Clinical director / Consultant Forensic Psychiatrist
South West Provider Collaborative / Devon Partnership NHS Trust
Jason is the clinical director for South West Provider Collaborative for Devon Partnership NHS Trust and is responsible for directing the re-design of clinical care pathways across the south west, in order to ensure that individuals in receipt of secure care are treated as close to home as possible, for the shortest possible period, within the least restrictive level. Jason is an experienced consultant forensic psychiatrist and previous clinical director of a good/outstanding rated secure service. He has worked within healthcare settings both internationally and within the NHS over the course of his career.
Mental health services for adults in low and medium secure care are commissioned by NHS England. Following a number of reviews, it was quite clear that there was an escalating demand for secure services as well as escalating costs, but there was no clear agreed clinical model or other mitigations to address these escalations, other than a moratorium on further procurement of secure services.
Incremental contracting over several years had left services uncoordinated. Clinicians and managers of services were trying to do the best for their populations, but by working in isolation the population need of the entire region was poorly understood. A number of reports essentially recommended placing providers and senior clinicians at the heart commissioning for their populations. A number of national pilots, aligned to the aims articulated in The five year forward view, were launched across the country. Known as the new care models, these pilots would bring together providers, senior clinicians and service users to co-design services to meet the needs of the population.
We were one of four sites chosen to become a secure services new care model. In 2016-17 the budget spend on secure care inpatient services was transferred to South West Provider Collaborative, allowing us to redesign services within the cash envelope. The aim was to ensure that anybody who needs to receive adult medium and low secure care gets it as close to home as possible, at the right level of security and for the shortest possible period. A further aim was to develop viable community alternatives to inpatient care (where appropriate) considering this first and foremost, rather than just admitting the person to inpatient services.
Our partnership is made up of five NHS organisations, one community interest company and two independent sector providers. One area where we are different from the other new care models is that every provider that provides medium and low secure services in the south west is part of our partnership. When we went live, we spanned 11 CCGs, covering a 22,000 square kilometre footprint and serving a population of five million.
Caring for patients closer to home
We had to either find a way of providing a community alternative or increase capacity in region by building more hospital beds to bring people closer to home. Historically, the south west has been underprovided for. There were more than 400 people in adult low and medium secure inpatient beds when we went live and more than 200 of them were being treated outside the south west. We had under provision of female services in particular – when we went live nearly 80% of our female patients needing secure services were dotted around the country compared to almost 50% of our males.
All our in-region providers worked in separate silos, so there was no overview of the total bed stock. If somebody from Cornwall needed a male low secure bed but the low secure service in Cornwall was full, the system would place the person wherever the first available bed in the country was identified. That might have been in Norwich – there was no consideration of whether there might have been a bed available just over the border in Devon.
We had to either find a way of providing a community alternative or increase capacity in region by building more hospital beds to bring people closer to home.
Only two of the now six STP footprints – Cornwall and Somerset – had a community forensic team, so for all the other areas, the only way to access specialist forensic services was by being admitted as an inpatient. One of our key strategic aims was to invest in community provision as an alternative to inpatient services, as we released efficiency savings by reducing the cost of the total inpatient cohort.
A further benefit of community forensic services is that where they are co-located with an inpatient service, you divert service users at the very beginning because there's a community alternative. You also reduce their length of stay if they do need admission because there's a very clear care pathway set out from the beginning of the admission. This enables you to use your inpatient beds more efficiently, thereby enabling you to reduce practices of sending people out of area to access care.
Making change in the absence of pump-priming funds
One of the asks at the beginning of this programme was for pumppriming investment in order to fund community forensic teams as we saw these as the vehicle for achieving the change needed. Unfortunately this was not available, but as the national programme progressed, money was eventually released and this was re-invested in national pilots for specialist community forensic teams. We were fortunate to succeed in our bid to be a wave 1 pilot site in Devon. In March 2020 it will have been in operation for two years.
That team has already demonstrated efficiency savings by reducing the number of people in secure services for the population they serve (namely Devon). As they've reduced the number of people, we've been able to use fewer and fewer out-of-area beds. This, alongside other initiatives, has reduced the number of people in secure inpatient services within region, as well as reduced the length of time they stay in these services, to the point where our efficiency savings release is more than enough to fully fund this service from April 2020. We have now also secured funding for wave two specialist community forensic teams in one of our other big providers. We are more than hopeful that the gains made for Devon can now expand into Bristol, North Somerset and South Gloucester.
We've also been able to support investment in specialist personality disorder community forensic services, which has potential in releasing further efficiencies that we can then use to invest in community services, ensuring the entire south west benefits from comprehensive specialist community forensic team coverage. In hindsight, if there was pump priming earlier in this whole programme, I think we'd probably have been a lot further along than we are now.
The other bit that we can celebrate is that, at absolutely no cost to the health economy, we've commissioned a new 75 bedded secure service in our region. One of our providers – Elysium – is providing this hospital right in the centre of our geography. Elysium provided the capital and built the facility. We filled this facility with people from the south west who needed secure inpatient care but were placed miles from home in out of region beds. So instead of paying for them to be treated miles from home, we pay for them to be treated in region. Only people from the south west use those beds. They have come home to the south west. According to our latest figures, we've now repatriated over 140 people. Where we started with over 200 people out of region, we've now got less than 40 people left out of region to repatriate home. All of this has been delivered without any additional cost.
We do have a gain and risk share arrangement with some of our partners. Over the first two years we continued to see the escalation in demand and costs leading to cost pressures of £16m, however, these were offset by £15m worth of clinical efficiencies. Between the risk and gain share providers, we incurred a cost of about £1m over the first two years. But this year all our innovations and initiatives are starting to bear dividends so we’ve now been able to pay that back as well as invest and have a sustainable business model. It hasn't come without having a high-risk appetite.
Creating stronger bonds between specialist and generalist services
Historically, NHS specialised commissioning was very niche, and many local commissioners saw it as something that NHS England did that they don't need to get involved in. The devolvement back into provider collaboratives has reignited the sense of responsibility within the south west.
As lead provider, employed by Devon Partnership NHS Trust, we have fully divested ourselves from the provider arm in terms of governance and leadership. Our governance has an internal firewall all the way to board level. We quality assure and performance manage Devon Partnership Trust's provider arm in the same way as we would any other organisation. We do work closely with our CCG colleagues quality assuring the services we commission and we've designed our governance from scratch, which I think is a good thing as it truly forces innovative solutions.
At absolutely no cost to the health economy, we’ve commissioned a new 75 bedded secure service in our region.
We have also had to work closely with CCGs through the STP's developing joint commissioning intentions, as we've now moved into commissioning community forensic services, which traditionally CCGs have commissioned. We want to ensure that together we commission whole pathway services. Historically, it is acknowledged that there’s been a lack of comprehensive commissioning of community services for this patient group across the entire region but this new joined-up approach has the potential to provide more comprehensive solutions as a system to meet the needs of the south west population as a whole.
One of the benefits of this programme is that we were able to harness senior clinical leadership, bringing senior clinicians on board at the very beginning. I think it’s the coming together of these senior clinicians and the senior operational managers to co-design solutions that has been one of the key enablers of our success. There is a clear understanding that everything hangs on meeting the strategic aims, and if there's any deviation from that, there has to be a very clear clinical or patient-led reason why. This has turned commissioning on its head and put clinical drivers at the forefront of service re-design rather than financial or other aspects.