakeholders, including Liverpool city council, the Mental Health Consortium, Mersey Care trust, Liverpool PCT and two GP leads for mental health.
Not for the faint hearted
Liverpool Mental Health Consortium manager Andy Kerr worked with other stakeholder groups to ensure that service users were sufficiently engaged in the programme being designed for them.
"We wanted to ensure at the end of the programme that we were able to describe a care pathway for a service user with schizophrenia and understand it in a cohesive way which could be explained to colleagues in the primary care or voluntary sector," says Mr Kerr.
The consortium reviewed service users' views about Liverpool's mental health services provision.
Liverpool PCT head of mental health integrated commissioning Lorraine Hodgkinson says that although the PCT and the local authority would have come together to develop a programme, involving the improvement programme team made things happen much faster. Ms Nixon agrees, although she says the programme has meant a lot of hard work for the stakeholders.
"Local government and primary care providers are now involved in this programme. With any piece of systems change it is having the capacity to take it forward, which is where having the back-up from ISIP came in. However, this kind of work is not for the faint hearted," she says.
Liverpool PCT and the city council used tools provided by ISIP to achieve sustainable service improvements along the schizophrenia care pathway. This included the "roadmap for transformational change", which Ms Nixon says was very useful in the early stages, particularly in establishing governance arrangements for the project.
Ms Nixon says that the PCT and local authority decided to bid for help from the ISIP team.
"They helped to provide additional support in terms of analysing the services we already had and modelling the data to forecast and test scenarios for a redesigned care pathway," she says.
The team seconded local change consultant Gill Gale to the Liverpool programme to provide the technical expertise of the improvement service on contracting, marketing and achieving value for money.
Ms Gale was also charged with initiating a culture change across both organisations as they built the relationships they needed to bring about effective joint commissioning. The PCT and local authority anticipated that with the improvement programme's help they could achieve outputs including:
the development of integrated evidence-based care pathways with measurable benefits;
clear capacity plans for the pathways' various elements;
an increased range of services delivered in community settings;
a clear strategy about "choice points" within and between pathways.
"We used the improvement programme's methodology to work out what we wanted to achieve and developed a stakeholder map for how to go about doing that," Ms Gale explains.
"We used the Roadmap for Transformational Change, sorted out the governance arrangements and identified a project manager and decided to focus on service users with schizophrenia," she adds.
"We got a group of service users together to understand what happens to clients during their care pathway and realised that it was a nightmare to navigate the process."
Ms Gale says she helped the PCT and council cost the activity of their clients' current care pathways, which raised questions about value for money, but that once they had done this the joint commissioners were able to look with greater clarity at how they wanted the service to look.
Ms Gale says that although the ISIP team is no longer involved in the project she is confident the work will continue: "The governance structure and the project director are in post and the PCT and the local authority have pooled resources, so I am confident that commissioning for this group of users will be different in future."
Rock up a hill
Ms Gale also highlights the work the PCT and council are doing to develop a mental health service tariff. "My role was to provide focus to make sure the work happened," she adds. "I am confident it will continue to move forward."
Debbie Nixon says one pioneering outcome of the Year of Care and improvement programme work was the development of an indicative mental health tariff for Liverpool.
"Not only do we have a consensus in terms of best practice and treatment for people with schizophrenia but we have developed a shadow tariff for next year for practice-based commissioning and our consortiums are interested in piloting this indicative tariff."
Liverpool Mental Health Consortium's Andy Kerr sums up the effect of the improvement programme's involvement: "It has enabled us to roll a rock up a hill and given us the kick up the backside we needed. Now we can keep going on our own with this."