Response to the consultation on Step up to Great Mental Health
Introduction
One in four adults experience at least one mental health problem in any given year. According to the three Clinical Commissioning Groups’ (CCGs) own survey, 86% of adults in Leicester, Leicestershire and Rutland are dissatisfied with mental health service provision in the area. My response considers each of the eight proposals (Appendix 2) put forward by the three CCGs for Leicester, Leicestershire and Rutland for improving and investing in mental health services.
Since 2010, mental health funding nationally has been cut. The number of mental health nurses fell by 5,545 by 2017 and has not recovered. In 2021 there is still 2,200 fewer mental health nurses in the UK. Remaining mental health budgets have been raided to plug holes elsewhere in the NHS. Over the past year, COVID-19 and Leicester’s extended lockdowns have shone a light on the inadequacies of mental health provision. During the pandemic, mental health has been an issue of major concern to many residents of Leicester East, which includes issues to do with waiting times, inconsistency of treatment provision and the lack of readily available care information.
There is a clear need to improve the provision of mental health services in Leicester East and it is therefore important that changes resulting from the consultation by the CCGs address the real needs of the community.
Throughout my response I refer to the Gunning Principles, as set out in Appendix 1, which sets the standards required for the conduct of public consultations. These standards relate to whether consultation proposals have been predetermined by decisions already made; the quality of information provided by the consultation materials; the timeframe given for consultation responses and the seriousness with which responses to the consultation have been considered. Therefore, in addition to analysing the likely effectiveness of the three CCGs’ proposals for the future of mental health services in Leicester, Leicestershire and Rutland, this report considers the adequacy of the consultation itself.
In the conclusion section, my response makes several suggestions and outlines positive aspects of the three CCGs’ plan for Leicester, Leicestershire and Rutland’s mental health services. My response also raises concerns about the level of public engagement and the level of information provided to support the consultation’s main proposals.
As indicated, Appendix 1 includes the Gunning Principles, Appendix 2 details the list of proposals put forward by the three CCGs for Leicester, Leicestershire and Rutland, and Appendix 3 highlights selected case studies as detailed in the consultation itself
The Consultation Proposals:
1.
The introduction of the Central Access Point phoneline as a means of providing readily available help and advice to the public regarding mental health treatment is to be welcomed. The information provided regarding the performance of the Central Access Point suggests that it has worked well during the pandemic, leading to a 41% reduction in patients coming through to community teams as a referral for assessment. Another positive sign is that most patients either received support from triage clinicians or were directed towards available community support and that 44% of patients who called the Central Access Point did not require further support.i It is also particularly helpful that the Central Access Point phone line is provided without charge and is therefore in line with the core NHS principle of offering services free at the point of need.
It is encouraging that feedback for the service from staff, service users and partners was “very positive.” However, it would have been helpful to have seen a more detailed analysis outlining what worked well and where improvements could have been made in the consultation document itself.
Most importantly, I am concerned that the consultation provides no detail regarding how the proposal will address existing inequalities that are prevalent within UK society.
As a study by the mental health charity Mind has pointed out, subjective assessments can easily be influenced by biases formed by structural racism ii It is therefore essential that Central Access Point Staff receive adequate education and training on the impact of historic and current racism in British society. It is also very important that the Central Access Point is staffed by employees who are representative of Leicester’s rich ethnic and cultural diversity.
In order to make it easier for the general public to make an informed choice, as per Gunning Principle 2, set out in Appendix 1, it would have been helpful to have included more detailed feedback from service users, staff and partners Nevertheless, of all the measures proposed in the consultation, the Central Access Point has the clearest evidential support and is a positive development, so long as its introduction is not coupled with a dilution of existing service provision. It will also be a useful counterpart to the proposed Suite of self-help and guidance tools in diversifying the means of access to mental health support.
2. Introduction of an Acute Mental Health Liaison Service
The proposal is for the Mental Health Triage, Frail Older Persons Advice and Liaison Service teams to be merged into a single Acute Mental Health Liaison Service by joining together these existing teams and basing them at the Leicester Royal Infirmary, near the emergency department, which will also support people who are already inpatients. The service will now be available twenty-four hours a day, seven days a week.
With regards to this proposal, it is concerning that the consolidation of the teams was implemented in April 2021 and before the consultation took place. This may be why its main focus appears to be on the availability of the new Acute Mental Health Liaison service itself, rather than how the changes will meet existing and future complex needs
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The detail that is included doesn’t clearly explain what has been gained and lost by the merging of teams that has already taken place. For instance, the consultation document implies that the Liaison Psychiatry and Psycho-Oncology Teams will be lost but isn’t clear how the specific needs of the patients receiving treatment from the services will be matched by their replacements. The only detail the consultation provides is vague. It suggests that an “alternative” will be “provided if required” but does not explain what this support will look like or how it will work. Equally important is the possible implication for equality of access to mental health services; according to the Leicestershire Partnership NHS Trust: Demographic Profile, “black British people were overrepresented amongst users of Inpatient Mental Health Services.”iii
This corresponds with national trends. According to the mental health foundation, “Black men are more likely to have experienced a psychotic disorder in the last year than White men” and “Black people are four times more likely to be detained under the Mental Health Act than White people.”
As previously mentioned, the cause of this disparity is known to be structural racism in British society and culture. The risk of removing the Liaison Psychiatry and PsychoOncology Teams without providing replacement services that address the same need is that it may exacerbate existing inequalities, indirectly discriminating against African, AfricanCaribbean, Asian, and other racialised groups twice over
The proposals suggest that 139 additional beds will be provided at the Leicester Royal Infirmary for acute mental health services. It is not clear what this estimation is based on and it may not meet the requirements of Leicester’s growing population. An inadequate estimation will disproportionately impact those demographics that rely on acute mental health services most.
It is concerning that changes in relation to – Building Better Hospitals for the Future – could have already predetermined the proposals for mental health services detailed in this consultation. Furthermore, it seems possible that the outcome of the consultation has been predetermined by changes already made to the service, which is in direct contradiction to Gunning Principle 1
3. Establish a Mental Health Urgent Care Hub
The proposal to have a mental health hub located at the Royal Infirmary as a more suitable alternative to A&E for those experiencing mental health crisis is welcome in principle Data provided by the three CCGs in their business case is encouraging. According to the three CCGs’ Pre-Consultation Business Case, the Hub has seen 3,500 patients between 7 April 2020 and 25 March 2021 and this has taken the pressure off A&E, which is a positive development. That the initiative has support from emergency services is also welcome iv
However, taking the pressure off Accident and Emergency does not necessarily improve the provision of acute care in cases where more intensive treatment, for instance inpatient treatment, is required Case study 3 reveals some of the potential flaws in the approach taken by the consultation. This case study indicates that a successful outcome – the most appropriate treatment – is for the patient to avoid being detained as an inpatient in acute care. However, this ideal scenario relies on there being less demand for acute inpatient care
in Leicester. For example, it does not take into account a high number of patients threatening self-harm or suicide.v
This also means that the issue of available beds – and hospital capacity – cannot be separated from the issue regarding the provision of services. There are certainly benefits to consolidating services at Leicester Royal Infirmary but the apparent emphasis placed on avoiding the need for beds highlights an assumption that the planned 139 extra acute mental health beds may not be enough to provide for Leicester’s growing population, a point argued by the Save Our NHS Leicestershire campaign vi It’s important that the three CCGs introduce a commitment to continue increasing the number of beds beyond the 139 already promised to meet need as Leicester’s population continues to rise.
At a time when Leicester’s population is increasing, it is important for the changes to local health services provide flexibility to increase capacity in a way that ensures people have access to wide range of treatments, so that they are able to benefit from the treatment that best suits their needs Once more, it is concerning that the outcome regarding this service may have been predetermined by the changes already made to the service as a result of the Building Better Hospitals for the Future consultation, which is in direct contradiction to Gunning Principle 1
4. Crisis Cafés
Crisis Cafés may make a positive difference to Leicester’s mental health service provision. However, according to a study conducted by health professionals, there is little data available regarding the effectiveness of Crisis Cafés:
“[…] crisis cafés have increased the most rapidly between 2016 and 2019 of all the emerging models but there is minimal evidence regarding the effectiveness of crisis cafés, whereas ADUs [Acute Day Units] have a substantial body of evidence (8-10, 12) but have declined over the same period.”vii
Birmingham and Solihull Mental Health Foundation Trust provides an acute day service. It includes intensive support for service users who are in an acute crisis and under the care of home treatment teams or inpatients nearing discharge viii Acute Day Units can therefore provide more structures and intensive treatment than Crisis Cafés. If introduced alongside Crisis Cafés, Acute Day Units could have an important role to play in the diversification and improvement of Leicester’s mental health services It is unclear why Acute Day Units have not been considered in addition to the Crisis Café model.
This is particularly concerning because the closure of Leicester General Hospital’s inpatient Acute Care capacity will make it harder to reverse the direction of travel if the Crisis Café plans do not work as intended and fail to relieve the pressure on other acute services. For instance, there is a risk that the planned increase of 139 beds for acute mental health inpatient care at the Leicester Royal Infirmary will not meet demand created by an increasing population
Furthermore, Case Study 4 is an individual with complex needs and it seems unlikely that attending a Crisis Café without additional support will prevent many people with similar conditions from ever relapsing again. However, the case study implies that Crisis Cafés may be an alternative to other forms of acute care, which may not be true in all circumstances.
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For instance, although young adults in their 20s and 30s tend to be the demographic most frequently requiring urgent care, for inpatient services requiring a bed, there is a greater weighting towards people in their 60s, 70s and 80s.ix Black British people were also overrepresented amongst users of Inpatient Mental Health Services.x In other words, there is no viable “one size fits all” approach and certain demographics will benefit less from the Crisis Café model than others
With regards to the level of information provided, there is no evidenced based explanation within the main consultation document and its supporting materials of why the three CCGs have placed so much emphasis on expanding the Crisis Café model. There is no information presented within the consultation and data presented to suggest that the Crisis Café works. The consultation may therefore be at risk of not providing enough information to the public to meet the standard set by Gunning Principle 2 (Appendix 1). Moving forward, it may be sensible for the CCGs to explore whether some of the planned Crisis Cafés can essentially serve as Acute Day Units instead, providing more intensive and structured support for those who need it and a greater variety of provision than currently proposed.
5. Crisis service
The proposal for the improvement and expansion of the Crisis Service has several positive aspects, notably the introduction of an option for self-referral. Also welcome is the commitment to completing the most urgent assessments within four hours and the less urgent assessments in 24 hours
However, there are some risks with introducing the practice of self-referral. These risks are highlighted by Case Study 5. In the case study provided, the patient is feeling isolated and alone and it is not clear that self-referral will always be the most appropriate course of action in similar cases. For instance, it may be beneficial for a patient’s mental health to speak to someone they know and trust, rather than self-refer by talking to a stranger.
Furthermore, as previously mentioned, Leicester is a diverse city. It is essential that those taking referrals from people in crisis reflect the diverse community, so that people who access the service can feel confident that their referral will be handled sensitively and appropriately.
6. Triage cars
The business case set out for the consultation states that the Street Triage service (of which the Triage Car service is a part) undertakes 50 assessments per month on the street and is able to divert patients to the most appropriate support service, including to the Urgent Care Hub xi However, it is unclear how many of these assessments were undertaken by the triage car service and no information has been provided regarding patient feedback. As with several other proposals included in the consultation document, it is concerning that there is a lack of clear data relating to this service’s effectiveness. The framing of Case Study 6, which appears to have been premised on the presumption that referral to an acute bed should be avoided, inadvertently highlights possible risks associated with the model The subject of the case study was found in the act of attempting to commit suicide. The outcome has the patient receiving care in the community. This of course carries risks, particularly given all available evidence suggesting that black people in similar situations are disproportionately overrepresented in acute inpatient care. The option of community care for this demographic
is rarely given.xii It is not clear that the consultation document has addressed this level of discrimination and difference of treatment. In particular how it impacts African, AfricanCaribbean, Asian, and other racialised groups.
7. Suite of self-help guidance and tools
It is clear that the information provided on mental health services to residents of Leicester, Leicestershire and Rutland is too fragmented and difficult to navigate This issue was clearly signposted in the CCGs’ Pre-Consultation Report and thus the decision to address this matter in the consultation is welcomexiii
However, while the initiative is positive, there are several risks associated with it. Firstly, if it is to be successful, the Suite needs to be the product of considerable patient input and codesign. The consultation document does not clearly detail how patients will be able to shape the design of this service. As the Equality Impact Assessment and/or demographic analysis makes clear, Leicester in particular, has a diverse population with a wide range of different needs and expectations, which will continue to evolve over time as demographics change in the area However, the consultation provides no detailed plan to address how the incorporation of this diversity, including engagement will be achieved.xiv A plan for ongoing public engagement as the service is introduced, which addresses the different needs presented within the demographic analysis supporting the consultation, would therefore be a welcome addition xv
Secondly, as is true of the Central Point of Access, if implemented carefully, this service will be a welcome way of making it easier for residents of the area to access the services they need. However, it is also important to bear in mind that access to reliable internet is linked to income. According to the ONS, incomes in Leicester are below the national average, there are also high numbers of people in my own constituency of Leicester East without access to the internet and/or digital devices, so there is a risk of indirect discrimination if too much emphasis is placed on online engagement, at the expense of allowing people to access a full diversity of services through the Central Access Point, or through third party organisations or face to face referrals via a GP.xvi
8. Community Treatment and Recovery Teams
The consultation proposal involves consolidating a number of teams that are currently serving the Leicester, Leicestershire and Rutland area. The new Treatment and Recovery Teams will serve the following groups: women who want to conceive a baby supporting them from pre-conception to 24 months after birth; individuals with complex needs associated with personality disorder; individuals who have had a first presentation of psychosis; individuals with complex needs that require enhanced rehabilitation and recovery support; individuals who are having difficulties with memory
The aim is to provide greater access to services in the community to relieve the pressure on waiting times, as well as GPs’ workloads. This aspect of the proposal is welcome, as it will hopefully ensure that patients receive appropriate care more quickly.
However, the consultation also presents Community Treatment and Recovery Teams as an alternative to existing intensive outpatient services, such as the Therapy Services for People with Personality Disorder (TSPPD) that is presently run from Francis Dixon Lodge at
Leicester’s General Hospital. Given that the proposed new community services are not committed to delivering the same intensity and length of care as, for example, the existing Therapy Services, it is unclear that the new services will always mark an improvement in the quality of service offered.
Besides the projected shortening of the time taken for treatment to be completed, the Consultation Document does not adequately explain how outcomes are improved by the new Treatment and Recovery Teams service. The care seems to be provided more quickly, but there is potentially a loss of quality in some of the community services that meet particular cultural need. In particular, it is important that the categories that the new community services serve are not too rigidly defined and prescriptive to accommodate the diversity of Leicester’s communities and their requirements.
As it stands, the proposal risks being perceived as an “efficiency savings” response to staffing and therefore capacity shortages, with more intensive outpatient services being reduced as part of managed decline. Once again, residents have not been provided with sufficient information for the public to consider this proposal properly, particularly in relation to how the proposed services meet the diverse needs of Leicester’s population and the consultation may therefore not meet the standard set by Gunning Principle 2
Conclusion
There are many positive aspects to the proposals outlined in this consultation, particularly the planned investment and diversification of mental health services in Leicester, Leicestershire and Rutland. For instance, the Central Access Point and Suite of Self-help Guidance and Tools could be positive additions to Leicester’s mental health services, especially considering the evidence that the introduction of the Central Access Point has so far met with considerable success.
However, the consultation does not provide enough data to support the case for some of its proposals. This is particularly true where services are likely to be combined or removed. Perhaps most notable is the removal of the Psycho-Oncology, Psychiatric Liaison and Personality Disorder services from Leicester General Hospital. These services provide specific, specialised care and it is unclear from the consultation document whether the breadth and depth of the expertise contained within these existing units and their staff will be retained in full if they are merged with other teams. Retaining these services to ensure that the specialist care they offer is kept in place even as the CCGs are developing new services would therefore be a welcome and reassuring development.
In terms of community care, it is unclear why such a heavy emphasis has been placed on particular models of care – for instance the Crisis Café – above others – such as Acute Day Units. The proposals suggest a considerable expansion of Crisis Cafés but it may be prudent for the three CCGs to investigate the possibility that some of these could be used for the more intensive type of provision Acute Day Unit service. This would make for greater diversity in service provision and decrease the likelihood that Crisis Cafés end up being used to cater for pressure for which they are not designed.
The consultation also places considerable emphasis on increasing access to mental health services in the community. While this is important, there is a danger that inpatient care, which disproportionately impacts older and black British patients, could become relatively
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overlooked, there is a risk that it will not receive the required investment relative to Leicester’s growing population when compared to other services.
Finally, it is disappointing that the consultation document does not make more specific reference to how each of the proposals will address the negative impacts identified in the supporting demographic analysis and/or Equality Impact Assessment document . It may be that this is implied in the examples chosen to illustrate the case studies but this is not explicitly clear. A concern is that this could lead to the consultation outcome indirectly discriminating against some groups, particularly Leicester’s African, African-Carribbean, Asian and other racialised groups Nor is there much clear evidence that many of the proposals resulted from co-design with patients, service users and local professionals, which should be addressed as the proposed changes to Leicester’s mental services are developed.
Appendix 1: The Gunning Principles
They were coined by Stephen Sedley QC in a court case in 1985 relating to a school closure consultation (R v London Borough of Brent ex parte Gunning). Prior to this, very little consideration had been given to the laws of consultation.
Sedley defined that a consultation is only legitimate when these four principles are met:
1. proposals are still at a formative stage
A final decision has not yet been made, or predetermined, by the decision makers
2. there is sufficient information to give ‘intelligent consideration’
The information provided must relate to the consultation and must be available, accessible, and easily interpretable for consultees to provide an informed response
3. there is adequate time for consideration and response
There must be sufficient opportunity for consultees to participate in the consultation. There is no set timeframe for consultation, despite the widely accepted twelve-week consultation period, as the length of time given for consultee to respond can vary depending on the subject and extent of impact of the consultation
4. ‘conscientious consideration’ must be given to the consultation responses before a decision is made
Decision-makers should be able to provide evidence that they took consultation responses into account
These principles were reinforced in 2001 in the ‘Coughlan Case (R v North and East Devon Health Authority ex parte Coughlan2), which involved a health authority closure and confirmed that they applied to all consultations, and then in a Supreme Court case in 2014 (R ex parte Moseley v LB Haringey3), which endorsed the legal standing of the four principles. Since then, the Gunning Principles have formed a strong legal foundation from which the legitimacy of public consultations is assessed, and are frequently referred to as a legal basis for judicial review decisions.
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Appendix 3: Case Studies:
1. Central Point of Access
Case study one: Rose
Rose is a 21-year-old who has been struggling to settle into university life as she is away from her family and friends. She has been self-harming (scratching) and drinking excessive amounts of alcohol. She says she feels low in mood so her temporary GP in Leicester has started her on a low-dose anti-depressant but it’s not helping. Her flatmate is worried that Rose might try to significantly harm herself, so she rings 111.
Care and treatment today
The NHS 111 service arranges an appointment for Rose to be seen at Leicester Royal Infirmary by a mental health practitioner in a few hours’ time. Rose is assessed by the mental health triage team at the hospital who feel she does not need care within the hospital such as psychological services. They feel she would benefit from a review of her antidepressant by her GP and she is given a range of support numbers, including the Turning Point crisis helpline.
Care and treatment proposed in the future
The NHS 111 service transfers the call straight to the Central Access Point. A recovery worker completes a questionnaire with Rose and her flatmate which looks at the reason for the call, current issues and risks, urgency of the call, a safety plan, and her current support network. They talk about the emotional support that Rose will need to help with the problems being experienced. A face-to-face appointment is arranged the same day for Rose to attend a local Crisis Café for additional support. Rose and her flatmate are told they can ring the Central Access Point at any time should they need further support.
2. Introducing an Acute Mental Health Liaison Sevice
Case study: Stephen
Stephen is a 45-year-old man, living in Hinckley, caring for his elderly mum. He has been admitted to Leicester Royal Infirmary with acute kidney injury. This appears to be due to dehydration. It is also noted by clinicians that he has low mood and poor food and fluid intake. Stephen has a history of anxiety and depression and is known to the community mental health team.
Care and treatment today
Staff on the ward feel that Stephen requires an urgent psychiatric assessment. Stephen is under the care of the community mental health team and so they call the team. They are advised to phone the mental health liaison team to see if anyone can assess the patient on the ward. The ward staff make a referral to the mental health liaison team, but this referral is made at 6pm on a Friday. Due to the current working hours of the team, this referral is not picked up until Monday morning. The patient is then seen and discussions are held with the relevant clinicians involved.
Care and treatment proposed in the future
Staff on the ward contact the mental health liaison service as they are concerned about Stephen’s mental health and feel a triage/assessment is needed. The referral is picked up
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the mental health liaison service co-ordinator immediately and allocated to a mental health practitioner at Leicester Royal Infirmary.
Stephen is reviewed on the ward by the mental health practitioner within four hours. The mental health practitioner discusses the assessment with Stephen’s community consultant psychiatrist, and they make some changes to his medication. Arrangements are made for Stephen to be reviewed by a mental health practitioner in the mental health liaison service on his discharge from hospital to discuss whether a referral to the crisis team would be needed to further support him. This follow-up appointment is arranged for three days’ time when the team feel his condition will have hopefully improved.
3. Establish a mental health urgent care hub
Case study: Ella
Ella is 23 and lives on her own in a flat in Loughborough. Ella is well known to mental health services and has a diagnosis of emotionally unstable personality disorder. She has an outpatient consultant and a community psychiatric nurse whom she sees every fortnight. It is a Saturday morning and Ella calls 999 saying she is having thoughts of ending her life and is unable to maintain her own safety.
Care and treatment today
The paramedics arrive at her home address. Ella continues to express suicidal thoughts and does not feel she can keep herself safe at home. The paramedics take her to the emergency department. After a 90-minute wait in the ambulance and a three-hour wait in the emergency department, an initial assessment finds that she needs to be seen by the mental health triage team. She is seen by this team: it is seven hours since the 999 call. Ella is more distressed and refuses to engage with the clinician in a meaningful way. Ella refuses to give any reassurances for her safety, refuses help from the crisis team and tries to leave the department. The team has no option but to call for a Mental Health Act Assessment and she is detained for her own safety in hospital, being admitted onto an acute ward where she remains an inpatient for 21 days. While in hospital, Ella discloses that prior to her admission, her partner was being physically abusive. The ward takes the necessary action.
Care and treatment proposed in the future
The paramedics arrive at her home address. Following a chat with Ella, they call the Mental Health Urgent Care Hub and speak to a clinician. The clinician accepts the referral, and the paramedics make their way to the Hub. The paramedics hand over directly to a mental health practitioner to carry out an assessment. Initial observations and an assessment are carried out.
Ella discloses that her partner has been physically abusive to her and that this is making her feel worse. The mental health professional completes an assessment looking at domestic abuse, stalking and 'honour'-based violence (known as a ‘DASH’ assessment). Ella is referred to domestic and sexual violence services and is supported to make contact with the police to report the abuse.
Ella is also referred to the crisis team for a period of home treatment. She is booked in for a phone call that evening and a home visit the following day. The mental health professional emails her regular care team informing them of the plan.
4. Crisis cafes Case study: Kimberley
Kimberley is a 25-year-old woman who lives in Melton Mowbray. She has borderline personality disorder, an eating disorder and depression. She regularly struggles and often self-harms. She makes numerous 999 calls and often goes to the hospital emergency department as she does not know where else to get support.
Care and treatment today
Kimberley has called 999 and been taken to the emergency department by ambulance. After painfully sitting for several hours waiting to speak to someone, she is eventually seen by a mental health practitioner. She is referred to the crisis team for a short-term intervention. This has happened many times before and has led to regular relapses when the interventions are not in place.
Care and treatment proposed in the future
Kimberley calls the mental health Central Access Point where she is given emotional support. She is given the details of her local Crisis Cafe so she can access face-to-face mental health support out-of-hours.
On her first visit to the cafe, she was anxious and only stayed for 15 minutes. As time has gone on, she has started accessing the support weekly, and has got to know people in the cafe really well and has built a happy community. Kimberley feels relaxed as the cafe does not have the clinical feel of the emergency department. For Kimberley, this has become a lifeline and prevents her from going into crises. Kimberley can visit the cafe daily, or as and when she needs it.
5. Crisis Care Case study: Ebrahim
Ebrahim is a 46-year-old man living in Highfields, Leicester. Ebrahim lives alone with support from his brother, who lives nearby. Ebrahim has been struggling with his mental health due to social isolation related to Covid-19. He is unemployed and has thoughts of ending his life as he has lost all hope. His brother wants to find help for Ebrahim before he deteriorates further.
Care and treatment today
Ebrahim’s brother phones his GP to ask for help at 11am. The GP receptionist arranges an appointment for 5pm. Ebrahim has his appointment with the GP who phones the crisis team at 6pm to make a referral. The crisis team phones Ebrahim at 8pm and it is decided he needs a four-hour urgent crisis assessment. The crisis team arranges a face-to-face assessment appointment at Leicester Royal Infirmary’s emergency department for 11pm.
The crisis team member assesses Ebrahim and arranges an appointment at his home for the following day.
Care and treatment proposed in the future
Ebrahim’s brother phones the Central Access Point at 11am. The initial triage questionnaire is completed and it is felt that clinical input is required. The call is transferred to a clinician in the Central Access Point who gets further information to decide the best course of action. This is completed with Ebrahim and his brother. A safety plan is put into place and a face-toface assessment appointment is arranged at Ebrahim’s home within four hours. At 2.30pm the crisis team clinician sees Ebrahim at his home.
If the initial phone call had been made in the late evening, or if the crisis team was unable to undertake the assessment within four hours, arrangements would have been made for Ebrahim to be assessed at the Mental Health Urgent Care Hub within two to four hours.
6. Triage Car
Case study: Stephen
Stephen is a 45-year-old man, living in Hinckley, caring for his elderly mum. He has been admitted to Leicester Royal Infirmary with acute kidney injury. This appears to be due to dehydration. It is also noted by clinicians that he has low mood and poor food and fluid intake. Stephen has a history of anxiety and depression and is known to the community mental health team.
Care and treatment today
Staff on the ward feel that Stephen requires an urgent psychiatric assessment. Stephen is under the care of the community mental health team and so they call the team. They are advised to phone the mental health liaison team to see if anyone can assess the patient on the ward. The ward staff make a referral to the mental health liaison team, but this referral is made at 6pm on a Friday. Due to the current working hours of the team, this referral is not picked up until Monday morning. The patient is then seen and discussions are held with the relevant clinicians involved.
Care and treatment proposed in the future
Staff on the ward contact the mental health liaison service as they are concerned about Stephen’s mental health and feel a triage/assessment is needed. The referral is picked up the mental health liaison service co-ordinator immediately and allocated to a mental health practitioner at Leicester Royal Infirmary.
Stephen is reviewed on the ward by the mental health practitioner within four hours. The mental health practitioner discusses the assessment with Stephen’s community consultant psychiatrist, and they make some changes to his medication.
Arrangements are made for Stephen to be reviewed by a mental health practitioner in the mental health liaison service on his discharge from hospital to discuss whether a referral to the crisis team would be needed to further support him. This follow-up appointment is arranged for three days’ time when the team feel his condition will have hopefully improved.
7. Suite of self-help guidance and tools Case study: Alan
Alan is a 70-year-old man living alone in Market Harborough. His husband, Gareth, died a couple of years ago and Alan has been increasingly lonely ever since. The problems of loneliness and social isolation have been compounded by the Covid-19 lockdowns. Alan is bored, fed up and missing social contact. He’s is not only missing his husband, but the dayto-day interactions that being out and about in the community bring.
Care and treatment today
Alan phones his GP and explains that he’s feeling sad and lonely. He says the pandemic is taking its toll on him. The GP (local doctor) talks Alan through his feelings to fully understand how he is feeling at this moment in time, the depth of the problems, and any clinical diagnosis. He thinks Alan may benefit from finding out more about low mood and potential befriending groups in the community. To help inform her response, the GP contacts the community knowledge and signposting service, run by Leicestershire Partnership Trust. The service provides accurate, up-to-date information on activities and services for mental and physical wellbeing. The service sends the GP information that might help Alan. A couple of weeks later Alan contacts the GP again, and the GP talks him through that information. Alan finds the information interesting but doesn’t call any of the contact numbers provided. He knows a bit more about what support might be out there but he is still lonely. He’s waiting for the pandemic to be over, and hopes to bump into people he knows in the town centre.
Care and treatment proposed in the future
Alan’s friend advises him to phone the Central Access Point number and speak to a Recovery Worker. Alan is told about the new way of finding information on Leicestershire Partnership’s website. It’s something that Alan can have a look at in his own time and go through in his own way. This new website tool asks Alan a series of questions, for example, whether there is an urgent mental health need, or whether it is a more general enquiry where speed and level of response is not as critical. After answering a few prompts, the website offers Alan two self-help guides which he finds very useful as they give an insight into how he’s feeling. Alan is impressed with how quick and simple it has been to find the information he needed. Buoyed by this, he contacts a group of people, mentioned in the information received, who have had a similar experience. Two days later he joins in an online chat with the group’s members. They agree, when the pandemic is over, to meet for coffee and cake in Welland Park.
8. Working with community to provide more mental health service locally Case study: Sunita
Sunita is a 36-year-old woman living in Leicester. She has a partner but lives alone. Sunita has recently lost her job as a receptionist after verbally abusing a customer. She has a history of self-harming behaviours and overdosed on medication twice in her early 20s. Aged eight, she was sexually abused; her abuser was prosecuted and jailed. Sunita has had contact with the crisis team before and, in the past six months, has become a more frequent attender at her GP practice. She has reported fluctuating mood and struggles with self-harm. It is thought she may have a personality disorder and a referral has been made.
Care and treatment today
Sunita is referred to the community mental health team who decline her as she is not using any psychiatric medication. Instead, she is referred to the personality disorder service. The process takes up to six weeks with letters being sent around the system. The service explains that Sunita will need to book onto an engagement group ahead of an assessment. The next available date is in eight months. During this period, Sunita overdoses on medication and needs hospital treatment. Sunita attends the engagement group and books an assessment, which starts three months later. Her assessment occurs over a five-month period. Sunita is placed on a waiting list for an entry-level therapy group to introduce her to group psychotherapy processes and to look at helping her develop skills for managing her emotions. Interim appointments with the service take place while the wait continues for the group therapy.
A year on from her assessment finishing, she joins the group, a six-month course of weekly sessions. On completion of that first group, where Sunita demonstrates good engagement, she is offered a more in-depth therapeutic offer. This second group runs for 18 months. Sunita engages well and shows good recovery in relation to her reduction in self-harming and improvements in relationships and mood management. Sunita is discharged. The time from referral to ending treatment is approximately months.
Care and treatment proposed in the future
Following a call from her GP to the Central Access Point, Sunita is referred to the treatment and recovery team. The team has a range of professionals with different expertise who all come together to consider the service user’s various needs. Sunita is assessed by the team who identify her clinical needs and support Sunita to think about her recovery goals. A clinical and a safety plan are created with Sunita. Sunita is offered an extended assessment (six sessions at weekly intervals) with a specialist who works with people diagnosed with personality disorder. This worker is based with the treatment and recovery team. Sunita has the option to include a session with her family or carer. Her partner attends with her at the third assessment and they talk about how Sunita’s difficulties impact on their relationship. This helps Sunita’s to decide on her recovery goals. Options for therapy are discussed with Sunita. She opts for an approach that involves group work, with input from a specialist worker. She is encouraged to be an active participant in her own recovery, learning to manage her risk behaviours by developing a better understanding of her difficulties and using skills to manage these.
Ten months into the programme, Sunita meets with an employment advice and support worker in the treatment and recovery team to look at plans around returning to work, which was one of her recovery goals. Sunita stop self-harming, improves her relationship with her partner, family and friends, and better manages her moods. Sunita leaves the programme and is subsequently discharged by the treatment and recovery team. Time from referral to final discharge is around 20-24 months.
ihttps://greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88785&type=full&servicetype=Att achment, p. 37 – 42.
ii https://www.mind.org.uk/news-campaigns/legal-news/legal-newsletter-june-2019/discrimination-in-mentalhealth-services/.
Tel: 07973816885
iiihttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88192&type=full&servicety pe=Attachment, p. 2.
ivhttps://greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88785&type=full&servicetype=At tachment, p. 48.
vhttps://greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88189&type=full&servicetype=At tachment, p. 7.
vi http://saveournhsleicestershire.org/2020/12/30/why-leicester-general-hospital-plans-add-up-to-closure/
vii https://www.medrxiv.org/content/10.1101/2021.07.08.21259617v1.full.pdf, p 1.
viiihttps://www.bsmhft.nhs.uk/our-services/adult-services/day-services/
ix
https://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88192&type=full&servicetyp e=Attachment
xhttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88192&type=full&servicety pe=Attachment
xihttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88187&type=full&servicety pe=Attachment, p. 35.
xii https://www.mentalhealth.org.uk/a-to-z/b/black-asian-and-minority-ethnic-bame-communities
xiiihttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88187&type=full&servicet ype=Attachment
xivhttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88191&type=full&servicet ype=Attachment, p. 3.
xvhttps://www.greatmentalhealthllr.nhs.uk/EasysiteWeb/getresource.axd?AssetID=88192&type=full&servicety pe=Attachment
xvihttps://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/bulletins/a nnualsurveyofhoursandearnings/2018