Independent Oversight and Assurance Group on Tayside's Mental Health Services

Integration Work Plan

32. This work plan brings together six recommendations from Trust and Respect, including the functioning of integration, strategic planning, dual diagnosis provision and crisis support, and advocacy availability.

33. In our activity on this work plan, we are particularly grateful to the very many service users and staff of community based mental health and learning disability services across Tayside, who have met with us and shared their stories and their experiences of community services and how well or otherwise, the integration of health and social care is working.

34. We appreciate being involved in some of the discussions convened by the very collaborative and inclusive Integration Scheme Review Group in the work that they were commissioned by the Health Board and Councils to undertake, to review the existing Integration Schemes.

35. We are grateful also to have been afforded the opportunity to meet with the Chairs, Vice Chairs and Chief Officers of the respective Integration Joint Boards and for us to present to them our reflections of their work and functioning.

36. There has been a significant review of the three Integration Schemes undertaken by NHS Tayside and the three local authorities. This was consistently described to us as a 'light touch' review, although we found it to be an extensive piece of work, with considerable investment of senior resource across the partnership.

37. In our view, the revised schemes in Dundee, Angus and Perth and Kinross now provide clarity on roles and responsibilities for mental health and learning disability services in Tayside. This was a central concern from the original Trust and Respect report.

38. All Partners are now clear that Perth and Kinross Integration Joint Board has the lead coordinating role for strategic planning and commissioning of the delivery of inpatient mental health and learning disability services. Dundee and Angus Integration Joint Boards are also clear that Perth and Kinross Integration Joint Board having this lead coordinating role, does not absolve them of their statutory duty to plan and commission for this delegated function. They must continue to participate and collaborate with Perth and Kinross in this activity, along with the Health Board, to achieve this effectively. We note the establishment of a Short-Life Working Group with representation of the 3 Integration Joint Boards and NHS Tayside to prepare a governance, reporting and decision-making structure for services coordinated by a Lead Partner.

39. We have previously expressed our concern about the very short consultation periods on the revised schemes in the three areas. Our work in Tayside involved us attending the Health Board meeting in June 2022 at which the Integration Schemes were presented for approval, we were not in attendance at the respective Councils' meetings considering the same issue. We noted that the revised Integration Schemes received no scrutiny at NHS Tayside's Board meeting in June 2022 within our third quarterly report to the Minister for Mental Wellbeing and Social Care.

40. Perth and Kinross Integration Joint Board has a clear lead coordinating role on behalf of all three Integration Joint Boards in relation to Mental Health and Learning Disability provision. Material decisions that are made on any matter of health and social care commissioning by an Integration Joint Board, should only be made following extensive and effective community engagement (including with Health Board and local authorities) and an open and transparent strategic planning approach. We have indicated to Tayside Executive Partners that they and their respective organisations, therefore need to remain fully engaged in the planning and delivery of Mental Health and Learning Disability services.

41. In our second quarterly report, we highlighted 3 specific areas that required urgent attention in respect of progressing a decision around single site provision in Tayside for inpatient mental health care; the physical environment in Strathmartine and addressing the issue of significant delayed discharges. We have addressed the need to make progress in respect of these, in the key priorities section of this report.

42. While the new integration schemes provide much greater clarity around mental health and learning disability services, there remain one or two issues that still require careful consideration in order to provide transparency and avoid confusion or inaction by Integration Joint Boards. These include the Lead Partner arrangements for primary care, which appear to now have placed the operational delivery responsibility with the Angus Chief Officer, and certain children health services for which Integration Joint Boards have clear strategic planning and commissioning responsibilities.

43. Having approved the revised schemes the key issue is how they will operate in practice, and how the three Integration Joint Boards and the Health Board work together, to bring clearer leadership for mental health services that improves quality and public trust in the service. Simply rewording a document will of itself make no difference to planning and operational delivery. Intentional action will be required by Integration Joint Boards, Chief Officers, Health Board and Councils if there is to be real and meaningful changes to the way business is done. We are advised that a development session will take place before end of February 2023 with Members of NHS Tayside Board and Chairs and Vice Chairs of Integration Joint Boards participating on this issue and this is to be welcomed.

44. We have made presentations to the Chairs, Vice Chairs and Chief Officers of all three Integration Joint Boards and to Tayside Executive Partners on how we believe the Integration Joint Boards have functioned since the beginning of 2019. We are encouraged by the developmental work that has already taken place in Angus and Perth and Kinross following our engagement, and we are confident that this will be continued across all three Integration Joint Boards.

45. Our work has identified that Integration Joint Boards in Tayside have tended to be too passive in taking on the role and responsibilities that the Public Bodies legislation envisaged. We have previously reported very good integrated health and social care provision in some areas, including some of national significance. Specifically, we have commended the Discharge Hub in Dundee; the work undertaken in Dundee to understand and make appropriate provision for autism in the universities; maximising the opportunities available through Action 15 funding in Angus; the streamlining of approaches to assessment of Autism Spectrum Disorder (ASD) in Arbroath; peer support provision; the provision of 24/7 crisis support by The Neuk in Perth is an exemplar service; the work of 'The Saints' at St Johnstone points to the reach and positive impact football continues to have within communities; and the quality of support and services provided by voluntary organisations across Tayside.

46. Most of the commissioning of services has thus far not been as a result of Integration Joint Board decision making, but instead has been led by Health and Social Care Partnerships and Chief Officers: indeed, most of the above provision has never been visible, in formal reporting terms, to any of the respective Integration Joint Boards. This lack of visibility of community resources and supports is a key issue for Integration Joint Boards in respect of them having oversight and being able to own their role and responsibilities, and Chief Officers, the Health Board and respective Councils, need to support them to do this.

Recommendation 2

Conduct an urgent whole-system review of mental health and wellbeing provision across Tayside to enable a fundamental redesign of mental health and wellbeing services for Tayside

Context of Oversight Group assessment: The development and publication of Living Life Well and adherence to progressing simultaneously the 31 work streams in 6 complex change projects within 7 different themes.

47. Tayside Executive Partners have indicated a RAG status of Amber in their final submission, a change from their previous assessment of Green in June 2021. The Oversight Group acknowledges and welcomes this reflection and amendment by Tayside Executive Partners on the extent of the progress made.

48. Dr Strang highlighted in his Progress Report that there was neither an implementation plan nor a resource framework in relation to Living Life Well, an issue that the Oversight Group has consistently referenced during our involvement. It is noted that these two key elements remain outstanding.

49. The Oversight Group has clarified that none of the Integration Joint Boards, as strategic decision-making bodies with commissioning responsibilities, had been formally engaged in the development of Living Life Well and it is a matter of record that all of them essentially only 'noted' the publication of the Plan. The absence of a financial framework remains a barrier to ensuring that all partner organisations can genuinely sign up to Living Life Well.

50. Tayside Executive Partners have set out a significant level of proposed further actions that will be coordinated by the Chief Officer, Perth and Kinross Health and Social Care Partnership. It is to Perth and Kinross Integration Joint Board and the Health Board's credit that these proposals for further action were fully supported and endorsed at their respective meetings in August 2022.

51. The extent of the challenge to achieve material and sustainable progress on each of these proposals should not be underestimated.

52. We are of the view that the Tayside approach, which is endeavouring to deliver on all work streams set out within Living Life Well concurrently, is unrealistic. The approach risks contributing to paralysis in the system, with planning and development effort spread too thinly to achieve anything meaningful in the required timescales. The governance structures for mental health also continue to be overly complex and unclear in terms of who has responsibility for what, and further reflection is required to ensure that it aligns appropriately with the revised Integration Schemes.

53. The Chief Officers and the Integration Joint Boards will need tangible ongoing support from Tayside Executive Partners to take forward these proposals. There is a long way to go on this recommendation and for this reason, the Oversight Group RAG rate this recommendation as Amber.

Recommendation 5

Review the delegated responsibilities for the delivery of mental health and wellbeing services across Tayside, to ensure clarity and understanding of the commitment between NHS Tayside and the three Integration Joint Boards. This should include the decision to host General Adult Psychiatry Inpatient services in Perth and Kinross Integration Joint Board.

Context of Oversight Group assessment: The lack of clarity across Tayside about roles and responsibilities of the respective public bodies in respect of the planning, commissioning, delivery and oversight of health and social care services.

54. A significant amount of work has been undertaken by the Health Board and three Councils in reviewing the Integration Schemes. The revised Schemes provide greater clarity of roles and responsibilities in the planning and delivery of health and social care provision across Tayside, and particularly in Mental Health and Learning Disability provision.

55. We have set out in our earlier reports some of the issues that Tayside Executive Partners should continue to reflect on in relation to the revised Integration Schemes. For example, the nature of the consultation undertaken in all three and how this relates to Trust and Respect issues about engagement, together with the need for clarity about Lead Partner responsibilities in Primary Care and certain children's health services.

56. We have indicated to all parts of the integrated system, including to Tayside Executive Partners, that merely re-writing parts of the Integration Schemes of itself will be insufficient in removing the confusion that has previously beset Tayside Executive Partners.

57. The Integration Joint Boards now need to embark on an ongoing development programme to ensure that their Members understand and effectively discharge their role and responsibilities. This includes strategic planning, the commissioning of services from the Health Board and respective Councils through Directions and having oversight of the performance of commissioned services. Equally, the Health Board and each of the Councils are also going to need to reflect on and adapt how they respond and embrace three Integration Joint Boards properly taking on their roles and responsibilities in future.

58. We have been encouraged by the speed of response by two of the three Integration Joint Boards on this, with development sessions already having been undertaken on what the revised Schemes mean for them and how are they going to do business in future. We welcome the work that has been undertaken in establishing common Directions approaches to ensure accountability is able to be applied.

59. We have been particularly encouraged by the coordinating leadership of the Chief Officer of Perth and Kinross Health and Social Care Partnership in bringing together the other Chief Officers, the Executive Director of Nursing and the Medical Director. Together, they are demonstrating a preparedness to engage on mental health and learning disability in a way that hasn't happened previously in Tayside. This level of senior collaborative working exclusively on integrated health and social care activity is commendable and could be a model worthy of consideration across Scotland.

60. Oversight Group give this a RAG status of Green.

Recommendation 13

Ensure that there is urgent priority given to strategic and operational planning of community mental health services in Tayside. All service development must be in conjunction with partner organisations and set in the context of the community they are serving.

Context of Oversight Group assessment: The need for effective local delivery and joined-up and coordinated strategic planning in a multi-partnership Health Board area.

61. Each of three Integration Joint Boards now have in place a strategic approach to community mental health services, with Perth and Kinross the last of the Integration Joint Boards to approve its strategy in December 2021.

62. A high-level review of the business of all three Integration Joint Boards between January 2019-December 2021 has been undertaken by the Oversight Group and shared with Chairs, Vice Chairs and Chief Officers. This has highlighted that while all three have an agreed strategic approach to mental health and learning disability provision, there has been infrequent review of progress by the Integration Joint Boards throughout this period, and there have been virtually no decisions taken by any of the Integration Joint Boards to commission services in line with their approved strategy.

63. However, that is not to say nothing has happened. As we have reported elsewhere, we have seen instances of very good, innovative provision, some of which is of national importance. But none of it appears to have been commissioned by Direction through the local Integration Joint Boards.

64. Decision making has in the main been undertaken by the Health and Social Care Partnership and/or the Chief Officer. This approach can lead to disjointed and inconsistent provision across Tayside and even within Health and Social Care Partnership areas. Action taken as set out in recommendation 5 will address this going forward and will establish effective governance around decision making and oversight.

65. Mention has already been made of the 3 recommendations we made within our second quarterly report. Within the parameters of the revised Integration Schemes, the Integration Joint Boards will have to own the collaborative and inclusive planning and decision making on these challenging issues, if progress is to be made. This also applies to achieving a pan-Tayside shift in the balance of care and ensuring that effective and consistent community mental health services are in place. The early leadership from the Chief Officer from Perth and Kinross Health and Social Care Partnership to coordinate activity is a promising indication that there is a commitment and drive to change the way that mental health and learning disability services are planned and delivered through Integration Joint Boards. This should be encouraged and supported by the Health Board and respective Councils in support of the Integration Joint Boards.

66. Tayside Executive Partners appropriately acknowledge 'the scale of work that remains to be achieved in order to ensure good mental health and wellbeing outcomes for the people of Tayside'. The Oversight Group acknowledges this and assess this recommendation as Amber.

Recommendation 14

Consider developing a model of integrated substance use and mental health services.

Context of Oversight Group assessment: The needs of individuals with a dual diagnosis of Mental Health and substance use were shown through Dr Strang's review not to be met across Tayside.

67. The Mental Welfare Commission published their report 'Ending the Exclusion' in September 2022 and were 'concerned to find that national guidance and standards that emphasise the need for services to work closely together to meet all the needs of a person, have not been realised' and concluded that 'current service provision is not good enough'.

68. As Tayside Executive Partners acknowledge, the focus across Tayside in the last three months has been on Medication Assisted Treatment Standards 1-5, in line with Scottish Government direction. Medication Assisted Treatment Standard 9, with a focus on people with a dual diagnosis, will be addressed at a later date.

69. Some activity has progressed in Tayside over recent times, but the output has been limited and the impact on people who need services has been negligible in terms scale and reach. This is not to devalue the initial important work that has been undertaken with Healthcare Improvement Scotland and in projects such as the Dundee Women's Service, but the numbers of individuals considered and supported are a tiny fraction of the overall population and there is a real issue of recency of action and the pace required is not where it needs to be.

70. The Mental Welfare Commission commended the work of the North Angus Hub as an exemplar in respect of a 'one door' approach to mental health provision regardless of the level of need. The Oversight Group has visited this service, met with the team and been impressed by their approach, commitment, and impact. It would be one of the services that we consider to be of national significance, not least because of the involvement of peers in the approach.

71. However, at the time we visited in June, the service had still to be rolled out across the rest of Angus. Despite the Team Leader making 9 or 10 presentations on the approach to colleagues across Tayside, there had been no commitment to roll out across the Board area.

72. It is our view that the work on this issue has been fragmented. In June we expressed our concern to Tayside Executive Partners, via their Executive Lead for our Integration work plan, that the activity underway on this recommendation was not coordinated in the way that it needs to be, nor that it had the required pace. In our discussions with colleagues, we have indicated our view that Medication Assisted Treatment Standard 9, if achieved, delivers on this recommendation and requested the Tayside plan to deliver Medication Assisted Treatment Standard 9 to be submitted to us. As indicated above, there is no plan as yet. It is worth remembering that Trust and Respect preceded the Medication Assisted Treatment Standards by some two years.

73. We have heard that there continues to be a 'siloed' approach between Community Mental Health Teams and substance use services in too many places. We heard of a 'three strikes and out' approach regarding appointments offered and not taken up in both Community Mental Health Teams and alcohol and drug services, resulting in a closed case outcome and a return to the GP who made the referral in the first place. A revolving door of provision. Tayside Executive Partners advise us that the system is that people are offered two appointments and then an opt-in letter as a general standard. Beyond that, Tayside Executive Partners advise that there would be safeguard and welfare checks, however, this is subject to there being a known level of risk.

74. Tayside Executive Partners have rated their RAG status as Amber on this recommendation, however, their further proposed actions are limited in number and substance. The Oversight Group is very concerned about the lack of strategic and coherent progress on this issue over the nearly three years since Trust and Respect and particularly given the presence of the Dundee Commission and its output over recent times.

75. Given the absence of a clear plan to deliver on this recommendation and subsequently Medication Assisted Treatment Standard 9, in our view a RAG rating of Red is appropriate.

Recommendation 16

Prioritise the re-instatement of a seven-day crisis resolution home treatment team service across Angus.

Context of Oversight Group assessment: The inequitable service provision for people across Tayside at the point of crisis in their mental health.

76. A seven-day service has been reinstated across Angus and fully operational since September 2021. The service has been evaluated and review recommendations have been made to ensure the embedded nature of this service going forward.

77. There are some issues of sustainability of the service given the dependence on existing staff levels to cover a seven-day period as the evaluation of the service highlighted. This is presently being addressed by Angus Health and Social Care Partnership.

78. Oversight Group assess a RAG rating of Green.

Recommendation 26

Make appropriate independent carer and advocacy services available to all patients and carers.

Context of Oversight Group assessment: The recognition that the most vulnerable individuals are often least able to represent themselves and need independent support to advocate on their behalf.

79. We met with representatives from all 6 of the advocacy organisations who were notified to us by Tayside Executive Partners as delivering advocacy services. It is fair to say that their perspective of availability and sufficiency of provision for carers and patients, varies considerably from that reported by Tayside Executive Partners in their final submission.

80. Almost all of the advocacy organisations we met with have had to restrict the availability of their services to circumstances where statutory powers have been exercised in respect of a patient's care. Even with this prioritisation, organisations are having difficulty meeting the demand for their service. One of the organisations we met with had not placed any restrictions on the availability of their service and they currently have a six-month waiting list. We are to understand that the organisation has put in place arrangements to maintain contact with people whilst they are on this list.

81. In their feedback, Tayside Executive Partners have indicated that they have encouraged some services to not limit their referrals but to maintain a watching brief on the understanding that if the situation worsens, they can be reprioritised. At the same time, Tayside Executive Partners have stated that in respect of the organisation that didn't limit its referrals, they believe that was the right thing to do.

82. From our discussions, we gained an appreciation of the difficulties organisations had encountered throughout Covid and the steps they were taking to remobilise their respective services. We heard about the difficulties organisations have faced through time limited funding for discreet elements of their services.

83. Given the scope of this recommendation, we were surprised to hear that no discussion had taken place with advocacy services collectively, on how the recommendation could be met and resources maximised.

84. From their final submission, there appears to be very little movement in the Tayside Executive Partners' position to that which was established and reported on in June 2021. Having met representatives of advocacy organisations we would encourage Tayside Executive Partners to ensure that those who commission services work more closely with third sector providers to offer guidance and support in terms of their service delivery. The Oversight Group continue to be of the view that this is Amber rated.