Andrew Reid

Dear Alison Mutch OBE Senior Coroner South Manchester Dear Ms Mutch Re: Andrew Reid: Regulation 28 Report to Prevent Future Deaths Thank you for your letter dated 10 April 2018, which highlighted the circumstances around the tragic death of Andrew Reid. The letter, original sent to the Mayor of Greater Manchester Andy Burnham, has been passed on to the GM Health and Social Care Partnership team (NHS England) as the organisation responsible for responding to such enquiries. Having considered your report, we have liaised with colleagues in Trafford Clinical Commissioning Group (CCG) and Manchester Health and Social Care Commissioning (MHCC) to bring all relevant information in this case into one response. The response is structured as below: Detailed response from MHCC who are working with Trafford CCG and Greater 1

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN
• Manchester Mental Health Trust (GMMH) to resolve the issues highlighted in this case
• View from the Greater Manchester (GM) Lead Commissioner for Mental Health and information on Responsible Commissioner Issues
• GM Mental Health and Wellbeing Strategy Investment and Improvement Programmes

1. Response from MHCC

The deceased was a registered patient with a Manchester GP at Chorlton Health Centre and he lived in Stretford in the borough of Trafford. This is important as NHS services are commissioned on the basis of GP registration (so Manchester in this case). Importantly, commissioners across in both Manchester and Trafford CCGs have put in place reciprocal arrangements to cover mental health patients needing support but who are registered in separate areas to where they reside. In this case, therefore the GP should have been able to refer to either the Manchester service or the Trafford service.

Manchester CCG and Manchester City Council have formed a partnership, the Manchester Health & Social Care (MHCC) partnership, to integrate the commissioning of services across the city. MHCC commissions Greater Manchester Mental Health Trust (GMMH), as the main provider of mental health services across the city, through a single integrated block contract. The Manchester CCG arm of MHCC is an associate to the GMMH contract, along with Salford, Bolton & Trafford CCGs.

Following a Transaction process, GMMH took over the services previously provided by Manchester Mental Health & Social Care Trust in January 2017. It is now the main provider of mental health services across Manchester, Salford, Trafford and Bolton. Pennine Care NHS Trust is the provider across the other GM boroughs which border Manchester (Stockport, Bury, Tameside and Glossop, Oldham and Rochdale). GMMH have embarked on an ambitious two 2

GMCA MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN year transformation programme in Manchester to improve services to achieve improved health and social care outcomes for people by introducing new service models to meet the needs of Manchester residents.

The transformation programme, which is receiving funding from the GM Transformation Fund (a fund held and allocated at a GM level following devolution of health and social care in the region), incorporates several priority work streams which are aimed at delivering improvements across the acute and crisis care pathways. Significant investment has been provided to support GMMH to deliver an enhanced Mental Health Liaison service across three acute hospital sites in Manchester. These are North Manchester General Hospital, Manchester Royal Infirmary and Wythenshawe Hospital. This investment will fund a significant increase in mental health liaison team staffing and brought together with investment into Children and Young Peoples (CYP) mental health, it will enable the delivery of an All-Age Liaison Mental Health service.

Locally, MHCC is funding the delivery of an Adult Acute Mental Health Enhanced Community Model, which will see improved access to services for those requiring mental health care. Urgent and crisis care services will be enhanced through the delivery of 24/7 Home Based Treatment, Enhanced Community Mental Health Teams and a dedicated Section 136 suite will further enhance the current offer to people in mental health crisis.

Within the Enhanced Community Services model, Home Treatment Teams (HTTs) will be fully developed and resourced to operate a 24/7 service that functions as a real enhanced alternative to hospital admission. Therefore it will be able to intervene earlier, working collaboratively with Community Mental Health Teams (CMHTs) to support service users to either avoid their potential crisis or reduce the amount of time they are in crisis whilst at home. 3

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN GMMH currently provide the Crisis Response and Home Treatment Team (CRHT) function within our block contract. This is connected with the Urgent Care Assessment Team (UCAT) and Home Treatment Team (HTT) in line with the agreed service specification. GPs are able to refer to the service, which is available based on people being registered with a Manchester GP or a GP of one of our GM associate commissioners, including Trafford CCG.

The UCAT is operational 24 hours a day and offers face to face assessments from 7am to 8pm at night. If a referral is received outside of these times, the UCAT team will contact the service user to complete a telephone assessment and arrange for a face to face assessment the next day. If more immediate action is required, the UCAT team may advise attendance at the nearest Accident and Emergency (A&E) department in order for the person to be assessed by the Mental Health Liaison Service.

The Mental Health HTTs provide short-term intensive community support. They work with service users and carers to find solutions by assertively engaging with service users in mental health crisis. The teams consist of medical staff, nurses, social workers, occupational therapists, pharmacists and support workers. Service users will be offered a comprehensive assessment of their needs and have an individualised care plan developed with them by a named key worker in order to address their needs. Mental Health HTTs will engage with other services involved in a service users care (for example CMHTs) in order to develop joint care plans. Following treatment by the Mental Health HTT, service users will be referred or signposted to appropriate follow up services.

Referrals to the Mental Health HTTs are accepted via the UCAT 24 hours per day from a dedicated phone line. Referrals are triaged and an assessment/admission to the Mental Health HTT offered, where it is established that this is the most appropriate course of action. Service users who are not accepted into Mental Health HTT will be referred or signposted into 4

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN alternative services which meet their individual needs.

UCAT is also the gateway for contacting the Manchester Gate Keeping Team who works with service users who have been assessed as requiring inpatient admission. Support is offered in the service users' homes and community settings.

Although it is not specified within the service specification for the HTT, it is expected that the Provider takes a common sense approach regarding referrals. As the HTT provides intensive home treatment, it is usually appropriate for the service to be delivered by the team closest to where the person lives. In this case, it ordinarily would be Trafford HTT. However, as the patient lived very close to Manchester, the Manchester HTT would have had the option to provide assessment rather than make an urgent referral to Trafford HTT. If this arrangement proved difficult following initial assessment, then arrangements could be made for the team closest to the patient's home address to take over care.

The Mental Health Liaison service is a 24 hour, 7 days a week service and provides comprehensive mental health and risk assessment for patients in all three the acute hospitals across the city (North Manchester General, Manchester Royal Infirmary and Wythenshawe). The Mental Health Liaison services at all these hospitals support A&E and acute hospital wards. The service is provided for any patients within the hospital regardless of where they live or which GP they are registered with.

An arrangement does exist between all GM mental health Trusts, which operates to ensure the most appropriate service for a patient resident or registered on or near the border of another service. This incident has highlighted the need to revisit this arrangement to reduce unnecessary variation in service commissioning and ensure that all providers are clear on service arrangements. Service provision must be based on a flexible, common-sense 5

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN approach which puts the patient's safety and accessibility at the centre.

In order to prevent future deaths, MHCC and Trafford CCG will work with GMMH to align both service specifications to ensure that an equitable service is available across our borders. We will also work with other Greater Manchester CCGs and Mental Health Trusts to agree clear cross border arrangements. There may continue to be some differences across CCG areas as there are both historical differences in investment and development of services. However, now that there are two main mental health Trusts providing services to most of Greater Manchester (with the exception of Wigan where the provider is North West Boroughs NHS Trust), with the support of the Greater Manchester Health & Social Care Partnership, there is a drive to transform services across the whole of Greater Manchester to the same level and standard.

2. Greater Manchester Lead Commissioner response: Responsible Commissioner Issues

On reviewing this case, confusion appeared to arise in determining the responsible commissioner and access to the commissioned specialist mental health services. Although the NHS is a nationally funded service, there are variations across the country in terms of the specific services commissioned for patients in a locality. Determining which CCG is responsible for the commissioning and funding of all health services is based on the Responsible Commissioner Guidance.

In general, the responsible commissioner for patients' primary care, acute hospital and mental health services is determined on the basis of registration with a GP practice or, where an individual patient is not registered, their place of residence.

The safety and well-being of patients is paramount. The underlying principle is that there 6

GMCA MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN should be no gaps in responsibility - no treatment should be refused or delayed due to uncertainty or ambiguity as to which commissioner is responsible for funding an individual's healthcare provision.

Since it is not possible to cover every eventuality within the Responsible Commissioner Guidance, the NHS is expected to act in the best interests of the patient at all times and work together in the spirit of partnership.

Guidance and supporting tools were published in November 2016 to describe the pathway for urgent and emergency mental health liaison services. Further implementation guidance followed in 2017 for both the community-based urgent and emergency mental health care pathway and the acute mental health care pathway. This was published to support local areas in improving their response times and treatment pathways. Commissioners in Greater Manchester have been required to work in line with this.

More than 10 years ago, there was also a specific acknowledgement across Greater Manchester commissioners that across the boundaries between localities such as Manchester and Trafford, patients who were registered with Manchester GPs might be resident in Trafford. On recognition of this, there was also a need to invest additional funding to ensure timely access to local specialist mental health services in Trafford (and vice versa). This was put in place with Manchester commissioners providing specific additional funding for mental health services in Trafford (including crisis out-of-hours support) so that any such patients were supported rapidly with the minimum possibility of confusion related to Responsible Commissioner considerations. The same reciprocal model was enacted by Trafford commissioners providing specific additional funding for mental health services in Manchester (including crisis out-of-hours support). 7

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN In Greater Manchester, required adherence with Responsible Commissioner principles has been communicated across all the GM MH Commissioners and Trusts. This included summary Cross Border Matrix tables to resolve any issues involving the service users registered and residency status shared with all specialist mental health out-of-hours and inpatient services.

As also highlighted in page 2 of this response, following a mental health services procurement exercise in Manchester last year, the same specialist Mental Health Trust provider was appointed to design, develop and deliver services in both Trafford and Manchester (Greater Manchester Mental Health NHS Foundation Trust).

This move to the same mental health services provider should then have led to a further reduced likelihood of events in terms of 'hand-offs between the Trafford and Manchester out- of-hours mental health services - especially as the Trust agreed to enact a model whereby all cases would not suffer breaks in service from a receiving team.

We appreciate that as the Coroner in this case you have noted concerns that despite this a difference in commissioning arrangements between Manchester and Trafford may have been contributory in the GPs experience of being passed between Trafford HBTT and Manchester UCAT - and then resulting in the service user needing to go to A&E for an assessment. We also note that it is this which prompted the Regulation 28 being issued.

In line with commissioner actions noted above, in this case the GP would appear to have acted appropriately in contacting the Manchester specialist out-of-hours mental health services or UCAT (as this service was funded by both Manchester and Trafford commissioners). This service should have been able to support the patient until appropriate provision in Trafford was in place. As such, the service user should not have been passed between teams, irrespective 8

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN of whether they were registered with Trafford or Manchester GPs.

Therefore, it seems the breakdown in understanding and support to this patient does not appear to be due to inappropriate differential models of commissioning of specialist mental health services between Trafford CCG and MHCC commissioners - but further action is clearly needed, as colleagues from MHCC have set out.

Trafford CCG and MHCC have been in contact with senior GMMH managers. It has been agreed that any referrals that are being disputed by each other or another team in Manchester are promptly escalated to the Service Manager, so that the issue can be resolved in a timely way. In their response, GMMH also stated that [The service managers] have reminded the teams of their responsibilities in that our priority is ensuring that the service user receives the care they need and to utilise and promote the use of the Cross Border Matrix to resolve any issues involving the service users registered and residency status'. The Trafford and Manchester commissioners have also agreed to work together with GMMH to see what else can be done to ensure the current differences in commissioning priorities between localities does not result in any further incidents.

The Greater Manchester Health & Social Care Partnership will also now work with mental health commissioners and providers across Greater Manchester to ensure the required additional communications and work is undertaken to remove the risk of such similar confusion or breakdown in support reoccurring.

3. Greater Manchester Mental Health and Well Being Strategy Investment and Improvement Programmes

The Partnership has made a public commitment to improve Mental Health (MH) services 9

GMCA MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN across Greater Manchester with significant additional investment agreed to ensure this happens.

As part of the Devolution Agreement signed between the Government and Greater Manchester in 2015, the region was awarded a £450 million Transformation Fund (TF) to support improvements across all health and social care services. At the end of July 2017, a £134 million investment from this combined allocation for Mental Health in GM was announced (£56m from the GM TF and £78m from GM CCGs baseline funding increases. This investment will support delivery of more consistent commissioning and provision through GM-wide and locality-coordinated service improvement programmes.

Importantly, this is the largest investment into mental health of its kind in the country and will support us to deliver on the aspirations of the GM Mental Health and Wellbeing Strategy and nationally mandated priorities set out in the NHS England policy The Five Year Forward View for Mental Health (2016-2021). This prioritised action in line with local GM service user and family concerns to resolve national and local problems in accessing crisis support including noting the following:

'In its recent review of crisis care, the Care Quality Commission found that only 14 per cent of adults surveyed felt they were provided with the right response when in crisis, and that only around half of community teams were able to offer an adequate 24/7 crisis service. Only a minority of hospital Accident & Emergency (A&E) departments has 24/7 cover from a liaison mental health service, even though the peak hours for mental health crisis presentations to A&E are between 11pm and 7am. Too often, people in mental health crisis are still accessing mental health care via contact with the police. The inquiry found that while adults were seen promptly where liaison mental health services were 10

GMCA GREATER MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN available in an A&E department and there were clear pathways through to community services, those aged under 16 were referred directly to children and young people's services but seen only when services were open during office hours. This could involve waiting a full weekend and lead to a significant variation in the quality of care on the basis of someone's age.'

In terms of supporting adult mental health, we are investing funds and changing commissioning/ service delivery practice in a number of areas across all localities in GM until 2020/21. Priorities in GM are to:
• Deliver against multi-agency suicide prevention plans, working towards a national 10% reduction in suicide rate by 2020/21. Work is ongoing and in development to ensure that we identify and intervene with people at greatest risk, for example people who may self-harm, men aged 35-64 and people who are in custodial settings. Money is also being invested into a Greater Manchester Suicide Bereavement Liaison service so that families of people who died by suicide get the right help and support
• Develop local options to support Adults who may be in mental health distress and crisis by increasing the capacity of existing Crisis Resolution and Home Treatment Team services and other support options such as crisis café's and safe spaces in the community
• Continue to work towards the national 2020/21 ambition of all acute hospitals having mental health liaison services that can meet the specific needs of people of all ages including children and young people and older adults; and delivering Core 24 mental health liaison standards for adults in more than 50% of acute hospitals (this is subject to hospitals being able to successfully recruit). This development of Liaison Mental Health services in acute hospitals will mean that more people who are inpatients in hospital who may experience distress have access to specialist mental health assessment and treatment 11

GMCA MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN
• Continue to improve access to psychological therapies (IAPT) services. Three thousand more people accessed treatment in 2017/18 and this will increase by a further 7,500 delivering a national and GM access rate of 19% for people with common mental health conditions. Approximately two-thirds of the increase is planned to be in new integrated services focused on people with co-morbid long term physical health conditions (such as Diabetes, Cardiovascular disease and Musculo-Skeletal problems). and/ or medically unexplained symptoms, delivered in primary care. We are also rolling out specialist IAPT services to support new parents as we recognise providing timely support to new parents will have longer term benefits for parents and their infants. This work is accompanied by plans to ensure that in GM we are meeting national targets, which are a 50% IAPT recovery rate; 75% of people accessing treatment within 6 weeks and 95% of people accessing treatment within 18 weeks.
• Ensure that at least 53% of people requiring early intervention for psychosis receive NICE concordant care within two weeks, and meeting a rising target of 60% by 2020/21.
• Support delivery of GM plans to reduce almost all inappropriate adult acute out of area placements by 2020/21 and implementing action plans for all patients who are placed out of area to ensure that they have appropriate package of care.
• Ensure that people with severe and enduring mental illness have access to appropriate physical health checks as a key part of our commitment to parity of esteem between physical and mental health recognising that many such individuals face life expectancy 20 years less than people without mental health problems.

Further to the activities listed above, we are investing significant amounts in early intervention and prevention work to transform mental health services for children and young people, delivering a more coherent and equitable mental health offer for young people and their families. We recognise that 50% of adult mental health problems begin before the age of 14, 12

GMCA MANCHESTER COMBINED AUTHORITY NHS in Greater Manchester Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN and 75% before the age of 24. Intervening earlier in the life course to promote positive mental and emotional wellbeing and develop resilience could give huge benefits to individuals and society as a whole.

In addition, we also have detailed plans in place to develop a 24/7 crisis support service that will respond to the needs of children and young people in times of severe emotional distress. Work is also underway in localities to provide greater prevention and earlier intervention options to support CYP mental health.

I hope that this detailed response and the information set out here assures you of our actions in response to lessons learned from this case and our commitment to improving mental health in the Greater Manchester.