Kent and Medway Joint Strategic Needs Assessment – Mental Health

Transcription

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.
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
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
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
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.
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
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).
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
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.
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
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
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.
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.
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
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
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.
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
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
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
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
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
West Kent
Older adult caseload
Medway
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
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
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.
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
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.
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
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.
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
and Medway, Plymouth,
Swindon
and Medway, Darlington
West Essex, Mid Essex,
Hampshire, East and North
Hertfordshire
East and North Hertfordshire,
South West Essex
Kent County Council
Essex, Hampshire
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
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
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
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
£100
Other community and hospital professional
teams / specialists
Mental Health Promotion Services
£80
£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
£140
£120
£100
teams / specialists
£80
£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
£140
£120
£100
teams / specialists
£80
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
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
Other community and hospital
professional teams / specialists
Secure and High Dependency
Provision
Services for Mentally Disordered
Offenders
Support Services
Darlington
ONS Cluster group
Medway
Plymouth
Swindon
ONS Cluster group
Hampshire
North Essex
West Kent
ONS Cluster group
Nationally
Accommodation
PCT
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
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
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

Kent and Medway Joint Strategic Needs Assessment – Mental Health

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