On March 29th, Gloucestershire LINk members were given a presentation on some new developments, codenamed “Fair Horizons”, in Gloucestershire’s NHS mental health trust, 2gether. About twenty people attended.
The name Fair Horizons is derived from the title of an obsolete government white paper, New Horizons: A shared vision for mental health, published in December 2009, which was superseded (after the general election) in February 2011 by No health without mental health: A cross-government mental health outcomes strategy for people of all ages.
The two government papers have some similarities and some differences. They both indicate the intention that government will adopt a more integrated approach to mental health, but there is a difference in emphasis. For example, in the obsolete paper the guiding values were:
- equality and justice
- reaching our full potential
- being in control of our lives
- valuing relationships
In the current paper the guiding values are similar but in a different order:
- Freedom – reaching our potential; personalisation and control
- Fairness – equality, justice and human rights
- Responsibility – everyone playing their part and valuing relationships
The biggest difference is that while the focus of the obsolete paper is on what it calls “cross-government action” — improved cooperation between government departments — the focus of the current paper is on outcomes for people. For example, the old paper has no specific objectives, while the current paper has six specific objectives for mental health, and it includes some consideration of how they can be measured:
- More people will have good mental health
- More people with mental health problems will recover
- More people with mental health problems will have good physical health
- More people will have a positive experience of care and support
- Fewer people will suffer avoidable harm
- Fewer people will experience stigma and discrimination
The presentation was given by the Trust’s Clinical Director for Social Inclusion and another staff member who is its clinical lead for Fair Horizons. They referred to the two government papers in reverse order, making it seem that the obsolete one is current and vice versa.
They described Fair Horizons as:
a new clinical model
However, the details that followed didn’t back up this claim. The changes that are specific to the Fair Horizons project seemed to be changes in management structure rather than changes in clinical practice.
In the NHS a lot of things are changing all the time, and the presentation made it difficult to pick out which changes are specific to Fair Horizons and which aren’t. For example, a lot of time was spent on the misleadingly named “payment by results” (PbR) system, which (as far as I can tell) is a financial accounting system that doesn’t directly affect the way patients are treated. PbR is a national system that will affect other mental health trusts equally, so it seemed to me confusing to bring it under the Fair Horizons heading.
A lot of time was spent, too, describing the new central point of contact — a single telephone number to replace the 67 different contact numbers currently in use. But when someone in the audience asked what the telephone number is, and someone else asked whether carers can use it, the presenters couldn’t say. It hasn’t been implemented yet. So this, too, is really a separate project. Again, it seemed to me confusing to lump it in with actual changes that are happening right now.
The core of Fair Horizons is that there will be integrated multi-discliplinary clinical teams operating across former divisions of age and intellectual ability. So, where there used to be separate clinical teams specializing in people with learning difficulties, adults with mental illnesses, and older people, there will now be “one-stop teams” combining work with all three.
Even the term “one-stop team” was confusing, though. Surely few patients previously had to have their learning difficulty, mental illness, and old age treated separately when now they can all be treated together. The example given, of a man of 66 who received treatment as a working-age adult, did not seem to be an argument for “one-stop teams” at all, but only for flexible interpretation of the boundaries between clinical specialisms.
The presentation included a huge amount of detail, far too much to take in all at once. It was clear, though, that Fair Horizons has really quite limited aims. While it brings together clinicians in the three categories mentioned above, the “Let’s Talk” service (IAPT), and services for children and young people (CYPS) remain separate from the one-stop teams, as do early intervention in psychosis (EIP) and day services. Indeed a private provider for day services was mentioned in passing. The amount of integration is less than meets the eye.
Reactions from the audience tended not to focus on the partial integration of services that’s at the heart of Fair Horizons. This might have been because the presentation ranged too widely and included too much detail of organizational structure, often without explaining how it would relate to patient experience.
There was a request for copies of the presentation slides because of the amount of detailed information in them, and for copies of a published paper on Fair Horizons by some staff of the Trust. The presenters agreed, but as I write this nearly two weeks later I have not seen them.
Someone asked who “clinicians” are. (They are the staff of the Trust who work with patients to provide care.) The presentation would have been better if it had started with this level of information and kept things very simple.
About a third of the audience didn’t realize they could already self-refer to Let’s Talk without seeing their GP first.
There was some confusion over whether the Trust’s crisis team really were a 24-hour crisis response service. The presenters thought they were, but some audience members’ experiences suggested otherwise. (At a conference, Averting Crisis, last September in the very same building as this event, staff of the crisis team had themselves said otherwise, admitting that their “emergency” number is not always manned and that they had been thinking about dropping the word “crisis” from the name of their team.)
Someone remarked that it felt as if community engagement was being bolted on at the end of the project, and the presenter agreed that they hadn’t presented to the LINk before now, although they had engaged with the community in other ways.
The presenters referred a couple of times to:
Designing services with our community
But on one of those occasions it was only to admit:
That’s the kind of thing we need a bit of help with.
All these seemed to me to be examples of how the Trust’s engagement with the public is not really very effective. This audience consisted of LINk members who presumably have more interest in these matters than the general public, yet some audience members didn’t arrive with basic understanding of how the Trust works, and they probably didn’t leave with it either.
There were also some audience members who were critical of the Trust’s Let’s Talk service. For example, there was some derision for the “computerized CBT” it offers, and someone complained of “going around in circles” for years because Let’s Talk’s connections with the Trust’s other services are inadequate.
Current government thinking on healthcare strategy is to focus on measurable health outcomes for service users, but the event gave the unfortunate impression that Trust’s thinking hasn’t caught up with this yet, that its focus is still on getting parts of the organization to work more closely together, and that this still has some way to go. Outcomes and measurement were not addressed at all.