Workshop two: Preparation for consultation on the future of acute mental health care for residents of Westminster, Kensington & Chelsea, and Brent

This report (opens pdf) below is from the second workshop on the consultation options (explained below)

Following temporary closure of mental health wards in the Gordon Hospital in 2020, plans for consultation on the future of acute mental health care for residents of Westminster, Kensington & Chelsea, and Brent have been considered by the North West London Integrated Care Board (NWL ICB), which is the consulting body. 

In developing plans, NHS commissioners are required to consider a full range of service change options that can improve outcomes and identify those which are viable and sustainable.  These will be developed into options for formal consultation, which is expected to happen later this summer.  The list of options must always include a “no change” configuration, so that it can be compared properly with whatever changes are proposed.

The development of these options is informed by detailed analysis which incorporates clinical evidence, views of service users and staff gathered during pre-consultation engagement, insights from other stakeholders, patients flows, financial and workforce considerations.  The options will all be set out in a comprehensive Pre-Consultation Business Case (PCBC) document, with detailed assessment of each against the agreed criteria and objectives which will be agreed in advance of the appraisal, taking account of input from stakeholders.

Following agreement by the Board, the NWL ICB would submit the PCBC to NHS England, which is the body responsible for authorising public consultations to proceed.

Table1.  The options appraisal process

Appraisal is a structured process through which all a full range of possible service solutions are considered and evaluated - and a range of options put forward for public consultation, all of which must be realistic and viable.  It is important that we do not offer for public consultation any options which we know to be undeliverable or unaffordable.

The appraisal process that we are using is summarised in the flow diagram at Table 1. 

It is based on three workshops to which stakeholders bringing a broad range of relevant perspectives are invited (service user, clinician, service manager, commissioner, statutory partner).  Individuals work together to discuss “what good looks like” and review realistic scenarios and criteria which are important when considering options to inform the process by which the final list of possible options is determined.

It is important to emphasise that these workshops are not the only way – or the only opportunity – for services users and other stakeholders to give their views.

Two workshops (consistent in content) were held with stakeholders on 27/03/23 and 18/04/23 to identify what good looks like in the provision of acute mental health services.  A report of the workshops can be found here  The outputs of those workshops supported the development of a set of scenarios for discussion in workshop 2.

Workshop 2 was held on 25 April 2023, between 11am-1.00pm in the Hindle and Wild rooms at 110 Rochester Row, SW1 1JP.

Thirty five stakeholders participated in the workshop.

The aim of workshop 2 was to review a list of realistic scenarios and to consider objectives and criteria which are important in developing and consider options.  The two key questions for this workshop were:

• Which options merit further work and evidence?
• What evidence will help decide which is the best?

Break-out session 1

The workshop started with a presentation three potential care models with variations of configuration totalling six different scenarios.   Following the presentation breakout groups of approximately 5 participants discussed the scenarios; there were opportunities during the breakout session for people to ask the presenters for clarity on points they had made.  The breakout groups were asked to consider the scenarios from the following perspectives:

• Were the scenarios clear and understandable?
• Do they represent the full range of realistic alternatives?
• Are there additions or variants which could be considered?

Each table were supplied with sticky notes which they could use to highlight things they thought were important.

After the breakout groups there was a plenary session where participants fed back their views.

The key points made about the scenarios, under the headers for discussions, were:

Were the scenarios clear and understandable?

• The scenarios were more understandable to those involved in CNWL mental health services than to other stakeholders. 

• Stakeholders said they would have preferred more information and data to support the models, including the wider implications for each scenario. 
• It was suggested that more data will be needed as these scenarios are developed into options for consultation, for example on the impact of the rise from 3,000 to 9,000 CMHT referrals, referral waiting times, the number of occupied bed days, the average length of stay in hospitals, what finances are available, the current waiting times for inpatient beds – and that all this information should be shown to relate directly to the local area and be considered when developing the models
• Some participants said that the scenarios need to consider the ratio of investment between inpatient beds and community care
• There was a view that Scenario C was incomplete – more detail was requested
• Community services were thought to need more consideration
• Stakeholders assumed that demands on services will increase – and that relevant assumptions should clearly be set out for consultation options.

Do they represent the full range of realistic alternatives?

• There was scope for some cross over between scenarios A and B
• Some participants said there should be more flexibility in the scenarios, rather than a binary choice between pre-Covid and current inpatient bed availability of 180 and 70 respectively – with bed capacity based on the needs of the community, perhaps by putting in extra beds at the hospitals
•  It was noted that there were no scenarios which considered reopening the Gordon as it currently is or closing all beds and basing all services in the community, although some participants thought the scenarios were too heavily ‘loaded’ towards care in the community, and did not take enough consideration of the percentage of people for whom community care is unrealistic 
• There was a view that the current numbers of inpatient beds are insufficient to meet service needs, so the scenarios and future models should reflect this and increase the number of beds
• Several people expressed the view that there should be provision in the south of the area (bi-borough)
• There were suggestions for providing inpatient beds in smaller settings, spread across local communities;  a community care centre with a small number of beds; or two to three bed facilities located close to community resources (this was described as sitting between scenarios B2 and C1)

Are there additions or variants which could be considered?

• Provision of acute beds in the new build at St Mary’s
• Short term acute beds at the Gordon whilst the long term planning is happening
• The longer term solution should include for temporary beds in Westminster
• Higher numbers of inpatient beds, particularly in the south of the borough, with wrap around community services
• Include a model with ‘recovery type’ options, such as that in Drayton Park – with self-referral
• Use some of the Gordon’s community space, such as the roof garden, to benefit community support

Other comments from participants

• How do the options presented tie in with the Mayor’s 6 tests when closing inpatient beds?
• Equity should be a headline objective, as well as promoting equality as some groups might need more resources as well as access to services
• No specific criteria for differences and similarities between Kensington & Chelsea and Westminster were mentioned, except that tourists and homeless people are attracted to the centre of London
• There could be learnings from other consultations, e.g. stroke and major trauma
• Some participants considered the scenarios presented binary options between community based care and inpatient care – and there was a preference for providing a blend of the two
• How do we know if community provision is working effectively, or not?
• If the current system were meeting demand for beds waiting times for admission would be shorter.  How does a 12% reduction in length of stay generate a 35% reduction in beds?
• Will there be a feasibility study?  If so, will this include capital investment in the Gordon?  How will options be defined?
• Discharge and readmission data should be considered

Break-out session 2

After feeding back from the table discussions in a plenary participants were shown a series of draft objectives which the consultation options might seek to achieve.  These had been derived from comments received during Workshop 1a and 1b.

To consider these in more depth, participants were invited to visit each of six stations set up around the room and leave their comments on sticky notes on flip charts.  Five stations presented an objective for the provision of mental health services, and one a viability test of deliverability;  people were asked to comment on what each element meant to them and what information would be useful for assessing them.

The objectives were:

1. Service quality – a pattern of services in place that results in the best possible outcomes and experience for our service users
2. Access to inpatient care – to ensure that access to inpatient services is available whenever needed
3. Access to community support – to deliver community-based services that are accessible to our patients and service users where they live
4. Quality of inpatient facilities – to deliver our inpatient services from facilities that are therapeutic and safe
5. Promoting equality – to reduce inequalities in outcomes, access and experience
6. This station asked people to consider deliverability as a viability test

The data from the stick notes is presented below.

Service quality

• Further considerations for the patient journey
  • Delayed Transfer of Care (DToC) must be considered in terms of making sure that beds are available
  • Make sure that ‘medically optimised’ patients (the point at which care and assessment can safely be continued in a non-acute setting) are not waiting for transfer out to therapeutic, MDT, inpatient support etc
  • Quality of patient journey in accessing inpatient care – not having to wait in inappropriate settings
• Flexible access to pathways
  • A ‘swift return’ of any patient should not be undermined
  • Some patients do need further support
  • Discharge should be patient centred, not service centred
• Environment
  • Inpatient environment must be safe, therapeutic, high quality
• Staff
  • Appropriate level of qualification, training and experience
• Joined up care considerations
  • What does ‘pattern of services’ actually mean?
  • Meeting physical needs as well as mental health is important
• Descriptions of pathways needed
  • Pathways that include both community and inpatient care
  • Mental health’s role in Integrated Neighbourhood Team (INTs)
• Other
  • Need temporary beds in WCC
• Useful information for assessment
  • Data needed in all areas for participants of engagement to fully engage and make comment
  • Service quality depends on building quality data – i.e. intelligence within communities
  • E.g. revolving doors
  • Data should be balanced – both positive and negative
  • Service user feedback data
  • Cost effectiveness
  • Need to involve social workers, nurses, clinicians, psychiatrists, psychologists

Access to inpatient care

• Speed of access
  • Time taken to access a bed should mean an acute mental health bed, not a place of safety bed
  • Would ideally improve on current waiting times in A&E – currently there can be difficulties obtaining beds via this route
  • There should be quick access, in borough and close to support networks
• Location of beds
  • There is a need for some beds in the south of Westminster
• Data needs
  • Need for information about waitlist for referrals to inpatient care
  • Impact of Covid surge and fallout over the last 2 years – may need to benchmark this against regional/national data
    • Time taken to access beds from the community, A&E, police cell, prison – before 2019 and now (2023)
  • Benchmarking bed numbers is not a good idea
  • Useful information should include outcomes for people who were not able to access a bed
  • Data/evidence insight for numbers who do not engage with services currently
• Other thoughts
  • Access to placements and housing to support discharge
  • Predicting future demand
  • DTOC rates

Access to community support

• Accessibility
  • Services should be accessible wherever you are
• Continuity of care
  • Community should complement inpatient care – before, during and after
  • Have the same person seeing you
• Cultural competence
  • Geared towards local needs
  • In practice, need joint delivery in community working with community leaders and groups
  • Context of local need is necessary to understand
  • Build trust with the local community, groups and leadership
  • Early identification of local needs of young people
  • Define ‘community’ – BAME is far too wide and not specific enough
• Admissions
  • Mental Health Act formal admissions need to be direct and not via Health-Based Place of Safety
• Communications
  • Digital support needed for people to find and support one another
  • Need good communication and information between different system parts e.g. between community teams and GPs to avoid people having to re-tell their stories
  • Safe handovers of care between hospital and community
  • Community support needs to be responsive
• Integrated Neighbourhood Teams (INTs)
  • Partnership with INTs
  • Explore potential for INTs to extend range of services across boroughs
• Staffing
  • CMHTs are stretched.  Need team managers and Band 7 input
  • There aren’t enough in-borough placements to meet needs
• Evidence
  • Need to show evidence of benefits of community interventions for families and residents

Quality of inpatient facilities

• Important elements include:

• Compassion
• Staff are looked after
• Safety for patients – proximity can lead to potential flash points; patients should be listened to when incidents are reported
• Staff should be committed to a social model of care
• Care should be well resourced and include arts and access to psychological therapies
• Useful information for assessing service quality:
  • Resident feedback, e.g. Voice Exchange
  • Staff engagement and review
  • Feasibility studies, e.g. ‘what is good enough?’
  • Consideration of a workforce skill mix covering inpatient and community services

Promoting equality

• What this means:
  • Culturally competent
  • Quality of social support available to people experiencing mental health crises, e.g. because of housing issues
  • To ensure access for people in disadvantaged groups, flexing provision
  • Need to ensure access to beds – currently unequal as no beds in south Westminster
  • Address barriers which prevent people reaching services
    • Impact of generational trauma of disadvantaged communities accessing health and social services, particularly mental health services
  • Social care/housing worries/better links following Sec 75 disaggregation
  • Bridge the BAME communities’ access who have higher inpatient admissions, but not engaging with communities.  Is there a bias in referrals?
  • Use the voluntary sector more to reach diverse communities
  • Equality is not about ensuring the same number of each ethnic group access a service – inequalities affect every aspect of a person’s life.  Over representations is a societal problem
• Further definition:
  • There is further definition of BAME groups required
    • Avoid vague and broad categories, e.g. Black/Black British/African
    • Identify the sub-groups
  • Equality seems sound in theory, but not in practice – especially with limited resources.  Perhaps better to adopt a framework around ‘equity’
  • What about people we don’t know about/understand well (particularly transient populations)
  • Does the inpatient plan feel enough to support the most vulnerable patients?

• Information required/to be added for assessment
  • JSNA – Grenfell to be included
  • Qualitative and quantitative data from our communities
  • The voice and experience of people in these communities (prior to service use and after experience of use)
  • National benchmarks of use of MHS for place
  • Need to know fares to and from areas to inpatient settings, including taxi fares for family members
  • Need information about access and who currently gets left out of accessing services
  • Population health data – ethnicity, deprivation, SMI (whether admitted) and intersectionality between these
  • Assessment of the impact of Grenfell
  • There is a workstream ‘20234 on forwards in the Borough’ – needs to be tied in

Deliverability

• Economies of scale make one site more viable, e.g. one on-call medical rota; having two sites could lead to delays in response if staff had to travel between sites
• Safe sites: consideration of the minimum number of staff needed on a site for ‘resilience’ and cross cover for incident responses such as restraint
• Affordability is not just about what is affordable to CNWL but should also consider what is affordable to the whole system.  Closure of The Gordon has financial implications for other parts of the system e.g. police, A&E and local authorities – and financial impacts must include these considerations

Next steps

The aim is that the same organisations and, if possible, the same individuals will have input at all three workshops.  Workshop one looked at what good looks like in acute mental health care, workshop two, reported here, looked at possible scenarios for models of care and workshop 3, to be held on 18 May will look at proposed consultation options.  A summary report, like this one, will be published for workshop 3.

It is anticipated that the final options for consultation will be announced in early June, and the options appraisal process will be reported fully when the PCBC is published.

In the meantime, this report along with the report from Workshop 1a and 1b is available and additional comments invited on the process and the topics covered.

You can also download this report here too

If you would like to comment on this report please add your comments here