Kent and Medway Joint Strategic Needs Assessment – Mental Health
Transcription
Kent and Medway Joint Strategic Needs Assessment – Mental Health
Kent and Medway Joint Strategic Needs Assessment – Mental Health Part Two: Facts and Figures about Current Services April 2009 CONTENTS Section Number Part One: Part Two: Part Three: Part Four: Part Five: Part Six: Part Seven: Part Eight: Part Nine: Part Ten: Part Eleven: Number Summary Introduction The Range of Services Commissioned to Meet the Needs of the Population The Total Resources Invested in Mental Health Investment in the Main Mental Health Service Groups Investment in selected Mental Health Staff Groups Acute Mental Health Inpatient Beds Page Number 1 5 7 11 14 17 18 Geographical Distribution of Community Services in Kent and Medway Referral and caseload rates 22 Use of Acute Inpatient Mental Health Services by Diagnostic Group Selected Care Pathways 35 Geographical Distribution of CMHT Caseload 42 28 38 APPENDICES APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX ONE: TWO: THREE: FOUR: FIVE: APPROACH TO COMPARISON WITH OTHER AREAS SERVICE MAPPING CATEGORIES CHARTS AND TABLES SHOWING INVESTMENT IN MAIN SERVICE TYPES INVESTMENT IN SELECTED MENTAL HEALTH SERVICE STAFF GROUPS TABLES AND MAPS - GEOGRAPHICAL DISTRIBUTION OF CASELOAD SUMMARY Context of this report This report is the product of an agreed approach within the adult mental health needs assessment project to review services based on available information about finance and activity. It represents a systematic approach to the review of investment, the range and balance of services, their geographical distribution, and how effectively they are being used to meet mental health need. Although intended to provide a balanced and impartial picture, by itself it is not intended to provide the evidence on which to base decisions about future investment. This report forms Part Two of the agreed approach to the Joint Strategic Needs Assessment for Mental Health in Kent and Medway. The other parts are: Epidemiology and demography (Part One, November 2008, subsequently updated in April 2009) Gap analysis between needs and services (Part Three, April 2009) Working paper summarising national guidance Summary of what is known about service user and carer views Overview and way forward Findings The report does not provide evidence on which to base future changes in investment. In many cases there are limits to the reliability of the available information. In some cases this means that the findings are inconclusive or require further work and local validation. The agreed approach included comparisons with other similar areas (described in Appendix One), but overall these have not proved instructive. That said, the high level findings about the services to meet the needs of Kent and Medway can be summarised as follows: The core adult mental health services have been commissioned to meet the needs of the population although some gaps remain compared to a fully comprehensive service (A&E liaison, community forensic and dual diagnosis) The information about services for older people with functional mental health problems (eg depression, psychosis) is too limited to base conclusions on Eastern and Coastal Kent and Medway spend less than other areas of the country on adult mental health relative to their population. Medway spends substantially less than the national average on older adult mental health services. 1 The differences in expenditure and in the patterns of investment are at least as likely to be based on historical development of services as on responses to local need; some specialist services such as perinatal mental health and specialist personality disorder services do not appear to be available in all areas. In some cases, the service model is different, eg carer support in Medway and assertive outreach in West Kent. Acute inpatient beds do not account for a disproportionate share of secondary mental health resources Medway’s services appears to have fewer services relative to its population than Kent in a number of adult service areas: beds, CMHT resources, staff, and caseload Eastern and Coastal Kent services have some markers which may relate to the higher need of its population (increase in forensic placements, higher caseloads, bed numbers, admissions for schizophrenia, and Mental Health Act assessments) but also some which raise questions about their responsiveness, such as lower referrals, issues in emergency pathways, and lower investment in access and crisis services. Prior to the current investment programme, it had the most limited primary mental health care in Kent and Medway West Kent has a higher referral rate and higher investment than other areas As in the rest of the country, finance and service mapping show an overwhelming investment in secondary mental health services (over 90 per cent) compared to primary mental health care Although there are some specific adjustments which could be made in the geographical distribution of resources, the overall pattern of staff resources and referrals at district level within PCT areas (ie East and West Kent) does not appear to be skewed towards the more affluent areas for adult services Over a third of inpatient admissions are for people with depression Significant numbers of people are admitted through A&E One third of routine referrals to secondary mental health services wait four weeks or more There was a wide variation across Kent and Medway and between providers in waiting times for primary care psychological therapies (from one to 20 weeks) The available monitoring information does not appear to be keeping pace with the questions being asked by commissioners or providers about the effectiveness of their service in meeting need or in providing effective interventions Please note that the above points apply to all three PCTs and/or Kent and Medway as a whole. Additional key messages for each PCT area are summarised below for adult mental health services. Eastern and Coastal Kent Has less well developed primary mental health care (staff and services) than Medway and West Kent. Has increased number of forensic placements over the last three years Invests less than the ONS cluster and England averages. 2 Has a lower proportion of investment in access and crisis services (including crisis teams) but a higher proportion in CMHTs than its ONS cluster and England averages. Has a higher number of adult beds per head of weighted population compared to ONS cluster and England averages, and higher occupancy levels compared to Kent and Medway Has fewer referrals to primary care and CMHTs than West Kent and Medway Has higher caseloads per team member than West Kent Has higher admissions for schizophrenia than West Kent and Medway Has the highest number of Mental health Act assessments in absolute terms in Kent and Medway and has the highest proportion out of hours West Kent Invests more than the ONS cluster and England averages. Invests less in accommodation services than Medway and Eastern and Coastal Kent, probably due to greater investment in the Supporting People Programme. Has more primary care psychological therapists than Eastern and Coastal Kent and Medway. Has more referrals to secondary mental health care than Eastern and Coastal Kent and Medway. Has fewer clients in its assertive outreach teams than Eastern and Coastal Kent and Medway. Had the lowest proportion of mental health admissions through A&E in Kent and Medway. Medway Has a different model of carer support to the rest of Kent. Invests a higher proportion of its resources in crisis teams than East and West Kent, and a higher proportion in access and crisis services than the ONS cluster and national averages Invests less overall than Kent, the ONS cluster and England averages for adults and older adults Has fewer staff in selected staff groups and fewer adult acute beds than the ONS cluster and England averages, and fewer CMHT resources and smaller CMHT caseloads than Kent Has most referrals to primary care services. Appears to have the lowest rate of admissions for schizophrenia and bipolar disorder. 3 The following particular limitations to the data should be noted.: The available information about older people’s services is inadequate for the purposes of most sections of the report. Not only is the mapping an 2007 finance incomplete, but the activity cannot be split between organic illness (dementia) and functional illness (eg depression, psychosis) Trust data on inpatient admissions and crisis services requires validation and has not been included. Trust data on referrals and caseload to psychological therapy services has not been included in order to avoid the risk of confusing primary care and secondary care psychological therapies. Trust specialist services have not been analysed in detail. 4 1. INTRODUCTION exercise were received, and in some cases these have been cross-checked for validation purposes. This summary sets out the findings of a review (based on available activity information) of how far the mental health services in Kent and Medway meet the needs of the population. At the request of the commissioners, comparators were identified for each PCT in the service mapping analysis. This is explained in Appendix One. It describes the approach and the results of the analysis. The information is drawn from three sources: The activity information provided by the Trust was for 2006/07, 2007/08 and the first six months of 2008/09, with snapshot information from October or November 2008. (The population was provided by the Trust, based on GP practices covered by the teams, based on Kent Primary Care Agency information in 2008. It is important to note that these are unweighted populations.) National finance and service mapping Activity data provided by Kent and Medway Partnership Trust Information provided by commissioners. The national mapping exercises are completed each year in a standard format agreed by the Department of Health, covering health and social care spending (but not prescribing). This includes comprehensive classification of adult mental health services into Most charts and maps that require use of colour have been placed in appendices and will require viewing on screen of the electronic version of the document. ‘Service groups’ of which there are fourteen ‘Service types’ which make up each service group. This report has been commissioned by the PCTs with the co-operation of the Trust. At the same time, Mental Health Strategies has provided support for the Trust’s own modelling work. As is normal practice Mental Health Strategies has ensured these workstreams have been kept entirely separate, with no overlap of personnel, documents or discussion. For example, the service type ‘clinical services’ covers acute inpatient wards or units, as well as six other service types, including NHS day care, specialist services and outpatients. The finance mapping uses the same classification for direct service spend, and provides an analysis per head of weighted population. (Appendix Two gives a list of the service types and groups.) A draft of this report was discussed with the project steering group. The conclusions are included in the overview report of the Joint Strategic Needs Assessment, with the epidemiological and demographic review, and the analysis of the gap between needs and services. This report uses the 2007 mapping exercise (covering financial year 2007/08) since it was current at the time the project began. The population used in the national mapping was the ONS 2006 estimates. During the project, finance and service mapping returns for the 2008 5 In each section, the following format is used: Table 1: Format of sections in the report Rationale Explanation of methods Analysis Limitations Conclusions (Where applicable) further analysis Options What the review of facts and figures is trying to find out, and why it is important How Mental Health Strategies approached the task, and the reasons for the choices made The facts and figures and what they show What the analysis cannot show, and other points to be borne in mind Implications for the needs assessment for Further analyses to be considered to develop future needs assessments Thanks are due to the following for their lead in providing the data and resolving queries: Karen White, Steve Wheddon, Dirk Riezebos, Roger Edmonds, Nigel Lowther, Michael Johnston (and other colleagues in KMPT), the Adult Mental Health Commissioning Team for Kent and Medway, including Lola Triumph, Jill Martin and Alex Thurlby. 6 2. THE RANGE OF SERVICES COMMISSIONED TO MEET THE NEEDS OF THE POPULATION Limitations This approach does not assess the level of service provided in Kent and Medway against the local need: it is a high level overview. Any gaps or errors in the local submissions will be reproduced. It is not a requirement to have a service of every type. The analysis does not cover services outside the service mapping classification. It will not cover new services started since the last mapping exercise (March 2007) or services entered against another service type. This section analyses secondary mental health and social care services, and primary mental health care services. Rationale The needs assessment seeks to find out whether the full range of services have been commissioned for the population, or whether there are any gaps in Kent and Medway Older adult service mapping returns are incomplete for West Kent and Medway. (The 2008 return for older people was reviewed but was no more complete.) These returns do not distinguish between functional (eg psychosis, depression) and organic mental illness (dementia). There is a separate needs assessment for dementia. Explanation of method Mental Health Strategies reviewed the March 2007 service mapping return for each Kent and Medway LIT against the national list of service types in order to identify those where there was no local service. A summary was produced where there appeared to be significant gaps. Finance mapping returns for adult services were checked to identify where new services had started since 2007. The local self-assessment returns for the three Kent and Medway LITs were also reviewed. The result of the analysis were then modified following information provided by the steering group. In order to identify the primary mental health care psychological therapies services commissioned for the population, the returns for the Improving Access to Psychological Therapy services (IAPT) programme were tabulated (as at April 2008). They were then revised with update information. 7 Analysis: mental health and social care services The following table shows the service groups and service types where there appear to be significant gaps in provision (in blank cells). Key Entry in 2007 service mapping Blank in 2007 mapping but entry in 2008 finance mapping Table 2: Selected service types from national service mapping Service Group/type Access and Crisis Services (selected) A&E Mental Health Liaison – Adult Assertive Outreach Team West East The returns for older people’s services (not illustrated) are incomplete for West Kent and Medway, so no firm conclusions are drawn. Business managers report that crisis teams do not serve people over 65, which is clearly a gap, although there is a rapid response team in Eastern and Coastal Kent. Medway Crisis Accommodation Crisis Resolution Team Early Intervention in Psychosis Service Carers' Services Carers Support Group Carers Support Service The service mapping returns for adult services suggest gaps in Kent and Medway in crisis accommodation, criminal justice diversion, womenonly community services and 24 hour nursed care. Dedicated mental health carer support appears lacking in Medway. Local self assessment shows red for dual diagnosis services in all three LITs. All these services require partnership working with other agencies. Carer Support Workers Self-help, Mutual Aid Group for Carers Short-term Breaks / Respite Care Service Various Local information can be used to supplement service mapping submissions as follows: Commissioners have decided not to prioritise crisis accommodation as there is no clearly established service model. They will however review this in the light of mature crisis teams and the performance of inpatient services in providing the requirement of NSF Standard Five for timely access to an appropriate hospital bed or an alternative bed or place for those assessed as needing a period of care away from their home. Community Forensic Services Criminal Justice Liaison and Diversion Service Women-only community day services NHS 24-hour nurse staffed care 8 Table 3: Stepped care services for primary mental health psychological therapies, 2008 24 hour nursed care for people with severed and enduring mental illness (DH, 1996) is covered in Kent and Medway by high staffed accommodation, inpatient rehabilitation and continuing care provision. A&E mental health liaison is covered by the crisis team model in West Kent and Medway. Sessional women-only day services are provided as part of services commissioned for both men and women. Carer support in Medway is provided by an organisation which provides ‘generic’ carer support, ie for all carers not specifically for mental health carers. (However, this was rated red in self assessment.) Type of stepped care intervention Assessment Books on prescription Case Management cCBT Exercise on Prescription Medication management Prescribing (medication) Cognitive Behavioural Therapy Self-Help Sign posting Social Prescribing Watchful Waiting Employment/vocational support Psychological therapies (identify modality) Nevertheless commissioners are currently considering these services and the other gaps listed. Analysis: primary mental health care The following table shows the range of primary care psychological therapy services in 2008. It is taken from the baseline audit of services before the start of the local programme to improve access to psychological therapies (IAPT). Key (W =West Kent, E = Eastern and Coastal Kent, M =Medway 9 GP - Step 1 W/E/M Low Intensity W/M W/M High Intensity W/E/M E M W/E/M W/E/M W/E/M W/E/M one PCT W/M W/M W/M W/M W/M W/E/M W/E/M W/E/M W/E/M W/E/M W/M W/E/M two PCTs All K&M PCTs In primary care psychological therapies, GPs were able to provide the basic range of services, but not books or exercise on prescription. (Exercise on prescription was only available in Medway at the time the information was gathered). Computerised Cognitive Behavioural Therapy (cCBT) was not available at all. Eastern and Coastal Kent had fewest services in 2008 (although exercise and books on prescription are currently available and may have been omitted from the baseline analysis), and employment and vocational support was lacking in primary care. Specialist services such as eating disorder services, learning disability services, neuropsychiatry and particular psychological therapy modalities are better mapped using local data. Some innovative services such as arts on prescription, or complementary and creative therapies require local mapping, as do mainstream support services with access arrangements for people with mental health problems. Conclusions There remain gaps in the mental health services commissioned to meet the needs of the working age population in Kent and Medway. Services for those with a dual diagnosis of mental illness and substance misuse are gaps, and community forensic and criminal justice diversion services are not fully developed. A&E liaison services are being strengthened. Across the area, several gaps relate to more comprehensive partnership working by secondary services with other agencies e.g. criminal justice, substance misuse and acute general hospitals. Medway has a different model for carer support and Eastern and Coastal Kent had fewer primary care services in 2008. Options for further analysis Service mapping returns are generated and signed off locally. Nevertheless service mapping can only provide a high level overview. Better local detail can be provided by local spreadsheets of services commissioned (as used by commissioners). In particular, it would be useful to update the primary care provision since this has changed due to the implementation of the IAPT programme. 10 3. THE TOTAL RESOURCES INVESTED IN MENTAL HEALTH The older adult finance mapping for 2007 Kent and Medway is incomplete and comprehensive analysis is not possible. Rationale Analysis The needs assessment considers whether the total resources invested to meet the needs of the population are similar to other areas, and comparable across Kent and Medway. The following table shows the total investment according to finance mapping in 2008. Explanation of method Table 4: Total investment 2008 (£k) The total health and social care spending on mental health (other than primary care staff and prescribing) is reported in the national finance mapping exercise (2007). This analysis shows the spending per head of weighted population (separately for adults and older adults), compared to national averages and selected individual comparators. Due to discrepancies in the 2007 returns, the 2008 finance mapping submission was also consulted, Age group Adult OPMHS Total Eastern and Coastal Kent 61,336.72 43,620.30 104,957.02 Medway 23,673.27 3,141.75 26,815.02 West Kent 57,563.28 37,987.80 95,551.08 Table 5: Adult mental health investment per head of weighted population 2007 Limitations Dedicated primary care mental health staff and specific projects are included in service mapping. However, prescribing costs and the time of GPs and community nurses are not. Any mental health needs of older adults met in acute general hospitals or community hospitals are not included. LIT Medway E Kent W Kent Total adult £ per ONS cluster England investment £k head av £ av £ 22,433 149 159 169 58,547 145 171 169 59,383 176 159 169 These tables show that investment in adult mental health in Eastern and Coastal Kent and in Medway is below the national average and below the average of the relevant ONS cluster group. The investment in West Kent is greater than the cluster group average and greater than the national average. The finance mapping returns for 2007 appear to show a higher figure for total expenditure for West Kent than is locally recognised. The Mental Health Commissioning Team for Kent and Medway believes this may be due to some double counting, especially in secure and high dependency services (which cover forensic mental health and psychiatric intensive care). 11 The Mental Health Commissioning Team has asked for local checks into the accuracy of the financial mapping returns for West Kent in 2007. Mental Health Strategies has therefore extracted the LIT figures for three years for total spend per head and the proportions invested in for secure and high dependency as follows. Table 7: Secure and high dependency: percentage of total direct spend 2006/08 Table 6: Investment £ per head of weighted population 2006/08 LIT Medway 2006 n/a 2007 149 2008 158 Eastern and Coastal Kent 191 145 152 West Kent 176 171 102 LIT 2006 2007 2008 Medway n/a 15 16 Eastern and Coastal Kent 19 18 18 West Kent 21 35 21 Although the percentages for each LIT are not comparable due to the changes in LIT boundaries, the above confirms that the figure for West Kent in 2007 has dropped significantly in 2008. Local investigations into the amount spent on forensic services will be able to provide more conclusive evidence of any errors in the 2007 return. The change in LIT boundaries (when population moved from West to East and to Medway) caused differences in the spend per head for each LIT, which means the 2007 figures are not comparable with previous years. The 2008 finance mapping will show that West Kent has a lower spend than in 2007, adding credibility to the suggestion that 2007 figures included errors. However, the same overall pattern of investment in Kent and Medway LITs remains: Eastern and Coastal Kent spends less per head than Medway, which spends less per head than West Kent. This is the reverse of the order of deprivation. Double-counting of spend on secure and high dependency provision in West Kent is suggested locally as a reason for error in West Kent’s finance mapping in 2007. The change in the percentage of direct spend in these services is shown in the following table 12 The following table shows the total investment and the spending per head of weighted population for older adult services. The returns for Kent showed NHS expenditure only and are shown separately in the table. Conclusions Commissioners in Eastern and Coastal Kent and Medway invest less than other comparable areas and less than the England average in adult mental health services. West Kent, the least deprived area, invests more. It is unlikely that this variation reflects local intentions (since, for example, Eastern and Coastal Kent has a priority for mental health) but it could reflect historical patterns or differences in efficiency in different parts of Kent and Medway. In itself, this difference does not amount to a case for spending more or less than current amounts. Table 8: Older adult service – investment per head of weighted population 2007 LIT Total investment £k £ per head of weighted population Medway 4,093 129 Options for further analysis Older adult services – NHS investment per head of weighted population Further information on total investment could be gained by: Eastern Kent and West Kent Coastal 22,499 16,363 182 Analysis of programme budgets. Local authorities have different legal duties compared to PCTs and a different reporting system. Their expenditure on adult mental health services can be identified and used to compare areas. Percentage of total PCT spend on mental health. 184 Although Eastern and Coastal and West Kent older adult mental health expenditure only covered the NHS in the 2007 mapping, it was still higher than Medway joint spend. In order to confirm Medway’s position, the 2008 finance mapping was consulted. This showed that the spend per head of weighted older adult population was £99, compared with £288 for the ONS cluster and £310 for England. 13 4. INVESTMENT IN THE MAIN MENTAL HEALTH SERVICE GROUPS The different pattern of investment in service groups in the individual comparator LITs means that direct comparisons are of limited benefit and very few conclusions can be drawn. This section analyses investment in secondary mental health care (with details in Appendix Three) and in specialist mental health services. Only the direct spend on service groups is analysed, so that wide variations in indirect, fixed or capital charge expenditure may limit the relevance of comparisons. Rationale The needs assessment seeks to determine whether the resources invested in each part of mental health services differ between local LITs and comparators. Relatively high or low investment in a particular service type would indicate an untypical response to population need. Analysis: secondary mental health care Tables and charts for the analysis of service groups are shown in Appendix Three. In this needs assessment, commissioners are interested in expenditure on specialist services, both locally for secure services, and out of district for others. Analysis: specialist mental health services Explanation of method The following table shows activity on secure and specialist services for 2008/09. Information is not available in this form for West Kent and Medway for the previous two years. The local investment in the service groups (£ per head of weighted population and percentage of direct spend) used for financial mapping was compared against the England average, the average for the ONS cluster and individual PCT comparators (as with the total investment). Commissioners provided information on secure and specialist services by PCT for 2008/09. This is a different method of analysing the same data as in service mapping, using local and more precise categories. Limitations Comparison at this level can only highlight areas for local investigation. 14 Table 9: Activity on secure and specialist services for 2008/09 Eastern and Coastal Kent West Kent Medway Number Number Number of Occupied of Occupied of Occupied Service Description Patients bed days Patients bed days Patients bed days MSU including TGU beds 40 12268 35 11958 16 4837 LSU 26 7918 17 4662 3 683 Continuing Care all ages 11 3914 32 9845 10 2737 Learning Disability 5 1278 7 2089 0 0 Personality Disorders 7 1875 11 3042 3 1029 Eating Disorders 6 482 3 224 0 0 Mother and Infant services 3 149 7 260 2 127 Residential Care for former long stay hospital patients 23 8395 12 3687 10 3252 In Eastern and Coastal Kent, placement information for previous years shows that both medium secure (MSU including Trevor Gibbens Unit in Maidstone) and low secure (LSU) placements (and therefore expenditure) have increased each year over the last three years. Numbers of patients are small for all the other specialist services, although the number of beds days has increased for personality disorder (in each of the two previous years there were five placements for Eastern and Coastal Kent). 15 According to finance mapping, compared to national and ONS averages: it appears just as likely that it could be the due to the historic development of the services. Investment in accommodation appears low in West Kent (compared to Kent and Medway and national) and high in Medway (compared to its cluster and national). However, commissioners point out that in West Kent the Supporting People Programme includes a significant amount of provision for adults with mental health problems, which is the reason for lower spend shown by service mapping Eastern and Coastal Kent invests more in CMHTs (compared to its cluster and national, but not to West Kent) Eastern and Coastal Kent (slightly – three per cent less) and West Kent (significantly) spend less on access and crisis services than their cluster and national averages. Medway spends slightly more than cluster and national average. Eastern and Coastal Kent appears to have a more community focused model given its investment in community teams, but investment in access and crisis services appears less than the average. In order to gain an additional perspective on the pattern of spending on access and crisis services, the return for the 2008 finance mapping exercise was consulted for crisis teams (which make up one part of access and crisis service group). This showed £2,500,000 for East, £1,958,000 for Medway and £2,635,000 for West, which appears to confirm the relatively lower spending in East and higher in West, given the population size and need. Options for further analysis The high proportion of spend on secure and high dependency services in West Kent in finance mapping for 2007/08 has been noted in the previous section. Medway spends a lower proportion than its ONS group average. Trends over time. Acute inpatient services are analysed in Section Seven. In terms of clinical services (which include inpatient services), percentage spend in East and West Kent is lower than ONS cluster and national averages but the difference is less than in the other services noted here. Medway is similar to the national average. Conclusions The pattern of local investment in adult services is different within Kent and Medway, ie the proportions spent in the standard service types differ between LITs. From this source alone, it is not possible to demonstrate that these differences do not reflect the needs of service users. However, 16 5. INVESTMENT IN SELECTED MENTAL HEALTH STAFF GROUPS All three LITs appear to have fewer adult community nurses than the cluster group and national average. Within Kent and Medway the actual numbers of whole-time equivalent (WTE) community mental health nurses are 188 East, 33 Medway and 143 West (rounded to whole numbers) - as stated MASTT appears to be mapped under West Kent in error. These figures require validation. Rationale The needs assessment seeks to determine whether the resources invested in each part of mental health services differ between local LITs and comparators. Relatively high or low investment in a particular staff group would indicate an untypical response to population need. Eastern and Coastal Kent staffing is broadly comparable with the average, taking adult and older adult together (although it appears to have fewer social workers than West Kent). Explanation of method In order to review the outcome produced by the investment in terms of staffing, the numbers per head of weighted population was analysed at LIT level for selected staff groups and services. The staff were psychiatrists, social workers and psychologists, chosen because the first two have fairly consistent roles in all mental health services, and because the commissioners have a priority interest in psychological therapies Although firm conclusions cannot be drawn, the number of adult psychiatrists and psychologists in West Kent appears higher – possibly due to the specialist services there. The actual numbers of psychiatrists (WTE) are 33.7 in East, 10.6 in Medway and 68.9 West: this appears to be an error. Even though Medway figures appear incomplete - and some appear to be errors, eg a total of 5.2 WTE adult and older adult social workers - the staffing (except older adult psychologists) appears so much smaller that further investigation is required. Limitations The numbers in most staff groups are small, making a less reliable base for comparison. Medway staffing appears to be distorted by the omission of MASTT from service mapping returns. Conclusions Analysis of investment in particular staff groups reflects the overall pattern of investment in mental health services. Comparison with other areas is inconclusive. Local investigation should review potential anomalies which emerge from the analysis, and authoritatively identify any significant differences in staffing levels between different parts of Kent and Medway, in order to determine whether they reflect population size or need. This review would have to take into account any differences in the number or type of patients seen. Staff numbers per 100,000 older adult weighted population appear larger due to the smaller size of the population. Errors in data entry will distort the analysis. Analysis Charts are shown in Appendix 4. 17 6. ACUTE MENTAL HEALTH INPATIENT SERVICES Rationale The needs assessment seeks to determine whether the resources invested in each part of mental health services differ between local LITs and comparators. Acute and assessment beds play a similar role in most mental health service systems. A high number of beds may indicate high need, or an unmodernised service system. An indication of pressure on beds can be gauged by overspill figures. Explanation of method The number of adult and older acute beds per head of weighted population was reviewed from service mapping. The Trust provided bed numbers as at December 2008 and occupancy rates. The PCT provided a 2008 KPI monitoring return which included use of one locality’s bed by another locality, and overspill placements for Eastern and Coastal Kent from 2006/07. Limitations Older adult acute assessment beds vary in their proportions of functional and organic use, and in some areas variation is explained by the relationship with continuing care provision. The service mapping figures vary slightly from the current figures given by the Trust. It should be noted that in this analysis the figures for Medway relate to that PCT (not to the total service provided from A Block in Gillingham for Medway and Swale residents). Current figures from the Trust in December 2008 differ slightly from service mapping figures. 18 Acute inpatient beds per 100,000 of weighted population for Eastern and Coastal Kent, comparator areas and England Darlington 46 Eastern and Coastal Kent 30 ONS cluster group 27 National (average) Figure 1: 28 0 10 20 30 40 50 Acute inpatient beds per 100,000 of weighted population for Medway, comparator areas and England Medway 16 Plymouth 0 Swindon 73 Figure 2: ONS cluster group 27 National (average) 28 0 20 40 60 80 Acute inpatient beds per 100,000 of weighted population for West Kent, comparator areas and England Hampshire 28 North Essex (LIT) 28 West Kent 20 Figure 3: ONS cluster group 25 National (average) 28 0 10 20 30 40 50 19 Table 10: Adult beds - per 100,000 of the weighted population PCT Darlington Eastern and Coastal Kent ONS cluster group Medway Plymouth Swindon ONS cluster group The 66 adult beds in West Kent are Littlebrook (32) and priority house (34). In Medway there are 56 beds for Medway (all ages) and Swale (working age adults). In Eastern and Coastal Kent there are 80 adult beds (57 at Arundel, 18 at St Martins and 5 at Thanet Mental Health Units). Acute Inpatient Unit/Ward Table 11: Older adult acute assessment beds – per 100,000 of the weighted population 46 30 27 16 0 73 27 Hampshire 28 North Essex (LIT) 28 West Kent 20 ONS cluster group 25 National (average) 28 Weighted populations based on the population estimates for 2006 published by the Office for National Statistics. Service data sourced from http://www.mhcombinedmap.org PCT Beds Darlington Eastern and Coastal Kent ONS cluster group 85 85 96 Medway Plymouth Swindon ONS cluster group 76 151 106 99 Hampshire 108 North Essex 93 West Kent 85 ONS cluster group 106 National (average) 81 Weighted populations based on the population estimates for 2006 published by the Office for National Statistics Service data sourced from http://www.mhcombinedmap.org2007/08 20 There are 63 older adult assessment and treatment beds in West Kent, and 101 in Eastern and Coastal Kent. the national average. Its investment in CMHTs, though comparable to the national average, is less than in Kent. Medway adult beds appear lower, and West Kent slightly lower, than cluster and national averages. Eastern and Coastal Kent is slightly higher. All older adult beds are lower than their cluster group average and but East and West Kent are slightly higher than the national average; Medway is lower. This information therefore does not provide evidence of a consistent relationship between inpatient services and community teams. It is at least as plausible that the relationship reflects the historical development of services. For example, some mental health systems develop the ability to operate with fewer beds, usually by working with higher thresholds. The adult occupancy figures in 2007/08 were 87 to 101 per cent in West Kent (including leave), 94 per cent in Medway and 90 to 99 per cent in West Kent. Eastern and Coastal Kent with high occupancy levels experienced 10 overspill placements in 2007/08, (and 30 in the previous year, when occupancy was not reported in this exercise). Local occupancy information appears to show pressure on beds in Eastern and Coastal Kent and possibly Medway. Options for further analysis Change in bed numbers over recent years (since crisis teams started) could be analysed. In August 2008, occupancy levels for Eastern and Coastal Kent including Swale) were around 95 per cent excluding leave. Eastern and Coastal Kent had experienced 10 admissions of its residents to other localities (100 bed days), and West Kent recorded that 147 bed days were used by Medway admissions, although this was not consistent with Medway’s report. Admission rates could be analysed. The numbers provided are presented below for information but require validation. Number of admissions to KMPT, 2006/08 Conclusions Overall, Kent and Medway mental health service system does not have higher bed numbers than the average. Admissions (not episodes) 2005/06 2006/07 2007/08 Medway has sigfnificantly fewer adult beds, West Kent lower than average and Eastern and Coastal Ketn slightly higher than average. In East and West Kent, this level of inpatient provision may be connected with higher CMHT investment (discussed in the previuous section). On the other hand, these LITs have lower-than-average investment in access and crisis services. Medway investment in access and crisis services is higher than 21 Eastern and Coastal Kent West Kent Medway KMPT 1002 894 1143 1201 1075 1264 528 453 438 2731 2422 2845 7. GEOGRAPHICAL DISTRIBUTION OF COMMUNITY SERVICES The number of whole time equivalent clinical staff for primary care psychological therapies was reproduced from IAPT baseline mapping worksheets. This section analyses community mental health teams, informal day and vocational projects in Kent, and primary care psychological therapy staff. Limitations Rationale Changes since the service mapping exercise will not be taken into account. Some community teams have different team structures, eg for dementia or intake. This increases the chance of error in calculating the staffing relative to the population of catchments. The needs assessment reviews how the resources in community services are distributed across Kent and Medway. Staffing in community teams was reviewed because they have a common role in services. Informal day and vocational service mainly serve their own local area, and their distribution may indicate access. Primary care psychological therapies could be expected to be distributed evenly across the area. Local information on informal day and vocational projects was not available for Medway. Capacity information (the number of people using services) is recorded by caseload and sessions per project) for Kent but only analysis of statutory funding was undertaken based on the data available. The analysis only relates to the funding by PCT and county council. Several projects receive non-statutory income, which is believed in some cases to be larger than the statutory funding. These sums which are not recognised in this analysis (because the information is not recorded by commissioners.) In addition, the analysis could be significantly changed by opening or closing a single project. Explanation of method The three types of analysis had the common aim of identifying the resources available in the different parts of Kent and Medway. The size of community mental health teams was taken from service mapping. Trust business managers advised corrections where numbers were significantly under-reported. The numbers were adjusted for the size of the unweighted population they served, based on Trust localities, and the number of staff per unweighted 100,000 population calculated. The more deprived localities would be expected to have more staff in order to respond to higher mental health need. Use of unweighted population means that the higher staffing in West Kent shown by analysis of service mapping data will be levelled down. The number of projects and percentage of the total day and vocational expenditure for adults in Kent was calculated by district, and compared to the district percentage of the unweighted population for Kent. 22 Analysis: community mental health teams The following tables show the staffing of the adult and older adult community teams. Table 12 (continued): Staffing of adult teams per 100,000 unweighted population Ashford 56 Canterbury 55 Coastal 42 Dover / Deal 62 Shepway 52 Swale 62 Thanet North 67 Thanet South 74 EASTERN AND COASTAL KENT 58 Staffing includes all members in service mapping. Medway and West Kent teams corrected based on local information Table 12: Staffing of adult teams per 100,000 unweighted population Staff per 100,000 Team unweighted population MASTT (Medway wide) 12 Chatham 33 Gillingham 20 Rochester 25 MEDWAY 38 Dartford CMHT Gravesham CMHT Kingswood (Maidstone) CMHT Pagoda (Maidstone) CMHT Swanley CMHT St John's (Sevenoaks) CMHT Tonbridge CMHT Tunbridge Wells and Weald CMHT WEST KENT 66 70 33 47 71 73 63 58 57 23 This shows that in East and West Kent the staffing is higher in the area with greatest need, with apparent outliers in Sevenoaks (more than expected) and Shepway (less). The numbers in Medway are smaller overall but the localities are distorted because the MASTT team covers the locality; possibly Chatham is higher than expected. For older adults, the pattern does not at face value appear to follow need as closely as with the adult teams. Ashford, Maidstone and Sevenoaks look higher than expected. This finding requires validation. Dartford and Gravesend have the highest need in West Kent, but the smallest teams. Table 13: Older adult community mental health teams-staff per 100,000 unweighted population Staff per 100,000 Area unweighted population MEDWAY 74 Analysis: informal day care and vocational projects in Kent. Ashford Canterbury and Coastal Dover / Deal Shepway Swale Thanet EASTERN AND COASTAL KENT 85 58 77 71 86 71 72 Dartford Gravesend Maidstone North Maidstone South Sevenoaks Tunbridge Wells WEST KENT 93 72 115 112 185 94 86 There are 29 funded informal day and vocational projects in Kent, on average serving about 1,800 people per month (2007/08). The Scrine Foundation in Canterbury was excluded as a service with a specialist function drawing from a wider area. The towns with the most projects are Maidstone and Canterbury, with five each. In the absence of comprehensive information on capacity or total funding, the statutory funding was analysed by the district where projects were located, and expressed as percentage. This was then shown alongside the percentage of the working age adult population in that district. A number of projects receive small grants from the Health and Wellbeing Fund in Eastern and Coastal Kent, and these are not included in this calculation. Staffing includes all members in service mapping. Medway and West Kent teams corrected based on local information 24 Table 14: Informal day and vocational services District funding per cent Ashford 5.3 Canterbury 11.7 Shepway 8 Dover 3.7 Swale 11.4 Thanet 3.9 Dartford 17.4 Gravesend 4.1 Maidstone 16.1 Sevenoaks 5.1 Tonbridge 7.4 Tunbridge Wells 6 Analysis: primary care psychological therapy staff. The number of whole time equivalent clinical staff in each locality was reproduced from the workforce planning spreadsheets produced by the PCT. In West Kent these correspond to the former PCT area, rather than to councils. Administrative and managerial staff are not included. 15-64 population per cent 8 10.9 7.0 7.5 9.5 8.8 6.7 7.1 10.5 8.1 8.4 7.5 Dartford and Maidstone are outliers in the sense that they have a higher percentage of the funding than population. Canterbury has a high number of projects, as stated, but this may reflect its size, as well as its historical position as a centre of mental health services. Projects there receive nearly 12 per cent of the funding for nearly 11 per cent of the adult population. Amongst the areas with higher deprivation, Thanet and Dover receive a lower percentage than their population. However, if a single project were to receive or lose statutory funding, the position in that district would change significantly. As stated, in reality several projects raise funding from other sources, so that the partnership approach between funders and local projectsis remains an essential consideration. 25 Table 15: Number of staff in clinical roles from IAPT workforce analysis April 2008 – WTE Role Graduate worker Nurse Counsellor Social Worker Counselling Psychologist Clinical Psychologist Employment Workers/Advisors CBT Therapist (diploma/masters in CBT) Total clinical staff WTE Dartford Maidstone SW Thanet Cant&Coast Ashford Dover Swale Shepway Medway 1 3 0.8 2 1 5.59 6.8 8.3 5 5 2.6 4.5 3.1 7 6.8 0 1.8 3.1 0.8 1.8 1 0.6 1 4 0.7 10.29 11.2 15.4 5 5 2.6 4.5 4.7 7 0 11.6 At PCT level. Eastern and Coastal Kent has a rate of 5.3 per 100,000 unweighted population aged 16 and over, Medway has 5.7 and West Kent 6.2, Analysis of these staffing levels by district population would not be instructive since a service requires a minimum critical mass. West Kent has the highest number of primary care psychological therapists and the greatest number of counselling psychologists. Eastern and Coastal Kent has poor take-up of graduate workers, according to these figures. 26 Conclusions Medway has fewer CMHT resources than Kent. For adult services in each PCT Kent, team size broadly relates to districts’ mental health need. However, in addition to apparent anomalies in particular districts, those districts with greatest need (all in Eastern and Coastal Kent) do not have more staff resources (per head of unweighted population) than the districts with most need in West Kent. It is possible that resources could be adjusted to improve alignment with population need: however, they would be marginal in adult teams. Statutory funding for informal day and vocational services is broadly distributed in line with population. Thanet, the district with the greatest need, did not have a proportionate share of funding. However, commissioners point out that this type of provision depends on effective partnership with the third sector, not just statutory funding. The small numbers of psychological therapy clinical staff in primary care appear evenly distributed across districts (but again without any apparent recognition of greater need in Thanet and Swale). However, the skill mix appears lower in Eastern and Coastal Kent. The size of older adult teams does not appear to relate to need of districts in Kent. Options for further analysis The capacity in each part of Kent of vocational and day services measured in caseload and sessions could be reviewed, provided measures of activity are consistent. Informal day and vocational projects are provided in Medway by Kent and Medway Partnership Trust. Similar analysis would require disaggregated budgets and mapping of the pattern of service use by locality or postcode of service users. 27 8. REFERRAL AND CASELOAD RATES The caseloads for community mental health teams were provided by the Trust as at November 2008. They are expressed as a rate per 100,000 of working age or older adult population. In Medway the caseload of MASTT, the intake team, has been distributed to the locality teams pro rata. This section analyses referrals to CMHTs and primary care psychological therapies, and caseload of CMHTs and assertive outreach teams. Rationale The caseloads and staffing for assertive outreach teams were taken from service mapping. Ethnicity information was only available for Eastern and Coastal Kent (not including Swale). The needs assessment seeks to determine whether differences in demand for services reflect mental health need, ie is the expressed demand for services higher in one area than another? Referrals and admissions are accepted measures of demand for services. Caseload is one measure of how effectively the service is meeting the need of its locality for secondary mental health care. For assertive outreach teams, also presented here, caseload is linked to staffing through policy implementation guidance. Inpatient admission rates appear to vary significantly and require checking. There are inconsistencies in data for crisis and early intervention teams which make it impossible to draw comparison between PCT areas without further validation. Limitations Explanation of method The analysis only has validity if the teams have the same role across Kent and Medway (or to a degree, if teams in each PCT area have the same role). Assertive outreach service models differ in Kent, and differences in intake models will affect the analysis. The demand for secondary mental health services was analysed by reviewing the referral rates for each community team, by current and former PCT areas. Referral rates per 100,000 unweighted population per year were used. Populations corresponding to working age adults and older adults were used. Differences between areas would warrant further explanation. Some teams have changed boundaries during the period under review. Some services are still organised by former PCT localities. Uniform population data was not always available (ie the same population figure was used for each year; some working age population figures provided used age bands that began at 15 rather than 18, and these have not been reconciled). Figures for Colin Sams referral and caseload have been excluded from West Kent totals. The demand for primary care psychological therapies was obtained from a survey by the commissioners of services by GP practices. The number of quarterly referrals for non statutory providers was obtained (for the last quarter in 2008). The numbers of referrals from Trust primary care psychological therapy services was obtained for July to December 2008. This enables annual totals for each PCT to be estimated. 28 Caseload figures vary over time. They do not indicate severity of mental illness or length of time receiving treatment. They may reflect the team’s operation as much as the need of the area (if, for example, teams do not regularly discharge those who are seen infrequently). Rates for older adults appear higher because the number of older adults is fewer than working age adults. The rate is higher than the actual number of staff since the older adult populations are below 100,000 at district level. Swale older people’s CMHT includes psychological therapies whereas others do not: the rate is therefore higher. The method of distributing the MASTT caseload magnifies the higher caseload in the Rochester team. Table 17: Referrals to community mental health teams PCT Medway East West It has not been possible to validate the admission rates for localities below PCT level for this analysis. Analysis: referrals for primary care psychological therapies. The following tables show the estimated annual number of referrals and rate, based on part-year activity from 2007/08 covering all providers. Table 16: Estimated referrals for primary care psychological therapies PCT Medway Eastern and Coastal Kent West Kent annual est. rate/100k unweighted 16 plus referrals pop 2,848 1,398 4,548 4,592 760 846 This shows that according to this method, Medway has the highest rate of referrals, and Eastern and Coastal Kent the lowest. The variation is very wide. Analysis: referrals to CMHTs The following table shows the number of referrals to adult CMHTs in the two years 2006/08. 29 2006/07 2007/08 2,981 6,649 8,080 2,831 6,504 7,550 The following table sets out the referral rate to adult CMHTs. At PCT level, West Kent has more referrals than East, with Medway in the middle. Between PCTs, it appears anomalous that Thanet, the most deprived district, should have a similar number of referrals to the average of West Kent. Table 18: Referral to adult CMHTs by locality per 100,000 unweighted population Adult CMHTs MEDWAY 2006/07 1,732 2007/08 1,645 Dartford Gravesend Swanley Maidstone teams Sevenoaks Tonbridge Tunbridge Wells WEST KENT 2,483 3,464 1,825 1,551 1,120 1,327 1,707 1,909 2,364 2,326 1,526 2,152 1,301 776 1,350 1,830 Ashford Canterbury and Coastal Dover Deal Shepway Swale Thant N&S EASTERN AND COASTAL KENT 1,374 1,343 1,221 1,342 1,810 1,821 1,476 1,387 1,362 1,201 1,395 1,459 1,844 1,444 The information also allows trends in numbers of referrals to be identified. In several teams these fluctuate, but over the 30 months there were some patterns in adult CMHTs as follows: Medway : increase intake, decrease locality teams West Kent : St Johns (Sevenoaks) and Kingswood (Maidstone) increasing, but Dartford, Gravesend and Tunbridge Wells decreasing Eastern and Coastal Kent: Ashford, Shepway, (also – but less marked Canterbury & Coastal and Thanet) increasing, Dover / Deal decreasing. The reasons for these patterns should be investigated by commissioners and the Trust. They are likely to be connected with local factors such as team reorganisations, but if they are connected with better demand management, or referrer dissatisfaction, there are potentially lessons to be learned. Medway localities not calculated due to high proportion of total referrals accounted for by MASTT At district level within PCTs, the profile of referrals appears to match deprivation, eg more in Dartford and Gravesham than in South West Kent. In Eastern and Coastal Kent, there are possible exceptions in Shepway and Dover, which have fewer referrals than Ashford. 30 The same pattern at PCT level is observed in adult and older adult referrals: Eastern and Coastal Kent has fewest, than Medway, with West Kent the highest. Table 19: Referral rate to older adult teams per 100,000 unweighted population 2006/07 2007/08 MEDWAY 2,630 2,660 Analysis: caseload The following table sets out the caseload as at November 2008. Dartford, Gravesham, Swanley (DGS) teams Maidstone teams South West Kent teams WEST KENT 1,815 4,580 3,163 3,121 Table 20: Caseload of community mental health teams 2,170 3,482 2,973 2,955 Adult caseload Nov 08 Medway Eastern and Coastal Kent West Kent Older adult caseload Medway Eastern and Coastal Kent West Kent Ashford 1,959 2,106 Canterbury 2,266 2,446 Dover Deal 1,919 1,748 Shepway 2,079 2,146 Swale 3,812 4,168 Thanet 3,036 2,688 EASTERN AND COASTAL KENT 2,480 2,500 Teams combined to former PCT areas in West Kent due to structure of dementia teams Some assumptions made in allocating referrals to teams West Kent has a higher referral rate for older adults. There are observable patterns within the PCT areas in East and West Kent: the rates for Dartford, Gravesham and Swanley look low (possibly due to smaller team sizes), and it is perhaps unexpected that Ashford and Swale are so close, especially since Swale referrals include psychology. The rates for Maidstone are so high that there is possibly an error. Part of the differences in these referral patterns by district could be accounted for by dementia referrals, which are not correlated with deprivation. 31 Number 1,743 9,927 8,023 1,719 4,722 5,237 Table 21: Adult CMHTs caseload per 100,000 unweighted population Team Chatham Gillingham Rochester MEDWAY Caseload clearly has a relationship with number of staff. The needs assessment is not focused on issues of productivity. However, in West Kent adult CMHTs, caseload per staff member ranges from 18 to 32, whereas in Eastern and Coastal Kent it ranges from 33 to 44 (in both cases omitting the highest and lowest in the full range). These broad figures must reflect the intensity of the service received by service users, and the high figures in Eastern and Coastal Kent must raise a question as to how frequently those on the caseload can actually be seen. rate 778 951 1,280 1,012 Table 22: Older adult CMHTs caseload rate per 100,000 Dartford Gravesend Swanley Maidstone teams Sevenoaks Tonbridge Tunbridge Wells WEST KENT 1,986 1,995 1,266 2,281 1,159 1,280 2,261 1,945 Ashford Canterbury Coastal Dover Deal Shepway Swale Thanet N&S EASTERN AND COASTAL KENT 1,885 2,220 1,399 1,694 2,148 2,734 3,117 2,205 Team MEDWAY Dartford and Gravesend Maidstone Tunbridge Wells and Sevenoaks WEST KENT rate 4,621 3,136 5,308 Ashford Canterbury Dover/Deal Shepway Swale Thanet EASTERN AND COASTAL KENT 2,768 3,824 2,217 3,138 4,374 4,960 5,527 4,655 3,502 There is not a great deal of difference in the older adult caseload rate between PCT areas. Within PCT areas, Dartford and Gravesham have a smaller caseload (as they have smaller teams). Canterbury has the second highest caseload, which does not reflect deprivation. However, dementia can be expected to account for a substantial proportion of the older adult caseload, and this does not relate as directly to deprivation. This shows that Medway has the lowest caseload rate, and Eastern and Coastal Kent the highest. Within PCTs, in Eastern and Coastal Kent, Thanet and Swale have the highest, reflecting the higher social need, although Shepway and Dover/Deal have a lower rate than Canterbury. In West Kent, the rates for Tunbridge Wells and Maidstone are higher than those in the areas with higher need, ie Dartford and Gravesham. 32 Table 24: Number on East Kent caseload in non-white ethnic coding categories and not specified/stated Analysis: assertive outreach teams Assertive outreach teams operate and are staffed in line with national policy guidance, although some local flexibility is allowed. The following tables show the actual staffing and caseload and rates (from 2007 service mapping) per 100,000 unweighted population 16-64 for the AOTs in Kent and Medway Not Not Asian Black Mixed Other specified stated Ashford 7 10 17 24 65 62 Canterbury 9 6 15 13 204 141 Coastal 5 1 6 11 82 1 Dover/Deal 11 13 24 21 111 3 Shepway 6 11 17 18 191 192 Thanet N&S 7 13 20 25 330 16 Table 23: Caseload and staff of AOTs PCT Eastern and Coastal Kent West Kent Medway Actual caseload staff 199 76 55 per 100k unweighted caseload staff 21.4 20.3 5 42.9 17.5 32.4 This shows that many more clients were recorded as ‘not specified’ and (except in Coastal /Dover Deal) ‘not stated’. This makes it impossible to be sure that the data is robust and no conclusions can be drawn. 4.6 4.7 2.9 Conclusions This shows that the teams in Eastern and Coastal Kent have a greater number of the population in contact with services (caseload) than both West Kent and Medway, fewer staff per head of population than in West Kent. Medway has fewest staff. These differences may be explained by the differences in service model, since Eastern and Coastal Kent has freestanding teams. Referral rates to teams could usefully be monitored locally as variations are not explained. Referral rates at PCT level show the same pattern in adults and older adults – lowest in Eastern and Coastal Kent, highest in West Kent, with Medway inbetween. The West Kent average is higher for adults than the Eastern and Coastal Kent districts with greater need. The explanation in West Kent could be more sources of referral (e.g. more GPs), lower thresholds or more requests from patients for referral. However, these numbers require local validation since the differences appear implausible for a service with clear capacity outlined in national policy implementation guidance. Analysis: ethnic origin The relationship between referrals and caseload is not consistent. Eastern and Coastal Kent has the highest caseload rate but the lowest referral rate. Medway has a lower caseload rate than the other localities. The ethnic origin of caseload in Eastern and Coastal Kent localities for which data was available was analysed. The coding of non-white groups is shown in the following table (with summary headings). 33 These relationships could reflect ‘treatment turnover’ (i.e. differences in numbers accepted, and length of time on the caseload) or referrer behaviour (e.g. not making referrals if teams are full). A lower caseload rate could reflect a focus on the service users with the most severe and complex needs. There is unexplained variation between numbers on assertive outreach caseloads in East, West and Medway. Eastern and Coastal Kent caseloads per staff member are higher than West Kent’s. Stakeholder views are needed to offer local explanations. Options for further analysis The rates in contact with functional community teams (EIS, and CRHT) can be reviewed. Inpatient referral rates can be reviewed. Data supplied by the Trust requires validation before this can be done. Caseload and team size could be systematically compared to review productivity. Further work could be undertakr to understand the ethnic origin of users of community service, for monitoring purposes. 34 9. USE OF ACUTE INPATIENT MENTAL HEALTH SERVICES BY DIAGNOSTIC GROUP HES data suppresses report fields where numbers are from one to five. Totals will therefore be lower than actual. The data rely on diagnosis and correct coding. Unlike KMPT data, HES admissions are for all PCT residents and will therefore include admissions to hospitals outside Kent and Medway. Rationale Inpatient services provide care and treatment for those who are most acutely unwell and most at risk. They are a recognised part of the acute care pathway. Use of inpatient services by the main diagnostic groups can illustrate the pathway for that group (by the proportion who are admitted). Differences between inpatient units and localities may also illustrate differences in need or responses to need. Diagnostic groups may provide indications of changes in the pattern of mental illness over time, or in the service response to new needs. Analysis The following tables analyse admissions by diagnostic code and specialty (using HES data) 2006/07. Table 25a: Hospital admissions for selected diagnostic groups ages 15 -64 PCT Medway Eastern and Coastal Kent West Kent Explanation of method KMPT provided information on diagnoses for adults of working age for two and a half years by locality, and (in line with the indicators suggested in the Association of Public Health Observatories report, Indications 7: Mental Health) a summary of rates of admission per 100,000 for selected diagnostic groups. Anxiety and depression Schizophrenia 127 60 303 263 Bipolar disorder 41 Total 228 103 88 610 484 204 133 Table 25b: Percentage of admissions for selected diagnostic groups ages 15-64 Limitations Diagnosis has two main limitations in this context. First, it does not correlate with severity or need, so that individuals with the same ICD 10 code may have different symptoms or needs. Second, the information depends on the diagnosis being recorded accurately. Often there will be a primary diagnosis and a number of secondary diagnoses. In addition, diagnosis can change over time. Where people are admitted to other providers, they would not be recorded in KMPT data. This is particularly relevant in relation to specialist services. The information provided by KMPT rates uses 2001 census populations. PCT Medway Eastern and Coastal Kent West Kent Anxiety and depression Schizophrenia 56% 26% 50% 54% 33% 27% Bipolar disorder 18% 17% 18% Within the limits of diagnostic categories, this analysis shows that about half the admissions for adults are for depression (Medway having the highest proportion) with about one third for schizophrenia (Eastern and Coastal Kent having the highest proportion.) 35 The following information has been provided by the Trust. The difference in the number of admissions requires validation. However, they are different years, with a different age range, in addition to the limitations noted earlier. Table 27: Diagnostic codes for specialist services Disorder Maternal mental illness ICD 10 code F53 Mental and behavioral disorders associated with the puerperium, not elsewhere classified Eating disorders F50 Anorexia and bulimia ADHD F.90 Aspergers F84.5 Table 26: Age Standardised Admissions (Consultant Episodes) ages 1674, 2007/08 and 2001 census population Diagnostic group Depression/Anxiety (ICD10 F32,F33,F40F48) Rate per 100,000 Schizophrenia (ICD10 F20,F21,F23.3,F25) Rate per 100,000 Bipolar (ICD10 F31) Rate per 100,000 Eastern and Coastal Kent West Kent Medway KMPT 328 67 295 64 103 54 726 64 311 64 206 42 245 53 180 39 91 48 69 36 647 57 455 40 Activity 7 admissions age over 18 years for Eastern and Coastal Kent in 30 months 2 admissions age over 18 years for Eastern and Coastal Kent in 30 months 1 admission age over 18 years for Eastern and Coastal Kent in 30 months 4 admissions age over 18 years for Eastern and Coastal Kent in 30 months These figures show that service users admitted to local acute inpatient services are not being recorded as having the above diagnoses, which relate to specialist services. KMPT does not provide such services. Secondary diagnoses also reveal little useful information. However, it cannot be safely concluded that people with these illnesses are not being admitted (eg with another diagnosis), nor that they are being appropriately treated in the community (since there is no information about community diagnoses in this report). When converted to a rate, the order between PCTs for schizophrenia is the same (East highest, Medway lowest), and the range for bipolar is similar. However, Eastern and Coastal Kent has a higher rate for depression and anxiety. The steering group for the project requested that the diagnostic codes for specialist services were reviewed. The results are as shown in the following table. The total numbers admitted will be compared with the prevalence estimates for these conditions following the update of the epidemiological and demographic needs assessment. 36 Conclusions The different sources agree that a large proportion (at least a third) of admissions are for depression, and that Eastern and Coastal Kent has more admissions for schizophrenia. Medway has the lowest rates for psychotic illness (schizophrenia and bipolar disorder.) The admission data used does not provide a systematic way of looking at the inpatient pathways for specialist services. It is not known whether records of community caseloads would contain diagnostic information. 37 10. SELECTED CARE PATHWAYS Table 28: Anxiety and depression admissions by specialty ages 15 -64 This section analyses admissions by specialty, Mental Health Act assessments, access to primary and secondary mental health services, and A&E attendances for intentional self harm. PCT Medway Eastern and Coastal Kent West Kent Source HES 2006/07 Rationale The needs assessment seeks to determine how far the current care pathways are meeting the needs of the population for assessment and treatment. Pathways relating to acute admissions and access to local community services are examined since they are stakeholder priorities. A&E and hospital 64 150 Mental health 63 153 64 199 This shows that a significant proportion of these admissions are coded to an acute hospital specialty, mainly A&E. The proportions of admissions for anxiety and depression to mental health and to other specialties varies greatly between West Kent and the other two PCTs, where they are equal. This suggests that local stakeholders should look into the operation of this pathway. Explanation of method The pattern of admissions by specialty was reviewed for selected diagnoses using HES data for 2006/07. The proportion of Mental Health Act assessments out of hours was obtained from the Trust for part of the current year. Additional information on local access to services was obtained from commissioners. Analysis: Mental Health Act assessments The following table shows the number of assessments under the Mental Health Act over 8 months. This includes all assessments for all ages and section 136 assessments. (Note; this is not the same as admissions under a section of the Act.) Limitations HES data suppresses report fields where numbers are from one to five. Totals will therefore be lower than actual. The data rely on diagnosis and correct coding. Admissions are for all PCT residents. They will therefore include admissions to hospitals outside Kent and Medway. ICD 10 diagnostic codes were for F32, F33 and F40-48: those for anxiety were not separately obtained but it is assumed that most hospital admissions will be for severe depression. Analysis: admissions by specialty The following table analyses hospital admissions for ICD 10 codes for anxiety and depression by mental health and other specialties (using HES data). 38 Analysis: access to primary and secondary services Table 29:Total number of MHA Assessments (Apr 08-Nov 08) West Kent (In Hours) West Kent (Out of Hours) Eastern and Coastal Kent (In Hours) Eastern and Coastal Kent (Out of Hours) Medway (In Hours) Medway (Out of Hours) TOTAL Apr May June July Aug Sept Oct Nov TOTAL 47 42 38 41 37 58 42 43 348 19 13 10 20 25 21 11 15 134 48 66 69 48 69 46 46 56 448 49 35 49 44 55 53 39 26 350 22 21 19 18 15 18 15 10 138 9 9 7 8 5 9 11 18 76 192 179 206 205 164 168 194 186 Information about access to local community services was given by commissioners as follows: Annual self assessment A summary of waiting times for psychological therapies A broad enquiry about use of A&E at Darenth Valley Hospital in Dartford Trust report against Key Performance Indicators (KPIs) for the five months of 2008/09 The waiting times for psychological therapies were reported from four providers. The average wait for assessment in KMPT services in December 2008 ranged from seven and eight weeks in Dartford and Dover/Deal respectively, to above 13 weeks in Swale, Medway and Mudstone and over 20 weeks in Canterbury. Review of returns from July 2008 showed that Canterbury waits had risen to December 2008 (dropping below 18 weeks in January 2009), and Medway and Maidstone had been consistent at about 12 and 15 weeks respectively, whereas Swale had fluctuated. In Eastern and Coastal Kent, KCA reported a range of waits from two to seven weeks, and CTL (the Counselling Team Ltd) reported waits from one to two weeks in Shepway. Commissioners are standardising their collection of activity information: activity and waiting time figures for independent sector and PCT provision were not available. Although only Canterbury showed waits above the national target of 18 weeks (which applies to some psychological therapy services), service users in three other areas were having to wait three months for assessment. 1494 This table shows fluctuation in the total number for each PCT and in the proportion between ‘in hours’ and ‘out of hours’. Even without adjusting for population size, it can be seen that Eastern and Coastal Kent has more assessments than West Kent, and that the proportion of out of hours assessments is greatest in Eastern and Coastal Kent. The following table shows the percentage of routine referrals to intake teams (adult community mental health services) assessed within four weeks (KPI 21, April to August 2008). There were 238 formal admissions to Eastern and Coastal Kent from April to September 2008. More work is needed to understand the reason for the difference in the recorded number of assessments and admissions. 39 Table 30: Percentage of routine referrals to secondary mental health services assessed within four weeks PCT Eastern and Coastal Kent West Kent Medway Table 31: intentional self harm, Eastern and Coastal Kent Hospitals Sept 2007 to August 2008 Per cent 66 63 69 Hospital Kent and Canterbury Hospital (KCH) Canterbury Queen Elizabeth the Queen Mother Hospital (QEH) Margate William Harvey Hospital (WHH) Ashford Total This shows that a third of routine referrals to secondary services wait more than four weeks. Although this waiting time does not apply to urgent and emergency referrals, it is still considerably below the expectations of commissioners and referrers. Eastern and Coastal Kent rated the primary/secondary care interface as red in the 2007 autumn assessment (the other two PCTs rated it amber, focusing on specific requirements for the indictor). Number 356 406 362 1,123 Ages are not given. There was one further admission to Deal, making a total of 1,124 in a year. This compares to approximately 6,500 referrals to adult CMHTs in Eastern and Coastal Kent per year. Details of 280 attendances at Medway Maritime Hospital between July and October (inclusive) were provided. 18 were aged 16 or 17. The following table shows the discharge destination of those over 18. Analysis: A&E attendances for intentional self harm In West Kent, an data enquiry by commissioners indicated that 851 patients attended A&E Darenth Valley Hospital in 2008 with the reason for attendance as recorded as Deliberate Self Harm (referred to by mental health practitioners as intentional self harm) , or 71 per month. In the first six months of 2008/09, Dartford CMHT received 456 referrals, ie 76 per month. However, these figures are not directly comparable since Darenth Valley A&E covers a wider catchment and the number of attendances presumably includes children and adolescents. Table 32: Discharge Destination Medway Hospital Mental Health Patients aged 18 and over July - October 2008 inclusive Discharge destination Admitted MASTT CDU Did not wait Discharged - no follow up HMP OPD Other SDTC Discharge field blank Total No information was provided about other hospitals in West Kent. In Eastern and Coastal Kent, commissioners have provided information for intentional self harm for a full year as follows. 40 Number 118 98 8 31 4 1 1 4 1 2 268 Numbers can fluctuate, but if there were 268 adult attendances in four months, an estimate of 800 per year would be possible. This compares to 2,800 referrals to adult CMHTs in Medway In secondary care, Eastern and Coastal Kent has a high number of emergency assessments under the Mental Health Act, which on the face of it corresponds with the greater need. A larger number of assessments also indicates a larger amount of staff time taken up doing them. The proportion of assessments out of hours varies: stakeholder views would be necessary to determine whether a high or low proportion of out of hours assessments represents a better service. It is unlikely that they are both desirable. Table 33: Admission Destination Medway Hospital Mental Health Patients aged 18 and over July - October 2008 inclusive Where admitted MASTT Emerald Medical Assessment Unit Observation Ward Ruby Sapphire Total Number 8 5 4 62 32 7 118 In Eastern and Coastal Kent and Medway, as many mental health admissions go to A&E as to mental health units. These patterns suggest the emergency pathway can be improved. Options for further analysis Further analysis could include: Review of age, gender by admission specialty and compulsory admission Review of average length of stay by admission specialty Analysis of A&E attendances by age. Section 136 assessments. Ruby are female-only beds, Sapphire are higher dependency and Emerald are mixed beds Taken together, the two previous tables show that nearly equal numbers were admitted or referred to MASTT, the assessment and short-term treatment team. Of those admitted, slightly more than half were admitted to the general hospital wards. This is consistent with the pathway identified in section 10. Of those admitted to mental health wards (which are on the same site) at least 32 of 44 were female. Conclusions From limited evidence, there appears to be poor access to primary care psychological therapies in parts of Kent. In addition, significant numbers of people who self harm present to A&E. The figures for A& E adult attendances are not systematically recorded, but may be 2,800 per year for five hospitals. 41 11. GEOGRAPHICAL DISTRIBUTION OF CMHT CASELOAD The Canterbury and Coastal Community Mental Health Team for Older People draws most referrals from the ‘Coastal’ (Herne Bay and Whitstable) rather than Canterbury postcodes. Rationale The needs assessment seeks to assess whether the services are used by those who are in the greatest need. Most of the caseload can be expected to live in the most deprived areas. Options for future analysis More fine-grained analysis of caseload and referrals may be available through tools such as Mosaic, which can map social characteristics of very small areas. Explanation of Method Analysis of referral flows to crisis and early intervention teams could show whether these services are drawing referrals from particular geographic areas. The postcodes of CMHT caseload were mapped according to the number from each postcode area, using the first three letters/numbers in the postcode, eg CT17. The results are shown in colour maps, which are reproduced in a separate document in appendix 5. Referrals by GP practice can also be analysed. Inpatient admissions can be mapped provided small numbers are suppressed to ensure individuals cannot be identified Limitations This method will show outliers, since it has a built in bias to reflect population density. Figures were not available for Medway and West Kent. This level of postcode analysis was used to ensure no service users could be identified. Analysis Tables and maps are shown in Appendix Five. Conclusion Whilst the maps show most referrals from towns, there are a large number of other postcodes with a small number of referrals from a wide area, including other localities. 42 APPENDICES APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX ONE: APPROACH TO COMPARISON WITH OTHER AREAS TWO: SERVICE MAPPING CATEGORIES THREE: CHARTS AND TABLES SHOWING INVESTMENT IN MAIN SERVICE TYPES FOUR: INVESTMENT IN SELECTED MENTAL HEALTH SERVICE STAFF GROUPS. FIVE: TABLES AND MAPS - GEOGRAPHICAL DISTRIBUTION OF CASELOAD 43 APPENDIX ONE: 2.3. APPROACH TO COMPARISON WITH OTHER AREAS Choice of a large number of comparators for a given authority is not always the most helpful approach, because: 2.1 INTRODUCTION Service and finance mapping information is collected by Mental Health Strategies on behalf of the Department of Health according to local implementation team (LIT) areas. It covers both health and social care investment, and a national average is generated. However, other data about mental health services is collected for different purposes according to different administrative units. A single PCT and a single local authority rarely cover the same area as a single Trust. 2.2 APPROACH TO COMPARATORS FOR KENT AND MEDWAY COMPARISON WITH AVERAGE FOR SIMILAR AREAS Service and financial mapping uses ONS clusters to generate an average figure for similar areas (LITs). These are shown for Kent and Medway PCTs in figure 1 following. The ONS clusters are a “best fit” from a broad economic picture: the individual authorities within the cluster are not necessarily good direct comparators for each other. Two sources identify comparator authorities: The CIPFA “nearest neighbours” database for local authorities The ONS 2001 area classification for health areas Both these show specific authorities which are statistically similar. (These are listed for Kent and Medway PCTs in figure 1 following). Unfortunately, as stated the boundaries of health areas (ie PCTs), local authorities and LITs frequently differ. Mental health providers differ in how they are organised, and do not necessarily provide the same services LITs often cover both urban areas and less deprived areas, or both unitary authorities and county councils, which are not appropriate for comparison A large number of comparators can be confusing and may imply more similarity than really exists amongst disparate areas For these reasons this report relies simply on the average for ONS clusters in order to provide an average across a large number of services, as described above. In terms of county councils, Kent is similar to both Essex and Hampshire (NB: Essex County Council does not cover the former South East or South West Essex areas comprising the unitary authorities of Southend and Thurrock) 2.4. SELECTED COMPARATORS Commissioners requested that comparators for each PCT be selected. This was done on the basis set out below. 2.4.1 Medway Medway is a unitary authority covered by only one PCT. However the closest local authority and health area comparators have no common members. The following have been chosen Plymouth – nearest neighbour local authority and a LIT area Swindon – same ONS group and also a LIT area East and North Hertfordshire and South West Essex are similar health areas in the ONS cluster but do not have a LIT. However, they would be suitable for comparison on ‘PCT-only’ measures which are not included in this exercise. 44 West Kent is a very similar health district and also provides a comparator. Table1: Comparators for Kent and Medway 2.4.2 Area Name Investment PCT West Kent National, ONS and Kent and Medway Medway Eastern and Coastal Kent National, ONS and Kent and Medway, Plymouth, Swindon National, ONS and Kent and Medway, Darlington West Essex, Mid Essex, Hampshire, East and North Hertfordshire East and North Hertfordshire, South West Essex Kent County Council Essex, Hampshire Eastern and Coastal Kent Darlington LIT has been selected since Darlington is rated extremely similar as a health district (as is North East Essex, which however does not have a LIT). For PCT based information, North East Essex would be a second comparator for future exercises 2.4.3 West Kent Extremely similar health areas are Mid Essex, West Essex and Hampshire. Mid and West Essex are now part of North Essex LIT (which also includes North East Essex). Both this LIT and Hampshire have therefore been shown as comparators. (Mid Essex is also in the same ONS cluster as West Kent). The corresponding PCTs, i.e. in Essex and Hampshire - with East and North Hertfordshire which is also extremely similar – are suitable comparators. 2.5. SUMMARY External comparisons for health and social care services and investment for each PCT in Kent and Medway are presented through: National average (England) ONS cluster average Comparisons within Kent, Medway and with North Essex LITs An additional comparator relating closely to each PCT Darlington, N E Essex n/a Table 2: ONS clusters relating to Kent and Medway Health area name West Kent Closest Medway South West Essex MID ESSEX Second closest WEST ESSEX Third closest Fourth closest EAST AND NORTH HERTFORDSHIRE HAMPSHIRE West Kent West Essex East and North Hertfordshire Eastern and NORTH DARLINGTON Suffolk Nottinghamshire Coastal EAST County Kent ESSEX Note: EXTREMELY SIMILAR districts are in capitals. Very similar are in lower case: Source: ONS Health areas 2001 This is shown in the following table. Please note that the PCT comparators are shown for information only. Very little of information used relates to PCTs – nearly all is based on LITs. 45 Table 3: ONS clusters for Kent and Medway PCTs Prospering Southern England –A Berkshire West Buckinghamshire Cambridgeshire Mid Essex Oxfordshire Surrey West Hertfordshire West Kent New and Growing Towns -A Bexley East and North Hertfordshire Havering Medway Milton Keynes Peterborough South West Essex Swindon West Essex Prospering Smaller Towns - A Bath and North East Somerset Bournemouth and Poole Bury Central Lancashire Eastern and Coastal Kent Solihull Care Trust South East Essex Stockport Trafford Vale of Glamorgan West Sussex Western Cheshire 46 APPENDIX TWO: SERVICE MAPPING CATEGORIES Adult service mapping 2007 - Kent and Medway services West Access and Crisis Services A&E Mental Health Liaison – Adult Assertive Outreach Team Approved Social Workers (ASWs) Crisis Accommodation Crisis Resolution Team Early Intervention in Psychosis Service Emergency Clinics / Walk-in Clinic Emergency Duty Team Homeless Mental Health Service Accommodation Services- other Adult/family Placement Scheme Board and Lodging Scheme Hostel Registered Care Home (18-65) Staffed Group Home Unstaffed Group Home Supported Housing Carers' Services Carers Support Group Carers Support Service Carer Support Workers Self-help, Mutual Aid Group for Carers Short-term Breaks / Respite Care Service Clinical Services 47 East Medway Acute Inpatient Unit/ Ward NHS Day Care Facility Psychiatric liaison service Psychiatric Outpatient Care Specialist Mental Health Services Peri-natal Mental Illness Service Mother and Baby Facility Community Mental Health Teams Community Mental Health Team Continuing Care Services - other NHS 24-hour nurse staffed care 24 Hour Staffed Care - Non NHS Registered Nursing Home Residential Rehabilitation Unit Rehabilitation or Continuing Care Team Day Services Day Centres/Resource Centre/Drop -in Education and Leisure Opportunity Employment Scheme Women-only community day services Direct Payments Direct Payment Home Support Services Home/Community Support Service Mental Health Promotion Mental Health Promotion Initiative Other community and/or hospital professional team/specialist Community Development Worker (CDW) - Black and Minority Ethnic Gateway Worker GP Counselling Service 48 Graduate Primary Care Worker Primary care mental health service Support Time and Recovery Worker 10. Personality Disorder Services Personality Disorder Service 11. Psychological Therapy Services- other Psychological Therapies and Counselling Services Specialist Psychotherapy Service Voluntary / Private Psychological Therapy and Counselling Service 12. Secure and High Dependency Services Local Low Secure Service - High Dependency Unit Local Medium Secure Service Local Psychiatric Intensive Care Unit Regional medium secure unit High Secure psychiatric hospital Services for Mentally Disordered/Ill Offenders Community Forensic Services Criminal Justice Liaison and Diversion Service Prison Psychiatric Inreach Service Support Services Advocacy Service Advice and Information Service Befriending and Volunteering Scheme Self-help and Mutual Aid Group Staff-facilitated Support Group Service User Group/Forum 49 Entry in 2007 service mapping Blank in 2007 mapping but entry in 2008 finance mapping Gap for further investigation 50 APPENDIX THREE: - CHARTS AND TABLES SHOWING INVESTMENT IN MAIN SERVICE TYPES Table 1: Kent and Medway and comparator LITs percentage investment in adult mental health services (£/per head) Carer's Services Clinical Services CMHTs Continuing Care Day Services Direct Payment Home Support Services Mental Health Promotion Services Other community and hospital professional teams / specialists Personality Disorder Services Psychological Therapy Services Secure and High Dependency Provision Services for Mentally Disordered Offenders Support Services Darlington Eastern and Coastal Kent ONS Cluster group Medway Plymouth Swindon ONS Cluster group Hampshire North Essex West Kent ONS Cluster group Nationally Accommodation PCT Access & Crisis Service Service Category 12% 8% 11% 12% 16% 9% 9% 15% 11% 4% 9% 11% 5% 13% 10% 17% 21% 7% 8% 6% 0% 5% 8% 10% 1% 1% 1% 0% 0% 1% 0% 1% 0% 0% 0% 1% 30% 16% 20% 20% 15% 9% 17% 16% 46% 16% 17% 20% 17% 21% 15% 14% 22% 12% 18% 23% 14% 20% 18% 15% 8% 11% 11% 5% 7% 9% 10% 12% 11% 5% 10% 11% 5% 3% 3% 2% 1% 3% 3% 4% 6% 4% 3% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 2% 2% 5% 0% 0% 1% 1% 0% 1% 1% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 6% 2% 2% 0% 2% 2% 1% 3% 0% 2% 1% 2% 0% 0% 0% 2% 3% 1% 1% 0% 1% 0% 1% 0% 4% 5% 4% 6% 6% 16% 5% 4% 0% 5% 5% 4% 8% 18% 19% 15% 6% 29% 25% 12% 11% 35% 25% 19% 0% 0% 1% 1% 1% 2% 1% 0% 0% 1% 1% 1% 2% 1% 1% 1% 0% 2% 1% 2% 1% 1% 1% 1% 51 Note: covers health and social care expenditure Figure 1 Direct Investment in Adult mental health services for Eastern and Coastal Kent, comparator areas and England (£/per head of weighted population) £160 Support Services Services for Mentally Disordered Offenders £140 Secure and High Dependency Provision £120 Psychological Therapy Services Personality Disorder Services £100 Other community and hospital professional teams / specialists Mental Health Promotion Services £80 Home Support Services £60 Direct Payment Day Services £40 Continuing Care £20 CMHTs Clinical Services £0 Darlington Eastern and Coastal Kent ONS Cluster group Nationally Carer's Services Accommodation 52 Figure 2: Direct Investment in Adult mental health services for Medway, the comparator areas, the ONS Cluster group and England £160 Support Services Services for Mentally Disordered Offenders £140 Secure and High Dependency Provision £120 Psychological Therapy Services Personality Disorder Services £100 Other community and hospital professional teams / specialists Mental Health Promotion Services £80 Home Support Services £60 Direct Payment Day Services £40 Continuing Care £20 CMHTs Clinical Services £0 Medway Plymouth Swindon ONS Cluster Nationally group Carer's Services Accommodation 53 Figure 3 Direct Investment in Adult mental health services for West Kent, the comparator areas, the ONS Cluster group and England £160 Support Services Services for Mentally Disordered Offenders £140 Secure and High Dependency Provision Psychological Therapy Services £120 Personality Disorder Services £100 Other community and hospital professional teams / specialists Mental Health Promotion Services £80 Home Support Services Direct Payment £60 Day Services £40 Continuing Care CMHTs £20 Clinical Services Carer's Services £0 Hampshire North Essex West Kent ONS Cluster Nationally group Accommodation Access & Crisis Service 54 Table 2: Kent and Medway and comparator LITs direct investment in adult mental health services (£/per head of weighted population Investment (£/head of the weighted adult population) Carer's Services Clinical Services CMHTs Continuing Care Day Services Direct Payment Home Support Services Mental Health Promotion Services Other community and hospital professional teams / specialists Personality Disorder Services Psychological Therapy Services Secure and High Dependency Provision Services for Mentally Disordered Offenders Support Services Darlington Eastern and Coastal Kent ONS Cluster group Medway Plymouth Swindon ONS Cluster group Hampshire North Essex West Kent ONS Cluster group Nationally Accommodation PCT Access & Crisis Service Service Category £12.4 £9.7 £14.7 £15.5 £21.5 £10.2 £11.4 £16.3 £13.6 £5.6 £11.4 £14.7 £5.6 £14.9 £13.2 £21.9 £28.4 £7.5 £9.9 £6.3 £0.0 £7.7 £9.9 £13.2 £0.7 £0.6 £0.7 £0.2 £0.2 £0.6 £0.3 £1.0 £0.1 £0.4 £0.3 £0.7 £30.7 £18.3 £27.0 £25.0 £20.3 £10.7 £21.3 £18.2 £58.9 £22.3 £21.3 £27.0 £17.5 £24.9 £20.4 £18.2 £29.3 £13.2 £22.3 £25.7 £17.8 £29.1 £22.3 £20.4 £8.5 £13.4 £15.3 £6.8 £9.6 £10.2 £12.2 £13.6 £13.7 £7.9 £12.2 £15.3 £5.1 £3.9 £4.6 £2.1 £1.5 £3.6 £4.2 £5.0 £7.8 £5.7 £4.2 £4.6 £0.3 £0.0 £0.3 £0.0 £0.0 £0.0 £0.0 £0.3 £0.0 £0.0 £0.0 £0.3 £2.6 £2.2 £3.3 £5.8 £0.0 £0.0 £1.7 £1.5 £0.3 £1.5 £1.7 £3.3 £0.0 £0.0 £0.1 £0.0 £0.0 £0.0 £0.0 £0.0 £0.0 £0.0 £0.0 £0.1 £5.9 £1.9 £3.1 £0.0 £2.6 £2.1 £1.4 £3.1 £0.2 £2.3 £1.4 £3.1 £0.0 £0.0 £0.5 £2.5 £3.4 £1.3 £0.7 £0.0 £1.2 £0.0 £0.7 £0.5 £3.8 £5.6 £4.9 £7.1 £7.9 £17.6 £7.0 £4.1 £0.0 £7.1 £7.0 £4.9 £8.3 £21.3 £26.3 £19.3 £8.0 £32.5 £31.9 £13.9 £13.6 £50.6 £31.9 £26.3 £0.3 £0.0 £1.5 £0.8 £1.5 £1.7 £1.5 £0.6 £0.5 £2.0 £1.5 £1.5 £2.0 £0.9 £1.6 £1.1 £0.0 £2.1 £1.5 £2.0 £1.4 £1.7 £1.5 £1.6 55 APPENDIX 4: INVESTMENT IN SELECTED MENTAL HEALTH SERVICE STAFF GROUPS Figure 4: WTE Staff per 100,000 of weighted population for Eastern and Coastal Kent, comparator areas and England 2007/08 20.1 Darlington 8.5 14.2 8.4 4.9 15.2 Eastern and Coastal Kent 1.6 8.3 2.9 10.9 Adult SW's 14.3 OA SW's 6.9 Adult Psychiatrists 19.7 ONS Cluster group 10.9 6.4 OA Psychologists 3.4 11.2 7.5 0 Adult Psychologists 16.4 17.7 Nationally OA Psychiatrists 7.2 10.5 14.6 4.3 10 20 30 56 40 50 Figure 5: East Kent and comparators: all nurses other than inpatient nurses per 100,000 of weighted population 90.2 247.3 Darlington 46.3 74.2 Eastern and Coastal Kent 89.8 Adult Nurses 65.7 OA Nurses ONS Cluster group 79.3 70.6 Nationally 0 50 100 150 200 250 57 300 350 400 Figure 6: West Kent and comparators: WTE staff per 100,000 weighted population 2007/08 18.9 Hampshire 8.5 6.3 1.4 19.8 3.4 15.6 North Essex 8.0 10.2 6.3 4.5 11.3 Adult SW's 20.7 20.9 West Kent 8.9 OA SW's 5.7 9.2 Adult Psychiatrists OA Psychiatrists 10.3 Adult Psychologists 18.2 14.6 11.4 ONS Cluster group 15.0 20.9 5.8 17.7 Nationally 11.2 7.5 0 OA Psychologists 10.5 14.6 4.3 10 20 30 40 58 50 Figure 7: West Kent and comparators All nurses other than inpatient per 1000 000 of weighted population, 2007/08 50.9 63.0 Hampshire 62.0 37.4 Hampshire North Essex axis North Essex 160 43.4 West Kent 160 ONS ClusterNationally group 160 160 160 29.9 West Kent Adult Nurses OA Nurses 81.8 70.0 ONS Cluster group 79.3 70.6 Nationally 0 20 40 60 80 100 120 140 59 160 180 200 Figure 8: Medway and comparators: WTE staff per 100,000 weighted population 2007/08 Medway 2.1 6.4 7.1 12.4 4.1 Plymouth 9.9 7.9 6.2 9.7 5.9 5.2 Swindon Adult SW's 22.7 OA SW's 15.8 4.5 Adult Psychiatrists 24.3 OA Psychiatrists 14.2 13.8 Adult Psychologists 4.1 OA Psychologists 17.6 ONS Cluster group 11.3 6.6 Nationally 13.9 20.0 4.5 17.7 11.2 7.5 10.5 14.6 4.3 60 Figure 9: Medway – all nurses other than inpatient nurses per 100,000 of weighted population 22.5 35.4 Medway 65.0 Plymouth 103.5 Medway Plymouth axis 180 21.6 Swindon 180 ONS ClusterNationally group 180 180 180 23.5 Adult Nurses Swindon OA Nurses 76.1 47.5 ONS Cluster group 79.3 70.6 Nationally 61 APPENDIX 5 Open Referrals by CMHT teams at 31st Oct 2008 Main postcodes of referrals Ashford TN23 TN24 TN25 TN26 TN27 TN30 TABLES AND MAPS - GEOGRAPHICAL DISTRIBUTION OF CASELOAD The tables opposite show the main postcodes of those on CMHT caseloads for adults and older adults, and the numbers in each postcode. In all cases, a large number of postcodes with 10 or fewer service users have been omitted from the tables, but are tinted on the maps in the section following (see key for details) CMTOP Intake 118 463 119 409 73 99 36 89 32 46 68 90 Dover DealCMTOP intake CT14 259 286 CT15 47 60 CT16 73 297 CT17 64 368 CT18 2 13 Shepway CT18 CT19 CT20 CT21 CT4 TN28 TN29 CMTOP Intake Thanet CT10 CT11 CT12 CT13 CT14 CT15 CT3 CT7 CT8 CT9 CMTOP N 227 192 105 56 32 11 70 157 147 362 46 122 176 163 11 57 69 Canterbur y& CMTOP Cant CT1 89 CT2 114 CT3 41 CT4 58 CT5 280 CT6 365 ME13 86 104 352 345 200 13 85 136 Intake S 192 75 40 9 4 1 10 13 43 692 69 399 248 84 29 11 108 99 78 138 Intake Coastal 411 50 280 31 46 8 73 11 83 239 88 302 187 110 Postcodes with 10 cases and below have been excluded 62 Referrals to Ashford CMHTOP 63 Referrals to Ashford Intake 64 Referrals to Canterbury CMHTOP 65 Referrals to Canterbury Intake 66 Referrals to Coastal Intake 67 Referrals to Dover/Deal CMHTOP 68 Referrals to Dover/Deal Intake 69 Referrals to Shepway CMHTOP 70 Referrals to Shepway Intake 71 Referrals to Thanet CMHTOP 72 Referrals to Thanet Intake North 73 Referrals to Thanet Intake South 74