Dear Mr Bainbridge

Re: Inquest Touching the Death of Robin Andrew James McEwan. Thank you for your Regulation 28 Report, dated 10 October 2018, requesting further information from NHS Harrogate and Rural District Clinical Commissioning Group (hereafter ‘the CCG’), and for granting an extension of time for providing the response until 25 January 2018. I was extremely sorry to learn of the death of Mr McEwan and my thoughts are with his family. I note the concerns raised with the CCG and have responded to each in turn below.
1. Mr McEwan had been using private counselling services for CBT. No reports from the service providing that service to the patient were supplied to the GP. If there had been statutory mental health care instead, one might expect some connection, particularly if medication was to be prescribed. One would expect sharing of information both ways in the interests of the patient and his ongoing treatment(s). What policies/procedures/advice/standing instructions/guidance etc. do you have for GPs, aware of such treatments, or referring the patient for them, to require and have a two way dialogue? Put another way, how do you currently address the way to remove any disconnect in communication as occurred in Mr McEwan’s case. If you have no such means, then what do you intend to do about that to prevent future deaths? The CCG will review the current process in Primary Care to ensure that when GPs refer an individual for private counselling, they request, with patient consent, a timely update on the patient’s progress to enable a proactive person-centred dialogue to occur regarding the best way to meet the patient’s needs through their episode of care. The CCG needs to ensure that a consistent approach is taken across North Yorkshire to address the issue that private counselling services do not routinely share information back into Primary Care. This is a safeguarding issue which affects a vulnerable group of patients which

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the CCG fully acknowledges and is committed to addressing as detailed within the attached action plan (appendix one; point 3). As a response to NHSE’s Guidance on Co-Locating Mental Health Therapists in Primary Care, August 2018, the CCG, on behalf of the North Yorkshire CCGs, is commissioning trained, first contact mental health workers based within GP Practices who will be Improving Access to Psychological Therapies (IAPT) compatible. It will be rolled out this year once training has been completed, and will help support a clinically consistent and responsive approach for initial access to mental health within primary care across North Yorkshire.
2. Have you a view about “Zero Suicide Alliance”? Are your Group subscribed, or subscribing, to its approach as others do, according to the evidence heard at the hearing? If not, why not? If not, then is/are there any other primary care approach (es) your Group refers to GPs as good practice? (other than those contained in NICE Guidelines). ‘Zero Suicide Alliance’ is currently being considered by the North Yorkshire Suicide Strategic Partnership Group, of which the CCG is a member. The ethos of the approach promoted by ‘Zero Suicide Alliance’ is captured within the North Yorkshire Multi-Agency Suicide Prevention Plan. The plan is being adopted by our local Sustainability and Transformation Partnership Boards (STPs), and Tees Esk and Wear Valley NHS Foundation Trust (TEWV) from whom the CCG commissions Secondary Care. The CCG, Public Health England and TEWV work in partnership through the Suicide Prevention Task Group and can access small funding streams to support initiatives to help to prevent suicide. The available STP funding focuses on the development of a range of targeted support to: address the reduction of stigma and discrimination, develop mentally healthy communities and workplaces, reduce loneliness, social and emotional isolation and reduce suicide. Through strengthening our partnership working and collaboration, and developing the GP Suicide Prevention Lead role for North Yorkshire, we can map all sources of funding identified, which can be used to support developing stronger support within Primary Care. Through the Mental Health & Learning Disability Strategic Partnership Board and our development of a GP Best Practice Lead for North Yorkshire on Suicide Prevention, the CCG will encourage providers to have the training offered through the North Yorkshire Suicide Strategic Partnership Group. The CCG fully supports the Secretary of State’s position that "Every suicide is a preventable death and there’s so much more we can do to reduce the number of people lost to it. The Zero Suicide Alliance’s new training and awareness tools will help health and care staff recognise the signs and step in before it’s too late, as well as ensuring openness and transparency when suicides do occur"
3. What diagnosis and self-help tools are commended to GPs for the care of patients with mental health problems in primary care? (other than NICE Guidelines). If none are commended and GPs are left to select for themselves, which are stated to be ones that should be avoided, and why? What policies/procedures/advice/standing instructions/guidance etc. do you have in selecting self-help tools, if any? What financial support is offered when such tools are not free of charge to the patient? How can a GP help prevent future deaths in this way? Primary Care use a range of tools to care for and support patients with mental health problems which are recommended by the CCG. The PHQ9 (Patient Health Questionnaire) and GAD 7 (Generalised Anxiety Disorder) questionnaire offers clinicians self-administrating screening and diagnostic tools for a range of

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mental health disorders; both are routinely used in Primary Care and as part of the referral process for the North Yorkshire IAPT Service by GPs. Silver Cloud is a free resource for patients to use through its site once they have been accepted into the IAPT Service. IAPT has an open referral process whereby an individual can contact the service directly, either through the TEWV website, linked via the CCG webpage, or contacting the Service by phone. A person does not require the need to be referred by their GP. If a patient is assessed by a GP as experiencing a severe and debilitating mental health condition then the patient would be referred to Secondary Care. The CCG, as part of the Mental Health and Learning Disability Strategic Partnership, will be considering how the CCG’s website can be further developed to include a portal to promote initiatives such as the Living Well in North Yorkshire scheme run by North Yorkshire County Council aimed at tackling social isolation. The CCG, as detailed in the attached action plan (appendix one; point 5) will review its website to include shared best practice and innovation, developed both locally and elsewhere, to include initiatives such as Time to Talk and Community Living Well for both patients and GPs.
4. What policies/procedures/advice/standing instructions/guidance etc. do you have (other than NICE Guidelines) for GPs (assuming a patient consents) to bring in support of family (as NICE Guidelines set out) for mental health support/care “scaffolding”? How could that be arranged? Would the Group accept that while a patient may have to wait a long time for statutory services (unless in obvious crisis), questioning about and planning for the security and safety of the patient must be a priority in the interim. What other safety planning steps might be commended? In the contexts of preventing future deaths and the increasing concern for managing the mental health of the Group’s population, what training would you expect your GPs to have re mental health in Primary Care? What CPD courses can you identify, for example, upcoming that are relevant which might be available to your GPs? The GPs in North Yorkshire, with the consent of the patient, liaise directly with carers, families, and mental health services at an initial stage. In January 2019, North Yorkshire Public Health England launched a self-harm e-pathway for Children and Young People living in North Yorkshire, aimed at professionals who support them. The plan is to develop a similar pathway for adults, following the evaluation of this initiative. Some GP practices have specific service information available within their practices and/or on their website for staff, patients, family members and carers, detailing specialist support, but this is a variable picture across North Yorkshire. The development of a web based resource for everyone to access consistently has been identified by Primary Care as a need. The North Yorkshire Mental Health Helpline is a countywide out of hour’s service offering mental health support and advice to people who may be concerned about their health or someone they care for. This service is jointly funded by Health and Social Care and is provided through Nottingham Community Housing Association who have specially trained staff. Public Health England has approached the CCG to help promote the awareness of MIRT (Major Incident Response Team) in North Yorkshire for GPs. MIRT is a confidential support service for people who are caught up in a distressing sudden event ‘outside’ normal life, and who provide support to families bereaved by suicide. Supporters are trained in Mental Health and Psychological First Aid, Safe Talk and Assist Skills. A jointly funded website with NHSE, Staying Safe, developed by 4 Mental Health, is another potentially life-saving resource that our communities have access to, including input from survivors of suicidal thought, bereaved families and friends. It provides information, guidance tools and a vital ‘safety plan’. All information is in an assessable format. There are a variety of training packages available such as We Need to Talk About Suicide, developed by Public Health and Health Education England. These support all public sector professionals to feel more

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confident talking about self-harm to someone. GP Continued Professional Development is voluntary, and unlike safeguarding, there is no mandated mental health training despite the latter often overlapping with the same vulnerable patient groups. The CCG accepts there is further work that needs to be done to share best practice regarding suicide prevention and to promote the training available for GPs within Primary Care. In addition, the CCG will look at providing additional training opportunities to GPs through their Protected Learning Time sessions and review how current safeguarding training could potentially incorporate suicide awareness. Actions for the CCG to take forward:
1. To develop stronger links between the CCG GP Lead for the Prevention of Suicide and North Yorkshire Public Health.
2. To review awareness of, and access to, GP training in suicide prevention across North Yorkshire.
3. To review the referral process in Primary Care when referring patients to private counselling services with the aim of ensuring GPs are informed regarding progress of patients who have engaged in counselling services so that they can offer appropriate support if needed.
4. To look at the development of Mental Health & Psychological First Aid within Primary Care and the CCGs.
5. To review and further develop the CCG website to promote mental health and suicide prevention for both the public and professionals. This will include ensuring the availability of self-help tools and support tools for carers/relatives/friends of patients suffering from mental health issues.
6. Finally, the CCG would like to offer the family of Mr McEwan, with their permission, the opportunity to undertake a Serious Incident Review into the specific concerns that his death has raised, to enable us to learn any lessons from his tragic death to prevent future suicides from occurring. A full action plan is attached as an appendix giving each action a timescale for completion within six months. This work will start with immediate effect and will be reported through the CCG’s Quality and Governance Committee as part of our governance and assurance framework. The CCG is committed to ensuring that the services commissioned for adults with mental health illnesses are both responsive and of high quality. The CCG is keen to reflect on the services commissioned with a view to making improvements and avoiding future patient harm. Thank you for raising these concerns with the CCG. I hope you feel that the information provided, together with the actions outlined above, fully addresses the concerns raised.