Dear Mr. Farrow

Re: Regulation 28 Report to Prevent Future Deaths – Rebecca Jayne Flint 07/09/20

Thank you for your Regulation 28 Report dated 17/07/22 concerning the sad death of Rebecca Jayne Flint on 07/09/20. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Ms. Flints family for their loss.

Thank you for highlighting your concerns during Ms. Flints Inquest which concluded on 17 March 2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.

The inquest concluded that Rebecca’s death was a result of suicide by asphyxiation. Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken.

In order to address the concerns raised the GM Mental Health System Quality and Safety Group commissioned a whole system peer panel review of the Regulation 28 chaired by the Executive Medical Lead for Mental Health (NHS GM). I hope the response below demonstrates to you and Ms Flints family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case including working collaboratively with our service users and carers to improve the quality of our care.

(1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role.

Greater Manchester system-wide work; the national and GM context

In February 2021, the Department of Health and Social Care published the White Paper ‘Integration and innovation: working together to improve health and social care for all’, which sets out legislative proposals for a Health and Care Bill. Whilst there are numerous proposals within the Bill one of the main changes was to the commissioning landscape where Integrated Care Boards (ICB) became statutory organisations and replaced Clinical Commissioning Group’s (CCG’s) taking over much of the constitutional roles from 1st July 2022. Previously, Greater Manchester (GM) CCGs commissioned a

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk wide spectrum of health and care services (including mental health) with numerous providers. As a result, there were a significant number of contracts held with different providers – at different investment values, different service specifications and outcomes. This applied to the specialist mental health services (including care coordination) from Greater Manchester Mental Health NHS FT (GMMH) and Pennine Care NHS FT (PCFT) as the two NHS Mental Health Trusts delivering services across Greater Manchester - who at the same time have been in receipt of funding at below the national average values. From 1st July 2022, most of these contracts have been novated to the new statutory GM ICB. While this exercise is not initially intended to align or standardise current service models, pathways, or pricing; this consolidation exercise will support and inform opportunities to do so as we move to the new ICB arrangements after the initial 2022/23 transition year. Work is now underway to review and refresh these contracts to reduce any unwarranted variation in terms of best practice, value for money and required performance standards (including care coordination arrangements across Community Mental Health Teams). This work is further strengthened by work across GM in line with the NHS Long Term Plan Community Mental Health Transformation Framework programme (NHS England » The community mental health framework for adults and older adults) that requires community mental health services to be modernised to offer whole-person, whole-population health approaches, aligned with the new Primary Care Networks and replacing the Care Programme Approach (CPA).

The Community Mental Health Transformation Framework, first published in September 2019, sets out how the vision for a new place-based community mental health model can be realised, and how we can modernise community mental health services to shift to whole person, whole population health approaches. In particular, to drive a renewed focus on people living in their communities with a range of long-term severe mental illnesses, and a new focus on people whose needs are deemed too severe for Improving Access to Psychological Therapies (IAPT) services but not severe enough to meet secondary care “thresholds”, including, for example, eating disorders and complex mental health difficulties associated with a diagnosis of “personality disorder”. In addition, the Framework ensures that the provision of NICE-recommended psychological therapies is seen as critical in ensuring that adults and older adults with severe mental illnesses can access evidence-based care in a timely manner within this new community-based mental health offer, to give them the best chance to get better and to stay well.

One of the key objectives of the GM Community MH Transformation Framework is to develop “new and integrated models of primary and community mental health care which will support adults and older adults with severe mental illnesses.” GM is continuing to make progress on this objective to improve community mental health services to meet the needs of our service users and their carers/family.

Across GM, we are continuing to implement a place-based approach to mental health care with all ten GM localities implementing the Living Well model. Living Well will increase access to care and support for people with serious mental illness and high levels of complexity who are seeking help and advice with their mental health. Access will be at a neighbourhood level within primary care networks with close connections to a local network of community groups and voluntary organisations. People will be able to access redesigned community mental health services and multidisciplinary teams including: mental health practitioners, social care staff, voluntary sector staff and peer workers.

There is not a standard national job description for care coordinators who work within community mental health teams. The core elements of Care Coordinator job descriptions will generally align to the roles and responsibilities defined within the CPA. Under this framework Care Coordinators are required to:

• work with other health professionals to assess an individual’s needs,
• write a care plan which shows how the NHS and other services will meet the individual’s needs, and,

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
• regularly review the care plan with the individual to check progress.

Care coordinators can be from different professional backgrounds (e.g. nursing, social work, occupational therapy) and therefore may have different elements to their job descriptions in line with their professional skills and expertise in addition to the core requirements of the role under CPA. There will also be appropriate local variation within job descriptions dependent upon the configuration of the service and what the services are contracted to provide.

GM Community Adult Mental Health Priority Programme Area Work

In line with the Long Term Plan and the Community Mental Health Framework for Adults and Older Adults, the CPA framework is being replaced nationally. As a result, the role of care coordinators will be replaced by the development of key workers with a clearer multidisciplinary team (MDT) approach to both assess and meet the needs of service users, to reduce the reliance on care co-ordinators and to increase resilience in systems of care, allowing all staff to make the best use of their skills and qualifications, and drawing on new roles including lived experience roles.

GM will start to embed the changes needed to better support people with serious mental illness and their family and carers by linking in with the external partners in primary care, the voluntary sector, and social services. Regular reviews of progress will help shape the implementation.

This combination of work in consolidating multiple contracts (and therefore different service expectations for care coordination) and the implementation of significant investment together with service model changes in community mental health team practice across Greater Manchester through work aligned with the NHS LTP Community MH Transformation Framework (including that for care coordination and CPA) will allow us to reduce unwarranted variation and provide greater standardisation of care.

(2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role.

Mental Health Provider Trusts

All CMHTs in the GMMH footprint have systems and processes in place to ensure that the service is able to maintain oversight of all individuals under the care of the team in the absence of a care coordinator during periods of leave or sickness.

These systems and processes ensure that teams maintain the minimum expected frequency of contact with individuals and respond to any escalations in their levels of need or risk. This includes the utilisation of a range of approaches as follows:
• Regular team manger review of allocated caseloads
• Multi-disciplinary team zoning to ensure the team can prioritise interventions for individuals with the highest level of risk
• Temporary reallocation to other care coordinators or members of the team during periods of prolonged absence
• Provision of a duty worker function during the team’s regular hours of operation to be able to provide both planned and crisis responses for individuals who are supported by the team when their care coordinator is unavailable.
• Handover process for planned holidays

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk The Trust is committed to developing the new key worker role and welcomes conversations with the ICS in respect of standards for CMHT’s across the Trust footprint with some possible local variations.

PCFT confirmed that when any of the trust’s clinicians are on a period of planned leave, patients are usually kept updated and advised of how to contact the service if needed, usually via a duty worker.

A patient in receipt of care coordinator services would have, as a matter of course a care plan with details on how to access the Team’s duty system and the local authority emergency duty system / service. It would also fall to the team manager to ensure that the Duty offer maintains a regular contact with the patient through phone calls or visits as required, this should also include carer contact information.

If a patient is on the waiting list for allocation then they and their nominated carer will have an interim care plan in the form of a letter with contact details of the team and usually a list of ‘waiting-well’ services that can be accessed in crisis situations.

If any clinicians are on a period of unplanned leave due to sickness or personal reasons, patients will already have details of the duty system which can provide any support or signposting as needed. For longer periods of absence, the team manager will have oversight of their caseloads and will reallocate to another colleague in the team on a risk assessed basis. This may mean that some patients are reallocated immediately, but others may need to wait. Under these circumstances there would be regular communication from the team and check ins to ensure their risks are not increasing.

GM System Work

The work being undertaken to consolidate multiple contracts under one single GM mental health programme with significant investment and community mental health service model review in line with the NHS LTP Community MH Transformation Framework, will allow us to reduce unwarranted variation and provide greater standardisation of care. The adult community mental health framework review will also specifically address care coordination role and CPA to strengthen the standardised approach. The single mental health programme and investment in this priority programme area will improve resourcing available to support the delivery of good quality care including periods of unplanned leave and sickness.

Actions taken or being taken including sharing learning across Greater Manchester:

1. Key Learning Points communication to be presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.

2. Key Learning Points communication to be presented/shared with the Greater Manchester Mental Health System Quality Group.

3. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.

4. In addition to providers learning through their joint lessons learned meetings, the newly developed NHS Greater Manchester Mental Health System Quality Group (NHS GM MH SQG), which reports to the GM System Quality Group, will also prepare a key learning points communication for whole system learning and share with the system by November 2022. The

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk NHS GM MH SQG will now provide the governance route for GM system quality and safety including the monitoring of system level actions following patient safety incidents. Following the Adult Community Mental Health Framework review, and in line with national changes, GM will then consider the development of a GM standardised set of principles for the role of adult community mental health teams.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.

I hope this response demonstrates to you and Ms. Flints family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided.

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.

Dear Mr Farrow,

Thank you for your letter of 17 July 2022 about the death of Rebecca Jayne Flint. I am replying as Minister with responsibility for Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Flint’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

In preparing this response, departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC).

Your report raises concerns about the Care Coordinator role within community mental health services, how this role may differ across trusts, the level of responsibility placed on Care Coordinators to ensure effective multi-disciplinary working, and the resourcing of the Care Coordinator role. The government is not able to comment on specific role requirements, or staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services.

You may wish to know that the mental health workforce increased by 5,900 full-time equivalent staff in December 2021 compared to December 2020, and by more than 11,800 compared to December 2010. However, we know there is more to do to ensure we have sufficient numbers of healthcare staff to deliver our aims for high quality, accessible mental health services. We therefore aim to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023/24 (compared to 2019/20).

Through the NHS Long Term Plan, we are investing an additional £2.3 billion a year to expand and transform mental health services in England by 2023/24. As part of this, we are investing almost £1 billion extra in community mental health care for adults with severe mental illness. This includes new integrated community models for adults with severe mental illness. These new models are still in the early stages, and will take time to embed nationally, but will give at least 370,000 adults greater choice and control over their care and are supported to live well in their communities by 2023/24.

As part of the transformation of community mental health services, in July 2021, NHS England published the Care Programme Approach (CPA) Position Statement which sets out a new

approach to delivering safe and high-quality care, including improving care co-ordination. The new approach looks to maintain the principles of CPA and ensure they are applied to all people in receipt of community mental health, not just those under the CPA.

In addition, local systems are in the process of reviewing their CPA processes and moving towards a universal standard of care which is increasingly personalised, flexible and supported by a stronger multi-disciplinary approach. This includes having a named key worker who would be working closely with other members of a multi-disciplinary team and sharing responsibility for an individual’s care and support.

More widely, work is also ongoing to expand and improve mental health crisis care provision. This includes improving the operation of all-age 24/7 crisis lines, crisis resolution home treatment teams and mental health liaison services in A&E departments.

We are also investing an additional £150 million to expand facilities for people experiencing mental health crises such as crisis houses, as well as introducing dedicated mental health ambulances.

Finally, I have been assured that the CQC continues to have ongoing engagement and contact with the Trust. In particular, I have been informed that CQC are aware of the concerns and pressures within Community Mental Health Teams and have undertaken a recent focused inspection of some of Greater Manchester Mental Health NHS Foundation Trust’s Community Mental Health Teams that were rated as inadequate. Following the inspection, CQC took regulatory action, including to issue a warning notice under Section 29A of the Health and Social Care Act. Further information can be found in their report. I am assured that the CQC continue to closely monitor how the Trust are managing any ongoing risks and pressures within these teams.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Kind regards,

MARIA CAULFIELD