Questions to the Governing Body in 2017-18

Q. 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’.

A. 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.

Q. 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?

A. 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.

Q. 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?

A. 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.

Q. 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.

A. 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.

Q. 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? 

A. 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.