Trust Board. 15 th January 2015 Paper Reference: TB(14-15) 146. Report Title: Executive Summary:

Transcription

1 Trust Board 15 th January 2015 Paper Reference: TB(14-15) 146 Report Title: Executive Summary: Clinical Strategy Welcome to our clinical strategy for It sets out our clinical priorities and ambitions for the clinical care that we offer. At the heart of our clinical strategy is our ambition to provide the best possible clinical care and support to service users and carers in the communities we serve. Our approach to care and support is to put the service users at the centre and use a recovery approaches to enable people to fulfil their potential, within and beyond their experience of mental illness and other chronic conditions. The key principles that underpin the strategy are Quality: continuous quality improvement Partnership: to work in partnership with stakeholders to deliver clinical care Parity of Esteem: put mental health on a par with physical health Recovery: to live a meaningful life, despite serious mental illness Seamless care: people moving through care and treatment seamlessly Outcomes: demonstrating quality of care through meaningful outcomes The chief objectives of the strategy are: To promote mental health and wellbeing To develop a needs based approach to patient care To make person centred care a reality To make integrated care the norm Finally the document states how we will achieve this Action Required: Link to Strategic Objectives: For approval/discussion. The clinical strategy aligns with all our strategic aims by ensuring: The clinical care we deliver to service users, their families and carers is of high quality and makes effective use of resources. We will work in partnership with all our stakeholders to deliver care Clinical care is delivered together with service users and carers making them the centre of decision making

2 Risks: Quality Impact: Resource Implications: Legal/Regulatory Implications: Equalities Impact: Groups Consulted: Author: Owner: The clinical care we deliver is driven by the recovery principles Our care will constantly improve in light of feedback and innovation Through education, research and innovation we will promote leadership to deliver high quality clinical care N/A A supporting strategy to the Quality strategy To be used to inform use of available resources Support compliance with external regulation including CQC Ensure that the Equality and Diversity Framework is implemented throughout our organisation so that our services take account of the diverse needs of our service users and challenge discrimination or inequality is an aim of the strategy. Clinical Leadership Group, EMC, QSAC, Shadow Board of Governors, Dr Emma Whicher, Medical Director & Clinical Leadership Group Dr Emma Whicher, Medical Director Page 2 of 3

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4 Clinical Strategy

5 Document Information This Strategy sets out South west London & St Georges mental health NHS Trust s clinical priorities and ambitions for the clinical care that we offer. The strategy covers the years 2015 to Date: 4 December 2014 Status: draft Current Version: V1.0- EMC 8/12/14 V1.1 QSAC 18/12/14 Subsequently shared with Shadow Council of GovernOrs and Carers, Family & Friends Group V1.2 Board 15/1/15 Transparency level: Public Restricted to: Reason: Author: Dr Emma Whicher & Clinical Leads Owner: Dr Emma Whicher Commissioned by: Trust Board File location: 1 P a g e

6 Table of Contents About the Strategy 4 About the Trust 5 Background 6 Figure 1 Trust Strategic Objectives 7 Figure 2 Core Trust Values and Behaviours 8 Figure 3 SWLSTG Strategy Hierarchy 8 Principles underpinning the delivery of our services 10 Quality 10 Partnership and Co-production 11 Parity Of Esteem 12 Recovery 13 Seamless care 14 Outcomes 15 Clinical objectives for the next five years 17 Objective 1: Promote mental health and wellbeing 17 Page No. Objective 2: Develop a needs based approach to patient care 20 Objective 3: Make patient centred care a reality 22 Objective 4:Make integrated care the norm 25 Taking the strategy forward 27 References 30 2 P a g e

7 Foreword We are delighted to present South West London and St George's Mental Health NHS Trust clinical strategy for the next 5 years. This is our opportunity to demonstrate the quality of clinical care we deliver whilst putting service users and their families at the heart of everything we do. We are committed to ensuring that the clinical needs of our patients drive their care and they are full partners in this process. As the trust we commit to excellence in clinical care, but also to ensure the value and efficiency of what we do serves our community in the best way possible. David Bradley CEO Dr Emma Whicher Medical Director 3 P a g e

8 About the strategy Welcome to our clinical strategy for It sets out our clinical priorities and ambitions for the clinical care that we offer. The Strategy will also support achievement of the Trust s Vision, which is: We aspire to be a cost effective centre of excellence; a place where patients choose to be treated; where clinicians want to train and work; and where our stakeholders want to work with us. At the heart of our clinical strategy is our ambition to provide the best possible clinical care and support to service users and carers in the communities we serve. Our approach to care and support is to put the service users at the centre and userecovery approaches to enable people to fulfil their potential, within and beyond their experience of mental illness and other chronic conditions. We want build on our position as the provider of local, specialist and national services by maintaining high standards of care and delivering a programme of continuous improvements in quality We want to provide information that enables people to see why we are the best choice for providing mental healthcare and wider community care. We recognise that we have to be safe, caring, effective and innovative. We will work collaboratively with, service users, carers, GPs, local authorities, and commissioners to deliver the best care we can and ensure that services meet service users and their families needs holistically. We will do this together with different organisations including charities and other NHS organisations. Quality underpins all the care and support we offer and we will ensure that the clinical care we deliver is evidence based and meets quality standards. Finally as an organisation we continually improve and develop in response to the feedback from our stakeholders. The key principles and objectives of the strategy are drawn from discussions we have held with clinical staff. The key principles that underpin the strategy are: Quality: continuous quality improvement Partnership: to work in partnership with stakeholders to deliver clinical care Parity of Esteem: put mental health on a par with physical health Recovery: to live a meaningful life, despite serious mental illness Seamless care: people moving through care and treatment seamlessly Outcomes: demonstrating quality of care through meaningful outcomes The chief objectives of the strategy are: To promote mental health and wellbeing To develop a needs based approach to patient care To make person centred care a reality To make integrated care the norm Finally the document states how we will achieve this

9 About the Trust South West London and St Georges Mental Health NHS Trust is the main provider of mental health services for adults, older people, children and adolescents living in the London boroughs of Kingston, Merton, Richmond, Sutton and Wandsworth. This includes inpatient and community services, as well as psychological therapies in primary care (IAPT), addiction services, specific learning disability and forensic services. We serve a population of over 1 million. The Trust also provides a range of specialist regional and national services including mental health services for deaf children and adults, eating disorder services and those for the treatment of obsessive-compulsive and body-dysmorphic disorders. We deliver care from three main hospital sites, Springfield University Hospital, Tolworth hospital and Queen Mary s Hospital as well as multiple locations in the community including GP surgeries and community centres. We have a staff of 2400 and our annual income is over 157 million. Our aim is to serve the mental health needs of everyone in our diverse communities. To do this we work in partnership with service users, carers, GPs, local authorities and the voluntary sector to: Promote mental health and improve awareness of its importance Support people with mental health problems and their families Provide care and treatment to the highest standards Help schools and employers to challenge stigma The Trust is a lead provider of education and training. This underpins the development of high quality clinical care. We provide education, training, and research in partnership with St George's University of London, Kingston University, London South Bank University, King's College London, University of Surrey, Tavistock Institute of Medical Psychology and Brunel University. Furthermore, we are a leading provider of postgraduate medical training, developing the consultants of the future.

10 Background Mental illness has a huge impact on the health and wellbeing of individuals. People with mental health problems are at higher risk of experiencing significant physical health problems; they are more likely to develop preventable conditions such as diabetes, heart disease, bowel cancer and breast cancer, and do so at a younger age. This contributes to a situation whereby people with serious mental health problems die 20 years younger on average than the general population. Rates of mental illness particularly depression are between two and three times more common in those with long-term conditions. Mental health co-morbidities contribute significantly to poor physical health outcomes and higher treatment costs. It is estimated that 1 in every 8 spent on treating a long-term condition is linked to a co-morbid mental illness. Mental illness further affects the way individuals manage their health and interact with services. People with mental health problems are more likely to misuse substances and less likely to be physically active. Furthermore, they are less likely to attend medical appointments and less likely to adhere to treatment and selfcare regimens. The national mental health strategy No Health without Mental Health 1 identified six key objectives, the delivery of which will improve outcomes for people with mental health problems: More people will have good mental health More people with mental health problems will recover More people with mental health problems will have good physical health More people will have a positive experience of care and support Fewer people will suffer avoidable harm Fewer people will experience stigma and discrimination We support these objectives and are committed to ensuring that people with mental health problems have the same opportunities to participate in and contribute to their communities as those without mental health problems. In order to address the significant inequalities in health and wellbeing experienced by those with mental ill health we have identified our clinical priorities for the next 5 years. We believe that these are fundamental to the delivery of high quality accessible care for service users and carers. Our vision is supported by our six strategic objectives (Fig 1) and the core Trust Values and Behaviours (Fig 2.). 6 P a g e

11 Figure 1 Trust strategic objectives 1: Quality and Value We will provide consistent, high quality, safe services that represent value for money. 6: Leadership and talent We will develop leadership and talent throughout the organisation. 2: Partnership We will develop stronger external partnerships and business opportunities that improve access, responsiveness and service range. 'We will provide innovative, high quality, personalised services that support people to manage their own health and wellbeing. 5: Innovation We will become a leading innovative provider of health and social care services. 3: Co-production 'We will have reciprocal relationships which value service users, carers, staff and the community as coproducers of services. 4: Recovery 'We will enable increased hope, control and opportunity for our service users. 7 P a g e

12 Figure 2 Core Trust values and behaviours VALUES BEHAVIOURS Openness Creating and maintaining valued relationships Sharing information Respect Creating equal partnerships Treating people with dignity and respect Encouraging diverse perspectives and views Fairness Treating people as we would like to be treated ourselves Collaboration Working in partnership in everything we do Listening and taking a genuine interest in others Welcoming and valuing diverse opinions Excellence Championing a strong service ethos Continuous improvement through innovation Creating national best practice The Trust s values underpin how we work with service users, families and the wider community. They must translate into everything we do. Our values, provide an approach of doing with rather than a doing to approach. Through this approach we can be sure that a person s strengths and needs are always at the centre of our day-to-day work. We have a range of strategies that support the delivery of these objectives (Fig 3) Figure 3: SWLSTG strategies Quality strategy Clinical Strategy Service Development Strategy Co-production Strategy Financial Strategy Workforce and Organisational Development Strategy Engagement and Communications Strategy Estates and Facilities Strategy IM&T Strategy Commercial Strategy Innovation Strategy Risk Management Strategy 8 P a g e

13 The clinical strategy aligns with all our strategic aims by ensuring: The clinical care we deliver to service users, their families and carers is of high quality and makes effective use of resources. We will work in partnership with all our stakeholders to deliver care Clinical care is delivered together with service users and carers making them the centre of decision making The clinical care we deliver is driven by the recovery principles, based on an individual s strengths. Our care will constantly improve in light of feedback and innovation Through education, research and innovation we will promote leadership to deliver high quality clinical care 9 P a g e

14 Principles underpinning the delivery of our services Quality There is an increased focus on quality of care and concerns about service user safety in the NHS following the Francis Inquiry into failures at Mid Staffordshire NHS Foundation Trust. Delivering high quality services is at the heart of our way of working. We are committed to the provision of consistent, person centred, high quality services. This involves continuous quality improvement and our commitment to being a learning organisation. Our care is also evidence based and underpinned by national standards including NICE. People should have access to effective end to end care with appropriate and timely access to a full range of evidence based interventions. These may include specialist psychiatric care, talking therapies or pharmacological interventions. These pathways including each individual element need to be understood by service users and their carers, their GPs, and other stakeholders. Furthermore the care we offer should be accessible to both those with mental health and physical health problems. This Quality Strategy provides a framework in which to embed quality improvement to support the delivery of quality in clinical care across the Trust by combining: Quality Assessment (data); Quality Improvement (actions) Quality Assurance (assurance systems) These quality principles inform the clinical care delivered to patients, their friends and family. Furthermore it assures our stakeholders and wider community of the excellence of this care. High quality care for young people Yasmin is a 16 year old girl who presented to mental health services through attendance at A&E after taking an overdose at school. She was assessed by the Child and Adolescent Mental Health liaison nurse who identified that she was experiencing feelings of hopelessness and fluctuating suicidal thoughts. Yasmin agreed to a safety plan with her mother maintaining close supervision and was discharged home with an appointment in 2 days to see the nurse together with a consultant child psychiatrist. At that appointment depression was diagnosed and antidepressant medication started. She was also offered Cognitive Behavioural Therapy. The safety and crisis plans were reviewed and the liaison nurse agreed how best to manage her return to school, the nurse then arranged a meeting the following Monday at school with the form tutor and year head. Yasmin attended this with her mother. From that meeting she was able to be reintegrated into school with additional support for the lessons where she faced the greatest problems. 10 P a g e

15 Partnership and Co- production Support and care for people with mental health needs is the responsibility and concern of many agencies and authorities across South West London. In order to promote mental wellbeing across the population and to meet the specific needs of people with more acute or severe problems, the Trust works in close partnership with diverse stakeholders. The Trust has formal partnership agreements with local authorities who have delegated a range of social care responsibilities to the Trust. This enables us to deliver integrated health and social care services from Trust managed teams and to meet shared objectives informed by common values. We also work closely with the South West London Commissioning Collaborative (SWLCC) with whom we have a clear and shared agenda for improving mental health in the community. Service users and their families are vital direct partners and collaborators in our work and in our future development. Collaboration is fundamental to working with individuals and their families. Furthermore using a co-production approach, the Trust is committed to ensuring their contribution to service development and delivery is critical to the shape of our services going forward. The Trust recognises it provides its local services within distinctive communities and places. GPs, the voluntary sector and community organisations are also important collaborators and partners. Through these organisations we can get to know our communities better and also develop innovative new methods of clinical care such as the development of Multispecialty Community Providers described in the NHS Five Year Forward View 2.We can also work together to support community capacity and resilience with regard to mental health, through greater understanding and public reducing stigma towards mental health and opening up a wider choice of community support options. Developing common purpose: The Trust, carers and the voluntary sector SWLSTG has been a member of the National Carers Trust Triangle of Care (ToC) membership scheme since its inception in 2012 and has recently gained its first Gold Star. We work very closely with carers and carers organisations in each of the five boroughs to promote the involvement of carers, families and friends in all our work, to support them in their own right as well as meeting the needs of service users better. This approach has been very well developed on acute adult inpatient wards such as Ward 3 where Sutton Carers Centre, the ward manager, Trust carers champion and the consultant psychiatrist have worked as a crossagency, multi-disciplinary team with common purpose, to change the way carers are greeted and provided with information upon first coming to the ward, involved in all stages of care, offered the opportunities to meet and talk with staff, and supported when their family member or friend is discharged. The Trust s network of carer and carer-organisation collaborators is a vital resource to improve our response to mental health in our communities. 11 P a g e

16 Parity of Esteem The Mandate to NHS England sets out the government s commitment to put mental health on a par with physical health, where there are already well-established standards for access to services. Parity of esteem means that, when compared with physical healthcare, mental healthcare is characterised by 3 : Equal access to the most effective and safest care and treatment Equal efforts to improve the quality of care The allocation of time, effort and resources on a basis commensurate with need Equal status within healthcare education and practice Equally high aspirations for service users; and Equal status in the measurement of health outcomes. The NHS Five Year Forward View 2, states the ambition to achieve genuine parity of esteem between physical and mental health by New waiting time standards comparable to those for people with physical illness will be implemented for psychological therapies and those experiencing a first episode of psychosis. The aim of the Five Year Forward View is also to expand access standards to cover a comprehensive range of mental health services, including children s services, eating disorders, and those with bipolar conditions. Furthermore the London Health Commission Better Health for London 4 aims to reduce the gap in life expectancy between adults with severe and enduring mental illness and the rest of the population by 10% within 10 years. To do this the Commission recommends mental health trusts work with commissioners to proactively offer access to smoking cessation, blood pressure monitoring and treatment, cancer screening and treatment and effective weight management programmes. As a Trust we will work towards the aims of the Five Year Forward View and London Health Commission. We also understand the importance of equity in the allocation of funding for mental health services by commissioners in implementing this. We also believe that we should prevent mental health problems from exacerbating physical ill health and vice versa. We need to promote, treat and improve the mental health and physical health of our service users. We need to advocate for equitable funding for mental health services but we must also lead by example and ensure that we have the capacity and capability to meet both the physical and mental health care needs of our service users. 12 P a g e

17 Recovery Recovery has become the overarching concern for people using mental health services their families and policy makers. The guiding principle of recovery for people with mental health problems is hope the belief that it is possible for someone with serious mental illness to regain a meaningful life. The Department of Health uses the following definition of Recovery: A deeply personal, unique process of changing one s attitudes, values, feelings, goals, skills and or roles. It is a way of living a satisfying, hopeful and contributing life even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one s life as one grows beyond the catastrophic effects of mental illnesses. 5 Recovery is about individualised approaches and, as the definition suggests, it is about having a satisfying and fulfilling life, as defined by each person. Importantly, recovery does not necessarily mean clinical recovery (usually defined in terms of symptoms and cure). However, it does mean building a life beyond illness without necessarily achieving the elimination of the symptoms. As a Trust we look beyond clinical recovery through facilitating recovery and promoting social inclusion by measuring the effectiveness of treatments and interventions in terms of the impact of these on the goals and outcomes that matter to the person and their family. As a consequence, we work collaboratively with service users and their carers to develop care plans in simple and meaningful language that the person would use and understand. We run the South West London Recovery College, the UK s first NHS College that provides a range of educational courses and resources for people with experience of mental illness, their friends, family and Trust staff. The Recovery College helps people to recognise and develop their personal resourcefulness in order to become experts in their own self-care, to make informed choices about the assistance they need to do this, and to do the things they want to do in life. Recovery also involves treating people in their community and as close to home as possible. Individual recovery Simon has a diagnosis of schizophrenia and lives independently in his flat. He hears voices and has trouble keeping track of thoughts and conversations, he also finds it hard to concentrate. As a result he has difficulty interacting with people in social settings and tends to withdraw, spending the majority of time on his own in his flat. Simon has stated that he would like to gain more control over his life and through discussion with his care coordinator has identified two recovery goals which are important to him: to give up smoking and to get a job. Simon and his care coordinator have collaboratively developed his care plan where his two recovery goals are the outcomes they are working towards. 13 P a g e

18 Seamless Care People should be able receive treatment and move between services seamlessly. There should be no administrative or structural issues that impede or delay the care they need. NICE recommends that a steppedcare model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals choose the most effective interventions. In stepped care the least intensive intervention that is appropriate for a person is typically provided first, and people can step up or down the pathway according to changing needs and response to treatment. (Fig 4). Our services are mainly focused at level 3 with some at level 4. Within these services there are varying levels of care, from outpatient or community follow-up services, to more intensive community and home treatment services, recovery houses and inpatient care. The introduction of mental health care clusters will enable us to monitor more effectively whether we are meeting the needs of our service users. We are working with our commissioners to ensure that we have flexibility in how interventions are provided having recognised the differing patterns of local need and our capability to provide particular interventions We also recognise our responsibility to work with our stakeholders in order to ensure that people are adequately supported at levels 1 and 2. Transitions between age based services also need to be seamless. For example children and young people within our CAHMS service need to move into our adult services in a systematic and planned way that does not lead to any gaps in service provision and support. Another aspect of seamless care is rapid access to crisis treatment for mental illness. We support the Crisis Concordat 6 which lays out the requirements for good crisis care: Access to support before crisis point Urgent and emergency access to crisis care The right quality of treatment and care when in crisis Recovery and staying well, and preventing future crises Furthermore integration between the Trust and different organisations such as general practice, social care, community care and acute hospitals is required to ensure seamless care for service users. Seamless care within Crisis and Home Treatment Teams When people are experiencing a mental health crisis, often many of their problems are related to or compounded by social problems such as relationship issues, housing, debt and other social stressors. The Trust s partnership working arrangement with Local Authorities has enabled us to include social workers and Approved Mental Health Professionals (AMHPs) within some of our Crisis and Homes Treatment Teams. These staff can support the assessment and resolution of social needs and facilitate communication and support with families (who may themselves be distressed and concerned, and who need information and advice). 14 P a g e

19 Figure 4 Stepped care model Level 4 Highly specialist services for severe conditions Level 3 Secondary health services providing specialist services for those with more serious health conditions Level 2 Primary care GPs and nurses providing low level clinical interventions for anyone with a moderate health condition Level 1 Supporting the whole population through health promotion, early intervention and helping people to keep themselves well Outcomes Health outcomes matter to service users and the public. Measuring and publishing information on health outcomes are important for encouraging improvements in quality. The Royal College of Psychiatrists have published guidance on recommended outcome measures to be used in psychiatry 7, but the routine incorporation of outcome measures is not the norm. Outcomes must reflect more than just improvements to clinical symptoms. It is widely accepted that support and outcomes in mental health need reflect a person s whole life and their self-defined goals. The 2013/14 NHS Outcomes Framework 8 places a stronger emphasis on mental health than in previous years. It takes into account recovery from common mental health problems (depression and anxiety) as well the treatment of more severe mental illness. Furthermore, the introduction of Payment by Results and the Mental Health Tariff has pushed the agenda towards outcomes based commissioning. Trusts will be required to collect clinician rated outcome measures, patient reported outcome measures, and carer and patient rated experience measures. We have developed a multidimensional outcome measure - Commissioning for Quality and Innovation (CQUIN) - in collaboration with our commissioners using the HONOS 4 factor model. It allows for a more descriptive and holistic approach to looking at mental health outcomes. We are piloting the Warwick and Edinburgh mental well-being scale as our first patient reported outcome measure (PROM). This will enable us to demonstrate that the treatment we provide on both an individual person and across wider groups of service users is effective. The Trust is now able to examine the combination of clinician rated outcomes, patient reported outcome 15 P a g e

20 measures and patient reported experience measures. This provides a triangulation of outcome measures and allows the trust to assess the benefits of the interventions we provide from different perspectives. Our vision is to improve both clinical outcomes and people s life chances by developing a series of outcome measures which follow the person s treatment. This would form part of a person s electronic case notes and would be accessible to them through the patient portal. Improving care with meaningful outcomes The Trust has been measuring outcomes using the Health of the Nation Outcome Scales (HoNOS). This is an outcome tool used by clinical staff to assess change in service users following treatment and support. Across all service users in contact with community adult services, the average HoNOS score was lower at the end of the episode of care than at the start and 65% of the measured improvements were statistically significant. We found that emotional well-being is the factor with the strongest improvement. We then built on this work and have piloted a well-being measure that is completed by service users. Around 200 people completed this measure and told us that the items it contains are meaningful to them and that the measure is easy to complete. We will expand the use of this measure and combine it with the clinician rated tool to identify where we are bringing benefits to service users and where we need to refine our treatment and support to improve our services 16 P a g e

21 Clinical objectives for the next five years Objective 1: Promote mental health and wellbeing The Royal College of Psychiatrists believes that mental health is a central public health issue 9. Most mental illness begins before adulthood and often continues through life. Improving mental health early in life will reduce inequalities, improve physical health, reduce health-risk behaviours and increase life expectancy, economic productivity, social functioning and quality of life. Effective population mental health strategies will improve well-being, resilience to mental illness and other adversity, including physical illness. Targeted strategies will also prevent future inequalities and reduce existing inequalities. To maximise impact, public health interventions should focus strongly on the early years, children and adolescents. Public health programmes should seek to build resilience and social skills, while at-risk groups, such as looked-after children, should be targeted to prevent the development of mental illness. Many existing public health programmes fail to consider the needs of those with mental health problems. Public health prevention programmes should seek to include people with mental health problems and provide appropriate support to maximise benefit. The communities that we live in, support our wellbeing and mental health. Part of creating a healthy and supportive community is developing mental health awareness and literacy among staff involved in public health provision and the wider community, as well as tackling stigma against mental illness. A second element is providing support for the broader determinants of mental health, including housing, social networks and employment. Greater attention should be paid to developing a more holistic view of mental health that considers what is necessary to support people to maintain their health and wellbeing, and to ensure quality of life not just when people are ill but also when they are well. A significant barrier for many people with mental health problems is the prevailing societal attitude towards mental illness, leading to stigma and discrimination. This seriously hinders people s recovery and attainment of a good quality of life. Therefore it is critical that people with mental health problems have timely access to evidence based interventions that promote their recovery. 17 P a g e

22 Community faith network The Trust has co-produced a Family Therapy course with local Senior Community Leaders. The 20 week course is the first of its kind in the country, aimed specifically at pastors, and helps them build skills to support families in local black and ethnic communities with mental health problems. The course enables pastors to provide their communities with access to mental health treatment and support, and is helping to address the lack of trust some communities have in traditional mental health services, as well as break down stigma and discrimination. Faith leaders are often the first port of call within our communities when families are facing challenges and difficulties, so it is important that they are equipped with the right tools and methods to provide the best support they can. The courses open up the real possibility of mental health advice, information and support being offered deep into communities, through avenues previously unseen, building community skills and capacity We will Work with our local communities to create communities that are accepting/supportive of people with mental health problems using a coproduction approach. Improve the employment and wider opportunities for people with mental health problems in the community to support wellbeing. Be advocates and leaders for good mental health by improving our clinical engagement with commissioners and other stakeholders Work with commissioners to ensure timely access to high quality evidence based clinical care for all those with mental health problems. Identify opportunities for mental health promotion in a systematic way and undertake targeted work with at risk groups including early interventions for parents, children and young people, BME groups, people with learning disability and in particular those in care in partnership with local authorities, public health and the voluntary sector Work with our commissioners to develop a mental health indicator around reducing stigma and discrimination (and advocate nationally) working with the MIND & Royal College of Psychiatrists. 18 P a g e

23 Position in 2020 Recognised by service users, commissioners and our local communities as a leader in mental health care as measured by our engagement with health and well-being boards, feedback from local communities and patients A reduction in perceived stigmatisation and discrimination as measured by service users and community surveys. An established programme of mental health promotion delivered through our Recovery College to our service users and their carers, staff, local communities and other stakeholders. Working in partnership to ensure people access wellbeing support across a network of providers to promote mental health. Routinely use peer support workers as a method of improving wellbeing underpinned by research. 19 P a g e

24 Objective 2: Develop a needs based approach to patient care Needs led assessments are the foundation of high quality, personalised care and support. We will ensure the range of health and care needs people may have are taken into account. This will include physical and social wellbeing needs, as well as mental health. We will focus on an individual s strengths and capabilities in assessing need. Diverse needs identified through needs-led assessments may be met by the Trust, or through resources offered by other organisations. We will help people navigate the range of support and interventions available to meet their needs and ensure people can access the resources to which they are entitled. This will include access to appropriate specialist psychiatric care, talking therapies, pharmacological interventions, peer worker and non-statutory sector support and use of personal health and social care budgets. We will also work with people in the context of their social networks, working in partnership with families and friends, where appropriate, and ensuring they can themselves access relevant support and information. We will ensure people have access to the best possible information and encourage their active, informed participation in their own health and social care. This will include crisis planning and optimizing any medication. The more people are involved in their care, and the more they are supported to recognise their own strengths and solutions, the more likely the success of the health and social care treatment and support we offer will be. We also understand that people with mental health problems who use our services are diverse with different experiences, cultures and backgrounds. As a consequence all assessments, care and support plans should meet the expectations of the Trust s Equality and Diversity Framework, ensuring no service user is denied appropriate services on the basis of assumptions. For instance the age of adults should not in itself determine the nature and level of support they are offered. Our staff will be well trained to recognise and address the impact of inequality and discrimination upon service users and their families. Holistic care Joan is a 67 year old woman who was referred by her GP for depression and some problems with her memory. Her husband died two years ago and she has coped well with the support of her family, but more recently, since having a diagnosis of diabetes and feeling physically less well, she has become very withdrawn. Her depressio has become very debilitating to the point that she is neglecting to eat and care for herself physically. The Mental Health Team assessed her needs, identifying how her depression, her social and emotional losses, her physical health and her reduced ability to cope with day to day tasks are interrelated. The support offered combines treatment and care from the Trust, her GP and the partner local authority, as well as identifying what is on offer from local voluntary and community organisations. The Mental Health Team liaised closely with her GP and the Diabetic Clinic to ensure treatment and support is coordinated. Joan has been encouraged to explain her needs from her own perspective as much as possible and her daughter who is her carer has been offered an assessment, information and services 20 P a g e

25 We will Train and develop our staff to ensure assessments and support plans utilize a strengths based approach and address all the relevant needs of service users. Where the support they require is outside the remit of our services we will work effectively with other services to provide access to a wide range of support opportunities and ensure they can access any resources to which they are entitled. Ensure that the Equality and Diversity Framework is implemented throughout our organisation so that our services take account of the diverse needs of our service users and challenge discrimination or inequality. Train our staff to achieve the best outcomes for both the mental and physical health and well-being of service users. Ensure access to services is based on need not age. Work with commissioners to enable access to Crisis care and psychiatric expertise is available 7 days a week. Optimise the use of medication in collaboration with service users and carers. Facilitate needs based care by ensuring the sharing of information across organisations. Position in 2020 Service users and their carers are confident that their physical, social and mental health needs will be assessed when they use our services and they will be supported to access the right ongoing support and treatment The Trust has implemented the EDF and embedded the principles throughout the organization People across South West London have consistent access to Home Treatment Teams, liaison psychiatry services and expert psychiatric review seven days a week. The Crisis Concordat has been implemented across South West London Medication Optimisation has been embedded in the Organisation Ensure that patient information is accurately recorded and then shared appropriately. 21 P a g e

26 Objective 3: Make person centred care a reality Person centred care is care that meets and responds to a person s goals, needs and preferences and where service users are autonomous and able to decide for themselves. The Department of Health s vision that there will be no decision about me, without me 10 means offering patients greater control of their care and treatment, giving them more opportunity to make informed choices, putting them first. We will make real the Department of Health s vision that there will be no decision about me, without me 10 by offering people greater control of their care and treatment, by making shared decision-making the norm within our services. We will ensure we offer supported self-care and collaborative care planning to provide better care and health outcomes. Working in partnership with service users and carers has increasingly become an integral part of health and social care and in particular the management of long term conditions. Moving to a position where this is the norm requires acknowledging the individual as an expert in the day to day management of their condition, including identifying their symptoms and setting personal goals. It also means encouraging people with long term conditions, their families and carers to actively participate in all aspects of treatment including assessment, care planning, crisis care and evaluation. We need to be able to put service users centre stage, communicating effectively with them, their families and carers. We need to be able to appreciate and respond to the diversity of the population and to recognise and respect patients rights. The services that we provide need to be built around our service users. The best way in which to do this is to ensure that we have the capacity and capability to respond to the needs of each individual service user. Service users tell us that they care about their experience of treatment as much as clinical effectiveness and safety. They want to feel informed, supported and listened to so that they can make meaningful decisions and choices about their care and support. We need to change the nature of our day-to-day interactions with our service users as the quality of their experience is as equally important to them as providing the most effective interventions and safe care and support. 22 P a g e

27 National Behavioural Cognitive Psychotherapy Unit John is a 25 year old man who gives a 6 year history of profound Obsessive Compulsive Disorder which started at university after a traumatic event. Ever since he has been convinced that his brain had changed and he spent hours trying to recreate his previous state of mind. At the time of admission to Springfield University hospital, he had spent two years totally bed bound. He was incontinent, had wasted muscles and had previously suffered from bed sores. Previous treatments had involved 5 trials of different medication known to be effective for OCD and 2 courses of CBT but none had resulted in any improvement. On admission to the Behavioural Cognitive Psychotherapy Unit, the first thing was to ensure his physical health. A wheelchair was obtained to prevent him spending so long in bed and physiotherapy to look at developing his wasted muscles, he was also commenced on a high dose of Sertraline. John expressed the view that he did not want CBT or "therapy". Therefore the team asked him what his life goals were and worked towards achieving these in a graduated way. These goals were addressed with the CBT therapist and also the Occupational Therapist who guided him through activities of daily living. A few months into his stay, and following weeks of muscle strengthening exercises, he amazed everyone by getting out of his wheelchair and joining in a game of badminton. He progressed well and at time of discharge, instead of occupying most of his waking life, his compulsive rituals only took a few seconds at a time and were far less frequent. He was happy and keen to progress and return eventually to university. We will We will treat people in a dignified way and respect them, their wishes and their preferences Ensure we offer service user involvement, shared decisionmaking, supported self-care and joint care planning to secure better care and better health outcomes Ensure that our staff work in partnership, with all of our patients and their carers in order to improve the quality of outcomes. Ensure that we have the capacity and capability to offer real choice to our service users. This includes evidence based interventions recommended by NICE and the ability to choose the place where they would prefer to receive care depending on their care needs. Provide education and selfmanagement support through our Recovery College to maximise people s control over their health and wellbeing 23 P a g e

28 Position in 2020 We are the preferred provider of mental health care services for service users, their families and carers. People feel that they are partners in all decisions made about their care. Treatment plans are meaningful to our service users and their carers and provide an action plan for a person s recovery. People have access to their own care record through the Patient Portal. Technology is used to support shared decision making and self-management. 24 P a g e

29 Objective 4: Make integrated care the norm Policy-makers agree that improving mental health outcomes requires a range of interventions that extend beyond health and social care to the community as a whole. This will require greater attention to integrated care pathways and integration of service provision with a systemic approach to implementation. The challenges of achieving this will require multiple stakeholders across different sectors working collaboratively. We recognise that achieving crosssystem working in this way is challenging but in order to improve outcomes for our service users we need to work with all relevant partners to achieve this. The Kings Fund highlighted a number of challenges for mental health service provision in London 11 : Current systems overlap, with a lack of coherent pathways Variability of primary and secondary care and their interface Lack of integration between physical and mental health care Lack of consistent and accessible data on activity and outcomes People do not know how to get help in a crisis. Delays in getting access to the right care Some groups are more likely to reach crisis point before accessing services Recovery is about more than mental health services We believe that many of these issues can be resolved by the development of integrated care pathways that are understood and owned by the staff that will deliver care in accordance with the pathway ; and understood by service users, their carers and referrers, the efficient use of which will improve mental health outcomes and the quality of patient care 25 P a g e

30 Mind and Body People with long term physical health conditions are more vulnerable to mental health conditions such as depression and anxiety. Our services have therefore developed links with local physical health care teams, this includes working with Community Physiotherapy teams, Cardiology, Respiratory, and Diabetes Teams and links with the Centre of Pain Education (COPE). Several of our clinicians spend time with these teams, to discuss appropriate referrals and meet clients with the team as required. We are also contributing to physiotherapy rehabilitation programmes, in which we introduce basic CBT techniques and are available to discuss how our service could benefit individuals on those programmes. We will open our Recovery College to those who need it to further support self-management for people with long term conditions. In our development of new service models we will be strengthening our position as an enabler for integrated mental health and well-being to ensure all clients needs medical, physical, psychological and social can be met. We will Share protocols between agencies and develop collaborations between agencies Strengthen coordination across our current care pathways and develop more integration through partnerships with other care services Work with our lead commissioner to identify cost effective models of care for our local geography and develop KPIs and other contracting or performance tools that support integration Embed mental health within non-mental health services and using people who can champion access to mental health care to facilitate access to services to meet the needs of individuals Work with GPs to enhance the care of people with mental health problems in primary care. Work with Commissioners to develop implement the Five Year Forward View and London Health Commission recommendations Position in 2020 Service users, carers and referrers experience improved access to coordinated pathways of care. Improved waiting times for psychological therapies and those experiencing a first episode of psychosis. People with have access to enhanced primary care mental health services Reduced use of inpatient care by those who are frail or have long term conditions 26 P a g e