NHS Herefordshire and Worcestershire
Integrated Care Board
Noted
The response outlines the current process for GPs to contact mental health teams, defends its appropriateness, and states that a review by a consultant psychiatrist was not clinically indicated in this case. It also mentions an independent review of the care provided will be shared with the family. (AI summary)
View full response
Dear Mrs Hunt
We are writing to respond to the Regulation 28 Report to Prevent Future Deaths which was addressed to Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care Board. Whilst we recognise our different roles, we are working collaboratively (along with other partners) in identifying the needs of our population for mental health services and ensuring that our services are designed to meet those needs.
Thank you for raising your concerns. We would like to address them each in turn:
Concern 1 – The system for GPs to contact Mental Health Teams for urgent review is not clear nor safe.
The Trust’s current process for enabling urgent access to mental health services is longstanding and we thought well recognised. GPs can contact the Single Point of Access (SPA) who pass the referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and either allocate themselves or the Crisis Team dependant on risk and clinical presentation. If a call comes through out of hours, it goes straight to the Crisis team which is a 24/7 service.
If on the rare occasion no staff are available to take the call (due to being on other calls) there is an answer phone facility or there is an option for the SPA to transfer the call to an alternative HTT to screen the referral.
We recognise that this is a different model to that of Birmingham with which you may be more familiar. Our model is different as our geography is much bigger. In Birmingham, GPs call SPA who then call one number which takes them to a joint Home Treatment Team and Crisis Team.
During our investigation and roundtable discussions the Trust was assured that GPs have been part of the transformation of our services and been provided with all the relevant numbers for their Neighbourhood Mental Health Teams and SPA for referral purposes. These numbers have not changed for several years. Relevant numbers have been confirmed with local GPs and are the
2
same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.
In addition, the Trust acted to remind GP colleagues of the process to contact SPA in communications sent on the 31st December 2022. The following information was reiterated and confirmed:
‘Routine referrals should be sent electronically. All routine referrals will be received via email to the Single Point of Access (SPA) on the following email address: WHCNHS.amhreferrals@nhs.net. Urgent/same day referrals should be telephoned through to the Single Point of Access on 01905 681477. If you need a copy of the referral form, you can contact the administration team on the Single Point of Access telephone number and request a copy. The Crisis Resolution Teams also provides advice on mental health services and presentations to health care professionals via a dedicated professionals line. This can be accessed by contacting the 24/7 Helpline on 0808 1969127.’
As part of striving for continuous improvement our Medical Leadership Forum (which includes the ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and ensure any concerns are addressed.
Concern 2 – The system in place is for the patient to call the Mental Health Practitioner. The patient is likely to be in crisis and therefore the burden should not be put on them to make the call.
We would like to reassure you that a process is in place which does not burden the patient with the responsibility of making a call to initiate engagement with services when in a crisis. In this instance, the patient in this case was not asked by the Home Treatment Team or the Crisis Team to call them at any point. Further, it is never the usual process for a patient to contact Home Treatment following a referral from a GP. The call takers from both the Home Treatment Team and the Crisis Team, who took the call from the SPA on the day in question both state they did not ask the GP to tell the patient to call either team. This is supported by the contemporaneous recording following the conversations.
The process is once the referral is triaged and accepted by Home Treatment (or the Crisis Team) from a GP, the Home Treatment Team contact the patient to initiate the engagement. On this occasion, the Crisis Team had clinical contact through the patient’s GP, prior to the Home Treatment Team. As soon as the Crisis Team referred back to the Home Treatment Team, a telephone call was received into the Home Treatment Team directly from the patient. The HTT call taker has expressed their ‘surprise’ at receiving an incoming call from the patient as this is not part of our process. The patient had not been directed to initiate contact by either the Crisis Team or the Home Treatment Team and therefore we cannot explain why the patient picked up the phone and called the Home Treatment Team directly.
However, in this instance it is believed the patient was also aware of our Healthy Minds Service through his professional role. This service is delivered adopting the national model of Increasing Access to Psychological Therapies (IAPT) programme. This service relies on the patient being self-motivated and engaging for their treatment to be beneficial. Referrals to Healthy Minds include self-referrals, so clinical staff wondered if this was why the patient called the team direct.
We hope the above assures you that patients in crisis would never be expected to contact either the Crisis or Home Treatment Team, with those teams contacting patients.
3
Concern 3 - GPs should be fully aware how to request an urgent psychiatric review for a patient.
The Trust follows a national model which allows GPs to refer for an urgent psychiatric assessment in terms of a psycho-social assessment by a Home Treatment or Crisis Clinician, and within that they can provide an opinion that they believe a medical review from a psychiatrist is required. However, the gatekeeping for this, as well as the responsibility to arrange it, falls on the Home Treatment and/or Crisis Clinician completing the subsequent assessment. GPs can also refer to the Neighbourhood Mental Health Team for a review from a psychiatrist although this route is not intended for urgent referrals.
The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a psychiatrist. We understood that they were reassured that the Trust follows the national model. Within our process the patient can see a consultant psychiatrist if they were taken on by the Home Treatment Team, as medical reviews are an integral part of how that team operates. The action from the investigation was therefore to ensure that local GPs were supported and provided with this information going forward. Again, this was achieved by sending all GPs direct communications with a reminder of this information on 31st December 2022. In addition, we have ensured that the relevant information is on Teamnet and also regularly discussed in the local primary care network meetings between GPs and their local mental health teams. As part of our engagement with primary care, each practice has a named contact in their local mental health team, to raise any concerns if they arise.
The main area of confusion appeared to be that the GP wanted an urgent review by a consultant psychiatrist and the Home Treatment Team only provide this for patients who are being brought onto their team for visits. The patient did not want Home Treatment Team input but agreed to medication changes which he suggested himself. It was identified that the GP wanted a specialist psychiatric review due to her concerns that the patient was “leading his own treatment plan”.
As the patient declined the input of the HTT other than a one-off assessment, he was not seen by the team, which would have involved medical review.
Both the Trust and ICB are working closely with primary care to ensure that our services are fit for purpose and have mechanisms in place to discuss any concerns that arise. The issues that have been raised will be discussed through these local fora on an anonymised basis, to capture any additional actions. As part of our operational delivery of mental health services, work has been commissioned from a third party to better understand the patient experience, one of our priority areas will be to review the crisis pathway to identify any further improvements.
Whilst we appreciate your concerns our clinical view is that the current system, which follows the national model, is appropriate. If following an urgent assessment/review by one of our gatekeeping teams (Crisis Resolution or Home Treatment) there is an identified need for urgent medical input, we have access to psychiatrists in hours or on-call psychiatrists out of hours. However, in this case, our view was that a review by a consultant psychiatrist was not clinically indicated and following the internal investigation we were satisfied that the outcome of the assessment was appropriate.
As you will be aware, the Trust reviewed the care provided in this instance and would ordinarily then provide that review to the ICB for approval. Given Dr Ellson’s professional role at the ICB, arrangements were made for the Trust report to be subject to review by an independent third party. This has now concluded and the outcome will be shared with Dr Ellson’s family.
4
From the Trust’s perspective it is recognised that some of the evidence provided here was not given at Court, even though a number of clinical staff had provided statements for preparation of the Inquest, they were not required to adduce oral evidence. It is accepted that proportionality is important in determining who will adduce oral evidence at a hearing, our learning is that had one of these witnesses attended Court they may have been able to address your concerns in evidence.
Neither the Trust or ICB has any representations to make in respect of publication of this response.
We hope that the above adequately responds to your concern, however, if you consider it is helpful to discuss further do not hesitate to contact either the Trust or ICB.
We are writing to respond to the Regulation 28 Report to Prevent Future Deaths which was addressed to Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care Board. Whilst we recognise our different roles, we are working collaboratively (along with other partners) in identifying the needs of our population for mental health services and ensuring that our services are designed to meet those needs.
Thank you for raising your concerns. We would like to address them each in turn:
Concern 1 – The system for GPs to contact Mental Health Teams for urgent review is not clear nor safe.
The Trust’s current process for enabling urgent access to mental health services is longstanding and we thought well recognised. GPs can contact the Single Point of Access (SPA) who pass the referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and either allocate themselves or the Crisis Team dependant on risk and clinical presentation. If a call comes through out of hours, it goes straight to the Crisis team which is a 24/7 service.
If on the rare occasion no staff are available to take the call (due to being on other calls) there is an answer phone facility or there is an option for the SPA to transfer the call to an alternative HTT to screen the referral.
We recognise that this is a different model to that of Birmingham with which you may be more familiar. Our model is different as our geography is much bigger. In Birmingham, GPs call SPA who then call one number which takes them to a joint Home Treatment Team and Crisis Team.
During our investigation and roundtable discussions the Trust was assured that GPs have been part of the transformation of our services and been provided with all the relevant numbers for their Neighbourhood Mental Health Teams and SPA for referral purposes. These numbers have not changed for several years. Relevant numbers have been confirmed with local GPs and are the
2
same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.
In addition, the Trust acted to remind GP colleagues of the process to contact SPA in communications sent on the 31st December 2022. The following information was reiterated and confirmed:
‘Routine referrals should be sent electronically. All routine referrals will be received via email to the Single Point of Access (SPA) on the following email address: WHCNHS.amhreferrals@nhs.net. Urgent/same day referrals should be telephoned through to the Single Point of Access on 01905 681477. If you need a copy of the referral form, you can contact the administration team on the Single Point of Access telephone number and request a copy. The Crisis Resolution Teams also provides advice on mental health services and presentations to health care professionals via a dedicated professionals line. This can be accessed by contacting the 24/7 Helpline on 0808 1969127.’
As part of striving for continuous improvement our Medical Leadership Forum (which includes the ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and ensure any concerns are addressed.
Concern 2 – The system in place is for the patient to call the Mental Health Practitioner. The patient is likely to be in crisis and therefore the burden should not be put on them to make the call.
We would like to reassure you that a process is in place which does not burden the patient with the responsibility of making a call to initiate engagement with services when in a crisis. In this instance, the patient in this case was not asked by the Home Treatment Team or the Crisis Team to call them at any point. Further, it is never the usual process for a patient to contact Home Treatment following a referral from a GP. The call takers from both the Home Treatment Team and the Crisis Team, who took the call from the SPA on the day in question both state they did not ask the GP to tell the patient to call either team. This is supported by the contemporaneous recording following the conversations.
The process is once the referral is triaged and accepted by Home Treatment (or the Crisis Team) from a GP, the Home Treatment Team contact the patient to initiate the engagement. On this occasion, the Crisis Team had clinical contact through the patient’s GP, prior to the Home Treatment Team. As soon as the Crisis Team referred back to the Home Treatment Team, a telephone call was received into the Home Treatment Team directly from the patient. The HTT call taker has expressed their ‘surprise’ at receiving an incoming call from the patient as this is not part of our process. The patient had not been directed to initiate contact by either the Crisis Team or the Home Treatment Team and therefore we cannot explain why the patient picked up the phone and called the Home Treatment Team directly.
However, in this instance it is believed the patient was also aware of our Healthy Minds Service through his professional role. This service is delivered adopting the national model of Increasing Access to Psychological Therapies (IAPT) programme. This service relies on the patient being self-motivated and engaging for their treatment to be beneficial. Referrals to Healthy Minds include self-referrals, so clinical staff wondered if this was why the patient called the team direct.
We hope the above assures you that patients in crisis would never be expected to contact either the Crisis or Home Treatment Team, with those teams contacting patients.
3
Concern 3 - GPs should be fully aware how to request an urgent psychiatric review for a patient.
The Trust follows a national model which allows GPs to refer for an urgent psychiatric assessment in terms of a psycho-social assessment by a Home Treatment or Crisis Clinician, and within that they can provide an opinion that they believe a medical review from a psychiatrist is required. However, the gatekeeping for this, as well as the responsibility to arrange it, falls on the Home Treatment and/or Crisis Clinician completing the subsequent assessment. GPs can also refer to the Neighbourhood Mental Health Team for a review from a psychiatrist although this route is not intended for urgent referrals.
The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a psychiatrist. We understood that they were reassured that the Trust follows the national model. Within our process the patient can see a consultant psychiatrist if they were taken on by the Home Treatment Team, as medical reviews are an integral part of how that team operates. The action from the investigation was therefore to ensure that local GPs were supported and provided with this information going forward. Again, this was achieved by sending all GPs direct communications with a reminder of this information on 31st December 2022. In addition, we have ensured that the relevant information is on Teamnet and also regularly discussed in the local primary care network meetings between GPs and their local mental health teams. As part of our engagement with primary care, each practice has a named contact in their local mental health team, to raise any concerns if they arise.
The main area of confusion appeared to be that the GP wanted an urgent review by a consultant psychiatrist and the Home Treatment Team only provide this for patients who are being brought onto their team for visits. The patient did not want Home Treatment Team input but agreed to medication changes which he suggested himself. It was identified that the GP wanted a specialist psychiatric review due to her concerns that the patient was “leading his own treatment plan”.
As the patient declined the input of the HTT other than a one-off assessment, he was not seen by the team, which would have involved medical review.
Both the Trust and ICB are working closely with primary care to ensure that our services are fit for purpose and have mechanisms in place to discuss any concerns that arise. The issues that have been raised will be discussed through these local fora on an anonymised basis, to capture any additional actions. As part of our operational delivery of mental health services, work has been commissioned from a third party to better understand the patient experience, one of our priority areas will be to review the crisis pathway to identify any further improvements.
Whilst we appreciate your concerns our clinical view is that the current system, which follows the national model, is appropriate. If following an urgent assessment/review by one of our gatekeeping teams (Crisis Resolution or Home Treatment) there is an identified need for urgent medical input, we have access to psychiatrists in hours or on-call psychiatrists out of hours. However, in this case, our view was that a review by a consultant psychiatrist was not clinically indicated and following the internal investigation we were satisfied that the outcome of the assessment was appropriate.
As you will be aware, the Trust reviewed the care provided in this instance and would ordinarily then provide that review to the ICB for approval. Given Dr Ellson’s professional role at the ICB, arrangements were made for the Trust report to be subject to review by an independent third party. This has now concluded and the outcome will be shared with Dr Ellson’s family.
4
From the Trust’s perspective it is recognised that some of the evidence provided here was not given at Court, even though a number of clinical staff had provided statements for preparation of the Inquest, they were not required to adduce oral evidence. It is accepted that proportionality is important in determining who will adduce oral evidence at a hearing, our learning is that had one of these witnesses attended Court they may have been able to address your concerns in evidence.
Neither the Trust or ICB has any representations to make in respect of publication of this response.
We hope that the above adequately responds to your concern, however, if you consider it is helpful to discuss further do not hesitate to contact either the Trust or ICB.