From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London POC1 851047 SWIA 2NS Tel: 020 7210 3000 Mrs L Hashmi 02 Mb-sofs@dhgsigov.uk Assistant Coroner HM Coroner' s Court The Phoenix Centre Church Street Heywood OLIO ILR 1 2 Mav 2094 1 Ilabn = Thank you for your letter following the inquest into the death of David Chatburn: I was sorry to read of the events that led to Mr Chatburn'$ death and wish to extend my sincere sympathies to his family. Iunderstand that Mr Chatburn had a history of mental health problems, including depression and drinking alcohol to excess and had probably been suffering from bi-polar disorder for some time. It was not until December 2012 that he agreed to consider medical treatment for this condition and his General Practitioner then prescribed the Lamotrigine which he believed was favoured by the local community psychiatrists. Mr Chatburn was not seen or assessed by a Consultant Psychiatrist and his GP continued solely to treat and manage his therapy, although it appeared that follow- up appointments were generally informal and opportunistic rather than pro-active: Mr Chatburn's mental health continued to fluctuate and, on l8th October 2013,a dog-walker discovered him hanged from a tree: You raise the following concerns: there was no referral made by the GP to the Psychiatric services for an expert diagnosislopinion/management and treatment plan. The GP considered that there was no need, as he felt clinically competent to manage the deceased'$ care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised aS a GP with a Special Interest ( GPwSpi and whilst confident in his ability to manage the deceased '$ care, his area of special interest was in fact the management of addictions. Irrespective, he felt that he was best placed to assess, diagnose and treat 2014 MAY long drug

the deceased on the basis that had he referred Mr Chatburn to the single point Of entry system, the person 'triaging would not have been medically qualified and would not have known the deceased as well as he he did. the GP did not consider the appropriateness of the medication prescribed, particularly in light of the patient'$ past health history - preferring to rely upon the presumed, anecdotal preferences of the community psychiatrists: the GP was unable to refer the deceased, aS a new patient, directly to the in-house community based psychiatrist, thus effectively defeating the object. the GP it was sufficient for him to simply discuss the deceased '$ care with the practice-based community psychiatrist and thus; no need for a referral to the single point of entry process. Such discussions were not necessarily case specific in any event but rather, general in nature. the GP'$ recollection of events was not supported by contemporaneous record keeping, thus calling into question accuracy: the GP did not use & recognised assessment tool, aS an adjunct or otherwise, in his clinical evaluation of the deceased. He felt that were ineffective and of little, if any, value. the processes GPs are expected to use in order to access mental health services for their patients are unnecessarily bureaucratic and deterrent GPs can no simply contact a Consultant Psychiatrist directly for advice. Everything must pass through the single point of entry: the 'triage ' process used by the single point of entry system is not always managed by a medically qualified practitioner this a vital stage in determining diversionlallocation. GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same. In order to do so, a 'special case must be argued. This potentially limits patient (and practitioner) accessibility and treatment The Department of Health is supporting local organisations in taking effective action to improve mental health: The Department's mental health strategy and implementation framework, and suicide prevention strategy (Preventing Suicide in England), focus on specific actions which local organisations can take to improve felt _ mental felt _ they - longer being

Department of Health mental health across the life course in their areas In addition; "Closing the priorities for essential change in mental health" (launched in January 2014) sets out the Department' $ priorities for action and progress over the next couple of years Mental health and well-being is & priority for this Government and we are investing over f400m to give thousands of people, in all areas of the country, access to improved psychological therapies Public Health England is also making mental health one of its five health impact priorities as part of work to improve the public'$ health. Their priorities for 2013/14 include a commitment to develop a national programme on mental health in public health that supports, "No Health Without Mental Health"' (a croSS-government outcomes strategy): This means prioritising the promotion of mental wellbeing; the prevention of mental health problems and suicide, and improving the wellbeing of those living with and recovering from mental illness. Many of the issues you raise concern the decisions and actions taken by the GP who diagnosed and treated Mr Chatburn: Inote that you have sent your report to the Pennine Care NHS Trust and the York House Surgery and I would expect them to properly address these concerns _ officials have consulted NHS England, as the main commissioner of primary care services, about your report. NHS England has advised that the GP s clinical behaviour will be discussed at their next Performers Screening Group (PSG) The PSG will then determine if any fic actions need to be taken_ In addition, the General Medical Council (GMC); which is independent of government; is the body responsible for setting medical standards for doctors If there is concern about the GP s fitness to practise, this should be raised directly with the GMC. Your remaining concerns relate to the current system for accessing mental health services in primary care Iam aware that a number of other inquests in the past have similarly focussed on the issue of a lack of clearly defined pathways for referral by GPs into mental health environments. The way in which these services are accessed is decided locally by the relevant NHS Trust: Thus your concerns surrounding the single of triage system and the evident bureaucracy are also more appropriately dealt with by the Clinical Commissioning Group (CCG) and Pennine Care Foundation Trust (FT) Iam aware that the CCG is preparing its response in conjunction with bothl (Medical Director for the Greater Manchester Area Team) and Pennine Care Gap: My specif good point entry;

You raise a concern that GPs were unable to refer patients outside their Clinical Commissioning area without special permission/approval by the CCG and that this potentially limits patient (and practitioner) accessibility and treatment: 1 can advise that this is no longer the case. From April 2014 patients with a mental health condition have had the same legal rights as physical health patients at first outpatient appointment to choose the provider that will deliver their care. The GP, or other 'referring healthcare professional, remains responsible for determining the clinically appropriate treatment to meet patients' needs Where the service or treatment is routinely commissioned by the patient'$ CCG, patients may choose any clinically appropriate provider in England, as as the provider has a contract with any NHS commissioner in England for that service When the service is not routinely commissioned by the CCG, patients may apply to their CCG' s Independent Funding Review Panel for a preferred referral to be considered for approval. Patients should discuss their with their GP. However; a number of 'exemptions to the legal right to choice of provider, at first outpatient appointment, remain. These will be set out in guidance that NHS England is about to consult on, entitled Interim Guidance: Implementing patients' right to choose any clinically appropriate provider of mental health services This guidance will help commissioners, GPs and providers implement the new legal right to choice. [ hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Chatburn'$ death to my attention: JEREMY HUNT Group long options