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Under scrutiny


23 February 2015

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As Chair of the Commons’ Health Select Committee Dr Sarah Wollaston argues that prevention of NHS financial ill health is better than cure. She talks to Victoria Vaughan

There was only one real candidate to replace Health Select Committee (HSC) chair Stephen Dorrell when he resigned in June 2014. After all, not many politicians can claim actual experience of working in the health service. And former GP Dr Sarah Wollaston spent 24 years at the NHS coalface, before entering Parliament in 2010 as the Conservative Party MP for Totnes in Devon.

As Chair of the Commons’ Health Select Committee Dr Sarah Wollaston argues that prevention of NHS financial ill health is better than cure. She talks to Victoria Vaughan

There was only one real candidate to replace Health Select Committee (HSC) chair Stephen Dorrell when he resigned in June 2014. After all, not many politicians can claim actual experience of working in the health service. And former GP Dr Sarah Wollaston spent 24 years at the NHS coalface, before entering Parliament in 2010 as the Conservative Party MP for Totnes in Devon.

It’s a role she’d coveted since entering Parliament. “I came in with a passion for health, and particularly public health”, she says. “But when you arrive here you realise how extraordinarily difficult it is, as a single backbencher, to change fundamentals of policy.” At the same time, she didn’t have a burning desire to climb the greasy ministerial poll (“you have to be prepared to agree publicly and support every decision that has already been made”). So that left only one way to make a serious difference: the “scrutiny route”.

To this end, her focus as Chair is to ensure the HSC lays down “strong markers” for the next government.

This started with the Committee’s first inquiry under Wollaston, Children’s and adolescents’ mental health and CAMHS, published in November 2014 and currently awaiting a response from the government. It called for NHS England and the Department of Health to monitor and increase spending levels to raise standards, but she adds that “the main driver needs to be towards prevention and early invention”.

In particular, Wollaston, who before working as a GP had been a forensic medical examiner – and has therefore “spent a night in the police cells” – is deeply concerned about the lack of appropriate places of safety for children experiencing an acute mental health crisis. “People sometimes do not believe me when I tell them that there are children as young as 12 and 13 in the West Country, having an acute mental health crisis, who are being seen in a police cell because there is no medical place of safety for them.

“In Devon and Cornwall constabulary area [this was the case for] 30 children in the last year. We are the worst area in the country for doing this”.

Wollaston is an advocate of parity of esteem between mental and physical health, which means valuing both equally. She says, “Investing money upfront in mental health and prevention, in public mental health, does save the system money. There is no doubt about that. And we know, for example, that liaison psychiatry helps to reduce the number of revolving door re-admissions into the secondary sector”.

Wollaston also believes there should be the same waiting times for those with a mental health condition as there is for those with a physical health issue. And that there should be early intervention for people with episodes of psychosis.

She says that the frustration for commissioners is the “perverse incentives” around a child being admitted as it comes under a different budget.

“Tier 3 plus is the area which refers to assertive outreach – what you do short of admitting someone to a bed. Tier 4 comes under NHS England but Tier 3 is under local commissioners.

“It turns out, due to the way that the system was designed, that Tier 3 plus,
that assertive outreach, does not seem to fall under anybody’s responsibility,” she says, adding that it is an “abnormality in the system” due to the Health and Social Care Act.

Tier 3 plus services can act as a bridge between inpatient services and community services, aiming to prevent the need for an admission, or facilitating more swift discharge back to the community. After hearing from key witnesses the HSC suggested that  this area might be a more useful focus for investment rather than inpatient services.

Peter Hindley, chair of the Royal College of Psychiatrists, told the HSC that young people “will not necessarily need to be admitted if they are assessed quickly and can be linked into appropriate community service”.

“You can often avert a crisis with a good out-of-hours assessment,” he said.

Dr Vinod Diwakar, Chief Medical Officer, Birmingham Children’s Hospital NHS Foundation Trust gave an example of the positive impact an out-of-hours emergency response team has had in his area.

“When you present in crisis there does need to be 24/7 access to an emergency response team, which we have. Now we can react quickly, before we had that service, a child would be admitted and I, as a paediatrician, would go and see them the next day. I do not have a lot of mental health training and would have to say, “I am sorry, you have to wait for the psychiatrist. Because they only came twice a week, this wasted an in-patient bed and also proved to be very frustrating for the young person.”          

However, the CAMHS Benchmarking report, initiated by the NHS  Benchmarking Network, says that less that 40% of services offer rapid access through crisis pathways. So access varies widely across the country.

Paediatric liaison services – which are multi-disciplinary child and adolescent mental health services provided in acute hospital settings – are a possible solution to the lack of care available in this area. However, as Wollaston says the “lack of clarity” around who the responsible commissioner is for these services, is a problem. Trusts often do not commission these services adding difficulty as they are delivered through A&E and paediatric wards which serve non local patients so who pays for these patients becomes an issue.

The division of commissioning responsibilities between NHS England (responsible for commissioning Tier 4 services) and CCGs (responsible for commissioning Tier 3) means there are now no incentives to fund Tier 3 plus services, and that there are also fewer incentives for Tier 4 providers to discharge their patients in a timely manner.

Dr Madhava Rao, Associate Clinical Director for CAMHS, Black Country Partnership NHS Foundation Trust explained how the change in commissioning arrangements has the potential to undermine progress in developing Tier 3.5 services.

“Three years back, before the division from the CCGs and NHS England was brought about, the CCGs – then the primary care trusts (PCTs) – were asked to top-slice some amount of their budget to form a regional fund to create beds… [for a] Tier 3 plus model.

“But, once this divide comes through from the CCG and NHS England, that same commissioning body will say that Tier 3 plus is a CCG problem and the CCG will say that a lack of beds is an NHS England problem.”

The Committee called for the “perverse incentives in the commissioning and funding arrangements for CAMHS” to be eliminated to ensure that commissioners invest in Tier 3 plus services.

It urged the Department of Health and NHS England to ensure all areas had clear ways to access funding to develop such services in their local area, where appropriate.

It said that the current fragmented commissioning arrangements make “no sense”, and are “dysfunctional” and called for integration for better use of resources. 

Wollaston pointed to this as one of the reasons that any further reorganisation of the NHS would be detrimental.

She says “we are picking up the abnormalities in the system after the passing of the Health and Social Care Act. The last thing we need now is another reorganisation. We have got to let the system as it is evolve, and we have got to allow commissioners working local area teams and NHS England nationally, to sort out where these should lie and move towards allowing more co-commissioning. I think it would be a big mistake to throw the cards up in the air and say, ‘We’ll start again’”.

More broadly, Wollaston says the NHS has “coped extraordinary well” in dealing with the demand to make £20bn in efficiency savings by this year, also known as the ‘Nicholson Challenge’ after the previous NHS chief executive Sir David Nicholson laid down the target.

For Wollaston this is a “crunch year” and “all the canaries in the mine, the markers for stress in the system, are starting to fall”, citing the 70% of acute sector providers that are expected to end the financial year in deficit. “We are starting to see signs of stress on the commissioning side of the equation. If you look at some of the markers – from time-to-treatment in cancer, time-to-first-treatment for other referrals, waiting times for A&E… most people who are looking at health services finances, recognise that it is going to be very difficult for levels of efficiency to carry on at the current pace without that starting to cause further stress in the whole system. And that is very challenging as a commissioner.”

A more personal challenge is that of preparing for the “very stressful job interview” that is trying to get re-elected in May.

“In years gone by, you did not know when the election date would be. It is no longer in the Prime Minister’s gift to set the date. We know the election is going to be on May 7. “We know that on 30 March, I will be locked out of my office, banished from the premises I am not the MP for Totnes unless the electorate choose to put me back.”

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