Mental Health Matters: Where were the commissioners?

How many warning signs are needed for a commissioner to properly scrutinise a service?

Yesterday HSJ reported how repeated concerns over the safety of children’s autism services across South Staffordshire, over several years, were given “minimal” attention due to the small size of the contract.

While minimal attention would have been justifiable if the service was performing well, local leaders had been sent serious complaints by families since at least 2013 — essentially saying children in crisis were not getting specialist help and were repeatedly passed between different services.

A major factor contributing to the service failings – as found by a review in 2018 – was the poor relationship between the autism diagnosis provider, Midlands Psychology, and the children and adolescent mental health service, run by South Staffordshire and Shropshire Foundation Trust.

Midlands Psychology was contracted for autism assessments, but there was a lack of clarity around which organisation was responsible for post-diagnosis support, which led to arguments.

Since the story was published, we’ve been alerted to a complaint that was made by Midlands Psychology to the Co-operation and Competition Panel back in 2011, a year after the contract was commissioned, which threw some pretty serious accusations at SSSFT.

According to legal website Lexology, the social enterprise alleged the trust obstructed the handover of services after it won the contract; obstructed their ability to provide services; and was putting patients and staff at risk by refusing to provide certain information.

The outcome of that complaint was never made public. But the perceived problems clearly continued, because four years later, in 2015, then regulator Monitor investigated another complaint by Midlands Psychology about the FT’s conduct.

Monitor subsequently told commissioning leaders to address the “difficult working relationship”, as well as the contractual “ambiguities” that were compounding the working situation.

Then three years later, in 2018, another review by Northumberland, Tyne and Wear FT again cited the relationship problems and contract issues between the two providers. The details of this review were leaked earlier this year.

While the issues with the contract have now been aired in public and admitted by local leaders – and families hope this leads to quick service improvements – perhaps there needs to be some proper thought and investigation into the lack of intervention from commissioners over the years.

As an aside, the shift away from competition in the health system should also make these kinds of problems less common (though it could of course have other downsides).

Beyond long waits

The service was originally procured to tackle long waiting times for autism diagnosis, which existed under the children and adolescent mental health services. While this was a laudable aim, you have to question whether much thought was given to what the new service should cover and who should do what.

One mother told HSJ that, despite an incident in which her son threatened to kill himself, her son was discharged by CAMHS back to Midlands Psychology with a letter stating his “difficulties are in the context of [autism spectrum disorder].”

Another said her son once had to wait for more than an hour, while in crisis, as a psychiatrist from CAMHS and the head of autism services at Midland Psychology “debated who was responsible for his care”.

Both scenarios reveal how the relationship between the two providers was impacting on services which are vital for those who rely on them, and could prevent inappropriate admissions further down the line.

National scrutiny

This month has seen a big spotlight shone on children’s inpatient mental health services, with the launch of a new independent taskforce by NHS England.

It appears to have been set up in response to increasing reports of poor quality inpatient CAMHS services.

However, problems such as those experienced in Staffordshire are rooted within community services.

We don’t yet know what the new taskforce will look into, but it would be a missed opportunity if children’s autism and learning disability services within the community were not also scrutinised.

Another suggestion for the new taskforce?

To scrutinise the role of commissioners, both in terms of how they monitor services and the quality of what is commissioned in the first place.