Issue one - concerns about delays in Ms U being seen by the Trust’s wellbeing service
24. Ms U complains there was a delay in having her first assessment and in her first EDMR treatment.
Initial assessment appointment
25. We will firstly consider any delays in Ms U having her first assessment appointment after the referral.
26. Ms U disputes the Trust’s position that she was referred in April 2018 and says it was actually January 2018. Ms U tells us after this there was a delay of four months as she had her assessment on 9 April 2018.
27. The Trust’s final complaint response dated 25 October 2019 states Ms U self-referred into the service via her General Practitioner (GP) on 5 April 2018. It also states her first assessment was offered to her on 9 April 2018 at 10.15am.
28. The Trust says when Ms U was called on 9 April 2018 she was on a bus and therefore could not speak. For this reason, the assessment was not completed. The Trust says Ms U completed an assessment on 26 April. Therefore, according to the Trust Ms U was seen within the expected timeframe for the service.
29. We have taken into account Ms U’s version of events, that she was referred in January 2018. We have balanced this alongside the available evidence. Ms U’s medical records shows evidence of a ‘patient boarding card’. This card includes details of the referral. We can see the referral source is noted as ‘self-referral-GP’ and the ‘date received’ is recorded as ‘05/04/2018’.
30. From the records we have seen, Ms U’s contact with the service before this was in October 2017. We have seen no evidence to suggest that the Trust received a referral before April 2018. Based on this, we find that the evidence suggests Ms U was referred in April 2018.
31. The records show after the referral was received by the Trust on 5 April 2018, it booked an assessment appointment for Ms U on 9 April 2018 at 10.15am. The records document the call summary as:
‘Called client at the agreed time- we went through checking details, but I couldn’t hear her very well. She said she was on the bus and didn’t want to speak loud. I asked whether there was a chance to go in a quiet and confidential place, she said it was a long journey. I explained we will not be able to do the assessment while she was on the bus, as we were going to be discussing sensitive information’.
32. We appreciate Ms U could not complete the assessment as she was on the bus, however this was no fault of the Trust.
33. We have seen the original appointment letter dated 6 April 2018, which was sent to Ms U giving details of the appointment. In this letter it states:
‘Please make sure you are somewhere quiet and private where you can concentrate and talk confidentially. We are unable to do the assessment if you are in a public place or driving for example’.
34. The letter also states, ‘our service is very busy and missed appointments lead to a longer wating times overall’. It also states ‘if you miss your appointment, we are unable to offer you another for two months’.
35. We therefore find that Ms U was well advised of the requirement to be in a quiet space and was told that there are likely delays if the assessment could not be completed.
36. The records show that after this the assessment was successfully completed during a call on 26 April 2018. It was identified that Ms U needed a complex assessment.
37. An appointment was offered to Ms U for 15 June 2018, however she could not make this. The complex assessment was successfully completed on 20 June 2018.
38. We understand the Trust’s wellbeing service is an ‘Improving Access to Psychological Therapy’ (IAPT) service. This is an NHS service designed to offer short-term psychological therapies to people suffering with mental health concerns. IAPT services are required to follow NHS England’s ‘the Improving Access to Psychological Therapies’ manual.
39. We have seen no reference in the manual of standard waiting times between referral and first assessment in cases where a person goes on to have treatment as Ms U did. However, we have identified that Ms U had her first assessment within four days of being referred.
40. We consider the Trust to have acted in line with our Principles of Good Administration as Ms U had her first appointment in four days. The principles say ‘public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits’.
Treatment appointment
41. Following the complex assessment being completed on 20 June 2018, a letter was sent to Ms U dated 28 June 2018. It confirmed Ms U required EMDR treatment and states ‘I have placed you on the waiting list for this treatment. This is a high-volume service and the wait for treatment is often a few months’.
42. We can see from the records, specifically a letter dated 11 December 2018, that Ms U’s first EMDR treatment was to take place on 18 December 2018.
43. Based on this we can see Ms U’s first treatment session took place around 36 weeks after the referral. We appreciate the wait must have caused Ms U distress and we are sorry to hear of this.
44. The IAPT manual gives guidance on the waiting time standards. It states:
‘The national waiting time standard for the IAPT programme refers to the period of time between the date that the initial referral was received and the start of the course of treatment. Of the referrals that have a course of treatment, 75% of people referred to the IAPT programme begin treatment within 6 weeks of referral, and 95% begin treatment within 18 weeks of referral’.
45. We have looked into the reasons for the delays in Ms U’s case, as she was seen beyond the six week and 18-week timeframes detailed in the IAPT manual, which is expected for five percent of people referred.
46. We understand the Trust has explained the delays in Ms U having her first EMDR session was due to a strain on the service.
47. From the records we can see this was communicated to Ms U more than once. Firstly, during a call on 10 September 2018, Ms U was told about the waiting times and that she would be seen around Christmas time. On 19 November, she was advised she was still on the waiting list and on 21 November she was told her appointment was likely to come up in a few weeks. It was also recorded during this call that Ms U was informed ‘we have lost a number of Practitioners and our provision for EMDR is currently scarce’. Ms U was again told about delays on 6 December.
48. We find the Trust to have acted in line with GMC guidance which says,
‘You must give patients the information they want to or need to know in a way that they can understand’.
49. It was therefore in line with the above guidance for the Trust to be clear about the delays and explain that Ms U was likely to get an appointment around Christmas time.
50. We have seen evidence of the Trust’s performance for 2018, which shows that 93.4 percent of service users began treatment within six weeks and 99.9 percent within 18 weeks. This is in line with the waiting time standards detailed in the IAPT manual.
51. We understand that to respond to the service strain and help reduce delays, the Trust reviewed this on a monthly basis. In response, actions were taken which included reviewing its workforce and filling vacancies.
52. We consider the Trust’s actions to be in line with our Principles of Good Administration which state public bodies should seek continuous improvement. We find that the Trust took actions to actively help reduce the delays. While it was unfortunate that Ms U waited longer than most, this is expected for a small number of patients and we have seen the Trust kept her updated. The Trust’s actions in response to the challenges it faced meant that it performed in line with the IAPT timeframes overall, which indicates the effectiveness of its actions.
53. We can also see the Trust has accepted and apologised for the delays in its response dated 25 October 2019. It states:
‘I understand the frustrating and upset in having to wait for therapy. I acknowledge this wait is not acceptable and I would like to apologise that this was your experience’.
54. We find the Trust’s actions are in line with our principles for remedy which state that ‘public bodies should promptly identify and acknowledge maladministration and poor service and apologise for them’.
55. Based on the above, we find that the Trust acted in line with the relevant guidance. We consider it took appropriate steps to address the demands for its service and the challenges it had with staffing and it met the national timeframes. While Ms U had to wait longer, we do not find this to be a service failure.
56. We fully realise this may be disappointing for Ms U and understand the wait caused her frustration.
Issue two - concerns about treatment offered
57. Ms U raises concerns that the treatment offered to her was not appropriate and EMDR treatment should have been offered.
58. The Trust’s final response, dated 25 October 2019, states the wellbeing service did offer Ms U EMDR therapy. It says:
‘You were offered 12 sessions of EDMR with [the therapist], the appointments starting on 18 December 2018. I understand, due to the setting and the distance you had to travel, you were not able to engage in these appointments. Looking through your records, I can see that [the therapist] understood this, and the same day, she made a referral for you to see another therapist nearer your home. I can see from your notes that she emailed you with this information, letting you know that she would be asking them to contact you directly. [Another therapist from the wellbeing service] was the therapist allocated to you. She offered you EDMR, starting on 15 January 2019’.
59. From a review of the records, we have seen evidence of an email sent to Ms U from the service on 11 December 2018. This states:
‘I am able to offer you an appointment to begin EDMR and wanted to check that you are still able to attend. Tuesday 18th December 2018, 1pm, [location]’.
60. The records detail ‘session 1 clinical session completed 18/12/2018 at 13:00 for stage WL- S3 EDMR’.
61. We can also see evidence of the conversation on the day of the session where Ms U raised concerns about the distance she had to travel. It notes ‘on arrival [Ms U] told me that she had found the journey to [location] too long and was finding the setting to be distressing for her’.
62. Following this we can see evidence of another email from the therapist to Ms U which confirms she has spoken to ‘[the wellbeing service] and they have agreed to offer [Ms U] EDMR treatment’.
63. Based on the evidence we have seen, Ms U did receive EMDR therapy. We realise a decision was made later for her to be discharged from the service, which we will discuss further in this report. However the records support the Trust’s position that EMDR therapy was offered.
64. NICE guidance, ‘common mental health problems: identification and pathways to care’, gives guidance on the model used in treating patients with a mental health condition. It says:
‘A stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions’.
65. We can see from the records that Ms U had experienced anxiety and depression, which are common mental health problems managed on an escalating stepped model of care as detailed in the ‘focus of the intervention’ section of the model.
66. The records indicate that Ms U had persistent subthreshold depressive symptoms, or mild to moderate depression, that had not responded to a low-intensity intervention. Therefore, she would fall within step two and three of the stepped-care model.
67. The model says the recommended interventions for steps two and three includes EMDR, particularly where there is a background of trauma, as was the case for Ms U. This is evidenced in the clinical notes following the complex assessment which took place on 20 June 2018. The notes say:
‘[Ms U] would like EMDR to reduce some of the distress around her trauma which impact her now by being triggered off.’
68. Based on the evidence we have seen, Ms U was offered EMDR therapy. This was in line with the NICE guidance. We are sorry to hear about the trauma that Ms U has suffered.
Issue three - concerns about stabilisation therapy
69. Ms U raises concerns that the Trust did not offer her stabilisation therapy while she waited for EMDR therapy.
70. The Trust says at the time the wellbeing service did not have anything on offer that would have met Ms U’s needs, including stabilisation therapy.
71. As part of our investigation, we contacted the CCG for further information about the services that were commissioned and available at the time.
72. The CCG has provided us with the contracts in place at the time between the CCG and the Trust. These show the services that were available at the time.
73. We can see stabilisation therapy is not detailed as a commissioned service and therefore the evidence suggests it was not available. We also find the IAPT manual includes NICE recommended psychological interventions. We can see stabilisation therapy is not included in this.
74. Based on the above, we find stabilisation therapy was not available and therefore there are no failings in the Trust not offering this to Ms U.
Issue four - the therapist could not access Ms U’s medical records during her consultation
75. Ms U says that during her first session on 18 December 2018, the therapist could not access her records. She says because of this, she did not have the right information for the session and was unprepared.
76. The Trust states in its response dated 17 October 2019:
‘The initial assessment was recorded in a different part of the IAPTUS database from usual, making it difficult to locate. It says we appreciate it was frustrating that it had not been available for the first sessions. However, any EMDR Practitioner would still need to conduct their own assessment as part of the protocol of EMDR, which requires a detailed history taking and assessment’.
77. Our clinical adviser has reviewed Ms U’s records and says that in practice, although it is good practice for a clinical practitioner to have access to relevant previous records, it is still the responsibility of the professional to conduct their own assessment.
78. The reason for this is that the assessment is based on how a person feels at that stage rather than before. NICE guidance ‘common mental health problems: identification and pathways to care’ supports this. The guidance says two key questions should be asked:
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?’.
79. We can see from these questions the assessment should have been a reflection of how Ms U felt at the time, rather than reference to previous records. We also note from the records that this assessment could not be completed, as Ms U found the journey and setting of the assessment venue distressing. The notes detail:
‘On arrival [Ms U] told me that she had found the journey to [location] too long and was finding the setting to be distressing for her. She expanded on this, telling me that the outside was intimidating (shuttered windows, barbed wire) and inside had no light and was reminiscent of a police station.
We did not complete our session.’
80. Based on the evidence that we have seen, we can appreciate the frustration that Ms U must have felt when the practitioner could not access her previous records. We have seen from NICE guidance there was no requirement for the practitioner to have seen these records, as they should complete their own assessment of how Ms U felt at the time.
81. We therefore find no evidence of failings in the practitioner not having access to Ms U’s records during the 18 December 2018 session.
Issue five - the practitioner walked out of the third session
82. Ms U complains the practitioner walked out of the third session on the 29 January 2019, stating that she could not work with her. She says this was unprofessional and left her in a vulnerable state with no support.
83. We appreciate this must have been very distressing for Ms U at a time that she needed support. We are sorry to hear about this.
84. The Trust says at the start of the session, Ms U told the practitioner she did not want to complete the form as she felt nothing had changed and, therefore, she should copy the previous weeks’ form. It says Ms U also said that talking is not helpful and counterproductive for post-traumatic stress disorder (PTSD) treatment.
85. It says despite the practitioner explaining the nature of EMDR treatment, as well as accepting Ms U’s difficulties in engaging with it, Ms U said she found it too upsetting and did not want to talk about any of the memories. The Trust say this made it impossible to continue EDMR. The Trust says this was explained to Ms U and also that she would be transferred back to a wellbeing therapy service.
86. Having reviewed the evidence, we can see an attendance note from the session which says:
‘At the start of the session the client complained about the form, because she doesn’t feel anything has changed for her and therefore, I should just copy the previous weeks one. She also reported that talking is not helpful and counterproductive for PTSD.
When asked she has thought about the memories she would like to work on, the client became defensive and said she’s told me everything in the 1st session. I explained that we talked about a lot of things that were potentially very traumatic to her as a child, and it is not down to me to decided [sic] which one she herself found traumatic.
There was a sense that everything I said is being rejected and criticised. I invited her to think about the dynamic in relationships where she is so defended and rejecting of others that she gets rejected back and can’t seem to get what she needs from others.
I brought to her attention that we seem to struggle to get on and there was a sense of battle with her, which I did not want to happen and did not feel was helpful to her. I said I will therefore refer her back to Wellbeing therapies. We finished the session earlier’.
87. Although we do not dispute Ms U’s memory of the events, from the evidence we have seen there is nothing to suggest that the practitioner walked out of the session.
88. We have considered if it was right for the practitioner to have ended the session.
89. NICE guidance, ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’, gives guidance on this. It states professionals should:
‘Work in partnership with people using mental health services and their families or carers. Offer help, treatment and care in an atmosphere of hope and optimism. Take time to build trusting, supportive, empathic and non judgemental relationships as an essential part of care’.
90. From the records, we can see that during the session there was no ‘therapeutic progress’ being made. Ms U also explained that it was ‘not helpful’ and ‘counterproductive for her PTSD’.
91. Our adviser explains it was therefore right for the session to be ended, as it was not helping Ms U, or giving her hope or optimism in line with NICE guidance.
92. We appreciate that Ms U was going through a difficult time, and she says that the session caused her further distress. We are sorry to hear about this. It is clear from the records that the session was not successful.
93. Based on the evidence we have seen, we find no evidence of failings as it was appropriate for the session to be ended, as it was causing Ms U further trauma and distress and not helping her.
Issue six - discharge
94. Ms U complains a manager told her about her discharge from the service in an inappropriate way and the discharge letter did not include an explanation.
95. The Trust’s complaint response says, ‘the letter is standard practice for all clients when discharged from the service. It is a standardised discharge letter and does not go into any detail about treatment’.
96. From a review of the records, we understand a discharge letter was sent to Mrs U on 12 February 2019. The letter reads as follows:
‘Dear [Ms U],
I am writing to confirm that you have been discharged from the service.
I would like to take this opportunity to wish you all the best for the future’.
97. We have taken clinical advice on this. Our adviser confirms that there is no standard for how a discharge letter should be written or the specific information that should be included in this.
98. We understand Ms U’s concerns that the discharge letter did not explain the reason for her discharge. From a review of the records, we can see that after Ms U’s third EMDR session on 29 January 2019, at the end of the session the practitioner advises her that she ‘will be referred back to the wellbeing therapies’.
99. After this a manager sent an email to Ms U on 30 January 2019 which states:
‘I think at this point the best plan would be for you and I to make an appointment to talk on the phone, and discuss your options, as I do not think we can offer you anything else as a service’…I’m sorry your experience with us has not been helpful, but as I’ve said above, I do not feel that we have anything else to offer you at the present time’.
100. We can see after this there were a number of attempts to and from Mrs U and the manager to discuss the discharge, but no successful contact was made. After this, Ms U was sent the discharge letter she complains about.
101. The records show the manager sent another email on 27 February 2019, which included an explanation that:
‘We have now offered you several treatment options as a service, none of which have worked out and we are unable to offer you anything more at the moment, as I said in my previous email’.
102. Although there is no requirement for specific information to be included in the discharge letter, we can see that the Trust did explain to Ms U the reasons for the discharge.
103. We therefore find no failings.
Conclusion
104. Our decision is that we do not uphold the complaint. We appreciate the events and the progression of the complaint have caused Ms U distress which we are sorry to hear. We hope the report shows that we have carefully considered the evidence from both Ms U and the Trust.