NHS Sheffield Clinical Commissioning Group

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Answers to Q&A session 2017

Below is a summary of the question and answers received in advance of our annual public meeting and also on the day. Our panel for the session was Dr Tim Moorhead Sheffield GP and chair of Sheffield CCG, Accountable Officer Maddy Ruff, Medical Director Zak McMurray, Director of Commissioning and Performance Brian Hughes and Acting Chief Nurse Mandy Philbin.

Questions relating to an individual’s care or treatment are responded to directly.

When a concern/issue about a certain service is brought to your attention, are there specific procedures for dealing with this, if so what are they? (Sheffield College)

We have a specific complaints department which deals with all complaints and compliments about services we provide and commission. This process is led by legislation which is The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.  We try to respond to all complaints within 25 working days of receiving them and work with complainants to ensure they are satisfied with the timescales we are working within. Our Accountable Officer sees every complaint and signs every one.

If it is a complaint about a primary care service such as your GP, dentist or optician then we will re-direct the complaint to that service provider. If you are unhappy about the response you receive you can then take it to NHS England for a further review.  If it is about a service such as your local hospital, mental health service, out of hours service, funding for continuing health care or another service which we commission then we will be the lead investigator. If it is a complaint about multiple organisations then it will be investigated jointly, with one of the organisations leading on it.

Once the complaint has been investigated and responded to, any lessons learnt from the investigation will be shared with the teams and improvements made to the services.  If the complainant is not satisfied with the response they have the right to take their complaint to the Parliamentary and Health Service Ombudsman, which is independent of the NHS. Or if it is social care they have the right to take their complaint to the Local Government Ombudsman (LGO), which is independent of local authorities and care providers.

Where in the NHS system is there access for 16-18 year olds to get help with mental health issues? (Sheffield College)

Your GP can help you by assessing your need and deciding decide which services you need. Your school or education setting can also advise you on which service you need to access and how to do it. For example they might suggest you need support on your mental health from a Council service such as the Multi-Agency Support Teams or Education Psychology. Mental health services and support for 16-18 year olds are generally through CAMHS (child and adolescent mental health services). We are also investing in community services who can provide support for children and young people who need mental health support, but who’s need isn’t high enough for Community CAMHS teams. For example, we have the Youth Information and Counselling Service at Star House in Sheffield City Centre which is available up to the age of 25 and you don’t need a referral to access it – you can walk in.

We have recognised that the system is complicated and we are trying our hardest to simplify it and make it easier which is why we developed the Sheffield Let’s Talk Directory which you can find on our website – this is a guide to emotional wellbeing and mental health services for children and young people.

When ringing an ambulance for an emergency why is the amount of time in minutes rising for them to get to the incident? (Sheffield College)

We think there is a perception that ambulance response times are rising but actually it is because the ambulance service is now working differently. People are aware of the eight minute response time when it is a serious/life threatening health problem this is the response time given. However, lower response times are given depending on the patient’s health condition and this is decided when a patient calls 999 by the information they give. If the urgency is less the response time might be greater so that the ambulance service can priorities on the basis of need.

What you can you do about improving staff attitudes to mental health crisis, when we repeatedly come across attitudes that make us feel marginalised? Following one young person’s experience in A&E when a member of staff said they were ’too busy sectioning people.’ (Chilypep)

We are providing a range of training sessions (see training and resources section) to professionals in Sheffield working in schools, colleges and the third sector. Training available includes Youth Mental Health First Aid, supporting eating disorders and self-harm prevention. In partnership with Chilypep we launched the #notheonlyone campaign which aims to reduce stigma around mental health. We are developing a workforce development strategy for organisations across the city to support staff to better support mental health. Part of this strategy will involve the development of a universal training module on mental health that any professional can access.

How can you help with campaigning against the cuts to NHS services? (Chilypep)

We are not allowed to be political as a CCG but we take every opportunity to campaign for resources for Sheffield and get the most funding we can for the city of Sheffield.

How can you allow young people and adults to have more control over access to services? (Chilypep)

We are trying to work more closely with children, young people and families to co-produce (develop together) how services are available in community settings and more person-centred planning – which means giving young people and adults more choice and control over their care. We’re also looking at introducing new access routes such as self-referral which will also give young people and adults more control over access.

Why are services so isolated from each other? (Chilypep)

We know that services can seem isolated from each other, this is normally a result of different services being set up and managed by different people. This is because the funding we receive for mental health services isn’t all in one place.  To overcome this, we’re working hard on bringing different groups and services together. For example the Healthy Minds Framework is improving links between CAMHS services and schools. The groups that lead our work are also made up of people from different organisations.

Our plan for mental health is also supported by people from lots of different services and they are working together to improve communication across the system. We’re also developing a mental health passport with Chilypep, this should allow a young person to keep a record of their story and mean they can share with each service they go to – to avoid having to tell their story repeatedly.

We know that communication in the system can be frustrating and cause problems, it will continue to be our priority to improve it and make our services as easy as possible to use for young

How can young people access more support through schools? At the moment, the quality of support depends on which school you go to. (Chilypep)

We are currently rolling-out the Healthy Minds Framework in a phased approach to all primary and secondary schools. The Healthy Minds Framework involves our CAMHS staff delivering training and support in schools. The content of the training and support is based on a school’s needs. The phased approach means we will be delivering in approximately 40 schools per year. We’ve taken this approach as it would be difficult to recruit enough staff to deliver to every school at once. The phased approach also means we can adjust what we deliver as time goes on – as we learn what works well and what doesn’t. We’re also working with the Council’s Multi-Agency Support Teams and Education Psychology teams to help improve mental health support in schools that don’t have Healthy Minds yet. We’re also providing free training on mental health which all schools can access. Our workforce development

What’s your view on the bursary for the nursing course being taken away? (Sheffield College)

This is something that is out of our control but we need to think how we build good services for the future and the nursing role is paramount in this. We also need to make Sheffield an attractive place for people to come to, to work in healthcare.

How does the transition work for services from 16 to 18-year-olds? (Sheffield College)

For mental health services CAMHS (Child and Adolescent Mental Health Services) would arrange the transition to adult service. For a lot of services, not including mental health, the boundary is not important eg ENT (Ear Nose and Throat) deal with children and adults.

Why does it take so long for emergency services to respond to elderly emergency buttons? (Sheffield College)

People use the button for a whole variety of reasons so it goes to a call centre and there is a conversation to understand the problem. If someone has fallen or is injured, the emergency services would be called immediately.

How effective has the joint work been in reducing delays in transfers?

We have been working with Sheffield Teaching Hospitals and Sheffield City Council as none of the three individual organisations could have sorted the problem on their own. We meet twice a week and work together, clinicians, social workers etc, to try to make it as simple as possible for people to get home. As a result of this work there has been a significant reduction in beds being held up.

Changing Faces is a charity part-funded by NHS England – how can we get involved with GPs to speak to them and educate them?

We can help you get in touch with GPs through our bulletin and through events.

Will joint working across health and social care involve similar training, for example infection control?

Joint training can be difficult to facilitate but there is national guidance on infection control.

I’m concerned about the way that doctors express things to relatives and communicate bad news.

A significant part of training for medical students today is communications, whereas there was very little training about 30 years ago. If you have concerns about the way a particular service has communicated with you or a relative, you could contact their complaints service or Patient Advice and Liaison Service.

The Chilypep model of working is a model that could apply to other generations. Would you think of ways of reaching more of our citizens for example through libraries?

We have formal consultations, for example around urgent care services and processes for ensuring we engage with the public but there are always grouped of people we can’t reach and we need to find innovative ways to do this. The Chilypep work is inspiring and we also work closely with organisations such as Healthwatch who help us reach people such as the homeless and other hard to reach groups. As part of the urgent care consultation we are also doing work with libraries, taking information to people wherever we can.

With all the changes taking place as part of improved joint working a lot of information will be lost to the public – are you planning a website or branding?

One of the things we have talked about is a new website for the Accountable Care Partnership and information about what we are doing, changes and pathways, in a way that is easy to navigate for people and then links them through to other websites.

What is the CCG doing to identify young carers before crisis hits them, as they can be a hidden group? And is social prescribing available for children as well as adults?

GP practices are supposed to have a register of young carers as well as adult carers and we are also trying to connect with the right people to make sure young carers are identified. Social prescribing is led by the local authority, and the lead is keen to have a whole life-cycle approach to social prescribing.

Can people who have lived with mental health issues help develop the nature of support in Sheffield?

Absolutely, we need to do genuine co-production of services and there are lots of levels and layers of participation in the city.

When does the Gluten Free prescribing consultation end and if you saved £3m last year why are you trying to save £100,000 from people who need it? Are there any savings for the last two years?

The consultation, which relates to Gluten Free prescribing for adults only, ends on October 20 and it will be a very difficult decision to make. Savings have been made over the last two years and the savings from changing the prescribing guidelines would make a difference.

How do you measure success? Without turning it into a numbers exercise. How can you be sure you’re measuring the right outcomes? (Chilypep)

We use a combination of both numbers and patient feedback to measure success. We look at numbers such as waiting times, number of sessions offered etc. We also look at before and after scores submitted by young people, these tell us whether they felt the support they received helped them.  We also ask young people, parents and families for feedback and for the help of organisations such as Chilypep to help us measure success.

Why when we started several years ago, as the CCG became an entity, have we got no further with co working with Social Care services as described through the Right first Time project? This is asked as it is widely accepted that investment in preventative services is very cost effective rather than the resort to hospital care, which is the route taken due to the lack of preventative care via social care in all its forms. The old saying “a stitch in time saves nine,” there is always truth in these proverbs as the cost of one night in hospital is far greater than one day of care via social care. 

The Right First Time partnership in Sheffield was innovative for its time and saw the whole system starting to work more closely together. This meant that we were in a really strong position when the Five Year Forward View was published in 2014 as Sheffield had already started a lot of the work set out in the vision. Because of this work we now have a very close relationship with Sheffield City Council and are already integrating health and social care services

This can be seen through our ‘neighbourhood’ working which sees groups of GP Practices work together to coordinate health and social care for people in their local area, and consider how to make the best and most effective use of local services.

This can also be seen through integration of the short term intervention team (STIT), which is part of the Council and Community Intermediate Care Service (CICS), which is part of Sheffield Teaching Hospitals. The two teams used to work independently of each other with separate assessments but are now one team, with just one assessment for patients to realise their needs.

A lot of work has also been done around preventative services through our Active Support and Recovery programme. This looks at a number of preventative areas such as care plans, risk assessments and keeping people at home where appropriate.

The Sheffield Accountable Care Partnership, which is as partnership of all the Sheffield NHS organisations, Council, charity, voluntary services and others, is the vehicle that is now accelerating all of this work to further integrate health and social care. We are in a strong position to take this forward because of the work started through Right First Time.

The following question comes from a group of people from Sheffield with lived experience of mental health problems, all of whom have been involved in user controlled mental health groups at local and national levels for more than 20 years.How many people are turned down/referred somewhere else? (Chilypep) 

Sheffield has a proud history of providing mental health support and services through groups that are controlled by people with lived experience of mental health problems. For example, individuals from the city played a major role in the development of the Hearing Voices movement in this country and the UK Advocacy Network, which developed and promoted the core principles of mental health advocacy, was based in Sheffield for 12 years. Local service user/survivor researchers have helped us to understand the experience and self-management strategies of people living with long-term depression and a large number of community based, user led mental health groups have operated in the city over the past 30 years. The National Survivor User Network (NSUN) Annual General Meeting and event will be held in Sheffield the day before the CCG's annual public meeting, bringing service users from all over the country together, with a particular focus on sharing the experience of local user led organisations and identifying issues of relevance to them at a national level. Currently, Sheffield is the home of people with lived experience of mental health problems who hold national positions with a range of organisations operating in the fields of health and social care, including the British Psychological Society, Mind, NSUN, SCIE, the Royal College of Psychiatrists, National Development Team for Inclusion, Shaping Our Lives and the National Institute for Health Research. Sheffield based individuals are responsible for conducting widely respected survivor research and hosting internationally acclaimed campaigns for people diagnosed with borderline personality disorder. Despite the withdrawal or reduction of funding from health and local authority commissioning agencies, a number of user controlled mental health groups continue to operate in Sheffield, including Your Voice, MHAGS and Survivors of Depression in Transition. As representatives of these groups and individuals who have been involved in genuinely user led activities for many years, we maintain that people with lived experience of mental health issues should determine the nature of support and services in Sheffield because we know what works best. To what extent does the CCG agree with this position and what plans does it have to demonstrate its commitment to this ideal by providing funding for user led groups?

We absolutely agree that the people with lived experience of mental health issues can and should take a significant role in determining the nature of support services in Sheffield, based on their own experience of what works best for them.

It is our over-arching desire to work collaboratively and increase the involvement of people with lived experience of mental illness through genuine co-production. We cannot get away from the fact that we are in the early stages of learning to do this effectively.

We base our commissioning decisions on what is determined by national strategies (which themselves have been developed through co-production), NICE guidance and other evidence sources, including the views of local clinicians with expertise in the field of mental health and their local evidence of practice, to commission a comprehensive range of services and interventions, to serve the population as a whole.

In relation to service user engagement, we have the Mental Health Partnership Board which has service user representation, and seek the views of services users through the Sunrise Group which is funded by CCG through Sheffield Health and Social Care Group, and through Flourish, which is funded through our co-commissioners in the Local Authority.

We also seek the views of service users through engagement on specific projects, through stakeholder engagement, for example through the Service Improvement Forum with Local Authority, and through partnership working with Healthwatch. We will pursue partnership working in all areas that lead to better outcomes for the population we serve.

I've recently read an article by Julian Mellentin regarding health professionals struggling to let go of the negative view about dairy fat which we now know had never any basis in science, I would like to ask two questions of your panel of Directors and GPs:

1) Are all health professionals now fully informed of the latest evidence and actively re-educating the public to correct years of miss information?

2) Is the NHS using butter in the hospitals catering instead of margarine? I think this is a great opportunity for health professionals to repair the negative view that's been wrongly created about dairy fat and I hope you do too.

We’d like to thank the Head of Dietetics at Sheffield Teaching Hospitals, Jane Kingsley, for her help with information to reply to this query.

As evidence about diet and health is published and reviewed, it is considered by expert scientific panels periodically and incorporated into national policy and NICE guidelines. Health professionals try to ensure that advice is based on evidence.

When educating health professionals or the public, dietitians recognise that it’s important not to demonise any one food and to consider the overall quality of the diet and personal preferences. Emphasis is on trying to avoid high total fat/ saturated fat intakes which can result from poor choice of snacks /excessive snack foods/ over reliance on processed foods or takeaway foods etc. Messages for the public often incorporate ‘everything in moderation’ principles and this applies to butter as well as other foods.

In terms of use of butter in NHS Catering – caterers follow national guidelines including those published by Public Health England ‘Government Buying Standards for Food and Catering Services’; and ‘Healthier and more sustainable catering : nutrition principles’. In line with national guidance, at STH margarines are used in most recipes but butter is offered to patients as a choice of spreading fat. Use of fats in cooking is based on the guidance and also takes into consideration other factors such as ease of use and cost.

How can you make sure we, and that people we meet, know what services are out there for young people – schools, nurses, police, GPs etc.? (Chilypep)

The Let’s Talk Directory provides an overview of all the mental health services in Sheffield for children and young people. You can also use the Sheffield Mental Health Guide and Sheffield Directory. In the future we will draw all information on children and young people’s mental health services onto a single website. Both the Sheffield Mental Health Guide and Sheffield Directory are being redesigned at the moment, once this is complete we will look at how we put all our information in one place. When we do this, we will communicate through Twitter, Facebook, our website and GP newsletters about the changes.

What’s the criteria for accessing services? (Chilypep)

There are different criteria for different services to ensure people get the right support when they need it. To access a service you will be assessed by a professional who will then work out which service you need.

How many people are turned down/referred somewhere else? (Chilypep)

In Community CAMHS, if someone is inappropriately referred to the service (their level of need isn’t right for CAMHS), the service will direct that person to a different service, such as the Council’s multi-agency support teams. In 2016/17, 21.5% of referrals (638 out of 2971 referrals) to our Community CAMHS service were re-directed to a different service. These referrals are young people who need mental health support from a different service that isn’t Community CAMHS.  We want to reduce the number of re-directed referrals by increasing support at an earlier stage and giving professionals better information and training on which service to send a young person to. If we don’t buy the service people can make a special request know as an Individual Funding request via their GP which is considered by a panel of clinicians.

How can we find out who our care co-ordinator is? (Chilypep)

Your GP should be able to support you to find this. If you’re in the Multi-Agency Support Teams you will have an assigned worker.  In Community CAMHS there will be a senior doctor responsible for your case.

In my shoes how would you feel if you didn’t know who was making decisions about your care; you didn’t know what treatment/therapy was given and why; you didn’t know what the options/alternatives were; you had to access 5+ services and none of them linked together; you were waiting for months to access a service and not getting updates about the progress of this; you didn’t have access to the private information that was written about you; you couldn’t access or control information written about you? (Chilypep)

We completely get this – this is about person-centred care. We are working across the city with our partners to link up education, health and care and doing a great deal about person-centred planning – putting people at the centre of decision making and care planning. We’re currently developing a project where personal health budgets will be provided to vulnerable young people to help give them more control over their care. We’re trying to improving the communication of our services by introducing services such as text message reminders. We know that the issues raised in the question exist and we’re working hard to address them through our transformation programme for children’s mental health. Our transformation plan is all about making services easier to use and access and much more young person friendly.

How can we make sure CAMHS and AMHS are more joined up (same notes system)? (Chilypep)

We are working together across children’s and adults services with the providers of these services on care pathways to improve the transitions arrangements from one service to another.  A joint transitions group is now place for children’s and adults mental health services which Chilypep is part of. This is to help the services be more joined up.

How much is spent in Sheffield on children’s mental health services? 

Sheffield CCG spend on Child and Adolescent Mental Health Services, or CAMHS, in 2016/17 was £4.9m. This figures does not include mental health services provided by Sheffield Health and Social Care NHS Foundation Trust which provides pychosis services for children over 14 and general mental health services from age 16 as spend is not broken down by age.

The latest submissions to NHS England indicate that our spend on CAMHS is about average for the country’s CCGs.

It is important to note that spending on children’s mental health does not only sit with the CCG – NHS England and Sheffield City Council also finance Child and Adolescent Mental Health Services which brings the total for the city to more than £10million.

Why has funding to primary care services been cut or remained stagnant when we are hearing a narrative from central government around having more funding and services located at primary care providers in order to ease the burden on acute services? (Could you answer with some reference to AMPS contracts please).

Funding for primary care services has increased. Sheffield CCG has had delegated responsibility for primary care commissioning with effect from April 2016, inheriting the budget previously managed by NHS England. In 2017/18 we received a 1.8% or £1,375k increase in that budget, although this is less than the national average increase of 3.1%  as we are deemed to be “over target” using the national funding formula.  Our financial plan showed that this would be fully committed for primary care services other than the 0.5% we have to retain as an uncommitted reserve in line with NHSE requirements.   The uplift has funded the inflationary contract uplift agreed as part of national negotiations and pressures such as list size increases and rent increases.  In addition the CCG is receipt of funding for specific initiatives as part of the GP Five Year Forward View. We have for example just received confirmation of £1 per head (approx. £0.6m) to support the establishment of primary care networks (we term neighbourhoods) in 2017/18.

In addition to the national funding, Sheffield CCG has increased its funding into locally commissioned primary care services over the last two years by over £3m, making funding available to practices to engage in for example our CASES project on elective care, improvements in clinical and cost effective prescribing  and working together in neighbourhoods.  Over the two years 2017 to 2019 all CCGs are required to make available non recurrently £3 per head to support resilience and transformation in primary  care and we are working with our Practices on the best ways to utilise this funding.

In relation to contracts with GP Practices for core services and this covers contracts which are APMS, PMS and GMS, the CCG has increased or decreased funding to individual practices to bring ALL practices towards the nationally agreed funding per patient. 2018/19 will see the end of various transition arrangements.  In Sheffield this resulted in approximately £3m of resources being “freed up” through this national policy.  The CCG agreed that this would be “recycled” into primary care on an equitable basis with all practices being offered an new Locally Commissioned Service contract which in 2017/18 was at £5 per head in return for the practice agreeing to undertake certain services above core.  The CCG also recognised that the migration to a standard funding level per patient potentially presented significant challenges to some practices. The CCG approved a special cases policy which allowed any practice (APMS, PMS or GMS) to make a case under rules set out by the CCG for additional funding. Essentially this sought to address issues where practices have a population that make up at least 10% of its list size with particular needs and where these needs are not fully recognised in the national formula. Funding has been awarded to a number of practices in the city.

NHS Sheffield Clinical Commissioning Group

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