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Developing mental health services in Harrogate Engagement Report 2

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CONTENTS

Page number 1. INTRODUCTION 3 1.1 Background 3 1.2 Purpose and structure of document 3 2.

METHOD

4

2.1 Qualitative interviews 4 3.

INTERVIEW FINDINGS

5

4.

DISCUSSION AND CONCLUSIONS

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Appendix 1: Engagement processes Appendix 2: Detailed notes from meetings

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1. INTRODUCTION 1.1 Background

Tees, Esk and Wear Valleys NHS Foundation Trust (“the Trust”) provides a wide range of mental health, learning disability and eating disorders services around County Durham, the Tees Valley, Scarborough, Whitby, Ryedale, Harrogate, Hambleton, Richmondshire and the Vale of York. The area served by the Trust has gradually expanded over the years, and now includes large areas of North Yorkshire formerly served by other providers. The services in Harrogate are commissioned by NHS Harrogate and Rural District (HaRD) CCG (“the CCG”) and this is a jointly commissioned project between the Trust and the CCG.

It has been widely accepted for many years that the inpatient mental health facilities provided on the Harrogate District Hospital site do not meet modern standards for inpatient mental health care. The two wards on the Briary Wing (Rowan and Cedar, for older people and adults of working age respectively) are scheduled for replacement. Over the past four years the Trust have developed business cases and have acquired land at Cardale Park in Harrogate with a view to a new and freestanding capital development. However, recent developments in other parts of the Trust’s portfolio, changes in the health and care sector as a whole, and financial pressures locally in the HaRD footprint resulted in a joint decision to pause the planning process.

This engagement review has been an open process, in which we have clearly explained the constraints faced by the Trust and the CCG with respect to their financial position.

1.2 Purpose and structure of document

This document sets out the results of our work. It represents the independent assessment and opinion of Mental Health Strategies.

After this introduction, the document is organised as follows:

Section 2 contains a brief description of the method adopted to undertake the review.

Section 3 explains the themes arising from our qualitative engagement work. Section 4 contains our discussion. Appendix 1 contains an overview of the engagement process, including what we

have done, where, who it was aimed at and how we structured the

sessions (the questions we asked), the numbers of people we have

engaged with (including a breakdown of sector). Appendix 2 contains detailed notes from sessions and individual returns to the

engagement.

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2. METHOD

This section summarises how the work was carried out. The project undertook a listening and engagement exercise with an agreed format for the meetings including the questions being asked. The questions were first co-produced’ in that people with lived experience of services in Harrogate met with one of our team and agreed the wording of them. The meetings included:

Face-to-face engagement events across various mental health sites and

locations in Harrogate from the beginning of September 2017 to 13th October

2017. This was a series of qualitative interviews with a range of people with experience of the functioning of various aspects of TEWV services across Harrogate and Rural District.

A larger public engagement event held at the White Hart Hotel in Harrogate on 27th September 2017

Opportunities for anyone to attend them as advertised locally via various communication networks.

Additionally, there was the opportunity for anyone to submit written responses via email or Freepost and seven were received through these routes.

2.1 Qualitative interviews

As outlined above we interviewed a range of people with experience of the organisation and delivery of TEWV’s services, or experience of receiving the services. A semi-structured interview framework was prepared and agreed and included the following questions: 1. In the future, what would you like the mental health services in Harrogate and

Rural District to look like? 2. Thinking about the strengths of the current Harrogate services, what are the

three things you’d like to see remain in future services? 3. Thinking about the things you’d like to see improved, what are the three priority

issues you’d most like to fix?

4. What are your thoughts on the future of inpatient beds for local adults and older people?

5. Thinking about the needs of carers and families – what would you like to see available to better support the families and carers of people with mental health conditions?

6. What type of community services would you like to see available to help keep you well?

7. Is there enough emphasis on recovery, social inclusion, training and education and/or volunteering through to employment to support active citizenship? If not, what other services would you like to see?

A stakeholders list was provided by the Trust and the CCG and people and organisations were contacted through administrative support provided from the Trust to attend pre-arranged visits / meetings / telephone interviews as required (See Appendix One for the engagement list).

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Records of issues arising from each visit / meeting / interview have been maintained, and have been analysed thematically for presentation in section 4 of this report. The views are presented without giving names of respondents.

3. INTERVIEW FINDINGS

This section presents the findings of our interviews with staff from TEWV services operating within Harrogate, and from people with lived experience and partner agencies.

There are ten themes, and each one is summarised with the main issues raised. We have used direct quotes in this section, which is the narrative from what respondents themselves said, or from written submissions or facilitator notes of feedback. Appendix Two contains the full account of participant feedback, including facilitator notes and individual returns. The themes are:

24/7 integrated and joined up services

Developing the workforce

Holistic approach

Financial context

Improved pathways

Location of inpatient beds

Alternatives to admission

More preventative approach

Partnership working

Improve patient and family outcomes – more recovery focus

These are further described below under the headings of the questions asked in the engagement.

3.1 In the future, what would you like the mental health services in Harrogate and

Rural District to look like?

Generally, people who engaged in the discussions had a clear view on what they wanted the future services of Harrogate and Rural District to look like. Some people spoke about the culture within services, with one worker stating that:

“As a service we currently create dependence”. And another observing that:

“..there is too much focus on retaining people in community services so they can access a range of non-health services – institutionalised!”

Another community worker referred to the service as:

“…risk averse – not quick at discharging especially… in Ripon”.

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In relation to the community model of services both workers and people with lived experience were in agreement that:

“Routine care should be a routine care offer over 7 days a week to meet the needs of Harrogate population”.

24/7 integrated and joined up services

The first theme was based on a consensus on the need for services to feel less disjointed and more joined up, including better relations with other providers, with clearer pathways and also in relation to some specific client groups:

“Emotionally unstable Personality Disorder clients particular benefit from no hand-offs when their needs escalate”.

This particular client group was discussed in various meetings. There was a view expressed by one staff member that Harrogate had:

“a high number of people with complex needs / personality disorder”.

And from another that:

“We need more DBT (dialectical behaviour therapy) focus and service”. A Community Mental Health Team (CMHT) team manager told us that:

“Services are currently disjointed – they’re not integrated or joined up”.

There was also a view that services didn’t want to share information, and that people were “guarding their own…” and were unwilling to work together, for the benefit of people in services. One community team member told us that they’d like to see:

“Shared caseloads, shared working not – “Somebody else’s problem!”

One carer wrote in to say: “All patients should have a single named support worker who is in

regular contact and can help navigate the current chaotic systems of support. There needs to be more joined up thinking – all current systems and processes are designed solely for the professionals and not for the patient or their carer. It needs refocusing”.

And from a Third Sector Provider, in relation to joined up commissioning:

“In future, we would like mental health services to be much more “joined up” than at present. The continuing twin stream of funding from NYCC Social Work and NHS is not particularly helpful and can lead to differing priorities. The present plethora of reviews in the mental health arena serves to emphasise this point… this is inefficient and unhelpful and while we are interfacing with the multiple reviews which we feel we must do to be heard we are less focused on those who depend on our help”.

From another carer:

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“Complete wrap around service so you feel secure (it would feel like staff that listen, don’t rush you, care plans that mean something, they know your history and what worked in the past)”.

Integration wasn’t all about organisations (such as the third sector) or the local authority but also referred to within the trust itself, as one staff member described,

“Properly integrated working – not just across organisations but also within the trust across MDT’s/multi-professions”.

One member in a group stated that they wanted:

“Integrated health and social care teams with more even emphasis on the social bit – too medically focussed”.

The issue of service and worker preferred orientation is explored further under the theme ‘holistic approaches’.

3.2 Thinking about the strengths of the current Harrogate services, what are the

three things you’d like to see remain in future services?

There was a lot of consensus about the strengths of the people who worked in the service.

One carer wrote:

“The strengths are the staff. Without them there are no services. Those that I’ve talked to enjoy the job that they do but recognise that they are short staffed have fewer resources than other areas of TEWV and are being asked to make further “efficiencies” on an already “thin” service”.

One manager said that:

“Staff go above and beyond, lots of them work at home out of hours”.

Although there were some very positive comments about the commitment and passion of the staff working in Harrogate, the second theme to emerge was the need to nurture, and invest in the development of the workforce.

Developing the workforce A therapist working in the service said:

“Safety – for staff and patients (need psychological containment and a clear pathway to follow)”.

One CMHT manager had the view that there needed to be:

“More cohesive team working – people under too much pressure & have low skill base - feel isolated in their work”.

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Comments were made about staffing shortages in the community teams and low staffing levels on the wards. This was having an impact on the ability to invest in staff, when courses were made available:

“Training and staff development - there’s no time to put anyone through mentoring, DBT and MSc PD - I can’t release anyone…”

There were some comments about the culture with services and that this required attention. Comments included improving:

“Culture, education and training for staff”.

And from a worker:

“Need a cultural transformation”.

And an in-patient nurse:

“Up-skilling staff and create a learning culture”. One service user suggested that:

“I see few people recovering from poor mental health. Many fear it. They fear change, they fear challenge. Therefore losing control, staying unwell and in a comfort zone gives the person an element of control. We need to create a compassionate culture where everyone loves and supports each other, no judgement, building social and cultural capital and massive recovery capital”.

Also referring to compassion, one person stated the need for more:

“Education – more understanding therefore more likely to care with genuine compassion…”

One service user referred to the attitudes of staff:

“Need to improve attitudes of workers”.

And another called for:

“An audit of the conduct and professional behaviour of legacy staff, proper insight into the “culture” and attitudes within the Harrogate area”.

In relation to the skills and knowledge in the workforce, whilst there was a view that people were caring, the ability to cope with more complex care needs was limited. And according to one worker this related to:

“No training for staff – bare minimum skills…” And that:

“We don’t have advanced practitioners”.

One carer reflected on her sister’s experience and shared her observation on medication usage and asked Harrogate teams:

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“NOT to use medication to manage patients on Briary – you don’t get that in Middlesbrough”.

In relation to the staff shortages and recent changes in the CMHTs one manager reflected that:

“We used to have an assessment service and removing this has led to loss of staff; serious incidents with workers being too busy doing assessment to look after seriously ill on caseload and morale is down and anxiety in the team rocketed – people feeling panic and fear..”

This particular manager reflected that the changes had just been too much, but that managers had listened and slowed the pace of change down. It wasn’t that they weren’t in favour of changes, but that the loss of staff combined with changes meant a lot of additional pressure was on those staff remaining. There was also a view however, that bringing about future changes in the clinical model might be met resistance. For example in relation to seven-day working they stated that:

“I would like to see CMHT working weekends but there’d be a lot of resistance to weekend working”.

In relation to nurses working on the inpatient wards one nurse shared:

“I joined the Trust hoping for a future in inpatient services. I wouldn’t want to travel to York. It feels really disappointing, and leaves my role up in the air”.

In relation to future changes one CMHT manager shared their view that:

“Staff are good – keep morale high, happy and autonomous in care delivery”.

In relation to managing change, one person said:

“Important that the change journey is managed so that staff are supported to make the transition successfully. Trust doesn’t do that well at the moment”.

And on a similar vein, a consultant said:

“Asking people to change their way of working requires effort from management and staff. Unless this happens then clinical decision-making doesn’t change”.

3.3 Thinking about the things you’d like to see improved, what are the three

priority issues you’d most like to fix?

This question was less about providing people with a ‘wish list’ but rather an opportunity to consider those aspects of delivery, or care experience, that people wished to see eradicated in a future model. People stated that they wanted to see improvements in the inpatient service, with comments ranging from having separate sex wards; to a new inpatient facility; to being more recovery focussed; having better physical healthcare; having less turnover of staff and being more proactive and less reactive.

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Holistic approach One respondent wrote:

“Adopt a holistic and realistic approach to prevention…. Not everyone will recover but everyone is at risk of slipping back into a worse condition without support and services which have been proven to work over a period. Continuity of care and support for such vulnerable people is important and we need to take care not to overlook this”.

And a carer suggested:

“One assessment for patients, holistic”.

This theme also highlighted an issue of ‘access’ to the right service to help people. One carer who was supportive of self-management also wrote:

“This “threshold” approach to accessing services is damaging and dangerous. Service Users are encouraged to recognise when they’re reaching crisis and follow their crisis plan. So when eventually they get a referral to secondary services they’re then told that they’re not ill enough / thin enough / etc. Why bother writing a crisis plan? Why encourage Service Users to be active participants in their care? What a waste of time”.

Access to the right help was an issue for some, with more recognition being sought for talking therapies:

“Psychological needs to be met by every contact, regardless of which profession is in contact with them”.

One nurse said:

“Access to psychological therapy at the right time”.

In relation to a more holistic approach, one CMHT member proudly highlighted an example of good practice:

“The recent formulation model is designed to counter medical dominance and we always ask about trauma”.

Financial context

People were generally aware and accepting of the context they worked within and of the impact of ‘austerity’. One community worker stated that:

“With the resources our community services have they do really well”.

Another worker stated that they thought they provide:

“The best care within resources available”. A number of people paraphrased a saying, which was that:

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“Our commissioners expect us to provide gold standard care but we only get enough money for bronze”.

One person asked for a:

“Better understanding of what £14.5m spent on – finance sharing”.

Respondents generally referred to ‘resources’ rather than ‘money’ or ‘finances’. And generally by resources the implication was that services were understaffed, or underfunded, or that people were being stretched too thinly.

For example, one CMHT member said that they needed:

“More resources for the outreach team and the crisis team”. An inpatient nurse argued that what was needed was:

“More resources for the CMHTs, especially if there are no inpatient services in Harrogate”.

And a psychiatrist believed that:

“Timely access to properly resourced acute services not just when in crisis”.

Improved pathways

When talking about seamless, joined up and integrated care some people also referred to the need for ‘pathways’. Sometimes this was in reference to the whole model of care, such as the nurse who said they:

“Would like a 7 day service, integrated model, with specialist pathways”.

At other times reference to pathways was within the context of specific approaches for specific client groups, such as the CMHT manager who was very clear in their view that Harrogate:

“Needs a more effective PD service”.

Pathways was also referred to explicitly from a General Practitioner who said that:

“We feel that mental health needs to be integrated with Primary Care and should be a front line service with access to Primary Care Mental Health in practice. Mental health is an ongoing condition and should be treated in the same way as most Long Term Conditions like Diabetes, COPD, Asthma etc where we have specialist nurses in Primary Care to lead in these areas”.

In reference to more complex case management, one worker commented that:

“Mental health nurses working in Primary Care as part of the Primary Care team, CAMHS, Ex Servicemen pathways and access for PTSD especially those with Drug and Alcohol associated problems. Crisis Team lack capacity and number of cases is increasing. CMHT

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increased capacity…. Both models of this integrated care result in a seamless journey for patients with MDT working and smoother transitions of care”.

From a Carer’s perspective:

“Services to be more joined up – seamless response should be in place”.

3.4 What are your thoughts on the future of inpatient beds for local adults and

older people? Location of inpatient beds

The impact on the people working in Harrogate of the decision to pause the development at Cardale Park is captured below:

“We feel very raw about the five years’ input into work on the new build”.

People expressed disappointment, but not necessarily surprise, when the announcement was made. For some, including service users, the decision to pause was welcomed as there was concern expressed about the isolated nature of the Cardale Park location. Harrogate presently has inpatient beds for adults and older people, and there was a mixed opinion on where the best future location for beds should be, whether it should be Harrogate, another town or York.

One patient felt that there should be:

“A new development within Harrogate”.

A view supported by another respondent who said:

“People prefer to access beds locally when needed rather than travelling to unfamiliar places away from their family and friends.”

This Carer had a contrasting view which was that:

“I don’t think there needs to be beds in Harrogate – put them in York”.

Supported by this Carer who stated that:

“I’d rather travel and get best environment – York – no problem, not everyone has a care but better to have centre of excellence”.

With another Carer saying:

“If Harrogate services do have to move to York, special buses will need to run, especially for older people. There will need to be proper liaison and outreach arrangements with the acute hospital in Harrogate. There will need to be proper arrangements for people on leave from psychiatric inpatient beds”.

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The opinions in support of, or against, a facility based in Harrogate were on a continuum, as above. Most people were concerned that it was about having the right facility with the right level of high quality specification that was of most importance.

There were ideas raised such as one senior colleague asking:

“If demand is so small for organic beds could it be run by the independent/private sector?”

And one Carer wrote:

“There needs to be more creative thinking. For example, if beds are not available in hospital, can care home beds be purchased as an alternative? This would work for dementia”.

The availability of Harrogate based beds for older adults raised some strong opinions. For example, one person stated that:

“Harrogate has a huge elderly population, it’s expensive and a retirement area. Making people go a long way away is really cruel and has a dramatic impact on patients”.

And here is another nurse reminding her colleagues that there is a need for:

“Local provision for older people so that patients who need admission can stay close to their family”.

One Carer asked the providers to:

“Be creative! Particularly for older people”.

There were comments requesting that the male and female beds on wards be separate in a new-build, for both adults and older people. And there was also recognition of the level of need on the wards. For example, one consultant said:

“Acuity is now much worse. I’m very concerned about the idea of managing people in nursing homes”.

A manager suggested that:

“Maybe there could be a single challenging behaviour unit for dementia in Harrogate – and functional illness services for older people could go elsewhere?”

A local GP Practice thought that:

“However I don't think we need increased beds for elderly patients if the trust were able to have an arrangement with specialist care home providing significant mental health input to a "few" specialist care home beds - step up - step down beds for mental health access”.

Alternatives to admission

The current model of available beds, which reflect a standard inpatient model of acute care, was questioned by some as to whether it reflects the best way of meeting needs.

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For example, one Carer wrote in to say:

“As a carer of a sufferer I feel that it is important that providers of services realise the nightmare of coping with someone in an acute phase of their illness, it is frightening, dangerous and impossible to provide this service in either the carers or sufferers at home. There must be sufficient beds to cover admissions in a crisis-situation as there are many cases when the “Crisis Response Team” cannot be a substitute to in-patient care”.

One CMHT member asked for there to be:

“Short term inpatient beds local to Harrogate – Not out of area”.

And a service user said: “We’d welcome a local crisis house like they have in Leeds. This could be in Harrogate or elsewhere, it wouldn’t matter too much”.

A CMHT nurse also suggested that what was required was the: “Development of 24 / 7 crisis house with overnight “respite” / emergency accommodation”.

And another person suggesting a:

“Crisis House - with appropriate discharge pathways, and staffed appropriately”.

Other suggestions included:

“Alternatives would be better – day centres, safe houses...”. “Crisis beds as an alternative to inpatient for short term...”. “Day care facilities are important. They provide some respite for carers and families as an alternative to inpatient care”.

3.5 Thinking about the needs of carers and families – what would you like to see

available to better support the families and carers of people with mental health conditions?

The experience of carers has been identified through the engagement process and the importance of caring for families is reflected below by a family member:

“Families are sometimes completely at breaking point. They’ve tried to look after people at home for so long, but family dynamics risk breaking down”.

People expressed a desire and support for greater involvement in the care of their loved one, and to have access to more education, clearer information and education to help them improve their knowledge and skills in caring:

A nurse recognised the need for:

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“Better communication with carers/families – involvement of carer…”.

One family member suggested that:

“Psychoeducation at post discharge…”. And another that:

“A joined journey/service ‘taken through the service together”.

Two Carers mentioned the ‘Triangle of Care’ as a helpful framework for ensuring family involvement. Other Carers spoke of the need for:

“Better partnership working with Carer / family”.

And:

“Better liaison with TEWV Care Co-ordinator and LA Carer support worker”.

In terms of innovative models one worker suggested the implementation of the:

“Icelandic model – when patient goes into crisis, staff work with family as well as patient. Had positive impact on both patients and carers resulting in reduced admissions”.

More preventative approach

The theme on prevention emerged in the context of asking about support for families but it was also a thread within other questions too. When asked about additional support for families, one Carer had this to say about the service:

“More pro-active. If a patient / Carer / family member / friend recognise that they or an individual is reaching crisis, immediate access to TEWV services as prevention service.”

One family member talked about:

“Prevention focused services…”.

And another person said:

“Prevention/education before reach crisis”.

There was a view from a family that longer term support would help prevent relapses:

“Prevention services, proactive not reactive, also long term support to prevent…”.

One Carer was critical of the term ‘recovery’ being used as a term to rationalise cuts in provision:

“Much of the reduction in contact with secondary mental healthcare is set in the context of recovery – there needs to be a recognition that for

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some this is not appropriate and that these services are often an integral part of prevention and recovery and reducing incidence of crisis and hospital admission”.

A CMHT worker acknowledged that services can be improved to shift their focus:

“CMHT must remain in an improved way focusing on partnership organisations looking at preventative care – support people to remain in workplace – more individual advocacy support…”.

This carer with 40 years’ experience referred to the loss of day care provision and their experience of this:

“As a carer I found that lack of occupation during the day and with it

the chance to meet people, socialise, make friends and learn new skills is vital. It provides a chance to live a “normal life” and hopefully return to work and is hugely important in preventing relapses. Most of the Day Care in Harrogate is provided by the voluntary sector and it would be helpful to service users if it was more of an integral part of the whole support system and acknowledged as such by statutory bodies. Many mental health professionals still seem unaware of services in the charity sector even in a small district such as Harrogate. Therefore I feel it is important that Day Care is recognised as one of the basic building blocks which prevent relapses requiring vastly more expensive support and is acknowledged as such”.

3.6 What type of community services would you like to see available to help keep you well?

The responses to this question were wide ranging and covered other themes – from the need for more “sheltered housing” to “need to think about third sector”. Partnership working People were encouraging about the need for improved partnership working.

“Health and third sector agencies and providers need to work closer together”.

One CMHT member talked positively about:

“Partnership – TEWV & NYCC appropriate housing for those leaving hospital”.

Another CMHT member and a Carer spoke highly of the Harrogate Hub:

“Harrogate ‘Hub’ model – very good..”. “Voluntary organisations such as Harrogate Hub can partner Mental health practice in Harrogate”.

A Carer commented:

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“All organisations – sharing resources, collaboration, stop charging each other…”.

Others with experience of the police suggested that the Trust could:

“Increase links with police etc + trained workers in police”.

Staff working in Windsor House liked the multi-disciplinary contact and supported the idea of a:

“Concentration of services under one facility inpatient / outpatient / community + social services all under one unit”.

Comments about the need to strengthen the third sector partnership working arrangement reinforced how valued these were by local people:

“Stronger third sector presence”. “Invaluable nature of voluntary sector”. “Joined up working between voluntary & TEWV”.

3.7 Is there enough emphasis on recovery, social inclusion, training and education and/or volunteering through to employment to support active citizenship? If not, what other services would you like to see?

Of all responses not one person thought that there was enough focus on recovery.

Improve patient and family outcomes – more recovery focus

In relation to recovery one person with lived experience stated that the service needed to consider:

“Moving away from passivity, passive behaviour to nurture recovery, wellbeing, good health, feeling great and having AMBITION for all the above..”.

One Carer asked for:

“Individualised plans – improved communication with services used”.

Another person with lived experience stated that they’d like to see an approach:

“Supporting growth and recovery and wellbeing potential and eventually self-actualisation”.

Carers suggested that when people spoke to them they should be:

“Treated with respect and dignity”. And have:

“Simple, realistic, achievable information and communication” with “Better communication between services and families..”.

A worker suggested that there be:

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“Better use of Recovery College – awareness training”.

Others suggested:

“Out of hours support, weekend working”.

Or a:

“Community café’ who can link you in”.

One person said:

“I really think that active citizenship is essential to promote recovery. There needs to be a linked and effective recovery pathway, which includes training, education, work placements and volunteering. All of these things are useful of themselves as well as being stepping stones towards fuller recovery”.

And the work the Trust has done was recognised and appreciate:

“There is more talk of recovery and support worker roles. There has been local training. We welcome the training on recovery. It’s doable and achievable. I welcome the process”.

The need for transformation

One CMHT leader stated that the whole clinical approach:

“Need a full scale shake up – need to start again!”

This was in the context of enhancing community teams, extending hours of working, bring in dedicated pathways and transforming assessment and treatment pathways, closer to primary care and all designed to prevent admission.

Another worker referred to the need for a:

“Cultural transformation…”.

The need for investing in the workforce has already been highlighted as a theme, but transformation here is referred to within the context of learning and people development:

“Up-skilling staff and create a learning culture”.

Also in relation to culture and the overarching response to meeting people’s needs, one senior worker stated that:

“The service is risk averse – not quick at discharging…..”.

And that there:

“Needs to be recovery not ‘risk’ based services”.

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4. DISCUSSION AND CONCLUSIONS

This section contains a discussion of the themes identified, and provides a commentary on the issues raised. Also contained within this section is an outline of areas for further consideration regarding the future location of inpatient services in Harrogate, and the actions that might be taken to move the service forward, in line with what has been suggested from the engagement. As in Section 3, the emerging themes are used to frame the discussion.

4.1 Theme 1 - 24/7 integrated and joined up services

One of the main trends underpinning all health services development is the concept of integration, of professional roles and approaches, of practices and process; co-located buildings, through to governance and commissioning arrangements. The move towards place based service models, providing care based on local needs and coproduced with people with lived expertise in their conditions is becoming more commonplace. The Five Year Forward View for Mental Health supports this direction of travel, and the theme of integration was raised through the engagement process, from all stakeholder groups. There are many areas identified where the Trust could take specific actions, locally with partners to engage with local teams and coproduce solutions to issues raised. The initial learning from the Harrogate Vanguard, in which the Trust is actively involved, has yet to be shared, and this would be one innovation where positive practice could be shared.

4.2 Theme 2 - Developing the workforce

The evidence supporting the link between a strong and engaged workforce and positive patient outcomes is now well established. Key messages from the engagement were that, overall, the commitment and passion of the workforce is strong. However, amongst other things, people also stated that:

There are staff shortages

There are deficits in knowledge, skills and in some cases positive attitudes

In the community staff feel burnt out

The skill mix needs to be reviewed

Culture needs improving to become more compassionate

Better resourced/deployment of staff

More education is required to enable staff to care with genuine compassion There is an opportunity for TEWV to demonstrate to staff in Harrogate their commitment to a new model and ensure that service changes are developed through a bottom up approach, building on this engagement. For example, investing in local training, bringing a greater focus on known problematic areas (such as trauma and complex cases), or supporting the design of recovery focussed pathways, will help in ensuring that people feel listened to, valued and appreciated.

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The inpatient staff group would benefit from regular open meetings to discuss the impact of the ‘pause’, the on-going planning process and to be encouraged and given every opportunity to be actively involved in the change process. This might also include a targeted review of their development needs and associated programme of training to ensure they are appropriately equipped to deliver any new future model.

4.3 Theme 3 - Holistic approach

Most mental health services pride themselves on providing a robust bio-psycho-social model of care that supports recovery. On the ground this is not always translated into a holistic approach, as services cope with crises and medical emergencies, meeting efficiency demands and constant and rapid change. Service users described the service as needing to be more holistic, offering a greater range of support to keep well and manage ‘blips’ or ‘setbacks’ that supported self-management. The energy and commitment to think collectively about the service model provides an opportunity to work closely with service users, families, partners and citizens to coproduce a new and innovative model of care which, on balance, would feel more holistic. This could include innovations around the use of IT, telehealth, building social and recovery capital, establishing peer support workers, and adopting new ways to manage acute mental health distress and ‘crisis’ that are less dependent on beds.

4.4 Theme 4 - Financial context

The CCG and the Trust must make the most of the resource available to them. This means ensuring value for money and the most effective use of the combined, whole system resource. This will inevitably require compromise; of quality, location, build design, workforce readiness (numbers, profile, knowledge, & skills) and so on. A number of respondents’ views raised questions about the financial and cost efficiency context. Within the known constraints there should be attempts to frame the on-going service redesign process in an open and transparent way that is true to the values of the NHS, and provides stakeholders with accurate knowledge about the historical financial legacy, as well as the decisions ‘made today’ that inform the overall shape of mental health care in Harrogate and surrounding areas in the future. Regardless of the financial context, the rationale for the changes people are seeking has been established through this engagement. This will help to win the hearts and minds of the various stakeholders who will be responsible for transforming the desired changes. The current model is not working for the people receiving, and for the people delivering the service. This is a strong enough reason for improvement.

4.5 Theme 5 - Improved pathways

There was unanimous support for care being delivered as close to home as possible. We were given to understand that Harrogate as an area has three times more referrals for some groups than other parts of TEWV. There has not been any detailed analysis of the causation.

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The needs of specific groups of people were discussed, for example the lack of dedicated pathways for people with complex, traumatic backgrounds (sometimes diagnosed with personality disorder). It was felt that the new focus on DBT training was welcomed but that people were too busy to undertake the interventions, and that the need far outweighed the local investment to date. There is an opportunity for the Trust and the CCG to work with service users who have complex needs to coproduce evidence based pathways and develop a model of care for this client group. This is likely to have a positive impact on other parts of the system such as inappropriate admissions, A&E attendance for self-harm, housing problems and dual diagnosis issues associated with substance misuse. Dissatisfaction was expressed by the CMHT managers about the recent rate of change in service models, and calls were made for reviewing links with primary care and managing new assessments into the service. The new process was not viewed positively and with the high rates of referrals into CMHTs (4264 – 2016/17 with 85% acceptance) the opportunity to operate a more efficient single point of access (SPA) or dedicated assessment process would be worth further review. We found that the community health team managers largely welcomed the proposed community models, but that the recent depletion of community nurses and the absence of dedicated training and development for managing complex cases, were seriously affecting the resilience of the team. Any proposed changes to the inpatient model will be dependent on having a resilient and fully established, skilled and highly functioning community service. There is an opportunity to work closely with the team to help them identify their optimum integrated configuration, with greater clarification of pathways, functions and roles required to deliver for the best outcomes.

4.6 Theme 6 - Location of inpatient beds

Both the Trust and the CCG agree that the inpatient facility in its present location is not a sustainable solution. The ‘do-nothing’ option is not open to the CCG and the Trust as the beds need to be decommissioned and re-provided elsewhere. The purchase of the plot of land at Cardale Park does not have widespread support from the local community, due to its location, being isolated and having limited transport links. We also heard some concerns from staff about its location. The on-going revenue costs associated with safely operating the proposed unit are no longer affordable within the current finances available. There are options that could be pursued for the future use of this land including: 1. Dedicated campus for older people using a model that combines accommodation

(ownership through to rental), supportive living through to specialist dementia beds. Such models exist elsewhere and have proven to be effective. The aging population in Harrogate may welcome such a proposition and this option would potentially address the views expressed for local bed availability for older people with mental health problems. This may benefit from a new partnership, with housing or an existing specialist provider of dementia settings.

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2. A campus for a new Integrated Hub offering a full suite of wellbeing services where mental health was fully embedded with other providers and agencies. Crisis accommodation could be made available for those experiencing acute distress. This may also require partnership with other health providers and commissioners.

The question of the potential loss of beds from Harrogate was explored and there was a mixed response from people. On the one hand, we heard that beds must remain in Harrogate for reasons of convenience, continuation of relationships and maintaining attachment with family, friends and neighbourhoods. On the other, we heard that the loss of beds would not be detrimental, that before beds were in Harrogate people used to travel to York, and that access to more robust community services including alternatives to admission (crisis house or sanctuary out of hours service) would help those in crisis. For older adults, there was a stronger and more firmly asserted view expressed that travelling for older people was more difficult, and that wherever possible beds should be provided locally. A number of people expressed the view that partnering with an independent provider (e.g. of nursing homes) would be one solution. This might be the development of a wing of an existing facility to accommodate in-patient beds. For adults, this option also exists through partnering with independent providers already in Harrogate. Since purchasing the plot at Cardale Park the Trust have commenced the development of a new build at Haxby Road in York. This provides an opportunity for the Trust to consider expansion of available beds on this site for the citizens of Harrogate. We heard from several engagement meetings that people thought this would be a wise option to pursue, as having access to a high quality and specialist inpatient facility would outweigh the inconvenience of travelling. Views were expressed that beds in York might lead to longer lengths of stay but our analysis of the use of mental health beds in other systems (nationally) does not support this assertion. Some people suggested that an outcome of having one specialist campus for the treatment and recovery of people in acute mental distress provides an opportunity to operate a larger inpatient facility, with highly specialist and skilled multi-disciplinary teams on one campus. In effect, the acute care pathway becomes a ‘hub and spoke’ model – the hubs are local communities or neighbourhoods, and spokes are crisis houses, crisis cafes and the York Campus. If this were to be pursued, the Trust will need to consider the impact of geographically dispersed units through a detailed analysis of historical patterns of admission, by place and cluster, to determine the areas of most need, and to match community resource to the need identified. Community services would be required across the week with out-of-hours provision, locally available for dispersed communities and towns. The Trust and the CCG could consider purchasing land and building a new unit elsewhere, either within or close to Harrogate. However, this option brings with it the same financial problems associated with Cardale Park (i.e. on-going financial commitment to safely run the unit which is currently unaffordable).

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If the land at Cardale Park is not used, proceeds from its sale could contribute to further developments at York, and/or contribute to local out-of-hours provision such as a crisis house, crisis café or sanctuary facility. A number of participants enquired about statistical modelling and underpinning analysis for the number of beds required for Harrogate. Internal analysis undertaken by TEWV has, we understand, estimated that future bed requirements, based on the historical patterns of bed usage for MHSOP would remain between 11 and 19 beds, and for AMH would reduce slightly to between 12 and 18 beds. Mental Health Strategies have not undertaken any independent analysis and system capacity modelling so are unable to comment on the accuracy of these proposals. In-patient bed usage does not occur in isolation and clearly any future pattern of bed usage will depend on the configuration, and effectiveness of the community model. Thus, the impact of the implementation of crisis houses, crisis cafes and so forth, would need to be considered in any future model, to provide adequate confidence on any assumptions made.

4.7 Theme 7 - Alternatives to admission

Alternatives to admission are scarce in Harrogate and surrounding areas, with the main service being the home treatment team. There are now very well established teams elsewhere in the country, which have positively and effectively helped to reduce admissions, which we have evaluated and would be happy to link you with, should you believe that to be beneficial. Some practitioners in Harrogate were familiar with the models in Leeds and Bradford, and were keen to bring these innovations to Harrogate. Service users were very interested in such models, as they believed them to be non-medical, and provided in least restrictive environments that supported greater self-management and autonomy, and which was in line with the Trust’s vision of implementing recovery.

4.8 Theme 8 - More preventative approach

This theme relates to how to make it easier for people to access services (the front door), to how to adopt a more proactive and assertive clinical model (the behaviours people experience when they’re in the service). Ultimately, the goal is to make it is easier to get treatment when required, for people of all ages, and as close to home as possible, and for only the period required, so as not to create dependency and reduce personal autonomy. The goal of earlier prevention could be embedded within any redesign work undertaken for new pathway development and service redesign. It is supportive of recovery, staff wellbeing and developing resilient communities. However, it requires the service system to be truly focussed on its core offer, which is to treat and help to recover those in mental distress. If a wider public health offer is required, this should be properly scoped, effectively commissioned and resourced to target population health improvements in line with best available evidence.

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The local authority currently employs 1.5 whole time equivalent (wte) carers’ support workers, to work expressly with people with serious mental health problems, which were seen as being positive, along with the Rethink carer’s service. Gaps were perceived as being day care, or daytime support and respite. People recognised the value of carers support and the need in turn to support them, particularly in dementia care, which was reported to have a very high numbers of carers.

4.9 Theme 9 - Partnership working Harrogate mental health services have been in the ‘arms’ of several host families over the years (Primary Care, Leeds & York, TEWV). As a service within a place, it does not have a rich heritage of capital investment, nor old family silver from asylum legacy. The picture that emerged from the engagement was of a system that has been under-invested in, where competition from surrounding conurbations is high to recruit and retain staff (i.e. Leeds, Bradford, York) and where partnership working has been generally under-developed. Partnership working was recognised as being positive by TEWV staff and essential for joined up care by service users. It was interesting that half way through the engagement North Yorkshire County Council announced a similar process to review their mental health offer across North Yorkshire, which was a missed opportunity for more joined up working. There are numerous possibilities to strengthen partnership working locally, with third sector or independent providers. This ranges from alternatives to acute care to older people’s pathways; from employment schemes to employing peer support worker roles; and from coproduction through to host families and housing solutions. People described their future vision for community services as being resilient, being accessible across the weekend and in the evening. There would be enough staff, with the right skills to provide joined up care. The third sector would be visible and vibrant, and primary care well engaged and able to take positive risks with people. The service would encourage growth and throughput, self management and recovery would be the norm, people would feel ‘psychologically safe’ and people wouldn’t be held on caseloads.

4.10 Theme 10 - Improve patient and family outcomes – more recovery focus

The overwhelming response from participants was that the services in Harrogate and surrounding districts had a long way to travel on their journey to become recovery focused. There are well-recognised frameworks for implementing recovery, with associated improvement approaches (such as ImROC – Implementing Recovery & Overcoming Organisational Challenges). Recovery is well embedded in international and national policy, and TEWV has its own strategy for implementation. But it will not happen of its own accord. The desire to create a new service model for Harrogate provides an ideal opportunity to embed recovery into all aspects of the service, from positive attitudes and behaviours, to the language used in assessments and care plans, to the names given to services and the dialogue that happens with citizens to challenge stigma.

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Recovery is more than a recovery college, it is a way of working that embraces all the strengths of a community, its families and citizens, and works to promote active citizenship, shared safety planning for wellness, and pathways through services to education, meaningful occupation and employment. A strong message to come from the engagement process was that whilst disappointment was expressed with the decision to ‘pause’ the development of the new inpatient unit at Cardale Park, this was also a great opportunity to do something different, and perhaps radical. The Five Year Forward View and its associated implementation guides provide the national context for the changes. Locally, the migration towards integration and the system level work to frame this provides opportunity for greater parity of esteem for mental health services. Local interpretation and ownership of the implications of these drivers to improve care pathways for a life-course approach to mental health and wellbeing is part of the next phase of the project. As part of this journey, managers and practitioners will have to redefine their goals, re-consider what outcomes they are trying to achieve and re-examine their workforce. Transformation is not just about buildings and service pathways. “It will involve changes in skills (such as a far greater emphasis on coaching to support self-management), structures (e.g. more partnerships with, and working through, community resources) and workforce, with the involvement of many more peer workers alongside traditional professionals. This transformation is perhaps the most daunting – but exciting – challenge.” (Recovery: The Business Case (Slade et al., 2017).

4.11 DEVELOPING THEMES INTO OPTIONS TO CONSIDER

This section presents what we have identified as the main variables that have arisen through the engagement process, both in relation to the issue of location of beds following the decision to stop the development at Cardale Park, and the wider issues to have emerged through the engagement process. The variables are essentially:

Retention of adult mental health beds in Harrogate, or transfer to another site

Retention of older people’s mental health beds in Harrogate, or transfer to another site

Retaining management of the entire pathway within TEWV and North Yorkshire, or subcontracting of some elements of that pathway to a different provider

Creation of new forms of dementia care in Harrogate

Creation of new forms of alternatives to acute mental health admission in Harrogate

There is an opportunity to radically transform services in Harrogate, to help them become more holistic and person centred. We have heard that there is support for such a transformation, but we have also heard that resistance may be high. Whilst resistance to change is not the enemy of change, it nevertheless needs to be properly understood, and sensitively managed to create a psychologically safe and

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compassionate care context. This will ensure that all involved understand their role and how to become involved in the new vision for Harrogate mental health services.

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APPENDIX 1

Engagement Processes

As described in Section 2 of the main report all meetings were held in spaces conducive to hear people’s views and were facilitated by experienced individuals. 17th August MIND, Harrogate - Service user meeting (8 people present) 22nd August CMHT Managers - 7 community managers 6th September Rowan Annexe, Briary Wing - 1 attendees (carer)

Psychiatric Liaison (2 nurse practitioners) 6th September Windsor House - 1 attendee Service Director + 4 individual interviews

with CMHT managers 7th September Windsor House - no attendees 7th September Alexander House - no attendees 25th September Alexander House - 5 attendees (psychiatrist, nurse practitioner,

psychologists) 26th September Windsor House, Harrogate - 4 attendees (psychology x 2, CBT,

manager) 26th September Alexander House, Knaresborough – no attendees (2-4pm) 27th September Rowan Annexe, Briary Wing – no attendees (9.30-11.30) 27th September White Hart Hotel (51 people present including: HBC Councillor, NYCC

Commissioning Manager, Carer & Public Governor, Voluntary Sector (Claro, MIND, Rethink), Carers, Service users, TEWV staff (Community, inpatient, Administration, Management)

4th October Rowan Annexe, Briary Wing 10 attendees (including inpatient nurses, consultant, HCA, ward manager, Pharmacist)

4th October The Orchards, Ripon – 6 attendees (TEWV employees) 5th October Windsor House (3-5pm) – 2 attendees (TEWV practitioners) 5th October Alexander House, (10-12noon) – 5 attendees (TEWV Practitioners) 12th October Rowan Ward Annexe, (10-12) - 10 attendees (of which most (nine)

were staff of various DGH based services (most attended part of the meeting only, many moved in and out as the meeting progressed)

12th October The Orchards, Ripon – 6 attendees (TEWV employees) 13th October Church Road Surgery, Boroughbridge, (10-12) 3 attendees (1 TEWV

staff member and 2 service users/carers) 13th October Windsor House – (2-4 pm) no attendees Total people who attended meetings = 118 people Individual responses through email and letters = 7 responses (4 carers, 2 lived experience and 1 GP practice) Total number actively engaged = 125

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The tables below set out in more detail the numbers of people that engaged and includes a breakdown of organisations and where identified, their role. People from TEWV participating in engagement = 62

Ma

na

ge

rs

RM

N

Psych

olo

gis

t

Psych

iatris

t

CM

HT

Mgr

Occ

The

rap

y

HC

A

Ad

min

Go

vern

or

Involv

em

ent

HE

Offic

e

The

rap

ist

Clin

ica

l

Lead

Mg

r -AM

H

Mg

r - OP

S

Ph

arm

acis

t

2 13 5 3 4 2 9 7 1 1 2 1 1 6 4 1

People from other organisations participating in engagement = 56

Carers 15

Service users 13

Harrogate B.C 2

NYCC – Commissioning Manager NYCC - Support Worker NYCC - STR

1 1 5

Claro Enterprises MIND Carers Resource Centre Crossroads Rethink

5 1 1 1 1

Public (unnamed orgs or roles) 9

Parliamentary Spokesperson 1

The following pages include details of the media communications and comprise:

1. Media release – issued on 31st August 2017

2. Briefing sent to Governors 31st August 2017

3. Feature in Yorkshire Post – 31st August 2017

4. Feature in Harrogate Advertiser 4th September 2017

5. Feature in Harrogate Advertiser 7th September 201

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31 August 2017 Developing a vision for mental health services in Harrogate and Rural District NHS Harrogate and Rural District Clinical Commissioning Group (the CCG) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) are inviting people to get involved in developing a future vision for adult and older people’s mental health services. We recognise the importance of good mental health services across the Harrogate area, and equally the support needed for carers. We want to know what’s important to people, what has worked well, and what needs improving to make sure services are financially sustainable in the future and, most importantly, that they meet the needs of local people. This is a priority for us all. We now have an opportunity and the ambition to do things differently - to look closely at the type of mental health care we need to provide in Harrogate. People who use our mental health services tell us that whenever possible they want to remain at home, close to family and friends. This means making sure that support is available when they’re experiencing a crisis. People also tell us we should work with them and their families to help them achieve the goals they’ve set themselves, making sure they get the care and treatment they need, when and where they need it. Over the coming weeks we’re inviting local public and patient involvement groups, voluntary organisations, mental health and social care professionals and the wider community to have their say about how services can be further improved. Our vision for the future We want to work with local people and colleagues across health and social care to create a vision for mental health services which builds on good evidence and that provides the best outcomes for people. This includes:

Empowering and supporting people to have more control over their lives.

Making sure people receive care in a trusted, respectful way and that they are able to

develop hope inspiring relationships, where recovery and wellbeing come first.

Making sure our services are easily accessible so that people can get the right level of support to help them stay well at home or as close to home as possible.

What services do we currently provide? Currently TEWV provides adult and older people’s inpatient and community services for people across Harrogate and Rural District.

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Inpatient services Mental health inpatient services are provided from the Briary Wing at Harrogate District Hospital. Adult acute assessment and treatment inpatient services are provided from Cedar ward. The 18-bed ward is mixed sex (with male and female zones) and consists of four dormitories (two male, two female) with access to five single rooms (one male, two female and two which can be used flexibly). People are admitted to the ward when they are experiencing a crisis or acute mental health problem that can no longer be managed within a community setting. Our aim is to provide high quality, patient-centred care with an emphasis on enhancing social inclusion and recovery in the least restrictive environment. Therapeutic activities and group work contribute to individuals’ recovery, wellbeing and reintegration back home. Older people’s acute assessment and treatment inpatient services are provided from Rowan ward. The 16-bed ward is mixed sex (with male and female zones) and provides services for people with dementia (organic illnesses) as well as those with mental illnesses such as severe depression (functional illnesses). The service aims to assess and treat people for six to eight weeks with a planned discharge to the patient’s own home or a long term placement which will meet the patient’s individual needs. The service will assess, treat, manage and reduce difficult behaviours and risk and provide advice and training to relevant partners, professionals and agencies as part of the individual discharge plans. We strive to reduce risks to such a level that the individual can be discharged to their own home or to a care setting suitable for their current and long term needs. A small number of patients whose needs cannot be met safely in this environment may need to be moved to an alternative, more specialist placement, such as Springwood. Community services We provide a range of general and specialist community mental health services for adults and older people across the Harrogate area: Adults

A crisis response and home intensive treatment team (available 24 hours a day, seven days a week) - supporting people aged 16 to 65 who need crisis support within 4hours and providing increased home treatment to help prevent admission to a mental health

assessment and treatment ward. The crisis team also work with our local authority

colleagues and police to support mental assessments in a health based place of safety (Section 136 suite).

Two community teams across Harrogate and Ripon (available 9am-5pm, Monday-

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Friday) - supporting people with moderate to severe need.

Adult primary care team (available 9am-5pm, Monday-Friday) who meet the needs of people with mild to moderate mental ill health.

Assertive outreach team (available 9am-5pm, Monday-Friday) - supporting people with

enduring mental illness. Older people.

A community care service based in Knaresborough, (available 9am-5pm, Monday- Friday).

A rapid response team in the care of the elderly (RRICE) (available 8am-6pm, seven days a week).

A memory service providing assessment advice and support for people with memory problems and their families.

An acute hospital liaison service which supports the acute hospital with assessment and care of older people with mental health difficulties who are admitted to acute hospitals

for physical health conditions. Currently most admissions to Rowan ward (older people)

are made by the RRICE team. The current pathway from community teams to inpatient units is being reviewed as part of the development of services in Harrogate. In the future the process for admission for both adults and older people will be similar:

referral to crisis team

crisis team to assess

decision made to admit or treat at home with home treatment intervention.

admit for a fast track admission and review within 72 hours.Demand for services.

Community services We are seeing a year on year increase in referrals to our older people’s services (from 2390 in 2014/15 to 3678 in 2016/17). Referrals to our adult services have reduced over the last three years (from 4696 in 2014/15 to 4264 in 2016/17. Overall, compared to other localities across TEWV, demand for mental health services is three times higher in the Harrogate area (this is based on numbers of referrals, adjusted to

take into account the expected mental health needs of the population). Inpatient services.

Over the last three years we have seen a reduction in the number of admissions (from 165 in 2014/15 to 131 in 2016/17) whilst lengths of stay have risen slightly (from 19 days in 2014/15 to 24 days in 2016/17). This has been assisted by the supportive work of crisis and home treatment in adult mental health services. In addition, the introduction of the personality disorder pathway has helped keep people at home. However, admission rates for adults in Harrogate are still higher than other areas of the Trust.

Why do we need to change? Since responsibility for mental health and learning disability

services transferred to TEWV in 2011 the Trust has been committed to replacing the inpatient accommodation at the Briary Wing in Harrogate. The building and environment is

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not fit for purpose (highlighted by the Care Quality Commission) and there is agreement that it needs replacing. The Briary Wing will likely remain on the Harrogate site until late 2019 at the earliest, but this will be reviewed from an environmental, staff and user/carer

perspective, as well as clinical need, as the engagement work progresses.

Over the last few years we have talked with people who access mental health services, their carers, staff and the public to review the options for inpatient care. A plot of land was purchased at Cardale Park in Harrogate in 2016. Increasingly people are able (and want) to receive the care and support they need at home. We need to make sure that we are making best use of our resources – that every pound spent on mental health services provides the best possible outcome for the people who access those services. We know that health and social care services across the country are facing significant financial challenges. People are living longer and the demand for mental health services is rising.

We therefore need to review how all funding is spent, including this development, and consider carefully any longer term investments. For example, the value of inpatient services is £4.6m (31.4%) of the total £14.5m spend on mental health in Harrogate. Proportionally, this is a large amount of money spend on a relatively small number of the total population of people experiencing mental health conditions. We also know that some hospital admissions (particularly for older people) can lead to more risks and a decline in health including:

Increased risk of illness and death

Diminished quality of life

Less autonomy and greater dependence

Admittance to nursing and residential homes

Increased lengths of hospitalisation

Readmission to hospital

Whilstsafe and well, we also acknowledge the risks that can arise from being in hospital.

We want to ensure that we are doing all that we can to prevent inappropriate hospital admissions. What should we consider? We now have an opportunity to think about the overall model of care in Harrogate, and not just in-patients. This may include considering whether more spent on community provision would provide an overall better service and reduce the need for people to have to spend time in hospital. We can also think about how this is linked to our overall recovery approach - to we recognise that inpatient care is at times a vital part of what keeps a person supporting people to achieve the goals they've set themselves and to making sure people get the care and support they need, when and where they need it.

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We will think about how we can:

Embed recovery values and principles into all we do.

Support a model of ‘co-production’.

Implement a harm minimisation approach to support an individual’s recovery, with people with lived experience and where appropriate, family members as partners and carers in the process.

Increased access to recovery training which supports recovery knowledge and self-management skills for staff, people with lived experience, family members and carers. We want to know:

In the future, what would you like the mental health services in Harrogate to look

like?

Thinking about the strengths of the current Harrogate services, what are the three

things you’d like to see remain in future services?

Thinking about the things you’d like to see improved, what are the three priority

issues you’d most like to fix?

What are your thoughts on the future of inpatient beds for local adults and older

people?

Thinking about the needs of carers and families – what would you like to see available to better support the families and carers of people with mental health

conditions?

What type of community services would you like to see available to help keep you

well?

Is there enough emphasis on recovery, social inclusion, training and education

and/or volunteering through to employment to support active citizenship?If not, what

other services would you like to see?

How to get involved We are contacting a wide range of community groups and organisations as well as service users and carers to invite them to take part in open meetings.

We are also holding an open workshops onWednesday, 27 September 2017 from 2.00-

4.00pmat the White Hart Hotel, Cold Bath Road, Harrogate, HG2 0NF

You don’t need to register to attend but it would help us plan if you could email tewv.harrogateengagement@nhs.net to let us know if you’re coming along. You can also respond to the questions outlined above and send them to tewv.harrogateengagement@nhs.net or FREEPOST TEWV by Friday, 6 October 2017. Of if you would like to speak to someone please contact 01423 553681. We look forward to hearing from you.

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26/17 31 August 2017

MEDIA RELEASE

Developing mental health services for Harrogate and Rural District Local people are being asked how they would improve mental health services in the Harrogate area, whilst making the most of the money available. NHS Harrogate and Rural District Clinical Commissioning Group (the CCG) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) are inviting people to get involved in developing a future vision for adult and older people’s mental health services. TEWV and the CCG have worked with partners, staff, and people who access mental health services and their carers to finalise plans for involving local people in the development and design of options. Over the coming weeks local public and patient involvement groups, voluntary organisations, mental health and social care professionals and the wider community will be urged to have their say about how services can be further improved. This will include discussions on the development of a new mental health hospital in Harrogate, which is currently under review as well as the increasing demand for mental health services. Activities include focus groups, meetings and an open workshop at the end of September. People will also be able to respond in writing until 6 October 2017. Amanda Bloor, Chief Officer at the CCG, said “We recognise the importance of good mental health services across Harrogate and equally the support needed for carers. “We want to know what is important to people, what has worked well, and what needs improving to make sure services are financially sustainable in the future and most importantly meet the needs of local people. This is a priority to us all. “Only by talking to people will we really be able to understand their opinions and experiences. At the end of the engagement period, feedback will be collated to inform the design and development of any future proposals.” Brent Kilmurray, chief operating officer at TEWV, said: “We now have an opportunity to take a step back and look closely at the type of mental health care we need in Harrogate.” “The people who use our services tell us that whenever possible they want to remain at home and this means making sure that support is available when they’re experiencing a crisis. “They also tell us we should work with them and their families to help them achieve the goals they’ve set themselves, making sure they get the care and treatment they need, when and where they need it.”

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More information about how people can get involved is available on the Trust’s website www.tewv.nhs.uk (Get involved). ENDS For more information please contact the communications team on 01325 552223 or tewv.enquiries@nhs.net. Notes for editors

NHS Harrogate and Rural District Clinical Commissioning Group (CCG) isthe NHS

organisation that commissions (or buys) health services for the residents of the Harrogate and Rural District locality. The CCG represents 17 GP practices and serves a resident population of approximately 160,000 people.

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) was formed in April 2006 and was authorised as a foundation trust on 1 July 2008. The Trust took over responsibility for services in York and Selby on 1 October 2015 and now provides mental health and learning disability services for the people of County Durham, Tees Valley and most of North Yorkshire. It also provides a range of specialist mental health and learning disability services to other parts of northern England. For more information please contact the communications team on 01325 552223 or tewv.enquiries@nhs.net.

31st August 2017 Yorkshire Post – Web

How would you improve mental health services in Harrogate District? How would you improve mental health services in Harrogate District? : But now NHS Harrogate and Rural District Clinical Commissioning Group (HaRD CCG) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) have invited people to have their say about what should be done.

Amanda Bloor, Chief Officer at HaRD CCG, said "We recognise the importance of good mental health services across Harrogate and equally the support needed for carers.

"We want to know what is important to people, what has worked well, and what needs improving to make sure services are financially sustainable in the future and most importantly meet the needs of local people. This is a priority to us all.

"Only by talking to people will we really be able to understand their opinions and experiences. At the end of the engagement period, feedback will be collated to inform the design and development of any future proposals."

Plans to build a "state of the art" mental health facility, just off Beckwith Head Road in Harrogate, were given the green light in August last year. But in July, TEWV and HaRD CCG took a joint decision to put the project on hold, in light of a £6.5million deficit in the CCG's budget. Now, the two organisations are urging members of the public and groups in the community to voice their opinion in a series of focus groups, meetings and an open workshop.

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Harrogate Advertiser - 4th September 2017

How would you improve mental health services in Harrogate District?

How would you improve mental health services in Harrogate District? : Residents across the

Harrogate District have been asked 'how they would improve mental health services in the

area, while making the most of the money available'.

Health chiefs, carers, and patients have raised concerns over the future of mental health

provisions in the area, after plans for a £16million in- patient mental health unit were put on

hold.

But now NHS Harrogate and Rural District Clinical Commissioning Group (HaRD CCG) and

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) have invited people to have

their say about what should be done.

Amanda Bloor, Chief Officer at HaRD CCG, said "We recognise the importance of good

mental health services across Harrogate and equally the support needed for carers.

"We want to know what is important to people, what has worked well, and what needs

improving to make sure services are financially sustainable in the future and most

importantly meet the needs of local people. This is a priority to us all.

"Only by talking to people will we really be able to understand their opinions and

experiences. At the end of the engagement period, feedback will be collated to inform the

design and development of any future proposals."

Plans to build a "state of the art" mental health facility, just off Beckwith Head Road in

Harrogate, were given the green light in August last year. But in July, TEWV and HaRD

CCG took a joint decision to put the project on hold, in light of a £6.5million deficit in the

CCG's budget.

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Harrogate Advertiser - 7/9/17

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In addition to the media communication above information about the engagement was also

Posted on Twitter (five times) and on Facebook (five times).

Below is an example of a Twitter feed on September 17th 2017:

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APPENDIX 2

Detailed notes from meetings The table below provides the full narrative captured through the engagement process.

1. In the future, what would you like the mental health services in Harrogate and Rural District to look like?

If it is accepted that the Briary Wing must be closed, on the basis that it is not fit for

purpose. I would like to see a modern inpatient mental health facility to replace it, situated

in the Harrogate area. I do not know the current status of the Cardale Park development,

but this appears to be a good solution. I appreciate that capital funding may be difficult,

but perhaps a form of Public Private Partnership which allows access to commercial

lending may be appropriate to deliver it.

I would not want to see inpatients located outside the immediate Harrogate area. It is

very unsettling for patients and their families to be transferred outside of their immediate

location. Individuals suffering from severe mental illness often rely on support from the

immediate local community. Transfers out of the immediate area (even within the same

Trust) would seem to me to be detrimental.

More pro-active. If a patient / Carer / family member / friend recognise that they or an

individual is reaching crisis, immediate access to TEWV services as prevention service

No admission via A&E if experiencing acute episode with no physical problems.

Development of 24 / 7 crisis house with overnight “respite” / emergency accommodation

Truly holistic 360⁰ assessment of patient on each presentation – TEWV currently pay lip

service

Integrated health and social care teams with more even emphasis on the social bit – too

medically focussed

I joined the Trust hoping for a future in inpatient services. I wouldn’t want to travel to

York. It feels really disappointing, and leaves my role up in the air.

Staff are keen to stay here if based here.

Harrogate has a huge elderly population, it’s expensive and a retirement area. Making

people go a long way away is really cruel and has a dramatic impact on patients.

Where has the money promised gone?

Some patients have become institutionalised – where are they going to go?

Services need to have a means of picking up physical illnesses too – each affects the

other very significantly. Acute wards just shoo people away.

Staff training is the main thing, and making sure there is enough staff. We can’t get

enough agency staff.

Local services – quite often beds are out-of-area, so that carers and staff have to travel

further.

Making sure people have access to services for their family.

I don’t agree with seeing people in clinic. Home visits really matter. Windsor House is

going the wrong way.

Referrals have increased, but staffing hasn’t. There used to be three CMHTs in

Harrogate and District, but they’ve now merged. Assertive outreach used to be bigger

too.

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A building that’s fit for purpose

Staff that talk each other and where information is shared

Complete wrap around service so you feel secure (it would feel like staff that listen, don’t

rush you, care plans that mean something, they know your history and what worked in

the past)

Need to improve attitudes of workers

Far better to have cells and would like a SPA to replace the assessment service

Would like a 7 day service, integrated model, with specialist pathways

As a service we currently create dependence

Have a high number of people with complex needs / personality disorder

In the community staff feel burnt out

No training for staff – bare minimum skills

Better resources and in particular, better 3rd sector provision. “Our commissioners expect

us to provide gold standard care but only get enough money for bronze”

Services are currently disjointed – they’re not integrated or joined up.

The behaviour at the moment is that everyone is guarding their own.

We need to bolster community resources – drop-in, nurse clinics, wider team.

We don’t have advanced practitioners.

There are plans to move towards 2 cells but why not have 1 cell – and lets have a SPA

(single point of access)

We have a higher proportion of people with PD

Have a low prevalence of psychosis – EIP based in the Orchards – Recovery team Ward

Would like to CMHT working weekends but there’d be a lot of resistance to weekend

working.

We used to have an assessment service and removing this has led to:

- Loss of staff

- SUI – too busy doing assessment to look after seriously ill on caseload

- Morale down and anxiety in the team rocketed – people feeling panic and fear

Rate of change has been too fast and too much:

- Loss of assessment service

- Changed model of triage

- All jobs frozen

- Might be re-banding staff from 6 -> 5

- It’s been a horrific 3 months!!

- We have 203 patients without a care co-ordinator

- But we’ve been allowed 3 agency staff for 6 months so that will help

IMPORTANT – local beds – lots of SU are out of area, distress to SU and family

What about the beds in Northallerton and likely impact?

Local beds – need inpatient and crisis beds

Take into account other service reviews, location of carers and public transport

If moving towards community need to increase overnight and weekend provision

Services provided 7 days

Could have 136 in hospital, Peppermill

Building like Abdale House – half way house following discharge?

Council/TEWV should open nursing homes

Could Peppermill expand to take Harrogate beds?

Homes built – sheltered housing

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Partnership – TEWV & NYCC appropriate housing for those leaving hospital

Need to think about third sector provision

Early management if vital

More work with GP’s – work in GP surgery?

Build should still go ahead. Other TEWV areas have local hospitals

Prevention focused services

Shortened waiting list for counselling

Simple, realistic, achievable information and communication

Education to GP’s – including access to exercise and wellbeing & explanations of how

services work

Greater access to services

Greater post discharge support

Holistic treatment

Goal orientated

Not a cost saving exercise

Earlier (preventative) specialist MH professionals

Review of ‘Gold Standard’ services across the UK/wider & emulate services

Health action plan (LD use)

Crisis beds

More community input

Slower transition from crisis team, maybe slow down frequency of visits before

Increase hours of opening – 24/7

Increase links with police etc + trained workers in policer

Good balance of inpatient/careplan

Increase in MH budget – why divide between locality

Improved equity of services – comparison of provision re Roseberry Park/West Park

Hospital

Local in-patient bed provision- in purpose built unit with en-suite facilities

Increase in recruitment of specialist staff – limited psychology provision on Briary

currently

Awareness of CAMHS services – catching people younger

Employment support workers – really important to help people returning to work

Harrogate ‘Hub’ model – very good

Use the ££ from Briary Services to invest in York hospital. Most people would agree that

this would be a suitable alternative. Quality of service over location

Crisis team – improved team resource

Why don’t we join resources with Hamm+Rich area – may = an accessible provision for

in-patient beds

Individualised plans – improved communication with services used

Concentration of services under one facility inpatient/outpatient/community + social

services all under one unit

Bring back day care services

Organic and functional MHSOP wards must be separately provided – not as current

model!

Increase volunteer provision to enhance O.T model

Prevention of readmission to hospital

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Non-medical model – health and third sector agencies and providers need to work closer

together – looking at the person as a whole not means tested

Social prescribing model

How £ is distributed between health and social care – new council office is not a priority –

use that ££ to upscale MH budget.

Significantly better funded

More transparent and visible for local people who are users or otherwise

Parents and close relatives should be able to work more closely (wherever possible and

where this is helpful) with the Community Mental health team and the Crisis Team.

The CMHT and the Crisis team should act more rapidly when there are signs of lapsing in

patients and not wait until patients are actually in crisis. There should be a balance

between being proactive and giving mentally ill people privacy.

Advocacy for work related mental health issues should be an element of practice where

this is evidently necessary and is the wish of the patient.

Talking Therapies should be offered to patients and not necessarily wait for patients to

ask. This should be part of the package of services available.

Voluntary organisations such as Harrogate Hub can partner mental health practice in

Harrogate.

Close relationships between community and inpatient staff very important.

Please don’t take inpatient service away!

Informal professional advice

Good local services

Treated with respect and dignity

Access to psychological therapy at the right time

MIND – people who listen and chat to me when I get bored

Transformative

Proactive and successful

Moving away from passivity, passive behaviour to nurture recovery, wellbeing, good

health, feeling great and having AMBITION for all the above

Supporting growth and recovery and wellbeing potential and eventually self-actualisation

Inpatient provision that is fit for purpose

Something for people to go to who are in crisis – ‘respite’ from own environment

Enhance, intensive day treatments programme

Right mix of professional staff (psychologist – employment support)

Crisis House -> with appropriate discharge pathways, and staffed appropriately

What is the capacity of other trust inpatient units

Supra-bed management model

All organisations – sharing resources, collaboration, stop charge each other

No difference between health and mental health

Care in the community

Carers perspective – integrated care carers

NYCC – training for staff, MH training not available to support workers, front line staff with

least training

MHSOP priority – not same provision

Resilience, empowerment for children

Require beds in hospital locally not in York

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Preferred treatment at home with local provision of short term admission

NYCC – recovery focussed and respite for prevention and crisis focus

Mild to moderate community group self-help from IAPT

Confidence building courses

? value of medical model - increase therapy, mindfulness and early intervention

Waiting too long and people get into crisis

Early access to MH services

Better use of Recovery College – awareness training

Language used important

Can we not link up with Hambleton and Richmond – pool resources

++Psychological therapies

More advocacy for people with MH problems in work

More partnership working i.e. Harrogate Hub

Would be great to have a new hospital

Invest in transport for patients to access services

More sheltered accommodation

Increase respite facilities

Proposed site – modern purposeful building

Strategy for all partners needed to address prevention

Close to home is really important

Prevention/education before reach crisis

Inpatient beds /?York

Better communication between services and families

Do not knock back when asking for help

Lack of choice in Harrogate – even more so in rural areas

Necessary – INTEGRATION

Use of media – newspaper education for families more readily available

Communicating data and case finding – measure demand

Better commissioning around 3rd sector around all service provision – co-ordination!!

Better understanding of what £14.5m spent on – finance sharing

Aspire to prevent all admissions

Take service to patient

Better community support for severe and enduring MH to prevent admission

Need strong community teams

The CCG should contribute more per head – like across the rest of the Trust

Definitely an inpatient facility for working age & older people.

If not a facility in Harrogate then it makes it very difficult for older people to visit family

If x 3 demand in Harrogate then we should have a local facility

Need more community staff

Want to see specialist services & understand how they are successful

Better funded, still have inpatient services & to be more responsive – adults and older

people

Trust value statement doesn’t fit “services closer to home unless you need inpatient

services”

More % of CCG budgets to be spent on MH services

Increase prescribing capacity

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Services are delivered so that nobody ever needs inpatient services

Same principles of best practice and best outcomes to be applied to MH as physical

health services

If all singing all dancing services then admission should be seen as a failure

When people absolutely do need a bed it should be AIMS compliant

Extended 7/7/ days

Need a mind-set change from GPs so no complaints when MH patients discharged

2. Thinking about the strengths of the current Harrogate services, what are the three

things you’d like to see remain in future services?

The crisis team

The s.136 place of safety suite (is there a requirement for more?)

Inpatient services within Harrogate (or the immediately surrounding villages)

Need a full scale shake up – need to start again!

Keep primary care, CNHTs x2, AOT and IAPT in Windsor House but add in EIP etc –

have all teams under one roof

Staff are good – keep morale high, happy and autonomous in care delivery

Caro – really important for the service to remain

Inpatient beds – reduction yes but not lose all

IAPT services – 6 week course

‘consistently there’ CPNs (not always consistent)

keep local crisis beds

Accessible, local services

Frequency of home visits

Better clozaril services

Making services more accessible

Community based access (not just GP)

More people to know about memory clinic

Communication between services

Good service from crisis team

CMHT must remain in an improved way focusing on partnership organisations looking at

preventative care – support people to remain in workplace – more individual advocacy

support

Fit for purpose inpatient facility

Improve rehab provision in the area – looking at Discovery Hub/Recovery College

Models

Difficulty in thinking of even one frankly

Inpatient provision

Community care

Good will from staff

Friendly, well trained staff

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Acorn Centre and Crisis Team

Access to employment advice

MIND really important – helps with loneliness and social isolation – other support groups

Friendly

Accessible

Inclusive

Staff go above and beyond, lots of them work at home out of hours

Psychologist working in GP practice (Coleburn) has reduced referrals significantly and

patient satisfaction has increased.

Coproduction must stay

IAPT group therapy

RRICE

Inpatient provision

Staff/teams

A&E liaison service

Sharing of information – working with families and understand power of attorney

Please listen more and understand the history

Advise risks of medication and encourage people to make informed choices

Expansion of crisis but make it separate to home treatment

We need to prioritise Harrogate in itself. Access to York is not easy. People really value

services in Harrogate.

If Harrogate services do have to move to York, special busses will need to run,

especially for older people. There will need to be proper liaison and outreach

arrangements with the acute hospital in Harrogate. There will need to be proper

arrangements for people on leave from psychiatric inpatient beds.

If there are no wards in Harrogate, it could mean an opportunity to develop something

new in Harrogate.

It’s very rare for someone to be admitted in Harrogate who doesn’t already know

someone on the ward. Relationships are better. It’s important to maintain a sense of a

familiar environment with familiar people.

Keep the specialist teams – early intervention, assertive outreach

Go back to a CMHT assessment team. Now all workers have assessment slots, and this

doesn’t work as well.

Change is incredibly rapid in TEWV.

Early intervention works better than the CMHTS.

The Assertive Outreach Team. Very positive experience, but not enough.

The North Yorkshire Carers support team –they’ve been really beneficial to

understanding information.

The Orchards is a strong services, we can see this, it’s doing a lot of good.

The strengths are the staff. Without them there are no services. Those that I’ve talked to

enjoy the job that they do but recognise that they are short staffed have fewer resources

than other areas of TEWV and are being asked to make further “efficiencies” on an

already “thin” service. There is also huge difficulty recruiting experienced in-patient and

community staff. Are individual caseloads becoming unmanageable and putting staff

under continued stress and affecting their own mental health? Are patients being

discharged too early? The loss of in-patient beds has put a huge strain on all staff.

There has been an increase in serious incidents on Cedar Ward - not exactly a

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therapeutic environment. TEWV need to develop a strategy to address lack of

affordable staff accommodation in HaRD. Perhaps, the development of range of

accommodation, for example, flats, rooms to rent when on shift pattern and staff return

to their own home.

A&E Liaison team within Acute Hospital. Heard only good things. It appears to be the

only service available that sees and listens to people in crisis. Needs to be properly

resourced to educate the Acute Trust (and Primary Care) which anecdotally is still poor

at responding to the needs of people, both young and old, with mental health problems.

How difficult is it to diagnose a UTI?

Care Home Liaison service – avoids unnecessary and life-shortening admissions to

acute hospital.

Inpatient services but in a new building – this was a strength

Staff know their area and know their clients

Gives confidence to the public that whole range of services

Specialist nurse are now working as generic nurses – concerned that they’re becoming

de-skilled

“Actually very happy in my job despite what I’ve said today”

Inpatient services but not at the Briary. Co-located community teams this leads to better

communication & continuity of service provision

Make best use of technology

3. Thinking about the things you’d like to see improved, what are the three priority

issues you’d most like to fix?

Better integration between the health and social care system and with the voluntary

sector. It seems that the social care system is being defunded and that has a detrimental

effect on the mental health of the community and also on the ability of that system to

interact with the health and voluntary sectors. For example, this consultation does not

refer to any involvement on the part of the local authority.

Retention of an appropriate inpatient facility in the town.

A sustainable mixed offering of inpatient, day care, community and voluntary services

which support care from the point of crisis through a clear and well funded recovery

pathway.

Easier access to care appropriate to patients needs

Inpatient unit

Stigma challenged / removed in Harrogate

Safety – for staff and patients (need psychological containment and a clear pathway to

follow)

More cohesive team working – people under too much pressure & have low skill base -

feel isolated in their work.

Therapeutic knowledge, skills and training

Staffing levels

CCG & Money – better investment

Training and staff development - there’s no time to put anyone through mentoring, DBT

and MSc PD (can’t release anyone)

Need more DBT focus and service

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Underpin the recovery orientated approach

Community services offered evening & weekends

New build

Physical healthcare

Invest in recovery

Building resilience

Services working more in collaboration – NYCC & TEWV etc

To be able to access services when needed e.g. Sunday 7.30am

Bradford Trust – joint funded

Sharing resources – TEWV/social care/NYCC

New build – single rooms, meaningful activity

Turn over of staff

Safe staffing

Occupational therapy needs to be addressed

Environment of inpatient beds

Culture, education and training fo staff

Better resourced/deployment of staff

Not time limited services

Inpatient units inc Rowan Ward

Outside space – inpatient unit not in hospital environment

GPs being more proactive

Specialist worker in surgeries

Named workers for carers

The inpatient facility need is paramount – access to outdoor space

Discharge (intensive) support on leaving hospital – inpatient care package individual and

personalised

Tailor services around the individual not vice versa

CMHT vital

No joined up process between Horizons and NHS

More beds! Even the shelved (can you believe it shelved!) plans are woefully

inadequate…

Expansion of day services, as someone is recovering what meaningful activities can

they engage in (this would also give relieve to carers)

An audit of the conduct and professional behaviour of legacy staff, proper insight into the

“culture” and attitudes within the Harrogate area

More staff – nurses/lead professionals x1 nurse with 70 caseload

Social care involvement in community teams

One assessment for patients, holistic

Focus on productivity – purposeful & productive time & motion study not helpful ->

M & F separate wards

New build

More services in Harrogate

Challenge self-neglect as that encourages +ve wellbeing

Encourage use of addiction support services

Cultural transformation

Up-skilling staff and create a learning culture

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Education – more understanding therefore more likely to care with genuine compassion

Staff as role models modelling recovery

Be very proactive

Stronger third sector presence

Responsive rather than reactive service – reduce fire fighting to become more proactive

– be able to reflect & plan inputs to care and treatment

Lower caseloads

Higher caseloads result in fewer discharges because of admin

Throughput has got worse over the last year (was 9/12 now 16/12)

Extended inpatient admission (1-2 years) – need more focus on a recovery ward as per

the Ripon model

Autism services

Physical healthcare – prioritising in MH – joined up services

Prevention services, proactive not reactive, also long term support to prevent

Wellbeing education for older people

Better integrated health, social care with partners- pathway, drop in drop out

Access to support for employment and education – CLARO has 2 year limit

Would like day hospital back

Need a more effective PD service

AOT model that works

SHIP model like in Leeds for self harm

The organic / functional mix doesn’t work – it needs separation.

There is a “cliff edge” from CMHTs to the third sector – responsibility is relinquished too

sharply. This leads to a repeated cycle of re-referral. People who stay engaged tend to

stay well.

Information being passed back and forth doesn’t work as well as it might. Only Assertive

Outreach and NYCC staff maintain good links with the third sector. This gap is getting

worse, although a role which briefly existed to focus on these relationships worked quite

well.

People are being helped by the third sector with greater needs – it feels like the burden

has been passed on without financial understanding, or proper relationships and

communication. The third sector are trying to second guess what CMHTs would find

most useful, given lack of direct communication.

There are multiple record systems. Linking them together into a single care record would

be really valuable.

Robust crisis support teams should be available like in Leeds and Bradford – as an

alternative to admission.

Caseloads are way too high. Local authority managers have capped social workers’

caseloads, so that CPNs now have caseloads of 60-70. Early intervention has caseloads

of 18, which is OK.

Training for GPs, who don’t have enough understanding of mental health. In Skipton

there are GP link workers, that link works less well in Harrogate.

There aren’t enough support staff to enable qualified staff to do their job.

“You should look at how many chiefs and Indians there are”. Frontline staff need more

numbers and training as an overall priority.

The system is too opaque

More resources for the outreach team and the crisis team

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More resources for the CMHTs, especially if there are no inpatient services in Harrogate.

Increase in funding for MH services in both health and social care.

We know that other CCGS outside of North Yorkshire spent approx. 115 -150% of the

monies spent by the local CCGs (those in NY receiving services from TEWV are in the

bottom 10 CCGs spend per head on MH and I’m not including Craven as they spend

more!) and that Liz Herring (Head of Service, Adult Mental Health, North Yorkshire) has

said that though the interventions using this level of funding are effective they are not

always safe. Being unsafe doesn’t necessarily mean that a Serious Untoward Incident

might / may occur but it’s “dodgy”. Will the consultation include a plan to increase

spending per head on MH service provision?

I had a response to a question raised at TEWV’s AGM this year regarding finance. “It

was confirmed that there had been a directive for Chief Executives of mental health

trusts to confirm that monies for front line services for mental health had been allocated

through the Mental Health Investment Standard. A response had been sent stating that

the standard had not been met in Harrogate.”

Timely access to properly resourced acute services not just when in crisis

This “threshold” approach to accessing services is damaging and dangerous. Service

Users are encouraged to recognise when they’re reaching crisis and follow their crisis

plan. So when eventually they get a referral to secondary services they’re then told that

they’re not ill enough / thin enough / etc. Why bother writing a crisis plan? Why

encourage Service Users to be active participants in their care? What a waste of time.

Integration between TEWV and NYCC. Anecdotally, TEWV patients are being

discharged from CPA before they’ve been seen by NYCC HAS MH support. Poor.

Harrogate community to have access to same provision of services in specialist

provision. Have had specialist training e.g. but don’t have any time to implement this due

to caseload numbers.

More staff available to be able to respond when clients are in crisis

Even when staff are unwell the Trust was unable to respond in timely fashion – staff

member had to wait 3/12 for a service

Younger persons dementia team

No strength in inpatient recovery service – they are all discharged to care homes & this

is due to lack of social care funding

Re-provide day hospitals if no beds. They also provided respite for carers that enabled

them to continue caring for longer

Respite beds

Harrogate services get paid less per person that inner city services

More access to medical staff – many areas relying on locum staff +++ vacancies in junior

doctors

More respite and day care: more individually focussed work, education & training

Able to provide rapid response to referrals – can’t do this now

Referrals have increased, caseloads have increased and staff are overloaded

+++time needed for paperwork

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4. What are your thoughts on the future of inpatient beds for local adults and older people?

A new development within Harrogate.

Scarborough is super – washing facilities, carers rooms, men and women separate, staff

presence excellent

I’d rather travel and get best environment – York – no problem, not everyone has a care

but better to have centre of excellence

Should close the wards

Don’t think there needs to be beds in Harrogate – put them in York

We will always need beds, issue is how many

Alternatives would be better – day centres, safe houses etc

Need to consider prevention of admission and look at day-care

Need to bolster community services

Could consider privatizing beds

Running a care home on land provided

Local beds/alternative place family/carers at increased stress

Need for specific services

Occupational therapy/activity focused day

Crisis beds as an alternative to inpatient for short term

Same facility for all ages

Separate facility for dementia beds (with sensory appropriate)

If demand is so small for organic beds could it be run by independent/private sector?

Less out of area placements – not ideal for patients/carers

Analyse other services for other things which work

Inpatient provision requires improvement

More modern facilities

Rehab facilities – require investment

No mixed wards

Specialist tailored package of care

OT provision – currently very under resourced

NOT using medication to manage patients on Briary – you don’t get that in

Middlesbrough

Inadequate

Call us a name that says what we do! In plain English “older People’s Crisis Team”

Integrated IT with GP’s MH & Social Services

Shared caseloads, shared working not – “Somebody else’s problem!”

A service operating every day

Functional and organic care beds – need both

Older people functional is not the same as younger – many many reasons

Beds – we will always need beds! (aging population, breakdown of social care, more self

funding & lack of support for those people

MHA – can’t convey under MHS – care home

Would like better co-working and interface with Rowan, CMHT and AHLS

Each person should their own room and be able to choose their own room temperature

M&F wards and separate wards for older people

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Be creative! Particularly for older people

Local provision for older people so that patients who need admission can stay close to

their family

Crossroads provide support to carers – respite (brief) so that carers can have a few

hours off. This is self funded or can be funded through direct payments.

Short term inpatient beds local to Harrogate – Not out of area

Not in York

Own room

Open and transparent

CRT home treatment model (Recovery crisis/community house, staffed)

CRT home treatment partnership model

Invest in home treatment – prefer to stay at home

Single unit for dementia Enhance inpatient facilities in York

Step down beds

Crisis house to avoid hitting secondary care – be able to talk about medication –

consider functional and organic

Drop in centres

We’re concerned about total number of beds -

Staff may well leave – the current situation makes recruitment very difficult. We can’t

imagine many of our current patients being managed outside inpatient settings.

Organising the current care in the community would be very difficult, and 24/7 care is

definitely needed for some people.

We may struggle for beds because of planned closures elsewhere. Closures aren’t just

planned in Harrogate.

Need local beds – without them A&E will be overloaded liaison service will need

bolstering – already difficult to recruit to

There are risks in trying to manage people out of area. People tend to stay longer.

Acuity is now much worse. I’m very concerned about the idea of managing people in

nursing homes.

We feel very raw about the five years’ input into work on the new build.

Maybe there could be a single challenging behaviour unit for dementia in Harrogate –

and functional illness services for older people could go elsewhere?

We’re aware that HDFT want this building back.

Why does so much national money need to go on CAMHS, not on services for older

people?

There are some inappropriate admissions, especially linked to housing and social

problems. Housing issues are managed much better in Leeds.

Need to consider rurality and access and transport

Staffing levels can fluctuate, but we have no fundamental concerns about inpatient

staffing.

100% it should stay in Harrogate.

It shouldn’t be mixed sex any more.

A new build could go in Ripon to service Northallerton and Harrogate?

New buildings are definitely needed, definitely not keeping the current wards.

Ripon would be a good compromise, a better option than Harrogate town.

The logistics of travel to York would not be good, including travel time for staff.

Geography really does matter in what TEWV are planning.

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The Orchards takes people from Scarborough at the moment.

We’d welcome a local crisis house like they have in Leeds. This could be in Harrogate or

elsewhere, it wouldn’t matter too much.

The new land in Harrogate isn’t well sited.

There will always be a need for inpatient beds. The closer the better.

We’d prefer Harrogate. We’d prefer a new build in Harrogate if at all possible.

It needs to be staffed properly, with appropriate levels of resources and staffing.

The government has said that when someone is experiencing mental distress, they

should be cared for in their community. Therefore we need in-patient facilities that are fit

for purpose, accessible (only Jennyfields and the Briary Wing can be reached by public

transport), providing a safe and therapeutic environment for seriously unwell people that

is within or close to HaRD.

Development of single sex wards – current plan has a mixed ward. Although research

suggests mixed wards are calmer (male only wards can be violent and women only

wards can be more disruptive (https://www.nursingtimes.net/the-effect-of-single-sex-

wards-in-mental-health/5065923.article)) it can be culturally insensitive and can be

harmful to vulnerable individuals of both sexes.

Is it best practice that functional and organic patients are on the same ward on inpatient

MHSOP facilities? My experience is that the needs of these two patient populations are

quite different and pose differing challenges in providing a therapeutic environment.

Change the wider system so that clients don’t stay on caseloads just to access services

provided by other organisations or the local authority – social care and housing

5. Thinking about the needs of carers and families – what would you like to see available to better support the families and carers of people with mental health conditions?

Unless in receipt of secondary care services carers cant access carers support services

Need basic services focussed on recovery

Ensure pts are on CPA only if their needs are sufficiently complex to warrant itDay care

facilities are important. They provide some respite for carers and families as an

alternative to inpatient care.

Families are sometimes completely at breaking point. They’ve tried to look after people

at home for so long, but family dynamics risk breaking down.

The local authority employ 1.5 carers’ support workers, to work expressly with people

with serious mental health problems. Harrogate does OK for this at the moment. The

County Council are reviewing this anyway at the moment.

Support groups weren’t that well attended.

Support to carers is essential to enabling things to work well

Would like more carers groups

Need to have events to inform carers of changes to services

Would like a carers café model with good training available

Carer respite services

Better communication with carers/families – involvement of carer

Liaison with carers

Involvement of advocates

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Signposting to services

Psychoeducation at post discharge

Peer support

Being offered a carers assessment – triangle of care

Managing and sharing the risk

Advanced directives – include carers

A joined journey/service ‘taken through the service together’

Wider review of who is a ‘carer’ - sons, daughters, brothers, sisters, friends etc

Suicide bereavement & services/processes – Derry model

Day care services (similar to Claro) like Hawthorn used to offer

Library/public places used to run groups

Families to be linked in to services as support mechanism

Information more accessible in all areas e.g. what to do if you’re concerned about

friends/neighbours mental health.

Need a crisis team that works!

Better services in the community

Treated as individuals not pigeon holed

Inclusive service not exclusive service

Better practical help and relief for carers. Proactive and worthwhile activities for people

recovering or enduring lasting conditions.

More staff with lower caseloads would enable more communication patients/carers

Good 3rd sector support

Access to respite care – Day Hospital and inpatients – since Trust run service has

closed carers/families now have to pay themselves

Family & friends carer group

Good quality care support

Free physical exercise to support wellbeing

Longer term intervention and support – short term support available, need a wider safety

net,

Dementia carers form 95% of carer population

Icelandic model – when patient goes into crisis, staff work with family as well as patient.

Had positive impact on both pt and carers resulting in reduced admissions.

Triangle of care

Services to be more joined up – seamless response should be in place

In particular CAMHS – a 16-25 service could be trialled.

Direct involvement, sensible approach to confidentiality

Support and education to carer to enable support

Family intervention – shared approach and understanding

Out of hours support, weekend working

Extended hours

Rethink are excellent

Perhaps a telephone link and peer support

Something for the person like a “Red Book”

Sort out TEWV confidentiality policy vs. the safety and continuing co-operation of Carers

/ family. In-patient care is more expensive than care in the community.

Better partnership working with Carer / family

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Family therapy / MH education programmes.

Better liaison with TEWV Care Co-ordinator and LA Carer support worker.

Day facilities

More education for GPs

More health promotion

A hub that provides a central resource

More carers assessment and carers support workers

Recognition of problems of rurality – we know it’s difficult so we come to you, 7?7

service

Consultants should also work 7/7 – community team needs access to medical advice 7/7

Hospital consultants are required to do so community teams should too.

Quick response when in crisis

6. What type of community services would you like to see available to help keep you well?

MIND – poor attitudes with same people going there for years, leads to competitive

behaviour (e.g. self-harm)

Need new groups with healthy dynamics – people need to feel safe

Housing needs strengthening

Hub of information – working more closely with local organisations

Provision of day service – community hub to avoid crisis

Accessible local services

Map of services – including voluntary sector

Invaluable nature of voluntary sector

Joined up working between voluntary & TEWV

‘social prescribing’ rather than medical prescribing

Need to increase provision of crisis in the event of bed closures, cost/benefit analysis

‘The best care within resources available’

Street triage – integration of ambulance/police

Holistic – meaningful, purposeful

24/7 mental health community services – not just crisis/emergency services

More joined up services (including voluntary sector)

Less waiting times for treatment

More input for eating disorders

Open access hub

Some MH input at benefits office (due to universal credits etc)

Gardening groups etc

Community café’ who can link you in

Wellbeing for older people

Early intervention for older people and exercise etc

Potentially better/more use of domiciliary care support interventions

Everything that is already here

Agree that everything is already here

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Subsidised/free physical exercise to support recovery

Better engagement

Well-staffed with appropriate people – poor access to psychiatry at the moment

Do the right thing for the right person at the right time – this will need a cultural shift in

teams – staff need to be appropriately trained and feel supported

Closer working with other types of services e.g. housing/benefits

Properly integrated working – not just across organisations but also within the trust

across NDT’s/multi-professions

Configured by staff and service users!

Communication is key! – between senior management and front-line staff

Language – stigma, wellbeing support service and mental health. Balance between

breaking down stigma and promoting mental health

Invest in low level intervention and support

GP refer to wider scope that IAPT group support

Develop WRAP plans

Mobile pop up services integrated service provision – in reach into rural communities

Range of services available as a local resources that the public are not known

Access to activities, groups, investment in transport, social inclusion, social activity and

supported access.

ORB is brilliant

Yoga groups (like in Ripon)

More voluntary work

Identify people’s strengths and encourage participation in everyday life.

Supported accommodation for people with complex trauma/needs

Community works well for people who want to be there.

The Vanguard service hasn’t impacted sufficiently on demand for admission. Admissions

from nursing homes are still happening, generally linked to aggression and challenging

behaviour. This is only worth continuing funding if it’s making the difference it’s

supposed to make. What’s the point in keeping it?

Once people are settled, they go on to Springwood, or Billingham Grange in Durham.

There are currently no ways of people staying long-term in Harrogate if this is required.

The police automatically bring people here – what will happen if the section 136 suite

goes?

There are not enough staff anywhere. People are superheroes – they put every patient

first, they give everything first.

The amount of community support is often very patchy – there’s a level of risk here

My impression of community services is that they are generally good. Community

services should be available 7 days a week, if there is any reduction in in-patient bed

numbers.

Working together with Primary Care and Public Health England / North Yorkshire to

deliver ongoing health and social care support for people living with Mental Health

problems not just those on the SMI list. Co-ordinated approach would manage people

better, give them skills to cope and decrease the need for Secondary Service

interventions and reduce the development of other health issues prevalent in Mental

Health populations. Need to set up a working party and think smart.

MH medication generally makes you fat. The number of Service Users and ex-patients

that have developed Type 2 diabetes and that are obese is appalling. MH patients

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already have a poor life expectancy and are more than likely due to their poor lifestyle

choices develop other long term conditions. MH services have historically only been

interested in the MH illness. Therefore there is a large cohort of people who are no

longer accessing secondary services who are being supported by their GPs (who can be

less than useless when it comes to MH) who will soon become a huge burden on the

NHS and CCG Continuing Care Budgets. There needs to be joined up working with LA

to have access to gym or keep fit classes. These need to be ongoing and not time

limited. Please don’t make us join an already running class – a step too far in social

integration.

Specialist Health Living programmes around living with a mental health conditions and

making healthy choices.

Money management – so many patients especially the younger ones are unable to

manage their money. Patients see their peers making life style choices which are

beyond the reach of their benefits. But to fit in, they beg and borrow and perhaps steal.

Money for what I might call essentials – food, electricity, etc - is spent, for example, on

the latest phone, a night out with the lads. Our local Mind offers 3 meals a week that

keep these individuals fed.

There is mindfulness for anxiety. Health to develop /provide similar low level therapies

for other MH conditions treated in secondary care.

More specialist support for overlooked but really debilitating and socially isolating

conditions such as OCD.

Liaison with social care to provide respite for patient and /or Carer. Would probably be

cost effective but health and LA treat it as a hot potato and sling it back and forth

between each other. Sort it out.

7. Is there enough emphasis on recovery, social inclusion, training and education and/or volunteering through to employment to support active citizenship?

8. If not, what other services would you like to see?

No. I really think that active citizenship is essential to promote recovery. There needs to

be a linked and effective recovery pathway, which includes training, education, work

placements and volunteering. All of these things are useful of themselves as well as

being stepping stones towards fuller recovery.

It would be interesting to see more of an emphasis on the link between exercise and

mental health. Are there specific programmes in place to promote exercise during the

recovery pathway?

The service is risk averse – not quick at discharging especially psychiatrists in Ripon

The recent formulation model is designed to counter medical dominance and we always

ask about trauma

Education – build resilience early – work with schools

MH first aid champions

Gaming – radical views around coding and educating children

Working with GPs – offering mindfulness etc but not under TEWV, independent offering

SU who are coming out of services need more encouragement and support

Need to look at recovery journey

Physical healthcare

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Needs to be recovery not ‘risk’ based services

Currently a ‘revolving door’

Finding effective voluntary services

Education and support from a young age

Pharmacy support – simplification of repeat prescription / link with NYCC/CMHT

Linking in with other services (living well)

Needs a central hub where there is access to help/info

More education into MH problems perhaps starting in schools

More opportunity to be involved in decision making – perhaps out of hours

Recovery College – linking in with voluntary sector

Tacking social isolation – rethink how services can help each other

Ref admission to York, Middlesbrough etc almost out of area placements +++risk of

suicide

Concern about +++ care homes springing up

Staff doing +++firefighting – lack of preventative work

If a new build goes ahead, how will the food be provided? A chef would be great please!

Rehab chef could help clients/service users/teach them.

Access to education and training available through MIND

I see few people recovering from poor mental health. Many fear it. They fear change,

they fear challenge. Therefore losing control, staying unwell and in a comfort zone gives

the person an element of control. We need to create a compassionate culture where

everyone loves and supports each other, no judgement, building social and cultural

capital and massive recovery capital.

Bolster resilience of staff to enable them to do what the organisation needs from them.

Asking people to change their way of working requires effort from management and

staff. Unless this happens then clinical decision making doesn’t change.

Move towards more inter-disciplinary rather than multi-disciplinary working. A lot of

‘waiting’ for one professional to make a decision in order for the patient to move along

the pathway.

Need more people to do more things – multi-skilled professionals.

When have we done enough?

Provide care that is ‘good enough’

Psychological needs to be met by every contact, regardless of which profession is in

contact with them.

Important that the change journey is managed so that staff are supported to make the

transition successfully. Trust doesn’t do that well at the moment.

Embed ideas about structured clinical management – find a more successful way to

manage patients who bounce around services.

Trust needs to ensure that staff feel safe and supported. Empower staff to take positive

clinical risks with appropriate clinical supervision, System must value quality of contacts

not just the number of contacts.

Change the ‘blame’ or ‘fear’ culture and this will start the cultural shift required.

Investment in educating school age children around wellbeing

Media – using media to promote, educate, promote recovery

In our case there was too much pressure to get back to work

Not been any training offered

Each person should have something tailored to their needs

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With the resources our community services have they do really well

Would like more services like The Orb and The Acorn

More open access

No recovery college – would like one opened.

We need to improve communications and CPA reviews. The third sector say they don’t

get invited to CPA reviews, or told about discharges. GPs are invited but don’t come.

That links back to having the time.

It’s not unusual for staff to be working at 8, 9 or 10 at night.

There is more talk of recovery and support worker roles. There has been local training.

We welcome the training on recovery. It’s doable and achievable. I welcome the

process.

Organisation, attitude, training. There’ll be a proportion of people whose families want

them home. Family, support services and mental health services all need to play their

part. But some people don’t want to take responsibility for individual family members.

There should be much better application of the Mental Health Act Code of Practice –

better training and consistent use.

Move away from a “safety first” approach. Better tailoring of care to individuals.

It’s too patchy – it depends who you get.

People aren’t given enough information as to what to do and where to go.

Better care planning processes – such as the MIND template

Benchmarking with up-to-date practices.

No. A TEWV manager once told me that their job was to deal with the issue presented

and then discharge them – so much for a holistic 360⁰ review.

Is this really a health function? If health and social care worked a bit closer this would

be picked up by appropriately trained and experienced social care staff. Why try to

make TEWV mental health staff “jack of all trades, master of none”. Does TEWV not

appreciate and value the qualifications / experience of mental health clinical staff?

If health and social care were more integrated any issues around education through to

employment would be picked up by social care workers embedded in Community

Teams. Why don’t MHSOP community teams have social care workers embedded

within health teams?

Should there be dedicated housing and education officers embedded in each team?

NYCC has / had a dedicated MH employment support officer – Jane Jewitt has

supported many patients to return to full time education and employment. She has also

supported employers helping patients to retain employment. She has been a guest

speaker at the Harrogate Patient and Carer Involvement Group to update Service Users,

Carers and other attendees on changes, for example, in benefits. This information is

then available to a wider audience on the group’s circulation list. One of her ex-clients

went back to college and took their ’A’ Levels, went on to take a degree, recently

completed a Masters degree and has just started their first job. Jane has been

re-organised into a generic employment team. Whether her specialist knowledge and

experience is being used to best effect is unclear.

Most MH services are provided 9 -5 Mon through Fri. MH isn’t. It may be more sensible

to provide services later so that Carers can get patients ready for clinic and medication

can take effect. A 9.00 am clinic appointment benefits who? Certainly not the patient or

Carer. TEWV need to provide services which are appropriate for their users not for their

staff.

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SMS service for – TEWV need to get into the 21st century. My dentist and hairdresser

have used this for years. In addition, I recall MHSOP Memory Clinic staff liking the idea

to remind their patients!

appointment reminders

meeting reminders

any other reminders

Better use of technology

Telehealth. NHS NY &Y PCT purchased 2000 units plus support in 2011. Less than 500

were used. I appreciate that the e-health programme was axed in 2014 but it may solve

some resource issues, address some rurality issues and bypass GPs who complained

about being inundated with information. Maybe telehealth needs to be Secondary care

tool? WSD telehealth study headlines were (at

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui

dance/DH_131684):

- 45% reduction in mortality rates

- 20% reduction in emergency admissions

- 15% reduction in A&E visits

- 14% reduction in elective admissions

- 14% reduction in bed days

- 8% reduction in tariff costs

Found some more current evidence at http://www.birmingham.ac.uk/Documents/college-

social-sciences/social-policy/hsmc-library/snappy-searches/Telehealth-Oct-16.pdf

Telemedicine - interactive medical service useful in rural areas, for example, clinics

Use of web chat / smart phones to support patients, Carer and staff

Anything else?

Need to change the language around mental health. It is on the whole dated, rooted in

the asylum and not really fit for purpose. How about mental well being instead? Instead

of recovery (which for most of TEWVs patients is an ideal) let’s talk about maintaining

well being. Instead of a Crisis Plan what about “Rainy Day Plan”? Instead of a harm

minimisation what about a partnership approach to my wellbeing?

TEWV to explore other therapeutic options before resorting to the medical model. NICE

guidelines have had their day and are out of date.

Concerned that the consultations in both Rich and Ham and Harrogate are being taken

in isolation. For example, when Bootham Park shut most patients were looked after by a

huge community team. But I bet a few beds had to be found. Maybe not at Harrogate or

even North Yorkshire but provision within TEWV had to be found. Therefore TEWV

looked for resource throughout its organisation. Before Harrogate had its S136 suite,

people were taken to Bootham Park. It’s a pity that VoY CCG have gone it alone

because it could have been a great opportunity for all the CCGs and TEWV to look at

the commissioning and provision of mental health across the county. A more realistic

picture and better services might have come out of it. HaRD is too under resourced and

small to stand alone and is therefore unable to provide modern impatient services. Have

the CCGs become more parochial?

I have concerns about the adult in-patient environment. The Briary Wing in Harrogate

District Hospital does not provide the standard of accommodation we expect (this has

been highlighted by the Care Quality Commission inspections) and this needs to be

addressed. CQC, during their inspection of TEWV in January 2015, identified the

following issues on Cedar Ward:

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- some environmental and ligature risks, that privacy and dignity was not maintained

- there were some rude and insensitive staff

- there were non anti-ligature beds in use on the ward

- the temperatures were variable which patients and staff found difficult. It was either

too hot or too cold.

According to Harrogate District NHS Foundation Trust at its Board of Directors meeting

held on 27 September 2017 “...it had been confirmed TEWV would continue to occupy

the Briary Wing until 2020.”

The CQC were told that the Trust was developing plans for the relocation of Cedar ward.

The CQC also said they saw in the Trust quality strategy 2014-19 that the Trust aimed to

ensure that by 2017/18 all the trusts’ acute assessment and treatment beds would be in

single en-suite bedrooms.

TEWV need to provide a response / action plan / etc. to these concerns.

In addition, it also looks like that it’ll cost TEWV more to remain there and so a solution

may have to be found sooner than later (see HDH BoD minutes 27/09/17).

Why are those who choose to engage with TEWV discriminated against?

If you’re hard to engage you may get – according to the TEWV website - Medication and

side effects, relapse prevention techniques, coping strategies, relaxation techniques,

problem solving, cognitive behavioural therapy (CBT) techniques, support in the

community with all aspects of daily living, patient centred approach. I guess “bog

standard” CMHT interventions may not even be “patient centred”! Everyone should be

offered all of this.

Are the needs of physically / sensory impaired patients being assessed and addressed.

Are all HaRD and TEWV facilities accessible? Does each organisation have a physical

and sensory impaired forum to support TEWV and HaRD in the decision making

process? In this pre-consultation phase is anyone meeting with these communities

either via NYCC forums or locality groups?

Are the needs of LGBT patients being assessed and addressed? Are all HaRD / TEWV

facilities LGBT friendly? Does each organisation have a LGBT forum to support TEWV

and HaRD in the decision making process? In this pre-consultation phase is anyone

meeting with these communities? Yorkshire MESMAC is in Community House,

Harrogate.

In addition you should consider a programme of assertive outreach to reach other

seldom heard voices: they’re not had to engage- it’s just that your organizations are not

going about it in the right way

Use the proposed site at Cardale Park to build modern purpose built facilities / offices for

TEWV clinical and medical teams.

No more hot desking.

Currently most of TEWV staff is “hot desking” at Windsor House which isn’t good

practice / doesn’t engender a sense of belonging / doesn’t develop team working /

doesn’t provide privacy when a difficult telephone call occurs. It’s just so wrong. These

are trained, highly experienced, professional people. Why do TEV treat them as call

centre staff?

What is the future of the s136 suite in the Briary Wing? Will patients deemed to be at risk

have to be escorted by the police to York (what happens if the facility in York is in use or

unavailable – what contingency plans are there?) or will the s136 still be built at Cardale

Park or are TEWV planning to build a new facility or do we return to the bad-old-days

when patients were detained in police cells. Need to have some clarification here.

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Are TEWV working with North Yorkshire Police regarding s136 arrangements and

conveyance?

Are TEWV working with Yorkshire Ambulance Service? Patient transport arrangements

need to be in place and could be potentially costly.

What impact will any change of provision have on the service within Harrogate District

Hospital (HDH)? In hours the enhanced liaison team and out-of–hours the IHTT will

have to locate beds / sort out transport / etc. This may impact on HDH and the “4-hour

rule”.

Have TEWV scoped what the impact of the closure of Cedar Ward will have on other

impatient resources especially as it looks like Ward 15 will close? Having to access

inpatient facilities out of Harrogate district is not, as you say in this briefing, receiving the

care and support they (the patient) need as close to home as possible.

Perhaps read Old Problems New Solutions: Improving acute psychiatric care for adults

in England

http://www.rcpsych.ac.uk/pdf/Old_Problems_New_Solutions_CAAPC_Report_England.p

df

Individual Returns The mental health support system does not provide help for people with mental health problems. It seems the exception is Psychosis. Psychosis is a mental health problem that causes people to perceive or interpret things differently from those around them. They have an impaired relationship with reality. They may have hallucinations or delusions. Asperger’s patients also see the world differently. They have impaired relations with the world around them and impaired social skills. They do not get the same level of treatment or support. The Harrogate Mental Health Service consist predominantly of psychiatric nurses who seem unable to cope with complex cases. They are also insensitive to patient’s needs. For example, my son had sleeping problems and usually only fell asleep in the early hours, yet they would persist in making 9am appointments. Setting patients up to fail, miss appointments and being scratched off the list. People with complex problems need better qualified psychologists or mental health specialists. People that behave normally and follow prescriptive rules probably don’t have mental health problems. Rude or aggressive behaviour results in being excluded from help. Drug taking is a symptom of depression, anxiety or other mental health problems. Drugs allow people to escape a bad intolerable reality. My son used ketamine, an anaesthetic. This did not give him pleasure but blotted out his anxiety and depression. He didn’t want to be a drug addict. The fundamental problem is the separation of Drug addiction which falls under local authorities and mental health which falls under the NHS. The Drug Centre, Horizons, focuses on safe drug use, rather than helping people to give up drugs. However as previously stated the underlying cause requires treatment by a qualified mental health specialist. We need joined up thinking. All this results in the deaths of so many young people.

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My son Jamie died on5th August 2017. The 2 authorities left him to die. He needed help and many excuses were made by mental health. He is aggressive. He doesn’t keep his appointments. There was o follow up, just exclusion, Last week Alison Bedford Russell spoke on Inside Health on Radio 4. Her story resonated with mine. Her son George aged 24 died of a drug overdose because there was no follow up. He too was left to die. Such unavoidable, unnecessary and sad deaths of two highly intelligent young men. Alison also experienced when phoning the Crisis team, being told to go to A&E or Samaritans. I experienced this too at times when Jamie was suicidal and in crisis. After him attending A7E and not getting help, he was so frustrated and angry he broke some car wing mirrors and this resulted in problems with the police. So the limited choice is death, crime or giving people the help they need. Young people taking drugs should be treated with compassion and a real desire to help troubled people. Not a sensorial unsympathetic attitude which results in exclusion from any help.

I am involved on various levels locally (I live in Richmond), regionally and nationally as an expert in experience in mental health matters. I have just seen your “Developing a Vision’ document dated 31st August. Could I please raise an urgent flag about the association between the wards being ”not fit for purpose” with the Care Quality Commission. This raises the presumption (and potential misrepresentation) with the target audience that CQC are actually saying this and using these same words. They do not; in their most recent report, they raise it as a “dignity and privacy” issue, but not a safety issue as such. There is certainly a general expectation that many MH wards across the country have facilities which are not optimum with todays standards and expectations, but my own guestimate is that 30%+ are worse that TEWV’s legacy sites in North Yorkshire. I did make a complaint to HRW CCG on 4th September, and received an apology from Janet Probert last Friday (15th September). I am still waiting to hear from CQC with their considered view on the matter. Could I ask that you reflect on this; the words on page 4 “highlighted by” seem inappropriate to me. Furthermore, overuse of the phrase “not fit for purpose” outside specialist business planning settings has significant implications for staff motivation and patient confidence. I assume you can connect with the HRW CCQ to get details, but if not, please let me know. Meanwhile, there is a meeting of the NYCC Health Scrutiny Committee on Friday afternoon (tomorrow) in relation to the HRW consultation which may elicit some general guidance on these matters.

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My limited experience of visiting the Briary Wing: Good care observed. Calm atmosphere. Good outcome for patients. Thank you TEWV! I don’t know what the research says but I would like to see female/male only wards. Through my work I know that there is a silent mental health epidemic, so there is an urgent need for more beds for under 18’s – less than 300 beds for Eating Disorders in the whole of country in contrast with 750 MacMillan Nurses in Yorkshire. I have joined the Trust as an active member, so I hope to hear the outcome of this meeting.

1. I constantly hear “care is better nearer to home” and then we close more and more beds,

using this as an excuse, and the “professionals” work 9-5. Thus the untrained carer is on their own, without support.

2. There is no crisis helpline to support carers out of hours. This is an absolute must have, particularly as more beds are lost.

3. The needs to be more creative thinking. For example, if beds are not available in hospital, can care home beds be purchased as an alternative. This would work for dementia.

4. My Wife was in a medical ward and a consultant and two Drs. said she needed to move to the Briary Wing. They added that she must not be moved elsewhere. Against this medical opinion TEWV transferred her elsewhere until I complained and pointed out that the lack of beds was solely due to TEWV mismanagement in closing available beds.

5. All Drs surgeries should have a dementia clinic to support those in the community and thus avoid the crisis that cause hospitalisation.

6. All patients should have a single named support worker who is in regular contact and can help navigate the current chaotic systems of support. There needs to be more joined up thinking – all current systems and processes are designed solely for the professionals and not for the patient or their carer. It needs refocussing.

7. The previous CEO of TEWV justified closing beds in Harrogate by referring to the fact that Harrogate had proportionately more beds that elsewhere in the country. I pointed out that this was lowering Harrogate to the lowest, unproven, common denominator. I asked if anyone had done a statistical analysis or assessed need. The answer was negative. I pointed out that readily available statistics show that Harrogate has, on average, a more aged population that the rest of the country and therefore this could give rise to a greater need, particularly dementia. Beds were still closed.

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The views expressed below are a collection of views from clients, trustees and members of staff from Claro Enterprises: Our experience of current provision:

There are a range of 3rd sector run day-time activities which are highly valued by those who use them, their carers and professionals in the area. Claro’s experience indicates that engaging in meaningful work activity in a team based supported setting is therapeutic, increases wellbeing, reduces exclusion and loneliness, helps sufferers stay well and reduces their need for hospital treatment.

Claro has provided consistency whilst other services have been in a state of flux. Many clients have been discharged from Secondary Mental Health Care and have little or no other support than that which they receive from Claro

Those who continue to access secondary mental healthcare experience greatly reduced contact with their CPN’s and have lost the support of some other services such as coordinated volunteers. CPN’s seem to change regularly to the point where some clients don’t know who their current CPN is.

The decrease in contact with CPN’s and other previously coordinated services has left the individuals we support more vulnerable and has had a detrimental effect on their recovery.

There is a lack of support for carers and families, the closure of respite services has left a gap that hasn’t been filled. For one client accessing respite really helped him through difficult periods.

Much of the reduction in contact with secondary mental healthcare is set in the context of recovery – there needs to be a recognition that for some this is not appropriate and that these services are often an integral part of prevention and recovery and reducing incidence of crisis and hospital admission

Out of hours crisis services are inadequate and potentially dangerous. We supported one client in crisis and contacted out of hours mental health services but could not find anyone who could go out and see her, eventually we contacted the police who did go out.

There is a recognition that the Briary Wing is not a good place to go. One client highlighted the lack of activity when in hospital and described how this is a barrier to recovery

People prefer to access beds locally when needed rather than travelling to unfamiliar places away from their family and friends.

Future Provision: Retain Beds locally in a setting which is therapeutic and provides meaningful occupation

- Going forward as the direction seems to be fewer inpatient facilities it will be important to develop a wider day care offering and find easier ways to refer people to such services. Another important need is for consistency of support staff who really know their clients and thus can see the early warning signs of people becoming more poorly - too often these signs are missed at present because of lack of continuity of support and people descend further before being offered help.

Provide a 24/7, 365 days a year crisis service. Look at the services in Bradford (Haven & Sanctuary) which offer non-clinical settings, out of hours support to people in crisis, avoiding hospital admissions.

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Adopt a holistic and realistic approach to prevention – Claro is fully supportive of the need to further emphasise recovery and prevention. However, we also know that for some it is unlikely that recovery will be possible either because of the nature of the condition or the length of time someone has been suffering. In the desire to increase efforts on recovery and prevention it is also important we continue to support those who are trying to manage a chronic condition. Not everyone will recover but everyone is at risk of slipping back into a worse condition without support and services which have been proven to work over a period. Continuity of care and support for such vulnerable people is important and we need to take care not to overlook this.

Having fixed periods of contact with CPN’s may be inappropriate and detrimental to long term, sustained mental wellness. Give care coordinators a realistic workload - it simply is not at present and they are so stretched service user needs are being missed or not attended to in a timely manner. Simply put more face to face checking in is required rather than waiting until service users cry for help.

To support the needs of families and carer’s better information of what services are available would be helpful. Could we have services for mental health such as McMillan Nurses or Admiral Nurses in the community who could point families at support which exists before people fall into crisis and require referral with all the formality and cost that creates.

In some areas, such as Elderly Dementia sufferers one wonders why a mental health ward is necessary or appropriate - perhaps more encouragement should be given to extending the range of service provision from existing specialist organisations such as Vida Healthcare to include assessment provision.

In future, we would like mental health services to be much more “joined up” than at present The continuing twin stream of funding from NYCC Social Work and NHS is not particularly helpful and can lead to differing priorities. The present plethora of reviews in the mental health arena serves to emphasise this point - this review plus the NYCC Review plus the Richmondshire, Hambleton review and those are only the ones Claro knows about! As a service provider, this is inefficient and unhelpful and while we are interfacing with the multiple reviews which we feel we must do to be heard we are less focused on those who depend on our help.

Dear Sirs, Ref: Harrogate & Rural District Mental Health Review Below I have detailed my comments on provision of services as per the above review. In order to put my comments in context I wish to inform you that I have been trustee of Claro Enterprises in Harrogate since its inception - (Workshop providing employment/training for suffers of mental ill health in Harrogate District.) I also have a close relative who has suffered from severe schizophrenia for the last 40 years and has used a wide range of services throughout his illness. In-Patient Beds

It is vital for patients who are suffering acute periods of illness that they are able to access an in-patient bed quickly and locally so that they have continuity of care with their psychiatrist and community nurses, also visits from carers and friends. It is totally counter productive, inhumane and not cost effective to move sufferers away from their local hospital, carers and medical support as is the practise at the present time.

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Our regional units are also hugely important for patients who require highly intensive support over and above any local provision although this is obviously not required by the majority of sufferers.

As a carer of a sufferer I feel that it is important that providers of services realise the nightmare of coping with someone in an acute phase of their illness, it is frightening, dangerous and impossible to provide this service in either the carers or sufferers home. There must be sufficient beds to cover admissions in a crisis situation as there are many cases when the “Crisis Response Team” cannot be a substitute to in-patient care.

Primary and Outreach Care

Community teams have been in existence for many years and I have met many very good staff. Unfortunately the lines between social and health support still exist and I feel this will always be the case until we have support staff who have training in both disciplines so they can provide a more comprehensive service.

Day Care

As a carer I found that lack of occupation during the day and with it the chance to meet people, socialise, make friends and learn new skills is vital. It provides a chance to live a “normal life” and hopefully return to work and is hugely important in preventing relapses. Most of the Day Care in Harrogate is provided by the voluntary sector and it would be helpful to service users if it was more of an integral part of the whole support system and acknowledged as such by statutory bodies. Many mental health professionals still seem unaware of services in the charity sector even in a small district such as Harrogate.

Therefore I feel it is important that Day Care is recognised as one of the basic building blocks which prevent relapses requiring vastly more expensive support and is acknowledged as such.

As a carer of many years I would be grateful if you would feed my comment into your review.

I have discussed with my clinical colleagues to get there opinion on the questions you set and hopefully they can help you a little in your review. 1. In the future, what would you like the mental health services in Harrogate to look like?

We feel that MH needs to be integrated with Primary Care and should be a front line service with access to Primary Care Mental Health in practice. MH is an ongoing condition and should be treated in the same way as most Long Term Conditions like Diabetes, COPD, Asthma etc where we have specialist nurses in Primary Care to lead in these areas. Currently we are part of the pilot with NCM and our Integrated Response Service where our community team consist of MH Nurses, Community Nurses, OT's, Social Services and Vol Sector and this is integral to managing those patients with complex health needs that are not necessarily housebound but have complex and multi-disciplinary heath care needs. Both models of this integrated care result in a seamless journey for patients with MDT working and smoother transitions of care. These will assist in reducing NEL's and A&E attendances in the long Term.

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CAMHS however needs to have improved access and capacity as this appears to be an ever increasing area, however we are aware that TEWV have improved the access and pathway recently.

2. Thinking about the strengths of the current Harrogate services, what are the three things you'd like to see remain in future services?

Integrated working within NCM pilot, Assistance with Care Homes particularly Specialist Dementia units.

3. Thinking about the things you'd like to see improved, what are the three

priority issues you'd most like to fix? MH nurses working in Primary Care as part of the Primary Care team, CAMHS, Ex Servicemen pathways and access for PTSD especially those with Drug and Alcohol associated problems. Crisis Team lack capacity and number of cases is increasing. CMHT increased capacity.

4. What are your thoughts on the future of inpatient beds for local adults and older people?

If the other areas were improved less inpatient beds would be needed. Having said that there will always be a need for some beds for younger patients and at present there are insufficient for teenagers. However I don't think we need increased beds for elderly patients if the trust were able to have an arrangement with specialist care home providing significant mental health input to a "few" specialist care home beds - step up - step down beds for MH access.

5. Thinking about the needs of carers and families - what would you like to see available to better support the families and carers of people with mental health conditions? Needs better integration with voluntary sector. 6. What type of community services would you like to see available to help keep you well? As described above. 7. Is there enough emphasis on recovery, social inclusion, training and education and/or volunteering through to employment to support active citizenship? If not, what other services would you like to see? We don't know enough about this. Managing Partner GP Practice

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Harrogate social media

Twitter:

10 posts 1 – 27 Sept

Post Engagement Impressions Eng rate

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TOTAL 3707 62

Facebook:

10 posts 1 – 27 Seppt

Post Message Posted Lifetime Post Total Reach

Lifetime Post Total Impressions

Lifetime Engaged Users

Lifetime: The total number of people your Page post has been served to (unique users)

Lifetime: Number of impressions of your Page post (total count)

Lifetime: The number of unique people who engaged in certain ways with your Page post. For example, by commenting on, liking, sharing or clicking on particular elements of the post. (Unique users)

Hope to see you at White Hart Hotel, Harrogate today, 2-4pm, to chat about developing mental health services http://ow.ly/rfBU30fkmTj 9/27/17 2:05 AM 553 977 13 Join us at White Hart Hotel, Harrogate tomorrow between, 2-4pm, to chat about developing mental health services http://ow.ly/rfBU30fkmTj 9/26/17 11:10 AM 475 780 7

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Come to White Hart Hotel, Harrogate on 27 Sept, 2-4pm, to chat about developing mental health services in the area http://ow.ly/rfBU30fkmTj 9/25/17 6:15 AM 355 586 3 Join us at White Hart Hotel, Harrogate on 27 Sept to chat about developing mental health services in the area http://ow.ly/rfBU30fkmTj 9/23/17 3:45 AM 348 581 1 We recognise the importance of good mental health services across the Harrogate area and the support needed for carers. We want to know what’s important, what has worked well, and what needs improving to make sure services are financially sustainable and meet the needs of local people. We’re inviting local public and patient involvement groups, voluntary organisations, mental health and social care professionals and the wider community to have their say about how services can be further improved. Find out more at http://ow.ly/C9r230eQomk 9/17/17 12:15 PM 649 1106 18 Do you or someone you know use mental health services for older people in Harrogate? Please get involved in helping to develop these services by sharing your views and opinions and helping to develop services in future. More information about how to get involved is available on our website http://ow.ly/jRf130eQnRo 9/13/17 5:15 AM 457 752 11 In conjunction with Harrogate and Rural District Clinical Commissioning Group (CCG) we are inviting people to get involved in developing a future vision for adult and older people’s mental health services in Harrogate. Find out more about how you can get involved on our website http://ow.ly/A8mK30eQn2C 9/9/17 3:20 AM 500 811 4

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How can we make best use of money available for mental health services for older people in Harrogate? Join our consultation in conjunction with Harrogate and Rural District Clinical Commissioning Group (CCG) and share your views. More information available at http://ow.ly/ikwG30eQmec #TEWVConsult 9/5/17 10:15 AM 624 1019 11 If you live in the Harrogate area, we'd like to hear your views to help develop mental health services for adults and older people. Please join our consultation that is taking place now and make your views and opinions count. Visit http://ow.ly/YTgc30eQlDX #TEWVConsult 9/1/17 7:02 AM 709 1290 16 Developing mental health services for Harrogate and Rural District http://ow.ly/HRk130eQ8pk #TEWVConsult #TEWVNews 9/1/17 5:17 AM 426 749 3

TOTAL 5096 8651 87