NHS England
NHS / Health Body
Action Planned
NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion regarding prevention services for alcohol, drug misuse and homelessness; the Intensive Support Team (IST) will provide support in December 2018. (AI summary)
View full response
Dear Mrs Hunt; Re: Regulation 28 Reports to Prevent Future Deaths cases and funding concerns Thank you for your Regulation 28 Report dated October 4 2018 concerning linked deaths identified by Birmingham and Solihull coroners with commensurate concerns about demands on NHS providers of mental health services and chronic underfunding of mental health services_ also thank you for forwarding letters from the Medical Directors of the 2 trusts providing services which support your concerns_ Thank you for forwarding the 7 regulation 28 reports Firstly , would like to express my deep condolences to the family of each of these individuals would also like to add that NHS England regards the concerns raised as a matter of great import and has carefully considered the response below: The regulation 28 reports conclude series of concerns which will summarise as follows_ High quality care for all, now and for future generations
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the above issues_ On November 12th 2018 NHS England received correspondence from the Birmingham and Solihull Clinical Commissioning Group (CCG) following a review of Regulation 28 letters and Provider responses_ The CCG noted that FTB had communicated a view that demand and funding were significant underlying issues; The view of BSHMFT also highlighted demand related issues but did not overtly articulate funding as an issue. The CCG commissions mental health services at Tier 1, 2 3 and 4 for adults and for Children and Young people (0-25 years of age), tiers 1,2 and 3 (with Tier commissioned by Specialised commissioners at NHS England): These services are commissioned from FTB and BSMHFT NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf), adult medium High quality care for all, now and for future generations the being
and high secure services, perinatal mental health, services for prisoners and services for the military and military veterans_ The CCG: Undertakes monthly contract review of its providers Since February 2018_ following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on CQC improvement Action Plan and System Improvement Plan. Is confident in its quality assurance processes 3 Participates in strategic planning as part of the Sustainability and transformation partnership which has at its core an ambition to provide comprehensive and timely services, including a zero suicide ambition Proactively manages demand with series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed; 5_ Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and E6,235,000 for FTB (22.6% increase) In 2018/19 the CCG provided additional investment in BSMHFT amounting to €3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase): Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution: Undertakes mortality and incident review seriously and in line with national policy_ The coroners' letters have prompted comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents_ On November 14" 2018, all stakeholders involved in the commissioning, provision and regulatory oversight of mental health services in Birmingham and Solihull were convened at a 'deep dive' meeting: The summary of outcomes from this meeting are as follows - Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis. 2 Information sharing: it is clear that commissioners and providers are not always sharing or reviewing the same data and intelligence The CCG has established a governance framework which will enable more proactive management of quality and in particular, learning from significant events and mortality _ This will enable issues to escalate to the wider system more expeditiously_ A review of trends showed that there is not an observed increase in suicides compared with national figures which is reassuring, but all stakeholders agreed in the need to support a zero suicide ambition across health and social care although many individuals do not come into contact with mental health services prior to death; Strategic planning: It is clear that funding is not the sole issue responsible for the failures highlighted in the cases reviewed although funding for an extra 32 mental health beds has been made available by the CCG There are several areas of High quality care for all, now and for future generations
strategic planning which require attention_ Data sharing and more effective communication across commissioners and providers, and between providers is one area of concern: Secondly, there is significant workforce challenge here and now; not unique to Birmingham and Solihull; which needs articulating and planning for. Thirdly, whilst there is debate about whether there is sufficient capacity in the system, it is indisputable that pressure exists at times which results in acutely ill patients not having access to acute mental health beds_ Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authorities and schools) and a 'Suicide prevention strategy: The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health: Transformation: whilst we determine what is required to make services 'safe' in line with a shared definition of what 'safe' means, it was clear that the system has further ambition to excel. Work will be undertaken in the following areas Primary mental healthcare services (Le: services delivered in primary care under the auspices of a General Practitioner): it is clear there is limited access to mental health services in primary care and this will require assessment, Secondary mental healthcare (i.e_ that delivered in hospitals or specialised centres): planning for future demand and capacity_ Specialist mental health service support in acute physical illness: we agree that this needs to improve in order to support patients who end up in our Emergency Departments or downstream acute inpatient hospital beds Commissioning: collaboration between specialised and CCG commissioned services needs to improve in order to enable patients to see a seamless pathway of care There is now a commitment from the CCG and Specialised commissioning team to collaborate in services each commissions_ This will commence with meetings scheduled in December 2018_ Upstream interventions (i.e. prevention of risk factors which predispose to mental iIl-health): The West Midlands Combined Authority has ambition to address social determinants of health and has mental health strategy which needs to fully resonate with the NHS Delivery of mental health services: the cases reviewed demonstrate that at times, services are neither integrated nor responsive and it was accepted that this needs to improve with work in the following areas - Pathways of care, in particular for crisis care , early intervention in psychosis (EIP) and for children and young people, need to be clearly defined s0 that services are available, accessible and acquired. Where patients do not acquire services i.e_ failure to attend appointments, NHS providers will make more robust plans to ensure contact is made_ review of EIP services in Birmingham and Solihull by the national clinical lead in the past month has determined that services are safe at present; Risk assessment: this needs to be available and of high quality 24 hours day, 7 days a week We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate_ This will be undertaken by the CCG and providers at established monthly quality review meetings. High quality care for all, now and for future generations will
Access to prevention services: there is a difference in opinion between the NHS and local authorities in what is deemed adequate provision of services for alcohol, drug and substance misuse and homelessness The CCG will be meeting the local authority to address this; External support to the system: stakeholders welcomed the support of the national Intensive Support team (IST) for mental health, mental health clinical networks and the West Midlands Clinical Senate_ These offers of support have already been made The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018, am therefore satisfied that all stakeholders in the provision and oversight of mental health services have taken the concerns you articulate seriously. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information_
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the above issues_ On November 12th 2018 NHS England received correspondence from the Birmingham and Solihull Clinical Commissioning Group (CCG) following a review of Regulation 28 letters and Provider responses_ The CCG noted that FTB had communicated a view that demand and funding were significant underlying issues; The view of BSHMFT also highlighted demand related issues but did not overtly articulate funding as an issue. The CCG commissions mental health services at Tier 1, 2 3 and 4 for adults and for Children and Young people (0-25 years of age), tiers 1,2 and 3 (with Tier commissioned by Specialised commissioners at NHS England): These services are commissioned from FTB and BSMHFT NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf), adult medium High quality care for all, now and for future generations the being
and high secure services, perinatal mental health, services for prisoners and services for the military and military veterans_ The CCG: Undertakes monthly contract review of its providers Since February 2018_ following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on CQC improvement Action Plan and System Improvement Plan. Is confident in its quality assurance processes 3 Participates in strategic planning as part of the Sustainability and transformation partnership which has at its core an ambition to provide comprehensive and timely services, including a zero suicide ambition Proactively manages demand with series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed; 5_ Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and E6,235,000 for FTB (22.6% increase) In 2018/19 the CCG provided additional investment in BSMHFT amounting to €3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase): Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution: Undertakes mortality and incident review seriously and in line with national policy_ The coroners' letters have prompted comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents_ On November 14" 2018, all stakeholders involved in the commissioning, provision and regulatory oversight of mental health services in Birmingham and Solihull were convened at a 'deep dive' meeting: The summary of outcomes from this meeting are as follows - Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis. 2 Information sharing: it is clear that commissioners and providers are not always sharing or reviewing the same data and intelligence The CCG has established a governance framework which will enable more proactive management of quality and in particular, learning from significant events and mortality _ This will enable issues to escalate to the wider system more expeditiously_ A review of trends showed that there is not an observed increase in suicides compared with national figures which is reassuring, but all stakeholders agreed in the need to support a zero suicide ambition across health and social care although many individuals do not come into contact with mental health services prior to death; Strategic planning: It is clear that funding is not the sole issue responsible for the failures highlighted in the cases reviewed although funding for an extra 32 mental health beds has been made available by the CCG There are several areas of High quality care for all, now and for future generations
strategic planning which require attention_ Data sharing and more effective communication across commissioners and providers, and between providers is one area of concern: Secondly, there is significant workforce challenge here and now; not unique to Birmingham and Solihull; which needs articulating and planning for. Thirdly, whilst there is debate about whether there is sufficient capacity in the system, it is indisputable that pressure exists at times which results in acutely ill patients not having access to acute mental health beds_ Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authorities and schools) and a 'Suicide prevention strategy: The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health: Transformation: whilst we determine what is required to make services 'safe' in line with a shared definition of what 'safe' means, it was clear that the system has further ambition to excel. Work will be undertaken in the following areas Primary mental healthcare services (Le: services delivered in primary care under the auspices of a General Practitioner): it is clear there is limited access to mental health services in primary care and this will require assessment, Secondary mental healthcare (i.e_ that delivered in hospitals or specialised centres): planning for future demand and capacity_ Specialist mental health service support in acute physical illness: we agree that this needs to improve in order to support patients who end up in our Emergency Departments or downstream acute inpatient hospital beds Commissioning: collaboration between specialised and CCG commissioned services needs to improve in order to enable patients to see a seamless pathway of care There is now a commitment from the CCG and Specialised commissioning team to collaborate in services each commissions_ This will commence with meetings scheduled in December 2018_ Upstream interventions (i.e. prevention of risk factors which predispose to mental iIl-health): The West Midlands Combined Authority has ambition to address social determinants of health and has mental health strategy which needs to fully resonate with the NHS Delivery of mental health services: the cases reviewed demonstrate that at times, services are neither integrated nor responsive and it was accepted that this needs to improve with work in the following areas - Pathways of care, in particular for crisis care , early intervention in psychosis (EIP) and for children and young people, need to be clearly defined s0 that services are available, accessible and acquired. Where patients do not acquire services i.e_ failure to attend appointments, NHS providers will make more robust plans to ensure contact is made_ review of EIP services in Birmingham and Solihull by the national clinical lead in the past month has determined that services are safe at present; Risk assessment: this needs to be available and of high quality 24 hours day, 7 days a week We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate_ This will be undertaken by the CCG and providers at established monthly quality review meetings. High quality care for all, now and for future generations will
Access to prevention services: there is a difference in opinion between the NHS and local authorities in what is deemed adequate provision of services for alcohol, drug and substance misuse and homelessness The CCG will be meeting the local authority to address this; External support to the system: stakeholders welcomed the support of the national Intensive Support team (IST) for mental health, mental health clinical networks and the West Midlands Clinical Senate_ These offers of support have already been made The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018, am therefore satisfied that all stakeholders in the provision and oversight of mental health services have taken the concerns you articulate seriously. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information_