Letter - Minister for HSS to HSS Scrutiny Panel re Mental Health Services - 25 March 2022

19-21 Broad Street | St Helier Jersey | JE2 3RR

Deputy Mary Le Hegarat , Chair

Health and Social Security Scrutiny Panel BY EMAIL

25 March 2022 Dear Chair

Follow up Review: Assessment of Mental Health Services

Thank you for your letters dated 14 and 22 March 2022 outlining additional questions from the Panel in respect of their follow-up review of mental health services. Please find below the responses to these questions:

Governance

1. Please could you provide the Panel with further details about the provision of mental health services in relation to the risk register for Health and Community Services (HCS)?

1. If possible, please can you provide details about any specific mental health risks identified on the risk register and the date these were registered?

As of 24 March 2022, there are currently 18 open risks on the HCS risk register that relate to the provision of mental health services. Since January 2022 work has commenced on reviewing all of the mental health risks and utilising the risk register as  part  of  a  routine  monthly  review  of  clinical  quality  and  risk  issues.  We acknowledge there is still some work to do in relation to historic risks and ensuring associated actions are recorded. It is important to note that some of these risks are assessed potential risks rather than actual current risks.

The theme of the current risks on the register and initial date of registration are as follows:

• Emergency Department Assessment room - physical environment (Feb 2018)

• Variation in standards of care within inpatient unit (Feb 2019)

• Physical environments / estate impacting negatively on care delivery (Feb 2019)

• Lack of or out of date policies and procedures (Feb 2019)

• Insufficient multi-disciplinary staffing (Feb 2019)

• Gaps in medication reconciliation on admission to hospital (Feb 2019)

• Lack of access to safeguarding information available (August 2019)

• Failure to operationalise learning from incidents (August 2019)

• Death or harm as a result of ligature points (September 2019)

• Resilience of Mental Health Law Administration team (November 2019)

• Lapsed MAYBO training resulting in risk (July 2020)

• Lack of consistent supervision & caseload management processes (Sept 2020)

• Medical staffing capacity / review (October 2020)

• Hand hygiene / infection prevention (November 2020)

• Out of hours medical cover at Rosewood House (Jan 2021) – resolved awaiting closure

• Insufficient Eating Disorders specialist skills (Jan 2021)

• Adult Self Neglect Strategy and implementation plan (May 2021)

• Admission of young people to adult MH unit (May 2021)

At the Mental Health Senior Leadership Team meeting on 8th March (which focused on quality and risk) a number of additional potential risks were identified to be added to the risk register with associated action / mitigation plans. This is underway.

2. Please can you provide details about any actions that arose in relation to mental health services as a result of the risk register?

The risk register is a tool to identify assess, and record actual or potential risks and identify the mitigating actions that can be taken to manage / address the risk. Therefore against each risk a number of actions may have been taken or planned. As an example, the physical environment of our inpatient units is identified as a risk on the risk register, and the panel will be aware of the multiple actions that have been taken in relation to this.

2. Please could you provide a timeline and detail of the action plan for Adult Mental Health Services at the start of the COVID-19 pandemic (including any changes identified to the HCS risk register and Red/Amber/Green ratings)?

An initial set of actions were undertaken in late March 2020 as the HCS Covid response arrangements were being developed in detail and the Gold command structure was established. This included a reconfiguration of operational responsibilities across mental health services, PPE / infection prevention arrangements, and revised arrangements for service delivery – including the identification of priority services and redeployment of some staff to sustain these.

These were further developed and a detailed Temporary reshaping of Adult Mental Health Service community services' document was formalised in 2020. [*This is attached here.]

[*Document provided in confidence to the Panel 25/03/2022.]

This document was shared by Senator Pallett with the Scrutiny Panel in May 2020.

Towards the end of 2020 / beginning of 2021 a mental health service reset / reopening plan was developed setting out the various stages of transition for each service. [*This is attached here:]

[*Document provided in confidence to the Panel 25/03/2022.]

3. At the Public Hearing on 28th February 2022, it was advised that Adult Mental Health Services was "redesigning our  community model". Please could you provide some more information about the redesign of the 'community model' for mental health services?

A key finding of the 2021 Independent Review of Adult Mental Health services was the need to develop a clear model of care for mental health services that needs to describe and be articulated as a whole system. It was noted that the services were experiencing difficulties with effective multi-disciplinary team working, silo working both professionally and within / across teams, and with a need to have a clear emphasis on safety, therapeutic interventions and transitions. A similar recommendation to review and define the model of care for mental health services was made in the 2019 Scrutiny review of mental health services. Whilst a number of service developments (such as triage / crisis and home treatment) have been introduced, these have tended to develop in a piecemeal' way which has created some disconnect and barriers between different aspects of our community mental health services – rather than developing integrated, coherent pathways & service offers across a single system.

Upon appointment of the new Director of Mental Health & Social Care, an initial assessment was made of priority actions required. A key priority area related to the design, delivery and development of the community mental health model. This was based on the external review findings, feedback from staff, direct observation, a review of recent concerns, and feedback from service users and carers. This was therefore determined as a priority action requirement, to be addressed within the first few months of 2022. In particular, this work intends to address repeated concerns that have been expressed in relation to ease of access to services (particularly in crisis), clarity of what is provided and for whom, consistency of service offer, clear expected outcomes, and the skills / training / development required by staff to effectively deliver this. The redesign of the community model will articulate clearly what is provided, how this is delivered, what the range of interventions available are, and what the anticipated outcomes are (and how these can be measured / monitored).

The redesign has been led through a workshop in February involving in excess of 60 staff from across a number of our mental health services and other partner services. The workshop looked at identified best practice / available evidence and models of care elsewhere, and considered where we are today in relation to this and how these can best be applied to the context of Jersey. It also heard feedback from a service user and carer conference on what matters to them, and what good care would look like. The workshop specifically focused on developing proposed future models in 3 key areas

• Access to care in a crisis and home treatment as an alternative to admission

• Community Mental Health team function

• Transitions

Draft outlines of proposed models were developed through the workshop, and these are now being further developed / refined by the senior leadership team in advance of a follow up session and further consultation – including with service user groups - in early April. It is anticipated the final model will be agreed by the end of April, with an implementation period that will include staff training and transition.

4. It was also advised at the Public Hearing that Adult Mental Health Services was "introducing a model of co-ordination of care". Please could you provide some more details about the co-ordination of care model and advise when it will be introduced / operational?

Regardless of the delivery model of community mental health services, a key required component of this is an effective system of planning & coordinating care for those with complex needs, which also ensures the involvement and support of the service user and their carers in the planning and delivery of care. This is particularly important where people have complex needs that require a number of different interventions from different agencies, to ensure that care is comprehensively planned, delivered and coordinated and that a collaborative assessment of risk is undertaken (resulting in a clear, joint risk management plan). Within the UK the mandated national system of care coordination is called the Care Programme Approach (CPA) which was introduced in 1991 (and is currently in process of a national review). A number of reviews – including the Independent review of 2021 – have identified the need for such a system to be in place in the Jersey mental health services.

Therefore, as part of the redesign process, we have included the development and implementation of a Jersey-relevant framework for effective care coordination that will replicate the core components of the CPA framework. Again the further development of the workshop outputs is currently being completed, and this will be incorporated into the final model alongside an associated implementation plan.

1. With reference to questions (3) and (4) above, please could you provide some further details about how these models of care work together.

The community model of care describes the overarching structure, delivery and objectives / expected outcomes for our community mental health services, and the different teams / services within this. The CPA-equivalent care coordination framework is a framework for the planning, coordination and review of individual care for those people with identified complex needs, regardless of where they are receiving care & treatment within our community services.

2. Please could you provide further details about any other models of care used by Adult Mental Health Services?

Different mental health services have different models of care, dependent upon their function and the wider context in which they operate. For example, some services have a primary diagnostic focus (such as the autism or ADHD services) whilst others have a primary treatment model focus (such as our psychological therapies services). How well these are articulated currently is variable across our system – it is a longer-term objective to standardise our approach to describing this, through service descriptions and local operating policies.

An example of a new and different model of care that is being developed currently (with a plan to operational delivery in October) is the Perinatal & Maternal Health model, which is a virtual team' that comprises members from a variety of health, social care and third sector agencies all collaborating together to deliver a comprehensive perinatal mental health and maternal health service for Jersey across the levels of prevention, primary care and specialist secondary care.

5. The Panel has been advised that the Mental Health Improvement Board (MHIB) ceased to operate because of the Covid-19 pandemic. Please could you outline the decision-making process behind the disbandment of the MHIB, including:

1. When was the last meeting of the MHIB?

The last meeting of the MHIB was held on 16th November 2020 – there is an available agenda for this meeting, although have been unable to locate any subsequent minutes. The last set of minutes available is for 28th September 2020.

The intent following the last meeting was for the MHIB to convert to a Partnership Board. Draft Terms of Reference had been communicated to MHIB members.

2. Has decision been communicated to the stakeholder groups?

I understand this decision was communicated to MHIB members as above.

3. When was the decision taken and by whom?

The MHIB was chaired by the Director General for Justice and Home Affairs (JHA). The decision to convene, pause or discontinue the Board is a decision of the Chair, and appears to have been made around November 2020.

6. Please can you provide some further details about the establishment, structure, membership and terms of reference of the new Mental Health Partnership Board?

The new Mental Health Strategic System Partnership Board is part of the implementation of our response to the external review of Mental Health services, with the aim of creating a strategic partnership forum that brings together key partners – including representation of service users and carers – to oversee and develop a single coherent mental health system. The Partnership Board will be supported by the operationally-focused Mental Health Network, which is already well established.

The Partnership Board will be chaired by the Director of Public Health. It seems that the development of a similar partnership board is a direction that was intended following the pause / cessation of the previous MHIB but appears to have not been progressed due to Covid.

The Partnership Board will meet for the first time in April. The proposed (final draft) Terms of Reference [*are attached here], and will be discussed & finalised at the first meeting. These include the structure, membership and objectives of the Board.

[*Document provided in confidence to the Panel 25/03/2022.]

7. The Panel cannot find evidence that the objectives of the (previous) Mental Health Strategy are shared publicly. Please could you confirm if these were made available on gov.je (or elsewhere)?

The previous Mental Health Strategy is publicly available on the Government of Jersey website (gov.je). https://www.gov.je/news/2015/pages/mentalhealthstrategy.aspx

8. Please could you provide some further details about why the outcomes of the previous strategy "fell by the wayside"?

It appears that some of this work was superseded by subsequent reviews, action plans and other operational priorities – although many of the themes and objectives / actions were replicated and therefore continued to be advanced as part of the later mental health improvement plan.

a.  Please advise whether the work on these outcomes will recommence as part of the refresh of the mental health strategy?

Yes – the intent is for the Strategic System Partnership Board to review progress against both the previous Mental Health Strategy and the Mental Health Improvement Plan (to support the setting of collective priorities and develop a shared position of where mental health services currently are) and then commence a refresh of the Strategy towards the end of the year.

9. Please can you provide a copy of the Mental Health Improvement Plan and advise whether this is publicly available?

[*The Mental Health Improvement Plan is attached here] [*Document provided in confidence to the Panel 25/03/2022.]

The detailed plan was not made publicly available.

10. The Mental Health Strategy for Jersey (2016-2020) stated an intention to publish an annual Mental Health Quality Report. Please could you confirm why no further annual reports were published after the report for 2016/2017?

This appears to have been lost in transition between responsible officers, and it is likely that this was not prioritised against other urgent actions, reviews and action plans that were subsequently developed.

11. The Panel learnt at the Public Hearing on the 28th February, that there are plans for a dementia strategy for Jersey, but that this will not be "owned and held" by Mental Health Services. Please could you clarify where responsibility for the strategy would sit and the input you envisage from Adult Mental Health Services?

Currently the responsibility for leading the development of a dementia strategy sits with the Improvement and Innovation team within HCS. It is important that this is not led by mental health, as an effective dementia strategy needs to be far reaching and incorporate all aspects of both physical and mental health & wellbeing, social needs, lifestyle and carer support needs – and therefore not seen as something that is owned' by mental health services, who offer a small (but essential) component.

It is expected that Adult Mental Health services will be a key partner in the development and delivery of the strategy – with specific focus on the delivery of timely assessment, diagnostic and support services for people with dementia, as well as the provision of specialist inpatient care when this is required and provision of specialist mental health advice and support to the General Hospital including for patients with dementia or other cognitive impairment – and that the Strategic Partnership Board will have a role in supporting the development and oversight of the strategy.

We are also currently exploring options for our mental health services in Jersey to be a research site for international research relating to dementia care and treatment.

12. Please can you provide some further details about the following groups and advise where these fit in the structure of Health and Community Services / Mental Health Services (please provide a structure chart to detail responsibility where possible):

1. Mental Health Law Group (as referenced in the public hearing on 28th February 2022);
2. Mental Health Legislation Oversight Group (as referenced in the public hearing on 28th February 2022)

It is likely that both of these terms have inadvertently been used to describe the same thing  –  the  new  Mental  Health  Legislation  Oversight Group,  which  is currently in the process of being developed with a view to commencing at the end of April. This group will review and monitor the application of mental health legislation and trends relating to this; identify any risks relating to the application of MH legislation; and input into proposed developments of legislation, linking to the already established mental health legislation working group between HCS and the law offices. The MHLOG will report to the HCS Quality and Risk Committee, and then to the HCS Board.

3. HCS Capacity and Liberty Team (as referenced in the HCS Business Plan).

This is a small team of 4 staff who work within the Legislation team and focus specifically on issues relating to capacity and liberty. These include a senior specialist practitioner, and 3 capacity and liberty assessors (who also have some responsibility for training).

Frontline Services

13. Please could you provide us with further written detail about the communications, training and guidance that was provided to frontline staff in relation to the powers under the Emergency COVID-19 Mental Health (Jersey) Regulations 2020. [The Panel notes that the powers were not used but would like information around the preparedness of the service and staff in the event that the Minister had declared an extraordinary period.]

A written communication was provided to relevant staff in April 2020 which set out that the amendments had been passed and the process by which these would be enacted. A summary of the amendments was also attached as part of the briefing, and these were discussed within team meetings to increase awareness.

Due to the nature of the amendments – and the small number of professional staff involved – it was not considered necessary to provide training.

14. In relation to the Community Triage Team / Crisis Team (the Triage Team), please can you provide some further details, and data where possible, about the relationship between the Triage Team and the emergency services?

1. What is the process for the call out of the Triage Team by the Police / Ambulance / Other Services?

Access to the triage team is via the switchboard – the duty worker is then contacted by bleep.

2. Is the Triage Team able to assist with all requests for assistance it receives?

Yes, although there are occasions when the triage team will not be available to respond immediately to a request for attendance / assessment (due to already responding to another referral). The team would note the request and indicate how quickly a response can be provided. As an urgent access component of our service, this is something that we would always seek to maintain and would consider any temporary closure of the triage team as a reportable incident.

15. Please can you provide us with some further information about the funding for the Mental Health Network and the online access to the "Hub of Hope Network"?

a.  Do you have any data in relation to these services?

These are not services. The Mental Health Network is an operational meeting of mental health providers and other key stakeholders / partners. It also refers to an online platform that provides information and support in relation to mental health & wellbeing. The Hub of Hope Network is an online platform that signposts people to potential service / support providers based upon their self-identified areas of need.

Estate and Service Locations

16. Once the building work at Clinique Pinel has been completed and is ready for occupation, please can you outline how this will affect the location of services in the buildings around the sites in St Saviour?

The current operational, patient facing buildings across both the north and south of the site are as follows:

North - Clinique Pinel and Rosewood House. South - Orchard House and Maison Du Lac.

Services from both south buildings will relocate to the north site, mainly into Clinique Pinel. Rosewood House will continue to provide inpatient Dementia care in the refurbished area of that building. We are currently exploring the potential use of the other part of Rosewood House to maximise effective use of the building.

17. Please can you clarify your short-term plans for the use of the Orchard House building for Adult Mental Health Services? Will it remain in use / partially in use until the new hospital facilities are operational?

The plan is to stop using Orchard House as an inpatient facility. There is yet to be a decision on whether any other HCS teams could use the facility short term. Jersey Property Holdings have identified the south of the site as a proposed housing redevelopment site. Our understanding is that the site will be handed over to Jersey Property Holdings before the new hospital has been delivered.

a.  When was the most recent Health and Safety report produced for Orchard House? What did this identify?

A full Health & Safety audit has not been undertaken at Orchard House in recent years.

However, a number of other processes are in place which assess compliance with various aspects of health & safety. For Orchard House these include :

• PMVA audit (completed July 2021 – identified need to update training compliance)

• Ligature Anchor Point Risk Assessment (Feb 2022)

• Risk Profile exercise (partially completed April 2021)

• Regular Health & Safety Walkabout tools (last Feb 2022)

The Jersey Nursing Assessment and Accreditation System (JNAAS) assessment also incorporates a range of health & safety related indicators. Orchard House was assessed in August 2021, where the key issues identified related to the need to increase training compliance (as per the Prevention and Management of Violence and Aggression (PMVA) audit), the need to improve collaboration in production of care planning & risk assessment, and compliance with policy in relation to medications management. Some other minor estates actions were identified. A follow up spot check was undertaken in March this year and the medication issues were found to now be compliant.

18. Will the place of safety located in the newly refurbished Clinique Pinel be used for children and young people?

Yes.

1. What consideration has been given to providing a separate place of safety for children and young people?

Due to the need to ensure that a place of safety is able to safely manage someone who has been detained under Article 36 - and may therefore be in acute distress and present with challenging behaviours or potential risks to others- there is a requirement to ensure the availability of staff to meet any immediate safety & risk needs. Therefore it has been concluded that currently there is not an appropriate alternative option to provide a separate place of safety. The operating arrangements for Clinique Pinel will ensure that appropriate separation and safeguarding arrangements are in place when the place of safety is being used for a young person.

2. What consideration has been given to providing a specific place of safety for individuals suffering from dementia?

The place of safety relates to a designated place where people can be safely held and assessed under Article 36 (or potentially when otherwise in crisis). It would be unusual for this to be required for a person with dementia, and – given the short term nature of the use of a place of safety, coupled with the function of this – there would be no requirement for a separate place of safety for people with dementia.

19. Please can you outline what discussions have been had about the mental service provision at the new General Hospital?

There is a specific mental health user group as part of the Our Hospital programme and there have been a number of meetings (22). To date, it has been agreed that mental health provision will be co-located on the site of the new hospital and draft plans for the inpatient design have been jointly developed. It is recognised that these plans are still in development and the mental health user group continues to meet.

Funding

20. Please can you provide further detail to advise where the growth money will be allocated for the management structure changes?

The majority of the £500,000 growth money is being allocated to developing new clinical roles and increasing capacity within our clinical services. Following a budget review, the new role of Director of Mental Health & Social Care will be funded from the growth money.

21. Please can you outline all funding that is provided to charities / third sector to provide frontline mental health services?

a.  Please could you outline the length of contract for these services, where applicable?

[*The table below shows the current contracts and their annual value.]

[*Table provided in confidence to the Panel 25/03/2022]

Off Island Placements

1. Please can you provide the total number of off-Island beds commissioned by HCS for Islanders with mental health issues, for each year since 2018?

1. Please can you provide the total cost for each year since 2018?
2. Please can you provide the average cost per bed?
3. Please can you confirm the average length of each placement?

The information requested in shown in the table below:

2021  25  3,316,721  135,278  229

2. Please can you provide the age range of Islanders with a mental health issue that have been provided with an off-Island bed commissioned by HCS, since 2018?

1. Please can you provide a breakdown of the number of adults with a mental health issue that have been provided with an off-Island bed, for each year since 2018?
2. What proportion of these adults were elderly patients with mental health issues?
3. How many children and young people with mental health issues have been provided with an off-Island bed, for each year since 2018?
4. How many adult prisoners and young offenders with mental health issues have been provided with an off-Island bed, for each year since 2018?

This information is provided below:

3. Please can you explain the rationale for outsourcing mental health care off- Island?

Off-island placements occur when specific mental health care or treatment is required that  cannot  be  provided  on  island.  Examples  of  this  include  inpatient  adolescent treatment within a dedicated CAMHS unit; treatment in a secure or forensic mental health unit; treatment within a unit providing a specialised intervention or treatment approach.

Due to the specialist nature, population size and volume of demand for many of these specialised clinical services, it would be impossible to provide these on island (as a comparator, many specialised services are not provided in all areas of the UK and NHS providers rely on regional arrangements or contractual relationships with neighbours to access these). Therefore whilst we are able to provide core mental health service provision on island, there will always be a requirement to outsource some of this.

a.  Please can you describe the process of commissioning an off-Island bed for Islanders with a mental health issue?

We are currently in the process of reviewing the off-island commissioning and oversight arrangements, with a view to implementing some changes in the process from April.

Currently, all decisions around off-island placements are made at a panel (this will continue)  which  comprises  members  of  senior  clinical  and  operational management staff, a finance officer (to support and record financial decisions & forecasts)  and  an  officer  from  CLS  (to  link  to  wider  Government  financial processes and policies).

The clinical rationale for referral is made by the referring clinician, and alternative options to an off-island placement are explored. The panel also considers a quality assessment of the proposed placement (including the regulatory CQC rating & recent reports if in the UK) and discuss the pathway that will be required on completion of the placement to effect a safe transition of care back to Jersey. Generally  the  proposed  placement  will  be  required  to  complete  a  clinical assessment and confirm that they are able to offer a bed.

All patients that are placed off island are allocated to a named professional from within  the  mental  health  services  who  has  responsibility  for  monitoring  the placement and maintaining contact.

I hope that the information provided here has answered the questions raised by the Panel across both letters dated 14 and 22 March 2022.

Yours sincerely

Deputy Richard Renouf

Minister for Health and Social Services