- Reducing unwarranted variation
- Collaborating to deliver person-centred mental health services
- Addressing mental health
Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) provides inpatient and community-based mental health care to 1.9 million people across the south west. AWP is the main provider of secondary mental health services in two integrated care systems (ICSs) – Bristol, North Somerset and South Gloucestershire (BNSSG), and Bath and North East Somerset, Swindon and Wiltshire (BSW).
Collaborating in a complex provider landscape
There is a complex history of commissioning and a mixed economy of mental health service provision across the two systems AWP operates in. This has led to variation in service delivery across and within the BSW and BNSSG ICSs. Dominic Hardisty, chief executive, AWP, reflects that: "Nowhere is that more apparent than in mental health, it's a lottery based on history."
While system partners understood these challenges before the pandemic, Covid-19 prompted further collaboration across both systems. As Dominic says, "when the chips were down, we worked together for patients, and as we emerged, we wanted to continue collaborating to deliver person-centred care close to home." System partners agreed that, for patients, partnership working should mean that there were no obvious dividing lines between services.
A mental health decision making group operates in each ICS. Although work was paused during the height of the pandemic, around 18 months ago these groups were re-started, and have been making significant progress since.
Dominic chairs or joint chairs the BSW and BNSSG ICS mental health decision making group, alongside a vice-chair with a commissioning background. This group involves partners from the NHS, local authorities, and the third sector.
Transparency between partners to nurture system thinking
A mental health finance oversight group (MHFOG) has been set up to support the work of the mental health decision making groups in the BSW and BNSSG ICSs. MHFOG does not have delegated financial responsibility but advises and supports the mental health decision making across the two systems.
The MHFOG also provides an overview of all the money that is being spent on mental health services in each system. In turn, this enables the systems to align contracts, make service changes, and where appropriate, rebalance funding allocations.
The group is led by Simon Truelove, finance director, AWP, who has worked in several provider and commissioner roles across the patch over the last 20 years. Simon says: "This gives me a credibility that I'm not just fighting the battle for AWP." Dominic reiterates the importance of, "wearing the system hat" and says, "it's not about individual organisations, you are focusing on what's best for patients."
Transparency is central to the effectiveness of MHFOG, and there are open discussions between partners about slippage on investments and how they can work collaboratively to ensure that the system can break even or offer money back into the integrated care board. Simon says: "This is true system working, there are no silos." Similarly, he describes the importance of challenging his own trust, as well as others, to demonstrate the value of investments into the sector.
However, there are challenges in shifting towards thinking as a system rather than an individual organisation. MHFOG has adjudicated in disputes between partners about appropriate levels of investment for services, examining where demand and resources were mismatched and helping partners reach agreement. In turn, this has helped to harmonise levels of investment between the BSW and BNSSG ICSs.
Driving forward efficiency and quality for service users
Amid significant resource constraints, the work of MHFOG and the mental health decision making groups enable those working in this footprint to make the best use of mental health money for service users. Also, having a cross system view of funding and spending allows key partners to see potential problems and unwarranted variation, and supports them to work collaboratively to solve these challenges.
For instance, there are three crisis houses in the BSW ICS, and one was funded through a separate, non-recurrent revenue stream to the others. MHFOG investigated this and encouraged partners to question the reasons for this variation. Ultimately, the group advised the mental health decision making group that there should be one consistent delivery model for these crisis houses.
MHFOG is currently working with local information teams to explore ways to reduce demand on secondary mental health services. In one place, third sector partners have been sending staff into AWP teams so that a multidisciplinary team can make an instant referral into the voluntary sector where appropriate. This has cut waiting times for patients and reduced pressure on secondary mental health services.
Overall, collaboration through the decision making and oversight groups has helped system partners to understand each other better. In the past, third sector colleagues in the patch have questioned the proportion of funding going into statutory mental health services. Now, there is a more joined up approach, and an enhanced understanding of what needs to be delivered by each partner.
In the BSW and BNSSG ICSs, the key next step is to formalise the existing mental health decision making groups. At present, the groups operate within a deliberately loose structure, but they believe there is an opportunity to mature and develop in this system. While the BSW ICS is further ahead in this process, due to a different history and context, BNSSG is following a similar trajectory and shares the same ambitions.
For MHFOG, they are looking to move towards open book accounting for all partners, which would mean sharing key financial information across each system, to build on the transparency and trust that exists within the group.
At a national level, the move to block contracts is viewed as supporting collaboration between different organisations and across pathways. Simon is optimistic about the impact that this will have, and says: "We'll see much more of this – that's what system working is all about."
Despite optimism about local collaboration and the national direction of travel, shortages of staff and capital funding remain very significant challenges for the mental health sector. Dominic says: "The mental health investment standard has gone further to achieve parity of esteem than anything else," but he emphasises the urgent need for further capital funding to underpin this progress.