Simon Graham

INHS|

Birmingham and Solihull
Clinical Commissioning Group

NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull
Coroner’s Regulation 28 reports to prevent future deaths

1. Introduction

1.1 This report provides a response to the Birmingham and Solihull Coroner, in
respect of the seven Regulation 28 reports issued to NHS Birmingham and Solihull
Clinical Commissioning Group (the CCG). These reports relate to the deaths of:

1.2 The CCG has taken the opportunity, as part of this investigation, to review its
broader quality assurance processes and identify any learning outside the scope of
the Regulation 28 reports. The CCG is aware that there are a number of other
unexplained deaths/potential suicides, since the reports were received from the
Coroner, which will be included into our analysis and further recommendations for
action but which are excluded from this report.

2. Background and context

2.4 On 05 October 2018, the CCG received seven Regulation 28 Reports to
Prevent Future Deaths from the Birmingham and Solihull Coroner. These deaths
occutred over a four month period, between May and August 2018. One of the
deceased had been under the care of services provided by Forward Thinking
Birmingham (FTB) at the time of their death, with the other six being under the care
of services provided by Birmingham and Solihull Mental Health NHS Foundation
Trust (BSMHFT).

2.2 The Regulation 28 reports were accompanied by letters from the medical
directors of BSMHFT and Birmingham Women’s and Children’s NHS Foundation
Trust on behalf of FTB. The letter from FTB highlighted pressures in mental health
services, which they felt were caused by demand for services, coupled with a lack of
funding. However, the letter from BSMHFT was explicit that they did not feel that
funding was a contributing factor in these incidents.

2.3. The CCG commissions a range of health services for the population of
Birmingham and Solihull. For mental health, this includes tiers one, two and three
mental health services for children and young people aged under 25, and tiers one,
two, three and four for adults.

2.4. The CCG commissions mental health services from both FTB and BSMHFT.
FTB provides mental health services for people aged under 25 years old through a
consortium of providers, with the CCG holding a contract with Birmingham Women’s
and Children’s NHS Foundation Trust as the main provider of these services.
BSMHFT provides mental health services for people aged 25 years old and over.

2.5 NHS England directly commissions specialised tier four inpatient mental
health services for children and young people, specialised mental health services
(e.g. eating disorders and services for the deaf), adult medium and high secure
services, perinatal mental health, services for prisoners and services for the military
and military veterans'.

3. Contract management

3.1. The CCG commissions services from FTB and BSMHFT through NHS
standard contracts. The standard contract sets out the required operational
standards, as well as national and local quality requirements.

Contracts and provider performance are monitored by the CCG through a range of
reports and meetings which include:

3.1.1 Monthly contract review meetings, which include oversight of performance,
activity and quality.

3.1.2 Arange of contractual key performance indicators and monthly and/or
quarterly reports, which include data relating to patient experience, patient
safety and clinical effectiveness.

3.1.3 |n accordance with the NHS England Serious Incident Reporting
Framework (2015), the reporting of serious incidents to the CCG within
two days of the provider becoming aware that a serious incident has
occurred.

3.1.4 Quarterly reporting from providers regarding their systems and processes
for learning from deaths, as set out in the National Quality Board
Publication: National Guidance on Learning from Deaths (2017).

! https/www.england.nhs.uk/commissioning/who-commissions-nhs-services/nhs-england/

2

3.1.5 Inresponse to a Care Quality Commission (CQC) inspection report in
February 2018 which found the FTB service to be inadequate?, a Quality
improvement Board was established to oversee and provide assurance on
the delivery of their CQC Improvement Action Plan and also the System
Improvement Plan.

4. Quality monitoring

4.1. The CCG’s approach to the management of quality is set out in the
Birmingham and Solihull Quality Strategy 2017-2018, which was approved in July
2017.

4.2 Serious incidents that are reported to the CCG are collated into a weekly
report which is reviewed for trends and issues that require escalation. Matters that
need to be addressed are raised through the monthly contract review meetings;
thereafter any urgent concerns are raised with the relevant provider, as a matter of
priority, at a senior level.

4.3 In addition to the direct monitoring of contracts, the CCG reports on the
contract meetings through Quality and Safety Committee and Finance and
Performance Committee, both of which are sub-committees of the CCG Governing
Body and have Governing Body membership. The Quality and Safety Committee
routinely receives a quality and safety integrated report. This report analyses a
number of quality indicators, including serious incidents, and highlights any areas of
concern for discussion and escalation if required.

4.4. The CCG is a member of the NHS England West Midlands Quality
Surveillance Group, covering Birmingham and the Black Country. The Group brings
together different health and care partners, including the Care Quality Commission,
NHS Improvement and Healthwatch. NHS England also operate a mortality leads
meeting, which is attended by a representative of the CCG.

4.5 The CCG’s independent internal auditors undertook a review of quality
assurance mechanisms, which they reported in January 2018. This audit specifically
reviewed the provider quality and performance review meetings in order to provide
assurance that there were effective mechanisms in place to share recommendations,
lessons learned and to monitor trends. The review concluded that there was
‘significant assurance’ that the mechanisms were appropriate and working
effectively.

5. Understanding and responding to capacity and demand

5.1. Since 2016, the CCG (both in the current form and as three former CCGs,
prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a

2 Available at https://www.cqc.org.uk/provider/RO3/inspection-summary#mhchildrenandyoung
3

number of steps, with partner organisations, to understand and respond to concerns
about capacity and demand within the local mental health system.

5.2 The CCG is committed to establishing and maintaining a mental health
system which facilitates timely access to inpatient care for those who need it, whilst
ensuring that community-based provision is adequately resourced to support
recovery in the most appropriate environment. Part of this approach involves the
CCG being an active partner in the Birmingham and Solihull Sustainability and
Transformation Partnership (the STP), and the Mental Health Programme Delivery
Board. The ambition of the STP is to achieve sustainability, through a strong focus
on prevention and recovery.

5.3. The Mental Health Programme Delivery Board's plan of action includes a
range of initiatives to deliver measurable changes for mental health services. This
includes reducing the number of patients being placed in inpatient units that are out
of the local area to zero by 2021. The plan is jointly owned by the CCG, Birmingham
Women’s and Children’s NHS Foundation Trust, BSMHFT, Solihull Metropolitan
Borough Council and Birmingham City Council. A ‘zero suicide’ ambition has been
committed to, which is led by the local authorities’ respective public health teams.
This ambition will be supported by evidence based, preventative action and high-
quality crisis support, as well as reducing stigma around mental health and improving
access through early intervention services.

5.4 To date, the CCG’s response to the increase in demand for mental health
services has included:

5.4.1 An independent system simulation modelling exercise, which was jointly
commissioned with FTB and BSMHFT, to develop an informed response
on the best solutions to address the demand and where investment should
be prioritised. This followed a sharp increase in demand for inpatient beds
in 2016.

5.4.2 An independent review of patients’ journeys into and out of inpatient
mental health beds was commissioned by the STP. The review considered
whether alternatives to admission could have been used and whether
patients stayed in hospital longer than necessary. The review found that in
both cases, improvements could be made to help avoid unnecessary
admissions and reduce the time taken to discharge patients.

5.4.3 Supporting operational initiatives to reduce delayed transfers of care,
where CCG funding of individual packages of care under Section 117
(jointly funded packages of health and social care) are required to facilitate
discharge from hospital.

5.4.4 Weekly, and daily peak period, delayed discharge escalation calls with
providers and local authority social work teams, in order to escalate any
delays and for swift resolution.

5.4.5 Continuing to support the use of admissions to other NHS mental health
trusts within the MERIT Vanguard? and to independent hospitals, where no
locally commissioned beds are available, and an admission is deemed
necessary.

5.4.6 Using evidence and data analysis to inform investment and approach.

5.4.7. Recognising that capacity is impacted by a wide range of factors and
encouraging action at all levels across the mental health care pathway.

5.4.8 In 2017/18 providing additional investment in mental health services above
the contract value amounting to £4,611,000 for BSMHFT (3.7% increase)
and £6,235,000 for FTB (22.6% increase).

5.4.9 In 2018/19 providing additional investment in BSMHFT amounting to
£3,117,000 (2.4% increase) and FTB amounting to £2,881 ,000 (9.3%
increase).

5.4.10 This reflects growth of 3.03% in core mental health budgets, in accordance
with the CCG's investment standard, which is above the national growth
standard of 2.85%. See annexes one and two for further information.

5.5 There are many further initiatives underway, which are underpinned by
performance monitoring, to make real improvements to local services. These
include:

5.5.1. Anumber of discussions have taken place at contract level with FTB,
regarding pressures on services and more patients accessing the service,
and specifically the effect that this has had on inpatient care. As a result,
there has been investment in the service over-and-above the contracted
level, as detailed above.

5.5.1 The issue of funding was formally raised by FTB when they issued an
activity query notice* on 14 September 2018, after the initial £1 -Amillion
that was invested by the CCG at the start of the year had been spent. This
notice set out concerns about demand and capacity, in community (+10%)
and inpatients (+1%). This resulted in a meeting taking place on 20
September 2018 and an action plan being jointly developed.

3 The MERIT Vanguard was supported through the Department of Health New Models of Care Programme. It is a partnership
between four NHS mental! health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust,
Black Country Partnership NHS Foundation Trust, Dudtey and Walsall Mentat Health Partnership NHS Trust and Coventry and
Wanwickshire Partnership NHS Trust. The Vanguard has sought to improve crisis care through a more flexible use of bed stock
across the region and by seeking to embed ‘recovery principles’ in practice.

4 This is a formal contractual clause in the NHS contract that is used when there are significant
changes to activity planning and management processes, which require either party to alert the other
if there have been unusual changes in activity or referrals and allow for either party to issue an activity
query notice, leading to a joint activity review, activity management plan or utilisation review.

5

5.5.2 It is acknowledged, through contract review meetings, there have been
informal decisions with BSMHFT about funding and capacity. However,
this has not been raised formally with the CCG.

5.5.3 In October 2018 BSMHFT developed a proposal for funding, via the
Solihull Local Transformation Plan fund, for additional investment in the
Solihull Early Intervention Team. This is currently being progressed.

6. Response to serious incident management

6.1 Serious incidents are managed in accordance with NHS England's serious
incident reporting framework and are reported to the CCG by all providers, including
FTB and BSMHFT, in accordance with the framework and their contractual
requirements.

6.2 Reports are shared with key CCG staff, in real time, and considered
through the CCG’s Serious Incidents Group. Following the initial notification, the
CCG can request an update at 72 hours on the immediate actions taken by the
provider, and will be doing this for all reported deaths in the future.

6.3 Following initial management of the incident, the provider is required to submit
a full root cause analysis (RCA) investigation report of the incident within 60 working
days. Each RCA is quality assured by the CCG, through a multidisciplinary panel
review, before being signed off. To improve the quality of RCAs and learning from
adverse events the CCG will convene a second tier panel, with specialist clinical
input, for review of serious incidents requiring clinical expertise.

6.4 To further strengthen the process for managing RCAs the CCG will produce a
weekly serious incident report, which will be circulated to a wider group of nominated
CCG clinicians and senior staff.

6.5 The CCG was aware of all of the seven deaths highlighted by the Coroner. All
had been reported as serious incidents by FTB or BSMHFT. To date, the CCG has
received four RCAs, which were received within the required timescales. However,
two of the RCAs have been referred back to the provider for additional work to be
carried out, as the CCG was not satisfied that all of the learning opportunities had
been identified to prevent a recurrence. The remaining RCA reports are scheduled to
be received by the CCG in November 2018, and will go through the same quality
assurance process.

6.6 On 25September 2018, the CCG’s Quality and Safety Committee received the
integrated quality and safety report, as part of its regular oversight of provider
performance. The Committee identified there were a number of unexplained
deaths/potential suicides, prior to receipt of the Coroner's letter and Regulation 28
reports. The Committee raised questions as to whether BSMHFT was an outlier in
the region. The Committee will continue to monitor the situation and make
recommendations, as appropriate, in response to any quality issues or concerns.

6

Should the investigation of these deaths reveal either a theme that needs to be
addressed, or safety issues arising from the individual investigations, the Committee
will consider the specific problem and identify any required actions.

6.7 In addition to the deaths that are the subject of the Regulation 28 reports, the
CCG has become aware of a number of additional unexplained deaths/potential
suicides, which are subject to current investigation. In response to this, the CCG’s
Medical Director and Chief Nurse held a meeting with the Medical Director of
BSMHET on 05 November 2018 to discuss BSMHFT’s understanding of this and to
also learn more about their oversight of risk assessments and care planning for
patients who are not detained under the Mental Health Act.

7. Conclusion

7.1. The CCG aspires to there being no avoidable deaths in Birmingham and
Solihull and takes every reported unexplained death very seriously. The CCG is
continuously working with providers to improve the quality and safety of services, as
well as looking at new and innovative ways to improve all mental health services.

7.2. The CCG has taken this opportunity to review the processes for managing
serious incidents, but to also consider whether a shortage of funding may have
contributed to these untimely deaths. The CCG has been unable to identify any
correlation between funding and these deaths, but has recognised the need to
continually improve its quality monitoring function and to also improve processes for
learning from deaths at the earliest opportunity.

7,3. The CCG recognises the need to take a multiagency approach to the
prevention of deaths, including creating robust partnerships with mental health
support services e.g. substance abuse services, community intervention and crisis
management. The CCG must also ensure that inpatient beds are maximised and
available for those who need them.

7.4 There is a system wide recognition of the need to improve access to early
intervention in mental health services to prevent mental health difficulties escalating,
to reduce pressure on crisis services and to improve flow through the system thereby
freeing up capacity. Equally, there needs to be improvement in the mechanisms for
transfer of patients from crisis care to community support and care.

75 The system wide mental health commissioning strategy should be revisited
and updated to ensure that resources are focussed on early intervention and
support, as well as supporting those transferred to or being treated within community
services.

7.6 The CCGwill continue to keep under review the pressures on mental health
services and the need to develop new initiatives to manage patient flow and improve
services.

7.7. The CCG will analyse the outstanding RCAs that will be received in the near
future, in relation to these deaths, to ensure that all necessary actions are
implemented.

7.8  Itis noted from the Coroner's letter and the Regulation 28 reports that under
funding may be a contributing factor to these deaths. The CCG is still awaiting
detailed investigation reports into all of the deaths. However, at this stage there is no
evidence that a lack of funding contributed to the deaths of the individuals
concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated
28 September 2018.

7.9 Notwithstanding this, the CCG recognises that there has been increased
demand for mental health services since 2016, and has responded to this additional
pressure with increased funding and through working with the FTB, BSMHFT and
the STP to look at different ways of working throughout the system. The CCG will
monitor the situation to ensure that all partnership working across Birmingham and
Solihull is focussed on improving access and the quality of care.

7.10 The CCG has processes in place for monitoring and responding to individual
serious incidents, as well as emerging trends and themes, which might indicate an
underlying issue. It is recognised, however, that there is always a need to continually
learn and improve. As a result of this investigation the CCG has made a number of
recommendations in relation to its monitoring systems, which are detailed in section
eight.

7.41 The CCG has identified a number of reported unexpected deaths/potential
suicides in the period since the Regulation 28 reports have been issued, and is
actively working with FTB and BSMHFT to understand the root causes of these
deaths and any contributory factors. In addition, the CCG will work to improve the
proader understanding of the local area’s position, in terms of performance against
comparable organisations, allowing for early identification of emerging changes in
performance.

7.12 As part of this review into the seven Regulation 28 reports, the CCG has
identified a number of areas where processes can be improved and these have been
incorporated into the recommendations below. These recommendations incorporate
system wide improvements, beyond the immediate situation and reports, and are
consistent with our aims for improving the quality and safety of services.

7.13 The recommendations in this response should form part of the system's
immediate response and longer term planning.

8. Recommendations

8.1. We intend to improve our learning from all mortality by implementing the
following recommendations:

8.1.1. Acomprehensive review of the CCG’s serious incident reporting policy,
including how the CCG manages serious incidents from reporting through
to the close down of actions. This is to ensure that all actions to bring
about improvements are implemented and there are clear early warning
signs for director-led intervention.

8.1.3

8.1.8

8.1.10

8.1.11

8.1.12

8.1.13

increasing primary care (general practice) reporting, with clear guidance
on when there should be escalation through the CCG’s serious incident
process. This is to ensure that any deaths that occur outside of mental
health services form part of the learning and review processes.

Undertaking an urgent review of the CCG’s operational processes to
ensure that appropriate and robust quality assurance mechanisms are in
place.

Continuing to work with all providers, to address any deficiencies in RCA
reports.

Improved scrutiny and challenge of learning from provider deaths
processes.

Quantifying and understanding trends in mortality data and ensuring that
there is a system in place for early identification of significant variation,
which can be reported through the CCG’s quality reports.

Ongoing monitoring of statistical data, which allows comparison with other
similar organisations, in order to identify outliers.

Triangulation, with qualitative reviews, of mortality undertaken by
individual organisations.

Improving communication and information sharing with oversight and
regulatory bodies, to ensure that all relevant sources of information are
used for early identification of emerging issues. This will include closer
working with the Coroner, NHS England, Care Quality Commission, NHS
Improvement and Health Education England.

Working with partners to help address challenges in recruiting and
retaining staff, to ensure services are appropriately resourced.

Updating the system wide mental health commissioning strategy,
including developing plans to reduce fragmentation of services and to
ensure care is delivered in the most appropriate setting.

Working with our Local Authorities to ensure a suicide prevention strategy
and plan is approved and implemented.

Ensuring action plans relating to learning from deaths and improvement
plans for managing demand and capacity are incorporated into contracts
as service delivery improvement plans.

The CCG, BSMHFT and FTB will work with the National Mental Health
Support Team to undertake a diagnostic review of early help and
intervention services, and thereafter develop a plan to address any issues
raised.

Annex 1: Key milestones - July 2016 to October 2018

July 2016

Paper discussed at Mental Health System Strategy Board- this set
out the issues in relation to capacity in the mental health system
and proposed the joint commissioning an independent system
simulation modelling exercise, to develop an informed response on
the best solutions to address the demand and where investment
should be prioritised.

Oct 2016

Mental Health Strategies are commissioned to undertake the
system simulation modelling exercise.

Feb 2017

Interim report produced by Mental Health Strategies.

£420,000 investment in community based personality disorder
service, provided by BSMHFT.

May 2017

Final report produced by Mental Health Strategies, including key
recommendations.

May 2017

Programme of work initiated, in response to recommendations.

July 2017

Additional inpatient bed capacity commissioned (investment os

£2.44million BSMHFT and £2.56million FTB).

l Nov 2017

Additional 32 bed capacity is mobilised via BSMHFT, for adults
aged 18+.

Dec 2017

| Changes to the Code of Practice to reduce detention under Section
136 of the Mental Health Act from 72 to 24 hours.

Jan 2018

1 £312,000 per annum recurrent investment in FTB to fund new
pathway for people with a diagnosis of personality disorder and
included funding for a clinical lead for personality disorder.

Feb 2018

CQC report published on FTB.

April 2018

Additional £700,000 invested in FTB community provision and
further £1.4million investment above contract value in 2018/19.

£60,000 invested recurrently in BSMHFT, to appoint a clinical lead
for personality disorder.

£110,000 non-recurrent investment across BSMHFT and FTB to
test a model of primary care liaison to reduce referrals into
secondary care.

June 2018

BSMHFT raise concerns about capacity verbally at Contract Review
Group meeting (CRG). No further action taken by BSMHFT.

Sept 2018

CCG identify funds to increase staffing ratio in ‘step up — step down’
provision with Servol (voluntary care service) to accept a wider
range of patients.

10

Sept 2018 | Report to Programme Delivery Board detailing limited progress in
relation to some key recommendations of system simulation report.

Sept 2018 | FTB issue Activity Query Notice (AQN). CCG meet with FTB to
discuss AQN.

Oct 2018 BSMHFT submit request for additional investment of £325,000 in

Solihull Early Intervention Service per annum, via CRG meeting on
26 October 2018.

Annex 2

Increase in funding for BSMHFT

BSMHFT

£000's | increase

Baseline 2017-18 (inc CQUIN)

124,885 :

Inpatient Capacity

2,119 | 1.7%
2,492 | 2.0%

om Investments

Total Investment 2017-18
Le

129,496 | 3.7% |

Baseline 2018-19 (inc CQUIN)

128,654

Inpatient Capacity

Other Investments

Increase in funding for FTB

Inpatient Capacity

Total Investment 2018-19

Baseline 2017-18 (inc CQUIN)

131,771 | 2.4%

£000's

Increase

Other Investments

Total Investment 2017-18

FTB

£000's | Increase
L |

Other Investments

Baseline 2018-19 (inc CQUIN)

Inpatient Capacity

30,889

Total Investment 2017-18

12

Mrs Louise Hunt

NHS 0)

YEA
7

England = a

Sam
aan

Professor Stephen Powis
National Medical Director
Skipton House

80 London Road

Senior Coroner SE1 6LH
Coroner's Court

Newton Street

Birmingham

B4 6NE. 7" December 2018

Dear Mrs Hunt,

Re: Regulation 28 Reports to Prevent Future Deaths — 7 cases and funding
concerns

Thank you for your Regulation 28 Report dated October 4" 2018 concerning 7 linked
deaths identified by Birmingham and Solihull coroners with commensurate concerns
about demands on NHS providers of mental health services and chronic underfunding of
mental health services. | also thank you for forwarding letters from the Medical Directors
of the 2 trusts providing services which support your concerns.

Thank you for forwarding the 7 regulation 28 reports.

Firstly, | would like to express my deep condolences to the family of each of these 7
individuals. | would also like to add that NHS England regards the concerns raised as a
matter of great import and has carefully considered the response below.

The regulation 28 reports conclude a series of concerns which | will summarise as
follows:-

High quality care for all, now and for future generations

|

|

Following the inquest you raised concerns in your Regulation 28 Report to NHS England
regarding the above issues.

On November 12" 2018, NHS England received correspondence from the Birmingham
and Solihull Clinical Commissioning Group (CCG) following a review of the Regulation
28 letters and Provider responses. The CCG noted that FTB had communicated a view
that demand and funding were significant underlying issues. The view of BSHMFT also
highlighted demand related issues but did not overtly articulate funding as an issue.

The CCG commissions mental health services at Tier 1, 2 , 3 and 4 for adults and for
Children and Young people (0-25 years of age), tiers 1,2 and 3 (with Tier 4 being
commissioned by Specialised commissioners at NHS England). These services are
commissioned from ETB and BSMHFT. NHS England directly commissions specialised
tier four inpatient mental health services for children and young people, specialised
mental health services (e.g. eating disorders and services for the deaf), adult medium

High quality care for all, now and for future generations

and high secure services, perinatal mental health, services for prisoners and services for
the military and military veterans.

The CCG:

1.

Undertakes a monthly contract review of its providers. Since February 2018,
following an ‘inadequate’ rating by the Care Quality Commission of FTB, the
CCG has led the development of a Quality Improvement Board to oversee and
provide assurance on a CQC improvement Action Plan and a System
Improvement Plan.

ls confident in its quality assurance processes.

Participates in strategic planning as part of the Sustainability and transformation
partnership which has at its core an ambition to provide comprehensive and
timely services, including a zero suicide ambition.

Proactively manages demand with a series of initiatives to reduce unnecessary
admissions and avoid delayed transfers of care, such that capacity can be
optimally managed.

Funding: In 2017/18 provided additional investment in mental health services
above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase)
and £6,235,000 for FTB (22.6% increase).In 2018/19 the CCG provided
additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and
FTB amounting to £2,881,000 (9.3% increase). Further funding discussions are
ongoing but at present the CCG is unable to validate a link between funding and
the deaths presented. However, the CCG continuously monitors this position and
demand in order to ensure it is responsive to any increase in demand where
funding would be either the sole, or contributory solution.

Undertakes mortality and incident review seriously and in line with national policy.
The coroners’ letters have prompted a comprehensive review of mortality and
incident governance which will result in improved care quality and learning from
incidents.

On November 14" 2018, all stakeholders involved in the commissioning, provision and
regulatory oversight of mental health services in Birmingham and Solihull were
convened at a ‘deep dive’ meeting. The summary of outcomes from this meeting are as
follows:-

1.

Oversight of strategic and operational issues: the CCG will lead the
establishment of an oversight group which involved all stakeholders . The
oversight group will work on the delivery of actions from this meeting and will
meet on a monthly basis.

Information sharing: it is clear that commissioners and providers are not always
sharing or reviewing the same data and intelligence. The CCG has established a
governance framework which will enable more proactive management of quality
and in particular, learning from significant events and mortality. This will enable
issues to escalate to the wider system more expeditiously. A review of trends
showed that there is not an observed increase in suicides compared with national
figures which is reassuring, but all stakeholders agreed in the need to support a
zero suicide ambition across health and social care although many individuals do
not come into contact with mental health services prior to death.

Strategic planning: It is clear that funding is not the sole issue responsible for the
failures highlighted in the cases reviewed although funding for an extra 32 mental
health beds has been made available by the CCG. There are several areas of

High quality care for all, now and for future generations

strategic planning which require attention. Data sharing and more effective
communication across commissioners and providers, and between providers is
one area of concern. Secondly, there is a significant workforce challenge here
and now, not unique to Birmingham and Solihull, which needs articulating and
planning for. Thirdly, whilst there is debate about whether there is sufficient
capacity in the system, it is indisputable that pressure exists at times which
results in acutely ill patients not having access to acute mental health beds.
Funding alone is not the issue but there is agreement that in order to answer the
question of the likely attribution of funding constraint on risk within services, all
stakeholders need to be party to a shared demand analysis (with an extended
invitation to partners from health and Justice, local authorities and schools) and a
‘Suicide prevention strategy.’ The Demand analysis will be led by the CCG and
the Suicide prevention strategy will be led by the Director of Public Health.

4. Transformation: whilst we determine what is required to make services ‘safe’ in

line with a shared definition of what ‘safe’ means, it was clear that the system has
further ambition to excel. Work will be undertaken in the following areas

a. Primary mental healthcare services (i.e. services delivered in primary care
under the auspices of a General Practitioner): it is clear there is limited
access to mental health services in primary care and this will require
assessment.

b. Secondary mental healthcare (i.e. that delivered in hospitals or
specialised centres): planning for future demand and capacity.

c. Specialist mental health service support in acute physical illness: we
agree that this needs to improve in order to support patients who end up
in our Emergency Departments or downstream acute inpatient hospital
beds.

d. Commissioning: collaboration between specialised and CCG
commissioned services needs to improve in order to enable patients to
see a seamless pathway of care. There is now a commitment from the
CCG and Specialised commissioning team to collaborate in services each
commissions. This will commence with meetings scheduled in December
2018.

e, Upstream interventions (i.e. prevention of risk factors which predispose to
mental ill-health); The West Midlands Combined Authority has ambition to
address social determinants of health and has a mental health strategy
which needs to fully resonate with the NHS.

5. Delivery of mental health services: the cases reviewed demonstrate that at times,

services are neither integrated nor responsive and it was accepted that this
needs to improve with work in the following areas:-

a. Pathways of care, in particular for crisis care, early intervention in
psychosis (EIP) and for children and young people, need to be clearly
defined so that services are available, accessible and acquired. Where
patients do not acquire services i.e. a failure to attend appointments, NHS
providers will make more robust plans to ensure contact is made. A
review of EIP services in Birmingham and Solihull by the national clinical
lead in the past month has determined that services are safe at present.

b. Risk assessment: this needs to be available and of high quality 24 hours
a day, 7 days a week. We will ensure services are commissioned and
provided to ensure this occurs in order to provide safe and effective care.
Provider and the CCG will identify any cases where risk assessment has
not been provided in a timely manner for patients and also investigate
where the outcome of that risk assessment is inadequate. This will be
undertaken by the CCG and providers at established monthly quality
review meetings.

High quality care for all, now and for future generations

c. Access to prevention services: there is a difference in opinion between
the NHS and local authorities in what is deemed adequate provision of
services for alcohol, drug and substance misuse and homelessness. The
CCG will be meeting the local authority to address this.

6. External support to the system: stakeholders welcomed the support of the
national Intensive Support team (IST) for mental health, mental health clinical
networks and the West Midlands Clinical Senate. These offers of support have
already been made. The Clinical network is currently providing support to review
and plan services and the IST will be asked to provide support in December
2018.

| am therefore satisfied that all stakeholders in the provision and oversight of mental
health services have taken the concerns you articulate seriously.

Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.

Yours sincerely,

a

Professor Stephen Powis
National Medical Director
NHS England

High quality care for all, now and for future generations