So who is in charge?!

Here’s what’s wrong with mental health care in the UK << he modestly claimed!

No one is in charge of it – at all.

It’s not a system – it’s a coincidence.

You might want to pop the kettle on before you tackle this one!

You’ve only got to follow the @Twitter feeds of a few MH trust Chief Executives (plenty to choose from) to see this phenomenon. In exchange with several of them, they may well agree with many criticisms and issues within “the system” and agree whilst saying, “our MH commissioners need to pay heed” or similar. And they are most usually quite correct to do so.

Several years ago, a senior police officer who was trying in good faith to get his head around the NHS structures that apply to mental health once asked me to “draw a map on one page of A4 of health areas.” I will admit I wanted to pat him on the head and say, “Ah, bless!” … but that’s not the done thing, so I smiled a wry smile and tried to explain:

Did he want a map of -

• Mental health trusts – they provide most, but not all of the mental health services.
• Acute trusts – they provide major hospitals, which includes A&E services to which some mental health emergencies must be taken and which have “liaison psychiatry services.”
• Ambulance trusts – they do what it says on the tin, but may or may not be “commissioned” to provide MH related conveyance services, outside of emergencies. << Very best of luck defining emergencies.
• Primary Care Trusts – these are now called Clinical Commissioning Groups following the Health and Social Care Act 2012. This was the Act that ensured a top-down reorganisation of our health service, following the election of the last government.
• Specialist trusts – providing services like children’s mental health services and / or learning disabilities services. Surprise though this may be: they don’t always come under one “umbrella” mental health provider.
• GP services - they provide primary care services to around 83% of patients who have mental health problems.
• Local authorities – they oversee and warrant the Approved Mental Health Professionals who make MHA decisions. Sometimes they employee the AMHPs directly, other times AMHPs are seconded to or employed by the NHS.  So this is not just about health!

He then tried just asking, “Who do I ring?!” Well, it depends what you’re ringing about, Sir! The police find this all very hard because we have a Chief Constable (or Commissioner in London) and if all else fails, you ring him or her.

West Midlands

Let’s use the West Midlands as an example to see what this means -

There is one ambulance trust – West Midlands Ambulance Service: they cover the whole region and provide ambulance services to all 22 Clinical Commissioning Groups across the West Midlands area.

This is covered by four police forces – Staffordshire, West Mercia, West Midlands and Warwickshire Police who in turn cover the area served by 19 acute trusts (A&E and hospital services) and 8 mental health trusts. Obviously, there is little co-terminosity! And of course, not all mental health trusts provide all mental health services, so you’ll find in Birmingham, that the “acute” Children’s Hospital Trust provide the children’s and adolescent mental health services (for both inpatients and outpatients.) In Birmingham, the learning disabilities services are not provided by Birmingham / Solihull Mental Health Trust, but by Birmingham Community Healthcare Trust. But in Coventry, learning disabilities are provided by the mental health trust: Coventry and Warwickshire Partnership Trust. “Partnership Trust” is mainly an NHS euphemism for “mental health trust.”

But even then, providers who straddle CCG areas may provide some services in one of their areas, but not in others – it depends what the CCGs have “commissioned” them to do on their behalf. Some of the services provided by Birmingham/Solihull Mental Health Trust are purely for Birmingham.

All clear?! – if this gets too intense as you continue, just pause on the pictures for a moment and imagine a long walk in the fresh air.

Of course the point where children becomes adults is blurred – CAMHS ends once someone turns sixteen but adult services start for those who are eighteen. What happens in between is often a lottery depending upon the service required and how local arrangements are set up.

NHS commissioning

Now – in terms of what services are provided -

It is the role of NHS Clinical Commissioning Groups to “commission” the services which they think they will required to fit their populations, demand, etc., etc.. This includes mental health services and they may be commissioned from “any qualified provider”, including private sector organisations like Serco who provide the out of hours GP contract for Cornwall.

Quite why one area (Birmingham) may commission a MH trust to provide only adult and older adult MH services whilst getting their CAMHS and LD elsewhere; whilst in Coventry they commission the lot from Coventry and Warwickshire Partnership Trust: I have no idea. For example, I’m not immediately clear how Birmingham benefits from having two MHA Places of Safety – one for CAMHS, one for adults – when Coventry have just one for all. The distinction doesn’t arise from clinical issues or even from demand (Birmingham detain over three times as many people), but from bureaucracy around who provides what to the city and that’s why the CAMHS PoS caters for people who are fifteen and younger whilst the adult PoS for those are seventeen and older.

“What happens to sixteen year olds detained under s136 in Birmingham”, you may ask? The police improvise and attempt to persuade. But as the two services are commissioned separately by different commissioning authorities, they take a view as to what they will do and the knock on effect appears to be for others to manage on case-by-case basis.

Some CCGs cross boundaries like the Sandwell and West Birmingham CCG who commission MH services for Sandwell from the Black Country Partnership Trust and those for west Birmingham from the Birmingham/Solihull Mental Health Trust. Actually, in reality this CCG lets a lead-Birmingham CCG commission the west Birmingham service on their behalf and I’m genuinely unclear as to whether the lead commissioners discuss their service differences. This might be why those two areas of Sandwell and Birmingham who provide s136 PoS facilities differ in how it operates and how one CCG has ended up with commissioning arrangements which lead to two different standards of service from two different providers, either side of a local authority border that they straddle. Must be interesting living on Shenstone Road in Edgbaston – it depends which side you live on as to how your 136 service and mental health service work despite the fact that the whole road has it’s health services commissioned by Sandwell and West Birmingham CCG – one side of the road is Birmingham, the other Sandwell.

I imagine your head is starting to hurt now?

In the Black Country there are two mental health trusts, on describing itself as a “partnership trust” the other as a “mental health trust”: one provides almost all services to all parts of the population, but it also provides specialist services (for learning disabilities, children’s services and some secure services) to the whole Black Country. The other provides some but not all services to the whole population. So if you live in Dudley and have a learning disability, your provider is not Dudley and Walsall Mental Health Trust, but the Black Country Partnership Trust. Why? I’m sure we’d hear explanations like economies of scale around the provision of specialist services. But that’s not how it happens in Coventry and Warwickshire …

In the CCGs there is a Chair to each CCG – the Chief Executive if you like, who is overall responsible for what is commissioned.  So they are in charge …. except they’re not!!

For mental health, some specialist services are “commissioned” by NHS England, not the CCGs. NHS England is the organisation that replaced the former Strategic Health Authorities when the Health and Social Care Act 2012 took effect and also took on board some responsibilities previously held by the Department of Health. So they are responsible for the more specialist services like high-secure hospitals and services connected to offenders with mental health problems.

Keep going – nearly done!  Pain relief is available at the end. 

Getting stuff done

So how do you get stuff done?! – let’s imagine you work in an area where something that should be happening in health isn’t happening. Who do you ring?! Well, if the service is commissioned but not working properly, you ring the Chief Executive of the NHS provider, like a mental health trust. But if it simply doesn’t exist as a service or if it’s not commissioned properly, you ring the CCG – they are responsible for ensuring what is needed gets commissioned properly. Unless of course, it was commissioned by NHS England … in which case, call them. What is commissioned on mental health/criminal justice by your CCG and by NHS England? Well no-one really knows because the structures are still new and it’s still being thrashed through.

Why not ring your “offender health commissioner” – this is an individual employed by NHS England in order to ensure that the commissioning of services that affect offenders – whether by the CCG or NHS England – is joined up and ensures provision throughout the criminal justice system and for those diverted from it for mental health and/or drug or alcohol problems. I’m not sure if they would appreciate the suggestion that they are plugging gaps because the role involves far more than that, but they are a point of access into health for criminal justice organisations and all PCCs and senior officers who lead on mental health should know who they are.

Of course, the offender health commissioner will be very interested in what were sometimes called “secure services” – these are the medium secure units which are provided by one provider but for a regional intake.  So Birmingham/Solihull Mental Health Trust provide two medium secure units in Birmingham for men and one for women/children, but those services take patients from many areas of the West Midlands and sometimes beyond.

The medium secure CAMHS service in Birmingham is actually a national service – a twenty-bed facility which constitutes around one a quarter of those kinds of beds in the UK. So absolutely not just a service for Birmingham/Solihull, despite the provider. When West Midlands patients need high secure hospital services, usually after serious offences and via the criminal justice system, they are admitted either to Rampton (in Nottinghamshire) or Ashworth (in Merseyside). Those are high-secure national mental health services, albeit it run by a local-sounding mental health provider.

The main reason that no-one is in charge is because the ability of “provider” trusts like mental health trusts or acute trusts to be able to argue about what they are “commissioned” to do. I have long since learned that if an MH Trust is not commissioned – i.e., paid – to provide a certain service like a s136 facility, they have no problem in telling you that the absence of such a facility and the knock-on consequences for the police is not something for them to worry about however much they may agree with you that it should exist. When I waded into this stuff earlier in my career, I was just invited to contact the PCT (it would now the CCG).  Some PCTs cared, others didn’t – some PCT MH commissioners were interested to learn about this service omission and satisfy unmet need, others couldn’t have cared less. This was often influenced by their perception (not necessarily founded on knowledge) about policing. It’s good to talk.

And remember, the extent to which unmet emergency and other mental health demand is met by 999 services and/or by parts of the NHS like A&E is not understood. Far less understood is: what amongst that demand could have been met and what will always require a police or ambulance or A&E response? As such, we could do with cross-provider research about mental health demand – where does it go, what does it look like and how could we prevent it, mitigate against it or react better to it?

We don’t know – because no one’s in charge.

If you are affected by the issues in this post I recommend a long, soothing bath with candles and whale music. Headache medications are available at all good pharmacies, which are not commissioned by the NHS.

Courtesy of Insp Michael Brown at Mental Health Cop