Carolyn Regan, chief executive of West London Mental Health Trust, shares her view on where next for commissioning as part of Provider Voices - a new publication series from NHS Providers.
We are slightly unusual as a trust: we have a very diverse range of services and we are currently in financial balance. It is interesting to reflect why mental health trusts as a group tend to stay in balance. One reason may be that there has historically been much less focus on mental health services nationally, strategically and politically. So the sector had a bit of time to come up with strategic plans and work out the best way to develop.
Single point of access
I worked on the mental health strategy in north-west London as a commissioner, and I have come back two years later as a provider to implement the strategy. The transformation agenda is huge: the most impact recently has been from our work around the single point of access. All referrals now come through phone or email, both of which are available round the clock.
It is interesting to reflect why mental health trusts as a group tend to stay in balance. One reason may be that there has historically been much less focus on mental health services nationally, strategically and politically. So the sector had a bit of time to come up with strategic plans and work out the best way to develop.
chief executive
The single point of access is staffed by clinicians 24/7, consultant-led in the daytime, and nurse-led out of hours. It is very new, has only been open nine months, and we have had about 4,000 referrals a month.
The users are a mix: from GPs; self-referral by patients (some already receiving mental health care, some new patients, and some want signposting information) plus carers and other services like the police. Many GPs say it has been a very helpful resource for getting advice with patients while they are still there in the consulting room. It takes time and energy to get a new model of care up and running and change the way we provide services.
We are developing a host of other things: primary care plus workers with GPs and the primary care teams; dementia link workers; a new perinatal service; an extended child and adolescent mental health (CAMHS) service.
New models of care
It does feel like there is some momentum behind mental health – we are delighted to be part of the CAMHS new models of care work delegated by NHS England in partnership with Central and North West London NHS Foundation Trust. This is a good time for new models of care in mental health and trying new things. It is also about partnership with other organisations and trusts, which were traditionally thought to be strength for mental health and community trusts.
This is a good time for new models of care in mental health and trying new things. It is also about partnership with other organisations and trusts, which were traditionally thought to be strength for mental health and community trusts.
chief executive
Partnership is seen as a sector strength because it allows space for innovation. Mental health trusts increasingly providing physical healthcare services: we won two contracts recently to support local people with community independence and reablement services (a natural expansion of what mental health trusts do) and offer alternatives to hospital admission. We have been in the business of partnership with the local authority and voluntary sectors for many years.
The importance of partnership working
There may be more that mental health services can do to help the whole system respond to the sort of challenges we are now seeing in acute urgent and emergency care services. We know that effective liaison psychiatry can and does help A&E departments and that often, patients attending A&E have both physical and mental health needs. Working in partnership with our acute and commissioning colleagues is the best way to meet these needs and mental health is well-placed to lead some of this work.
Finally, there is a big element of co-production, with patients engaged in strategic planning, recruitment of staff, service redesign and evaluation.
Providers wanting to make a start with working cooperatively should start with something they can deliver, a smallish practical project. Get it delivered, and show partners that you mean what you say about working together.
Providers wanting to make a start with working cooperatively should start with something they can deliver, a smallish practical project. Get it delivered, and show partners that you mean what you say about working together.
chief executive
It is an advantage for staff to have experience of commissioning and providing. I was from a provider background; followed by years of commissioning; then working as a strategic health authority chief executive; then in clinical commissioning groups; now I am back on the provider side. I think we need that blend of experience and understanding of the issues on both sides of table, and we see this breadth of experience much less now than we need to.
Common challenges
The challenges facing a commissioner are no different than for a provider: quality and finances. Within that, there is partnership working and innovation: an opportunity to do something radically different and transformative. We know existing services are not sustainable for many reasons, including patients and service users saying so.
So we have to find affordable high-quality vehicles for delivering care for the future, and to innovate. In our daily lives, we use technology and apps, as part of how we live today. We want something on our smartphone that is accessible, responsive and tailored to our individual needs.
Public services could use the tech revolution to provide some of that: personal insights in terms of review/feedback, ongoing inputs and updates and communities of interest. The public sector has been very slow to adapt.
Sustainability and transformation partnerships
The sustainability and transformation partnership (STP) process is clearly meant to drive more alignment between commissioners and providers over a larger footprint. Our track record in north west London of providers, commissioners and others working together is very good; so we are building on a solid foundation. Others may ask whether the strategic plan is well-known and owned, and it’s about taking this on during the next phase of the work. However, it is really about showing deliverables and hopefully not about starting from a blank sheet of paper.
Mental health is absolutely core to our STP, not just in terms of the right quality of care for supporting people with serious long-term problems, but also recognising that staying mentally well and healthy are as important as doing so physically.
chief executive
Mental health is absolutely core to our STP, not just in terms of the right quality of care for supporting people with serious long-term problems, but also recognising that staying mentally well and healthy are as important as doing so physically. It is about helping children get the best start in life and helping adults to stay healthy and address social isolation: the wider determinants of health.
Our STP also has a vital acknowledgement of the life expectancy gap between people with serious mental health problems and the rest of the population. Addressing that gap is about early identification, good crisis support services, supporting children with mental health problems, and ensuring we consider the physical needs of people with mental health problems and vice versa.
The variation we are seeing emerge, through new care models, more integrated services and accountable care partnerships, is welcome.
Let’s welcome diversity in delivery and organisational forms that meet local situations shaped by local players, including patients, carers and residents better. We know one size does not fit all.
Let’s welcome diversity in delivery and organisational forms that meet local situations shaped by local players, including patients, carers and residents better. We know one size does not fit all.
chief executive
Saying this, I am assuming we can answer the questions: is enough funding going in; is there good governance, and can we evaluate outcomes for and with service users and carers? If we can say yes to those, then great. This whole agenda is about local players working out the key issues for their area, driving transformation and taking people with them.
Commissioner size matters
We know that many CCGs are very small for the job they are tasked to do. Their challenge is to keep the unique local perspective, and also achieve economies of scale. That is about recruiting and retaining the best possible staff. Bigger commissioners have a better chance.
We could retain local CCGs within bigger overall collaborative commissioning arrangements where that makes sense for local decision making but also ensure economies of scale, while avoiding past issues where organisational boundaries got in the way.
When collaboration across an area is starting out, you have to get all the players in a room and have authentic conversations on roles and responsibilities, such as why we are here and what we are trying to solve; how we’ll learn from other places and how to manage the risks.
That involves developing different community provider roles. Blurring of the boundaries might be good, to encourage more active movement of staff between organisations – that helps with understanding and perspective. If you can set out, as in any new relationship, what you aspire to and where you are going, what you are trying to solve and how you will measure success, be it over a small community or a large geography, that is the smart approach.
If you can set out, as in any new relationship, what you aspire to and where you are going, what you are trying to solve and how you will measure success, be it over a small community or a large geography, that is the smart approach.
chief executive
A more personalised approach
The growing emphasis on a more personalised service and personalised budgets is interesting. I worked for a long period in learning disability services, which saw a big move towards personal budgets, and it has been recently floated in maternity care and other services. I think they are a good way of service users having some control over their package of care. Sometimes, it can be very complicated to navigate the system: how you access, what you can pay for and what you need. That can become a bureaucratic exercise in itself, which we can simplify.
But there will be no point in personal budgets if there is no real choice. Some areas have limited choice. In London, with dense and multiple services, personal maternity budgets could work well. People can vote with their feet when they see provider star ratings from other services.
I think consumer-driven reviews will become increasingly important, and mental health services could be at the forefront. We emphasise co-production with users on recruitment panels, transformation and evaluation boards. Patients are teaching us about providing a more personalised service. I think the acute sector has much to learn from mental health here.
The future of the purchaser-provider split
Do I still have faith in the purchaser-provider split, and commissioning in general? Broadly, it is still the basis of NHS relationships, but times have changed. This is a very different world from 25 years ago and we must adapt accordingly. Services now are not about one-size-fits-all: we are more holistic about meeting people’s care needs, and there is much more focus on good governance. Finance is more transparent and above board – and that is a good thing. But mental health remains the poor relation.
None of this can be at the expense of trying new things and innovation. So I welcome new care models and organisational forms, and the potential blurring of purchaser and provider roles and responsibilities. Accountable care partnerships will add another welcome dynamic.
Above all, this should be an opportunity to create something new and exciting to meet the needs of our communities.
Read the full Provider Voices: Where next for commissioning?
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