How services are structured in Merton
South West London and St George’s Mental Health NHS Trust
The local mental health trust for Merton is the South West London and St George’s Mental Health NHS Trust. The Trust has its base at Springfield Psychiatric Hospital in Tooting, which houses inpatient wards. The community mental health services (run on a hub and spoke model) are based at the Wilson Hospital, with a community spoke provided in the west of the borough. The Wilson Hospital site is temporary and due for redevelopment under the Better Healthcare Closer to Home project. It has various other services but these do not include a GP practice. The structures for Merton includes an assessment service for all new referrals, three locality-based Recovery and Support Teams, an Early Intervention Service, a Personality Disorder Service and a Crisis Resolution/Home Treatment Team. About 2,500 Merton residents will be treated in secondary care, and 3,000 in IAPTs over any year.
When someone is referred to the Trust their first contact is with the Assessment Team, who assesses their needs and will either advise the GP about their treatment within physical care, or signpost them to the appropriate secondary care service. Referrals to the Mental Health Trust could come through GPs, the inpatient wards or other health services such as A&E.
Journey of a service user from referral to the Mental Health Trust to return to primary care.
People are admitted to the inpatient wards if they present a risk to themselves or the public that could not be managed in the community. As soon as patients are admitted, the Trust begins to consider their discharge and the services they can use after discharge from the ward. Information is given to patients and services are signposted where possible.
If someone experiences a psychosis for the first time, they will receive intensive treatment from the Early Intervention Service using a psycho-social model for a two-year period to help the service user to best manage their illness and to prevent their illness progressing further. Service users will then either be referred on to the Recovery and Support Team or, if they have stabilised, back to their GP.
Recovery and Support Team
The three Recovery and Support Teams in Merton provide on-going care for people with serious mental illness (SMI). The team is mainly staffed by community psychiatric nurses, social workers, doctors, psychologists, employment workers and Recovery and Support Team workers.
The nurses, social workers and occupational therapists will undertake the role of the Care Coordinators and establish an overview of the service user’s care; ensuring appropriate linkages are made into other services such as supported housing or social services.
There is a shift in approach at the moment, with Care Coordinators having a greater focus on enabling recovery and agreed outcomes within agreed timescales and specific goals for their service users – the intention is to ensure people’s independence wherever possible and for them to be supported in the least restrictive manner consequent to their needs. Care Coordinators see their service users about once every two weeks on average although this will vary according to the service user’s condition. In between these visits, the service users will be seen by their Recovery and Support workers. Most service users are seen in their homes but they may also come to the team base, especially if they need blood tests for their medication.
The Mental Health Trust tries to maintain consistency in providing care workers for service users but due to the impact of people changing jobs and restructuring this is not always possible.
The South West London Recovery College, operated by the Mental Health Trust, runs self-management courses to help service users to develop the skills to manage their own recovery. Carers and Community Mental Health Team (CMHT) staff can also attend the courses. The Recovery College approach is to help people recognise and develop their personal resourcefulness and the message is ‘hope’ – that service users can recover a meaningful life.
There are short introductory courses (half a day) and longer-term ones (three to 10 weeks, half-day weekly sessions) on, for example, spirituality and the five ways to wellbeing. There are also more practical courses such as an introduction to the Internet.
The college runs on a hub and spoke model with courses delivered both at Springfield Hospital as the hub and at a variety of places within the community – libraries, adult education centres and community halls across South West London. The community venue in Merton is Vestry Hall in Mitcham.
How care is structured
Care Plan Approach (CPA)
Each service user normally has a Care Plan Approach (CPA) review every six months. In this meeting, usually held with a consultant psychiatrist, views can be expressed, problems identified, progress discussed, medication reviewed and necessary changes made to the care plan.
Each service user also has a personalised care plan that should include identifying and achieving their recovery goals. These goals are agreed with the service users – they are about moving their life forward and building the life they want to live.
Care clusters and care packages
New mental health care clusters and care packages were introduced in April 2013 but have not yet been agreed at a national level as the model for contracting. The care clusters are groupings of service users that define their needs within super clusters – psychosis, non-psychosis and organic. Care packages are written descriptions of the care that service users in each of the care clusters will receive.
The care packages include information about the amount of time spent by different Mental Health Trust staff with the service user, therapeutic services that should be offered (e.g. ‘physical health monitoring and intervention’) and enabling services (such as the Recovery College – mentioned above). However, given the individuality of patient need, many patients do not neatly fit the prescribed clusters and their care plans will also vary as a result.
A snapshot review starts to give us a picture and to indicate what further work we need to do to start to understand local needs better. The analysis draws on information provided by mental health services at the South West London and St George’s Mental Health NHS Trust for the period July 2010 to June 2011. More updated data for the past five years from 2009-2013 has been made available but is currently under analysis as part of the Merton Mental Health Review. This analysis will be used to update the following section when available.
Age affects the type of caseload for mental health services. In older adults there is higher demand for acute services by patients with organic mental health conditions. These include conditions such as dementia and Alzheimer’s. In working age adults there, is a high demand for acute services by patients with schizophrenia or mood disorders.
Locally, because we have very little definitive data on the prevalence and incidence of mental health conditions, a detailed review of adult mental health services is under way in Merton, which includes a mental health needs assessment. The review will result in the development of an adult mental health strategy for Merton, and will be used to update the mental health section of the JSNA.
Breakdown of diagnosis for Merton inpatient admissions for adults and older people, South West London and St George’s Mental Health NHS Trust, Apr 2012- Mar 2013. The pie charts below show that for working age adults the commonest reasons for inpatient admissions were schizophrenia and mood disorders, while in older adults the commonest reasons were spread equally between schizophrenia, mood disorders and organic conditions including dementia.
Breakdown of diagnosis in the Merton Community Mental Health Team for adults based on average monthly caseload, South West London and St George’s Mental Health NHS Trust, Nov 2011- Oct 2012. The pie chart below shows that for adults the commonest condition for which they were seen was schizophrenia followed by mood disorders, neurotic disorders and personality disorders. The bar chart below shows the breakdown by age groups.
In Merton, schizophrenia and mood disorders are the most common cause of mental health admissions. However, it is unclear what proportion of these admissions are readmissions and so it is not possible to identify the prevalence of mental health conditions locally from this data. Schizophrenia and mood disorders also account for most mental health cases for the community mental health team (CMHT) in Merton. There appears to be a gender difference in conditions, with a higher proportion of the schizophrenia caseload being male, and a higher proportion of the mood disorders caseload being female. Psychoactive substance use accounts for 6% of acute admissions, a little higher in comparison with the contribution to the community caseload, which is 4%. This may be due to a number of reasons, e.g. that a high proportion of these admissions are readmissions or that patients who use psychotropic substance have more complex conditions (dual diagnosis) and therefore have greater need for specialist services. Further investigation is recommended to identify the specific needs of this group of individuals to assess if the balance of admission and community support is appropriate and to understand which services care is accessed through.
Merton’s use of Community Mental Health Services for adults by gender, Nov 2011-Oct 2012.
A breakdown of acute admissions data by ethnic group suggests that compared with the expected proportion of the population black populations are well represented. This may reflect a more ethnically diverse population in Merton or a greater increase in prevalence for mental health issues in ethnic minority groups. This suggests ethnic communities are accessing mental health services in Merton but further investigation is needed to understand whether ethnic minority groups are equitably diagnosed with mental health conditions, or are equitably accessing or have access to appropriate mental health services. This pattern is also seen in the ethnic breakdown for the CMHT’s caseloads in Merton.
Merton’s use of Community Mental Health Services by ethnic group, Nov 2011 to Oct 2012
Merton’s inpatient admissions for working age adults by ethnic group, Mar 2012- Apr 2013.
Merton’s inpatient admissions for older people by ethnic group, Mar 2012- Apr 2013.