Questions to the Governing Body

Question: What are the CCGs plan to embed ‘STOMP’ into practice?
‘STOMP’ stands for ‘Stopping the over medication of people with learning disabilities, autism or both’.

Answer from Governing Body:
The Harrogate District Learning Disability team works to ensure appropriate use of psychotropic medications, this was the case before the STOMP initiative and has been continue since its publication. The team consists of psychiatry , nursing , psychology, speech and language therapists, occupational therapists, physiotherapists and support worker who all work together to support this practice.

Clients of the team with a behavioural presentation will follow a Positive Behaviour Support (PBS) pathway to ensure our practice follows the best available evidence and the least restrictive options.

New medication prescribing for a  for a behavioural presentation would be very unusual, short term and at the end of a very long and though process to identify the reason for the behavioural  presentation, offer alternative therapies, and put in place guidance for carers.

Prescribing for mental illness is always done in consultation with the client and when appropriate their family and carers. Risks and side effects are explained and easy read information is supplied. Psychiatry and nursing will follow up and monitor new prescriptions to ensure they are working as intended and the client, family and carers are reminded of risks and side effects.

Rational for prescribing is regularly reviewed and discussed with the client and / or carers as appropriate.

The team are also working to reduce the prescribing to people who have a long history of psychotropic medication use. Reducing these prescriptions can be challenging as the original reason (many years before) can be unclear.

During the past year a new post of Community Crisis Intervention Practitioner has been introduced across the Tees Esk and Wear Valley,  North Yorkshire learning disability teams for an initial period of two years. The purpose of this post is to support the work of the learning disability teams with Positive Behaviour Support which will help reduce the need for using these types of drugs which will clearly be beneficial, and to promote alternatives to medication and hospital admission for people with behaviour that challenges carers.  

There can be some challenges when reducing prescriptions as the STOMP agenda is not fully understood within the wider community. This can lead to a mismatch between what is expected and the service delivered by the team. The team do address this when working with individuals and their carers but feel further publicity of STOMP will be advantageous.

Where appropriate, patients that have both autism and a learning disability access the service from the same Learning Disabilities Team of Tees, Esk and Wear Valley NHS Trust that was referred to in the previous response. Their position on STOMP and the use of psychotropic medication was described.

Adults with autism: A diagnosis service is provided by The Tuke Centre (at The Retreat, York), however this service does not prescribe any medication for adults with autism as medication is not recommended as a treatment for autism. If a patient requires medication for other reasons such as mental health issues, that would be prescribed by the mental health services (from TEWV) or by their GP, with access to specialist advice. The TEWV-MH position with regards to STOMP and the use of psychotropic medication in adults with autism is with the aim to avoid the unnecessary use of medication. Each individual case will be considered and managed in its own right, but will involve accessing specialist advice on available and accessible options for the management of the long-term and/or immediate situation, including using or avoiding medication. It includes making reasonable adjustment, applying coping strategies where these would be considered of likely benefit and preferable, and aiming to avoid the use of medication where possible. The department routinely carries our medication reviews to consider if a drug remains effective, beneficial and necessary. The team collectively reviews audit data gathered regarding use of drug treatments, allowing comparison against previous usage levels and to similar local departments, which indicates the department to be typically low prescribers.

Children with autism: The diagnosis component of this autism service is separate, with those involved in diagnosis not being involved in prescribing. Should the Harrogate Trust Paediatricians feel a young person with autism had co-morbidities that required psychotropic drugs, sedatives and anti-epileptics (if not used for epilepsy) to manage behaviour, then a referral would be made to TEWV’s CAMHS for assessment of the co-morbidity, rather than initiate these medications. TEWV CAMHS position with regards to STOMP and psychotropic medication in children with autism is similar to that above for adult mental health.

Our team has contacted clinicians within the key service providers to this CCG, and while information has been gathered, we recognise that this may not capture all the detail of everything that is being done within the health service. Should we receive further information over the next few weeks that would add to the response above then we would be pleased to advise you of this.  There is a regional steering group led by NHS England which the CCG is linked into which is progressing delivery of STOMP on a wider footprint.

Question: I am running a local campaign focusing on government budget cuts impacting local MH services within the Harrogate and Knaresborough area. The campaign’s specific focus is on the HaRD CCG's decision on halting the funding and construction of a much needed MH ward on Beckwith Head road, for inpatient care for adults. I am wanting, along with several other colleagues helping me in the campaign, to ask a few questions in a public capacity at your next Governing Body meeting:

1. When was the decision made to fund and construct the Ward and when was the decision reversed?

2. What reasoning was behind the decision to halt the funding and was their a consensus across the body?

3. How much money was saved from this decision and where was that money spent instead?

4. What actions have the CCG taken since to make up for the potential services lost in local MH facilities?

5. How much public feedback was collected regarding the construction of new MH facilities locally and was this feedback taken into account when decision to scrap the ward was made?

Answer from Governing Body:
The CCG and Tees, Esk and Wears NHS Valley Trust never made the decision to build a new facility and therefore no decision has been reversed. Currently there are a number of engagement events taking place with the public in order to gain a view on the best way to spend the money that we have. In November a decision will be made together with TEWV based on public feedback. Dr Sweeney reiterated that no money is being removed from mental health funding and the focus is on how to best spend the money that we have.

Engagement events had been widely promoted through patient and public groups and through the formal consultation. These engagement events are currently ongoing and no decisions will be made until engagement has been completed.

Question: Since the setting up of the CCG, what improvements have been made to the treatment available to GPs for 8-18 year olds with Eating Disorders?

Answer from Governing Body:
There has been an enhanced service since 2016 and additional funding has been received locally and nationally. Community services are being provided by Child and Adolescent Mental Health Services (CAHMS), with a service in operation 09:00-17:00 5 days per week. The CCG is also currently in discussions with TEWV and NHS England in how services can be further developed.

Question: As you know the NHS approved the prescribing of the Flash Glucose Monitoring on 1 November 2017.

I now ask this CCG to approve the use of Flash Glucose Monitoring for those who manage their diabetes with Insulin in the Harrogate area .

At present the Abbott FreeStyle Libre is available to scan and use whenever needed, in bed, in the theatre, in the supermarket, in the car, in the classroom and at work on trains, boats and planes and whilst undetaking a variety of sports.  During these activities it is difficult to use a finger pricker.  I usually take up to 50 scans a day to manage my own diabetes.  As we know even the Prime Minister - Mrs May uses one discreetly to manage her diabetes in Parliament and whilst on visits abroad.

Other scanners will become available but the choice will be on clinical need by the Nurse or Doctor treating the patient with diabetes as other blood glucose monitors. The overwhelming success of Flash GM to the patient and the NHS is shown in the lower HbA1c results and the lack of hypos and fear of hypos resulting in fewer hospital admissions. This will show even higher improved results when the system is available for all Type 1 diabetics and not the few who can afford £100 a month.

I find it difficult to describe how this Flash GM has changed my life having used many other products over the 40 years of being Type 1 diabetic. To take my scanner away would be like having my right arm removed - please let others who are not able to buy this product be offered this device to change and extend their lives too. It needs to be offered on prescription without expense to prevent the complications that so often go with being a diabetic like blindness, hospital admissions and expensive surgery for amputations.

I trust that this CCG will agree to this request and authorise its use without further delay.

Answer from Governing Body:
FreeStyle Libre has recently become available on prescription on the NHS. As with any new medicines or devices, the CCG is working with local specialists and regional diabetic networks to establish which patients are most likely to benefit from FreeStyle Libre.  There has also been a recent national recommendation made by the Regional Medicines Optimisation Committee which is helping to inform the CCG’s decision (the RMOC is a national committee set up by NHS England which will provide advice and make recommendations on the optimal use of medicines for the benefit of patients and the NHS). The CCG will consider FreeStyle Libre alongside other new drugs, devices or services and make a decision based on cost-effectiveness.  A decision is expected in the next couple of months.

Question: What plans do you have to address issues and costs associated with the poor MS service and particularly no MS specialist nurse in Harrogate and Rural District? 

Answer from Governing Body:
We are aware of the Right Care data and have previously investigated the apparent disparity between Harrogate and Rural District and our comparator CCGs. The data is misleading because of the different ways that services are contracted. Harrogate has a neurological rehabilitation service based on Lascelles Ward, which is funded as part of the Acute Hospital Contract and the beds on this ward are often used by people with Multiple Sclerosis. Similar treatment centres in other CCGs can be funded in different ways, for example through a Community Contract or even a Voluntary Sector contract. The different ways of contracting services significantly distort the figures for both the number of admissions and length of stay and makes genuine comparisons very difficult.

This does not imply that we are not interested in reducing unnecessary admissions and we are keen to ensure that the best possible care is provided in the community to support all long term conditions, including multiple sclerosis. We are currently working to update the specification for community services with the ambition to provide much more patient centred and integrated care. As part of this work we will be consulting widely with our population and we would be very happy to receive input from the Harrogate MS Society as part of this work.

Question: If there are no Mental Health beds available in York or Middlesborough what will happen to severely ill patients? Do you have other places of safety for them and might those places be police cells?

Answer from Governing Body:
The Governing Body feels that police cells are not appropriate places of safety for patients in crisis. Our existing policy is for these patients and their families to be supported in the community.  Suffering from a severe mental illness can be extremely traumatic and the whole aim of the case for change being presented today is to ensure there are enhanced community services that can support people hopefully before but in the event of a crisis. Increasing our community focused care should mean that only by exception, will acutely ill patients be placed under a Section 136 and require to be taken to a designated place of safety.

Question: I have heard that you are accepting questions for your upcoming public discussion and I would be grateful if you would consider my questions below as part of your consideration. I intend to ask my school if I may attend but nevertheless I would like to add my questions for your consideration.

I am going to reside under the assumption that you reading this have children, or, most certainly, that you were once one yourself. Now, considering this from a child's perspective, imagine this situation:

You are young and vulnerable and are suffering from severe mental health issues. For example, let us assume that you have anorexia (as so many young people so sadly do today). You have recently moved because the Briary Unit was the only facility in which you could find a place (which is not a ludicrous distance away). Without the mental help you are receiving, your anorexia will kill you within a matter of months and you are unable to find help elsewhere. Suddenly, you receive a letter/ E-mail/ etc. that states that they can no longer provide you with care. What do you do? As a mentally unstable and vulnerable person, do you move away from your entire life, potentially worsening your already fragile mental state? What do your family do? There is absolutely nothing that you, or anyone else, can do.

Hundreds of vulnerable people will have no access to mental help.

Have any of you considered how many deaths you will cause?

How much potential that will simply be swept under the governments money-hungry blanket?

How popular will your wonderful tourist town be when the suicide rates sky-rocket?

How many lives are you willing to trade?

 Answer from Governing Body:
There is no doubt people will recognise the concerns described and your email raises a number of important concerns, which we share – namely:

How can people get the treatment they need for mental ill health as early as possible?

Are there things we could do differently to prevent people from becoming ill in the first place?

How can we ensure people receive the care and treatment they need in or near their home with support from community based health and care professionals?

The best way to ensure care supports ensuring recovery?

 The Governing Body will be reflecting carefully today on the evidence before it and aims to take a decision about how we can best achieve these things for our population. As a matter of clarity the services we are considering today related only to adults and older people – people aged 18 and older but our goals are the same for people of all ages.

Colin Martin added that it is well publicised that the demand for Mental Health services continues to rise. There are a number of national initiatives to ensure staff and resources are available for these services.  

Question: Who will pay for the travel expenses of families of inpatients in an out of area facility? This will need to be factored in to any decision and the funding identified.

Do you foresee any issues with the reluctance of patients to be admitted informally out of area? This may result in an increase in admissions under the MHA 1983.

Answer from Governing Body:
The Governing Body understand the concerns and certainly would not want to put any additional burden on carers or families at what is already an extremely difficult time for them. As part of the ongoing engagement, we will be considering any travel implications on our patients or their families. It is important to reiterate that we believe that the proposed approach will reduce the need for admissions and travel from the area with the introduction of additional community services and a greater focus on early intervention, recovery and resilience.

With increasing our community resources we will provide more high quality packages of care at home, which will mean informal admissions are not requested by clinical teams, as they will have the additional capacity to safely support more patients in their own home.

Question: At your meeting on Thursday, 6 December 2018, when you meet as HaRD Clinical Commissioning Group (CCG) Governing Body please can you inform the public what provision ( financial or practical) will be made for carers  and families to visit inpatient relatives outside of the district, especially those who do not have the benefit of private transport.

Answer from Governing Body:
As said in the previous answer, we certainly would not want to put any additional burden on carers or families at what would be a difficult time for them and we will be considering any travel implications on our patients or their families as part of our decision making today and will continue to consider this if we gain approval to progress with our recommended solution and as part of the continued engagement with local people and the public. We believe that the proposed approach will reduce the need for admissions and travel from the area with the introduction of additional community services and a greater focus on early intervention, recovery and resilience.

Dr Bruce Willoughby emphasised that the direction of travel is trying to minimise the need for specialist inpatient beds and that only the most critical cases will need this level of specialised treatment in an inpatient facility.

Question: I understand that the Briary Unit is scheduled for closure, and have a few questions about this:

What are the expected time scales? What date is the Briary Unit expected to close? Is it expected that the new facilities in York will be "up and running" by this date?

Could you give the figures for the number of beds we will lose in the Briary Unit, and the number of beds in the new unit in York, that will be available for Harrogate patients? What, if any, will be the net loss of beds for Harrogate patients? If there is a loss, how is it proposed that the excess patients will be cared for?

Is it envisaged that savings are going to be made, and if so, could you give some idea of the amount? Is it intended that any such savings will be used for community care projects? - if so, do you have any evidence that this will be of benefit to Harrogate patients?

Answer from Governing Body:
No definitive timescale has been set for the closure of the Briary Wing or the opening of the new facility to house the new requirements. Colin Martin informed that a new building at York Hospital is currently under construction and is not expected to complete until March 2020.

There are currently 34 beds at the Briary Wing but only 30 are being utilised.  Some work has been done to look at bed provision and what will be required and it is thought that 26 will be required. However, we do not currently know precisely if this number is right as we do not have the enhanced community services in place that will stop the need to a hospital admission. We can assure patients and public that if a patient needs a in-patient bed then a bed will be available to them. We are currently looking at a location as near as possible to patient’s homes and we have used York as an example to map through that utilisation. It is important to remember that the facility is about having good inpatient specialist care that meets the need to the individual and to ensure community services are in place to help prevent a crisis from happening in the first place.

Amanda Bloor emphasised that the amount invested in Mental Health services is only going to increase. The case for change demonstrated that with a new facility, with a new staffing model, we can have a better equipped facility with less spend on inpatient beds. The savings will release £0.5m that can be invested into better community services locally that people can access 24/7 in home and in the community. Through conversations with members of the public it is apparent that they support the need for this change and to ensure that if someone needs an acute bed it is available for them and of the highest quality and fit for the future but most importantly that  prevention is key and a rapid community response team that stops people getting to the point of crisis where they need a bed.

Question: Please could I ask how whether there is a plan for the proposed investment in community services to include developing new preventative services in partnership with the third sector in the Harrogate area?

Answer from Governing Body:
Yes, there is a plan to do this and we recognise that third sector partnership working a vital part of a person’s recovery, want to work more closely with the 3rd sector.

Question: As a vital part of mental health recovery can be visitation and leave-days, would this not be compromised by the proposal of a move away from family and friends?

Answer from Governing Body:
There is no doubt that family visiting is a vital part of someone’s recovery and there is lots of evidence that supports this. We do not want to reduce recovery rates, we want to enhance them and that will be at the heart of any decisions that are made. We are very interested in engaging with patients, their friends and family and members of the public to coproduce solutions to these issues.

Question: What guarantees can be made that if more provision of care is made in the community that funding will be maintained in the long term?

What alternatives can be guaranteed if people who are referred from Knaresborough or Harrogate cannot be accommodated in Middlesborough or York?

Answer from Governing Body:
The Governing Body understands the concerns but can assure that the CCG has a commitment to community services.

Colin Martin reinforced that we are looking at beds as close to home as possible but the facility is also important. All patients will stay within the Trusts boundaries, however some patients may need specialist care, for example there are only two units for specialised intensive psychiatric care.

Amanda Bloor reiterated that the total amount of money being invested into mental health services will only increase.

Question: I understand the consultation was to include Wetherby. Nothing has taken place in Wetherby regard Harrogate as the destination hospital.

At the meeting at The Old Swan there were 12 people whose partners have, or had dementia. They all left their email addresses but there has been no follow up communication. This raises questions on the thoroughness (or maybe willingness) to consult and react, rather than drive this down an already predetermine course?

Answer from Governing Body:
Joanne Crewe has met with Ken previously at an engagement event and is aware of this concern. Although we can confirm that engagement has taken place in Wetherby we recognise that there has clearly not been enough from feedback received today. As part of the second phase of engagement we will ensure effective engagement takes place in Wetherby.

In terms of email addresses being left at the meeting at the Old Swan, if members of the public were not contacted following this meetings there is no excuse and we will ensure this is picked up.

Statement from Health Watch North Yorkshire regardig Mental Health Transformation

At Healthwatch North Yorkshire, we have noted the transformation of Mental Health plan and recommendation to proceed with the options described in Solution 3. This follows a decision by the neighbouring CCG (Hambleton Richmondshire and Whitby) to take a similar decision and close inpatient mental health wards in Northallerton.

Viewed holistically, we have concerns about the ability of the system to provide adequate beds for residents of Harrogate and Rural District at alternate locations, as recent TEWV board papers show the following YTD occupancy statistics against the 85% target:

Trust-wide: 94.85%
Durham and Darlington: 92.54%
Teesside: 102.7%
North Yorkshire: 94.58%
York and Selby: 90%

These statistics were observed prior to the closure of Ward 14 and 15 at the Friarage Hospital in Northallerton and the corresponding loss of inpatient beds.

Nationally, we would also highlight the work of the CQC 2017 State of Mental Health Care report(https://www.cqc.org.uk/sites/default/files/20170720_stateofmh_report.pdf) which found that "people who need acute inpatient care should be admitted to a bed close to home. There are too many parts of the country where this is not always the case; patients might be admitted to a ward many miles from home. Also, in a few services, patients who take home leave might have to return to a bed on a different ward. This is not good for continuity of care." A recent King's Fund Report (https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers) about national provision of hospital beds made the observation regarding mental health inpatient care that "there are signs of a growing shortage of beds, as can be seen in extremely high levels of average bed occupancy and stubbornly large numbers of delayed transfers of care. There are also specific concerns about bed stock in mental health, with the Royal College of Psychiatrists warning of a ‘national crisis’ resulting in more patients needing to be sent out of area for treatment (Coggan 2017). Current levels of occupancy mean the average hospital in England is at risk of being unable to effectively manage patient flow leaving it vulnerable to fluctuations in demand. Against this backdrop, it will be challenging to reduce the number of beds significantly. Bed occupancy cannot continue to rise indefinitely and there is only limited spare capacity, while falls in average length of stay appear to be slowing."

We have been told that service users do not want to travel a long way for inpatient care and that continuity of care and the ability of support networks to aid in recovery are negatively impacted when inpatient care is not provided locally.

Additionally, we are concerned at the potential loss of Section 136 facilities across the county.  North Yorkshire was previously held up nationally as the only region in England with no health based places of safety.  A great deal of positive work has been done in recent years to remedy this situation, and currently the county has four such locations.  One is currently scheduled for closure and these proposals could reduce these numbers to only 2 for a population of 600,000+ in the largest geographical county in England.  This can only lead to a significant increase in the number of people in mental health crisis being subjected to unnecessary and traumatising detention when they are most in need of care.

At Healthwatch we remain concerned at current and potential loss of inpatient facilities within North Yorkshire. We accept that patient flows in each CCG district may not match those of larger urban centres; however, the decisions appear to have been taken in isolation.  Any potential for relocation of inpatient facilities in Harrogate could and should be taken in conjunction with neighbouring CCGs. So far, no consideration appears to have been given to maintaining an inpatient facility in North Yorkshire capable of taking patient flows from both the Friarage and Harrogate hospital rather than relocating all of these patients outside of North Yorkshire.

We will continue to work with all parties going forward to ensure that patient views are represented.